Expression profiling of extramedullary acute myeloid leukemia suggests involvement of epithelial-mesenchymal transition pathways

Extramedullary (EM) colonization is a rare complication of acute myeloid leukemia (AML), occurring in about 10% of patients, but the processes underlying tissue invasion are not entirely characterized. Through the application of RNAseq technology, we examined the transcriptome profile of 13 AMLs, 9 of whom presented an EM localization. Our analysis revealed significant deregulation within the extracellular matrix (ECM)-receptor interaction and focal-adhesion pathways, specifically in the EM sites. The transcription factor TWIST1, which is known to impact on cancer invasion by dysregulating epithelial-mesenchymal-transition (EMT) processes, was significantly upregulated in EM-AML. To test the functional impact of TWIST1 overexpression, we treated OCI-AML3s with TWIST1-siRNA or metformin, a drug known to inhibit tumor progression in cancer models. After 48 h, we showed downregulation of TWIST1, and of the EMT-related genes FN1 and SNAI2. This was associated with significant impairment of migration and invasion processes by Boyden chamber assays. Our study shed light on the molecular mechanisms associated with EM tissue invasion in AML, and on the ability of metformin to interfere with key players of this process. TWIST1 may configure as candidate marker of EM-AML progression, and inhibition of EMT-pathways may represent an innovative therapeutic intervention to prevent or treat this complication.

Bone Marrow Microenvironment Involvement in t-MN: Focus on Mesenchymal Stem Cells

Therapy-related myeloid neoplasms (t-MN) are a late complication of cytotoxic therapy (CT) used in the treatment of both malignant and non-malignant diseases. Historically, t-MN has been considered to be a direct consequence of DNA damage induced in normal hematopoietic stem or progenitor cells (HSPC) by CT. However, we now know that treatment-induced mutations in HSC are not the only players involved in t-MN development, but additional factors may contribute to the onset of t-MN. One of the known drivers involved in this field is the bone marrow microenvironment (BMM) and, in particular, bone marrow mesenchymal stem cells (BM-MSC), whose role in t-MN pathogenesis is the topic of this mini-review. BM-MSCs, physiologically, support HSC maintenance, self-renewal, and differentiation through hematopoietic-stromal interactions and the production of cytokines. In addition, BM-MSCs maintain the stability of the BM immune microenvironment and reduce the damage caused to HSC by stress stimuli. In the t-MN context, chemo/radiotherapy may induce damage to the BM-MSC and likewise alter BM-MSC functions by promoting pro-inflammatory response, clonal selection and/or the production of factors that may favor malignant hematopoiesis. Over the last decade, it has been shown that BM-MSC isolated from patients with de novo and therapy-related MN exhibit decreased proliferative and clonogenic capacity, altered morphology, increased senescence, defective osteogenic differentiation potential, impaired immune-regulatory properties, and reduced ability to support HSC growth and differentiation, as compared to normal BM-MSC. Although the understanding of the genetic and gene expression profile associated with ex vivo-expanded t-MN-MSCs remains limited and debatable, its potential role in prognostic and therapeutic terms is acting as a flywheel of attraction for many researchers.

Absence of FGFR3-TACC3 rearrangement in hematological malignancies with numerical chromosomal alteration

FGFR-TACC, found in different tumor types, is characterized by the fusion of a member of fibroblast grown factor receptor (FGFR) tyrosine kinase (TK) family to a member of the transforming acidic coiled-coil (TACC) proteins. Because chromosome numerical alterations, hallmarks of FGFR-TACC fusions are present in many hematological disorders and there are no data on the prevalence, we studied a series of patients with acute myeloid leukemia and myelodysplastic syndrome who presented numerical alterations using cytogenetic traditional analysis. None of the analyzed samples showed FGFR3-TACC3 gene fusion, so screening for this mutation at diagnosis is not recommended.

Total thyroidectomy for Graves' disease treatment

OBJECTIVES

Graves' disease (GD) is the most common cause of hyperthyroidism, and accounts worldwide for 60-80% of all cases. The diagnosis is based on clinical findings, and is confirmed by the presence of TRAB, suppression of TSH, and elevation of free thyroxin (free T4), and triiodinethyronin (free T3). GD can be treated by antithyroid drugs, radioactive iodine, or surgery. The aim of this study was to review retrospectively the surgical management, in terms of safety and efficacy, in 50 patients operated in the Department of Surgical Sciences since 2005 through 2010 and followed up at the Endocrinology Unit A of the Experimental Medicine Department. We assessed postoperative complications, which included the presence, persistence and development of ophthalmopathy, transient hypocalcemia, permanent hypoparathyroidism and recurrent laryngeal nerve palsy.

