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Normal gastrointestinal mucosa at biopsy and subsequent cancer risk: nationwide population-based, sibling-controlled cohort study. BMC Cancer 2022; 22:890. [PMID: 35964121 PMCID: PMC9375922 DOI: 10.1186/s12885-022-09992-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/10/2022] [Indexed: 11/10/2022] Open
Abstract
Background While individuals with normal gastrointestinal (GI) mucosa on endoscopy have a lower risk of colorectal cancer, risks of other cancers remain unexplored. Methods Through Sweden’s 28 pathology departments, we identified 415,092 individuals with a first GI biopsy with histologically normal mucosa during 1965–2016 and no prior cancer. These individuals were compared to 1,939,215 matched reference individuals from the general population. Follow-up began 6 months after biopsy, and incident cancer data were retrieved from the Swedish Cancer Register. Flexible parametric model was applied to estimate cumulative incidences and hazard ratios (HRs) for cancers. We also used full siblings (n = 441,534) as a secondary comparison group. Results During a median follow-up of 10.9 years, 40,935 individuals with normal mucosa (incidence rate: 82.74 per 10,000 person-years) and 177,350 reference individuals (incidence rate: 75.26) developed cancer. Restricting the data to individuals where follow-up revealed no cancer in the first 6 months, we still observed an increased risk of any cancer in those with a histologically normal mucosa (average HR = 1.07; 95%CI = 1.06–1.09). Although the HR for any and specific cancers decreased shortly after biopsy, we observed a long-term excess risk of any cancer, with an HR of 1.08 (95%CI = 1.05–1.12) and a cumulative incidence difference of 0.93% (95%CI = 0.61%-1.25%) at 30 years after biopsy. An elevated risk of gastric cancer, lung cancer, and hematological malignancy (including lymphoproliferative malignancy) was also observed at 20 or 30 years since biopsy. Sibling analyses confirmed the above findings. Conclusion Individuals with a histologically normal mucosa at biopsy and where follow-up revealed no cancer in the first 6 months, may still be at increased risk of cancer, although excess risks are small. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09992-5.
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2
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Ludvigsson JF, Sun J, Olén O, Song M, Halfvarson J, Roelstraete B, Khalili H, Fang F. Normal Gastrointestinal Mucosa at Biopsy and Overall Mortality: Nationwide Population-Based Cohort Study. Clin Epidemiol 2022; 14:889-900. [PMID: 35903063 PMCID: PMC9314761 DOI: 10.2147/clep.s362362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/22/2022] [Indexed: 11/23/2022] Open
Abstract
Background Normal gastrointestinal (GI) mucosa on endoscopy has been linked to a lower risk of colorectal cancer (CRC) but its association to overall death is unknown. Methods We identified 466,987 individuals with a first GI biopsy 1965–2016 with normal mucosa (60.6% upper GI and 39.4% lower GI) through all Swedish pathology departments (n = 28). They were individually matched to 2,321,217 reference individuals without a GI biopsy and also compared to 505,076 full siblings. Flexible parametric models were applied to estimate hazard ratio (HRs) and 95% confidence interval (95% CI) for death. Results During a median follow-up of ~11 years, 85,859 (18.39%) of individuals with normal mucosa and 377,653 (16.27%) of reference individuals died. This corresponded to incidence rates of 147.56/10,000 vs 127.90/10,000 person-years respectively (rate difference: 19.66/10,000 person-years), with the multivariable-adjusted HR of 1.21 (95% CI: 1.20–1.22). Excess mortality was seen for both upper and lower biopsy with normal mucosa. Particularly higher HRs for death were seen in males, individuals biopsied when aged <40 years, those without a prior record of GI disease, and those with high education. Mortality risk was most increased in the first five years after biopsy (HR = 1.34; 95% CI: 1.32–1.36) but decreased thereafter. Having a GI biopsy with normal mucosa was associated with excess mortality from cardiovascular (CVD)disease (HR = 1.02; 95% CI: 1.01–1.03), cancer (HR = 1.58; 95% CI: 1.56–1.61), GI disease (HR = 1.65; 95% CI: 1.58–1.71), and other causes (HR = 1.10; 95% CI: 1.08–1.11). Sibling comparisons yielded similar results. Conclusion Compared with individuals without a GI biopsy, those with a normal GI biopsy due to clinical symptoms had a higher mortality particularly in the first five years after biopsy, and especially from GI disease and cancer.
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Affiliation(s)
- Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatrics, Örebro University Hospital, Örebro, Sweden.,Division of Digestive and Liver Disease, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Jiangwei Sun
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ola Olén
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden.,Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Mingyang Song
- Departments of Epidemiology and Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jonas Halfvarson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Bjorn Roelstraete
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Hamed Khalili
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Broad Institute of MIT and Harvard, Cambridge, MA, 02142, USA
| | - Fang Fang
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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3
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Wang M, Kong WJ, Feng Y, Lu JJ, Hui WJ, Liu WD, Li ZQ, Shi T, Cui M, Sun ZZ, Gao F. Epidemiological, clinical, and histological presentation of celiac disease in Northwest China. World J Gastroenterol 2022; 28:1272-1283. [PMID: 35431514 PMCID: PMC8968484 DOI: 10.3748/wjg.v28.i12.1272] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 11/16/2021] [Accepted: 02/27/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Research on celiac disease (CD) in northwest China is still in its infancy. At present, large-sample data on the epidemiological, clinical, and pathological characteristics of CD are limited.
AIM To investigate the epidemiological, clinical, and pathological characteristics of CD in northwest China.
METHODS The clinical data of 2884 patients with gastrointestinal (GI) symptoms were retrospectively analyzed. Total immunoglobulin A (IgA) and anti-tissue transglutaminase (tTG) IgA levels were examined in all patients. Gastroscopy and colonoscopy were performed in patients with positive anti-tTG IgA and deficient total IgA levels. Atrophy of the duodenal and ileal villi was examined and histopathological examinations were performed. The modified Marsh–Oberhuber classification system was used to grade villous atrophy in the duodenum or distal ileum. The patients’ Helicobacter pylori (H. pylori) infection status was compared in terms of clinical presentation and Marsh grade. Statistical analyses were performed using the t-test or chi-square test.
RESULTS Among the 2884 patients, 73 were positive for serum anti-tTG IgA, and 50 were diagnosed with CD. The CD detection rate was significantly higher in Kazakhs (4.39%) than in Uyghurs (2.19%), Huis (0.71%), and Hans (0.55%). The main symptoms of CD were chronic diarrhea, anorexia, anemia, fatigue, weight loss, sleep disorders, osteopenia, and osteoporosis. The body mass index of patients with CD was significantly lower than that of patients without CD. A total of 69 patients with positive serum anti-tTG IgA and two patients with deficient total IgA levels underwent GI endoscopy. Endoscopy revealed crypt hyperplasia and/or duodenal villous atrophy, mainly manifested as nodular mucosal atrophy, grooves, and fissures. The difference in H. pylori infection rates was not statistically significant between CD and non-CD patients but was significantly different among CD patients with different Marsh grades.
CONCLUSION Among the patients with GI symptoms in northwestern China, the prevalence of CD was more in the Uyghur and Kazakh populations. H. pylori infection may be associated with CD severity.
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Affiliation(s)
- Man Wang
- Department of Gastroenterology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang Uygur Autonomous Region, China
| | - Wen-Jie Kong
- Department of Gastroenterology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang Uygur Autonomous Region, China
| | - Yan Feng
- Department of Gastroenterology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang Uygur Autonomous Region, China
| | - Jia-Jie Lu
- Department of Gastroenterology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang Uygur Autonomous Region, China
| | - Wen-Jia Hui
- Department of Gastroenterology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang Uygur Autonomous Region, China
| | - Wei-Dong Liu
- Department of Gastroenterology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang Uygur Autonomous Region, China
| | - Zi-Qiong Li
- Department of Gastroenterology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang Uygur Autonomous Region, China
| | - Tian Shi
- Department of Gastroenterology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang Uygur Autonomous Region, China
| | - Mei Cui
- Department of Pathology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang Uygur Autonomous Region, China
| | - Zhen-Zhu Sun
- Department of Pathology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang Uygur Autonomous Region, China
| | - Feng Gao
- Department of Gastroenterology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang Uygur Autonomous Region, China
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von Graffenried T, Rizzi M, Russo M, Nydegger A, Kayemba‐Kay’s S. Atypical hematological manifestation of celiac disease: A case report of aplastic anemia in a 2-year-old child and review of the literature. Pediatr Investig 2021; 5:159-162. [PMID: 34179715 PMCID: PMC8212756 DOI: 10.1002/ped4.12267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/01/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Celiac disease typically presents with symptoms of malabsorption, but extraintestinal manifestations are increasingly reported. Aplastic anemia as the mode of celiac disease presentation is extremely rare in children. CASE PRESENTATION We report a 2-year-old boy who presented with loose stools, loss of appetite, and bicytopenia with severe aregenerative normocytic anemia. Investigations, including bone marrow aspirate and biopsy, revealed aplastic anemia. Screening for malabsorption showed increased plasma concentrations of anti-transglutaminase and anti-gliadin antibodies. A duodenal biopsy confirmed the histologic features of celiac disease. The child received a packed red cell transfusion and was started on a gluten-free diet, with a very good prognosis and normalization of both his blood and histological parameters. To the best of our knowledge, our report is the sixth pediatric case in the literature. CONCLUSION Screening for celiac disease should be performed in children with unexplained hematological abnormalities such as aplastic anemia with or without gastrointestinal symptoms.
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Affiliation(s)
- Thea von Graffenried
- Pediatric Gastroenterology UnitDepartment of PediatricsUniversity of LausanneCentre Hospitalier Universitaire VaudoisLausanneSwitzerland
| | - Mattia Rizzi
- Hemato‐Oncology UnitDepartment of PediatricsUniversity of LausanneSwitzerland
| | - Michel Russo
- Department of PediatricsCentre Hospitalier du Valais RomandSionSwitzerland
| | - Andreas Nydegger
- Pediatric Gastroenterology UnitDepartment of PediatricsUniversity of LausanneCentre Hospitalier Universitaire VaudoisLausanneSwitzerland
| | - Simon Kayemba‐Kay’s
- Department of PediatricsCentre Hospitalier du Valais RomandSionSwitzerland
- Department of PediatricsCentre Hospitalier des Pays de MorlaixFrance
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5
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Sakhuja S, Holtz LR. Progression of pediatric celiac disease from potential celiac disease to celiac disease: a retrospective cohort study. BMC Pediatr 2021; 21:149. [PMID: 33781221 PMCID: PMC8006356 DOI: 10.1186/s12887-021-02625-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 03/23/2021] [Indexed: 11/17/2022] Open
Abstract
Background A subset of patients with serology suggesting celiac disease have an initially negative biopsy but subsequently develop histopathologic celiac disease. Here we characterize patients with potential celiac disease who progress to celiac disease. Methods We performed a retrospective analysis of children (0–18 years of age) with biopsy-confirmed celiac disease seen at St. Louis Children’s Hospital between 2013 and 2018. Results Three hundred sixteen of 327 (96%) children with biopsy-confirmed celiac disease were diagnosed on initial biopsy. The 11 children with potential celiac disease who progressed to celiac disease had lower anti-tissue transglutaminase (anti-TTG IgA) concentrations (2.4 (1.6–5) X upper limit of normal (ULN) vs. 6.41 (3.4–10.5) X ULN) at time of first biopsy. Their median anti-TTG IgA concentrations rose from 2.4 (1.6–5) X ULN to 3.6 (3.1–9.2) X ULN between biopsies. Conclusions Four percent of biopsy confirmed celiac patients initially had a negative biopsy, but later developed histopathologic celiac disease. This is likely an underestimate as no surveillance algorithm was in place. We recommend repeat assessment in children whose serology suggests celiac disease despite normal small bowel biopsy. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02625-z.
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Affiliation(s)
- Shruti Sakhuja
- Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid, Campus, Box 8208, St. Louis, MO, 63110, USA
| | - Lori R Holtz
- Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid, Campus, Box 8208, St. Louis, MO, 63110, USA.
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6
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Maheshwari A, He Z, Weidner MN, Lin P, Bober R, Del Rosario FJ. Influence of Age and Type 1 Diabetes Mellitus on Serological Test for Celiac Disease in Children. Pediatr Gastroenterol Hepatol Nutr 2021; 24:218-229. [PMID: 33833977 PMCID: PMC8007846 DOI: 10.5223/pghn.2021.24.2.218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/12/2020] [Accepted: 10/03/2020] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Serological tests of tissue transglutaminase (TTG) and deamidated gliadin (DGP) antibodies for celiac disease diagnosis show conflicting correlation with histology in young children and in type 1 diabetes mellitus (T1DM). Tests' ability to predict histology and cutoff values based on age and T1DM was evaluated. METHODS A retrospective study of children who had celiac serological tests between 6/1/2002 and 12/31/2014 at a pediatric hospital. RESULTS TTG IgA displayed similar results in predicting histology between <4.0 and ≥4.0 years age groups with sensitivity 98% and 93%, and specificity 88% and 86%, respectively. In children <4.0 years old, sensitivity for DGP antibodies was 100% and specificity 94%; in ≥4.0 years age groups, sensitivity was 60%, 88% for DGP IgA and IgG and specificity 95%, 96%, respectively. TTG IgA had low specificity in patients with T1DM compared with non-T1DM, 42% vs. 91%. Positive TTG IgA with normal histology was associated with higher T1DM prevalence at 36% compared with negative tests at 4%. Finally, the TTG IgA cutoff value was higher in T1DM at 36 vs. 16.3 units in non-T1DM. DGP IgG cutoff showed similar values between age groups; TTG IgA and DGP IgA cutoffs were lower in <4.0 years at 8.3 and 11.9 units than ≥4.0 years at 23.4 and 19.9, respectively. CONCLUSION TTG IgA is sufficient for the <4.0 years age group and DGP antibodies had no advantage over TTG IgA in older children. The cutoff value to determine a positive TTG IgA should be higher for children with T1DM.
