1
|
Hujoel IA, Hujoel MLA. The Rising Incidence and Poor Outcomes of Enteropathy-Associated T-Cell Lymphoma. Am J Gastroenterol 2024:00000434-990000000-00983. [PMID: 38235779 DOI: 10.14309/ajg.0000000000002666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/15/2024] [Indexed: 01/19/2024]
Abstract
INTRODUCTION Enteropathy-associated T-cell lymphoma (EATL) is associated with celiac disease. With the rising prevalence of celiac disease, we hypothesized that the prevalence of EATL is also increasing. METHODS We used the Surveillance, Epidemiology, and End Results database, which is a population-based US cancer surveillance program. We used the ICD-0-3 code 9717/3 to identify patients with EATL diagnosed between 2000 and 2020. Incidence rates were calculated using the SEER*Stat software, and annual percent change was calculated using the Joinpoint software. Log-rank tests were used to evaluate for significant difference in survival curves between groups. A Cox proportional hazards regression model was used for continuous variables and quantifying association strength of predictors. RESULTS A total of 463 cases of EATL were identified (273 male, 190 female) with a median age of 65 (range 23-90+) years. Most of the cases were at an advanced stage at diagnosis and were treated with a combination of surgery and chemotherapy. The median survival time was 6 months. The 2000-2020 age-adjusted incidence rate per 100,000 people was 0.014, and the incidence increased between 2000 and 2020, with an annual percent change of 2.58 ( P < 0.05). Increased age at diagnosis and lack of treatment had significant impacts on survival while sex, year of diagnosis, race, and time between diagnosis and treatment had no significant impact on survival. DISCUSSION There was a significant increase in the incidence of EATL in the United States between 2000 and 2020. Survival in this cancer remains poor and unchanged over the past 2 decades.
Collapse
Affiliation(s)
- Isabel A Hujoel
- Division of Gastroenterology, University of Washington, Seattle, Washington, USA
| | - Margaux L A Hujoel
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| |
Collapse
|
2
|
Hujoel IA, Hujoel MLA. Investigating the role of iron status in the development of coeliac disease: a Mendelian randomisation study. BMJ Open Gastroenterol 2024; 11:e001236. [PMID: 38177066 PMCID: PMC10773400 DOI: 10.1136/bmjgast-2023-001236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/11/2023] [Indexed: 01/06/2024] Open
Abstract
OBJECTIVE The environmental trigger behind the increasing prevalence of coeliac disease is not known. One suggested cause is iron deficiency, which is common in coeliac disease. We aimed to evaluate this possible association with Mendelian randomisation (MR), which under certain assumptions can suggest a causal relationship. DESIGN We conducted a two-sample MR study examining the relationship between single nucleotide polymorphisms (SNPs) associated with iron status and the presence of coeliac disease. The SNPs were drawn from a meta-analysis of three genome-wide association studies (GWAS). The association between these SNPs and coeliac disease was assessed using GWAS summary statistics from the UK Biobank. This consists of 336 638 white British individuals, 1855 with coeliac disease. We performed an MR Egger test for pleiotropy and assessed the plausibility of the assumptions of MR to evaluate for possible causality. RESULTS There were four SNPs strongly associated with systemic iron status. These were not associated with known risk factors for coeliac disease. All four SNPs were available in the UK Biobank coeliac disease summary statistics. Harmonising exposure and outcome associations, we found that higher iron status was negatively associated with risk of coeliac disease (OR per 1 SD increase in serum iron: 0.65, 95% CI 0.47 to 0.91). Leave-one-out analyses had consistent results, and no single SNP drove the association. All three assumptions of MR appeared plausible. CONCLUSION We found that genetically lower iron levels were associated with an increased risk of coeliac disease. Our findings highlight a potential opportunity for coeliac disease prevention.
