Cost-Effectiveness Analysis of Screening for Celiac Disease in the Adult Population

Population level screening for celiac disease: is now the time?

PURPOSE OF REVIEW

As incidence and prevalence of celiac disease is increasing, subclinical and asymptomatic presentations are more commonly identified through celiac disease screening. However, the United States Preventive Services Task Force released a statement in 2017 maintaining that there is insufficient evidence to recommend general population screening for celiac disease for asymptomatic individuals. This review summarizes the current available evidence on celiac disease screening.

RECENT FINDINGS

Literature demonstrates that by limiting screening to individuals with recognized symptoms, celiac disease diagnosis is frequently delayed or missed entirely. Most individuals with screening-identified celiac disease have previously unrecognized symptoms that improve through treatment with a gluten-free diet. Screening-identified individuals also demonstrate signs of impaired nutrition, growth, bone health, and quality of life which improve with treatment. Overall, celiac disease screening is viewed favorably by those identified through celiac disease screening programs.

SUMMARY

Individuals with screening-identified celiac disease may still incur complications from untreated disease and receive benefit from treatment with a gluten-free diet. More data is needed to determine the cost effectiveness of different mass screening approaches that incorporate the societal perspective towards screening.

Defining the optimum strategy for identifying adults and children with coeliac disease: systematic review and economic modelling

BACKGROUND

Coeliac disease is an autoimmune disorder triggered by ingesting gluten. It affects approximately 1% of the UK population, but only one in three people is thought to have a diagnosis. Untreated coeliac disease may lead to malnutrition, anaemia, osteoporosis and lymphoma.

OBJECTIVES

The objectives were to define at-risk groups and determine the cost-effectiveness of active case-finding strategies in primary care.

DESIGN

(1) Systematic review of the accuracy of potential diagnostic indicators for coeliac disease. (2) Routine data analysis to develop prediction models for identification of people who may benefit from testing for coeliac disease. (3) Systematic review of the accuracy of diagnostic tests for coeliac disease. (4) Systematic review of the accuracy of genetic tests for coeliac disease (literature search conducted in April 2021). (5) Online survey to identify diagnostic thresholds for testing, starting treatment and referral for biopsy. (6) Economic modelling to identify the cost-effectiveness of different active case-finding strategies, informed by the findings from previous objectives.

DATA SOURCES

For the first systematic review, the following databases were searched from 1997 to April 2021: MEDLINE® (National Library of Medicine, Bethesda, MD, USA), Embase® (Elsevier, Amsterdam, the Netherlands), Cochrane Library, Web of Science™ (Clarivate™, Philadelphia, PA, USA), the World Health Organization International Clinical Trials Registry Platform ( WHO ICTRP ) and the National Institutes of Health Clinical Trials database. For the second systematic review, the following databases were searched from January 1990 to August 2020: MEDLINE, Embase, Cochrane Library, Web of Science, Kleijnen Systematic Reviews ( KSR ) Evidence, WHO ICTRP and the National Institutes of Health Clinical Trials database. For prediction model development, Clinical Practice Research Datalink GOLD, Clinical Practice Research Datalink Aurum and a subcohort of the Avon Longitudinal Study of Parents and Children were used; for estimates for the economic models, Clinical Practice Research Datalink Aurum was used.

REVIEW METHODS

For review 1, cohort and case-control studies reporting on a diagnostic indicator in a population with and a population without coeliac disease were eligible. For review 2, diagnostic cohort studies including patients presenting with coeliac disease symptoms who were tested with serological tests for coeliac disease and underwent a duodenal biopsy as reference standard were eligible. In both reviews, risk of bias was assessed using the quality assessment of diagnostic accuracy studies 2 tool. Bivariate random-effects meta-analyses were fitted, in which binomial likelihoods for the numbers of true positives and true negatives were assumed.

RESULTS

People with dermatitis herpetiformis, a family history of coeliac disease, migraine, anaemia, type 1 diabetes, osteoporosis or chronic liver disease are 1.5-2 times more likely than the general population to have coeliac disease; individual gastrointestinal symptoms were not useful for identifying coeliac disease. For children, women and men, prediction models included 24, 24 and 21 indicators of coeliac disease, respectively. The models showed good discrimination between patients with and patients without coeliac disease, but performed less well when externally validated. Serological tests were found to have good diagnostic accuracy for coeliac disease. Immunoglobulin A tissue transglutaminase had the highest sensitivity and endomysial antibody the highest specificity. There was little improvement when tests were used in combination. Survey respondents (n = 472) wanted to be 66% certain of the diagnosis from a blood test before starting a gluten-free diet if symptomatic, and 90% certain if asymptomatic. Cost-effectiveness analyses found that, among adults, and using serological testing alone, immunoglobulin A tissue transglutaminase was most cost-effective at a 1% pre-test probability (equivalent to population screening). Strategies using immunoglobulin A endomysial antibody plus human leucocyte antigen or human leucocyte antigen plus immunoglobulin A tissue transglutaminase with any pre-test probability had similar cost-effectiveness results, which were also similar to the cost-effectiveness results of immunoglobulin A tissue transglutaminase at a 1% pre-test probability. The most practical alternative for implementation within the NHS is likely to be a combination of human leucocyte antigen and immunoglobulin A tissue transglutaminase testing among those with a pre-test probability above 1.5%. Among children, the most cost-effective strategy was a 10% pre-test probability with human leucocyte antigen plus immunoglobulin A tissue transglutaminase, but there was uncertainty around the most cost-effective pre-test probability. There was substantial uncertainty in economic model results, which means that there would be great value in conducting further research.

LIMITATIONS

The interpretation of meta-analyses was limited by the substantial heterogeneity between the included studies, and most included studies were judged to be at high risk of bias. The main limitations of the prediction models were that we were restricted to diagnostic indicators that were recorded by general practitioners and that, because coeliac disease is underdiagnosed, it is also under-reported in health-care data. The cost-effectiveness model is a simplification of coeliac disease and modelled an average cohort rather than individuals. Evidence was weak on the probability of routine coeliac disease diagnosis, the accuracy of serological and genetic tests and the utility of a gluten-free diet.

CONCLUSIONS

Population screening with immunoglobulin A tissue transglutaminase (1% pre-test probability) and of immunoglobulin A endomysial antibody followed by human leucocyte antigen testing or human leucocyte antigen testing followed by immunoglobulin A tissue transglutaminase with any pre-test probability appear to have similar cost-effectiveness results. As decisions to implement population screening cannot be made based on our economic analysis alone, and given the practical challenges of identifying patients with higher pre-test probabilities, we recommend that human leucocyte antigen combined with immunoglobulin A tissue transglutaminase testing should be considered for adults with at least a 1.5% pre-test probability of coeliac disease, equivalent to having at least one predictor. A more targeted strategy of 10% pre-test probability is recommended for children (e.g. children with anaemia).

FUTURE WORK

Future work should consider whether or not population-based screening for coeliac disease could meet the UK National Screening Committee criteria and whether or not it necessitates a long-term randomised controlled trial of screening strategies. Large prospective cohort studies in which all participants receive accurate tests for coeliac disease are needed.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019115506 and CRD42020170766.

FUNDING

This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 44. See the NIHR Journals Library website for further project information.

