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Youssef EM, Wu GY. Subnormal Serum Liver Enzyme Levels: A Review of Pathophysiology and Clinical Significance. J Clin Transl Hepatol 2024; 12:428-435. [PMID: 38638374 PMCID: PMC11022067 DOI: 10.14218/jcth.2023.00446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/09/2024] [Accepted: 02/18/2024] [Indexed: 04/20/2024] Open
Abstract
Subnormal levels of liver enzymes, below the lower limit of normal on local laboratory reports, can be useful diagnostically. For instance, subnormal levels of aminotransferases can be observed in vitamin B6 deficiency and chronic kidney disease. Subnormal alkaline phosphatase levels may indicate the presence of hypophosphatasia, Wilson's disease, deficiencies of divalent ions, or malnutrition. Subnormal levels of gamma glutamyl transferase may be seen in cases of acute intrahepatic cholestasis, the use of certain medications, and in bone disease. Finally, subnormal levels of 5'-nucleotidase have been reported in lead poisoning and nonspherocytic hemolytic anemia. The aim of this review is to bring attention to the fact that subnormal levels of these enzymes should not be ignored as they may indicate pathological conditions and provide a means of early diagnosis.
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Affiliation(s)
| | - George Y. Wu
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
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Qureshi MH. The Correlation Between Serum Anti-tissue Transglutaminase (Anti-tTG) Antibody Levels and Histological Severity of Celiac Disease in Adolescents and Adults: A Meta-Analysis. Cureus 2023; 15:e51169. [PMID: 38283435 PMCID: PMC10814693 DOI: 10.7759/cureus.51169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2023] [Indexed: 01/30/2024] Open
Abstract
Celiac disease is an autoimmune disorder characterized by a broad spectrum of histological damage to the intestinal mucosa. Comprehension and understanding of the association between anti-tissue transglutaminase (anti-tTG) antibody levels and the histological severity of celiac disease are not well established, prompting the need for meta-analysis. This study aims to offer insights into the diagnostic abilities of anti-tTG antibody levels in determining the histological severity of celiac disease by providing quantitative evidence based on a diverse range of studies. An extensive search was conducted across four electronic research databases to identify primary research articles reporting serum anti-tTG antibody levels in correlation with different Marsh grades, signifying the histological severity of celiac disease. The software tool RevMan 5.4 (the Cochrane Collaboration, London, UK) was used to compile standardized mean differences (SMD) alongside their respective confidence intervals. A total of 13 studies were included in the meta-analysis, with a patient pool of 2505 patients. Marsh grade I and II were found to have higher anti-tTG antibody levels compared to those with grade 0 (SMD 1.50; 95% CI: 1.12, 1.87; p-value <0.00001). Antibody levels were higher in Marsh grade IIIa when compared to both grade 0 (SMD 0.97; 95% CI: 0.67, 1.28; p-value <0.00001) and grade ≤2 (SMD 0.61; 95% CI: 0.44, 0.79; p-value <0.00001). Patients with Marsh IIIb also reported greater anti-tTG levels compared to grade 0 (SMD 1.48; 95% CI: 0.99, 1.96; p-value <0.00001) and grade ≤2 (SMD 0.98; 95% CI: 0.79, 1.18; p-value <0.00001). Likewise, Marsh grade ≥IIIc reported high levels of anti-tTG antibodies in comparison with grade 0 (SMD 1.06; 95% CI: 0.72, 1.39; p-value <0.00001) and grade ≤2 (SMD 1.18; 95% CI: 1.02, 1.34; p-value <0.00001). Our meta-analysis revealed a consistent, robust correlation between anti-tTG antibody levels and the histological severity of celiac disease, with a clear trend of increasing antibody levels corresponding to the severity of mucosal damage. Large-scale primary research initiatives are needed to reach definitive conclusions.
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Affiliation(s)
- Muhammad Hassan Qureshi
- Medicine, Combined Military Hospital, Lahore, PAK
- Health, Medicine, and Social Care, Anglia Ruskin University, Cambridge, GBR
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Khan AS, Albaqshi BM, Alismael AM, Bohamad AH, Almutawah AA, Alabdellah AH, Almajed AS, Almajed AS, Almajed AS. The Role of Physicians' Factors in Underdiagnosis of Celiac Disease in the Eastern Province of Saudi Arabia. Cureus 2023; 15:e44690. [PMID: 37809243 PMCID: PMC10551662 DOI: 10.7759/cureus.44690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/10/2023] Open
Abstract
Background Celiac disease is an autoimmune disorder triggered by gluten and related prolamines, which can cause a variety of symptoms and complications if left untreated. Despite being a common lifelong disorder, it often goes undiagnosed for a long time, leading to negative impacts on patients' health and quality of life. The diagnosis of celiac disease requires the presence of celiac-specific autoantibodies and distinctive histological changes in the small intestinal mucosa. Lack of disease knowledge among healthcare professionals and patients' adherence to gluten-free diets may contribute to diagnostic delays. Objectives This study aims to assess the reasons for celiac disease underdiagnosis and identify the functional deficiencies of healthcare professionals in the diagnosis and treatment of celiac disease, particularly in the Saudi population. Materials and methods A cross-sectional, questionnaire-based study was conducted among physicians in the Eastern Province of Saudi Arabia during the year 2023, between May and July. Participants were asked to complete an online self-administered questionnaire that included questions about their demographic characteristics, professional experience, and knowledge and attitudes toward celiac disease. The study recruited gastroenterologists, gastroenterology fellows, internal and family medicine specialists, residents, and general practitioners working in private or public health centers in various cities of the Eastern Province. Results The data were collected from 180 physicians who fulfilled the inclusion criteria of the study, with most participants aged under 30 years and predominantly male. Family medicine and general practitioners were the most represented specialties. While 49.4% of physicians knew that adult celiac disease was rare, only 19.4% frequently recommended celiac disease serology to their patients. In terms of risk, most physicians knew that adult celiac disease was a moderately severe and disabling disease, but only 24.4% thought that the cancer risk in patients with celiac disease was moderate. About 75.6% of physicians had an overall poor knowledge level regarding celiac disease, with gastroenterologists and internal medicine specialists demonstrating better knowledge compared to other specialties (P = 0.001). Conclusion The study found that a majority of physicians in the Eastern Province of Saudi Arabia had poor knowledge about celiac disease. This lack of knowledge could have implications for patient care, as it could lead to delays in diagnosis, inadequate treatment, and increased risk of complications.
