Giovanni V. Coppa

Coeliac disease in the year 2000: exploring the iceberg

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

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

Background: Recent studies suggest that coeliac disease (CD) is one of the commonest, life‐long disorders in Italy. The aims of this multicentre work were: (a) to establish the prevalence of CD on a nationwide basis; and (b) to characterize the CD clinical spectrum in Italy. Patients and methods: Fifteen centres screened 17201 students aged 6–15 years (68.6% of the eligible population) by the combined determination of serum IgG‐ and IgA‐antigliadin antibody (AGA) test; 1289 (7.5%) were IgG and/or IgA‐AGA positive and were recalled for the second‐level investigation; 111 of them met the criteria for the intestinal biopsy: IgA‐AGA positivity and/or AEA positivity or IgG‐AGA positivity plus serum IgA deficiency. Results: Intestinal biopsy was performed on 98 of the 111 subjects. CD was diagnosed in 82 subjects (75 biopsy proven, 7 not biopsied but with associated AGA and AEA positivity). Most of the screening‐detected coeliac patients showed low‐grade intensity illness often associated with decreased psychophysical well‐being. There were two AEA negative cases with associated CD and IgA deficiency. The prevalence of undiagnosed CD was 4.77 × 1000 (95% CI 3.79–5.91), 1 in 210 subjects. The overall prevalence of CD, including known CD cases, was 5.44 × 1000 (95% CI 4.57–6.44), 1 in 184 subjects. The ratio of known to undiagnosed CD cases was 1 in 7. Conclusions: These findings confirm that, in Italy, CD is one of the most common chronic disorders showing a wide and heterogeneous clinical spectrum. Most CD cases remain undiagnosed unless actively searched.

Oligosaccharides in human milk during different phases of lactation.

Twenty‐one oligosaccharides of human milk were quantified by high‐performance anion‐exchange chromatography. Milk samples were collected from 18 mothers during the first 3 mo of lactation. The data show that the highest amount of all oligosaccharides is present at day 4 postpartum (20 g l−1) and then decreases by about 20% at day 30 of lactation. The protective role played by these substances against different infectious agents, in different organs and systems of the breastfed baby, is emphasized.

Human Milk Oligosaccharides Inhibit the Adhesion to Caco-2 Cells of Diarrheal Pathogens: Escherichia coli , Vibrio cholerae , and Salmonella fyris

Breast-fed children, compared with the bottle-fed ones, have a lower incidence of acute gastroenteritis due to the presence of several antiinfective factors in human milk. The aim of this work is to study the ability of human milk oligosaccharides to prevent infections related to some common pathogenic bacteria. Oligosaccharides of human milk were fractionated by gel-filtration and characterized by thin-layer chromatography and high-performance anion exchange chromatography. Fractions obtained contained, respectively, 1) acidic oligosaccharides, 2) neutral high-molecular-weight oligosaccharides, and 3) neutral low-molecular-weight oligosaccharides. Experiments were carried out to study the ability of oligosaccharides in inhibiting the adhesion of three intestinal microorganisms (enteropathogenic Escherichia coli serotype O119, Vibrio cholerae, and Salmonella fyris) to differentiated Caco-2 cells. The study showed that the acidic fraction had an antiadhesive effect on the all three pathogenic strains studied (with different degrees of inhibition). The neutral high-molecular-weight fraction significantly inhibited the adhesion of E. coli O119 and V. cholerae, but not that of S. fyris; the neutral low-molecular-weight fraction was effective toward E. coli O119 and S. fyris but not V. cholerae. Our results demonstrate that human milk oligosaccharides inhibit the adhesion to epithelial cells not only of common pathogens like E. coli but also for the first time of other aggressive bacteria as V. cholerae and S. fyris. Consequently, oligosaccharides are one of the important defensive factors contained in human milk against acute diarrheal infections of breast-fed infants.

Intestinal permeability changes during the first month: effect of natural versus artificial feeding.

