Cortisol levels in hair are altered in irritable bowel syndrome - A case control study in primary care

OBJECTIVE

Stress is an important component in the pathophysiology of irritable bowel syndrome (IBS). Long term Hypothalamus Pituitary Adrenal (HPA)-axis activity can be studied by measuring hair cortisol concentrations (HCC). Some previous studies have indicated a dysregulated HPA-axis in IBS patients, but cortisol levels in hair have not yet been studied. We investigated whether HCC and self-reported stress differentiate IBS patients from controls.

METHODS

In a cross-sectional study within 10 Swedish Primary Health Care Centers we compared patients in working age with active IBS to patients without GI complaints. The participants donated hair samples and completed questionnaires including a scale of self-reported perceived stress (PSS). 169 Rome III-fulfilling IBS patients and 316 non-IBS patients were available for final analyses.

RESULTS

IBS patients had significantly lower HCC, median=16.3pg/mg, IQR=26.9pg/mg, compared to non-IBS patients, median=22.8pg/mg, IQR=29.1pg/mg. There was also a difference in the distribution of HCC quintiles between the two groups, with 30.2% IBS patients and 14.2% of non-IBS patients in the lowest quintile of HCC. PSS was higher among IBS patients with a mean (SD) total score of 25.3 (8.0) compared to controls 21.4, (7.5). Quintiles of HCC and PSS stayed significantly but very weakly related to IBS (B=-0.332, Std error=0.146, p<0.005) in multivariable analyses.

CONCLUSION

This study suggests a possible suppression of the HPA-axis activity in a considerable portion of IBS patients.

Nursing assistants: "he seems to be ill" - a reason for nurses to take action: validation of the Early Detection Scale of Infection (EDIS)

BACKGROUND

Signs and symptoms of infection in frail elderly are atypical, causing delay in diagnosis and treatment. To improve communication between healthcare staff of signs and symptoms of infection we developed an instrument, using qualitative data from observations by nursing assistants when they suspected infection. The aim of this study was to assess the validity of nursing assistants observations by developing and testing the instrument for early detection of infection in elderly nursing home residents.

METHODS

The early detection of infection (EDIS) instrument was based on data from focus interviews with nursing assistants. Over one year the nursing assistants used EDIS to document episodes of suspected early signs and symptoms of infection in 204 nursing home residents. Two physicians classified documented episodes as "no infection", "possible infection", and "infection". The content validity of the 13 items of the EDIS was established to explore the relationships between the items. The construct validity was used to explore the relationship between the items and the presence or absence of infection. The predictive value of the developed model was evaluated by the percentage of correct classifications of the observed cases. Generalized linear model (ordinal multinomial distribution and logit link) was used.

RESULTS

Of the 388 events of suspected infection, 20 % were assessed as no infection, 31 % as possible infection and 49 % as infection. Content validity analysis showed that 12/13 of the items correlated significantly with at least one other statement. The range in number of significant inter-correlations was from 0 ("pain") to 8 ("general signs and symptoms of illness"). The construct validity showed that the items "temperature" , "respiratory symptoms" and "general signs and symptoms of illness" were significantly related to "infection", and these were also selected in the model-building. These items predicted correct alternative responses in 61 % of the cases.

CONCLUSION

The validation of EDIS suggests that the observation of "general signs and symptoms of illness", made by nursing assistants should be taken seriously in detecting early infection in frail elderly. Also, the statement "He/She is not as usual" should lead to follow-up.

Importance of dietary advice, nutritional supplements and compliance for maintaining body weight and body fat after hip fracture

OBJECTIVE

Poor nutritional status amongst elderly individuals with hip fractures is well documented. Studies have suggested that 30-50 % of patients admitted to orthopaedic departments suffer from protein-energy malnutrition (PEM).

DESIGN

An 6 month intervention study.

SETTING

The study was conducted in Sweden between February 2005 and October 2006.

PARTICIPANTS

Elderly patients with hip fractures (n=32).

METHODS

Evaluation of compliance with individual nutritional support and whether body weight and body fat (BF) could be maintained after six months. Evaluation of possible effects of nutritional supplements and dietary advice after hip fracture on BMI, BF, and Mini Nutritional Assessment (MNA).