Early diagnosis of coeliac disease in the Preventive Youth Health Care Centres in the Netherlands: study protocol of a case finding study (GLUTENSCREEN)

Introduction

Coeliac disease (CD) occurs in 1% of the population, develops early in life and is severely underdiagnosed. Undiagnosed and untreated disease is associated with short-term and long-term complications. The current healthcare approach is unable to solve the underdiagnosis of CD and timely diagnosis and treatment is only achieved by active case finding. Aim: to perform a case finding project to detect CD children who visit the Youth Health Care Centres (YHCCs) in a well-described region in the Netherlands to evaluate whether it is feasible, cost-effective and well accepted by the population.

Methods/analysis

Prospective intervention cohort study. Parents of all children aged 12 months and 4 years attending the YHCCs for a regular visit are asked whether their child has one or more CD-related symptoms from a standardised list. If so, they will be invited to participate in the case finding study. After informed consent, a point of care test (POCT) to assess CD-specific antibodies against tissue transglutaminase (TG2A) is performed onsite the YHCCs. If the POCT is positive, CD is highly suspected and the child will be referred to hospital for definitive diagnosis according to the Guideline Coeliac Disease of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition guideline.

Main outcomes

Incidence rate of new CD diagnoses in the study region in comparison to the one in the same age diagnosed by standard of care in the rest of the Netherlands.Feasibility and cost-effectiveness of active CD case finding at the YHCCs. All costs of active case finding, diagnostics and treatment of CD and the potential short-term and long-term consequences of the disease will be calculated for the setting with and without case finding.Ethical acceptability: by questionnaires on parental and healthcare professionals' satisfaction.A statistical analysis plan was prepared and is published on the GLUTENSCREEN website (Statistical-Analysis-Plan-11-5-2021_def.pdf (glutenscreen.nl) and added as annex 1).

Ethics and dissemination

The Medical Ethics Committee Leiden approved this study. If we prove that case finding at the YHCC is feasible, cost-effective and well accepted by the population, implementation is recommended.

Trial registration number

NL63291.058.17.

Is mass screening for coeliac disease a wise use of resources? A health economic evaluation

Background

Living with undiagnosed symptomatic coeliac disease is connected with deteriorated health, and persons with coeliac disease often wait a long time for their diagnosis. A mass screening would lower the delay, but its cost-effectiveness is still unclear. Our aim was to determine the cost-effectiveness of a coeliac disease mass screening at 12 years of age, taking a life course perspective on future benefits and drawbacks.

Methods

The cost-effectiveness was derived as cost per quality-adjusted life-year (QALY) using a Markov model. As a basis for our assumptions, we mainly used information from the Exploring the Iceberg of Celiacs in Sweden (ETICS) study, a school-based screening conducted in 2005/2006 and 2009/2010, where 13,279 12-year-old children participated and 240 were diagnosed with coeliac disease, and a study involving members of the Swedish Coeliac Association with 1031 adult participants.

Results

The cost for coeliac disease screening was 40,105 Euro per gained QALY. Sensitivity analyses support screening based on high compliance to a gluten-free diet, rapid progression from symptom-free coeliac disease to coeliac disease with symptoms, long delay from celiac disease with symptoms to diagnosis, and a low QALY score for undiagnosed coeliac disease cases.

Conclusions

A coeliac disease mass screening is cost-effective based on the commonly used threshold of 50,000 Euro per gained QALY. However, this is based on many assumptions, especially regarding the natural history of coeliac disease and the effects on long-term health for individuals with coeliac disease still eating gluten.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-01737-1.

High rates of serology testing for coeliac disease, and low rates of endoscopy in serologically positive children and adults in Israel: lessons from a large real-world database

BACKGROUND

Although coeliac disease is common worldwide, little is known regarding screening patterns in unselected populations, and on real-life adherence to professional guidelines for coeliac disease diagnosis and management.

OBJECTIVE

To explore current practices in the diagnosis and management of coeliac disease, using data from a large Health Maintenance Organization in Israel that covers 54% of the population.

METHODS

A population-based electronic database of about 4.5 million individuals was reviewed during the period of 1 January 2008 to 31 December 2015. Rates and results of coeliac disease serology testing and endoscopy procedures were examined. Subgroup analysis was performed by age, sex, ethnicity and socioeconomic status.

RESULTS

Coeliac disease serology cumulative testing rate was 17.1% and 8.9% in the paediatric and adult population, respectively. The cumulative incidence of positive coeliac disease serology was 0.45% in children and 0.17% in adults, and was associated with age, sex, ethnicity and socioeconomic status sub-groups (P-value < 0.01). Gastrointestinal endoscopies were not subsequently performed in 44.1% of children and 47.1% of adults with positive coeliac disease serology. Within the study period, 36% of children and 56% of adults never achieved coeliac disease serology normalization.

CONCLUSION

In a large real-life database, screening for coeliac disease was common. However, confirmatory intestinal biopsies were under-utilized, and coeliac disease serology often remained positive over a long period time in both children and adults.

Prevalence of celiac disease in primary care: the need for its own code

BACKGROUND

Celiac disease (CD) is an autoimmune chronic enteropathy of the small intestine caused by exposure to gluten in genetically predisposed individuals. CD is not easy to diagnose due to its unspecific symptomatology, especially in adults, a diagnosed/undiagnosed ratio of 1:7 is estimated. CD does not have its own code in the International Classification of Primary Care (ICPC) but it is coded under code D99 "Disease digestive system, other", which hinders diagnosis, intervention and research. The aim of this study is to investigate the prevalence of CD in Aragón, Spain, using the information available from Primary Care, as well as to discuss the difficulties involved in determining prevalence of CD from data collected at this level of medical intervention.

METHODS

We designed an epidemiological cross-sectional study and analysed 26,964 electronic clinical records from the Aragonese Health Service under code ICPC D99 collected up to December 31st, 2016. The clinical records were classified by their editable field "descriptor" according to their probability of being related to CD. Analyses of gender, age, age at diagnosis, province and health sector were carried out.

RESULTS

We found 4534 clinical records under 293 different descriptors with a high probability of referring to CD. Prevalence in Aragón was estimated to be 0.35% ranging from 0.24 to 0.81% with important differences among health sectors.

CONCLUSIONS

The prevalence of 0.35% is a long way from the generally accepted 1% but within the usually considered ratio 1:7 of diagnosed:undiagnosed cases. Differences among sectors should be carefully analysed. Lacking its own ICPC code, diagnosis of CD in Primary Care Services is not included in a single category, but it is distributed under several descriptors, which makes it difficult to offer any firm diagnosis for treatment and hinders research. Finally, the high prevalence of CD justifies its own ICPC code and the need to withdraw CD from the generic D99 code "Disease digestive system other".

The impact of diagnosis on health-related quality of life in people with coeliac disease: a UK population-based longitudinal perspective

Background

Before diagnosis, people with coeliac disease suffer reduced quality of life, which improves substantially after the disease has been diagnosed. Delayed diagnosis is common. The aim of this study was to assess changes over time in prevalence of coeliac disease symptoms/associated medical conditions, time to diagnosis, quality of life and its determinants before and after diagnosis in the United Kingdom.

Methods

A postal questionnaire was designed in 2015 and sent to 4000 individuals with diagnosed coeliac disease, requesting information on respondents’ socio-demographic and clinical characteristics, and their quality of life pre- and post-diagnosis using the EQ-5D instrument. Data were analysed and compared with results from a survey conducted in 2006 using descriptive analyses, univariate and multivariable regression methods.