MATERIALS AND METHODS

We analyzed data from 50 patients with GD who were eligible and underwent Total Thyroidectomy (TT). Thirty-nine patients underwent TT for recurrent hyperthyroidism after medical therapy and eleven patients for severe ophtalmopathy. The mean follow up was 41 months (range: 10-70).

RESULTS

Eleven patients had ophtalmopathy before surgery. Four patients developed an ophtalmopathy after surgery. Eleven patients presented hypocalcemia, transient in ten patients and permanent in one patient. Five patients developed a transient disphony. Conclusions. Total thyroidectomy is a safe and radical procedure in Graves' disease treatment. Complications of TT are not different than subtotal thyroidectomy if it's performed by expert surgeons.

Increased risk of acute myeloid leukaemia due to polymorphisms in detoxification and DNA repair enzymes

BACKGROUND

Polymorphisms in genes involved in detoxification and DNA-repair pathways may modify the individual's risk for genomic damage, and, as a consequence, the risk of developing malignant diseases.

PATIENTS AND METHODS

We performed a case-control study including 160 cases of acute myeloid leukaemia (AML) and 162 matched controls to test the impact of six genomic polymorphisms on the risk to develop AML and/or therapy-related AML.

RESULTS

We found a significantly higher prevalence of the polymorphic variants RAD51-G135C and CYP3A4-A-290G genes in AML cases, when compared with controls (P = 0.02 and P = 0.04), increasing the risk of AML 2.1-folds (95% CI: 1.1-4.0) and 3.2-fold (95% CI: 1.1-11.5), respectively. Carriers of both the RAD51-G135C and CYP3A4-A-290G variants were at highest AML risk (P = 0.003; OR:13,6; 95% CI: 2.0-585.5), suggesting a synergistic effect between these polymorphisms.

CONCLUSIONS

These results suggest that polymorphic variants in DNA-repair and detoxification enzymes may co-operate in modulating the individual's risk of AML.

Reduced BRCA1 expression due to promoter hypermethylation in therapy-related acute myeloid leukaemia

BRCA1 plays a pivotal role in the repair of DNA damage, especially following chemotherapy and ionising radiation. We were interested in the regulation of BRCA1 expression in acute myeloid leukaemia (AML), in particular in therapy-related forms (t-AML). Using real-time PCR and Western blot, we found that BRCA1 mRNA was expressed at barely detectable levels by normal peripheral blood granulocytes, monocytes and lymphocytes, whereas control BM-mononuclear cells and selected CD34+ progenitor cells displayed significantly higher BRCA1 expression (P=0.0003). Acute myeloid leukaemia samples showed heterogeneous BRCA1 mRNA levels, which were lower than those of normal bone marrows (P=0.0001). We found a high frequency of hypermethylation of the BRCA1 promoter region in AML (51/133 samples, 38%), in particular in patients with karyotypic aberrations (P=0.026), and in t-AML, as compared to de novo AML (76 vs 31%, P=0.0002). Examining eight primary tumour samples from hypermethylated t-AML patients, BRCA1 was hypermethylated in three of four breast cancer samples, whereas it was unmethylated in the other four tumours. BRCA1 hypermethylation correlated to reduced BRCA1 mRNA (P=0.0004), and to increased DNA methyltransferase DNMT3A (P=0.003) expression. Our data show that reduced BRCA1 expression owing to promoter hypermethylation is frequent in t-AML and that this could contribute to secondary leukaemogenesis.

Anti-human versus anti-guinea pig tissue transglutaminase antibodies as the first-level serological screening test for coeliac disease in the general population

BACKGROUND

So far the reliability of the anti-guinea pig and anti-human tissue transglutaminase antibodies for the coeliac disease diagnosis has been evaluated in selected groups of patients.

AIM

To compare the diagnostic accuracy of anti-human versus anti-guinea pig tissue transglutaminase in the coeliac disease screening of the general population.