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Affiliation(s)
- Abdul Sattar Khan
- Family and Community Medicine Department, King Faisal University, Al-Ahsa, SAU
| | - Baqer M Albaqshi
- Family and Community Medicine Department, King Faisal University, Al-Ahsa, SAU
| | - Ali M Alismael
- Family and Community Medicine Department, King Faisal University, Al-Ahsa, SAU
| | | | - Ahmed A Almutawah
- Family and Community Medicine Department, King Faisal University, Al-Ahsa, SAU
| | - Ali H Alabdellah
- Family and Community Medicine Department, King Faisal University, Al-Ahsa, SAU
| | - Alhwraa S Almajed
- Family and Community Medicine Department, King Faisal University, Al-Ahsa, SAU
| | - Abdullah S Almajed
- Family and Community Medicine Department, King Faisal University, Al-Ahsa, SAU
| | - Adnan S Almajed
- Family and Community Medicine Department, King Faisal University, Al-Ahsa, SAU
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Qasem WA, Roumi AA, Al Mojil K, Sakijha H, AlMughamis N. Awareness of celiac disease among the public in Kuwait: a cross-sectional survey. BMC Res Notes 2023; 16:133. [PMID: 37400855 DOI: 10.1186/s13104-023-06415-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 06/20/2023] [Indexed: 07/05/2023] Open
Abstract
OBJECTIVE Health literacy levels among the general population predict better health outcomes and uptake of health services. Inequities in health literacy and uptake of health services are often observed in deprived neighborhoods. There is a paucity of data on literacy regarding celiac disease in Kuwait. Therefore, the present survey aims to address this paucity of data. RESULTS We conducted a survey of 350 respondents in six governates of Kuwait. Although around 51% of respondents were aware of peanut allergy and gluten sensitivity, less than 15% were aware of celiac disease. More than 40% of respondents reported that a gluten-free diet should be promoted for everyone. Better awareness regarding CD was associated with Kuwaiti nationality, higher education levels and higher age. Among different governates, residents of Al-Asimah reported the highest awareness levels, while the rest of the governates did not differ significantly. While eating behavior did not significantly predict awareness regarding CD.
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Affiliation(s)
| | - Ali Al Roumi
- Kuwait University Medical School, Safat, 13110, Kuwait
| | | | - Hind Sakijha
- Wazin Telehealth, Kuwait City, Al Asimah, Kuwait
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Muacevic A, Adler JR, Doğan AE, Özdener F. Factors Affecting Prognosis in the Course of Pediatric Celiac Disease. Cureus 2022; 14:e32208. [PMID: 36620822 PMCID: PMC9812003 DOI: 10.7759/cureus.32208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2022] [Indexed: 12/09/2022] Open
Abstract
Introduction Celiac disease (CD) is a rather frequent chronic autoimmune disease that causes impaired growth in children. The present study aims to evaluate patients' condition after diagnosis cross-sectionally and determine the factors affecting prognosis. Methods Control visits were performed at the end of the 13-month intervention period. The study was designed as a single-center retrospective study and included patients diagnosed with CD. The study cohort consisted of 211 patients aged 1 to 18 years. Statistical parameters include Helicobacter positivity, Marsh classification; economic status; and body mass index (BMI) z-score, weight z-score, and height z-score to observe the difference between admission and follow-up. Results Treatment adherence is one of the most critical factors influencing improvement in developmental parameters during control visits (p<0.033). It was observed that the weight z-scores at the control visit deteriorated significantly with a longer duration of complaints (p=0.033). Better improvement of control visit BMI z-scores among patients with complaints compared to asymptomatic patients (p=0.036) indicate the importance of early diagnosis in asymptomatic cases. Developmental parameters of patients with CD without growth retardation (GR) show faster improvement compared to patients with GR (p<0.001). Families with good socioeconomic status can easily adapt to the diet by reaching a greater variety of gluten-free products, so anthropometric measurements are observed to be significantly higher at the control visit (p<0.002). Conclusions Treatment adherence is the most critical factor for improvement in CD treatment, as in all treatments. In addition, the investigation of suspected, additional disease symptoms during the follow-up of a CD patient is also of great importance for early diagnosis. The importance of early diagnosis has been emphasized in terms of anthropometric improvement in asymptomatic CD cases.