Results

The survey response rate was 40%. Sixty-five percent of respondents reported at least 4 symptoms pre-diagnosis, a significant reduction by 13 percentage points (95% CI: -16.9, − 9.4; p-value: < 0.001) compared to 2006. Pre-diagnosis mean duration of symptoms was 12.8 years (SD: 15.3), a non-significant reduction of 0.6 years (95% CI: -2, 0.8; p-value: 0.426) compared to 2006. There was a significant improvement of 0.20 (95% CI: 0.18, 0.22; p-value: < 0.001) in quality of life from pre- (0.65) to post-diagnosis (0.85). Pre-diagnosis values were significantly higher by 0.09 (95% CI: 0.06, 0.12; p-value: < 0.001) than in 2006. Number of symptoms and low income were associated with decreased quality of life.

Conclusions

Undiagnosed coeliac disease is associated with a substantial decrement in quality of life. Time to diagnosis has not significantly shortened over the decade 2006–2015, but symptoms are less severe when diagnosis occurs. Harmonising clinical guidelines for intensified active case finding will help improve quality of life of people with coeliac disease.

Electronic supplementary material

The online version of this article (10.1186/s12876-019-0980-6) contains supplementary material, which is available to authorized users.

Coeliac disease

Coeliac disease is an immune-mediated enteropathy against dietary gluten present in wheat, rye and barley and is one of the most common lifelong food-related disorders worldwide. Coeliac disease is also considered to be a systemic disorder characterized by a variable combination of gluten-related signs and symptoms and disease-specific antibodies in addition to enteropathy. The ingestion of gluten leads to the generation of harmful gluten peptides, which, in predisposed individuals, can induce adaptive and innate immune responses. The clinical presentation is extremely variable; patients may have severe gastrointestinal symptoms and malabsorption, extraintestinal symptoms or have no symptoms at all. Owing to the multifaceted clinical presentation, diagnosis remains a challenge and coeliac disease is heavily underdiagnosed. The diagnosis of coeliac disease is achieved by combining coeliac disease serology and small intestinal mucosal histology during a gluten-containing diet. Currently, the only effective treatment for coeliac disease is a lifelong strict gluten-free diet; however, the diet is restrictive and gluten is difficult to avoid. Optimizing diagnosis and care in coeliac disease requires continuous research and education of both patients and health-care professionals.

Elevated anti-tissue transglutaminase antibodies in children newly diagnosed with type 1 diabetes do not always indicate coeliac disease

AIM

Elevated levels of anti-tissue transglutaminase (anti-tTG) antibody may spontaneously normalise in children with newly diagnosed type 1 diabetes, even if they eat gluten. The prevalence of this phenomenon and predictors of a subsequent coeliac disease (CD) diagnosis were determined.

METHODS

The medical records of children diagnosed with type 1 diabetes at Ha'Emek Medical Centre, Israel, from 2007 to 2015, were retrospectively reviewed for elevated anti-tTG antibody levels. Demographic, clinical, laboratory and histological findings were compared between CD patients and those with transient coeliac serology.

RESULTS

Of 425 patients with new onset type 1 diabetes, 34 (8%) had elevated anti-tTG antibodies: CD was diagnosed in 14, anti-tTG normalisation occurred in 13 and duodenal biopsies did not suggest CD in seven without anti-tTG antibody normalisation. Protective factors for a subsequent CD diagnosis were older age (p = 0.009) and mildly elevated anti-tTG antibody levels at the time of the type 1 diabetes diagnosis (p = 0.007), and decreased anti-tTG levels within six months of diagnosis (p = 0.03).

CONCLUSION

Serological follow-up of a diet containing gluten is recommended for children who have newly diagnosed type 1 diabetes and slightly elevated anti-tTG antibodies with no symptoms that suggest CD.

Value of routine duodenal mucosal biopsies in the evaluation of anemia in a large Australian referral centre

Background and Aim

Small bowel mucosal biopsies (SBBx) are routinely performed to investigate unexplained anemia; however, previous studies have demonstrated a low yield in diagnosing celiac disease. Our aim was to determine the yield of routine SBBx in a large cohort of patients who underwent gastroscopy for the investigation of anemia.

Methods

Data from consecutive patients who underwent gastroscopy for the investigation of anemia in a tertiary hospital, from January 2008–December 2011, were prospectively collected. Measured outcomes were the prevalence of celiac disease, the yield of duodenal biopsies, and the correlation between celiac serology and diagnosis.

Results

Over 4 years, 987 patients (385 M:602 F; 48.27 ± 15.89 years) underwent endoscopy for anemia, of which 534 (54.1%) had proven iron deficiency anemia (IDA). Abnormal SBBx consistent with celiac disease were found in 2% (22/987), with a higher prevalence in females (3.2%, n = 19 vs 0.8%, n = 3 in males) and in those with IDA (3.6%, n = 19 vs 0.7%, n = 3 in non‐IDA). Macroscopic endoscopic abnormalities were present in 86% (19/22) of patients with celiac disease. Of the 178 patients who had celiac serology, tissue transglutaminase antibody had the highest sensitivity (80%) and specificity (99%). Combined serology had a sensitivity of 85.7%.

Conclusion

Only 2% of patients with unexplained anemia had abnormal SBBx consistent with celiac disease and even fewer patients in non‐IDA. Given the availability and high sensitivity of celiac serology and macroscopic changes on endoscopy, SBBx should not be routine during endoscopy but should be limited to those with positive celiac serology, abnormal endoscopic appearance, or females with IDA.

Celiac Disease Prevention

Celiac disease (CD) is a common autoimmune disorder induced by ingestion of gluten in genetically susceptible individuals. Despite the prerequisite for a genetic predisposition, only a minority of the 40% of the Caucasian population that has this genetic predisposition develops the disease. Thus, environmental and/or lifestyle factors play a causal role in the development of CD. The incidence of CD has increased over the last half-century, resulting in rising interest in identifying risk factors for CD to enable primary prevention. Early infant feeding practices have been suggested as one of the factors influencing the risk of CD in genetically susceptible individuals. However, recent large prospective studies have shown that neither the timing of gluten introduction nor the duration or maintenance of breastfeeding influence the risk of CD. Also, other environmental influences have been investigated as potential risk factors, but have not led to primary prevention strategies. Secondary prevention is possible through early diagnosis and treatment. Since CD is significantly underdiagnosed and a large proportion of CD patients are asymptomatic at the time of diagnosis, secondary prevention will not identify all CD patients, as long as mass screening has not been introduced. As following a gluten-free diet is a major challenge, tertiary prevention strategies are discussed as well.

Prevalence of Celiac Disease in Patients with Autoimmune Thyroid Disease: A Meta-Analysis

BACKGROUND

Several screening studies have indicated an increased prevalence of celiac disease (CD) among individuals with autoimmune thyroid disease (ATD), but estimates have varied substantially.

OBJECTIVE

The aim of this study was to examine the prevalence of CD in patients with ATD.

METHOD

A systematic review was conducted of articles published in PubMed Medline or EMBASE until September 2015. Non-English papers with English-language abstracts were also included, as were research abstracts without full text available when relevant data were included in the abstract. Search terms included "celiac disease" combined with "hypothyroidism" or "hyperthyroidism" or "thyroid disease." Fixed-effects inverse variance-weighted models were used. Meta-regression was used to examine heterogeneity in subgroups.