Summary: The aim of the study was to investigate the effect of age and feeding pattern on intestinal permeability during the first month of life. The subjects were 72 full-term, healthy neonates who were (a) exclusively breast-fed (BF group, n = 36) or (b) artificially fed (CM group, n = 36) with either an adapted formula (AF group, n = 17) or a partly hydrolyzed (hypoantigenic) formula (HA group, n = 19). A lactulose/mannitol (lac/man) intestinal permeability test was performed at 1 and 7 days (steady-state method, n = 72), then at 30 days of life (single oral load, n = 47). Urinary lactulose and mannitol were measured by HPLC. The mean lac/man urinary ratio dropped from 1.27 ± 0.73 (day 1) to 0.34 ± 0.36 at day 7 and to 0.22 ± 0.21 at day 30. At 7 days BF infants showed a significantly lower lac/man urinary ratio (0.22 ± 0.25) than the CM group (0.47 ± 0.41). The human neonate shows a developmental pattern of sugar intestinal permeability that resembles gut closure observed in other mammals. Intestinal permeability decreases faster in breast-fed babics than in those fed with adapted or HA formulas.

Preliminary study of breastfeeding and bacterial adhesion to uroepithelial cells

The oligosaccharide content of breast-milk and urine from ten nursing mothers and their babies, collected 30 days after delivery, was analysed by thin-layer and high-performance liquid chromatography. Each womans milk and urinary oligosaccharide profiles were very similar, and the pattern of oligosaccharides excreted by her infant was also strongly correlated with that of her milk. The babies excreted 300-500 mg/day oligosaccharides and the mothers 500-800 mg/day. The effect of oligosaccharide fractions from a 500 ml pool of colostrum on bacterial adhesion to uroepithelial cells was tested on a strain of Escherichia coli isolated from an infant with urinary tract infection. The high-molecular-weight sialylated oligosaccharides had no effect but neutral oligosaccharides caused inhibition of bacterial adhesion which rose as the size of the oligosaccharides decreased. These findings suggest that breastfeeding may have a preventive effect on urinary tract infection in both mother and infant.

Dose dependent effects of protracted ingestion of small amounts of gliadin in coeliac disease children: a clinical and jejunal morphometric study.

This study aimed to investigate the effects of chronic ingestion of small amounts of gliadin on children with coeliac disease. A four week challenge was performed on 20 children who had been on a gluten free diet for mean (SD) 14 (3) months. They were given a daily dose of either 100 mg (group A, n = 10, mean age 4 (2) years) or 500 mg of gliadin (group B, mean age 5 (3) years). The effects of the gliadin were monitored by morphometric study of the jejunal mucosa, intestinal permeability test with cellobiose/mannitol, and serum antigliadin antibody test. After the challenge, group A patients showed a significant increase in the mean intraepithelial lymphocyte count (before challenge 11 (3), afterwards 19 (6)) and a decrease in the villous height/crypt depth ratio (beforehand 1.5 (0.1), afterwards 1.3 (0.2)), while the intestinal permeability test remained normal and the IgA-antigliadin antibody increased in four of 10 children. After the challenge group B showed more pronounced histological changes, an increase in the mean urinary cellobiose/mannitol % (beforehand 0.028 (0.020), afterwards 0.058 (0.028)), and IgA-antigliadin antibody positivity in six of eight subjects. The discriminant analysis function showed that the pretreatment group, group A after challenge, and group B after challenge were correctly classified in 90% of cases by functions based on the individual intraepithelial lymphocyte count and the villous height/crypt depth ratio. This study shows that chronic ingestion of small amounts of gluten causes dose-dependent damage to the small intestinal mucosa in children with coeliac disease. The predictive value of laboratory tests, such as the antigliadin antibody test and the intestinal permeability test seems to be lower in treated patients than in those with active coeliac disease.