RESULTS

Overall compliance with supplement intake was 73%. After six months, BMI was unchanged. Women's BF had decreased (P < 0.01), although the mean calorie intake with nutritional support was 34 calories per kg body weight/day. Three groups could be identified: one group with increased body weight and BF, one with loss of body weight and BF, and one with increased body weight together with increased TBW and loss of BF. PARTICIPANTS who consumed 0-1 supplements daily lost more weight than those who consumed 2 supplements daily. There was a positive difference (p= < 0.001) for women between MNA values at baseline and after six months.

CONCLUSION

In the present study compliance was satisfactory at the group level, and the energy and protein intake increased significantly. BMI was unchanged during the 6 months period. However, the women lost BF during the study period of with some had increasing total body water (TBW). MNA values for women changed in a positive direction.

Point‐of‐care testing has a limited effect on time to clinical decision in primary health care

OBJECTIVE

To investigate the clinical logistics of laboratory routines at primary health care centres (PHCs).

DESIGN AND METHODS

Prospective registration was carried out for each PHC using questionnaires during 2-week intervals between the end of November 2001 and mid-January 2002. The study included 9 PHCs in the county of Ostergötland and 4 in the county of Jönköping, Sweden, with different numbers of blood tests analysed using point-of-care testing (POCT). Data for B-glucose, HbA1c, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), thyroid-stimulating hormone (TSH), T4, cholesterol, HDL-cholesterol, LDL-cholesterol and triglycerides were collected. Main outcome measures were median time from sampling to available test result (TATa) and median time from sampling to clinical decision (TATd), and the proportion of patients informed of the outcome of the blood test in question during the sampling occasion.

RESULTS

A total of 3542 samples were collected. The median TATa showed that B-glucose, ESR and CRP were immediately analysed at all 13 PHCs. For the other tests, TATa varied from immediately to about two days. The median TATd varied from immediately to about a week. When POCT was used, 30% of the patients were informed about the outcome of the test during the sampling occasion.

CONCLUSION

POCT has a limited effect on the clinical logistics in PHCs.

Carotid intima-media thickness and apolipoprotein B/apolipoprotein A-I ratio in middle-aged patients with Type 2 diabetes

AIMS

To explore the association between carotid intima-media thickness (IMT) and the apolipoprotein B (apoB)/apolipoprotein A-I (apoA-I) ratio compared with conventional lipids in middle-aged patients with Type 2 diabetes.

METHODS

We analysed data from 247 patients with Type 2 diabetes, aged 55-66 years, in the Cardiovascular Risk factors in Patients with Diabetes-a Prospective study in Primary care (CARDIPP-1) study. Primary care nurses measured blood pressure and anthropometric characteristics. Blood samples were taken for laboratory analyses. The carotid IMT was determined by ultrasonography at the University Hospital in Linköping and at the County Hospital Ryhov, Jönköping, Sweden.

RESULTS

The ApoB/apoA-I ratio (r = 0.207, P = 0.001), apoB (r = 0.166, P = 0.009) and non-high-density lipoprotein cholesterol (non-HDL-c) (r = 0.129, P = 0.046) correlated with IMT. Conventional lipids, high-sensitivity C-reactive protein (hsCRP), glycated haemoglobin (HbA(1c)) and systolic blood pressure were not significantly correlated to IMT. A stepwise logistic regression analysis was conducted with IMT as the dependent variable and the apoB/apoA-I ratio, HbA(1c), hsCRP, low-density lipoprotein cholesterol (LDL-c), total cholesterol, non-HDL-c and treatment with statins as independent variables. Following adjustment for age and gender, only the apoB/apoA-I ratio remained significantly associated with IMT (odds ratio 4.3, 95% confidence intervals 1.7-10.8, P = 0.002).

CONCLUSIONS

We conclude that there was a significant association between the apoB/apoA-I ratio and IMT in middle-aged patients with Type 2 diabetes. The association was independent of conventional lipids, hsCRP, glycaemic control and use of statins.

IgA endomysium antibodies--an early predictor for celiac disease in children without villous atrophy

AIM

To evaluate possible differences between children with anti-endomysium antibodies (EMA) positivity and normal small bowel mucosa and children with positive EMA and an enteropathy diagnosed as celiac disease (CD).