Collapse
Affiliation(s)
| | - Margaux Louise Anna Hujoel
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| |
Collapse
|
3
|
Hujoel IA, Hujoel MLA, Choung RS, Murray JA. Symptom Outcomes of Celiac Disease in Those on a Gluten-free Diet. J Clin Gastroenterol 2023:00004836-990000000-00236. [PMID: 38019078 DOI: 10.1097/mcg.0000000000001946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/20/2023] [Indexed: 11/30/2023]
Abstract
GOALS We aimed to evaluate symptom outcomes in those on a gluten-free diet during the 5 years after diagnosis. BACKGROUND Celiac disease is common; however, little is known about long-term symptom outcomes. STUDY We performed a retrospective chart review on individuals with celiac disease followed at a tertiary referral center between 2012 and 2018. To minimize bias, strict inclusion/exclusion criteria were utilized. Only those with definitive biopsy-proven celiac disease, on a gluten-free diet, and with systematic follow-up were included. The standardized care at this center reduced the risk that decisions on testing and follow-up visits were determined by symptom status. Summary statistics were computed and generalized linear models with a logit link were used to associate the proportion of symptomatic visits with various covariates using R statistical programming. RESULTS Of the 1023 records reviewed, 212 met inclusion/exclusion criteria; 146 (69%) were female and the mean age at diagnosis was 43 (range: 11 to 84 y old). During follow-up, over 50% remained symptomatic, with many having the same symptoms that prompted the diagnosis. The only predictors for remaining symptomatic were female sex and younger age at diagnosis. Abnormal serology during follow-up and small bowel normalization were not predictive. CONCLUSIONS In individuals with definitive celiac disease with systematic long-term follow-up in a Celiac Clinic, roughly half remained symptomatic despite a gluten-free diet. Many suffer from the same symptoms that prompted the diagnosis of celiac disease. Small bowel healing and abnormal serology in follow-up were not predictive of remaining symptomatic. These findings stress the importance of long-term care in celiac disease.
Collapse
Affiliation(s)
- Isabel A Hujoel
- Division of Gastroenterology, Department of Internal Medicine University of Washington, Seattle, WA
| | - Margaux L A Hujoel
- Division of Genetics, Department of Medicine Brigham and Women's Hospital and Harvard Medical School, Boston
- Program in Medical and Population Genetics Broad Institute of MIT and Harvard, Cambridge, MA
| | - Rok Seon Choung
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Joseph A Murray
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| |
Collapse
|
4
|
Jansson-Knodell CL, Celdir MG, Hujoel IA, Lyu R, Gardinier D, Weekley K, Prokop LJ, Rubio-Tapia A. Relationship between gluten availability and celiac disease prevalence: A geo-epidemiologic systematic review. J Gastroenterol Hepatol 2023; 38:1695-1709. [PMID: 37332011 DOI: 10.1111/jgh.16260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/04/2023] [Accepted: 05/31/2023] [Indexed: 06/20/2023]
Abstract
Celiac disease is a global disease requiring genetic susceptibility and gluten exposure to trigger immune-mediated enteropathy. The effect of the degree of gluten-containing grain availability on celiac disease prevalence is unknown. Our objective was to compare country-based gluten availability to celiac prevalence using a systematic literature review. We searched MEDLINE, Embase, Cochrane, and Scopus until May 2021. We included population-based serum screening with confirmatory testing (second serological study or small intestine biopsy) and excluded specific, high-risk, or referral populations. We determined country-specific gluten availability using the United Nations food balance for wheat, barley, and rye. Human leukocyte antigen (HLA) frequencies were obtained from allelefrequencies.net. The primary outcome was association between gluten-containing grain availability and celiac disease prevalence. Generalized linear mixed models method with Poisson's link was used for analysis. We identified 5641 articles and included 120 studies on 427 146 subjects from 41 countries. Celiac disease prevalence was 0-3.1%, median 0.75% (interquartile range 0.35, 1.22). Median wheat supply was 246 g/capita/day (interquartile range 214.8, 360.7). The risk ratio (RR) for wheat availability on celiac disease was 1.002 (95% confidence interval [CI]: 1.0001, 1.004, P = 0.036). A protective association was seen with barley, RR 0.973 (95% CI: 0.956, 0.99, P = 0.003), and rye, RR 0.989 (95% CI: 0.982, 0.997, P = 0.006). The RR for gross domestic product on celiac disease prevalence was 1.009 (95% CI: 1.005, 1.014, P < 0.001). The RR for HLA-DQ2 was 0.982 (95% CI: 0.979, 0.986, P < 0.001), and that for HLA-DQ8 was 0.957 (95% CI: 0.950, 0.964, P < 0.001). In this geo-epidemiologic study, gluten-containing grain availability showed mixed associations with celiac disease prevalence.