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Affiliation(s)
- Anshu Maheshwari
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Pediatrics, Sidney Kimmel College of Medicine, Philadelphia, PA, USA.,Department of Pediatrics, University of Illinois College of Medicine in Peoria and Children's Hospital of Illinois, Peoria, IL, USA
| | - Zhaoping He
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Pediatrics, Sidney Kimmel College of Medicine, Philadelphia, PA, USA
| | - Melissa Nicole Weidner
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Pediatrics, Sidney Kimmel College of Medicine, Philadelphia, PA, USA.,Department of Pediatrics, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Patrick Lin
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Pediatrics, Sidney Kimmel College of Medicine, Philadelphia, PA, USA.,Department of Pediatrics, Lehigh Valley Reilly Children's Hospital, Allentown, PA, USA
| | - Ryan Bober
- Department of Pediatrics, Sidney Kimmel College of Medicine, Philadelphia, PA, USA.,Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Fernando J Del Rosario
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Pediatrics, Sidney Kimmel College of Medicine, Philadelphia, PA, USA
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7
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Emami MH, Soltani S, Eskandari N, Masjedi M. The Circulating Midkine in the Newly Diagnosed Celiac Disease: Clinical Implications. Adv Biomed Res 2021; 10:1. [PMID: 33959558 PMCID: PMC8095258 DOI: 10.4103/abr.abr_8_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 05/03/2020] [Accepted: 10/19/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Celiac disease (CeD) is a chronic inflammatory small intestine disorder caused by an abnormal immune response to an array of the epitopes of the wheat gluten and related proteins of rye and barley in genetically susceptible individuals. Midkine (MK) is an angiogenic cytokine, chemotactic in the direction of polymorphonuclear neutrophils and macrophages, and a T-regulatory cell suppressor. So far, a possible relationship with CeD has not yet been explored. Diagnosis of CeD is based on serologic test in a clinical setting suggestive of CeD and confirmatory histologic examination of the duodenal biopsy. Sometimes, genetic testing of human leukocyte antigen (HLA)-DQ2 and HLA-DQ8 may be needed. The objective of this study was to measure and compare the circulating MK in the celiac patients and healthy individuals. Materials and Methods: Twenty newly untreated CeD cases and 20 normal controls were enrolled in this study. The enzyme-linked immunosorbent assay was used to measure the circulating MK in the celiac patients and controls. Results: There was insignificant difference in the circulating MK between the patients and controls (P > 0.05). Conclusions: The study results suggest that the MK marker does not have any diagnostic value in CeD activity to be used at the time of diagnosis or during follow-ups.
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Affiliation(s)
- Mohammad Hassan Emami
- Poursina Hakim Digestive Diseases Research Centre, Isfahan University of Medical Sciences, Isahan, Iran
| | - Shima Soltani
- Department of Immunology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nahid Eskandari
- Department of Immunology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Masjedi
- Department of Immunology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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8
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Axelrad JE, Sachs MC, Ludvigsson JF, Olén O. A Novel Method for Quantifying Intestinal Inflammatory Burden in Inflammatory Bowel Disease Using Register Data. Clin Epidemiol 2020; 12:1059-1072. [PMID: 33116900 PMCID: PMC7553663 DOI: 10.2147/clep.s265404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 08/01/2020] [Indexed: 12/12/2022] Open
Abstract
Background The Swedish Quality Register for Inflammatory Bowel Disease (SWIBREG) contains clinical data for the study of inflammatory bowel disease (IBD). The Epidemiology Strengthened by histoPathology Reports in Sweden (ESPRESSO) cohort was recently established for the study of gastrointestinal histopathology. We aimed to develop and validate a histology score from ESPRESSO using clinical information from SWIBREG, and secondarily, to evaluate the association of the score on IBD-related hospitalization. Methods In a nationwide, population-based cohort study of patients with IBD during 1969-2017, we linked endoscopic inflammation in SWIBREG with histologic inflammation in ESPRESSO. We established a clinically interpretable model for predicting the endoscopic score from histology using scalable Bayesian rule lists to define a SNOMED-based histology score applicable to the ESPRESSO cohort. We also assessed the impact of baseline endoscopic and histology scores on time to IBD-related hospitalization. Results We identified 5225 individuals with IBD comprising 11,051 endoscopic assessments in SWIBREG linked to a histopathology record in ESPRESSO. We created predictive models to calculate a SNOMED-based histology score which predicted the endoscopic score. Split-sample validated areas under the ROC curves for the score predicting a non-zero endoscopic score were 0.80 (0.78-0.81) in UC, 0.70 (0.68-0.72) in CD, and 0.76 (0.73-0.78) in IBD-U. In a subset of 2741 individuals with an initial IBD diagnosis and a corresponding record in ESPRESSO with an endoscopic assessment in SWIBREG, the baseline endoscopic and histology scores were associated with time to IBD-related hospitalization (endoscopy log-rank UC p<0.001, CD p=0.020, IBD-U p<0.001; histology log-rank UC p=0.018, CD p=0.960, IBD-U p=0.034). Conclusion Histopathology data in ESPRESSO accurately predict endoscopic scores in SWIBREG. Baseline endoscopic and histologic scores were associated with time to IBD-related hospitalization, particularly in UC. The SNOMED-based histology score can be used as a measure of disease activity in future register-based IBD studies.
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Affiliation(s)
- Jordan E Axelrad
- Division of Gastroenterology, Department of Medicine, NYU School of Medicine, New York, New York, USA
| | - Michael C Sachs
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatrics, Orebro University Hospital, Orebro, Sweden.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK.,Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Ola Olén
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden.,Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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9
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Ensari A, Marsh MN. Diagnosing celiac disease: A critical overview. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2019; 30:389-397. [PMID: 31060993 PMCID: PMC6505646 DOI: 10.5152/tjg.2018.18635] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 12/22/2018] [Indexed: 12/11/2022]
Abstract
The diagnosis of celiac disease (CD) no longer rests on a malabsorptive state or severe mucosal lesions. For the present, diagnosis will always require the gold-standard of a biopsy, interpreted through its progressive phases (Marsh classification). Marsh classification articulated the immunopathological spectrum of gluten-induced mucosal changes in association with the recognition of innate (Marsh I infiltration) and T cell-based adaptive (Marsh II, and the surface re-organisation typifying Marsh III lesions) responses. Through the Marsh classification the diagnostic goalposts were considerably widened thus, over its time-course, permitting countless patients to begin a gluten-free diet but who, on previous criteria, would have been denied such vital treatment. The revisions of this classification failed to provide additional insight in the interpretation of mucosal pathology. Morever, the subclassification of Marsh 3 imposed an enormous amount of extra work on pathologists with no aid in diagnosis, treatment, or prognosis. Therefore, it should now be apparent that if gastroenterologists ignore these sub-classifications in clinical decision-making, then on that basis alone, there is no need whatsoever for pathologists to persist in reporting them. Since new treatments are under critical assessment, we might have to consider use of some other higher level histological techniques sensitive enough to detect the changes sought. A promising alternative would be to hear more voices from imaginative histopathologists or morphologists together with some more insightful approaches, involving molecular-based techniques and stem cell research may be to evaluate mucosal pathology in CD.
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Affiliation(s)
- Arzu Ensari
- Department of Pathology, Ankara University School of Medicine, Ankara, Turkey
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10
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Ludvigsson JF, Lashkariani M. Cohort profile: ESPRESSO (Epidemiology Strengthened by histoPathology Reports in Sweden). Clin Epidemiol 2019; 11:101-114. [PMID: 30679926 PMCID: PMC6336132 DOI: 10.2147/clep.s191914] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The ESPRESSO study constitutes a novel approach to examine the etiology and prognosis of gastrointestinal disease in which histopathology plays a prominent role. Between 2015 and 2017, all pathology departments (n=28) in Sweden were contacted and asked to procure histopathology record data from the gastrointestinal tract (pharynx to anus), liver, gallbladder, and pancreas. For each individual, local histopathology IT personnel retrieved data on personal identity number, date of histopathology, topography (where the biopsy is taken), morphology (biopsy appearance), and where available free text. In total, between 1965 and 2017, histopathology record data were available in 2.1 million unique individuals, but the number of data entries was 6.1 million because more than one biopsy was performed in many of the study participants. Index individuals with histopathology data were matched with up to five controls from the general population. We also identified all first-degree relatives (parents, children, full siblings), and the index individual's first spouse. The total study population consisted of 13.0 million individuals. Data from all the study participants have been linked to Swedish National Healthcare Registers allowing research not only on such aspects as fetal and perinatal conditions and the risk of future gastrointestinal disease but also on the risk of comorbidity and complications (including cancer and death). Furthermore, the ESPRESSO database allows researchers and practitioners to identify diagnoses and disease phenotypes not currently indexed in national registers (including disease precursors). The ESPRESSO database increases the sensitivity and specificity of already-recorded diseases in the national health registers. This paper is an overview of the ESPRESSO database.
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Affiliation(s)
- Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden, .,Department of Pediatrics, Örebro University Hospital, Örebro, Sweden, .,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building 2, City Hospital, Nottingham, UK, .,Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA,
| | - Mariam Lashkariani
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,
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11
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Ludvigsson JF, Lebwohl B, Chen Q, Bröms G, Wolf RL, Green PHR, Emilsson L. Anxiety after coeliac disease diagnosis predicts mucosal healing: a population-based study. Aliment Pharmacol Ther 2018; 48:1091-1098. [PMID: 30288774 DOI: 10.1111/apt.14991] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/01/2018] [Accepted: 08/28/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Coeliac disease has been linked to anxiety and depression. However, their association with mucosal healing is unknown. AIM To examine the relationship between anxiety, depression and mucosal healing in coeliac disease. METHODS Between 1969 and 2008, we collected data on all small intestinal biopsies with villous atrophy from Sweden's 28 pathology departments. We restricted our cohort to individuals with data on follow-up biopsy (either persistent villous atrophy [n = 3317] or mucosal healing [n = 4331]). Through Cox regression, we estimated hazard ratios (HRs) for anxiety or depression. RESULTS During follow-up, 123 (2.8/1000 person-years) individuals with mucosal healing had developed anxiety, compared to 94 (2.1/1000 person-years) with persistent villous atrophy. Mucosal healing was hence associated with a higher risk of future anxiety (HR = 1.49; 95% CI = 1.12-1.96). Similarly, 167 (3.8/1000 person-years) individuals with mucosal healing developed depression, compared to 148 (3.3/1000 person-years) with persistent villous atrophy, corresponding to a HR of 1.25 (95% CI = 0.99-1.59). Mucosal healing was more common in individuals with prior diagnoses of anxiety or depression before follow-up biopsy. Anxiety diagnosed between diagnostic and follow-up biopsy for coeliac disease was associated with an almost nine-fold increased chance of mucosal healing (odds ratio = 8.94; 95%CI = 2.03-39.27). CONCLUSION Anxiety and depression are more common in coeliac disease patients with mucosal healing, both before and after follow-up biopsy, an association potentially mediated through more vigilant compliance with a gluten-free diet. This finding raises concern that achieving the goal of mucosal healing may come at a cost of an increased risk of mood disorders.
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Affiliation(s)
- Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Paediatrics, Örebro University Hospital, Örebro, Sweden.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital, Nottingham, UK.,Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York City, New York
| | - Benjamin Lebwohl
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York City, New York
| | - Qi Chen
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Gabriella Bröms
- Division of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden.,Department of Internal Medicine, Danderyd Hospital, Stockholm, Sweden.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Randi L Wolf
- Department of Health & Behavior Studies, Program in Nutrition, Teachers College, Columbia University, New York City, New York
| | - Peter H R Green
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York City, New York
| | - Louise Emilsson
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Health Management and Health Economy, Institute of Health and Society, University of Oslo, Oslo, Norway.,Centre for Clinical Research, Vårdcentralen Värmlands Nysäter, Värmlands Nysäter, Sweden
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12
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Obrenovich MEM. Leaky Gut, Leaky Brain? Microorganisms 2018; 6:microorganisms6040107. [PMID: 30340384 PMCID: PMC6313445 DOI: 10.3390/microorganisms6040107] [Citation(s) in RCA: 147] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/12/2018] [Accepted: 10/15/2018] [Indexed: 12/12/2022] Open
Abstract
'Leaky gut' syndrome, long-associated with celiac disease, has attracted much attention in recent years and for decades, was widely known in complementary/alternative medicine circles. It is often described as an increase in the permeability of the intestinal mucosa, which could allow bacteria, toxic digestive metabolites, bacterial toxins, and small molecules to 'leak' into the bloodstream. Nervous system involvement with celiac disease is know to occur even at subclinical levels. Gluten and gluten sensitivity are considered to trigger this syndrome in individuals genetically predisposed to celiac disease. However, the incidence of celiac disease in the general population is quite low. Nevertheless, increased public interest in gluten sensitivity has contributed to expanded food labels stating 'gluten-free' and the proliferation of gluten-free products, which further drives gluten-free lifestyle changes by individuals without frank celiac disease. Moreover, systemic inflammation is associated with celiac disease, depression, and psychiatric comorbidities. This mini-review focuses on the possible neurophysiological basis of leaky gut; leaky brain disease; and the microbiota's contribution to inflammation, gastrointestinal, and blood-brain barrier integrity, in order to build a case for possible mechanisms that could foster further 'leaky' syndromes. We ask whether a gluten-free diet is important for anyone or only those with celiac disease.