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Mansour HH, Mohsen NA, El-Shabrawi MHF, Awad SM, Abd El-Kareem D. Serologic, endoscopic and pathologic findings in pediatric celiac disease: A single center experience in a low/middle income country. World J Clin Pediatr 2022; 11:296-307. [DOI: 10.5409/wjcp.v11.i3.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Mansour HH, Mohsen NA, El-Shabrawi MHF, Awad SM, Abd El-Kareem D. Serologic, endoscopic and pathologic findings in pediatric celiac disease: A single center experience in a low/middle income country. World J Clin Pediatr 2022; 11:295-306. [PMID: 35663003 PMCID: PMC9134153 DOI: 10.5409/wjcp.v11.i3.295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/25/2021] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Studies in Africa, Asia, and Latin America are needed to provide a comprehensive picture of the global incidence of celiac disease (CD).
AIM To describe the serology, endoscopic and histological findings in typical and atypical presentations of pediatric CD at a tertiary referral hospital in an African low/middle income country (LMIC).
METHODS This observational study was conducted on 199 patients with CD from 2010 to 2019. The patients were divided into typical and atypical groups according to the presenting symptoms including 120 and 79 patients respectively. Serology, upper gastrointestinal endoscopy with duodenal biopsy were performed for patients who had symptoms suggestive of CD. The severity of the intestinal damage was graded according to the histo-pathologic Marsh-Oberhuber classification.
RESULTS Chronic diarrhea was the main intestinal presentation in the typical group. Anemia was the most common extraintestinal symptom in both the typical and atypical group. Marsh-Oberhuber type 3b and 3c was significantly higher in the seropositive patients with a P value of 0.007. A significant correlation was observed between the histological grade of the biopsied duodenal mucosa and the clinical presentation (P < 0.001). Age was significantly higher in the atypical group (P value < 0.001).
CONCLUSION Although typical CD was observed in 120 patients in this study, the clinical variability of the condition was frequently observed. Age only was a significant predictor for the appearance of atypical CD. Therefore, CD presentations in LMIC are not different from industrialized countries.
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Affiliation(s)
- Hala H Mansour
- Department of Pediatrics, Faculty of Medicine Kasr Al Ainy, Cairo University, Cairo 12411, Egypt
| | - Nabil A Mohsen
- Department of Pediatrics, Faculty of Medicine Kasr Al Ainy, Cairo University, Cairo 12411, Egypt
| | - Mortada HF El-Shabrawi
- Department of Pediatrics, Faculty of Medicine Kasr Al Ainy, Cairo University, Cairo 12411, Egypt
| | - Somia M Awad
- Department of Pediatrics, Faculty of Medicine Kasr Al Ainy, Cairo University, Cairo 12411, Egypt
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Bommu VJL, Mirza L. Osteoporosis Can Be the Sole Presentation in Celiac Disease. Cureus 2021; 13:e20602. [PMID: 35103178 PMCID: PMC8780933 DOI: 10.7759/cureus.20602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 11/07/2022] Open
Abstract
Celiac disease, an autoimmune condition causing gluten intolerance and disrupted absorption of nutrients, predisposes to osteoporosis. The release of pro-inflammatory cytokines, calcium malabsorption, and the activation of osteoclasts represent the main mechanisms responsible for bone derangement. This is evidenced by the low T-score on dual-energy x-ray absorptiometry (DXA) scans in these patients. However, these changes are reversible with the early initiation of a gluten-free diet. Hence, it is important for physicians to consider screening for celiac disease panel in patients presenting with osteoporotic features with no clear etiology.
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Gottschick C, Raupach-Rosin H, Langer S, Hassan L, Horn J, Dorendorf E, Caputo M, Bittner M, Beier L, Rübsamen N, Schlinkmann K, Zoch B, Guzman CA, Hansen G, Heselich V, Holzapfel E, Hübner J, Pietschmann T, Pieper DH, Pletz M, Riese P, Schmidt-Pokrzywniak A, Hartwig S, von Kaisenberg C, Aydogdu M, Buhles M, Dressler F, Eberl W, Haase R, Edler von Koch F, Feidicker S, Frambach T, Franz HGB, Guthmann F, Koch HG, Seeger S, Oberhoff C, Pauker W, Petry KU, Schild RL, Tchirikov M, Röhrig E, Karch A, Mikolajczyk R. Cohort Profile: The LoewenKIDS Study - life-course perspective on infections, the microbiome and the development of the immune system in early childhood. Int J Epidemiol 2020; 48:1042-1043h. [PMID: 30815674 PMCID: PMC7108547 DOI: 10.1093/ije/dyz001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2019] [Indexed: 12/26/2022] Open
Affiliation(s)
- Cornelia Gottschick
- Institut of Medical Epidemiology, Biometry and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | | | - Susan Langer
- Institut of Medical Epidemiology, Biometry and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Lamiaa Hassan
- Institut of Medical Epidemiology, Biometry and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Johannes Horn
- Institut of Medical Epidemiology, Biometry and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | | | | | | | - Lea Beier
- Research Group Epidemiological and Statistical Methods
| | | | | | - Beate Zoch
- Research Group Epidemiological and Statistical Methods
| | - Carlos A Guzman
- Department Vaccinology and Applied Microbiology, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Gesine Hansen
