One-Year Outcomes Among Children Identified With Celiac Disease Through a Mass Screening Program

BACKGROUND & AIMS

Celiac disease (CD) mass screening remains controversial in part because of a paucity of data to support its benefit. The Autoimmunity Screening for Kids study is a mass screening study for pediatric CD and type 1 diabetes in Colorado.

METHODS

This study prospectively follows up children ages 1 to 17 years who screened positive for tissue transglutaminase IgA autoantibodies in the Autoimmunity Screening for Kids study subsequently referred for diagnostic evaluation. Children diagnosed with CD by biopsy or serologic criteria were included in this study. Evaluation at baseline and 12 month follow-up evaluation included demographics, laboratory studies, symptoms, health-related quality of life, anxiety/depression, and gluten-free diet adherence. Paired Student t test, chi-square, and Wilcoxon sign rank tests compared baseline and follow-up data. For symptom scores, odds of improvement were assessed.

RESULTS

Of the 52 children with CD enrolled, 42 children completed 12-month follow-up evaluation. On the symptom questionnaire completed at diagnostic evaluation, 38 of 42 children reported 1 or more symptoms. CD mean symptom severity and frequency scores improved from baseline to follow-up evaluation (P < .001). Reported health-related quality of life scores improved among caregivers (P = .002). There was no significant change in reported anxiety or depression. Iron deficiency without anemia was common at baseline (21 of 24 children; 87.5%) and normalized at follow-up evaluation (11 of 21 children; 52.3%). Twenty-six of 28 families reported good or excellent gluten-free diet adherence.

CONCLUSIONS

This novel study of children with CD identified through a mass screening program demonstrated improvement in symptoms, quality of life, and iron deficiency after 1 year follow-up evaluation. This demonstrates that there may be benefit to CD mass screening.

Exploratory Multisite MR Spectroscopic Imaging Shows White Matter Neuroaxonal Loss Associated with Complications of Type 1 Diabetes in Children

BACKGROUND AND PURPOSE

Type 1 diabetes affects over 200,000 children in the United States and is associated with an increased risk of cognitive dysfunction. Prior single-site, single-voxel MRS case reports and studies have identified associations between reduced NAA/Cr, a marker of neuroaxonal loss, and type 1 diabetes. However, NAA/Cr differences among children with various disease complications or across different brain tissues remain unclear. To better understand this phenomenon and the role of MRS in characterizing it, we conducted a multisite pilot study.

MATERIALS AND METHODS

In 25 children, 6-14 years of age, with type 1 diabetes across 3 sites, we acquired T1WI and axial 2D MRSI along with phantom studies to calibrate scanner effects. We quantified tissue-weighted NAA/Cr in WM and deep GM and modeled them against study covariates.

RESULTS

We found that MRSI differentiated WM and deep GM by NAA/Cr on the individual level. On the population level, we found significant negative associations of WM NAA/Cr with chronic hyperglycemia quantified by hemoglobin A1c (P < .005) and a history of diabetic ketoacidosis at disease onset (P < .05). We found a statistical interaction (P < .05) between A1c and ketoacidosis, suggesting that neuroaxonal loss from ketoacidosis may outweigh that from poor glucose control. These associations were not present in deep GM.

CONCLUSIONS

Our pilot study suggests that MRSI differentiates GM and WM by NAA/Cr in this population, disease complications may lead to neuroaxonal loss in WM in children, and deeper investigation is warranted to further untangle how diabetic ketoacidosis and chronic hyperglycemia affect brain health and cognition in type 1 diabetes.

Childhood growth prior to screen-detected celiac disease: prospective follow-up of an at-risk birth cohort

OBJECTIVES

To determine the association between childhood growth prior to the development of celiac disease (CD) and CD autoimmunity (CDA) identified by periodic serological screening.

STUDY DESIGN

The Diabetes Autoimmunity Study in the Young cohort includes 1979 genetically at-risk children from Denver, Colorado, with annual growth measurements from age nine months until ten years. Between 1993 and February 2019, 120 children developed CDA defined by persistent positive tissue transglutaminase autoantibodies (TGA); among these, 71 met our criteria for CD based on histopathological findings or high TGA levels. Age- and sex-specific z-scores of weight, body mass index (BMI), and height prior to seroconversion were derived using US reference charts as standards. Joint modeling of serial growth measurements was used to estimate adjusted hazard ratios (aHRs) accounting for celiac-associated human leukocyte antigens, early-life feeding practices, and socio-demographics.

RESULTS

In the first 10 years of life, there were no significant associations between the child's current weight, BMI and height and the risk of screening-detected CDA or CD, neither was the weight nor BMI velocity associated with CDA or CD as identified by screening (all aHRs approximated 1). Increased height velocity was associated with later CD, but not CDA, development (aHR per 0.01-z score/year, 1.28; 95% confidence interval [CI] 1.18-1.38 and 1.03; 0.97-1.09, respectively).

CONCLUSIONS

In the first 10 years of life, from prospectively collected serial growth measurements, we found no evidence of impaired childhood growth before CD and CDA development as identified through early and periodic screening.