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Affiliation(s)
- Mark E M Obrenovich
- Research Service, Louis Stokes Cleveland Department of Veteran's Affairs Medical Center, Cleveland, OH 44106, USA.
- Department of Chemistry, Case Western Reserve University, Cleveland, OH 44106, USA.
- The Gilgamesh Foundation for Medical Science and Research, Cleveland, OH 44116, USA.
- Department of Medicinal and Biological Chemistry, College of Pharmacy and Pharmaceutical Sciences, University of Toledo, Toledo, OH 43606, USA.
- Departments of Chemistry and Biological and Environmental Sciences, Cleveland State University, Cleveland, OH 44115, USA.
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13
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Kuja-Halkola R, Lebwohl B, Halfvarson J, Emilsson L, Magnusson PK, Ludvigsson JF. Birth weight, sex, and celiac disease: a nationwide twin study. Clin Epidemiol 2017; 9:567-577. [PMID: 29184446 PMCID: PMC5689064 DOI: 10.2147/clep.s149181] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective Earlier research suggests that birth weight may be associated with celiac disease (CD), but the direction of association has been unclear potentially due to confounding effect from genetic and intrafamilial factors. Through within-twin analyses, we aimed to minimize confounding effects such as twins that share genetic and early environmental exposures. Materials and methods Using the Swedish Twin Registry, we examined the birth weight of 146,830 twins according to the CD status. CD was defined as having villous atrophy according to a small intestinal biopsy reports. Results The prevalence of diagnosed CD was 0.5% (n=669), and we included 407 discordant pairs of CD–non-CD twins. Comparing the 669 CD patients with non-CD twins, the association between birth weight and future CD was not statistically significant (odds ratio [OR] per 1000 g increase in birth weight: 1.16; 95% confidence interval [CI]=0.97–1.38). In males, the association was positive and statistically significant (OR=1.50; 95% CI=1.11–2.02). However, the association was not significant in within-pair analyses for both dizygotic and monozygotic twins and for both sexes. Conclusion This population-based study found that in male twins, higher birth weight was associated with higher risk of CD. However, when comparing discordant twin pairs in within-twin pair analyses, there was no statistically significant association between birth weight, intrauterine growth, and future risk of CD.
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Affiliation(s)
- Ralf Kuja-Halkola
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Benjamin Lebwohl
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine, Celiac Disease Center, Columbia University Medical Center, Columbia University, New York, NY, USA
| | - Jonas Halfvarson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Louise Emilsson
- Department of Health Management and Health Economy, Institute of Health and Society, University of Oslo, Oslo, Norway.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Centre for Clinical Research, Vårdcentralen Värmlands Nysäter, County Council of Värmland, Värmland
| | - Patrik K Magnusson
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine, Celiac Disease Center, Columbia University Medical Center, Columbia University, New York, NY, USA.,Department of Pediatrics, Örebro University Hospital, Örebro, Sweden.,Division of Epidemiology and Public Health, School of Medicine, City Hospital, University of Nottingham, Nottingham, UK
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14
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Alaedini A, Lebwohl B, Wormser GP, Green PH, Ludvigsson JF. Borrelia infection and risk of celiac disease. BMC Med 2017; 15:169. [PMID: 28911326 PMCID: PMC5599869 DOI: 10.1186/s12916-017-0926-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 08/09/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Environmental factors, including infectious agents, are speculated to play a role in the rising prevalence and the geographic distribution of celiac disease, an autoimmune disorder. In the USA and Sweden where the regional variation in the frequency of celiac disease has been studied, a similarity with the geographic distribution of Lyme disease, an emerging multisystemic infection caused by Borrelia burgdorferi spirochetes, has been found, thus raising the possibility of a link. We aimed to determine if infection with Borrelia contributes to an increased risk of celiac disease. METHODS Biopsy reports from all of Sweden's pathology departments were used to identify 15,769 individuals with celiac disease. Through linkage to the nationwide Patient Register, we compared the rate of earlier occurrence of Lyme disease in the patients with celiac disease to that in 78,331 matched controls. To further assess the temporal relationship between Borrelia infection and celiac disease, we also examined the risk of subsequent Lyme disease in patients with a diagnosis of celiac disease. RESULTS Twenty-five individuals (0.16%) with celiac disease had a prior diagnosis of Lyme disease, whereas 79 (0.5%) had a subsequent diagnosis of Lyme disease. A modest association between Lyme disease and celiac disease was seen both before (odds ratio, 1.61; 95% confidence interval (CI), 1.06-2.47) and after the diagnosis of celiac disease (hazard ratio, 1.82; 95% CI, 1.40-2.35), with the risk of disease being highest in the first year of follow-up. CONCLUSIONS Only a minor fraction of the celiac disease patient population had a prior diagnosis of Lyme disease. The similar association between Lyme disease and celiac disease both before and after the diagnosis of celiac disease is strongly suggestive of surveillance bias as a likely contributor. Taken together, the data indicate that Borrelia infection is not a substantive risk factor in the development of celiac disease.
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Affiliation(s)
- Armin Alaedini
- Department of Medicine, Columbia University Medical Center, New York, NY, USA. .,Celiac Disease Center, Columbia University Medical Center, New York, NY, USA. .,Institute of Human Nutrition, Columbia University Medical Center, New York, NY, USA.
| | - Benjamin Lebwohl
- Department of Medicine, Columbia University Medical Center, New York, NY, USA.,Celiac Disease Center, Columbia University Medical Center, New York, NY, USA.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Gary P Wormser
- Division of Infectious Diseases, Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - Peter H Green
- Department of Medicine, Columbia University Medical Center, New York, NY, USA.,Celiac Disease Center, Columbia University Medical Center, New York, NY, USA
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden. .,Department of Pediatrics, Örebro University Hospital, Örebro, Sweden. .,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK.
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15
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Ludvigsson JF, Choung RS, Marietta EV, Murray JA, Emilsson L. Increased risk of herpes zoster in patients with coeliac disease - nationwide cohort study. Scand J Public Health 2017; 46:859-866. [PMID: 28701089 DOI: 10.1177/1403494817714713] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Clinical experience suggests that patients with coeliac disease (CD) are more prone to develop herpes zoster (HZ), but robust studies are lacking. METHODS We identified 29,064 patients with CD 1969-2008 using biopsy report data from Sweden's 28 pathology departments. CD was equalled to villous atrophy (Marsh histopathology grade III). Each patient was matched on age, sex, calendar year and county of residence to up to five reference individuals ( n=144,342) from the general population. We then used Cox regression to estimate hazard ratios (HRs) for future HZ (defined as having a hospital-based inpatient or outpatient record of this diagnosis in the Swedish Patient Register). RESULTS During follow-up, 154 (0.53%) individuals with CD and 499 (0.35%) reference individuals developed HZ. Among individuals aged ≥60 years, 1.06% of CD individuals and 0.85% of reference individuals had a lifetime record of HZ. Overall, CD was associated with a 1.62-fold increased risk of HZ (95% CI=1.35-1.95), and was seen also when we considered comorbidity with lymphoproliferative disease, systemic lupus erythematosus, type 1 diabetes, thyroid disease, rheumatoid disease and excluded individuals with a record of dermatitis herpetiformis. The increased risk remained significant after more than five years of follow-up (1.46; 1.16-1.84) Conclusions: CD is associated with HZ, the increased relative risk persists over time from celiac diagnosis but the absolute risk is small.
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Affiliation(s)
- Jonas F Ludvigsson
- 1 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden.,2 Department of Paediatrics, Örebro University Hospital, Sweden.,3 Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, UK.,4 Department of Medicine, Columbia University College of Physicians and Surgeons, New York, USA
| | - Rok Seon Choung
- 5 Division of Gastroenterology and Hepatology, Department of Immunology, Mayo Clinic, USA
| | - Eric V Marietta
- 5 Division of Gastroenterology and Hepatology, Department of Immunology, Mayo Clinic, USA
| | - Joseph A Murray
- 5 Division of Gastroenterology and Hepatology, Department of Immunology, Mayo Clinic, USA
| | - Louise Emilsson
- 6 Department of Health Management and Health Economy, Institute of Health and Society, University of Oslo, Norway.,7 Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA.,8 Centre for clinical research & Vårdcentralen Värmlands Nysäter, County council of Värmland, Sweden
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16
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Mårild K, Størdal K, Bulik CM, Rewers M, Ekbom A, Liu E, Ludvigsson JF. Celiac Disease and Anorexia Nervosa: A Nationwide Study. Pediatrics 2017; 139:peds.2016-4367. [PMID: 28557761 DOI: 10.1542/peds.2016-4367] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Previous research suggests an association of celiac disease (CD) with anorexia nervosa (AN), but data are mostly limited to case reports. We aimed to determine whether CD is associated with the diagnosis of AN. METHODS Register-based cohort and case-control study including women with CD (n = 17 959) and sex- and age-matched population-based controls (n = 89 379). CD (villous atrophy) was identified through the histopathology records of Sweden's 28 pathology departments. Inpatient and hospital-based outpatient records were used to identify AN. Hazard ratios for incident AN diagnosis were estimated by using stratified Cox regression with CD diagnosis as a time-dependent exposure variable. In the secondary analyses, we used conditional logistic regression to estimate odds ratios for being diagnosed with AN before CD. RESULTS Median age of CD diagnosis was 28 years. During 1 174 401 person-years of follow-up, 54 patients with CD were diagnosed with AN (27/100 000 person-years) compared with 180 matched controls (18/100 000 person-years). The hazard ratio for later AN was 1.46 (95% confidence interval [CI], 1.08-1.98) and 1.31 beyond the first year after CD diagnosis (95% CI, 0.95-1.81). A previous AN diagnosis was also associated with CD (odds ratio, 2.18; 95% CI, 1.45-3.29). Estimates remained largely unchanged when adjusted for socioeconomic characteristics and type 1 diabetes. CONCLUSIONS The bidirectional association between AN diagnosis and CD warrants attention in the initial assessment and follow-up of these conditions because underdiagnosis and misdiagnosis of these disorders likely cause protracted and unnecessary morbidity.
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Affiliation(s)
- Karl Mårild
- Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway; .,Barbara Davis Center, University of Colorado, Aurora, Colorado
| | - Ketil Størdal
- Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway.,Department of Pediatrics, Østfold Hospital Trust, Grålum, Norway
| | - Cynthia M Bulik
- Department of Medical Epidemiology and Biostatistics and.,Departments of Psychiatry and.,Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Marian Rewers
- Barbara Davis Center, University of Colorado, Aurora, Colorado
| | - Anders Ekbom
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Edwin Liu
- Barbara Davis Center, University of Colorado, Aurora, Colorado
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics and.,Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom; and.,Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
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17
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Emilsson L, Lebwohl B, Green PH, Murray JA, Mårild K, Ludvigsson JF. Mucosal healing and the risk of serious infections in patients with celiac disease. United European Gastroenterol J 2017; 6:55-62. [PMID: 29435314 DOI: 10.1177/2050640617707868] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 04/03/2017] [Indexed: 12/14/2022] Open
Abstract
Background Patients with celiac disease (CD) are at increased risk of certain infections, but it is unknown if mucosal healing influences this risk. Methods We collected data on 29,096 individuals with CD (equal to villous atrophy) through Sweden's 28 pathology departments undergoing biopsy 1969-2008. Through the Swedish Patient Register we obtained information on any infection and specifically sepsis, streptococcal infection, influenza, Clostridium difficile, herpes zoster and pneumococcal infection up until December 2009. We used Cox regression to calculate hazard ratios (HRs) for the risk of future diagnosis of infection according to mucosal healing on follow-up biopsy (persistent villous atrophy vs mucosal healing). Results Of 5598 CD individuals with no record of any infections before follow-up biopsy, 45% had persistent villous atrophy, 619 (24%) of them had a later infection, compared to 579 (19%) in those with mucosal healing (p < 0.01); the yearly incidence was 2.1% in both groups. Adjusting for age, sex, calendar period, time between biopsies and education, persistent villous atrophy was however not associated with later infection overall (HR = 0.99; 95% CI = 0.88-1.11) or with any of the specific infections. Conclusions In CD, mucosal healing does not influence the risk of serious infection requiring hospital-based medical attention.