- Department of Pediatric Pulmonology, Allergology and Neonatology, Hanover Medical School, Hanover, Germany
| | - Valerie Heselich
- Department of Paediatrics, Dr. von Hauner Children's Hospital, Ludwig- Maximilians-University Munich, Germany
| | - Eva Holzapfel
- Department of Paediatrics, Dr. von Hauner Children's Hospital, Ludwig- Maximilians-University Munich, Germany
| | - Johannes Hübner
- Department of Paediatrics, Dr. von Hauner Children's Hospital, Ludwig- Maximilians-University Munich, Germany
| | - Thomas Pietschmann
- Institute of Experimental Virology, TWINCORE, Centre for Experimental and Clinical Infection Research; a joint venture between the Medical School Hannover (MHH) and the Helmholtz Centre for Infection Research (HZI), Hannover, Germany
| | - Dietmar H Pieper
- Research Group Microbial Interactions and Processes, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Mathias Pletz
- Institute for Infectious Diseases and Infection Control, University Hospital Jena, Germany
| | - Peggy Riese
- Department Vaccinology and Applied Microbiology, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Andrea Schmidt-Pokrzywniak
- Institut of Medical Epidemiology, Biometry and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Saskia Hartwig
- Institut of Medical Epidemiology, Biometry and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Constantin von Kaisenberg
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hanover Medical School, Hanover, Germany
| | - Mustafa Aydogdu
- Department of Gynecology, Gyneoncology and Senology, Klinikum Bremen-Mitte, Bremen, Germany
| | - Matthias Buhles
- Department of Gynecology and Obstetrics, Community Hospital Wolfenbüttel, Germany
| | - Frank Dressler
- Department of Pediatric Pulmonology, Allergology and Neonatology, Hanover Medical School, Hanover, Germany
| | - Wolfgang Eberl
- Department of Paediatrics, Hospital Braunschweig, Germany
| | - Roland Haase
- Section for Neonatology and Pediatric Intensive Care, University Hospital Halle (Saale), Germany
| | - Franz Edler von Koch
- Department of Gynecology and Obstetrics, Hospital Dritter Orden, Munich-Nymphenburg, Germany
| | - Susanne Feidicker
- Department of Gynecology and Obstetrics, Diaconical Hospital DIAKO Ev., Bremen, Germany
| | - Torsten Frambach
- Department of Gynecology and Obstetrics, Hospital St. Joseph Stift Bremen, Germany
| | - Heiko G B Franz
- Department of Gynecology and Obstetrics, Hospital Braunschweig, Germany
| | - Florian Guthmann
- Department of Neonatology, Children and Youth Hospital AUF DER BULT, Hanover, Germany
| | - Hans G Koch
- Department of Paediatrics, Hospital Braunschweig, Germany
| | - Sven Seeger
- Department of Gynecology and Obstetrics, Hospital St. Elisabeth und St. Barbara, Halle (Saale), Germany
| | - Carsten Oberhoff
- Department of Gynecology and Obstetrics, Klinikum Links der Weser, Bremen, Germany
| | - Wladimir Pauker
- Department of Gynecology and Obstetrics, Klinikum Bremen-Nord, Bremen, Germany
| | - Karl U Petry
- Department of Gynecology and Obstetrics, Hospital Wolfsburg, Germany
| | - Ralf L Schild
- Department of Obstetrics and Perinatal Medicine, DIAKOVERE Henriettenstift Hanover, Germany
| | - Michael Tchirikov
- University Clinic and Outpatient Clinic for Obstetrics and Prenatal Medicine, Halle (Saale), Germany
| | - Eckhard Röhrig
- Department of Obstetrics, Dr. Geisenhofer Women's Clinic, Munich, Germany
| | - André Karch
- Research Group Epidemiological and Statistical Methods.,Department of Clinical Epidemiology, Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - Rafael Mikolajczyk
- Institut of Medical Epidemiology, Biometry and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany.,Research Group Epidemiological and Statistical Methods
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Campagna G, Tatangelo R, La Fratta I, Rizzuto A, Ballerini P, Cocco D, Savi S, Rotunno A, Rotunno PF, Speranza L, Franceschelli S, Grilli A, Pesce M. Insights in the Evaluation of Gluten Dietary Avoidance in Healthy Subjects. J Am Coll Nutr 2019; 39:178-186. [PMID: 31393225 DOI: 10.1080/07315724.2019.1631902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: The amount of healthy subjects adopting a gluten-free diet (GFD) for nonmedical reasons actually surpasses the numbers of those who are dealing with a permanent gluten-related disorder.Objective: The study aimed to better clarify the interactions between a GFD and physical and psychological well-being.Methods: Sixty healthy subjects with normal weight were enrolled. Thirty subjects (15 female) were submitted to a normocaloric GFD and considered as the experimental group (EG), and 30 subjects (15 female) were submitted to a normocaloric diet (CG) for 6 months. The hematochemical and psychological parameters before and after the diet were recorded.Results: Significant improvement was demonstrated in red blood count, hemoglobin, total cholesterol, and high-density lipoprotein parameters in the EG after the gluten-free diet. However, a significant increase of α-amylase pancreatic activity and reduction of vitamin B12 and magnesium levels in the EG were observed. Regarding the psychological parameters, the GFD significantly improved scores assessing body satisfaction, but increased social insecurity.Conclusions: The study is the first to consider significant modulation in hematochemical parameters as well as psychological ones by gluten avoidance in healthy individuals. Although these subjects were not characterized by intestinal mucosa damage, some of the effects were similar to those observed in celiac disease patients who began to adhere to a GFD.