METHODS

Children with suspected CD and positive EMA (>or=1/10) undergoing small bowel biopsy during 1996 to 2002, were investigated (n=133). Data registered were: year and month of birth, timing of the first biopsy, sex, heredity for CD, dermatitis herpetiformis and diabetes mellitus and outcome of the anti-gliadin antibody test (AGA). The case group, with EMA positivity and normal histology (n=39; 59% female, mean age at the first biopsy 7.3 years, range 1.4-16), was compared with the disease control group, with positive EMA and a biopsy suggestive and further on diagnosed as CD (n=94; 56% female; mean age 7.6 years at the first biopsy, range 0.70-17).

RESULTS

AGA positivity and heredity for CD were found to predict the outcome of a pathological jejunal mucosa. Nineteen of the 39 children in the case group were rebiopsied of whom 11 had developed an enteropathy during a follow-up period of 2-7 years (median 4.5 years).

CONCLUSIONS

EMA positivity in the absence of small bowel enteropathy could be a very early predictor for later overt CD, and necessitates further follow-up, especially if the child is AGA positive and there is a family history of CD.

Patients with irritable bowel syndrome in primary care appear not to be heavy healthcare utilizers

BACKGROUND

Irritable bowel syndrome is a frequently diagnosed gastrointestinal condition in general practice. Managing this chronic condition requires a co-ordinated effort between patient and doctor.

AIM

To explore the patterns of treatment and healthcare utilization of irritable bowel syndrome cases in a Swedish primary care setting.

METHODS

All cases with a registered diagnosis of irritable bowel syndrome were identified retrospectively for a 5-year period through computerized medical records at three primary healthcare centres in Sweden. Documentation of diagnosis, healthcare visits, treatments, investigations, medications, referrals, laboratory tests, mental and demographic data were retrieved from the records.

RESULTS

Of all 723 irritable bowel syndrome patients identified, only 37% had a follow-up appointment to their General Practitioner during the study period. For 80%, the General Practitioner initiated some treatment during the initial consultation and 75% were prescribed medication. Fibre and bulking laxatives and acid-suppressive drugs were the most common medication. Almost a quarter was referred for complementary investigations at hospital, only 8.9% of the irritable bowel syndrome patients were referred to a specialist investigation. Laboratory investigations varied and were ordered more frequently (P = 0.05) for men.

CONCLUSIONS

Irritable bowel syndrome patients appear not to be heavy utilizers of primary care and, of those who attend, the majority are managed by their General Practitioner.

Increased prevalence of anti-gliadin IgA-antibodies with aberrant duodenal histopathological findings in patients with IgA-nephropathy and related disorders

BACKGROUND

Antibodies present in coeliac disease may occur in IgA-nephropathy. This raises the question of food intolerance in the disease. Evidence for a true correlation between the two disorders has however been scarce.

DESIGN

Sera from 89 patients with IgA-nephropathy and 13 other patients with IgA deposits in the glomeruli of kidney biopsies were analysed for IgA-antibodies to gliadin, endomysium and tissue transglutaminase (92/102 patients).

RESULTS

Eleven out of 89 (12.4%) of the patients with IgA-nephropathy and five of the 13 others (38%) had elevated titres of IgA-antibodies to gliadin but, in all cases but one, normal IgA-antibodies to endomysium. Patients with IgA-nephropathy and elevated IgA-antibodies to gliadin had elevated total serum IgA more frequently than patients who had not (p<0.01). Two patients with IgA-nephropathy and one with Hennoch Schönlein's purpura had elevated IgA-antibodies to tissue transglutaminase. Small bowel biopsy in 7 out of 11 IgA-antibodies to gliadin positive patients with IgA-nephropathy was pathologic in three cases (two with Marsh I) . One patient with chronic glomerulnephritis also had Marsh I.

CONCLUSIONS

We found no increased frequency of verified coeliac disease in 89 patients with IgA-nephropathy. Two patients with IgA-nephropathy and one patient with chronic glomerulonephritis with IgA deposits in the kidney biopsy had a Marsh I histopathology. The findings suggest a possible link of celiac disease to IgA-nephropathy and a role for antibodies to food antigens in this disorder.

Oats to children with newly diagnosed coeliac disease: a randomised double blind study

BACKGROUND

Treatment of coeliac disease (CD) requires lifelong adherence to a strict gluten free diet (GFD) which hitherto has consisted of a diet free of wheat, rye, barley, and oats. Recent studies, mainly in adults, have shown that oats are non-toxic to CD patients. In children, only open studies comprising a small number of patients have been performed.