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Affiliation(s)
- Louise Emilsson
- Department of Health Management and Health Economy, Institute of Health and Society, University of Oslo, Norway.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Vårdcentralen Värmlands Nysäter & Centre for Clinical Research, County Council of Värmland, Sweden
| | - Benjamin Lebwohl
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Peter Hr Green
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Department of Immunology, Mayo Clinic, Rochester, MN, USA
| | - Karl Mårild
- Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway.,Barbara Davis Center, University of Colorado, Aurora, CO, USA
| | - Jonas F Ludvigsson
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Paediatrics, Örebro University Hospital, Örebro, Sweden.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital, Nottingham, UK
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18
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Anxiety and depression in caregivers of individuals with celiac disease - A population-based study. Dig Liver Dis 2017; 49:273-279. [PMID: 27923553 DOI: 10.1016/j.dld.2016.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 11/07/2016] [Accepted: 11/08/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Partner burden is common in celiac disease (CD), but it is unclear if parents of children with CD have increased burden, and if this may translate into depression and anxiety meriting healthcare. METHODS Nationwide population-based study of 41,753 parents and spouses ("caregivers") to 29,096 celiac patients and 215,752 caregivers to 144,522 matched controls. Caregivers were identified from the Swedish Total Population Register, and linked to data on psychiatric disease in the National Patient Registry. Hazard ratios (HRs) for depression, anxiety, and (as a reference outcome measure) bipolar disorder were examined in a lifetime fashion but also in temporal relationship to date of CD diagnosis using Cox regression. A priori, we focused on parents of individuals diagnosed ≤19 years of age (children at the age of disease onset) and spouses of individuals diagnosed in adulthood, as such parents and spouses ("high-risk caregivers") were most likely to live together with the patient at time of disease onset. RESULTS On Cox analysis, depression was 11% more common in high-risk caregivers (HR=1.11: 95%CI=1.03-1.19) than in control caregivers while anxiety was 7% more common (HR=1.07: 95%CI=0.98-1.16). Combining anxiety and depression into a composite outcome measure, there was an 8% statistically significant risk increase (95%CI=1.02-1.14). The highest excess risks for both depression and anxiety were seen just before and 4-8 years after the CD diagnosis. In contrast, bipolar disorder was not more common in caregivers to CD patients. CONCLUSION Caregivers to patients with CD may be at increased risk of severe burden.
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Kurien M, Sanders DS, Ekbom A, Ciacci C, Ludvigsson JF. Increased rate of abdominal surgery both before and after diagnosis of celiac disease. Dig Liver Dis 2017; 49:147-151. [PMID: 27765577 DOI: 10.1016/j.dld.2016.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 09/14/2016] [Accepted: 09/15/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The detection of celiac disease (CD) is suboptimal. AIMS We hypothesized that misdiagnosis is leading to diagnostic delays, and examine this assertion by determining if patients have increased risk of abdominal surgery before CD diagnosis. METHODS Through biopsy reports from Sweden's 28 pathology departments we identified all individuals with CD (Marsh stage 3; n=29,096). Using hospital-based data on inpatient and outpatient surgery recorded in the Swedish Patient Register, we compared abdominal surgery (appendectomy, laparotomy, biliary tract surgery, and uterine surgery) with that in 144,522 controls matched for age, sex, county and calendar year. Conditional logistic regression estimated odds ratios (ORs). RESULTS 4064 (14.0%) individuals with CD and 15,760 (10.9%) controls had a record of earlier abdominal surgery (OR=1.36, 95% CI=1.31-1.42). Risk estimates were highest in the first year after surgery (OR=2.00; 95% CI=1.79-2.22). Appendectomy, laparotomy, biliary tract surgery, and uterine surgery were all associated with having a later CD diagnosis. Of note, abdominal surgery was also more common after CD diagnosis (hazard ratio=1.34; 95% CI=1.29-1.39). CONCLUSIONS There is an increased risk of abdominal surgery both before and after CD diagnosis. Surgical complications associated with CD may best explain these outcomes. Medical nihilism and lack of CD awareness may be contributing to outcomes.
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Affiliation(s)
- Matthew Kurien
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom; Academic Unit of Gastroenterology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - David S Sanders
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, United Kingdom; Academic Unit of Gastroenterology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Anders Ekbom
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Carolina Ciacci
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Jonas F Ludvigsson
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Paediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom; Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.
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20
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Relationship between Helicobacter pylori infection and celiac disease: a cross-sectional study and a brief review of the literature. GASTROENTEROLOGY REVIEW 2017; 12:49-54. [PMID: 28337237 PMCID: PMC5360666 DOI: 10.5114/pg.2017.65681] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 12/24/2015] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Whether Helicobacter pylori triggers celiac disease (CD) or protects against CD is currently the subject of research. In the literature, there are epidemiologic studies that have reported conflicting results regarding the association between H. pylori and CD. AIM To compare the prevalence of CD autoantibody positivity and the levels of CD autoantibodies between H. pylori-positive and H. pylori-negative subjects. MATERIAL AND METHODS This study was prospectively designed and included 240 dyspeptic patients who underwent upper gastrointestinal endoscopy with gastric and duodenal biopsies. The patients were divided into two groups according to presence of H. pylori infection. The serum levels of immunoglobulin (Ig) A, tissue transglutaminase antibodies (tTGA; IgA and IgG classes), and anti-endomysial antibodies (EMA; IgA and IgG classes) were measured for all participants by a blinded biochemistry expert. RESULTS There were no significant differences in the serum levels of CD autoantibodies or IgA between the two groups. There were also no significant differences in the percentages of subjects with positive CD serologies or subjects with IgA deficiencies between the groups. CONCLUSIONS Helicobacter pylori remains one of the bacterial species that is most likely to trigger autoimmunity. However, studies have failed to reveal a relationship between H. pylori and CD; thus, additional basic work on the immunological aspects of the microbial-host interactions and longitudinal studies enrolling patients at very early stages of the disease may help us to address this issue.
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Ludvigsson JF, Lebwohl B, Green PHR, Chung WK, Mårild K. Celiac disease and Down syndrome mortality: a nationwide cohort study. BMC Pediatr 2017; 17:41. [PMID: 28143429 PMCID: PMC5282819 DOI: 10.1186/s12887-017-0801-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 01/26/2017] [Indexed: 12/20/2022] Open
Abstract
Background Individuals with Down syndrome (DS) have increased mortality and are also at increased risk of celiac disease (CD). It is unknown if CD influences mortality in DS. In this study we examined the risk of death in individuals with DS according to celiac status. Methods In this nationwide population-based cohort study, we first identified individuals with CD (diagnosed 1969–2008) through small intestinal biopsy report data showing villous atrophy (Marsh stage III) from Sweden’s 28 pathology departments. Celiac individuals were then matched with up to five reference individuals from the general population. In these cohorts we identified individuals with DS using International Classification of Disease codes (ICD) registered in the Swedish Patient Register (includes inpatients and hospital-based outpatients), the Medical Birth Register, and the Register of Congenital Malformations. Of 29,096 individuals with CD, 201 (0.7%) had DS compared to 124 of the 144,522 reference individuals (0.09%). Data on mortality were obtained from the Swedish Cause of Death Registry. Hazard ratios (HRs) for death were calculated using Cox regression. Results During follow-up, there were seven deaths among individuals with DS and CD (7/201, 3.5%) as compared with 14 deaths among DS individuals without a record of CD (14/124, 11.3%). Adjusting for potential confounders, CD did not influence the risk of death in DS (HR = 1.36; 95%CI = 0.33–5.59). Cardiovascular death occurred in two individuals with CD and three individuals without CD, while death from malignancy occurred in one individual with CD and two individuals without CD. Conclusion While both DS and CD have been linked to increased risk of death, this study found no excess mortality in DS patients with a concurrent diagnosis of CD, however confidence intervals were wide. Electronic supplementary material The online version of this article (doi:10.1186/s12887-017-0801-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 171 77, Stockholm, Sweden. .,Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden. .,Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.
| | - Benjamin Lebwohl
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 171 77, Stockholm, Sweden.,Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Peter H R Green
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Wendy K Chung
- Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Karl Mårild
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 171 77, Stockholm, Sweden.,Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
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Kuja-Halkola R, Lebwohl B, Halfvarson J, Wijmenga C, Magnusson PKE, Ludvigsson JF. Heritability of non-HLA genetics in coeliac disease: a population-based study in 107 000 twins. Gut 2016; 65:1793-1798. [PMID: 27207974 DOI: 10.1136/gutjnl-2016-311713] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 04/25/2016] [Accepted: 04/28/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVE Almost 100% individuals with coeliac disease (CD) are carriers of the human leucocyte antigen (HLA) DQ2/DQ8 alleles. Earlier studies have, however, failed to consider the HLA system when estimating heritability in CD, thus violating an underlying assumption of heritability analysis. We examined the heritability of CD in a large population-based sample of twins, considering HLA. DESIGN In a population-representative sample of 107 912 twins, we identified individuals with CD (equal to villous atrophy) through biopsy reports from all Swedish pathology departments. We calculated concordance rates and tetrachoric correlations for monozygotic (MZ) and dizygotic (DZ) twin pairs. Further, we estimated heritability of CD, first strictly from observed data, and then the non-HLA heritability, representing the heritability of all genetic factors except the HLA locus, using an approach that circumvent the violation of underlying assumptions. RESULTS We identified 513 twins with a diagnosis of CD (prevalence 0.48%). Concordance rates were higher in MZ pairs (0.49) than in DZ pairs (0.10), as were tetrachoric correlations (0.89 in MZ vs 0.51 in DZ pairs). The heritability of CD was 75% (95% CI 55% to 96%). The non-HLA heritability was slightly attenuated, 68% (95% CI 40% to 96%), with shared (17%) and non-shared (15%) environmental factors explaining the remaining variability of CD. CONCLUSIONS CD is characterised by a high heritability, but our study also suggests that non-shared environmental factors may be of importance to CD development. HLA seems to have only moderate impact on heritability estimates.
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Affiliation(s)
- Ralf Kuja-Halkola
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Benjamin Lebwohl
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine, Celiac Disease Center, Columbia University Medical Center, Columbia University, New York, USA
| | - Jonas Halfvarson
- Faculty of Medicine and Health, Department of Gastroenterology, Örebro University, Örebro, Sweden
| | - Cisca Wijmenga
- Department of Genetics, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Patrik K E Magnusson
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatrics, Örebro University Hospital, Örebro, Sweden.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital, Nottingham, UK
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Laszkowska M, Roy A, Lebwohl B, Green PHR, Sundelin HEK, Ludvigsson JF. Nationwide population-based cohort study of celiac disease and risk of Ehlers-Danlos syndrome and joint hypermobility syndrome. Dig Liver Dis 2016; 48:1030-4. [PMID: 27321543 DOI: 10.1016/j.dld.2016.05.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 05/18/2016] [Accepted: 05/21/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with celiac disease (CD) often have articular complaints, and small prior studies suggest an association with Ehlers-Danlos syndrome (EDS)/joint hypermobility syndrome (JHS). AIMS This study examines the risks of EDS/JHS in patients with CD. METHODS This cohort study compared all individuals in Sweden diagnosed with CD based on small intestinal biopsy between 1969-2008 (n=28,631) to 139,832 matched reference individuals, and to a second reference group undergoing biopsy without having CD (n=16,104). Rates of EDS/JHS were determined based on diagnostic codes in the Swedish Patient Register. Hazard ratios (HRs) for EDS/JHS were estimated through Cox regression. RESULTS There are 45 and 148 cases of EDS/JHS in patients with CD and reference individuals, respectively. This corresponds to a 49% increased risk of EDS/JHS in CD (95%CI=1.07-2.07). The HR for EDS was 2.43 (95%CI=1.20-4.91) and for JHS 1.34 (95%CI=0.93-1.95). Compared to reference individuals undergoing intestinal biopsy, CD was not a risk factor for EDS/JHS. A stronger association was seen in patients initially diagnosed with EDS/JHS and subsequently diagnosed with CD (odds ratio=2.29; 95%CI=1.21-4.34). CONCLUSIONS Individuals with CD have higher risk of EDS/JHS than the general population, which may be due to surveillance bias or factors intrinsic to celiac development.
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Affiliation(s)
- Monika Laszkowska
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Abhik Roy
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Peter H R Green
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | | | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics, Örebro University Hospital, Örebro, Sweden; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK.
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Lebwohl B, Roy A, Alaedini A, Green PHR, Ludvigsson JF. Risk of Headache-Related Healthcare Visits in Patients With Celiac Disease: A Population-Based Observational Study. Headache 2016; 56:849-858. [PMID: 26972425 DOI: 10.1111/head.12784] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Patients with celiac disease (CD) are reported to be at increased risk for headaches, though large studies are lacking. We aimed to examine the risk of headache-related healthcare encounters in patients with CD in a nationwide population-based setting. METHODS In this population-based retrospective cohort study, we searched all (n = 28) pathology departments in Sweden and identified patients with CD based on the presence of villous atrophy (VA). Each patient was matched to up to 5 controls, by age, gender, calendar period, and region. Using Cox proportional hazards, we tested for an association between CD and subsequent headache-related visit. We also tested this association for those with intestinal inflammation but normal villi, and subjects with positive CD serologies but normal histology. RESULTS Among 28,638 patients with CD and 143,126 controls, headache-related visit occurred in 1,337 (4.7%) and 4,102 (2.9%), respectively. The incidence of headache-related visit was 423 per 100,000 person-years in CD patients and 254 per 100,000 person-years in controls (HR 1.66; 95% CI 1.56-1.77; P < .0001). Individuals having inflammation without VA on small intestinal biopsy (n = 12,898; HR 2.08; 95% CI 1.90-2.27; P < .0001) and those with normal mucosa but positive CD serology (n = 3,617; HR 1.83; 95% CI 1.57-2.12; P < .0001) were also at increased risk for headache-related visit. CONCLUSIONS In this population-based study we found a significantly increased risk of headache-related visits in patients with CD; this increase was also present in patients with intestinal inflammation and those with positive CD serology but with normal mucosal architecture on small bowel biopsy. Though limited by surveillance bias, this study indicates that headache-related visits are more common in these populations.