SUBJECTS

Two healthy Italian populations living in Marche region and in Western Sardinia.

METHODS

Both anti-guinea pig and anti-human tissue transglutaminase were determined using an enzyme-linked immunosorbent assay-based commercially available kit (Eu-tTG, Eurospital, Trieste, Italy).

RESULTS

During the period 1999-2001, 3541 subjects (1500 from "continental" Italy and 2041 from Sardinia) were screened for coeliac disease using both anti-guinea pig and anti-human tissue transglutaminase as first-level tests. Both these tests were negative in 3439/3541 sera, while 29 resulted positive for both of them and 73 showed discordant results. Overall, 50 intestinal biopsies were performed in 22, 21 and 7 subjects with positivity to both screening tests, to anti-guinea pig and to anti-human tissue transglutaminase alone, respectively. A coeliac disease diagnosis was made in 25 subjects giving an overall prevalence of 1:126 individuals. The anti-tissue transglutaminase specificity and sensitivity were 98 and 92% for guinea pig and 99.6 and 96% for human tissue transglutaminase, respectively.

CONCLUSIONS

The anti-human tissue transglutaminase test should definitely replace the anti-guinea pig-derived one as first-level screening tool for identifying all subjects who need the second-level investigations (small intestinal biopsy).

[Treatment of childhood obesity. Long-term outcome and predictive factors of success in a group of 130 subjects]

BACKGROUND

In the last years the prevalence of childhood obesity has notably increased. The treatment of this condition is very difficult, because of the frequent relapses. The aim of our study was to examine the long-term outcomes of different dietary treatments (1200 or 1400 calories or chetogenic diet, derived from the protein sparing modified fast) in children and adolescents with primary obesity, in order to show factors predictive of the long-term success.

METHODS

A group of 130 obese children previously undergoing a dietary treatment have been re-evaluated after a 3, 5 and 7 years period from the beginning of the diet.

RESULTS

Ninety-seven out of 130 contacted patients (52 males and 45 females; mean age: 16+/-3 years) participated in this study. An overall improvement of the weight indexes has been observed (relative DBMI mean value: -10.5%). About 1/5 of the whole study-group is not overweight anymore. The statistical analysis (ANOVA and multiple regression analysis) showed that the factors positively affecting the long-term outcome were the following: use of chetogenic diet, initial success of the treatment, older age and strong motivation at the beginning of the diet, gender (male) and lack of familiarity for obesity.

CONCLUSIONS

It is important, in the clinical practice, to consider the above factors that can predict the long-term success of the dietary treatment, in order to individualize the therapy.

The serum IgA class anti-tissue transglutaminase antibodies in the diagnosis and follow up of coeliac disease. Results of an international multi-centre study. International Working Group on Eu-tTG

OBJECTIVES

So far the reliability of the anti-tissue transglutaminase (anti-tTG) test for the diagnosis of coeliac disease has mostly been evaluated using slightly different enzyme-linked immunosorbent assays (ELISAs) in selected and usually small groups of patients. The aims of this study were: (1) to evaluate the reliability of the IgA anti-tTG antibodies for the diagnosis of coeliac disease; and (2) to define the sensitivity and specificity of a commercially available kit for the anti-tTG antibodies' quantitative determination.

DESIGN

Each centre in this international multi-centre study collected sera from three groups of subjects: coeliac disease patients at the onset of (1) or on a gluten-free diet for at least 12 months (2); disease and healthy controls (3).

METHODS

The anti-tTG antibodies were determined in duplicate using an ELISA-based commercially available kit (Eu-tTG Eurospital, Trieste, Italy).

RESULTS

The following overall cases and controls have been enrolled: (1) 399 subjects with active coeliac disease; (2) 351 treated coeliac disease cases; (3) 432 controls. The centralized re-testing was performed on: (1) group a: 176 patients with active coeliac disease (mean anti-tTG, 21 arbitrary units [AU]); (2) group b: 172 treated coeliac disease cases (mean anti-tTG, 5 AU); (3) group c: 206 controls (mean anti-tTG, 3 AU). In active coeliacs, the anti-tTG antibodies showed a significant progressive decrease with age, while in controls an opposite trend was found. In active coeliac disease patients, the anti-tTG antibodies were significantly higher in coeliacs with a grade III enteropathy than in those showing a grade II lesion. In treated coeliacs, the mean anti-tTG values were significantly lower in patients strictly adhering to a gluten-free diet than in those reporting dietary transgressions. The sensitivity and the specificity of the Eu-tTG assay were 90% and 96%, respectively.