AIM

To determine if children with CD tolerate oats in their GFD.

PATIENTS AND METHODS

In this double blind multicentre study involving eight paediatric clinics, 116 children with newly diagnosed CD were randomised to one of two groups: one group was given a standard GFD (GFD-std) and one group was given a GFD with additional wheat free oat products (GFD-oats). The study period was one year. Small bowel biopsy was performed at the beginning and end of the study. Serum IgA antigliadin, antiendomysium, and antitissue transglutaminase antibodies were monitored at 0, 3, 6, and 12 months.

RESULTS

Ninety three patients completed the study. Median (range) daily oat intake in the GFD-oats group (n = 42) was 15 (5-40) g at the six month control and 15 (0-43) g at the end of the study. All patients were in clinical remission after the study period. The GFD-oats and GFD-std groups did not differ significantly at the end of the study regarding coeliac serology markers or small bowel mucosal architecture, including numbers of intraepithelial lymphocytes. Significantly more children in the youngest age group withdrew.

CONCLUSIONS

This is the first randomised double blind study showing that the addition of moderate amounts of oats to a GFD does not prevent clinical or small bowel mucosal healing, or humoral immunological downregulation in coeliac children. This is in accordance with the findings of studies in adult coeliacs and indicates that oats, added to the otherwise GFD, can be accepted and tolerated by the majority of children with CD.

Better dietary compliance in patients with coeliac disease diagnosed in early childhood

BACKGROUND

In coeliac disease (CD) there is a permanent gluten intolerance requiring life-long adherence to a strict gluten-free diet (GFD). An inadequate diet increases the risk for long-term complications. Coeliac patients often have great difficulty in maintaining a strictly GFD. We aimed to study whether young adults with CD diagnosed before the age of 4 years have a better dietary compliance than patients diagnosed later in life.

METHOD

Twenty-nine adults with CD diagnosed in childhood were studied. They had had CD for 17-24 (mean 20) years. Their compliance to GFD was assessed using a questionnaire and serological markers (IgA and IgG anti-endomysium antibodies and IgA anti-tissue transglutaminase antibodies).

RESULTS

At least 80% of the coeliac patients who had been diagnosed before the age of 4 years complied with the GFD compared to 36% of the CD patients older than 4 years at diagnosis (P < 0.05).

CONCLUSION

This is the first study to show that patients with CD diagnosed before 4 years of age keep to a GFD significantly better than patients diagnosed after 4 years. It is thus important to diagnose childhood CD as early as possible in order to minimize the risk for reduced well-being and other potentially serious complications in coeliac individuals on an inadequate diet.

Familial prevalence of coeliac disease: a twenty-year follow-up study

BACKGROUND

The genetic predisposition of coeliac disease (CD) is well known. Previous studies of first-degree relatives of coeliac patients have shown that as many as 10% have the disease. In 1981, we published a study in which all first-degree relatives of 32 index patients with CD were investigated by small-bowel biopsy. We found 2 relatives (2%) with CD. The present study is a re-investigation of all first-degree relatives of the same index patients performed 20-25 years after the first study to reveal any new cases of CD in this high-risk population.

METHODS

All 120 first-degree relatives were screened for CD by means of serological markers of CD. The relatives with positive markers were submitted to small-bowel biopsy.

RESULTS

Eight new cases of CD were found among the relatives. Two had been investigated by small-bowel biopsy 20 years previously, when they had only minor mucosal changes not classified as CD. The other six new cases of CD were found among offspring of the index patients and were born after completion of the previous study. Thus no new case of CD was found among those relatives who had a completely normal small-bowel biopsy 20-25 years previously.

CONCLUSIONS

The high prevalence of CD among first-degree relatives of coeliac patients (8.3% in this study) supports the need to screen for CD in this high-risk population. Even relatives with only mild enteropathy should be followed carefully, since some may subsequently develop CD.

High prevalence rates of adult silent coeliac disease, as seen in Sweden, must be expected in Denmark

AIM

To disclose the prevalence of adult "silent" coeliac disease in Denmark and Sweden.