RESULTS

A pooled analysis, based on 6024 ATD patients, found a prevalence of biopsy-confirmed CD of 1.6% [confidence interval (CI) 1.3-1.9%]. Heterogeneity was large (I(2) = 70.7%). The prevalence was higher in children with ATD (6.2% [CI 4.0-8.4%]) than it was in adults (2.7%) or in studies examining both adults and children (1.0%). CD was also more prevalent in hyperthyroidism (2.6% [CI 0.7-4.4%]) than it was in hypothyroidism (1.4% [CI 1.0-1.9%]).

CONCLUSIONS

About 1/62 patients with ATD have biopsy-verified CD. It is argued that patients with ATD should be screened for CD, given this increased prevalence.

Cost-Effectiveness Evaluation of EHR: Simulation of an Abdominal Aortic Aneurysm in the Emergency Department

Health care organizations have installed electronic systems to increase efficiency in health care. Empirically assessing the cost-effectiveness of technologies to the health care system is a challenging and complex task. This study examined cost-effectiveness of additional clinical information supplied via an EHR system by simulating a case of abdominal aortic aneurysm devised and acted professionally by the Israel Center of Medical Simulation. We conducted a simulation-based study on physicians who were asked to treat a simulated patient for the prevalent medical scenario of hip and leg pain that actually corresponded to an abdominal aortic aneurysm. Half of the participating physicians from the Department of Emergency Medicine at Tel-Hashomer Hospital - Israel's largest - had access to an EHR system that integrates medical data from multiple health providers (community and hospitals) in addition to the local health record, and half did not. To model medical decision making, the results of the simulation were combined with a Markov Model within a decision tree. Cost-effectiveness was analyzed by comparing the effects of the admission/discharge decision in units of quality adjusted life years (QALYs) to the estimated costs. The results showed that using EHR in the ED increases the QALY of the patient and improves medical decision-making. The expenditure per patient for one QALY unit as a result of using the EHR was $1229, which is very cost-effective according to many accepted threshold values (less than all these values). Thus, using the EHR contributes to making a cost-effective decision in this specific but prevalent case.

Unrecognized Celiac Disease in Children Presenting for Rheumatology Evaluation

BACKGROUND AND OBJECTIVES

Current clinical guidelines do not consider patients with rheumatic conditions to be at high risk for celiac disease (CD) despite numerous reported associations between the two in adults and children. The objective of this study was to evaluate the prevalence of CD among patients presenting for pediatric rheumatology evaluation.

METHODS

A total of 2125 patients presenting for initial evaluation by the Division of Pediatric Rheumatology at the Hospital for Special Surgery between June 2006 and December 2013 were screened for CD as a part of the standard initial serologic evaluation. The charts of these patients were evaluated retrospectively at the end of this period.

RESULTS

36 patients (30 girls, 6 boys, mean age 9.4 ± 4.3 years, range 2-16 years) received a diagnosis of CD after serologic testing and evaluation by pediatric gastroenterology. Eight additional patients with known diagnoses of CD presented during this time period. The total prevalence of CD over this 6.5-year period was 2.0%. The most common presenting complaints among patients diagnosed with CD were myalgias, arthralgias, and rash. Less frequently, patients reported gastrointestinal complaints including abdominal pain, nausea, and diarrhea. All patients reported improvement or complete resolution of their musculoskeletal symptoms after initiation of a gluten-free diet.

CONCLUSIONS

This study identified 36 new cases of CD among children presenting for rheumatology evaluation, for an overall prevalence rate of 2.0%. The majority of patients who ultimately received a diagnosis of CD presented with extraintestinal manifestations. These results underscore the importance of screening children presenting for rheumatology evaluation for CD.

The prevention of coeliac disease

Primary prevention of coeliac disease is currently not possible. Previously, a 'window of opportunity' was suggested for primary prevention, by introducing gluten between four and six months of age. However, results from recent prospective studies establish that the timing of gluten introduction and the duration or maintenance of breastfeeding do not influence the development of the disease. Secondary prevention is possible through early diagnosis and treatment. Since coeliac disease is severely underdiagnosed, the only way to achieve large-scale secondary prevention is by mass screening. Prospective studies indicate that important health problems, such as reduced foetal growth and birth weight, delayed growth in height and weight in children, and reduced bone mineral density in both children and adults can be prevented by mass screening. Adherence to a strict gluten-free diet may be considered as tertiary prevention.

Celiac disease: prevention in children

Several studies have suggested a protective role of breastfeeding and/or the timing and quantity of gluten introduction in the subsequent development of celiac disease. Especially, prolonged breastfeeding during the introduction of gluten-containing feeding has been associated with a reduced risk of developing celiac disease in infancy. The mentioned results suggest the existence of a 'window of opportunity' between 4 and 6 months of age in which gluten can be introduced in small amounts. Therefore, the European Society for Pediatric Gastroenterology Hepatology and Nutrition recommends avoiding gluten introduction before the age of 4 months and after the age of 7 months and that gluten should be preferably introduced during ongoing breastfeeding. However, the influence of breastfeeding in the development of celiac disease is not clear, since some studies report prevention and others do not, and the studies reporting a protective effect of breastfeeding do not make clear if it concerns prevention of the disease or delays the onset of symptoms. In addition, most of the studies on this topic have been observational and retrospective. For these reasons, prospective studies are needed to understand the relationship between early nutrition in particular and environmental factors in general, concerning the development and possible prevention of celiac disease. Some of these studies are ongoing. One example is the European multicenter PreventCD project (www.preventcoeliacdisease.com) among infants with a first-degree family member with celiac disease carrying HLA-DQ2 and/or -DQ8, randomized to a double-blind dietary intervention with 100 mg of gluten daily or placebo between the age of 4-6 months. All included children are already 3 years old, and the first analyses are being prepared (http://www.trialregister.nl).

Screening for celiac disease in the general population and in high-risk groups

BACKGROUND

Celiac disease (CD) occurs in approximately 1% of the Western population. It is a lifelong disorder that is associated with impaired quality of life (QOL) and an excessive risk of comorbidity and death.

OBJECTIVES

To review the literature on screening for CD in relation to the current World Health Organization (WHO) criteria for mass screening.

METHODS

We performed a PubMed search to identify indexed papers on CD screening with a publication date from 1900 until 1 June 2014. When we deemed an abstract relevant, we read the corresponding paper in detail.

RESULTS

CD fulfills several WHO criteria for mass screening (high prevalence, available treatment and difficult clinical detection), but it has not yet been established that treatment of asymptomatic CD may reduce the excessive risk of severe complications, leading to higher QOL nor that it is cost-effective.

CONCLUSIONS

Current evidence is not sufficient to support mass screening for CD, but active case-finding may be appropriate, as we recognize that most patients with CD will still be missed by this strategy. Although proof of benefit is still lacking, screening for CD may be appropriate in high-risk groups.

Randomized feeding intervention in infants at high risk for celiac disease

BACKGROUND

A window of opportunity has been suggested for reducing the risk of celiac disease by introducing gluten to infants at 4 to 6 months of age.

METHODS

We performed a multicenter, randomized, double-blind, placebo-controlled dietary-intervention study involving 944 children who were positive for HLA-DQ2 or HLA-DQ8 and had at least one first-degree relative with celiac disease. From 16 to 24 weeks of age, 475 participants received 100 mg of immunologically active gluten daily, and 469 received placebo. Anti-transglutaminase type 2 and antigliadin antibodies were periodically measured. The primary outcome was the frequency of biopsy-confirmed celiac disease at 3 years of age.