CONCLUSION

The results of this study show that the commercially available test for the anti-tTG antibodies' determination is a reproducible and valuable tool for the diagnosis and follow up of coeliac disease.

Tissue transglutaminase autoantibodies in patients with non-Hodgkin's lymphoma. Case reports

BACKGROUND

Tissue transglutaminase (tTG) has recently been identified as the autoantigen recognized by endomysial antibodies in celiac disease (CD) patients and this has permitted the use of an ELISA test to detect the presence in the serum of autoantibodies specific for the diagnosis of CD.

AIM

We report two cases of anti-tTG positivity in patients with non-Hodgkin's lymphoma (NHL) without evidence of CD.

CASE REPORTS

Both patients were males aged 67 and 69 years respectively; both were hospitalized for fever and peripheral adenopathy. Lymph node histology showed an immunoblastic high-grade T-cell NHL at the IVth the stage of disease in both cases. They were included in a multicenter study on the association between CD and NHL. Serological screening for CD showed the presence of serum anti-tTG antibodies, with values within the range of those recorded in untreated CD patients in our laboratory; however, both patients had negative anti-endomysial antibodies and in both cases intestinal histology showed normal mucosa with villi and crypts of normal height and depth (villi/crypts ratio > or = 2.5, within the range of normal subjects for our laboratory), and no increase in intraepithelial lymphocytes. The HLA phenotype was obtained giving the following antigens: Case 1: A 3, A 24(9), B 22, B 35, BW 6, DR 1, DR 11(5), DQ 3, DR 52. Case 2: A 2, A 3, B 51(5), B 8, BW 4, BW 6, DR B1*02, DR B1*03, DR B3*01. Both subjects were also positive for serum anti-smooth muscle antibodies and one for antinuclear antibodies.

CONCLUSIONS

(1) Serum anti-tTG positivity can be found in subjects with NHL without CD and the real frequency of these 'false positives' must be investigated both in subjects with lymphoproliferative disorders and in patients with autoimmune diseases. (2) In patients with NHL, without CD, anti-tTG positivity may be unassociated with EmA positivity and the biological significance of this finding must be clarified.

Effect of a water-soluble fiber (galactomannans)-enriched formula on gastric emptying time of regurgitating infants evaluated using an ultrasound technique

BACKGROUND

Milk formulas enriched with water-soluble fibers are a first-line measure for infants with gastroesophageal reflux. However, it has been reported that these compounds could affect gastric emptying. The aim of this study was to evaluate the effects of these thickeners on gastric emptying time in infants with frequent regurgitation or vomiting.

METHODS

Forty-seven infants, aged 1 to 12 months, with uncomplicated gastroesophageal reflux underwent two ultrasound evaluations of gastric emptying time after receiving either a standard formula or a formula enriched with 0.4 g galactomannan per 100 ml diluted milk. Gastric emptying time was calculated by measuring the antrum area at baseline and at defined intervals over the next 3 hours.

RESULTS

The gastric emptying time (mean +/- SD) for the standard and the thickened formula was 136 +/- 33 and 133 +/- 34 minutes, respectively. There was no significant difference in the gastric emptying patterns of the two formulas. Gastric emptying time was longer after the standard formula in 15 of the 47 subjects, shorter in 15 of the 47, and the same in 17 of the 47.

CONCLUSIONS

The ingestion of a water-soluble fiber-enriched formula does not have any significant influence on the gastric emptying time of infants with frequent regurgitation or vomiting.

Antiendomysium versus antigliadin antibodies in screening the general population for coeliac disease

BACKGROUND

It has recently been shown that mass screening for coeliac disease, using either the serum antigliadin (AGA) or antiendomysium antibodies (EMA) as screening test, can detect large numbers of cases that had escaped clinical diagnosis. The influence of the diagnostic algorithm on the results of the coeliac screening has not yet been evaluated. Our aim was to compare the validity of the AGA and the EMA protocols in 2096 students living in northwest Sardinia, who took part in a serologic screening for coeliac disease.