Collapse
Affiliation(s)
- Claire L Jansson-Knodell
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Melis G Celdir
- Department of Gastroenterology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Isabel A Hujoel
- Department of Gastroenterology, University of Washington, Seattle, Washington, USA
| | - Ruishen Lyu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - David Gardinier
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kendra Weekley
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Larry J Prokop
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota, USA
| | - Alberto Rubio-Tapia
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
5
|
Celdir MG, Jansson-Knodell CL, Hujoel IA, Prokop LJ, Wang Z, Murad MH, Murray JA. Latitude and Celiac Disease Prevalence: A Meta-Analysis and Meta-Regression. Clin Gastroenterol Hepatol 2022; 20:e1231-e1239. [PMID: 33007509 DOI: 10.1016/j.cgh.2020.09.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 09/15/2020] [Accepted: 09/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The latitudinal gradient effect is described for several autoimmune diseases including celiac disease in the United States. However, the association between latitude and global celiac disease prevalence is unknown. We aimed to explore the association between latitude and serology-based celiac disease prevalence through meta-analysis. METHODS We searched MEDLINE, Embase, Cochrane, and Scopus databases from their beginning through June 29, 2018, to identify screening studies that targeted a general population sample, used serology-based screening tests, and provided a clear location from which we could assign a latitude. Studies were excluded if sampling was based on symptoms, risk factors, or referral. Study selection and data extraction were performed by independent reviewers. The association measures between latitude and prevalence of serology-based celiac disease were evaluated with random-effects meta-analyses and meta-regression. RESULTS Of the identified 4667 unique citations, 128 studies were included, with 155 prevalence estimates representing 40 countries. Celiac disease was more prevalent at the higher latitudes of 51° to 60° (relative risk [RR], 1.62; 95% CI, 1.09-2.38) and 61° to 70° (RR, 2.30; 95% CI, 1.36-3.89) compared with the 41° to 50° reference level. No statistically significant difference was observed at lower latitudes. When latitude was treated as continuous, we found a statistically significant association between CD prevalence and latitude overall in the world (RR, 1.03, 95% CI, 1.01-1.05) and a subregional analysis of Europe (RR, 1.05; 95% CI, 1.02-1.07) and North America (RR, 1.1; 95% CI, 1.0-1.2). CONCLUSIONS In this comprehensive review of screening studies, we found that a higher latitude was associated with greater serology-based celiac disease prevalence.
Collapse
Affiliation(s)
- Melis G Celdir
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Isabel A Hujoel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Zhen Wang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - M Hassan Murad
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
6
|
Hujoel IA, Hujoel MLA. The Role of Copper and Zinc in Irritable Bowel Syndrome: A Mendelian Randomization Study. Am J Epidemiol 2022; 191:85-92. [PMID: 34132328 DOI: 10.1093/aje/kwab180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 05/30/2021] [Accepted: 06/11/2021] [Indexed: 11/14/2022] Open
Abstract
Irritable bowel syndrome (IBS) has been associated with copper and zinc imbalance and a zinc-deficient diet. Mendelian randomization was used in this study to evaluate if genetically determined copper and zinc levels play a causal role in the development of IBS. Three single-nucleotide polymorphisms (SNPs; rs1175550, rs2769264, and rs2769270) associated with erythrocyte copper levels, and 3 SNPs associated with erythrocyte zinc levels (rs11638477, rs1532423, and rs2120019) in the Australian Twin Study (1993-1996 and 2001-2005) were used as instrumental variables for levels of these metals. The association of these SNPs with IBS was tested using summary statistics computed from data on 340,331 individuals from the UK Biobank, 5,548 of whom had IBS (2006-2010). Genetically predicted high serum copper levels were associated with a lower risk of IBS (odds ratio = 0.89; 95% confidence interval: 0.80, 0.98). Genetically predicted, high serum zinc levels were nonsignificantly associated with a higher risk of IBS (odds ratio = 1.06; 95% confidence interval: 0.95, 1.18). Sensitivity analysis did not suggest the presence of pleiotropy. These results suggest that high erythrocyte copper levels may be protective against IBS development. Targeting higher levels, therefore, may provide an avenue to reduce the likelihood of IBS development in high-risk individuals.