Bone Mineral Density across the Lifespan in Patients with Type 1 Diabetes

CONTEXT

Fracture risk in people with type 1 diabetes (T1D) is higher than their peers without diabetes.

OBJECTIVE

To compare bone mineral density (BMD) across the lifespan in individuals with T1D and age- and sex-matched healthy controls.

DESIGN

Cross-sectional.

SETTING

Subjects (5-71 years) with T1D and matched controls from ongoing research studies at Barbara Davis Center for Diabetes.

PATIENTS OR OTHER PARTICIPANTS

Participants with lumbar spine BMD by dual X-ray absorptiometry (DXA) were divided into 2 groups: children ≤20 years and adults >20 years.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Comparison of BMD by diabetes status across age groups and sex using a linear least squares model adjusted for age and body mass index (body mass index (BMI) for adults; and BMI z-score in children).

RESULTS

Lumbar spine BMD from 194 patients with T1D and 156 controls were analyzed. There was no difference in age- and BMI-adjusted lumbar spine BMD between patients with T1D and controls: among male children (least squares mean ± standard error of the mean [LSM ± SEM]; 0.80 ± 0.01 vs 0.80 ± 0.02 g/cm2, P = .98) or adults (1.01 ± 0.03 vs 1.01 ± 0.03 g/cm2, P = .95), and female children (0.78 ± 0.02 vs 0.81 ± 0.02 g/cm2, P = .23) or adults (0.98 ± 0.02 vs 1.01 ± 0.02 g/cm2, P = .19). Lumbar spine (0.98 ± 0.02 vs 1.04 ± 0.02 g/cm2, P = .05), femoral neck (0.71 ± 0.02 vs 0.79 ± 0.02 g/cm2, P = .003), and total hip (0.84 ± 0.02 vs 0.91 ± 0.02, P = .005) BMD was lower among postmenopausal women with T1D than postmenopausal women without diabetes.

CONCLUSION

Across age groups, lumbar spine BMD was similar in patients with T1D compared with age- and sex-matched participants without diabetes, except postmenopausal females with T1D had lower lumbar spine, femoral neck, and total hip BMD.

Continuous Glucose Monitoring Predicts Progression to Diabetes in Autoantibody Positive Children

CONTEXT

Accurate measures are needed for the prediction and diagnosis of type 1 diabetes (T1D) in at-risk persons.

OBJECTIVE

The purpose of this study was to explore the value of continuous glucose monitoring (CGM) in predicting T1D onset.

DESIGN AND SETTING

The Diabetes Autoimmunity Study in the Young (DAISY) prospectively follows children at increased risk for development of islet autoantibodies (islet autoantibody positive; Ab+) and T1D.

PARTICIPANTS

We analyzed 23 Ab+ participants with available longitudinal CGM data.

MAIN OUTCOME MEASURE

CGM metrics as glycemic predictors of progression to T1D.

RESULTS

Of 23 Ab+ participants with a baseline CGM, 8 progressed to diabetes at a median age of 13.8 years during a median follow-up of 17.7 years (interquartile range, 14.6 to 22.0 years). Compared with nonprogressors, participants who progressed to diabetes had significantly increased baseline glycemic variability (SD, 29 vs 21 mg/dL; P = 0.047), daytime sensor average (122 vs 106 mg/dL; P = 0.02), and daytime sensor area under the curve (AUC, 470,370 vs 415,465; P = 0.047). They spent 24% of time at >140 mg/dL and 12% at >160 mg/dL compared with, respectively, 8% and 3% for nonprogressors (both P = 0.005). A receiver-operating characteristic curve analysis showed an AUC of 0.85 for percentage of time spent at >140 or 160 mg/dL. The cutoff of 18% time spent at >140 mg/dL had 75% sensitivity, 100% specificity, and a 100% positive predictive value for diabetes prediction, although these values could change because some nonprogressors may develop diabetes with longer follow-up.

CONCLUSIONS

Eighteen percent or greater CGM time spent at >140 mg/dL predicts progression to diabetes in Ab+ children.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

High Incidence of Celiac Disease in a Long-term Study of Adolescents With Susceptibility Genotypes

BACKGROUND & AIMS

Little is known about the incidence of celiac disease in the general population of children in the United States. We aimed to estimate the cumulative incidence of celiac disease in adolescents born in the Denver metropolitan area.

METHODS

We collected data on HLA-DR, DQ genotypes of 31,766 infants, born from 1993 through 2004 at St. Joseph's Hospital in Denver, from the Diabetes Autoimmunity Study in the Young. Subjects with susceptibility genotypes for celiac disease and type 1 diabetes were followed up for up to 20 years for development of tissue transglutaminase autoantibodies (tTGA). Outcomes were the development of celiac disease autoimmunity (CDA) or celiac disease. CDA was defined as persistence of tTGA for at least 3 months or development of celiac disease. Celiac disease was defined based on detection of Marsh 2 or greater lesions in biopsy specimens or persistent high levels of tTGA. For each genotype, the cumulative incidence of CDA and celiac disease were determined. To estimate the cumulative incidence in the Denver general population, outcomes by each genotype were weighted according to the frequency of each of these genotypes in the general population.