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Affiliation(s)
- Giovanna Campagna
- School of Medicine and Health Science, University "G. d'Annunzio," Chieti, Italy
| | - Raffaella Tatangelo
- School of Medicine and Health Science, University "G. d'Annunzio," Chieti, Italy
| | - Irene La Fratta
- School of Medicine and Health Science, University "G. d'Annunzio," Chieti, Italy
| | - Alessia Rizzuto
- School of Medicine and Health Science, University "G. d'Annunzio," Chieti, Italy
| | - Patrizia Ballerini
- School of Medicine and Health Science, University "G. d'Annunzio," Chieti, Italy
| | - Domenico Cocco
- School of Medicine and Health Science, University "G. d'Annunzio," Chieti, Italy
| | - Samuele Savi
- School of Medicine and Health Science, University "G. d'Annunzio," Chieti, Italy
| | - Antonio Rotunno
- School of Medicine and Health Science, University "G. d'Annunzio," Chieti, Italy
| | - Pietro Falco Rotunno
- School of Medicine and Health Science, University "G. d'Annunzio," Chieti, Italy
| | - Lorenza Speranza
- School of Medicine and Health Science, University "G. d'Annunzio," Chieti, Italy
| | - Sara Franceschelli
- School of Medicine and Health Science, University "G. d'Annunzio," Chieti, Italy
| | - Alfredo Grilli
- School of Medicine and Health Science, University "G. d'Annunzio," Chieti, Italy
| | - Mirko Pesce
- School of Medicine and Health Science, University "G. d'Annunzio," Chieti, Italy
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Mohammadibakhsh R, Sohrabi R, Salemi M, Mirghaed MT, Behzadifar M. Celiac disease in Iran: a systematic review and meta-analysis. Electron Physician 2017; 9:3883-3895. [PMID: 28461861 PMCID: PMC5407219 DOI: 10.19082/3883] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 01/21/2017] [Indexed: 01/13/2023] Open
Abstract
Introduction Celiac disease (CD) is a chronic autoimmune-mediated disorder with both intestinal and systemic manifestations. The aim of this study was to determine the prevalence of celiac disease in Iran. Methods We conducted a systematic search on Embase, Pub Med, Web of Science, Google Scholar, MagIran, Scientific Information database (SID) and Iranmedex from 2003 through to November 2015. The Der-Simonian/Laird’s (DL), with a 95% confidence interval employed to estimate the overall pooled prevalence. Heterogeneity was investigated by using subgroup analysis based on sample size and time of study. Results Sixty-three studies with 36,833 participants met inclusion criteria for analysis. The overall prevalence of celiac disease in 63 studies that had used serological tests for the diagnosis was observed as 3% (95% CI: 0.03–0.03) and the overall prevalence of celiac disease in studies that had used biopsy method for diagnosis was observed as 2% (95% CI: 0.01–0.02). Conclusion The prevalence of celiac disease in Iran was similar or even higher than world-wide reported.
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Affiliation(s)
| | - Rahim Sohrabi
- Ph.D. Student of Health Policy, Iranian Social Security Organization, Zanjan Province Health Administration, Zanjan, Iran
| | - Morteza Salemi
- Ph.D. Student of Health Policy, Social Determinants in Health Promotion Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Masood Taheri Mirghaed
- Ph.D. Student of Health Policy, Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Masoud Behzadifar
- Ph.D. Student of Health Policy, Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
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Laass MW, Schmitz R, Uhlig HH, Zimmer KP, Thamm M, Koletzko S. The prevalence of celiac disease in children and adolescents in Germany. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 112:553-60. [PMID: 26356552 DOI: 10.3238/arztebl.2015.0553] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 07/02/2015] [Accepted: 07/02/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Untreated celiac disease is associated with increased morbidity and mortality. Until now, no up-to-date figures have been available on the prevalence of celiac disease among children and adolescents in Germany, or on the percentage of undiagnosed cases. METHODS To estimate the prevalence of celiac disease, serum samples obtained from 2003 to 2006 from participants in the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) were studied for celiac disease-specific autoantibodies and total IgA. RESULTS Of the 12 741 study participants aged 1 to 17 years (6546 boys, 6195 girls), 9 (0.07%) had a reported history of celiac disease. An elevated concentration of serum autoantibodies to tissue transglutaminase was found in 91 children with a normal IgA concentration and in 7 with IgA deficiency. The prevalence of undiagnosed celiac disease, based on positive autoantibody findings, was 0.8% (95% confidence interval 0.6-1.0%), and the overall prevalence of the disease was 0.9%. Seropositive children and adolescents had lower ferritin and red blood cell folate concentrations than seronegative ones; they also tended to be shorter and to weigh less as reflected by age- and sex-standardized z-scores. CONCLUSION The 0.9% prevalence of celiac disease in Germany, as determined from a combination of serological findings and clinical histories, is similar to reported prevalences elsewhere in Europe and North America. Pediatricians, primary care physicians, internists, and other specialists should be aware of the broad spectrum of clinical manifestations of this disease. Children who have symptoms suggestive of celiac disease or belong to a group at risk for it should be tested for antibodies against tissue transglutaminase, as should symptomatic adults after the exclusion of other possible causes. It is not yet clear whether asymptomatic adults from high-risk groups should be tested.