RESULTS

Celiac disease was confirmed by means of biopsies in 77 children. To avoid underestimation of the frequency of celiac disease, 3 additional children who received a diagnosis of celiac disease according to the 2012 European Society for Pediatric Gastroenterology, Hepatology, and Nutrition diagnostic criteria (without having undergone biopsies) were included in the analyses (80 children; median age, 2.8 years; 59% were girls). The cumulative incidence of celiac disease among patients 3 years of age was 5.2% (95% confidence interval [CI], 3.6 to 6.8), with similar rates in the gluten group and the placebo group (5.9% [95% CI, 3.7 to 8.1] and 4.5% [95% CI, 2.5 to 6.5], respectively; hazard ratio in the gluten group, 1.23; 95% CI, 0.79 to 1.91). Rates of elevated levels of anti-transglutaminase type 2 and antigliadin antibodies were also similar in the two study groups (7.0% [95% CI, 4.7 to 9.4] in the gluten group and 5.7% [95% CI, 3.5 to 7.9] in the placebo group; hazard ratio, 1.14; 95% CI, 0.76 to 1.73). Breast-feeding, regardless of whether it was exclusive or whether it was ongoing during gluten introduction, did not significantly influence the development of celiac disease or the effect of the intervention.

CONCLUSIONS

As compared with placebo, the introduction of small quantities of gluten at 16 to 24 weeks of age did not reduce the risk of celiac disease by 3 years of age in this group of high-risk children. (Funded by the European Commission and others; PreventCD Current Controlled Trials number, ISRCTN74582487.).

Screening for celiac disease in 1st degree relatives: a 10-year follow-up study

Background

Although it is known that first degree relatives of celiac patients have an increased risk for celiac disease few studies are available on its incidence. We investigated the incidence of serologic conversion and of new cases of celiac disease among first degree relatives with negative results at a first screening.

Methods

From a total of 634 first degree relatives of 186 biopsy-proven celiac disease patients diagnosed between October 2000 and October 2010, 450 subjects agreed to participate in the study (Group I), and underwent serologic screening. Between January 2010 and October 2012, out of the initial group of 450, 205 previously sero-negative subjects consented to participate in a second stage of the study and undergo new serologic testing (Group II). All serologically positive individuals of both groups (I and II) were genotyped for celiac disease-predisposing alleles (HLA-DQ2/DQ8).

Results

19 subjects (4.2%) out of the 450 subjects of Group I disclosed positive serologic results, presence of DQ2 and/or DQ8 alleles and celiac disease-compatible mucosal abnormalities. The 205 previously negative first degree relatives from Group II that underwent new serologic testing disclosed eight sero-converted subjects. Mucosal abnormalities in five of these patients confirmed the diagnosis of celiac disease. During the 10-year period of the study the incidence of sero-conversion was 8/205 and the incidence of biopsy-proven celiac disease cases was 5/205.

Conclusions

Our data are coincident with other works on this subject and confirm once again that relatives of celiac patients, especially first degree relatives are at high risk of developing celiac disease. In view of the relatively low incidence further studies are needed to try to establish a useful and cost-effective algorithm for follow-up of relatives of celiac patients.

Case-finding for coeliac disease in secondary care: a prospective multicentre UK study

BACKGROUND

Coeliac disease affects 1% of the population. Despite this high prevalence, the majority of individuals are undetected. Many patients present with subtle symptoms which may also contribute to under diagnosis. Our aim was to determine the relative importance of different presenting characteristics.

METHODS

Unselected gastroenterology patients referred to 4 hospitals in South Yorkshire were investigated for coeliac disease. Diagnosis was based on positive serology and the presence of villous atrophy. Odds ratios were calculated for presenting characteristics and multivariate analysis performed to identify independent risk factors.

RESULTS

4089 patients were assessed (41.5% male, mean age 55.8 ± 18.2 years); 129 had coeliac disease (3.2%, 95% CI 2.6-3.7%). Multivariate analysis of patients referred to secondary care showed family history of coeliac disease (OR 1.26, p < 0.0001), anaemia (OR 1.03, p < 0.0001) and osteoporosis (OR 1.1, p = 0.006) were independent risk factors for diagnosis of coeliac disease. When compared to population controls, diarrhoea (OR 4.1, p < 0.0001), weight loss (OR 2.7, p = 0.02), irritable bowel syndrome symptoms (OR 3.2, p = 0.005) thyroid disease (OR 4.4, p = 0.01) and diabetes (OR 3.0, p = 0.05) were also associated with increased coeliac disease risk.

CONCLUSIONS

Coeliac disease accounts for 1 in 31 referrals in secondary care to unselected gastroenterology clinics. A low threshold for coeliac disease testing should be adopted.

Transglutaminase IgA antibodies in a celiac disease mass screening and the role of HLA-DQ genotyping and endomysial antibodies in sequential testing

OBJECTIVES

The aim of this study was to evaluate hypothetical screening strategies in a Swedish celiac disease (CD) mass screening.

METHODS

Of 10,041 Swedish sixth graders born in 1993 invited to a population-based CD mass screening, 7208 participated. Anti-tissue transglutaminase (tTG) immunoglobulin (Ig) A were analyzed in all children and total serum IgA (s-IgA) in 7161 children. Additional analyses of tTG-IgG, endomysial antibodies (EMA) IgA and IgG, and human leukocyte antigen (HLA) alleles were performed according to a standardized protocol. Children with elevated levels of serological markers were recommended to undergo a small intestinal biopsy to verify diagnosis, and 153 children with CD were thus identified. Sensitivity, specificity, positive predictive values (PPVs) and negative predictive values (NPVs) were calculated and receiver operating characteristic curves were plotted.

RESULTS

By lowering the cutoff for tTG-IgA, 17 additional cases of CD were identified at the cost of 32 biopsies. All children with tTG-IgA >50 U/mL (10 times the recommended upper limit of normal) had gluten enteropathy. Area under the receiver operating characteristic curve for tTG-IgA was 0.988. All cases carried HLA-DQ2 or HLA-DQ8, as did 53% of the controls. For different hypothetical screening strategies, sensitivity, specificity, PPV, and NPV ranged between 87.6% and 100%, 99.5% and 99.9%, 79.7% and 89.7%, and 99.7% and 100%, respectively. Efforts to increase sensitivity by lowering tTG-IgA cutoff would result in increased number of small intestinal biopsies and lower PPV. Sequential testing for both EMA and HLA-DQ genotyping would reduce the number of negative small intestinal biopsies.

CONCLUSIONS

tTG-IgA is a robust marker when used in CD mass screening and its performance can be enhanced by sequential testing for EMA or HLA-DQ genotyping.

Cost-effectiveness of universal serologic screening to prevent nontraumatic hip and vertebral fractures in patients with celiac disease

BACKGROUND & AIMS

Patients with asymptomatic or poorly managed celiac disease can experience bone loss, placing them at risk for hip and vertebral fractures. We analyzed the cost-effectiveness of universal serologic screening (USS) vs symptomatic at-risk screening (SAS) strategies for celiac disease because of the risk of nontraumatic hip and vertebral fractures if untreated or undiagnosed.

METHODS

We developed a lifetime Markov model of the screening strategies, each with male or female cohorts of 1000 patients who were 12 years old when screening began. We screened serum samples for levels of immunoglobulin A, compared with tissue transglutaminase and total immunoglobulin A, and findings were confirmed by mucosal biopsy. Transition probabilities and quality of life estimates were obtained from the literature. We used generalizable cost estimates and Medicare reimbursement rates and ran deterministic and probabilistic sensitivity analyses.