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Affiliation(s)
- Benjamin Lebwohl
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Department of Medical Epidemiology and Biostatistics, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden.,Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| | | | - Armin Alaedini
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Peter H R Green
- Department of Medicine, Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden.,Department of Pediatrics, Örebro University Hospital, Sweden
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25
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Kurien M, Mollazadegan K, Sanders DS, Ludvigsson JF. Celiac Disease Increases Risk of Thyroid Disease in Patients With Type 1 Diabetes: A Nationwide Cohort Study. Diabetes Care 2016; 39:371-5. [PMID: 26681723 DOI: 10.2337/dc15-2117] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 11/06/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Both type 1 diabetes (T1D) and celiac disease (CD) have been linked to autoimmune thyroid disease (ATD). We examined if individuals with both T1D and CD were at a higher risk of ATD than those with only T1D. RESEARCH DESIGN AND METHODS This study was a nationwide population-based cohort study. We defined T1D as having an inpatient or a hospital-based outpatient diagnosis of T1D at age ≤30 years in the Swedish National Patient Register between 1964 and 2009. Data on CD were obtained through small intestinal biopsy reports showing villous atrophy (Marsh histopathology grade III) between 1969 and 2008 at any of the 28 pathology departments in Sweden. ATD included hyperthyreosis and hypothyreosis, defined according to the Swedish National Patient Register. We identified 947 individuals with T1D and biopsy-verified CD. These were matched to 4,584 control subjects with T1D but no CD diagnosis. Cox regression then estimated the risk of ATD. RESULTS Among T1D, CD was a risk factor for later ATD. During follow-up, 90 T1D+CD patients developed ATD (expected n = 54). Adjusting for sex, age, and calendar period, this corresponded to a hazard ratio (HR) of 1.67 (95% CI 1.32-2.11; P < 0.001). This excess risk was highest in those who had CD for 10 years or more (HR 2.22 [95% CI 1.49-3.23]). Risk increases were seen in both males and females. CD was a risk factor for both hypothyreosis (HR 1.66 [95% CI 1.30-2.12]) and hyperthyreosis (HR 1.72 [95% CI 0.95-3.11]). CONCLUSIONS Among patients with T1D, CD is a risk factor for the later development of ATD.
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Affiliation(s)
- Matthew Kurien
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, U.K. Academic Unit of Gastroenterology, University of Sheffield, Sheffield, U.K
| | - Kaziwe Mollazadegan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - David S Sanders
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, U.K. Academic Unit of Gastroenterology, University of Sheffield, Sheffield, U.K
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden
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Increased risk of non-alcoholic fatty liver disease after diagnosis of celiac disease. J Hepatol 2015; 62:1405-11. [PMID: 25617505 PMCID: PMC4439270 DOI: 10.1016/j.jhep.2015.01.013] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 12/30/2014] [Accepted: 01/08/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Non-alcoholic fatty liver disease is a common cause of chronic liver disease. Celiac disease alters intestinal permeability and treatment with a gluten-free diet often causes weight gain, but so far there are few reports of non-alcoholic fatty liver disease in patients with celiac disease. METHODS Population-based cohort study. We compared the risk of non-alcoholic fatty liver disease diagnosed from 1997 to 2009 in individuals with celiac disease (n = 26,816) to matched reference individuals (n = 130,051). Patients with any liver disease prior to celiac disease were excluded, as were individuals with a lifetime diagnosis of alcohol-related disorder to minimize misclassification of non-alcoholic fatty liver disease. Cox regression estimated hazard ratios for non-alcoholic fatty liver disease were determined. RESULTS During 246,559 person-years of follow-up, 53 individuals with celiac disease had a diagnosis of non-alcoholic fatty liver disease (21/100,000 person-years). In comparison, we identified 85 reference individuals diagnosed with non-alcoholic fatty liver disease during 1,488,413 person-years (6/100,000 person-years). This corresponded to a hazard ratio of 2.8 (95% CI 2.0-3.8), with the highest risk estimates seen in children (HR = 4.6; 95% CI 2.3-9.1). The risk increase in the first year after celiac disease diagnosis was 13.3 (95% CI 3.5-50.3) but remained significantly elevated even beyond 15 years after the diagnosis of celiac disease (HR = 2.5; 95% CI 1.0-5.9). CONCLUSION Individuals with celiac disease are at increased risk of non-alcoholic fatty liver disease compared to the general population. Excess risks were highest in the first year after celiac disease diagnosis, but persisted through 15 years after diagnosis with celiac disease.
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Lebwohl B, Stephansson O, Green PHR, Ludvigsson JF. Mucosal healing in patients with celiac disease and outcomes of pregnancy: a nationwide population-based study. Clin Gastroenterol Hepatol 2015; 13:1111-7.e2. [PMID: 25460563 PMCID: PMC4440846 DOI: 10.1016/j.cgh.2014.11.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 11/10/2014] [Accepted: 11/13/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Studies have associated undiagnosed celiac disease with adverse outcomes of pregnancy. We investigated the association between persistent villous atrophy and outcomes of pregnancy in women with celiac disease. METHODS We collected data on 337 women with celiac disease who gave birth (to 460 infants) within 5 years of a follow-up biopsy, from 28 pathology departments in Sweden. We compared birth outcomes from women whose follow-up biopsy showed persistent villous atrophy (Marsh score, 3; n = 142; 31% of study population) with those of women with mucosal recovery (n = 318; 69%). We used multivariable logistic regression (adjusted for maternal age, parity, country of birth, smoking, infant sex, and calendar year of birth) to evaluate the association between persistent villous atrophy and pregnancy outcomes. RESULTS Intrauterine growth restriction occurred during 3.5% of pregnancies in women with persistent villous atrophy vs 3.8% of those with mucosal healing (adjusted odds ratio [OR], 0.61; 95% confidence interval [CI], 0.19-1.99). There was no significant association between persistent villous atrophy and low birth weight (OR, 0.98; 95% CI, 0.41-2.39), preterm birth (OR, 1.66; 95% CI, 0.72-3.83), or cesarean section (OR, 0.86; 95% CI, 0.51-1.46). CONCLUSIONS Although undiagnosed celiac disease has been associated with adverse outcomes of pregnancy, we found no evidence from a nationwide population-based study that persistent villous atrophy, based on analysis of follow-up biopsies, increases risk compared with mucosal healing.
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Affiliation(s)
- Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden,Division of Obstetrics and Gynecology, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Peter HR Green
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Jonas F. Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,Department of Pediatrics, Örebro University Hospital, Sweden,Correspondence and reprint requests: Jonas F Ludvigsson, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden,
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Mårild K, Lebwohl B, Green PHR, Murray JA, Ludvigsson JF. Blockers of Angiotensin Other Than Olmesartan in Patients With Villous Atrophy: A Nationwide Case-Control Study. Mayo Clin Proc 2015; 90:730-7. [PMID: 26046408 PMCID: PMC4469984 DOI: 10.1016/j.mayocp.2015.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 02/20/2015] [Accepted: 04/02/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine the association between the previous use of nonolmesartan angiotensin receptor blockers (ARBs) or any angiotensin-converting enzyme inhibitor (ACEI) and subsequent villous atrophy (VA) in patients with small-intestinal VA as compared with general population-matched controls. PATIENTS AND METHODS A case-control study was used to link nationwide histopathology data on 2933 individuals with VA (Marsh grade 3) to the Swedish Prescribed Drug Register to examine the association between the use of ACEIs as well as the specific use of ARBs other than olmesartan and subsequent VA. Olmesartan is not available in Sweden, so this exposure was not examined. All individuals with VA had biopsies performed between July 1, 2005, and January 29, 2008, and matched on age, sex, calendar period of birth, and county of residence to 14,571 controls from the general population. RESULTS Use of nonolmesartan ARBs was not associated with VA (odds ratio, 0.84; 95% CI, 0.64-1.09; P=.19). Neither was VA associated with a previous medication of any ACEI (odds ratio, 1.08; 95% CI, 0.90-1.30; P=.41). Restricting the analysis to individuals with repeated prescriptions for ACEIs or ARBs revealed only marginally changed risk estimates for VA. CONCLUSION The lack of association between the use of ACEIs and nonolmesartan ARBs and subsequent VA suggests that these medications are not a major risk factor for the development of VA in the general population.
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Affiliation(s)
- Karl Mårild
- Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway; Department of Medical Epidemiology & Biostatistics, Karolinska Institutet, Stockholm, Sweden.
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University Medical Center, Columbia University, New York, NY
| | - Peter H R Green
- Celiac Disease Center, Department of Medicine, Columbia University Medical Center, Columbia University, New York, NY
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Departments of Medicine and Immunology, Mayo Clinic, Rochester, MN
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology & Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
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Nataj Arab HH, Masjedi M, Alsahebfosoul F, Mokhtari M, Jamali N, Emami MH, Saffaei A. Phenotypical characterization of the peripheral blood T cells in patients with celiac disease: does it differentiate suspicious celiac disease cases? GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2015; 8:132-9. [PMID: 25926938 PMCID: PMC4403025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 11/18/2014] [Indexed: 11/09/2022]
Abstract
AIM The present study aimed to study the immunological changes seen in the intestinal epithelium of the celiac patients could also be detected in the peripheral blood lymphocyte populations. BACKGROUND Celiac disease (CD) is a small bowel enteropathy caused by permanent wheat gluten intolerance. One of the earliest signs of CD is an increase in the numbers of the intestinal intraepithelial lymphocytes (iIEL). PATIENTS AND METHODS In this case-control study, totally 13 untreated subjects with acceptable criteria for CD without any complication and 16 healthy subjects without any positive criteria for CD were selected. Peripheral blood T cells were analyzed by two-color flow cytometry in both groups. RESULTS The mean age of patients was 33.6 ± 3.4 years and two patients had Marsh IIIB, five patients had Marsh IIIA and six patients had Marsh II histology class. The mean percentages of the TCR(+) T cells in the patients were significantly higher than the controls (p=0.015). However, the mean percentages of the αβTCR(+) T cells were significantly lower in the untreated patients than the controls (p=0.025). There were no significant difference between the mean percentages of lymphocytes expressing the CD3, CD4 and CD8 molecules in the patients and the controls. CONCLUSION The change in the percentages of the peripheral blood T cells expressing the γδTCR and αβTCR in the celiac patients could be used in conjunction with the other serological markers to identify new CD cases.
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Affiliation(s)
| | | | | | | | | | | | - Ali Saffaei
- Pharmacy Students’ Research Committee, School of Pharmacy, Isfahan University of Medical sciences, Isfahan, Iran
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Lebwohl B, Sundström A, Jabri B, Kupfer SS, Green PHR, Ludvigsson JF. Isotretinoin use and celiac disease: a population-based cross-sectional study. Am J Clin Dermatol 2014; 15:537-42. [PMID: 25022269 DOI: 10.1007/s40257-014-0090-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND AIM Isotretinoin, a vitamin A analogue, can promote a pro-inflammatory milieu in the small intestine in response to dietary antigens. We hypothesized that oral isotretinoin exposure would increase the risk of celiac disease (CD). METHODS We contacted all 28 pathology departments in Sweden, and through biopsy reports identified 26,739 individuals with CD. We then compared the prevalence of ever using oral isotretinoin to the prevalence in 134,277 matched controls through conditional logistic regression. Data on isotretinoin exposure were obtained from the national Swedish Prescribed Drug Registry. As the only indication for isotretinoin use in Sweden is acne, we also examined its relationship to CD. Data on acne were obtained from the Swedish Patient Registry. RESULTS Ninety-three individuals with CD (0.35 %) and 378 matched controls (0.28 %) had a prescription of isotretinoin. This corresponded to an odds ratio (OR) of 1.22 [95 % confidence interval (CI) 0.97-1.54]. Risk estimates were similar in men and women, and when we restricted our data to individuals diagnosed after the start of the Prescribed Drug Registry. Restricting our analyses to individuals diagnosed aged 12-45 years did not influence the risk estimates (OR 1.38, 95 % CI 0.97-1.97). Meanwhile, having a diagnosis of acne was positively associated with CD (OR 1.34, 95 % CI 1.20-1.51). CONCLUSIONS This study found no association between isotretinoin use and CD, but a small excess risk of CD in patients with a diagnosis of acne.