Collapse
|
7
|
Hujoel IA, Jansson-Knodell CL, Hujoel PP, Hujoel MLA, Choung RS, Murray JA, Rubio-Tapia A. Estimating the Impact of Verification Bias on Celiac Disease Testing. J Clin Gastroenterol 2021; 55:327-334. [PMID: 32433257 PMCID: PMC7674196 DOI: 10.1097/mcg.0000000000001361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/06/2020] [Indexed: 01/19/2023]
Abstract
GOAL The goal of this study was to estimate the impact of verification bias on the diagnostic accuracy of immunoglobulin A tissue transglutaminase (IgA tTG) in detecting celiac disease as reported by an authoritative meta-analysis, the 2016 Comparative Effectiveness Review (CER). BACKGROUND Verification bias is introduced to diagnostic accuracy studies when screening test results impact the decision to verify disease status. MATERIALS AND METHODS We adjusted the sensitivity and specificity of IgA tTG reported by the 2016 CER with the proportion of IgA tTG positive and negative individuals who are referred for confirmatory small bowel biopsy. We performed a systematic review from January 1, 2007, to July 19, 2017, to determine these referral rates. RESULTS The systematic review identified 793 articles of which 9 met inclusion criteria (n=36,477). Overall, 3.6% [95% confidence interval (CI): 1.1%-10.9%] of IgA tTG negative and 79.2.2% (95% CI: 65.0%-88.7%) of IgA tTG positive individuals were referred for biopsy. Adjusting for these referral rates the 2016 CER reported sensitivity of IgA tTG dropped from 92.6% (95% CI: 90.2%-94.5%) to 57.1% (95% CI: 35.4%-76.4%) and the specificity increased from 97.6% (95% CI: 96.3%-98.5%) to 99.6% (95% CI: 98.4%-99.9%). CONCLUSIONS The CER may have largely overestimated the sensitivity of IgA tTG due to a failure to account for verification bias. These findings suggest caution in the interpretation of a negative IgA tTG to rule out celiac disease in clinical practice. More broadly, they highlight the impact of verification bias on diagnostic accuracy estimates and suggest that studies at risk for this bias be excluded from systematic reviews.
Collapse
Affiliation(s)
- Isabel A. Hujoel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905
| | | | - Philippe P. Hujoel
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, 98195
| | - Margaux L. A. Hujoel
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02215
| | - Rok Seon Choung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905
| | - Joseph A. Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905
| | - Alberto Rubio-Tapia
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, 44103
| |
Collapse
|
8
|
Hujoel IA, Wu TT, Sweetser S. Diarrhea in a Retired Couple From Mexico. Gastroenterology 2021; 160:1039-1040. [PMID: 32565013 DOI: 10.1053/j.gastro.2020.05.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/11/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Isabel A Hujoel
- Department of Internal Medicine and Division of Gastroenterology and Hepatology.