RESULTS

For men, the average lifetime costs were $8532 and $8472 for USS and SAS strategies, respectively, corresponding to average quality-adjusted life year gains of 25.511 and 25.515. Similarly for women, costs were $11,383 and $11,328 for USS and SAS strategies, respectively, corresponding to quality-adjusted life year gains of 25.74 and 25.75. Compared with the current standard of care (SAS), USS produced higher average lifetime costs and lower quality of life for each sex. Deterministic and probabilistic sensitivity analyses showed that the model was robust to realistic changes in all the variables, making USS cost-ineffective on the basis of these outcomes.

CONCLUSIONS

USS and SAS are similar in lifetime costs and quality of life, although the current SAS strategy was overall more cost-effective in preventing bone loss and fractures among patients with undiagnosed or subclinical disease. On the basis of best available supportive evidence, it is more cost-effective to maintain the standard celiac screening practices, although future robust population-based evidence in other health outcomes could be leveraged to reevaluate current screening guidelines.

Implementing a Monte‐Carlo simulation on admission decisions

Purpose

Although very significant and applicable, there have been no formal justifications for the use of Monte‐Carlo models and Markov chains in evaluating hospital admission decisions or concrete data supporting their use. For these reasons, this research was designed to provide a deeper understanding of these models. The purpose of this paper is to examine the usefulness of a computerized Monte‐Carlo simulation of admission decisions under the constraints of emergency departments.

Design/methodology/approach

The authors construct a simple decision tree using the expected utility method to represent the complex admission decision process terms of quality adjusted life years (QALY) then show the advantages of using a Monte‐Carlo simulation in evaluating admission decisions in a cohort simulation, using a decision tree and a Markov chain.

Findings

After showing that the Monte‐Carlo simulation outperforms an expected utility method without a simulation, the authors develop a decision tree with such a model. real cohort simulation data are used to demonstrate that the integration of a Monte‐Carlo simulation shows which patients should be admitted.

Research limitations/implications

This paper may encourage researchers to use Monte‐Carlo simulation in evaluating admission decision implications. The authors also propose applying the model when using a computer simulation that deals with various CVD symptoms in clinical cohorts.

Originality/value

Aside from demonstrating the value of a Monte‐Carlo simulation as a powerful analysis tool, the paper's findings may prompt researchers to conduct a decision analysis with a Monte‐Carlo simulation in the healthcare environment.

Are we diagnosing too many people with coeliac disease?

This review will try to address the question of whether we are diagnosing too many people with coeliac disease. The key reasons for diagnosing coeliac disease may be that it is a common condition affecting up to 1% of the adult population. Delays in diagnosis are common. The average time delay reported by Coeliac UK (National Medical Patient Charity), for patients with symptoms prior to the diagnosis being made is 13 years. For every adult case detected, it is estimated that there are eight cases not detected. Patients with coeliac disease have an associated morbidity and mortality. In addition, quality of life studies suggest that the majority of patients benefit from a gluten-free diet (GFD). Furthermore, the GFD reduces or alleviates the risk of the associated complications. All of these facts could even be used to support the argument for screening! However, conversely the tests for coeliac disease are not 100% sensitive and specific. In addition, we do not know whether patients with milder symptoms will derive less benefit from treatment and are at less risk of complications. Furthermore, evidence presented in this review suggests that actual outcomes for screening studies in an adult population have revealed poor uptake and subsequently difficulties with adherence. What little published data that are available also infers that individuals recognised through screening programmes could have been detected if carefully questioned for symptoms. There is evidence to suggest that diagnosing celiac disease is cost-effective and that the diagnostic costs are offset by reduced medical expenditures, reduced hospital and general practice attendances, but this view depends on the population prevalence of coeliac disease. We believe on the basis of the evidence presented in this review that we are not diagnosing too many adults with coeliac disease. However, the authors consider case-finding with a low threshold for serological testing to be the optimal approach. If you look for coeliac disease you will find it.

Diagnosis of celiac disease

This article reviews issues related to identifying the appropriate patient to test for celiac disease, the performance characteristics of serologic testing, the role of gene testing for human leukocyte antigen DQ2 and DQ8 haplotypes, and issues related to the performance of small intestinal biopsy. The article concludes with a review of special diagnostic considerations in pediatric patients.

Spontaneous normalization of anti-tissue transglutaminase antibody levels is common in children with type 1 diabetes mellitus

BACKGROUND

The prevalence of celiac disease among type 1 diabetes mellitus (T1DM) patients is 5-10 times higher than in the general population. Thus, evaluation of celiac serology is indicated at diagnosis of T1DM and on follow up.

AIM

This study was prompted by the observation that elevated anti-TTG antibody levels in diabetic children may spontaneously normalize despite continued consumption of gluten. The objective of the study was to investigate the prevalence of this phenomenon and associated factors.

MATERIALS AND METHODS

The files of all children diagnosed with type 1 diabetes mellitus from 2003-2009 at a tertiary pediatric medical center were reviewed for those with elevated serum levels of anti-TTG antibody. Clinical, medical, laboratory, and treatment data were collected. Findings were compared between patients diagnosed with celiac disease and patients with initially elevated anti-TTG antibody levels that spontaneously normalized.

RESULTS

Forty-eight of the 738 patients with type 1 diabetes attending our center (6.5%) had elevated anti-TTG antibody blood levels. Celiac disease was diagnosed in 23, and anti-TTG antibody levels normalized in 17 (35.4%), all of whom consumed gluten. At one-year follow-up, there was no significant difference between the groups in HbA1c level or change in anthropometric measurements.

CONCLUSION

Physicians treating children with type 1 diabetes and mildly elevated anti-TTG antibody levels might consider 12-month serologic follow-up on a gluten-containing diet rather than immediate duodenal biopsy.

Screening for celiac disease in average-risk and high-risk populations

The prevalence of celiac disease is rising. As a result there is increasing interest in the associated mortality and morbidity of the disease. Screening of asymptomatic individuals in the general population is not currently recommended; instead, a strategy of case finding is the preferred approach, taking into account the myriad modes of presentation of celiac disease. Although a gluten-free diet is the treatment of choice in symptomatic patients with celiac disease, there is no consensus on whether institution of a gluten-free diet will improve the quality of life in asymptomatic screen-detected celiac disease patients. A review of the studies that have been performed on this subject is presented. Certain patient groups such as those with autoimmune diseases may be offered screening in the context of an informed discussion regarding the potential benefits, with the caveat that the data on this issue are sparse. Active case finding seems to be the most prudent option in most clinical situations.

Externalities from grain consumption: a survey

The US Department of Agriculture (USDA) publishes their MyPyramid plan as a recommended eating model for all Americans. As part of this model, grain consumption is emphasized. This grain consumption has the potential to generate positive externalities, such as reduced rates of obesity, diabetes and other chronic diseases. Such positive externalities can potentially produce tangible economic benefits in terms of public health. In contrast, newer nutritional research shows that grain consumption may have negative effects on health for certain population groups. Celiac disease is four times as common as it was 50 years ago and is often under-diagnosed. Other population groups exhibit gluten sensitivity which can impact the development of asthma, allergies and neurological difficulties. This survey intends to provide a comprehensive description of both the positive and negative externalities associated with grain consumption and the resulting impact on human health.

Delay to celiac disease diagnosis and its implications for health-related quality of life

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.