RESULTS

Of 1339 subjects followed up, 66 developed CDA and met criteria for celiac disease and 46 developed only CDA. Seropositivity for tTGA resolved spontaneously, without treatment, in 21 of the 46 subjects with only CDA (46%). The estimated cumulative incidence for CDA in the Denver general population at 5, 10, and 15 years of age was 2.4%, 4.3%, and 5.1%, respectively, and incidence values for celiac disease were 1.6%, 2.8%, and 3.1%, respectively.

CONCLUSIONS

In a 20-year prospective study of 1339 children with genetic risk factors for celiac disease, we found the cumulative incidence of CDA and celiac disease to be high within the first 10 years. Although more than 5% of children may experience a period of CDA, not all children develop celiac disease or require gluten-free diets.

Reduced Bone Mineral Density Is Associated with Celiac Disease Autoimmunity in Children with Type 1 Diabetes

OBJECTIVE

To evaluate the association between bone mineral density (BMD), glycemic control (hemoglobin A1c [HbA1c]), and celiac autoimmunity in children with type 1 diabetes mellitus (T1D) and in an appropriate control population.

STUDY DESIGN

BMD was assessed cross-sectionally in 252 children with T1D (123 positive for anti-tissue transglutaminase antibody [tTGA] and 129 matched children who were negative for tTGA). In addition, BMD was assessed in 141 children without diabetes who carried T1D-associated HLD-DR, DQ genotypes (71 positive for tTGA and 70 negative).

RESULTS

Children with T1D who were positive for tTGA had significantly worse BMD L1-L4 z-score compared with children with T1D who were negative for tTGA (-0.45 ± 1.22 vs 0.09 ± 1.10, P = .0003). No differences in growth measures, urine N-telopeptides, 25-hydroxyvitamin D, ferritin, thyroid stimulating hormone, or HbA1c were found. However, both higher HbA1c (β = -1.25 ± 0.85, P = .0016) and tTGA (β = -0.13 ± 0.05, P = .0056) were significant and independent predictors of lower BMD in multivariate analyses. No differences in BMD or other variables measured were found between children without diabetes who were positive vs negative for tTGA.

CONCLUSIONS

The results suggest a synergistic effect of hyperglycemia and celiac autoimmunity on low BMD.

Comparison of Metabolic Outcomes in Children Diagnosed with Type 1 Diabetes Through Research Screening (Diabetes Autoimmunity Study in the Young [DAISY]) Versus in the Community

BACKGROUND

Children with positive islet autoantibodies monitored prospectively avoid metabolic decompensation at type 1 diabetes (T1D) diagnosis. However, the effects of early diagnosis and treatment on preservation of insulin secretion and long-term metabolic control are unknown. We compared characteristics of children detected through research screening (Diabetes Autoimmunity Study in the Young [DAISY]) versus community controls at baseline and, in a subset, 6- and 12-month metabolic outcomes.

MATERIALS AND METHODS

This was a case-control study comparing DAISY children with T1D to children diagnosed in the general community. All participants underwent mixed-meal tolerance testing; a subset wore a continuous glucose monitoring (CGM) device. Fasting and stimulated C-peptide levels, insulin dose-adjusted hemoglobin A1c (IDAA1c), and CGM variables were compared.

RESULTS

Children (21 DAISY, 21 community) were enrolled and matched by age, time of diagnosis, and diabetes duration; 18 were enrolled within 2 months and 24 within 2.5 years on average from diagnosis. In the overall group and the subgroup of participants enrolled 2.5 years from diagnosis, there were no IDAA1c or C-peptide differences between DAISY versus community children. The subgroup of DAISY versus community children enrolled near diagnosis, however, had lower baseline hemoglobin A1c (6.5±1.4% vs. 9.2±2.9%; P=0.0007) and IDAA1c (7.4±2.1% vs. 11.2±3.5%; P=0.04) and higher stimulated C-peptide (2.5±0.5 vs. 1.6±0.2 ng/mL; P=0.02). In this subgroup, IDAA1c differences persisted at 6 months but not at 1 year. CGM analyses revealed lower minimum overnight glycemia in community children (72 vs. 119 mg/dL; P=0.01).

CONCLUSIONS

Favorable patterns of IDAA1c and C-peptide seen in research-screened versus community-diagnosed children with T1D within 2 months of diagnosis are no longer apparent 1 year from diagnosis.

Early hyperglycemia detected by continuous glucose monitoring in children at risk for type 1 diabetes

OBJECTIVE

We explore continuous glucose monitoring (CGM) as a new approach to defining early hyperglycemia and diagnosing type 1 diabetes in children with positive islet autoantibodies (Ab+).

RESEARCH DESIGN AND METHODS

Fourteen Ab+ children, free of signs or symptoms of diabetes, and nine antibody-negative (Ab-) subjects, followed by the Diabetes Autoimmunity Study in the Young, were asked to wear a Dexcom SEVEN CGM.