| | - Tsung-Teh Wu
- Department of Anatomic Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Seth Sweetser
- Department of Internal Medicine and Division of Gastroenterology and Hepatology
| |
Collapse
|
9
|
Hujoel PP, Kato T, Hujoel IA, Hujoel MLA. Bleeding tendency and ascorbic acid requirements: systematic review and meta-analysis of clinical trials. Nutr Rev 2021; 79:964-975. [PMID: 33517432 DOI: 10.1093/nutrit/nuaa115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
CONTEXT The World Health Organization set the recommended daily vitamin C intake, henceforth referred to as ascorbic acid (AA), on the basis of scurvy prevention. Double-blind AA depletion-repletion studies suggest that this recommended AA dose may be too low to prevent microvascular fragility. OBJECTIVES (1) To conduct a systematic review and meta-analysis of controlled clinical trials on whether AA supplementation leads to a reduced gingival bleeding tendency, a manifestation of microvascular fragility; and (2) to relate AA plasma levels to retinal hemorrhaging, another manifestation of microvascular fragility. DATA SOURCES Data were reviewed from 15 trials conducted in 6 countries with 1140 predominantly healthy participants with measures of gingival bleeding tendency, and from the National Health and Nutrition Examination Survey (NHANES) III of 8210 US residents with measures of retinal hemorrhaging. RESULTS In clinical trials, AA supplementation reduced gingival bleeding tendency when estimated baseline AA plasma levels were < 28 μmol/L (standardized mean difference [SMD], -0.83; 95%CI, -1.16 to -0.49; P < 0.002). Supplementation with AA did not unequivocally reduce gingival bleeding tendency when baseline estimated AA plasma levels were >48 μmol/L or unknown (respective standardized mean differences: -0.23, 95%CI, -0.45 to -0.01, P < 0.05; and -0.56; 95%CI: -1.19 to 0.06, P < 0.08). In NHANES III, prevalence of both retinal hemorrhaging and gingival bleeding tendency increased when AA plasma levels were within the range that protects against scurvy (11-28 μmol/L; respective prevalence ratios adjusted for age and sex: 1.47; 95%CI: 1.22-1.77; and 1.64; 95%CI: 1.32-2.03; P < 0.001 for both). CONCLUSION Consistent evidence from controlled clinical trials indicates that setting human AA requirements based on scurvy prevention leads to AA plasma levels that may be too low to prevent an increased gingival bleeding tendency. Gingival bleeding tendency and retinal hemorrhaging coincide with low AA plasma levels and thus may be reflective of a systemic microvascular pathology that is reversible with an increased daily AA intake.
Collapse
Affiliation(s)
- Philippe P Hujoel
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA.,Department of Oral Health Sciences, School of Dentistry, University of Washington, Seattle, Washington, USA
| | - Tomotaka Kato
- Department of Oral Health Sciences, School of Dentistry, University of Washington, Seattle, Washington, USA
| | - Isabel A Hujoel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Margaux L A Hujoel
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
10
|
Hujoel IA. Nutritional status in irritable bowel syndrome: A North American population-based study. JGH Open 2020; 4:656-662. [PMID: 32782953 PMCID: PMC7411643 DOI: 10.1002/jgh3.12311] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/23/2020] [Accepted: 01/29/2020] [Indexed: 12/17/2022]
Abstract
Background and Aim Irritable bowel syndrome (IBS) affects 12% of the population, and the evidence supporting current medical interventions is poor. There is increasing focus on the therapeutic benefit of diet and supplementation. We aim to compare dietary composition and hematologic and biochemical markers in those with and without IBS to determine potential targets for therapeutic supplementation. Methods All 17 national surveys between 1959 and 2019 were screened, and only 1, the Second National Health and Nutrition Examination Survey (NHANES II) (1976–1980), provided comprehensive data on IBS. We performed a cross‐sectional analysis of hematologic and biochemical markers and dietary composition of 12 295 individuals, aged 18–74, in NHANES II. Results Individuals with IBS had significantly higher copper–zinc ratios (1.70 vs 1.55, P = 0.048) and were more likely to have ratios above 1.8 (odds ratio 1.79, 95% confidence interval 1.02–3.13), indicative of underlying copper–zinc imbalance. While more likely to report dietary avoidances, they had no other evidence of nutritional deficiencies. In addition, dietary recall showed that those with IBS consumed more calories (P = 0.02), were more likely to take vitamin supplements (P = 0.003), and that their macro and micronutrient intake was not significantly different. Conclusions The findings suggest that individuals with IBS should be screened for copper–zinc imbalance. Given zinc's role in the immune system, the “brain–gut” axis, and the gastrointestinal barrier, the identified copper–zinc imbalance may play a role in perpetuating the underlying pathophysiology of IBS. Further studies are needed to investigate this hypothesis and the potential role of therapeutic zinc supplementation.