EXPERIMENTAL DESIGN

1573 Danish and 1866 Swedish healthy blood donors were screened for the presence of serum anti-gliadin antibodies (AGA) by enzyme-linked immunosorbent assay. AGA-positive serum samples were further analysed for IgA anti-endomysium antibodies (EmA) by indirect immunofluorescence microscopy.

MAIN RESULTS

The Danish donor population had a higher mean age than the Swedish (41.4 years versus 37.6 years) and a higher proportion of females (41% versus 32%), and had a lower mean level of AGA (17.3 units versus 20.6 units). Sixty-one (3.9%) Danish donors had AGA above the cut-off limit, and four of these also had positive EmA tests. Sixty (3.2%) Swedish donors had AGA above the cut-off limit, and five of these also had positive EmA. Coeliac pathology was proven by biopsy in all five coeliac disease-suspected Swedish donors. No small intestinal biopsy was performed in the coeliac disease-suspected Danish donors.

CONCLUSIONS

Based upon the finding of EmA in AGA-positive serum samples, silent coeliac disease may be suspected in 1 per 394 Danish blood donors (2.5 per 1,000). A similar rate was proven in 1 per 373 Swedish blood donors (2.7 per 1,000), indicating no major differences in the prevalence of adult silent coeliac disease between the two neighbouring countries.

New automated immunoassay measuring immunoglobulin A antigliadin antibodies for prediction of celiac disease in childhood

The prevalence of celiac disease (CD) in Sweden is about 4 cases per 1,000 people. Screening for CD with serological tests indicates similar high prevalences in many other countries. Between 1 November 1992 and 30 April 1995, 133 children (9 months to 16.7 years of age) with suspected CD were studied. The predictive value (PV) of immunoglobulin A antigliadin antibodies (IgA-AGA) in the serum as assayed with two new commercial automated immunoassays--the Pharmacia CAP System Gliadin IgA FEIA (CAP) and the UNICAP-100 (UNICAP)--and with three "in-house" methods was evaluated using assessment of the small intestinal mucosa morphology as the "gold standard." All serum samples were analyzed for total serum IgA. At presentation the diagnostic sensitivities and specificities of the different tests varied from 0.72 to 0.88 and 0.67 to 0.87, respectively. All methods showed a higher sensitivity for CD in younger children. The area under each assay's receiver operating characteristic curve was calculated and varied between 0.82 and 0.89. The positive and negative PVs for the CAP and UNICAP, which were assays with a high sensitivity and a high specificity, respectively, were estimated. In the clinically selected population (prevalence of CD, 1 in 3) the positive PV was about 55%, and in the general population (prevalence, 1 in 250) it was about 1%. The negative PVs for both CAP and UNICAP were close to 100%; thus, when the AGA test was negative, the risk for CD was small. Interestingly, five children had serum IgA levels below the detection limit (<0.07 g/liter) when on a gluten-free diet, whereas they had normal levels at the time of the first biopsy. In conclusion, the automated immunoassays--based on ImmunoCAP technology--for analysis of IgA-AGA had a reliability comparable to that of the in-house methods.

Development of IgG1 and IgG4 antibodies against beta-lactoglobulin and ovalbumin in healthy and atopic children

BACKGROUND

The IgG responses to food antigens are preferentially restricted to the IgG1 and IgG4 subclasses. Increased levels of IgG1 and IgG4 antibodies against food allergens have been reported in girls and adults with current atopic eczema.

OBJECTIVE

To study the relation between the levels of IgG1 and IgG4 antibodies against beta-lactoglobulin and ovalbumin and the development of atopic disease.

MATERIAL AND METHODS

Atopic symptoms were recorded in 36 girls from birth to 7 years of age. Blood samples were taken at 3 and 8 months and at 2, 4, and 7 years. IgG1 and IgG4 antibodies were measured by ELISA.

RESULTS

Anti-beta-lactoglobulin IgG1 was detected at all ages, peaking at 8 months. Anti-beta-lactoglobulin IgG4 antibodies were detected in 18 to 29 girls at different ages and the antibody levels peaked at 2 years. The levels of anti-beta-lactoglobulin IgG1 were lower in atopic, as compared with healthy individuals at 4 and 7 years (P < .01 and P < .05) and lower anti-beta-lactoglobulin IgG4 antibody levels were found in atopic individuals (P < .05) at 4 years. Anti-ovalbumin IgG1 antibodies were detected in 3/35 girls at 3 months and in 16/35 to 26/35 girls later in life. The number of positive samples and antibody levels peaked at 2 years. Anti-ovalbumin IgG4 positive samples increased from 4/33 at 8 months to 30/32 at 7 years. The levels increased up to 2 years and then remained stable. The anti-ovalbumin IgG1 antibody levels were lower in atopic girls at 4 years (P < .05), while the anti-ovalbumin IgG4 antibody levels were similar at all ages.