METHODS

The sample included 2096 of 2345 eligible students (89%) aged 11-15 years who underwent serum IgG AGA, IgA AGA, and IgA EMA determinations. Total serum IgA level was measured in sera showing isolated IgG AGA positivity. Subjects showing at least one of the following: a) EMA positivity, b) IgA AGA positivity, or c) IgG AGA positivity and IgA deficiency (<5 mg/dl) were asked to submit to a small-intestinal biopsy.

RESULTS

The prevalence of coeliac disease was 19 (16 showing typical enteropathy, 1 potential case, and 2 known cases) of 2096 (0.91%; 95% confidence interval = 0.50-1.31). Seventeen small-intestinal biopsy specimens were needed to confirm 16 cases of manifest coeliac disease (positive predictive value (PPV) = 94%) by the EMA protocol, whereas the AGA protocol required 21 biopsy specimens for 12 cases of coeliac disease (PPV = 57%). None of six IgA-deficient, IgG AGA-positive cases detected by the AGA protocol also had coeliac disease.

CONCLUSIONS

The EMA protocol is superior to the AGA protocol for mass screening of coeliac disease because of higher sensitivity, decreased need for intestinal biopsy, and possibility to detect potential cases of coeliac disease.

Compliance with gluten-free diet in adolescents with screening-detected celiac disease: a 5-year follow-up study

After 5 years of treatment, 22 patients with celiac disease, diagnosed by means of serologic mass screening (mean age, 17.9 years), showed a lower compliance with a gluten-free diet and frequent positivity of serum anti-endomysium antibodies (32%) in comparison with a group of 22 age-matched patients diagnosed because of "typical" symptoms during childhood.

Why is coeliac disease endemic in the people of the Sahara?

The prevalence of antiendomysial antibody (AEA) in 989 Saharawi children was 5.6%. Intestinal biopsies in a subsample confirmed that AEA is a marker of coellac disease in people living in a developing country.

Severe and protracted diarrhea: results of the 3-year SIGEP multicenter survey. Working Group of the Italian Society of Pediatric Gastroenterology and Hepatology (SIGEP)

BACKGROUND

The spectrum of severe and protracted diarrhea (SPD), previously defined as intractable diarrhea, has changed during the past several decades. Despite recent advances in determining the cause of SPD and in treatment, this syndrome still represents a challenge and is becoming a major problem affecting health care resources. This study was conducted to characterize the epidemiology, spectrum of causes, and the outcome of SPD in Italy in recent years.

METHODS

All the SPD cases seen at the major centers of pediatric gastroenterology in Italy during a 3-year period (1993-1996) were recruited in this multicenter, prospective survey.

RESULTS

Thirty-two children (26 boys and 6 girls; median age at the onset of SPD, 40 days) were enrolled in this study by 9 of 26 participating centers. Twelve were newly diagnosed cases, with an estimated SPD incidence rate in Italy of 0.64 to 0.92 x 10(-5) infants per year. The most common causes were autoimmune enteropathy (n = 8) and ultrastructural abnormalities of the enterocyte (n = 7), whereas food intolerance and postenteritis syndrome were less frequent (3 and 2 cases, respectively). Two children with autoimmune enteropathy fulfilled the criteria for the X-linked variant of this condition. At the end of the study period, 9 of 31 patients had recovered, 15 still had diarrhea, and 7 had died.

CONCLUSIONS

Severe and protracted diarrhea is a rare but challenging problem in Italy. Because parenteral nutrition or intestinal transplantation are the only options in a subset of cases (e.g., ultrastructural abnormalities of the enterocyte), infants with SPD should be referred to specialized centers where advanced diagnostic and therapeutic facilities are available.

Quantitative antigliadin antibody measurement in clinical practice: an Italian multicentre study. SIGEP Working Group on Quantitative AGA Standardization

BACKGROUND

The determination of class G and A serum antigliadin antibodies remains one of the most widely used screening tests for coeliac disease. The results from different laboratories are not always comparable, on account of changes in the technique and the different ways of expressing the results.

AIMS

To: a) evaluate the physiological variation of serum antigliadin antibodies expressed in ng/ml, and b) establish the cut-off of quantitative antigliadin antibodies.