Celiac disease diagnosis and management: a 46-year-old woman with anemia

Celiac disease is one of the most prevalent autoimmune gastrointestinal disorders, but as the case of Ms J illustrates, diagnosis is often delayed or missed. Based on serologic studies, the prevalence of celiac disease in many populations is estimated to be approximately 1% and has been increasing steadily over the last 50 years. Evaluation for celiac disease is generally straightforward and uses commonly available serologic tests; however, the signs and symptoms of celiac disease are nonspecific and highly heterogeneous, making diagnosis difficult. Although celiac disease is often considered a mild disorder treatable with simple dietary changes, in reality celiac disease imparts considerable risks, including reduced bone mineral density, impaired quality of life, and increased overall mortality. In addition, a gluten-free diet is highly burdensome and can profoundly affect patients and their families. For these reasons, care of individuals with celiac disease requires prompt diagnosis and ongoing multidisciplinary management.

Is it time to screen for adult coeliac disease?

To meet the principles of screening as described by Wilson and Jungner a disease must be common, a significant health burden, detectable and treatable. The key lies in the early detection and alteration of the natural history of disease. Coeliac disease affects 1 in 100 people. Despite this patients frequently have delays in diagnosis or may remain undetected. There is an associated morbidity and mortality which can be effectively treated by simple means of a gluten-free diet. For these reasons coeliac disease has been suggested as appropriate for mass screening. However, there are caveats to this: a complex clinical spectrum, a natural history that is imperfectly understood, overestimation of morbidity and mortality, poor adherence to treatment, and costs of service provision may argue against the time being right for mass screening. This review article provides the most contemporary overview and reference base to allow any clinician to understand the benefits or limitations of a screening programme for adult coeliac disease.

Parents' willingness to pay for coeliac disease screening of their child

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.

Celiac disease: an underappreciated issue in women&#x2019;s health

Celiac disease (CD) is an immune-mediated enteropathy that is secondary to gluten ingestion and classically associated with gastrointestinal symptoms. Diagnosis is based on serology and confirmatory duodenal biopsy, and the only treatment is lifelong avoidance of gluten. CD has been increasingly recognized to encompass a wide variety of manifestations that are relevant to women&#x2019;s health, including infertility, adverse pregnancy outcomes and reduced BMD. Currently, CD is underdiagnosed, largely owing to lack of recognition of the diverse manifestations by general practitioners. Increased awareness of the clinical spectrum of this disease, as well as targeted testing in at-risk individuals (including women with unexplained infertility and previous adverse pregnancy outcomes, and in specific populations with reduced BMD) is greatly needed in order to improve rates of diagnosis.

The PreventCD Study design: towards new strategies for the prevention of coeliac disease

BACKGROUND

PreventCD (www.preventcd.com) is a European multicentre study, which studies the influence of infant nutrition, and that of genetic, immunologic and environmental factors, on the risk of developing coeliac disease (CD). The hypothesis is that it is possible to induce tolerance to gluten by introducing small quantities of gluten to infants, preferably while they are still being breast-fed, and that this might also reduce the risk for related autoimmune disorders.

AIM

To describe the design of this ongoing European CD research project.

METHODS

PreventCD encompasses two study designs and two study populations: (i) a European multicentre study: a prospective, double-blind, randomized dietary-intervention study among infants from families with high risk of CD, and (ii) a Swedish population-based CD screening study among 12-year-olds from the general population, divided into two birth cohorts that differ with respect to infant feeding practices.

DISCUSSION

PreventCD is expected to elucidate some of the genetic and immunological mechanisms involved in the process of immune intolerance.

Impact of symptoms on quality of life before and after diagnosis of coeliac disease: results from a UK population survey

Background

Coeliac disease is a common chronic autoimmune disorder. Underdiagnosis is common and the quality of life impact of symptoms may be severe. We report a study of symptom duration and quality of life before and after diagnosis in a representative sample of people with diagnosed coeliac disease in the UK.

Methods

Postal questionnaire of 2000 people with diagnosed coeliac disease, requesting information on date of diagnosis, type and duration of symptoms, and quality of life before and after diagnosis using the EQ-5D instrument.

Results

The survey response rate was 40% (788/2000). Mean duration of symptoms prior to diagnosis was 13.2 years, with some evidence of shorter duration in recent years. Respondents reported a mean of 13 consultations with their GP about their symptoms prior to diagnosis. The mean utility value of pre-diagnosis quality of life was 0.56, compared to 0.84 at time of survey, a highly statistically significant improvement of 0.27 (95% c.i. 0.25, 0.30).

Conclusions

The symptoms of undiagnosed coeliac disease are associated with a prolonged and substantial decrement to quality of life. These results strengthen the case for detailed examination of the cost-effectiveness of improved methods of detection and diagnosis, including population screening.

Coeliac disease and reproductive disorders

Reproductive problems, such as delayed menarche, amenorrhea, early menopause, infertility, impotence, hypogonadism, recurrent abortions, and low-birth-weight or preterm deliveries, are now known to be among the atypical symptoms of coeliac disease (CD). The pathogenesis of reproductive disorders in CD is unclear, but some hypotheses have been suggested, including autoimmunity and macro- and/or micronutrient deficiency. Recent investigations which have focused on tissue transglutaminase are promising with respect to the clarification of the mechanism of infertility and poor pregnancy outcomes in CD. In this review, the effects of CD on male and female reproductive disorders and pregnancy outcomes are discussed and the need for CD screening in the case of reproductive problems is emphasized.

Systematic review: adherence to a gluten-free diet in adult patients with coeliac disease

BACKGROUND

Coeliac disease is increasingly diagnosed in adult patients who present with atypical symptoms or who are asymptomatic and detected by case screening. Its treatment, a gluten-free diet, can have a considerable impact on daily living. Understanding the factors associated with non-adherence is important in terms of supporting patients with their condition.

AIM

To investigate factors associated with adherence to a gluten-free diet in adults with coeliac disease.

METHODS

A literature search of multiple electronic databases using a pre-determined search string for literature between 1980 and November 2007 identified a possible 611 hits. After checking for relevance, 38 studies were included in this review.

RESULTS

Rates for strict adherence range from 42% to 91% depending on definition and method of assessment and are the lowest among ethnic minorities and those diagnosed in childhood. Adherence is most strongly associated with cognitive, emotional and socio-cultural influences, membership of an advocacy group and regular dietetic follow-up. Screen and symptom-detected coeliac patients do not differ in their adherence to a gluten-free diet.

CONCLUSIONS

The existing evidence for factors associated with non-adherence to a gluten-free diet is of variable quality. Further and more rigorous research is needed to characterize those individuals most likely to be non-adherent to assist them better with their treatment.

Long-term health and quality-of-life consequences of mass screening for childhood celiac disease: a 10-year follow-up study

OBJECTIVE

Mass screening for celiac disease is controversial. The objective of this study was to determine whether detection of childhood celiac disease by mass screening improves long-term health status and health-related quality of life.

METHODS

We conducted a prospective 10-year follow-up study of 32 children who were aged 2 to 4 years, had celiac disease identified by mass screening, and had a gluten-free diet (19) or a normal gluten-containing diet (13). The follow-up included assessments of general health status, celiac disease-associated symptoms, celiac disease-associated serum antibodies, and health-related quality of life.

RESULTS

Ten years after mass screening, 81% of the children were adhering to a gluten-free diet. The health status improved in 66% of the treated children: in 41% by early treatment and in 25% by prevention of the gluten-dependent symptoms that they developed after diagnosis. For 19% of the children, treatment after screening would not have improved their health status, because they had no symptoms at screening and have remained symptom-free while consuming gluten. The health-related quality of life of the children with symptoms improved significantly after 1 year of gluten-free diet. Ten years after screening, the health-related quality of life of the children with celiac disease was similar to that of the reference population.