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Affiliation(s)
- Martin W Laass
- Institute and Outpatient Clinics of Pediatric and Adolescent Medicine, University Hospital Carl Gustav Carus, Dresden, Department of Epidemiology and Health Monitoring of the Robert Koch Institute, Berlin, Translational Gastroenterology Unit and Department of Pediatrics, John Radcliffe Hospital, Oxford, United Kingdom, Department of General Pediatrics and Neonatology, Center for Pediatric and Adolescent Care, Justus Liebig University, Gießen, Epidemiology Laboratory, Department of Epidemiology and Health Monitoring of the Robert Koch Institute, Berlin, Dr von Hauner Children's Hospital, Campus Innenstadt, Ludwig-Maximilians-Universität München
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Palman J, May J, Pilkington C. Macrophage activation syndrome triggered by coeliac disease: a unique case report. Pediatr Rheumatol Online J 2016; 14:66. [PMID: 27938384 PMCID: PMC5148910 DOI: 10.1186/s12969-016-0128-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 12/02/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Macrophage activation syndrome is described as a "clinical syndrome of hyperinflammation resulting in an uncontrolled and ineffective immune response" in the context of an autoinflammatory or rheumatic disease. Current associations of macrophage activation syndrome with autoimmune disease most notably include a host of rheumatological conditions and inflammatory bowel disease. Epidemiological studies have shown that macrophage activation syndrome is precipitated by autoimmune disease more commonly than previously thought. Diagnosing the precipitating factor is essential for effective treatment and prognosis. CASE PRESENTATION We report a case of a six year old girl with coeliac disease diagnosed after two episodes of secondary haemophagocytic lymphohistiocytosis. Her condition only responded to treatment once the patient was placed on a gluten free diet. Further immunological testing confirmed anti-transglutaminase and anti-endomysial antibodies, however histological biopsy was deemed inappropriate due to the severity of her condition. She has remained stable with no further episodes of macrophage activation syndrome since commencing a gluten free diet. CONCLUSION This case report is the first literature that links macrophage activation syndrome to coeliac disease and highlights the challenge of diagnosing coeliac disease with unusual features such as associated prolonged fever. Clinicians should have a low threshold for screening children with other autoimmune diseases for coeliac disease.
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Affiliation(s)
- J. Palman
- University College London Great Ormond Street Institute of Child Health, London, UK
| | - J. May
- Great Ormond Street Hospital, London, UK
| | - C. Pilkington
- University College London Great Ormond Street Institute of Child Health, London, UK ,Great Ormond Street Hospital, London, UK
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Abstract
Bullous autoimmune diseases are organ-specific disorders characterized by an autoantibody-mediated blistering of skin and mucous membranes. The detection of tissue-bound and serum autoantibodies is prerequisite for the diagnosis of autoimmune blistering diseases. The individual entities of this group may be difficult to differentiate on clinical grounds alone. An accurate diagnosis is however important for prognosis and therapy. A preliminary diagnostic step includes direct and indirect immunofluorescence microscopy, which provide information about the binding pattern and isotype of autoantibodies and allow the diagnosis of the autoimmune blistering disease. Subsequent characterization of the molecular specificity of autoantibodies is necessary for the exact classification of autoimmune bullous dermatoses. The quantitative measurement of autoantibodies against structural proteins of the skin may be often used to assess disease severity at follow-up.
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Affiliation(s)
- K Hoffmann
- Klinik für Dermatologie und Venerologie, Universitätsklinikum Freiburg, Hauptstraße 7, 79104, Freiburg, Deutschland
| | - M Hertl
- Klinik für Dermatologie und Allergologie, Universitätsklinikum Marburg, Baldingerstraße, 35043, Marburg, Deutschland
| | - C Sitaru
- Klinik für Dermatologie und Venerologie, Universitätsklinikum Freiburg, Hauptstraße 7, 79104, Freiburg, Deutschland. .,MVZ Labor Clotten, Merzhauserstr. 112A, 79100, Freiburg, Deutschland.
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Celiac disease: understanding the gluten-free diet. Eur J Nutr 2016; 56:449-459. [DOI: 10.1007/s00394-016-1238-5] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 05/27/2016] [Indexed: 12/15/2022]
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Stein J, Schuppan D. Coeliac Disease - New Pathophysiological Findings and Their Implications for Therapy. VISZERALMEDIZIN 2015; 30:156-65. [PMID: 26288589 PMCID: PMC4513807 DOI: 10.1159/000365099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Coeliac disease (CD) is one of the most common diseases worldwide, resulting from a combination of environmental (gluten) and genetic (human leucocyte antigen (HLA) and non-HLA genes) factors. Depending on the geographical location, the prevalence of CD has been estimated to approximate 0.5-1%. The only treatment currently available for CD is a gluten-free diet (GFD) excluding gluten-containing cereals such as wheat, rye, and barley, and other foodstuffs with natural or added gluten. However, adherence rates and patient acceptance are often poor. Moreover, even in fully adherent patients, the diet may fail to induce clinical or histological improvement. Hence, it is unsurprising that studies show CD patients to be highly interested in non-dietary alternatives. The following review focuses on current pathophysiological concepts of CD, spotlighting those pathways which may serve as new possible, non-dietary therapeutic targets in the treatment of CD.