PATIENTS

Patients were 127 individuals with active coeliac disease. Controls were 395 non-coeliac subjects (198 females and 197 males) aged 6 months to 45 years (median age: 4.9 years).

METHODS

Antigliadin antibody enriched samples were obtained by affinity chromatography. The concentration of the eluted antigliadin antibodies was evaluated by nephelometry and enzyme-linked immunosorbent assay to establish a primary standard. An enzyme-linked immunosorbent assay for antigliadin antibody determination was run according to standard procedures.

RESULTS

In controls, IgG-antigliadin antibody showed high variability in the 50th-90th centile range that peaked during the second year of life while IgA-antigliadin antibodies showed a lower variability and a less pronounced trend to decreasing values with age. A certain degree of overlapping between controls and coeliac patients was seen for both IgA- and IgG-antigliadin antibodies. The receiver operating characteristic analysis showed that the best discrimination was achieved by a cut-off of 8-10 ng/ml for IgA-antigliadin antibodies and 150-200 ng/ml for IgG-antigliadin antibodies.

CONCLUSIONS

Antigliadin antibody concentration is not normally distributed and changes with age in non-coeliac subjects. The receiver operating characteristic analysis is a valuable tool for fixing the antigliadin antibody cut-offs between control and diseased individuals. The diagnosis of coeliac disease should always be confirmed by intestinal biopsy.

[High prevalence of hepatitis C virus infection in patients with non-Hodgkin's lymphoma at the onset. Preliminary results of an Italian multicenter study]

143 patients with non-Hodgkin lymphoma (NHL) at the onset entered this perspective study on NHL-associated risk factors. They were 87 males and 56 females with a mean age of 52.3 years (range 14.6-82.3). An associated hepatitis C virus (HCV) infection was found in 16 of the 143 NHL cases (11.2%; 95% CI 6.5-17.5). They were 11 males and 5 females [mean age 59.9] year with disseminated (13/16) or localized NHL disease (3/16)]. The NHL histological subgroup was low grade (6/16), intermediate grade (2/16) or high grade (8/16). The cell origin was B in 15/16 cases and B cell-T cell rich in 1/16. The discovery of HCV infection was contemporary to lymphoma diagnosis in 6/16 cases but preceded the NHL onset in the other 10 patients. In these 10 patients the median time between HCV infection diagnosis and NHL onset was 3.6 years (range 1-14.5). These data confirm that in Italy the prevalence of HCV infection in patients with NHL (11.2%) is significantly higher than expected in the general population (1.3-3.2%). The finding that, in most cases, HCV infection was definitely antecedent to NHL onset, usually by years, adds evidence to the possible causative role of the HCV in lymphomagenesis.

The spectrum of coeliac disease in children

Coeliac disease is the life-long intolerance to dietary gluten, usually characterized by severe damage to the small-intestinal mucosa. The widespread use of sensitive diagnostic tools, such as the serum anti-gliadin and the anti-endomysial antibodies, has shown not only that coeliac disease is one of the commonest disorders in Western countries but also that this condition is characterized by a higher degree of clinical variability than previously thought (typical, atypical and silent forms). The existence of a latent-potential coeliac disease and even a gluten-sensitive disease with immunological activation of an otherwise normal small-intestinal mucosa has recently been postulated. An increased prevalence of coeliac disease in a number of other disorders has also been reported in both children and adults. The reasons for such a wide clinical heterogeneity are still poorly understood but are likely to depend on both genetic and environmental factors. Further investigations are required to evaluate the impact of undiagnosed, clinically milder forms of coeliac disease on the well-being of the population.

Is the sugar intestinal permeability test a reliable investigation for coeliac disease screening?

BACKGROUND

The lactulose/mannitol (L/M) intestinal permeability test is a simple, non-invasive screening test for coeliac disease. The reliability of the L/M test has so far only been tested in selected groups of patients with coeliac disease.

AIM

To evaluate the reliability of the L/M test in a group of patients with coeliac disease who had been diagnosed during mass serological screening of the general population.

PATIENTS AND METHODS

Twenty nine patients with coeliac disease detected by screening and 54 age matched coeliac disease free controls aged 11-15 years underwent an L/M test with 5 g lactulose and 2 g mannitol in isotonic aqueous solution. Urinary sugars were measured by high performance liquid chromatography.