RESULTS

The Ab+ subjects showed more hyperglycemia, with 18% time spent above 140 mg/dL, compared with 9% in Ab- subjects (P = 0.04). Their average maximum daytime glucose value was higher, and they had increased glycemic variability. The mean HbA1c in the Ab+ subjects was 5.5% (37 mmol/mol). Among Ab+ subjects, ≥18-20% CGM time spent above 140 mg/dL seems to predict progression to diabetes.

CONCLUSIONS

CGM can detect early hyperglycemia in Ab+ children who are at high risk for progression to diabetes. Proposed CGM predictors of progression to diabetes require further validation.

Celiac autoimmunity in children with type 1 diabetes: a two-year follow-up

OBJECTIVE

To determine the benefits of screening for celiac autoimmunity via immunoglobulin A transglutaminase autoantibodies (TG) in children with type 1 diabetes (T1D).

STUDY DESIGN

We followed up 79 screening-identified TG+ and 56 matched TG- children with T1D for 2 years to evaluate growth, bone mineral density, nutritional status, and diabetes control. TG+ subjects self-selected to gluten-free or gluten-containing diet.

RESULTS

Of the initial cohort, 80% were available for reexamination after 2 years. TG+ subjects had consistently lower weight z-scores and higher urine N-telopeptides than TG- subjects, but similar measures of bone density and diabetes outcomes. TG+ children who remained on a gluten-containing diet had lower insulin-like growth factor binding protein 3 z-scores compared with TG+ subjects who reported following a gluten-free diet. Children who continued with high TG index throughout the study had lower bone mineral density z-scores, ferritin, and vitamin D 25OH levels, compared with the TG- group.

CONCLUSIONS

No significant adverse outcomes were identified in children with T1D with screening-identified TG+ who delay therapy with a gluten-free diet for 2 years. Children with persistently high levels of TG may be at greater risk. The optimal timing of screening and treatment for celiac disease in children with T1D requires further investigation.

A report on the International Transglutaminase Autoantibody Workshop for Celiac Disease

OBJECTIVES

Measurement of transglutaminase autoantibodies (TGAA) is considered to be the most efficient single serologic test for celiac disease (CD) by the American Gastroenterological Association Institute. We hypothesized that a large international collaborative effort toward improving and standardizing TGAA measurement is both feasible and necessary. The primary aim of this workshop is to compare TGAA assays among various research and clinical laboratories to examine assay concordance and improve (and eventually standardize) the TGAA assay.

METHODS

A total of 20 laboratories (5 commercial laboratories, 15 research and clinical laboratories) participated that included enzyme-linked immunosorbent assay (ELISA) and radiobinding assays. A total of 150 serum samples were distributed to each laboratory, with each laboratory receiving an equal aliquot that was coded and blinded, composed of 100 healthy control sera and 50 CD sera.

RESULTS

Laboratory sensitivity ranged from 69% to 93% and specificity ranged from 96% to 100%. By receiver operator characteristic analysis, the area under the curve (C index) ranged from 0.9488 to 0.9904. When analyzing for linear correlation, r-squared was as high as 0.8882 but as low as 0.4244 for the celiac samples between different laboratories performing ELISA.

CONCLUSIONS

This transglutaminase autoantibody workshop allows for larger-scale international participation for the purposes of improving and eventually standardizing the TGAA assay with subsequent workshops.

Natural history of antibodies to deamidated gliadin peptides and transglutaminase in early childhood celiac disease

INTRODUCTION

Gliadin proteins play a key role in the pathogenesis of celiac disease; however, as a screen for celiac disease, anti-gliadin antibody testing has been replaced by the more sensitive and specific serological assays for transglutaminase autoantibodies (TGAA). A new generation of anti-gliadin antibody assays has been developed to detect synthetic, deamidated homologous gliadin peptides (DGP) with high sensitivity and specificity.

METHODS

Sera were collected prospectively from children with an increased risk for celiac disease as part of an ongoing study at Denver, and studied for the development of celiac autoimmunity. We investigated the high-performance DGP antibody assay in 50 TGAA-positive children both before the development of celiac autoimmunity and following the institution of a gluten-free diet to determine the relationship of DGP antibodies to TGAA. TGAA were measured by an in-house radioassay.

RESULTS

DGP antibodies and TGAA parallel each other over the period of years children were studied. DGP antibodies resolved sooner than TGAA in subjects on a gluten-free diet. DGP antibodies appeared earlier than TGAA in 9 children.

CONCLUSIONS

Measuring DGP antibodies may be more useful than TGAA in monitoring children on a gluten-free diet. DGP antibodies can precede the appearance of TGAA in some at-risk children.

Impact of celiac autoimmunity on children with type 1 diabetes

OBJECTIVE

Children with type 1 diabetes (T1DM) are at increased risk for celiac disease (CD); however, the benefits of screening for IgA tissue transglutaminase autoantibodies (TG), a marker for CD, are unclear.

STUDY DESIGN

We compared 71 screening-identified TG+ with 63 matched TG- children with TIDM. Growth, bone density, and diabetes control measures were obtained.