Preterm Milk Oligosaccharides During the First Month of Lactation

OBJECTIVE: Oligosaccharides represent one of the main components of human milk, and they have been assigned important biological functions for newborns. Qualitatively and quantitatively, their presence in milk is strictly related to the expression of the mothers Se and/or Le genes, on the basis of which 4 different milk groups have been described. The aim of the study was to provide new data on the oligosaccharide composition of preterm milk in relation to the 4 groups. METHODS: High-pH anion-exchange chromatography was used to quantify levels of 23 oligosaccharides and lactose in 252 milk samples collected from 63 mothers during the first month of lactation and to identify the 4 milk groups. RESULTS: Substantial differences in oligosaccharide contents were found within the groups and were strictly related to the presence or absence of specific fucosyl-oligosaccharides. The highest concentration was found in group 1 (>20 g/L), the lowest level was found in group 4 (∼10 g/L), and intermediate values were observed in groups 2 and 3. No statistically significant differences in lactose concentrations were observed among the groups. CONCLUSIONS: Our data confirm lower lactose concentrations in preterm milk, compared with term milk, and they provide the first detailed characterization of oligosaccharides in preterm milk, demonstrating important differences in oligosaccharide contents in the 4 groups. These differences might exert an influence on several biological functions that are particularly important for preterm infants and currently are attributed to milk oligosaccharides.

Enzyme-Replacement Therapy in a 5-Month-Old Boy With Attenuated Presymptomatic MPS I: 5-Year Follow-up

Mucopolysaccharidosis type I (MPS I) is a progressive and multisystemic disease, even in its attenuated Hurler-Scheie and Scheie forms. Clinical trials of enzyme-replacement therapy in MPS I have shown clinical benefit in patients with considerable preexisting disease, but no data exist on the effect of beginning enzyme replacement before the onset of significant clinical signs of disease. Here we present the 5-year follow-up of a boy with attenuated MPS I who had laronidase therapy initiated at the age of 5 months and compare his clinical course to that of his older sister, who began treatment at 5 years of age after she had developed typical signs of MPS I. After 5 years of treatment, the younger sibling has not developed any clinical manifestations of MPS I except for mild corneal clouding. In contrast, although many of the older siblings clinical features have improved after 5 years of treatment, her dysostosis multiplex, cardiac valve involvement, and corneal clouding, although stabilized, have persisted. We suggest that early treatment of attenuated MPS I may significantly delay or prevent the onset of the major clinical signs, substantially modifying the natural history of the disease.

Dietary compliance in screening-detected coeliac disease adolescents

In 1992–94 we screened 6315 students for coeliac disease (CD) by testing antigliadin antibodies (AGA) as the first‐level investigation. We found 28 biopsy‐proven coeliac patients who were invited to start the gluten‐free diet (GFD). The aim of this study was a clinical and laboratory follow‐up in these screening–detected coeliac adolescents. Patients were 17 females and 11 males with a mean age at diagnosis of 12.8 ± 1 years (range 11–14). Mean follow‐up duration time was 23 ± 7 months (range 9–37). Twenty‐three of the 28 screening‐detected coeliac patients came to the control visit, 3 refused the follow‐up and 2 subjects were not found. Twelve patients (52.2%) stated that they never ate any gluten‐containing food, while 11 of them (47.8%) reported occasional transgressions to the diet. GFD acceptance was reported as good (n= 6), moderate (n= 11) or low (n= 6). After starting the GFD, signs of improvement were seen in most patients, such as weight gain, increased height velocity and increased feeling of well‐being. AGA (both IgG and IgA classes) and antiendomysium antibodies (AEA) were normal in 19 subjects, 2 cases had IgG‐AG A and AEA positivity, 1 patient showed abnormal AGA and AEA levels, while isolated IgA‐AGA positivity persisted in 1 case. This study shows that even silent CD cases can clinically benefit from the GFD. The consequences of occasional transgressions to the GFD remain unclear.