Collapse
Affiliation(s)
- Isabel A Hujoel
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA
| |
Collapse
|
11
|
Jansson-Knodell CL, Hujoel IA, West CP, Taneja V, Prokop LJ, Rubio-Tapia A, Murray JA. Sex Difference in Celiac Disease in Undiagnosed Populations: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2019; 17:1954-1968.e13. [PMID: 30448593 DOI: 10.1016/j.cgh.2018.11.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/29/2018] [Accepted: 11/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS A higher proportion of female vs male patients receive a diagnosis of celiac disease. Little is known about sex-based differences in the prevalence of celiac disease in undiagnosed populations. We aimed to address this knowledge gap with a systematic review and meta-analysis. METHODS We searched MEDLINE, Embase, Cochrane, and Scopus databases through 2017 for studies of screen-detected or undiagnosed celiac disease. Our final analysis included studies that included screening and confirmatory tests (either second serologic analysis or a small intestine biopsy) and provided information on the sex of participants. Studies were excluded if they were performed with specific, high-risk, or referral populations. The primary outcome was the percentage of undetected celiac disease among female and male patients. RESULTS We identified 4070 articles and analyzed data from 87. Our meta-analysis comprised data from 291,969 study participants. The pooled prevalence of undetected celiac disease in female participants was 0.589% (95% CI, 0.549%-0.629%) and in male participants was 0.415% (95% CI, 0.343%-0.487%). The risk of undetected celiac disease was higher among female than male participants (relative risk [RR], 1.42; 95% CI, 1.27-1.57; P < .00001). The I2 was 5% (low heterogeneity among studies). In subgroup analyses, the RR of celiac disease for girls vs boys was 1.79 (95% CI, 1.44-2.22; P < .00001; I2 = 18%), the RR for female vs male blood donors was 1.13 (95% CI, 0.76-1.69; P = .54; I2 = 0), and the RR for women vs men with villous atrophy was 1.38 (95% CI, 1.07-1.79; P = .01; I2 = 0). CONCLUSIONS In a systematic review and meta-analysis, we found a higher risk for celiac disease in women than men in an undiagnosed populations (identified through general population screening). The increased risk for celiac disease among girls and women should be considered for screening, diagnosis, and management strategies.
Collapse
Affiliation(s)
| | - Isabel A Hujoel
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Colin P West
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Veena Taneja
- Department of Immunology, Mayo Clinic, Rochester, Minnesota
| | | | - Alberto Rubio-Tapia
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
12
|
Abstract
The presentation in celiac disease is shifting from the classical malabsorptive presentation to more nonclassical presentations, requiring clinicians to maintain a high level of suspicion for the disease and to be aware of the possible extraintestinal manifestations. The diagnosis of celiac disease is guided by initial screening with serology, followed by confirmation with an upper endoscopy and small intestinal biopsy. In some pediatric cases, biopsy may be avoided.
Collapse
Affiliation(s)
- Isabel A Hujoel
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Norelle R Reilly
- Division of Pediatric Gastroenterology, Columbia University Medicine Center, 630 West 168th Street, PH-17, New York, NY 10032, USA
| | - Alberto Rubio-Tapia
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
| |
Collapse
|
13
|
Hujoel IA, Rubio-Tapia A. Letter: identifying coeliac disease among patients with bloating-Authors' reply. Aliment Pharmacol Ther 2018; 48:883. [PMID: 30281830 DOI: 10.1111/apt.14964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Isabel A Hujoel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Alberto Rubio-Tapia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
14
|
Hujoel IA, Murphree DH, Van Dyke CT, Choung RS, Sharma A, Murray JA, Rubio-Tapia A. Machine Learning in Detection of Undiagnosed Celiac Disease. Clin Gastroenterol Hepatol 2018; 16:1354-1355.e1. [PMID: 29253540 PMCID: PMC6004230 DOI: 10.1016/j.cgh.2017.12.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 12/06/2017] [Accepted: 12/12/2017] [Indexed: 02/07/2023]
Affiliation(s)
| | | | - Carol T. Van Dyke
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Rok Seon Choung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Ayush Sharma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Joseph A. Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Alberto Rubio-Tapia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
15
|
Hujoel IA, Jaeger TM. 65-Year-Old Woman With Chronic Eosinophilia. Mayo Clin Proc 2018; 93:646-650. [PMID: 29395353 DOI: 10.1016/j.mayocp.2017.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 04/29/2017] [Accepted: 05/04/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Isabel A Hujoel
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic, Rochester, MN
| | - Thomas M Jaeger
- Advisor to resident and Consultant in Primary Care Internal Medicine, Mayo Clinic, Rochester, MN.