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Affiliation(s)
- Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
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Picarelli A, Borghini R, Donato G, Di Tola M, Boccabella C, Isonne C, Giordano M, Di Cristofano C, Romeo F, Di Cioccio G, Marcheggiano A, Villanacci V, Tiberti A. Weaknesses of histological analysis in celiac disease diagnosis: new possible scenarios. Scand J Gastroenterol 2014; 49:1318-24. [PMID: 25113634 DOI: 10.3109/00365521.2014.948052] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Celiac disease (CD) is an autoimmune disorder triggered by the ingestion of gluten. Serology and organ culture system can support CD diagnosis, despite histology being the gold standard. AIM We wanted to test the uniformity of application of Marsh-Oberhuber criteria by five different histologists. We also compared histological and serological data with cultural results to consider new possible strategies in CD diagnosis. METHODS We studied 114 patients, who were divided in two groups. Group A was composed of 66 patients on a gluten-containing diet, with gluten-related signs and symptoms, showing positive serological anti-endomysial antibodies (EMA) and anti-tissue transglutaminase (anti- tTG). Group B was composed of 48 disease-control patients, presenting serological EMA and anti-tTG negative results. All patients studied underwent esophagogastroduodenoscopy with duodenal biopsy and duodenal mucosa organ culture. All histological samples were evaluated by five different histologists according to an appropriate questionnaire following Marsh-Oberhuber classification. Cohen κ inter-test was used for evaluating the agreement between histologists regarding group A. RESULTS Strength of agreement was fair/moderate for villous:crypt ratio, moderate/good for villous height and crypt depth, and poor for intraepithelial lymphocytosis. Patients belonging to group A presented positive serological as well as cultural results in 100% of cases. None of the patients belonging to group B presented serological or cultural positive results. DISCUSSION Our study stresses the limits of histological interpretation due to the lack of uniformity in the use of Marsh-Oberhuber classification. These findings could cast doubt on the role of histology as CD gold standard and could open a debate on the most appropriate CD diagnostic procedure.
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Affiliation(s)
- Antonio Picarelli
- Department of Internal Medicine and Medical Specialties, Sapienza University , Rome , Italy
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Does urticaria risk increase in patients with celiac disease? A large population-based cohort study. Eur J Dermatol 2014; 23:681-7. [PMID: 24135663 DOI: 10.1684/ejd.2013.2158] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Case reports and smaller case-control studies suggest an association between celiac disease (CD) and urticaria but risk estimates have varied considerably across studies and as yet there are no studies on CD and the risk of future urticaria. OBJECTIVE To examine the association between CD and urticaria. METHODS We identified 28,900 patients with biopsy-verified CD (equal to Marsh stage 3) and compared them with 143,397 age- and sex-matched controls with regards to the risk of urticaria and chronic urticaria (duration ≥6 weeks). Hazard ratios (HRs) were estimated using a Cox regression model. RESULTS During follow-up, 453 patients with CD and no previous diagnosis of urticaria developed urticaria (expected n = 300) and 79 of these 453 had chronic urticaria (expected n = 41). The corresponding HRs were 1.51 for any urticaria (95%CI = 1.36-1.68) and 1.92 for chronic urticaria (95%CI = 1.48-2.48). The absolute risk for urticaria in CD was 140/100,000 person-years (excess risk = 47/100,000 person-years). Corresponding figures for chronic urticaria were 24/100,000 person-years and 12/100,000 person-years. Patients with CD were also at increased risk of having both urticaria (odds ratio, OR = 1.31; 95%CI = 1.12-1.52) and chronic urticaria (OR = 1.54; 95%CI = 1.08-2.18) prior to the CD diagnosis. CONCLUSION This study suggests that CD is associated with urticaria, especially chronic urticaria.
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Abstract
BACKGROUND AND GOALS Seroreactivity against the Saccharomyces cerevisiae (ASCA), Pseudomonas fluorescens-associated sequence (I2), and Bacteroides caccae TonB-linked outer membrane protein (OmpW) has been detected in celiac disease patients with small-bowel mucosal atrophy. Levels of these antibodies decrease during a gluten-free diet, but their functions and time of appearance in celiac disease are not known. We aimed to search for evidence of possible microbial targets of the immune responses in the early-stage celiac disease patients who showed normal small-bowel mucosal architecture at the time of the first investigations, but later on a gluten-containing diet developed mucosal atrophy. MATERIALS AND METHODS Forty-four cases with proven early-stage celiac disease and normal mucosal morphology were enrolled. Patients' sera were tested for celiac disease antibodies against tissue transglutaminase (tTG-ab), endomysium, and for microbial antibodies against I2, OmpW, and ASCA IgG and IgA isotypes in both at the time of diagnosis and while on a gluten-free diet. RESULTS Thirty-four (77%) of 44 patients with early-stage celiac disease had elevated serum antibodies to one or more of the antibodies ASCA, I2, and OmpW. Furthermore, 5 of 6 cases negative for both tTG-ab and endomysium showed positivity for the microbial markers. Seroreactivity to ASCA IgA, ASCA IgG, and OmpW decreased significantly during gluten-free diet. CONCLUSIONS Seroreactivity to different microbial antigens is evident already in patients with early-stage celiac disease. ASCA antibodies seem to be gluten-dependent. The results indicate that the microbial targets might have a role in the early development of celiac disease.
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Smoking, use of moist snuff and risk of celiac disease: a prospective study. BMC Gastroenterol 2014; 14:120. [PMID: 24994113 PMCID: PMC4087123 DOI: 10.1186/1471-230x-14-120] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 06/26/2014] [Indexed: 01/05/2023] Open
Abstract
Background Smoking status has been linked to several chronic inflammatory conditions but earlier research on smoking and celiac disease (CD) is contradictive. There are little data on moist snuff use and CD. The purpose of this study was to investigate the association between smoking, moist snuff use and later CD. Methods We identified individuals with biopsy-verified CD (villous atrophy, histopathology stage Marsh III) through biopsy-reports from Sweden’s 28 pathology departments. Data on smoking and moist snuff were collected from the Swedish construction worker database “Bygghälsan” that includes preventive health care check-up data. Through poisson regression we calculated relative risks (RRs) for later CD according to smoking status (n = 305,722), and moist snuff status (n = 199,200) adjusting for age, sex and decade. Results During follow-up 488 individuals with smoking data, and 310 with moist snuff data had a diagnosis of CD. The risk of CD was independent of smoking status with all RRs being statistically insignificant and ranging between 0.9 and 1.0. Compared to non-smokers, neither current smokers (RR = 0.93; 95% CI = 0.76-1.14) nor ex-smokers (RR = 0.98; 95% CI = 0.75-1.28) were at increased or decreased risk of CD. Risk estimates were similar in moderate smokers (RR = 0.92; 0.72-1.16) and heavy smokers (RR = 0.95; 0.74-1.24), and did not change when we examined the risk more than ten years after health examination (RR-moderate: 0.90; and RR-heavy: 0.95; both p > 0.05). Moist snuff use was not associated with later CD (RR = 1.00; 0.78-1.28), or with CD after more than ten years of follow-up (RR = 1.05; 0.80-1.38). Conclusions We found no association between smoking, moist snuff use and future CD.
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Tortora R, Capone P, Imperatore N, De Stefano G, Gerbino N, Leo M, Caporaso N, Rispo A. Predictive value of "Marsh 1" type histology in subjects with suspected cealic disease. Scand J Gastroenterol 2014; 49:801-6. [PMID: 24958090 DOI: 10.3109/00365521.2014.919019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The diagnosis of celiac disease (CD) is based on histology in combination with anti-tissue transglutaminase (a-tTG) and anti-endomysial antibodies (EMAs). The increase of intraepithelial lymphocytes defines the Marsh 1 histology that appears not to be specific for CD. AIM To explore the positive predictive value (PPV) and clinical relevance of Marsh 1 histology in suspected CD. METHODS We carried out an observational prospective study including all consecutive subjects with a Marsh 1 histology. All patients were tested for a-tTG and EMAs. Diagnosis of potential CD was defined in the presence of Marsh 1 with positive a-tTG and EMAs. Patients were investigated for symptoms, CD familial aggregation, other diseases, and current medication. RESULTS Sixty-three patients with Marsh 1 were included. Diagnosis of potential CD was made in 23 subjects (36%), so that Marsh 1 histology showed a PPV of 36%. With regard to familial aggregation, patients with potential CD showed a higher frequency of familiarity for CD (60.8% vs. 15.0%; p < 0.01). No significant difference was detected between CD and non-CD in terms of intestinal and extra-intestinal symptoms. We also documented the presence of conditions other than CD in the remaining population: 7 patients (17.5%) with immuno-mediated diseases while 5 patients (12.5%) showed Helicobacter pylori (HP) infection. About medication, 3 patients (7.5%) were on non-steroidal anti-inflammatory drugs, while another 4 (10%) patients were being treated with other drugs. CONCLUSION The Marsh 1 type histology is not specific for CD and it can also be associated with immuno-mediated disorders, HP infection, and drugs.
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Affiliation(s)
- Raffaella Tortora
- Department of Clinical Medicine and Surgery - University of Naples "Federico II", Gastroenterology , Naples , Italy
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Tjernberg AR, Ludvigsson JF. Children with celiac disease are more likely to have attended hospital for prior respiratory syncytial virus infection. Dig Dis Sci 2014; 59:1502-8. [PMID: 24510390 DOI: 10.1007/s10620-014-3046-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 01/20/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIM The purpose of this study was to examine the association between celiac disease (CD) and prior respiratory syncytial virus (RSV) infection or any viral bronchiolitis. METHODS This was a retrospective case-control study. During 2006-2008 small intestinal biopsy data were collected from Sweden's 28 pathology departments. We identified 3,835 children diagnosed with CD (villous atrophy, Marsh stage 3) before the age of 2 years in 1987 or later. Using conditional logistic regression we calculated odds ratios (ORs) for having a prior diagnosis of respiratory syncytial virus or other viral bronchiolitis compared to 19,102 age- and sex-matched controls. RESULTS Of the 3,835 children with CD, 36 (0.9 %) had a prior diagnosis of RSV compared to 117/19,102 (0.6 %) matched controls. This corresponded to an OR of 1.46 (95 % CI 1.03-2.07). ORs were similar in girls and boys. The highest ORs were seen in children developing early CD (before 1 year of age (OR 1.82; 95 % CI 0.91-3.62). Prior record of any type of viral bronchiolitis was found in 3.4 % (132/3,835) of individuals with CD and in 2.0 % (390/19,102) of the matched controls corresponding to an OR of 1.60 (95 % CI 1.33-1.92). CONCLUSIONS Children with CD diagnosed <2 years of age were more likely to have attended hospital for a prior RSV infection or any viral bronchiolitis than other children.
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Osman M, Taha B, Al Duboni G. Assessment of the response to gluten-free diet in an Iraqi population with coeliac disease. A histological and serological follow-up study. Arch Med Sci 2014; 10:294-9. [PMID: 24904663 PMCID: PMC4042032 DOI: 10.5114/aoms.2012.31297] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 02/21/2012] [Accepted: 03/11/2012] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Coeliac disease (CD) is a common diagnosis among children and adults in Iraq; however, removal of gluten from the diet is essential for patients with CD. The aim of this study, the first such study in Iraq, was to assess the serological and histological recovery profiles of coeliac patients, in both children and adults groups after commencing a gluten-free diet (GFD) for at least 1 year ± 1 month. MATERIAL AND METHODS The study group comprised 78 proved coeliac patients (46 children and 32 adults, median age: 15 years, range: 1-66 years) who all agreed to undergo endoscopy in addition to serological assessment before and after treatment. The duodenal biopsies were interpreted histologically according to modified Marsh criteria and the sera were tested for anti-gliadin antibody (AGA), endomysium antibody (EMA) and anti-tissue transglutaminase antibody (tTG). RESULTS Complete histological remission was seen in 29 (63.1%) of 46 treated children CD patients, while only 5 (10.9%) showed Marsh IIIa changes compared with 11 (24%) before GFD. Similarly none of the 32 adults after GFD showed Marsh IIIb and Marsh IIIc compared with 46.9% and 28.1% before treatment respectively (p = 001). Meanwhile, there was strongly significant reduction in AGA, EMA, and tTG antibodies levels (p = 0.00001) following GFD. CONCLUSIONS Repeating the duodenal biopsy 1 year ±1 month after diagnosis and starting a GFD supports the routine measurement of using histological findings as a gold standard test to confirm recovery of Iraqi CD patients along with using known coeliac serology antibodies.
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Affiliation(s)
- Muhamed Osman
- Department of Pathology, Faculty of Medicine and Defence Health, University Pertahanan Malaysia (UPNM), Kuala Lumpur, Malaysia
| | - Balsam Taha
- Specialized Surgeries Hospital, Medical City, Baghdad, Iraq
| | - Ghada Al Duboni
- Clinical Immunologist, Department of Basic Sciences, College of Dentistry, University of Baghdad, Baghdad, Iraq
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Ludvigsson JF, Mariosa D, Lebwohl B, Fang F. No association between biopsy-verified celiac disease and subsequent amyotrophic lateral sclerosis--a population-based cohort study. Eur J Neurol 2014; 21:976-82. [PMID: 24708265 DOI: 10.1111/ene.12419] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 02/24/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Earlier data suggest an association between amyotrophic lateral sclerosis (ALS) and autoimmune disease, but data on its association with celiac disease (CD) are limited. METHODS The risk of ALS in 29 093 individuals with CD, according to small intestine biopsy (villous atrophy, Marsh 3) carried out at Sweden's 28 pathology departments in 1969-2008, was compared with that in 144 515 age- and sex-matched reference individuals from the general population. ALS was defined as a hospitalization or outpatient visit with ALS according to the Swedish Patient Register. We used Cox regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for ALS. RESULTS During follow-up 12 (3.7/100 000 person-years) individuals with CD and 56 (3.5/100 000 person-years) reference individuals had a diagnosis of ALS. This corresponded to an HR of 1.0 (95% CI 0.5-1.8). HRs were significantly higher in the first year of follow-up (4.1; 1.2-13.4) than 1-5 years after first CD diagnosis (0.8; 0.2-2.7) or after more than 5 years of follow-up (0.5; 0.2-1.5). Relative risk estimates were similar in men and women but were higher at the end of the study period [HR for ALS in patients diagnosed with CD in year 2000 or later was 2.1 (95% CI 0.9-4.8)]. CONCLUSIONS This study found no association between CD and ALS. Earlier reports of a positive association may be due to surveillance bias just after CD diagnosis or expedited diagnostic work-up of ALS.