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Affiliation(s)
- Jürgen Stein
- Department of Gastroenterology and Clinical Nutrition, Sachsenhausen Hospital, Teaching Hospital of the Goethe University Frankfurt, Germany ; Interdisciplinary Crohn Colitis Centre Rhein-Main, Frankfurt/M., Germany
| | - Detlef Schuppan
- Institute of Translational Immunology, University Medical Center, Hospital Mainz, Germany ; Division of Gastroenterology, Beth Israel deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Laass MW, Schmitz R, Uhlig HH, Zimmer KP, Thamm M, Koletzko S. The prevalence of celiac disease in children and adolescents in Germany. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015. [PMID: 26356552 DOI: 10.3238/arztebl.2015.0553.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Untreated celiac disease is associated with increased morbidity and mortality. Until now, no up-to-date figures have been available on the prevalence of celiac disease among children and adolescents in Germany, or on the percentage of undiagnosed cases. METHODS To estimate the prevalence of celiac disease, serum samples obtained from 2003 to 2006 from participants in the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) were studied for celiac disease-specific autoantibodies and total IgA. RESULTS Of the 12 741 study participants aged 1 to 17 years (6546 boys, 6195 girls), 9 (0.07%) had a reported history of celiac disease. An elevated concentration of serum autoantibodies to tissue transglutaminase was found in 91 children with a normal IgA concentration and in 7 with IgA deficiency. The prevalence of undiagnosed celiac disease, based on positive autoantibody findings, was 0.8% (95% confidence interval 0.6-1.0%), and the overall prevalence of the disease was 0.9%. Seropositive children and adolescents had lower ferritin and red blood cell folate concentrations than seronegative ones; they also tended to be shorter and to weigh less as reflected by age- and sex-standardized z-scores. CONCLUSION The 0.9% prevalence of celiac disease in Germany, as determined from a combination of serological findings and clinical histories, is similar to reported prevalences elsewhere in Europe and North America. Pediatricians, primary care physicians, internists, and other specialists should be aware of the broad spectrum of clinical manifestations of this disease. Children who have symptoms suggestive of celiac disease or belong to a group at risk for it should be tested for antibodies against tissue transglutaminase, as should symptomatic adults after the exclusion of other possible causes. It is not yet clear whether asymptomatic adults from high-risk groups should be tested.
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Affiliation(s)
- Martin W Laass
- Institute and Outpatient Clinics of Pediatric and Adolescent Medicine, University Hospital Carl Gustav Carus, Dresden, Department of Epidemiology and Health Monitoring of the Robert Koch Institute, Berlin, Translational Gastroenterology Unit and Department of Pediatrics, John Radcliffe Hospital, Oxford, United Kingdom, Department of General Pediatrics and Neonatology, Center for Pediatric and Adolescent Care, Justus Liebig University, Gießen, Epidemiology Laboratory, Department of Epidemiology and Health Monitoring of the Robert Koch Institute, Berlin, Dr von Hauner Children's Hospital, Campus Innenstadt, Ludwig-Maximilians-Universität München
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Theethira TG, Dennis M. Celiac disease and the gluten-free diet: consequences and recommendations for improvement. Dig Dis 2015; 33:175-182. [PMID: 25925920 DOI: 10.1159/000369504] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Celiac disease (CD) is a chronic small intestinal immune-mediated enteropathy precipitated by exposure to dietary gluten in genetically susceptible individuals. CD-related enteropathy leads to multiple nutritional deficiencies involving macro- and micronutrients. Currently, medical nutrition therapy consisting of the gluten-free diet (GFD) is the only accepted treatment for CD. KEY MESSAGES The GFD is the cornerstone of treatment for CD. Prior published studies have concluded that maintenance of the GFD results in improvement of the majority of nutritional deficiencies. In the past, counseling for CD focused mainly on the elimination of gluten in the diet. However, the GFD is not without its inadequacies; compliance to the GFD may result in certain deficiencies such as fiber, B vitamins, iron, and trace minerals. Paucity of fortified gluten-free foods may be responsible for certain deficiencies which develop on the GFD. Weight gain and obesity have been added to the list of nutritional consequences while on the GFD and have been partially attributed to hypercaloric content of commercially available gluten-free foods. Follow-up of patients diagnosed with CD after starting the GFD has been reported to be irregular and, hence, less than ideal. CONCLUSIONS Monitoring of the nutritional status using blood tests and use of appropriate gluten-free supplementation are integral components in the management of CD. The ideal GFD should be nutrient-dense with naturally gluten-free foods, balanced with macro- and micronutrients, reasonably priced, and easily accessible. Rotation of the pseudo-cereals provides a good source of complex carbohydrates, protein, fiber, fatty acids, vitamins and minerals. Fortification/enrichment of commonly consumed gluten-free commercial grain products should be encouraged. Dietitians specializing in CD play a critical role in the education and maintenance of the GFD for patients with CD.