| |
Collapse
|
16
|
Hujoel IA, Van Dyke CT, Brantner T, Larson J, King KS, Sharma A, Murray JA, Rubio-Tapia A. Natural history and clinical detection of undiagnosed coeliac disease in a North American community. Aliment Pharmacol Ther 2018; 47:1358-1366. [PMID: 29577349 PMCID: PMC5910260 DOI: 10.1111/apt.14625] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 01/14/2018] [Accepted: 03/02/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Coeliac disease is a substantially underdiagnosed disorder, with clinical testing currently guided by case finding. AIM To determine the presence of indications for diagnostic testing and frequency of clinical testing in undiagnosed coeliac disease. METHODS This was a case-control study of adults without prior diagnosis of coeliac disease. Undiagnosed cases were identified through sequential serology, and unaffected age- and gender-matched controls were selected. Medical records were systematically reviewed for indications for and evidence of clinical testing. RESULTS Of 47 557 adults, 408 cases of undiagnosed coeliac disease were identified. 408 serology negative matched controls were selected. Eight-matched pairs were excluded, leading to 800 included individuals (61% female; median age 44.2 years). The odds of any indication for clinical testing were similar among undiagnosed coeliac disease and controls (odds ratio (OR) 1.18; 95% CI: 0.85-1.63, P = 0.32). Most individual indications were not associated with serologic status. Exceptions to this include hypothyroidism, which was more likely in cases of undiagnosed coeliac disease, and dyspepsia and chronic diarrhoea, which were less likely. Cases of undiagnosed coeliac disease were more likely to develop osteoporosis (P = 0.005), dermatitis herpetiformis (P = 0.006), chronic fatigue (P = 0.033), thyroiditis (P = 0.003), autoimmune diseases (P = 0.008), and have a family member diagnosed with coeliac disease (P = 0.001). CONCLUSION This study strongly suggests that current case finding is not effective in detecting undiagnosed coeliac disease. Individuals with undiagnosed coeliac disease were more likely than controls to develop indications for testing overtime. A more effective method for detection of coeliac disease is needed.
Collapse
Affiliation(s)
| | - Carol T. Van Dyke
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Tricia Brantner
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Joseph Larson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN 55905
| | - Katherine S. King
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN 55905
| | - Ayush Sharma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Joseph A. Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| | - Alberto Rubio-Tapia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905
| |
Collapse
|
17
|
Jansson-Knodell CL, Hujoel IA, Rubio-Tapia A, Murray JA. Not All That Flattens Villi Is Celiac Disease: A Review of Enteropathies. Mayo Clin Proc 2018; 93:509-517. [PMID: 29622097 DOI: 10.1016/j.mayocp.2017.10.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 10/20/2017] [Accepted: 10/24/2017] [Indexed: 12/27/2022]
Abstract
Enteropathies can be overwhelming for clinicians. There is a wide spectrum of diseases involved; their effect on patients can be severe; and their underlying cause can be obscure. In this article, we outline a practical approach to enteropathies that are most common and not to be missed and is applicable to general and specialist physicians.
Collapse
Affiliation(s)
| | | | | | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
| |
Collapse
|
18
|
Rubio-Tapia A, Hujoel IA, Wu TT. An Unusual Finding During Evaluation of Iron Deficiency. Gastroenterology 2017; 153:1486-1487. [PMID: 29104102 DOI: 10.1053/j.gastro.2017.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 04/05/2017] [Indexed: 12/02/2022]
Affiliation(s)
- Alberto Rubio-Tapia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Isabel A Hujoel
- Division of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Tsung-Teh Wu
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
19
|
Rubio-Tapia A, Hujoel IA, Smyrk TC, Poterucha JJ. Emerging secondary syphilis presenting as syphilitic hepatitis. Hepatology 2017; 65:2113-2115. [PMID: 27981616 DOI: 10.1002/hep.28974] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 12/01/2016] [Indexed: 12/07/2022]
Affiliation(s)
| | | | | | - John J Poterucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| |
Collapse
|
20
|
Lin E, Hujoel IA, Mason TG. Still Febrile After All These Weeks. Am J Med 2017; 130:e81-e83. [PMID: 27751898 DOI: 10.1016/j.amjmed.2016.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 09/12/2016] [Accepted: 09/12/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Erica Lin
- Department of Rheumatology, Mayo Clinic, Rochester, Minn
| | | | - Thomas G Mason
- Department of Rheumatology, Mayo Clinic, Rochester, Minn.