CONCLUSION

An early IgG1 response and later appearing IgG4 antibodies to the two food antigens beta-lactoglobulin and ovalbumin are common during the first years of life. The levels were similar in the nonatopic and the atopic girls up to four years; then they tended to be lower in the first group.

Screening for coeliac disease in apparently healthy blood donors

As gliadin is a common food antigen for many people, we have developed an ELISA for the detection of class-specific antigliadin antibodies (AGA), with which sera from a large population of apparently healthy blood donors was analysed. A very high prevalence (1/256) of positive AGA was found. However, the positive predictive value (+PV) was found to be very low, 20% for IgA-AGA and 0% for IgG-AGA alone. When screening large populations with no or few symptoms, it is desirable to have a high +PV to avoid unnecessary biopsies. IgA antiendomysium antibodies (IgA-EMA) were evaluated both as a single test and in combination with IgA-AGA. When screening individuals for CD in a population with no or few symptoms the easy and cheap IgA-AGA assay should be used as a first test and the IgA-EMA to verify the diagnosis and avoid unnecessary biopsies.

Is small bowel biopsy necessary in adults with suspected celiac disease and IgA anti-endomysium antibodies? 100% positive predictive value for celiac disease in adults

The comparative diagnostic value of IgA anti-endomysium and IgA antigliadin antibodies in adults with histologically confirmed celiac disease is reported. Sera from 144 adult patients (without concurrent dermatitis herpetiformis or IgA deficiency) who underwent small bowel biopsy were analyzed for both IgA anti-endomysium and IgA anti-gliadin antibodies. Nineteen patients (13%) had celiac disease. The presence of IgA antiendomysium antibodies had a sensitivity of 74% and a specificity of 100%. The positive and negative predictive values were 100% and 96%, respectively, and the diagnostic accuracy was 97%. In contrast, IgA anti-gliadin antibodies had positive and negative predictive values of 28% and 96%, respectively, with a diagnostic accuracy of 71%. Based on these data, we suggest that small bowel biopsy is not necessary to diagnose celiac disease in symptomatic adults with IgA antiendomysium antibodies. Due to a negative predictive value of 96%, some symptomatic adults lacking anti-endomysium antibodies will not be correctly diagnosed without small bowel biopsy.

Anti-endomysium and anti-gliadin antibodies as serological markers for coeliac disease in childhood: a clinical study to develop a practical routine

Anti-gliadin and anti-endomysium antibodies were analyzed in 174 children with suspected or verified coeliac disease with the aim of developing a practical routine. The biopsy was performed without knowledge of the antibody levels. To screen for coeliac disease is children younger than 2 years, we suggest the use of IgA anti-gliadin antibodies, giving a sensitivity of 100% and a specificity of 86%. In older children both tests should be used in parallel, i.e. a biopsy should be performed if at least one of the tests is positive, giving a sensitivity of 98% and a specificity of 81%. To avoid unnecessary biopsy before mucosal relapse can be demonstrated during gluten challenge in a child without clinical symptoms, we suggest that the tests are used as serial testing, i.e. a biopsy should be performed if both tests are positive.

IgA antiendomysium antibodies have a high positive predictive value for celiac disease in asymptomatic patients

Many attempts have been made to find screening tests for celiac disease to reduce the need for biopsy, or to achieve better selection criteria before intestinal biopsy. We have recently analyzed apparently healthy blood donors for antigliadin antibodies (AGA) to select subjects for further gastrointestinal investigation. A prevalence of gluten enteropathy of at least 1/256 was found in this population. The positive predictive value (+PV), however, was only 20%. In the present study we have analyzed IgA antiendomysium antibodies (IgA-EmA) to estimate the sensitivity and specificity of the test, and determine whether or not the +PV of the assay increases when screening for adult celiac disease in an asymptomatic population. We found that asymptomatic persons with celiac disease may have IgA-EmA. We found a 100% specificity of IgA-EmA in the tested population of blood donors, whereas the sensitivity was about the same as that of IgA-AGA. This result of a +PV of 100% indicates that a positive IgA-EmA could replace biopsy in diagnosing celiac disease. However, further extended studies are needed to determine whether this is applicable in other populations. To screen patients for celiac disease, we recommend the easy and cheap IgA-AGA assay as a preliminary test and the IgA-EmA to verify the diagnosis and avoid unnecessary biopsies.