RESULTS

The median % urinary recovery of lactulose (lactulose UR) was significantly higher in patients with coeliac disease than in controls (0.63 v 0.18, p < 0.001). The mean mannitol % UR was lower in patients with coeliac disease than in controls (17.6 v 18.5) but the difference was not significant. The median urinary L%/M% ratio was significantly higher in patients with coeliac disease than in controls (0.038 v 0.014, p < 0.001). However, 16 of the 29 patients with coeliac disease showed an L%/M% ratio within normal limits (< 0.044).

CONCLUSIONS

The L/M intestinal permeability test is not a valuable tool for screening of coeliac disease in the general population. The pattern of the urinary probe recovery suggests that many patients with coeliac disease could remain symptomless because the extent of their intestinal mucosal damage is small ("short" coeliac disease).

Dietary compliance in screening-detected coeliac disease adolescents

In 1992-94 we screened 6315 students for coeliac disease (CD) by testing antigliadin antibodies (AGA) as the first-level investigation. We found 28 biopsy-proven coeliac patients who were invited to start the gluten-free diet (GFD). The aim of this study was a clinical and laboratory follow-up in these screening-detected coeliac adolescents. Patients were 17 females and 11 males with a mean age at diagnosis of 12.8 +/- 1 years (range 11-4). Mean follow-up duration time was 23 +/- 7 months (range 9-37). Twenty-three of the 28 screening-detected coeliac patients came to the control visit, 3 refused the follow-up and 2 subjects were not found. Twelve patients (52.2%) stated that they never ate any gluten-containing food, while 11 of them (47.8%) reported occasional transgressions to the diet. GFD acceptance was reported as good (n = 6), moderate (n = 11) or low (n = 6). After starting the GFD, signs of improvement were seen in most patients, such as weight gain, increased height velocity and increased feeling of well-being. AGA (both IgG and IgA classes) and antiendomysium antibodies (AEA) were normal in 19 subjects, 2 cases had IgG-AGA and AEA positivity, 1 patient showed abnormal AGA and AEA levels, while isolated IgA-AGA positivity persisted in 1 case. This study shows that even silent CD cases can clinically benefit from the GFD. The consequences of occasional transgressions to the GFD remain unclear.

The coeliac iceberg in Italy. A multicentre antigliadin antibodies screening for coeliac disease in school-age subjects

BACKGROUND

Recent studies suggest that coeliac disease (CD) is one of the commonest, life-long disorders in Italy. The aims of this multicentre work were: (a) to establish the prevalence of CD on a nationwide basis; and (b) to characterize the CD clinical spectrum in Italy.

PATIENTS AND METHODS

Fifteen centres screened 17,201 students aged 6-15 years (68.6% of the eligible population) by the combined determination of serum IgG- and IgA-antigliadin antibody (AGA) test; 1289 (7.5%) were IgG and/or IgA-AGA positive and were recalled for the second-level investigation; 111 of them met the criteria for the intestinal biopsy: IgA-AGA positivity and/or AEA positivity or IgG-AGA positivity plus serum IgA deficiency.

RESULTS

Intestinal biopsy was performed on 98 of the 111 subjects. CD was diagnosed in 82 subjects (75 biopsy proven, 7 not biopsied but with associated AGA and AEA positivity). Most of the screening-detected coeliac patients showed low-grade intensity illness often associated with decreased psychophysical well-being. There were two AEA negative cases with associated CD and IgA deficiency. The prevalence of undiagnosed CD was 4.77 x 1000 (95% CI 3.79-5.91), 1 in 210 subjects. The overall prevalence of CD, including known CD cases, was 5.44 x 1000 (95% CI 4.57-6.44), 1 in 184 subjects. The ratio of known to undiagnosed CD cases was 1 in 7.

CONCLUSIONS

These findings confirm that, in Italy, CD is one of the most common chronic disorders showing a wide and heterogeneous clinical spectrum. Most CD cases remain undiagnosed unless actively searched.