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Affiliation(s)
- J F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden
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Schiller LR, Pardi DS, Spiller R, Semrad CE, Surawicz CM, Giannella RA, Krejs GJ, Farthing MJG, Sellin JH. Gastro 2013 APDW/WCOG Shanghai working party report: chronic diarrhea: definition, classification, diagnosis. J Gastroenterol Hepatol 2014; 29:6-25. [PMID: 24117999 DOI: 10.1111/jgh.12392] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/27/2013] [Indexed: 02/06/2023]
Abstract
Diarrhea is best defined as passage of loose stools often with more frequent bowel movements. For clinical purposes, the Bristol Stool Form Scale works well to distinguish stool form and to identify loose stools. Laboratory testing of stool consistency has lagged behind. Acute diarrhea is likely to be due to infection and to be self-limited. As diarrhea becomes chronic, it is less likely to be due to infection; duration of 1 month seems to work well as a cut-off for chronic diarrhea, but detailed scientific knowledge is missing about the utility of this definition. In addition to duration of diarrhea, classifications by presenting scenario, by pathophysiology, and by stool characteristics (e.g. watery, fatty, or inflammatory) may help the canny clinician refine the differential diagnosis of chronic diarrhea. In this regard, a careful history remains the essential part of the evaluation of a patient with diarrhea. Imaging the intestine with endoscopy and radiographic techniques is useful, and biopsy of the small intestine and colon for histological assessment provides key diagnostic information. Endomicroscopy and molecular pathology are only now being explored for the diagnosis of chronic diarrhea. Interest in the microbiome of the gut is increasing; aside from a handful of well-described infections because of pathogens, little is known about alterations in the microbiome in chronic diarrhea. Serological tests have well-defined roles in the diagnosis of celiac disease but have less clearly defined application in autoimmune enteropathies and inflammatory bowel disease. Measurement of peptide hormones is of value in the diagnosis and management of endocrine tumors causing diarrhea, but these are so rare that these tests are of little value in screening because there will be many more false-positives than true-positive results. Chemical analysis of stools is of use in classifying chronic diarrhea and may limit the differential diagnosis that must be considered, but interpretation of the results is still evolving. Breath tests for assessment of carbohydrate malabsorption, small bowel bacterial overgrowth, and intestinal transit are fraught with technical limitations that decrease sensitivity and specificity. Likewise, tests of bile acid malabsorption have had limited utility beyond empirical trials of bile acid sequestrants.
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Valitutti F, Di Nardo G, Barbato M, Aloi M, Celletti I, Trovato CM, Pierdomenico M, Marcheggiano A, Cucchiara S. Mapping histologic patchiness of celiac disease by push enteroscopy. Gastrointest Endosc 2014; 79:95-100. [PMID: 23886355 DOI: 10.1016/j.gie.2013.06.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Accepted: 06/17/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Despite great improvements in serologic testing, duodenal biopsies are still required to diagnose the majority of celiac disease (CD) cases. Nevertheless, the histologic pattern of CD is often patchy, leading to the risk of missing the diagnosis. OBJECTIVE To evaluate the patchiness of the CD histologic lesions along the small bowel (SB), push enteroscopy has been performed instead of conventional upper GI endoscopy. DESIGN Prospective, single-center study. SETTING Tertiary-care referral center. PATIENTS A total of 41 pediatric patients with suspected CD. INTERVENTION Prospective evaluation of bulb, duodenal, and jejunal biopsy specimens in the diagnosis of CD. MAIN OUTCOME MEASUREMENTS Pattern of lesion distribution along the SB (from bulb up to 60 cm beyond the ligament of Treitz) and yield as well accuracy of pediatric CD diagnosis by using push enteroscopy. RESULTS There was a homogeneous pattern of histologic damage in 17 patients (41.5%), whereas 24 patients (58.5%) had a lesion pattern of patchiness. The second and fourth duodenal regions were involved in 38 children (92.7%) and 37 children (90.2%), respectively; the bulb was involved in 37 patients (90.2%); both distal and proximal jejunal samples showed histologic lesions in 38 children (92.7%). In 1 patient, without lesions in the bulb and duodenum, CD was diagnosed according to proximal and distal jejunal biopsies only (3B and C, respectively). A significant correlation was found between the degree of villous atrophy and the serum anti-transglutaminase titer. LIMITATIONS Small sample size; academic tertiary-care setting. CONCLUSION CD histologic lesions often have a discontinuous distribution along the SB, occasionally with an exclusive jejunal involvement. A high degree of villous atrophy correlates with a high anti-transglutaminase titer. When the new ESPGHAN "biopsy-sparing" criteria are not applicable, in case of potential CD, push enteroscopy might be a valuable second-step tool to re-evaluate and identify false "potential" CD hiding exclusive jejunal lesions.
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Affiliation(s)
- Francesco Valitutti
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Giovanni Di Nardo
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Maria Barbato
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Ilaria Celletti
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Chiara Maria Trovato
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Maria Pierdomenico
- ENEA, Italian National Agency for new Technologies, Energy and Sustainable Economic Development, Rome, Italy
| | | | - Salvatore Cucchiara
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
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Ludvigsson JF, Lebwohl B, Rubio-Tapia A, Murray JA, Green PHR, Ekbom A. Risk of lymphoproliferative malignancy in celiac patients with a family history of lymphoproliferative malignancy. J Gastroenterol 2013; 48:1324-31. [PMID: 23440554 PMCID: PMC3664649 DOI: 10.1007/s00535-013-0757-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 01/11/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Individuals with celiac disease (CD) are at increased risk of lymphoproliferative malignancy (LPM). We examined if a family history of LPM or any cancer influenced the risk of LPM in individuals with CD. METHODS We identified 28,996 individuals with biopsy-verified CD (equal to villous atrophy, Marsh histopathology stage 3), of whom 616 had family history of LPM. Cox regression then estimated hazard ratios (HRs) for LPM in these 616 compared with two control groups. We also examined the risk of LPM in CD individuals with a family history of any cancer (n = 8,439). RESULTS During follow-up, 2/616 CD individuals with a family history of LPM, and 235/28,380 CD individuals without a family history of LPM developed LPM themselves. CD individuals with a family history of LPM were not at increased risk of LPM compared to general population controls (HR = 1.18; 95 % CI = 0.27-5.10), or compared to CD individuals without a family history of LPM (adjusted HR = 0.31; 95 % CI = 0.08-1.23). We found no increased risk of LPM in CD individuals with a family history of any cancer. CONCLUSION This study found no evidence that a family history of LPM or any cancer increases the risk of future LPM in individuals with CD. Despite the large number of study participants, this study is nevertheless limited by few positive events due to a low absolute risk of LPM even in individuals with CD.
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Affiliation(s)
- Jonas F Ludvigsson
- Department of Medicine, Clinical Epidemiology Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden,
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Ludvigsson JF, Reichenberg A, Hultman C, Murray JA. A nationwide study of the association between celiac disease and the risk of autistic spectrum disorders. JAMA Psychiatry 2013; 70:1224-30. [PMID: 24068245 PMCID: PMC3884520 DOI: 10.1001/jamapsychiatry.2013.2048] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Most case reports suggest an association between autistic spectrum disorders (ASDs) and celiac disease (CD) or positive CD serologic test results, but larger studies are contradictory. OBJECTIVE To examine the association between ASDs and CD according to small intestinal histopathologic findings. DESIGN AND SETTING Nationwide case-control study in Sweden. MAIN OUTCOMES AND MEASURES Through 28 Swedish biopsy registers, we collected data about 26,995 individuals with CD (equal to villous atrophy, Marsh stage 3), 12,304 individuals with inflammation (Marsh stages 1-2), and 3719 individuals with normal mucosa (Marsh stage 0) but positive CD serologic test results (IgA/IgG gliadin, endomysium, or tissue transglutaminase) and compared them with 213,208 age- and sex-matched controls. Conditional logistic regression estimated odds ratios (ORs) for having a prior diagnosis of an ASD according to the Swedish National Patient Register. In another analysis, we used the Cox proportional hazards regression model to estimate hazard ratios (HRs) for future ASDs in individuals undergoing small intestinal biopsy. RESULTS A prior ASD was not associated with CD (OR, 0.93; 95% CI, 0.51-1.68) or inflammation (OR 1.03; 95% CI, 0.40-2.64) but was associated with a markedly increased risk of having a normal mucosa but a positive CD serologic test result (OR, 4.57; 95% CI, 1.58-13.22). Restricting our data to individuals without a diagnosis of an ASD at the time of biopsy, CD (HR, 1.39; 95% CI, 1.13-1.71) and inflammation (HR, 2.01; 95% CI, 1.29-3.13) were both associated with moderate excess risks of later ASDs, whereas the HR for later ASDs in individuals with normal mucosa but positive CD serologic test results was 3.09 (95% CI, 1.99-4.80). CONCLUSIONS AND RELEVANCE Although this study found no association between CD or inflammation and earlier ASDs, there was a markedly increased risk of ASDs in individuals with normal mucosa but a positive CD serologic test result.
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Affiliation(s)
- Jonas F Ludvigsson
- Clinical Epidemiology Unit, Department of Medicine, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden,Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden,Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine, Rochester, USA,Correspondence and reprint requests: Jonas F. Ludvigsson, Department of Pediatrics, Örebro University Hospital, Sweden, Phone: +46 (0) 19- 6021000, Fax: +46 (0) 19-187915,
| | - Abraham Reichenberg
- Department of Psychosis Studies, Institute of Psychiatry, King’s College London, UK,Department of Psychiatry, Mount Sinai School of Medicine, New York, USA
| | - Christina Hultman
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden
| | - Joseph A. Murray
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine, Rochester, USA
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Ludvigsson JF, Hadjivassiliou M. Can head trauma trigger celiac disease? Nation-wide case-control study. BMC Neurol 2013; 13:105. [PMID: 23927742 PMCID: PMC3750483 DOI: 10.1186/1471-2377-13-105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 08/07/2013] [Indexed: 12/31/2022] Open
Abstract
Background TG6, a brain expressed transglutaminase, is implicated in the neurological manifestations of celiac disease (CD). We hypothesized that earlier brain injury due to head trauma may be more common in patients with CD, potentially through trauma-induced TG6 leading to interaction with TG2. Methods Through biopsy reports from all 28 pathology departments in Sweden we identified 29,096 individuals with CD (in this study defined as villous atrophy). We then examined the risk of earlier head trauma in CD compared to the risk in 144,522 controls matched for age, sex, county and calendar year. Odds ratios (ORs) were calculated using conditional logistic regression. Results 981 (3.4%) individuals with CD and 4,449 (3.1%) controls had a record of earlier head trauma. Individuals with head trauma were hence at a 1.10-fold increased risk of future CD (95% CI = 1.02-1.17). ORs were independent of sex or age at CD. The highest risk of future CD was seen during the first year after trauma. There was no association between severity of trauma and risk of developing CD. Conclusions This study found a very small excess risk for future CD in individuals with an earlier head trauma.
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Mårild K, Ye W, Lebwohl B, Green PHR, Blaser MJ, Card T, Ludvigsson JF. Antibiotic exposure and the development of coeliac disease: a nationwide case-control study. BMC Gastroenterol 2013; 13:109. [PMID: 23834758 PMCID: PMC3720284 DOI: 10.1186/1471-230x-13-109] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 06/28/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The intestinal microbiota has been proposed to play a pathogenic role in coeliac disease (CD). Although antibiotics are common environmental factors with a profound impact on intestinal microbiota, data on antibiotic use as a risk factor for subsequent CD development are scarce. METHODS In this population-based case-control study we linked nationwide histopathology data on 2,933 individuals with CD (Marsh stage 3; villous atrophy) to the Swedish Prescribed Drug Register to examine the association between use of systemic antibiotics and subsequent CD. We also examined the association between antibiotic use in 2,118 individuals with inflammation (Marsh 1-2) and in 620 individuals with normal mucosa (Marsh 0) but positive CD serology. All individuals undergoing biopsy were matched for age and sex with 28,262 controls from the population. RESULTS Antibiotic use was associated with CD (Odds ratio [OR] = 1.40; 95% confidence interval [CI] = 1.27-1.53), inflammation (OR = 1.90; 95% CI = 1.72-2.10) and normal mucosa with positive CD serology (OR = 1.58; 95% CI = 1.30-1.92). ORs for prior antibiotic use in CD were similar when we excluded antibiotic use in the last year (OR = 1.30; 95% CI = 1.08-1.56) or restricted to individuals without comorbidity (OR = 1.30; 95% CI = 1.16 - 1.46). CONCLUSIONS The positive association between antibiotic use and subsequent CD but also with lesions that may represent early CD suggests that intestinal dysbiosis may play a role in the pathogenesis of CD. However, non-causal explanations for this positive association cannot be excluded.