| |
Collapse
|
21
|
Hujoel IA. The association between serum calcium levels and Chvostek sign: A population-based study. Neurol Clin Pract 2016; 6:321-328. [PMID: 29443134 PMCID: PMC5727700 DOI: 10.1212/cpj.0000000000000270] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 03/31/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Chvostek sign-a contraction of ipsilateral facial muscles subsequent to percussion over the facial nerve-is considered a clinical indicator of hypocalcemia. I sought to evaluate the association between Chvostek sign and serum calcium levels. METHODS I performed a cross-sectional analysis of data gathered from a nationwide probability sample of 3,434 individuals, aged 25-74 years, in the First National Health and Nutrition Examination Survey, conducted from 1971 to 1975. RESULTS Increasing serum calcium levels were associated with an increased odds for a positive Chvostek sign. When compared to calcium levels in the lowest quartile (5.47-9.4 mg/dL), individuals with serum calcium levels of 9.4-9.6 mg/dL, 9.6-9.9 mg/dL, and 9.9-11.9 mg/dL had a 195% (95% confidence interval [CI] 23.3%-604%), 124% (95% CI -0.8% to 407%), and 159% (95% CI 33.8%-401%) increased odds-as opposed to the expected decreased odds-for a positive Chvostek sign. When adjusting for age, sex, and race, these increased odds were 220% (95% CI 32%-679%), 125% (95% 0.00%-409%), and 172% (35%-448%), respectively. For every 1 g/dL increase in serum calcium level, the odds for a positive Chvostek sign increased by 4% (95% CI 0.00%-8%). CONCLUSIONS A positive Chvostek sign is informative of normal to increased serum calcium levels rather than hypocalcemia.
Collapse
|
22
|
Salameh TS, Bullock KM, Hujoel IA, Niehoff ML, Wolden-Hanson T, Kim J, Morley JE, Farr SA, Banks WA. Central Nervous System Delivery of Intranasal Insulin: Mechanisms of Uptake and Effects on Cognition. J Alzheimers Dis 2016; 47:715-28. [PMID: 26401706 DOI: 10.3233/jad-150307] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Intranasal insulin has shown efficacy in patients with Alzheimer's disease (AD), but there are no preclinical studies determining whether or how it reaches the brain. Here, we showed that insulin applied at the level of the cribriform plate via the nasal route quickly distributed throughout the brain and reversed learning and memory deficits in an AD mouse model. Intranasal insulin entered the blood stream poorly and had no peripheral metabolic effects. Uptake into the brain from the cribriform plate was saturable, stimulated by PKC inhibition, and responded differently to cellular pathway inhibitors than did insulin transport at the blood-brain barrier. In summary, these results show intranasal delivery to be an effective way to deliver insulin to the brain.
Collapse
Affiliation(s)
- Therese S Salameh
- Geriatrics Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA.,Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Kristin M Bullock
- Geriatrics Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Isabel A Hujoel
- Geriatrics Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Michael L Niehoff
- Division of Geriatrics, Department of Internal Medicine, Saint Louis University, St. Louis, MO, USA.,Veterans Affairs Medical Center-St. Louis, St. Louis, MO, USA
| | - Tami Wolden-Hanson
- Geriatrics Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Junghyun Kim
- Division of Geriatrics, Department of Internal Medicine, Saint Louis University, St. Louis, MO, USA
| | - John E Morley
- Division of Geriatrics, Department of Internal Medicine, Saint Louis University, St. Louis, MO, USA
| | - Susan A Farr
- Division of Geriatrics, Department of Internal Medicine, Saint Louis University, St. Louis, MO, USA.,Veterans Affairs Medical Center-St. Louis, St. Louis, MO, USA
| | - William A Banks
- Geriatrics Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA.,Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
23
|
Affiliation(s)
- Isabel A Hujoel
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alberto Rubio-Tapia
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|