RESULTS

The group was 10 +/- 3 years of age, 46% male, with TIDM for 4 +/- 3 years. Z scores for weight (0.3 +/- 1 vs 0.7 +/- 0.8, P = .024), body mass index (BMI) (0.3 +/- 0.9 vs 0.8 +/- -0.8, P = .005), and midarm circumference (0.3 +/- 1.1 vs 0.6 +/- 0.9, P = .031) were lower in the TG+ group. Bone mineral density and diabetes control measures were similar. When limiting the analysis to the 35 TG+ subjects with biopsy changes of CD, the BMI Z score was lower than the control group (0.4 +/- 0.9 vs 0.7 +/- 0.7, P = .05).

CONCLUSIONS

In children with TIDM, screening-identified evidence of CD is associated with altered body composition, but not bone mineral density or diabetes control. Further study is needed to determine the benefit of early diagnosis and treatment of CD in TIDM children.

Rotavirus infection frequency and risk of celiac disease autoimmunity in early childhood: a longitudinal study

OBJECTIVE

Few studies have assessed the role of specific gastrointestinal infections in celiac disease. We investigated whether increased frequency of rotavirus infection, a common cause of gastrointestinal infection and inflammation, predicts increased risk of celiac disease autoimmunity.

METHODS

A cohort of 1,931 children from the Denver metropolitan area who carried celiac disease human leukocyte antigen (HLA) risk alleles were followed from infancy for development of celiac disease autoimmunity, defined as positivity at two or more subsequent clinic visits for tissue transglutaminase (tTG) autoantibodies measured using a radioimmunoassay with human recombinant tTG. Blood samples were obtained at ages 9, 15, and 24 months, and annually thereafter. Rotavirus antibodies were assayed using an indirect enzyme immunoassay in serial serum samples from each case and two matched controls. Frequency of infections were estimated by the number of increases (> 2 assay coefficient of variation) in rotavirus antibody between clinic visits.

RESULTS

Fifty-four cases developed celiac disease autoimmunity at a median age of 4.4 yr. Thirty-six had an intestinal biopsy, of which 27 (75%) were positive for celiac disease. Frequent rotavirus infections predicted a higher risk of celiac disease autoimmunity (compared with zero infections, rate ratio 1.94, 95% confidence interval [CI] 0.39-9.56, for one infection and rate ratio 3.76, 95% CI 0.76-18.7, for > or = 2 infections, rate ratio for trend per increase in number of infections = 1.94, 95% CI 1.04-3.61, p = 0.037). The result was similar after adjustment for gender, ethnic group, maternal education, breast-feeding, day-care attendance, number of siblings, season of birth, and number of HLA DR3-DQ2 haplotypes.

CONCLUSIONS

This prospective study provides the first indication that a high frequency of rotavirus infections may increase the risk of celiac disease autoimmunity in childhood in genetically predisposed individuals.

Risk of celiac disease autoimmunity and timing of gluten introduction in the diet of infants at increased risk of disease

CONTEXT

While gluten ingestion is responsible for the signs and symptoms of celiac disease, it is not known what factors are associated with initial appearance of the disease.

OBJECTIVE

To examine whether the timing of gluten exposure in the infant diet was associated with the development of celiac disease autoimmunity (CDA).

DESIGN, SETTING, AND PATIENTS

Prospective observational study conducted in Denver, Colo, from 1994-2004 of 1560 children at increased risk for celiac disease or type 1 diabetes, as defined by possession of either HLA-DR3 or DR4 alleles, or having a first-degree relative with type 1 diabetes. The mean follow-up was 4.8 years.

MAIN OUTCOME MEASURE

Risk of CDA defined as being positive for tissue transglutaminase (tTG) autoantibody on 2 or more consecutive visits or being positive for tTG once and having a positive small bowel biopsy for celiac disease, by timing of introduction of gluten-containing foods into the diet.

RESULTS

Fifty-one children developed CDA. Findings adjusted for HLA-DR3 status indicated that children exposed to foods containing wheat, barley, or rye (gluten-containing foods) in the first 3 months of life (3 [6%] CDA positive vs 40 [3%] CDA negative) had a 5-fold increased risk of CDA compared with children exposed to gluten-containing foods at 4 to 6 months (12 [23%] CDA positive vs 574 [38%] CDA negative) (hazard ratio [HR], 5.17; 95% confidence interval [CI], 1.44-18.57). Children not exposed to gluten until the seventh month or later (36 [71%] CDA positive vs 895 [59%] CDA negative) had a marginally increased risk of CDA compared with those exposed at 4 to 6 months (HR, 1.87; 95% CI, 0.97-3.60). After restricting our case group to only the 25 CDA-positive children who had biopsy-diagnosed celiac disease, initial exposure to wheat, barley, or rye in the first 3 months (3 [12%] CDA positive vs 40 [3%] CDA negative) or in the seventh month or later (19 [76%] CDA positive vs 912 [59%] CDA negative) significantly increased risk of CDA compared with exposure at 4 to 6 months (3 [12%] CDA positive vs 583 [38%] CDA negative) (HR, 22.97; 95% CI, 4.55-115.93; P = .001; and HR, 3.98; 95% CI, 1.18-13.46; P = .04, respectively).