CONCLUSION

Identification by mass screening led 10 years later to health improvement in 66% of children without deterioration of generic health-related quality of life. There is a good compliance after mass screening. In a research setting, delaying treatment for children without symptoms seems to be an option after a positive screening test. Long-term follow-up studies are needed to assess possible long-term complications in untreated, nonsymptomatic celiac disease.

Impact of mass screening for gluten-sensitive enteropathy in working population

AIM: To assess: (1) frequency and clinical relevance of gluten sensitive enteropathy (GSE) detected by serology in a mass screening program; (2) sensitivity of antitransglutaminase (tTGA) and antiendomysium antibodies (EmA); and (3) adherence to gluten-free diet (GFD) and follow-up.

METHODS: One thousand, eight hundred and sixty-eight subjects recruited from an occupational health department underwent analysis for tTGA and EmA and, if positive, duodenal biopsy, DQ2/DQ8 genotyping, clinical feature recording, blood tests, and densitometry were performed. Since > 98% of individuals had tTGA < 2 U/mL, this value was established as the cut-off limit of normality and was considered positive when confirmed twice in the same sample. Adherence to a GFD and follow up were registered.

RESULTS: Twenty-six (1.39%) subjects had positive tTGA and/or EmA, and 21 underwent biopsy: six Marsh III (one IIIa, four IIIb, one IIIc), nine Marsh I and six Marsh 0 (frequency of GSE 1:125). The sensitivity of EmA for GSE was 46.6% (11.1% for Marsh I, 100% for Marsh III), while for tTGA, it was 93.3% (88.8% for Marsh I, 100% for Marsh III). All 15 patients with abnormal histology had clinical features related to GSE. Marsh I and III subjects had more abdominal pain than Marsh 0 (P = 0.029), and a similar trend was observed for distension and diarrhea. No differences in the percentage of osteopenia were found between Marsh I and III (P = 0.608). Adherence to follow-up was 69.2%. Of 15 GSE patients, 66.7% followed a GFD with 80% responding to it.

CONCLUSION: GSE in the general population is frequent and clinically relevant, irrespective of histological severity. tTGA is the marker of choice. Mass screening programs are useful in identifying patients who can benefit from GFD and follow-up.

Is this really celiac disease? Pitfalls in diagnosis

Celiac disease (CD) is an autoimmune enteropathy triggered in susceptible individuals by ingestion of gliadin-containing grains. Although the autoimmune process targets mainly the intestinal mucosa, CD can manifest itself with a variety signs and symptoms affecting any organ or tissue. For many years, CD has been underdiagnosed because of poor awareness. However, studies showing a high prevalence of CD in North America, followed by a consensus conference on CD organized by the National Institutes of Health, have fueled a campaign to raise awareness among subspecialists and primary physicians. Nevertheless, guidelines for the diagnosis of CD remain poorly appreciated and many health care professionals remain confused about its proper management. This review is intended to clarify "facts and fantasies" about CD diagnosis.

Decision-analytical modelling in health-care economic evaluations

OBJECTIVE

Decision-analytical modelling is widely used in health-care economic evaluations, especially in situations where evaluators lack clinical trial data, and in circumstances where such evaluations factor into reimbursement pricing decisions. This paper aims to improve the understanding and use of modelling techniques in this context, with particular emphasis on Markov modelling.

METHODS

We provide an overview, in this paper, of the principles and methodological details of decision-analytical modelling. We propose a common route for practicing modelling that accommodates any type of decision-analytical modelling techniques. We use the treatment of chronic hepatitis B as an example to indicate the process of development, presentation and analysis of the Markov model, and discuss the strengths, weaknesses and pitfalls of different approaches.

CONCLUSIONS

Good practice of modelling requires careful planning, conduct and analysis of the model, and needs input from modellers and users.

Population screening for coeliac disease in primary care by district nurses using a rapid antibody test: diagnostic accuracy and feasibility study

OBJECTIVE

To evaluate the feasibility and diagnostic accuracy of screening for coeliac disease by rapid detection of IgA antibodies to tissue transglutaminase performed in primary care.

DESIGN

District nurses screened 6 year old children using rapid antibody testing of finger prick blood. They also collected capillary blood samples for laboratory determination of IgA and IgG antibodies to endomysium and IgA antibodies to tissue transglutaminase. Children with positive rapid test results were directly sent for biopsy of the small intestine. Setting Primary care in Jász-Nagykun-Szolnok county, Hungary.

PARTICIPANTS

2690 children (77% of 6 year olds living in the county) and 120 nurses.

MAIN OUTCOME MEASURES

Positivity for antibodies to endomysium or transglutaminase in the laboratory and coeliac disease confirmed at biopsy.

RESULTS

37 children (1.4%, 95% confidence interval 0.9% to 1.8%) had biopsy confirmed coeliac disease. Only five of these children had been diagnosed clinically before screening. Rapid testing had a 78.1% sensitivity (70.0% to 89.3%) and 100% specificity (88.4% to 100%) for a final diagnosis of coeliac disease by biopsy. Sensitivity was 65.1% (50.2% to 77.6%) and specificity was 100% (99.8% to 100%) compared with combined results of IgA and IgG laboratory tests. Trained laboratory workers detected 30 of the 31 newly diagnosed IgA competent patients with the rapid test kit used blindly. Median time to biopsy after a positive rapid test result was significantly shorter (20 days, range 4-148) than after a positive laboratory result (142 days, 70-256; P<0.001). Children with coeliac disease detected at screening were smaller and had worse health status than their peers but they improved on a gluten-free diet.

CONCLUSIONS

A simple rapid antibody test enabled primary care nurses to detect patients with coeliac disease in the community who were not picked up in clinical care. Extra training is needed to improve sensitivity.

Population screening for celiac disease: follow up of patients identified by positive serology

BACKGROUND AND AIM

A previous study that evaluated the prevalence of celiac disease (CD) in a cohort of healthy blood donors, found that 3.8% of subjects had positive serology for CD. The aim of the present study was to examine how the screening results and the diagnosis of CD affected these patients' lifestyle and attitude toward CD.

METHODS

All subjects with positive serology for CD (n = 59) found in the previous study of healthy blood donors (n = 1571) were contacted and interviewed. Data collected included current and previous symptoms compatible with CD, medical follow up since being informed of positive serology for CD and adherence to gluten-free diet (GFD). Information was obtained regarding attitude towards the screening for CD, the results of the screening, and the effect of screening on subjects' lifestyle.

RESULTS

Of the 59 subjects, 51 were available for telephone interview, including all 10 subjects diagnosed with CD (positive serology and biopsy), 17/20 with positive serology and normal intestinal mucosa, and 24/29 with positive serology who refused to undergo intestinal biopsy. Of the 10 patients diagnosed with CD, four adhere to GFD. Only 1/17 subjects with normal intestinal mucosa repeated serology. Two of the 24 who initially refused a biopsy, underwent an intestinal biopsy, and one of them was currently diagnosed with CD. Only one patient diagnosed with CD had all his family members screened for CD.

CONCLUSIONS

The data suggest that many of the patients identified in this screened population do not ultimately benefit from the purpose of the screening, which was early identification and treatment of a common disease with potential serious consequences.