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Affiliation(s)
- Karl Mårild
- Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden.
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Ludvigsson JF, Nordenskjöld A, Murray JA, Olén O. A large nationwide population-based case-control study of the association between intussusception and later celiac disease. BMC Gastroenterol 2013; 13:89. [PMID: 23679928 PMCID: PMC3661363 DOI: 10.1186/1471-230x-13-89] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 05/13/2013] [Indexed: 02/07/2023] Open
Abstract
Background Case reports and case series studies suggest a positive association between intussusception and celiac disease (CD). Methods We contacted Sweden’s 28 pathology departments and obtained data on 29,096 patients with biopsy-verified CD (equal to Marsh stage 3) through biopsy reports. Patients with CD were matched for age, sex, calendar period and county of residence with up to five reference individuals from the general population (n = 144,522). Cases of intussusception were identified from nationwide inpatient, hospital-based outpatient and day-surgery data from the Swedish Patient Register. Odds ratios (ORs) for future CD in patients with intussusception were estimated using conditional logistic regression. Results 34 (0.12%) individuals with CD had a diagnosis of intussusception vs. 143 (0.10%) reference individuals, suggesting that intussusception was not a risk factor for later CD (OR = 1.17; 95% confidence interval (CI) = 0.82–1.67). The OR for CD in patients with at least two records of intussusception was 0.40 (95% CI = 0.06–2.99). In contrast, a post-hoc analysis showed that CD was associated with a statistically significantly increased risk of intussusception after CD diagnosis (hazard ratio = 1.95; 95% CI = 1.01–3.77); however, this analysis was based on only 12 cases with both CD and intussusception. Conclusion We found no association between intussusception and future CD; and a mostly modest increased risk of intussusception after a diagnosis of CD.
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Affiliation(s)
- Jonas F Ludvigsson
- Clinical Epidemiology Unit, Department of Medicine, Karolinska University Hospital and Karolinska Institutet, Karolinska, Sweden.
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Oral administration of Bifidobacterium longum CECT 7347 ameliorates gliadin-induced alterations in liver iron mobilisation. Br J Nutr 2013; 110:1828-36. [PMID: 23657133 DOI: 10.1017/s0007114513001098] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Coeliac disease is an autoimmune disorder triggered by gluten intake, causing intestinal inflammation and mucosal damage commonly associated with the malabsorption of nutrients and ferropenic anaemia. The present study evaluates the effects of the oral administration of Bifidobacterium longum CECT 7347 on gliadin-mediated alterations in hepatic Fe deposition and Hb concentration, liver transferrin receptor (TfR)-2, IL-6, TNF-α and hepcidin (Hamp) expression (mRNA), and active hepcidin peptide production by liquid chromatography–MS/MS. Weanling rats, sensitised or not with interferon (IFN)-γ, were fed with gliadins and/or the bifidobacterial strain. Gliadin feeding increased hepatic Fe deposition; however, only gliadin-fed sensitised animals showed lower Hb concentrations than the controls. TfR2 expression decreased after gliadins were fed to both sensitised and non-sensitised animals,and restored by the administration of B. longum. These observations were accompanied by increases in IL-6 expression levels in all the treatment groups; however, TNF-α expression only increased significantly in animals fed gliadins alone or together with B. longum if they had previously been sensitised with IFN-γ. Liver expression levels of Hamp diminished in all cases to the lowest values in animals sensitised with IFN-γ after being fed with gliadins and/or bifidobacteria. In these animals, plasma Hamp active peptide concentrations significantly increased when compared with the controls. Significant correlations were calculated between Hamp expression and liver Fe contents (liver Fe = 1/0·0032 + 0·032 x Hamp(exp)), and Hb concentrations (Hb = 11·49 + 10·13 x (Hamp(exp))1/2). These data indicate that oral administration of B. longum ameliorates gliadin-mediated perturbations in liver Fe deposition and mobilisation.
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Biagi F, Trotta L, Alfano C, Balduzzi D, Staffieri V, Bianchi PI, Marchese A, Vattiato C, Zilli A, Luinetti O, Gobbi P, Corazza GR. Prevalence and natural history of potential celiac disease in adult patients. Scand J Gastroenterol 2013; 48:537-42. [PMID: 23506211 DOI: 10.3109/00365521.2013.777470] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Potential celiac disease (PCD) is a form of CD characterized by positive endomysial/tissue transglutaminase antibodies and a preserved duodenal mucosa despite a gluten-containing diet (GCD); it can evolve into flat, active CD. This evolution is, however, not certain. Our aim was to retrospectively study the prevalence and the natural history of adult patients with PCD. METHODS The clinical notes of all 47 patients with PCD attending our clinic between September 1999 and October 2011 were retrospectively reevaluated. To study their clinical features, patients with active CD, randomly selected and matched for sex and date of birth, served as controls. Symptoms, associated diseases, familiarity, and laboratory data at diagnosis were compared. RESULTS Prevalence of PCD among all celiac patients directly diagnosed in our center was 42/187, (1/4.4, 18.3%, 95% confidence interval (CI) 13.3-23.4%). Age at diagnosis, laboratory data, prevalence of symptoms, associated diseases, and familiarity for CD did not differ between patients with PCD and those with active CD. Some patients with PCD maintained a normal duodenal mucosa for many years and their symptoms spontaneously improved despite maintaining a GCD. CONCLUSIONS PCD is not a rare form of CD. Having found no difference at all in age at diagnosis and clinical features between PCD and active CD could suggest that PCD is not a prodrome of CD but is a separate entity that can only subsequently evolve into active CD.
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Affiliation(s)
- Federico Biagi
- Coeliac Centre/First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
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Picarelli A, Di Tola M, Marino M, Libanori V, Borghini R, Salvi E, Donato G, Vitolo D, Tiberti A, Marcheggiano A, Bassotti G, Corazziari E. Usefulness of the organ culture system when villous height/crypt depth ratio, intraepithelial lymphocyte count, or serum antibody tests are not diagnostic for celiac disease. Transl Res 2013. [PMID: 23177794 DOI: 10.1016/j.trsl.2012.10.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The existence of mild forms of celiac disease (CD) can make the histology-based diagnosis difficult to reach. Since anti-endomysium (EMA) and anti-tissue transglutaminase (anti-tTG) are detectable in culture supernatants of duodenal biopsies from CD patients, our aim was to assess if this system can support the histology in the diagnostic work-up. A total of 559 suspected CD patients underwent serum EMA/anti-tTG detection, upper endoscopy with duodenal biopsy sampling, histologic analysis, and organ culture to detect EMA/anti-tTG in supernatants. A subgroup of 30 patients with organ culture positive results were put on a gluten-free diet (GFD). Their gluten-dependency was evaluated by the psychological general well-being and beck depression inventory indexes. Statistical analysis was performed by Cohen k inter-test, Friedman test, and Dunn multiple comparison. Two hundred forty-one out of 559 (43.1%) patients showed intestinal villous atrophy, whereas serum and organ culture EMA/anti-tTG were positive in 293/559 (52.4%) and 334/559 (59.7%) patients, respectively. The strength of agreement resulted good for serology vs histology (k = 0.730), good for organ culture vs histology (k = 0.662), and very good for serology vs organ culture (k = 0.852). After 12 months of GFD, psychological general well-being index significantly increased, and beck depression inventory index significantly decreased (P < 0.001 for each one). Data highlight the organ culture system as a useful tool to assist the histology in diagnosing CD, mainly in cases without villous atrophy or in seronegative patients. The marked improvement in quality of life after a GFD further supports the reliability of this system in diagnosing CD.
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Affiliation(s)
- Antonio Picarelli
- Department of Internal Medicine and Medical Specialties, Sapienza University, 00161 Rome, Italy.
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Ludvigsson JF, Murray JA, Adams PC, Elmberg M. Does hemochromatosis predispose to celiac disease? A study of 29,096 celiac disease patients. Scand J Gastroenterol 2013; 48:176-82. [PMID: 23256862 PMCID: PMC3576703 DOI: 10.3109/00365521.2012.749511] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Case reports suggest an association between hereditary hemochromatosis (HH) and celiac disease (CD), but estimates of association are lacking. We estimated the association between HH and CD in a population-based study. MATERIAL AND METHODS Case-control study. We identified 29,096 individuals with biopsy-verified CD (equal to villous atrophy, Marsh stage III) through biopsy reports from all 28 pathology departments in Sweden. We then investigated the risk of a clinical diagnosis of HH in CD and in 144,522 controls matched for age, sex, county and calendar year. Conditional logistic regression was used to calculate odds ratios (ORs) for CD in patients with HH. RESULTS HH was seen in 30 patients with CD and in 60 matched controls. HH was hence associated with an increased risk of CD (OR = 2.30; 95% CI = 1.53-3.45). Restricting HH to individuals with at least two records of HH, the OR for CD was 2.54 (95% CI = 1.57-4.11), with a similar risk estimate when we only looked at HH diagnosed before CD (and matched date in controls) (OR = 2.64; 95% CI = 1.24-5.60). CONCLUSION HH seems to be associated with an increased risk of CD.
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Affiliation(s)
- Jonas F Ludvigsson
- Department of Paediatrics, Örebro University Hospital, Sweden,Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden,Division of Gastroenterology and Hepatology, Departments of Medicine and Immunology, Mayo Clinic College of Medicine, Rochester, USA
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Departments of Medicine and Immunology, Mayo Clinic College of Medicine, Rochester, USA
| | - Paul C Adams
- Division of Gastroenterology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Maria Elmberg
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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Ludvigsson JF, Leffler DA, Bai J, Biagi F, Fasano A, Green PHR, Hadjivassiliou M, Kaukinen K, Kelly C, Leonard JN, Lundin KE, Murray JA, Sanders DS, Walker MM, Zingone F, Ciacci C. The Oslo definitions for coeliac disease and related terms. Gut 2013; 62:43-52. [PMID: 22345659 PMCID: PMC3440559 DOI: 10.1136/gutjnl-2011-301346] [Citation(s) in RCA: 1032] [Impact Index Per Article: 93.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The literature suggests a lack of consensus on the use of terms related to coeliac disease (CD) and gluten. DESIGN A multidisciplinary task force of 16 physicians from seven countries used the electronic database PubMed to review the literature for CD-related terms up to January 2011. Teams of physicians then suggested a definition for each term, followed by feedback of these definitions through a web survey on definitions, discussions during a meeting in Oslo and phone conferences. In addition to 'CD', the following descriptors of CD were evaluated (in alphabetical order): asymptomatic, atypical, classical, latent, non-classical, overt, paediatric classical, potential, refractory, silent, subclinical, symptomatic, typical, CD serology, CD autoimmunity, genetically at risk of CD, dermatitis herpetiformis, gluten, gluten ataxia, gluten intolerance, gluten sensitivity and gliadin-specific antibodies. RESULTS CD was defined as 'a chronic small intestinal immune-mediated enteropathy precipitated by exposure to dietary gluten in genetically predisposed individuals'. Classical CD was defined as 'CD presenting with signs and symptoms of malabsorption. Diarrhoea, steatorrhoea, weight loss or growth failure is required.' 'Gluten-related disorders' is the suggested umbrella term for all diseases triggered by gluten and the term gluten intolerance should not to be used. Other definitions are presented in the paper. CONCLUSION This paper presents the Oslo definitions for CD-related terms.
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Affiliation(s)
- Jonas F Ludvigsson
- Department of Paediatrics, Örebro University Hospital, 701 85 Örebro, Sweden and Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Daniel A Leffler
- Correspondence and reprint requests: Daniel A Leffler, Division of Gastroenterology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA,
| | - Julio Bai
- Department of Medicine, Dr C. Bonorino Udaondo Gastroenterology Hospital. Del Salvador University, Buenos Aires, (1264) Argentina
| | - Federico Biagi
- Coeliac Centre/1st Dept. of Internal Medicine, University of Pavia, Fondazione IRCCS Policlinico San Matteo, P.le Golgi, 19, Pavia, 27100 Italy
| | - Alessio Fasano
- Center for Coeliac Research University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Peter HR Green
- MD Coeliac Disease center at Columbia University, New York, NY, 10032, USA
| | | | - Katri Kaukinen
- School of Medicine, FIN-33014 University of Tampere, Finland
| | - Ciaran Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Jonathan N Leonard
- Department of Dermatology, Imperial College NHS Healthcare Trust, St Mary’s Hospital, London W2 1NY, UK
| | - Knut E Lundin
- Dept of Gastroenterology and Centre for Immune Regulation, Oslo University Hospital, 0027 Oslo, Norway
| | | | - David S Sanders
- Gastroenterology and Liver Unit, Royal Hallamshire Hospital & University of Sheffield, Sheffield, 2JF UK
| | - Marjorie M Walker
- Centre for Pathology, Faculty of Medicine, Imperial College, St Mary’s Hospital, London W2 1NY, UK
| | - Fabiana Zingone
- Department of Clinical and Experimental Medicine, Federico II University of Naples, Naples, 80131, Italy
| | - Carolina Ciacci
- Chair of Gastroenterology, University of Salerno, Salerno, 84084 Italy
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