CONCLUSION

Timing of introduction of gluten into the infant diet is associated with the appearance of CDA in children at increased risk for the disease.

Clinical features of children with screening-identified evidence of celiac disease

OBJECTIVE

At-risk groups commonly undergo screening for autoantibodies associated with celiac disease (CD). However, the clinical significance of a positive test remains uncertain. The objective of this study was to evaluate growth and clinical features of children who test positive for an autoantibody associated with CD.

METHODS

A case-control study of Denver area healthy infants and young children with and without CD autoantibodies was conducted. A cohort of HLA-characterized children were followed prospectively since birth for the development of immunoglobulin A antitissue transglutaminase autoantibodies (TG). Clinical evaluation, questionnaire, blood draw, and small bowel biopsy were performed. Growth and nutrition and frequency of positive responses were measured.

RESULTS

Compared with 100 age- and gender-matched TG-negative controls, 18 TG-positive children, 5.5 +/- 0.5 years of age, had a greater number of symptoms and lower z scores for weight-for-height and for body mass index. Responses that were independently associated with TG-positive status were irritability/lethargy, abdominal distention/gas, and difficulty with weight gain.

CONCLUSIONS

Screening-identified TG-positive children demonstrate mild alterations in growth and nutrition and report more symptoms than control subjects. Additional study is needed on the benefit and risk of identifying CD in at-risk groups.

A prospective study of the incidence of childhood celiac disease

OBJECTIVES

To estimate the frequency of celiac disease (CD) in children in the general population of Denver, Colorado.

STUDY DESIGN

From 22,346 newborns characterized as expressing 0, 1, or 2 HLA-DR3(DQB1*0201) alleles, 987 were selected for a prospective stratified cohort study. Participants were followed for as long as 7 years with serial testing for serum IgA anti-transglutaminase antibodies and for evidence of CD (intestinal mucosal changes or persistent seropositivity).

RESULTS

Of 40 children with at least one positive serologic test, 19 had evidence of CD (10 by biopsy, 9 by persistent seropositivity). Those expressing 0, 1, or 2 HLA-DR3 alleles had, respectively, 0.3% (95% CI, 0.0-2.7), 3.4% (3.0-11.7), and 3.2% (1.0-11.0) risk for evidence of CD by age 5 years. The adjusted risk estimate for evidence of CD by age 5 years for the Denver general population was 0.9% (0.4-2.0), or 1 in 104 (1:49-221). After adjusting for number of HLA-DR3 alleles expressed, risk was higher in females: RR=3.34 (1.00-10.9, P=.048). Evidence of CD was not observed before age 2.6 years.

CONCLUSIONS

Celiac disease may affect 0.9% of Denver children by 5 years of age. Children positive for the HLA-DR3 allele and females appear to be at increased risk.

[Quantification of brain metabolites by 1H spectroscopy using cyclohexane as an external reference]

We tested the reliability of quantifying brain metabolite concentrations by MR spectroscopy. We employed a PRESS sequence and used a cyclohexane sample as an external standard. The signal intensity ratios of water and cyclohexane were measured by changing the geometrical arrangement of the cyclohexane sample and water phantom with various loading factors of the coil. Choline (Cho) concentrations were calculated from the signal intensity ratios of Cho and water and compared with actual Cho concentrations (1.0 to 2.6 mmol/L). The brain metabolites Cho, creatine/phosphocreatine (Cr/PCr) and N-acetylaspartate (NAA) were evaluated in five normal volunteers and six patients with metastatic brain cancer before (0 Gy), after 20 Gy and after 40 Gy of whole brain radiotherapy. Variation in the ratio of spectrum intensity between water and cyclohexane was less than 1.5% for various geometrical arrangements and loading factors. The error in quantification of Cho concentrations in the phantom study was 0.05 +/- 0.10 mmol/L. The concentrations measured in the volunteers were: Cho 1.6 +/- 0.4 mmol/L, Cr/PCr 6.4 +/- 1.1 mmol/L and NAA 8.2 +/- 0.1 mmol/L. There was no significant difference (p > 0.05) in these concentrations between the control group and the patients before, during, or after radiotherapy.

An external reference for in vivo quantification of 1H spectroscopy

We studied the validity of using an external signal reference for absolute quantification of brain metabolites. We chose cyclohexane as the signal standard. An expression of a perturbed magnetic field in diamagnetic cylindrical materials was first obtained by using a method of equivalent magnetic charges. Broadening of the spectrum in this perturbed magnetic field was then computed. We performed phantom studies. We measured the full width at half maximum (FWHM) of the cyclohexane and the signal ratio (SR) between water and cyclohexane in spheres of two different diameters, and in cylinders of various diameters and lengths. The observed FWHM and SR in the small cylinders had large variations in distribution, whereas those in the spheres and in the large cylinders had small variations. Specifically, in a cylinder with a diameter > 5 cm and with a length > 10 cm, the variation of the SR was < 1.0%. The diameter and the length of the cylinder preferably are large when a cylindrical material is adopted as an external signal standard.