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Tchidjou HK, De Matteis A, Di Iorio L, Finocchi A. Celiac Disease in an Adoptive Child with Recurrent Giardia Infection. Int J Health Sci (Qassim) 2015; 9:193-197. [PMID: 26309440 PMCID: PMC4538898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Abstract
Celiac disease (CD) is an inflammatory disease of the small intestine. A complete management and differential diagnosis of such disease includes food intolerances, intestinal infections, and irritable bowel syndrome. We describe an 8-years-old adoptive girl from Congo with negative medical history. Patient followed for recurrent abdominal pain and diarrhea associated to Giardia infection, unresponsive to antiparasitic therapy. Persistence of symptoms despite antiparasitic therapy, prompted us to perform: 1- Blood screening of Celiac disease, which was negative; 2- Genetic evaluation of celiac disease, which revealed the presence of HLA-DQ2 heterodimer; and 3- Esophagogastroduodenoscopy, which showed duodenal villous atrophy and crypt hyperplasia, associated with Helicobacter Pylori infection. The child was treated in accordance with international recommendations using a Gluten-free diet and specific antibiotics, which lead to the resolution of the symptoms. Our patient's clinical history seems peculiar, considering that, recurrent Giardiasis may mimic the symptoms of Celiac disease and may simulate clinical and histological picture of active Celiac disease. Early diagnosis may help prevent the complications of untreated celiac disease.
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Affiliation(s)
- Hyppolite K. Tchidjou
- University Department of Pediatrics (DPUO), Children’s Hospital Bambino Gesù, Rome, Italy
| | - Arianna De Matteis
- University Department of Pediatrics (DPUO), Children’s Hospital Bambino Gesù, Rome, Italy
| | - Laura Di Iorio
- University Department of Pediatrics (DPUO), Children’s Hospital Bambino Gesù, Rome, Italy
| | - Andrea Finocchi
- University Department of Pediatrics (DPUO), Children’s Hospital Bambino Gesù, Rome, Italy
- Chair of Pediatrics, University of Tor-Vergata, Rome, Italy
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Castillo NE, Theethira TG, Leffler DA. The present and the future in the diagnosis and management of celiac disease. Gastroenterol Rep (Oxf) 2015; 3:3-11. [PMID: 25326000 PMCID: PMC4324867 DOI: 10.1093/gastro/gou065] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 08/26/2014] [Indexed: 12/19/2022] Open
Abstract
Celiac disease is an autoimmune enteropathy caused by gluten in genetically predisposed individuals. In celiac disease, adaptive and innate immune activation results in intestinal damage and a wide range of clinical manifestations. In the past, celiac disease was thought to result in signs and symptoms solely related to the gastrointestinal tract. Now, more than half of the adult population presents with extra-intestinal manifestations that can also be expected to improve on a gluten-free diet. For this reason, it is recommended that physicians have a low threshold of suspicion for celiac disease. Current knowledge of the immune pathogenesis of this autoimmune disease has served as a catalyst for the development of novel diagnostic tools and therapeutics. Over the years, highly sensitive and specific serological assays, in addition to genetic markers, have been found to target specific steps in the cascade pathway of celiac disease. Also the advent of the gluten challenge has enabled experts to design diagnostic algorithms and monitor clinical responses in clinical trials. The gluten challenge has provided substantial benefit in the advance of novel therapeutics as an adjuvant treatment to the gluten free diet. Generally, a strict gluten-free diet is highly burdensome to patients and can be limited in its efficacy. Alternative therapies-including gluten modification, modulation of intestinal permeability and immune response-could be central to the future treatment of celiac disease.
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Affiliation(s)
- Natalia E Castillo
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Daniel A Leffler
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Alessiani M, Serra P, Zelaschi D, Gianola M. Diagnosis of coeliac disease after incidental finding of pneumatosis cystoides intestinalis. BMJ Case Rep 2014; 2014:bcr-2014-204823. [PMID: 24872496 DOI: 10.1136/bcr-2014-204823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Mario Alessiani
- Department of Surgery, Varzi Hospital, Varzi, Italy Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Piero Serra
- Department of Surgery, Varzi Hospital, Varzi, Italy
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Bürgin-Wolff A. Two-step approach. DEUTSCHES ARZTEBLATT INTERNATIONAL 2014; 111:213. [PMID: 24717309 PMCID: PMC3983702 DOI: 10.3238/arztebl.2014.0213b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Tromm A. Necessary additional points. DEUTSCHES ARZTEBLATT INTERNATIONAL 2014; 111:213. [PMID: 24717308 PMCID: PMC3983701 DOI: 10.3238/arztebl.2014.0213a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Abendroth K. Osteomalacia rather than osteoporosiss. DEUTSCHES ARZTEBLATT INTERNATIONAL 2014; 111:212. [PMID: 24717307 PMCID: PMC3983700 DOI: 10.3238/arztebl.2014.0212b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Razeghi S. Practicable only to a degree. DEUTSCHES ARZTEBLATT INTERNATIONAL 2014; 111:212. [PMID: 24717306 PMCID: PMC3983699 DOI: 10.3238/arztebl.2014.0212a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Zimmer KP, Schuppan D. In reply. DEUTSCHES ARZTEBLATT INTERNATIONAL 2014; 111:213-214. [PMID: 24717310 PMCID: PMC3983703 DOI: 10.3238/arztebl.2014.0213c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Klaus-Peter Zimmer
- *Department of General Pediatrics and Neonatology, Center for Pediatric and Adolescent Medicine, University Hospital Gießen and Marburg GmbH, Justus Liebig University, Gießen,
| | - Detlef Schuppan
- **Institute of Translational Immunology and Department of Medicine I, Johannes Gutenberg University, Mainz
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