High prevalence of celiac disease in healthy adults revealed by antigliadin antibodies

Sera from 1866 healthy blood donors and from 40 untreated adults with celiac disease were analyzed using a micro-ELISA assay. Blood donors with IgA antigliadin activity greater than 40 units corresponding to the 96.8th percentile and IgG antigliadin activity greater than 20 units corresponding to the 91.3rd percentile were selected for further investigation and jejunal biopsy. Seven of 49 blood donors with high IgA antigliadin activity showed mucosal lesions typical for celiac disease. None of the donors with high IgG antigliadin activity (35 subjects) but without high IgA activity had such mucosal lesions. A prevalence of celiac disease of at least 1/256 was observed in the donor group. There were significant age-group differences in IgA antigliadin activity. In the present study, a high IgA antigliadin activity had a positive predictive value between 18% and 25% in individuals without symptoms indicative of celiac disease depending on the way the cut-off points were chosen. In contrast, the positive predictive value of high IgG antigliadin activity alone was estimated to be 0%.

The effect of maternal avoidance of eggs, cow's milk, and fish during lactation on the development of IgE, IgG, and IgA antibodies in infants

Serum levels of IgE, IgE antibodies to egg white (EW) and cow's milk (CM), IgG, and IgA antibodies to ovalbumin (OA) and beta-lactoglobulin (BLG) were measured in a group of 115 infants with a family history of atopy/allergy at birth and at 3, 6, 9, 12, and 18 months of age. The mothers of 65 infants avoided eggs, CM, and fish during the first 3 months of lactation (maternal antigen avoidance diet, D group), whereas the remaining 50 mothers had no diet restrictions (no maternal antigen avoidance diet, ND group). CM was introduced after 6 months of age and EW after 9 months. The only statistically significant difference between the D and ND group infants was a lower rate of specimens with IgE antibodies to EW and/or CM in the infants at 3 months of age (p = 0.008). IgE antibodies to EW and/or CM appeared in 62 infants during the study period and often during complete breast-feeding. In 40 of the infants, IgE antibodies appeared before the introduction of EW and CM into the diet. The IgE concentrations of the D and the ND group infants were similar. Cord-blood IgE was a poor predictor of atopy/allergy; for example, only seven of 103 infants with double heredity for atopy/allergy had values above the 90th percentile of our normal reference. The concentrations of IgG antibodies to OA and BLG were similar in the two groups. The levels decreased significantly (p less than 0.001) from birth to 6 months of age, indicating a passive placental transfer.(ABSTRACT TRUNCATED AT 250 WORDS)

Presence of IgA and IgG antigliadin antibodies in healthy adults as measured by micro-ELISA. Effect of various cutoff levels on specificity and sensitivity when diagnosing coeliac disease

In this study a micro-ELISA (ELISA = enzyme-linked immunosorbent assay) was established and used to evaluate IgA and IgG antigliadin antibodies in 1,866 healthy adults. There was a covariation between the level of IgA antigliadin antibodies and the total serum IgA concentration, probably due to an increased IgA response in some healthy subjects. We could not find any correlation between the presence of IgG and IgA antibodies in the healthy population using the 97.5th percentile as a cutoff value. The specificity of various cutoff levels was compared with the sensitivity of the test in a population of 40 patients with coeliac disease. IgA antigliadin antibodies had a high specificity (95%) at a cutoff value giving a high sensitivity (80%). This was not possible with IgG antigliadin antibodies which had a low sensitivity (40%) when the cutoff value was selected to give a high specificity. Due to the low prevalence of coeliac disease, a decrease in the specificity of the test will have a pronounced effect on the positive predictive value. The results indicate that only IgA antigliadin antibodies are useful markers when screening subjects with few typical symptoms for biopsy when diagnosing coeliac disease, whereas IgG antibodies are of low value because of their low specificity.