Comparative study of combination chemotherapy of ovarian cancer: cyclophosphamide, adriamycin and cisplatin versus 5-fluorouracil, cyclophosphamide and mitomycin C

CAP, a multiple-drug combination therapy using cyclophosphamide (750 mg/m2), adriamycin (20-30 mg/m2) and cisplatin (50-75 mg/m2), was applied to 69 cases of epithelial ovarian cancer. The results of this therapy were compared with those of FAM (involving 5-fluorouracil, cyclophosphamide and mitomycin C) in 47 cases of the same cancer, retrospectively. The 5-year survival rate was 61.6% for cases treated with CAP and 56.3% for cases treated with FAM. All 9 patients at stage Ia treated with CAP are free of disease, however, 3 patients out of 13 at stage Ia treated with FAM experienced a recurrence of the disease and died. In stage III and IV cases with detectable lesions, a response was observed in 61.3% (19/31) treated with CAP and in 10.5% (2/19) treated with FAM.

[Cisplatin, adriamycin and cyclophosphamide combination chemotherapy of epithelial ovarian cancer]

The chemotherapeutic effects of cisplatin + adriamycin + cyclophosphamide (PAC) on 50 epithelial ovarian cancers were compared with the effects of 5-fluorouracil + cyclophosphamide + mitomycin C (FAM) in 17 patients. The cumulative survival at 5 years was 61.1% in all patients, 62.5% in patients treated with PAC and 54.7% in patients treated with FAM. The 5-year survival rate was 100% in Stage I, 63.5% in Stage II, 40.1% in Stage III and 22.2% in Stage IV. Of 22 patients with Stage III and IV treated with PAC, 16 patients responded (8CRs + 8PRs). The median survival duration of the treated patients was 19 months. On the other hand, of 8 patients treated with FAM, only one patient responded (PR). The median survival duration was 7 months. These results indicated the effectiveness of PAC chemotherapy against advanced ovarian cancer. No severe toxicity was observed during treatment with PAC or FAM.

Malignant lymphoma of the uterine cervix. Cytologic diagnosis of a case with immunocytochemical corroboration

The cytologic findings in a case of primary malignant lymphoma of the uterine cervix initially suggested the presence of a malignant neoplasm. By the use of immunologic methods, the lymphoma cells were shown to possess the nature of B lymphocytes. The need for cytochemical study to make a definitive diagnosis of this rare condition is emphasized. The cytologic findings are compared with those of cytologically similar conditions in the cervix: reticulum-cell sarcoma, chloroma and endometrial stromal sarcoma.

Verrucous carcinoma of the uterine cervix: report of a case with follow-up of 6 1/2 years

A case of verrucous carcinoma of the uterine cervix was reported with a long-term follow-up and close observation. The patient was a 73-year-old, Japanese female, who had a suspicious Papanicolaou smear on routine examination. The cervix was replaced by a papillary mass, which was diagnosed as benign papilloma. The patient was followed every 6 months with cytology, colposcopy, and punch biopsy. No cytologic or microscopic diagnosis of invasive squamous cell carcinoma was made during the entire follow-up period. Total abdominal hysterectomy and partial vaginectomy were performed after 6 1/2 years' follow-up, and the tumor was finally diagnosed as verrucous carcinoma. The patient is alive and well 4 years after the operation.

Cytologic findings of ascites from patients with ovarian dysgerminoma

The cytomorphologic observations of ascites from three patients with ovarian dysgerminomas are presented. As compared with those in adenocarcinoma, the cytologic findings in this rare malignant ovarian tumor showed more cells lying isolated or in sheetlike arrangements, fewer cells with discrete cytoplasmic vacuoles, less frequent thickening of the nuclear membrane and more frequent multinucleolation.

Adenocarcinoma of the uterine cervix metastatic from primary stomach cancer. Cytologic findings in six cases

The cytologic features of six cases of stomach cancer metastatic to the uterine cervix are presented. Atypical cells were found in cytology samples from four patients. Fewer atypical cells, larger cellular and nuclear areas, more discrete vacuoles, increased frequencies of thickening of the nuclear membrane and more coarsely granular chromatin patterns were the characteristic cytologic findings of metastatic cervical adenocarcinoma as compared with primary endocervical adenocarcinoma.

Abortifacient effect and uterine cervix-dilating action of 16, 16-dimethyl trans delta 2 PGE1 methyl ester (ONO 802) in the form of a vaginal suppository (a randomized, double-blind, controlled study in the second trimester of pregnancy)

A newly synthesized 16, 16-dimethyl trans delta 2 PGE1 methyl ester (ONO 802) was clinically applied in the form of a vaginal suppository for therapeutic abortion of second trimester pregnancies. Its effects were studied in a double-blind test comparing it with an inactive placebo suppository. The study was conducted at 12 Japanese university hospitals. The number of patients was 125 in total, i.e. 63 receiving ONO 802 vaginal suppository (containing 1.0 mg ONO 802) and 62 receiving inactive placebo suppository. ONO 802 was more effective than placebo with a success rate of 87% (complete (71%) and incomplete (16%) abortions). The onset of uterine contractions was observed in 154.3+/-18.1 min. and the onset of uterine bleeding in 323.6+/-41.0 min. The expulsion of the fetus and placenta was observed in 955.4+/-97.0 and 961.6+/-97.0 min., respectively. The cervix dilating effect of ONO 802 was observed in 63.5% of the patients at 3 hours after the start of administration. Nausea, vomiting, abdominal cramps, diarrhea and pyrexia were noticed. However, all these side effects were transient and mild, requiring no treatment. No abnormality was observed in the puerperal course, duration of uterine bleeding or onset of subsequent menstruation following the therapeutic abortion. Therefore, the present study demonstrated that ONO 802 vaginal suppository was an effective and valuable drug for therapeutic abortion of second trimester pregnancies.