[Protein-losing gastroenteropathy (Ménétrier's disease) in childhood: a report of 3 cases]

So far, Ménétrier's disease has been thought to be an uncommon disorder in children. It is characterized by hypertrophic gastritis, protein-losing enteropathy, hypoproteinemia and edema. During childhood, the main features of this condition include an abrupt onset and a spontaneous recovery. In this paper we describe three children, aging between 3 months and 3 years, who presented with protracted vomiting, generalized edema, colitis (one case) and elevated serum aminotransferases (one case). The diagnosis of Ménétrier's disease was made by finding the typical endoscopic and histological picture of the gastric mucosa (two cases) or by the radiological findings (one case). The fecal alpha-1-antitrypsin excretion, which is a marker of the protein-losing enteropathy, was high in all patients. Two cases showed evidences for a primary CMV infection as the possible cause of Ménétrier's disease, due to the presence of cytomegalic inclusions in the gastric mucosa and the IgM class anti-CMV antibodies positivity. All 3 cases, who received only a support treatment (plasma and albumin intravenous infusions), completely recovered in a 2-3 weeks time. In conclusion, it is confirmed that in children a protein-losing gastroenteropathy may be caused by a primary infection with CMV.

Molecular characterization of a carboxy-terminal eukaryotic-cell-binding domain of intimin from enteropathogenic Escherichia coli

A eukaryotic cell-binding domain from the intimin (Int) polypeptide of enteropathogenic Escherichia coli O127 (EPEC) was investigated. Derivatives of the carboxy-terminal 280-amino-acid domains of Int (Int-EPEC280) and the Int homolog invasin (Inv) from Yersinia pseudotuberculosis (InvYP280) were fused to the E. coli maltose-binding protein (MBP), expressed, and purified. The smallest MBP-IntEPEC fusion protein that efficiently mediated binding to HEp-2 cells, monitored by using purified fusion proteins in fluorescence activated cell sorter analysis or by using fluorescent Covaspheres coated with purified fusions, contained the carboxy-terminal 150 amino acids of Int. Replacement of Cys-937 with Ser (IntEPEC280CS) destroyed the cell-binding activity of IntEPEC280. Covaspheres coated with MBP-IntEPEC280 were associated with HEp-2 cell microvilli but failed to induce actin accumulation underneath bound particles or cell spreading on coated plastic surfaces. MBP-IntEPEC280, but not MBP, MBP-IntEPEC280CS, or MBP-InvYP280, inhibited EPEC entry into HEp-2 cells.

High prevalence of undiagnosed coeliac disease in 5280 Italian students screened by antigliadin antibodies

Many cases of coeliac disease are currently undiagnosed. We carried out a pilot study on screening for coeliac disease in a school population. The screening protocol consisted of three parts: (1) IgG and IgA antigliadin antibody (AGA) assay; (2) antiendomysium antibody and total serum IgA determinations; (3) jejunal biopsy. A total of 5280 students aged 11-15 years (71.7% of the eligible population) underwent the first evaluation; 113 subjects performed the second tests and 35 of these needed the third investigation. Coeliac disease was diagnosed in 23 cases, most of which were atypical or silent forms. The prevalence of undiagnosed coeliac disease was 4.36 per 1000 screened subjects (95% CI 2.58-6.14) and 5.03 per 1000 (95% CI 3.41-6.65) in the general population. The ratio of known to undiagnosed cases was 1 to 6.4. This high prevalence of undiagnosed coeliac disease raises a number of problems that require further evaluation.

Coeliac disease in the year 2000: exploring the iceberg

It is now generally believed that subclinical coeliac disease is common in the general population. We have undertaken screening for this disorder in a school district in central Italy. Screening was divided into three levels: first, IgG and IgA antigliadin antibody (AGA) assay on capillary blood obtained by finger prick; second, AGA plus IgA anti-endomysium antibody (AEA) test and measurement of serum immunoglobulins in venous blood; and third, intestinal biopsy. 3351 students (66% of the eligible population) aged 11-15 years attended first-level screening. 71 (2%) were recalled because of AGA positivity; 18 of these satisfied second-level criteria and underwent intestinal biopsy. Coeliac disease was diagnosed in 11 subjects, most of whom had no serious symptoms. Selective IgA deficiency was found in 4 subjects, 1 of whom also had coeliac disease. The prevalence of subclinical coeliac disease in the study group was 3.28 per 1000. Coeliac disease screening is feasible and involves only slight discomfort to the general population. Such screening can detect large numbers of cases of coeliac disease, which can be treated with a gluten-free diet. Many subclinical cases of coeliac disease would not be detected by screening only a selected group of at-risk patients.