Teratoma of the neck in a newborn infant--a case report

A case of teratoma of the neck in a newborn is presented. Teratoma of the neck is a rare lesion and is mostly found in the newborn, but in some cases in the fetus and stillborn infant. Although in this case prenatal diagnosis was possible via ultrasonography, the infant did not survive because of respiratory distress. Hence, urgent surgery is imperative in such cases.

Teratoma of the neck in a newborn infant - a case report

A case of teratoma of the neck in a newborn baby is presented. Teratoma of the neck is a rare lesion and almost always found in the newborn, but also in the fetus and stillborn infant. Although the mass was found prenatally by ultrasonography in the present case, the patient could not be saved because of respiratory distress. Urgent surgical management is the only way to save life in this kind of neonate.

Birth weight assessed by factor analysis

To investigate the relevancy of birth weight, data on 300 term newborn infants were subjected to a reevaluation of 31 variables related to body measurements of both the mother and child and to the placenta. Factor analysis was introduced to analyze the data obtained. Each group was composed of multiple factor axes, of which factor structures were rather simple in Appropriate for Date (AFD) for approximating the practical images, compared to Heavy for Date (HFD) and Light for Date (LFD). In AFD, the birth weight was thought contributive by the limiting effect of the placenta, independently of the measurements of the mother. We found that the birth weight in itself seems to have a different meaning in each group, and it is difficult to readily categorize the findings on the table of equivalent parameters for labelling of the newborn.

[Cryosurgery for dysplasia, carcinoma in situ, and microinvasive carcinoma of the uterine cervix (author's transl)]

One hundred and three patients with dysplasia, carcinoma in situ, or microinvasive carcinoma of the uterine cervix were treated with cryosurgery during 8 years from 1972 to 1978. Twenty-nine patients underwent several types of operations during 4-41 days (mean 18 days) after cryosurgery, and 74 patients were followed for 3-78 months (mean 3 years) after treatment. Seventy-six per cent of the patients who underwent an operation had residual lesions in their histologic materials. Seventy per cent of the patients who were followed, on the other hand, showed consecutively negative cytology and pathology after cryosurgery. It is necessary for the more effective management of CIN with cryosurgery to perform endocervical curettage in every case, to select small lesion for treatment, and to use more powerful method of cryocauterization.

[Histological grading of hydatidiform mole (author's transl)]

This study was performed to seek possibility of selecting the high risk group in the patients with hydatidiform mole at its delivery. The histologic specimens from 83 patients with hydatidiform mole were reviewed and classified by modified Hertig's grading. Lymphocyte count of peripheral blood was also studied as an immunological index. I. There were 36 Grade I cases, 16 Grade IIa, 23 Grade IIb, and 8 Grade III cases. Two subsequent destructive moles were found from the patients with Grade I, three from Grade IIb, and two from Grade III respectively. The incidence of developing subsequent destructive mole was 6% in Grade I, 8% in Grade II, and 25% in Grade III. II. There was no correlation between histological grading and patients age nor weeks in gestation. When the ratio of syncytiotrophoblast and cytotrophoblast was considered, most of Grade II or III cases were obtained from those in whom the cytotrophoblast prevailed over syncytiotrophoblast. III. The patients with lymphocyte less than 1500/mm3 in their peripheral blood were apt to take abnormal clinical course comparing to those with lymphocyte more than 1501/mm3. The more accurate prediction of clinical course was suggested by combination of histological grading and lymphocyte count.

Nuclear DNA content of trophoblastic tumors

The nuclear DNA content of trophoblasts was measured in 25 cases of normal pregnancy, 46 cases with hydatidiform mole, ten cases with destructive mole and six cases of chorionepithelioma (choriocarcinoma). In normal pregnancy, DNA distribution in syncytiotrophoblasts and cytotrophoblasts showed a sharp peak at the diploid region, although a few cytotrophoblasts with increased DNA content were observed in the first trimester. In chorionepithelioma the DNA content of the trophoblastic cells showed extremely wide distribution without any special peak. In destructive mole, although a wide distribution was observed, the sharp peak was usually noted at the diploid range. Cases with hydatidiform mole were divided into two categories according to the DNA distribution patterns. Type I showed the patterns similar to the first trimester of normal pregnancy and type II resembled the patterns of destructive mole. In hydatidiform mole of type II, subsequent progress towards destructive mole was frequently encountered.