Laura Petrarca

The Celiac Iceberg: Characterization of the Disease in Primary Schoolchildren

Objective: Celiac disease (CD) has a prevalence of 0.55% to 1% in Italy. Identifying CD in schoolchildren to characterize CD iceberg and evaluate the effect of diagnosis in screening-detected children. Methods: A total of 7377 5- to 8-year-old children were invited to participate. A total of 5733 salivary samples were collected and tested for anti-transglutaminase antibodies (tTGAb), using a fluid-phase radioimmunoassay. Salivary tTGAb-positive children were analyzed for serum antibodies (anti-endomysium antibodies, radioimmunoassay, and enzyme-linked immunosorbent assay tTGAb). Positive children underwent endoscopy and then started gluten-free diet (GFD) and periodical follow-up. Results: Forty-six subjects were found salivary tTGAb–positive and 16 border-line. Forty-five of 46 and 5 of 15 of them were also serum antibody–positive. Forty-two children showed duodenal villous atrophy and 1 had only type 1 lesions. Three children started GFD without performing endoscopy. CD prevalence (including 23 previously diagnosed children with CD) was 1.2%. Considering all 65 celiacs in our sample, a silent CD was found in 64%, typical in 28%, atypical in 7%, and potential in 1%. All patients showed strict adherence to GFD, weight and stature increase, and well-being improvement. Eighty-five percent and all but 2 screening-detected children with CD had Italian parents. Conclusions: Our sample size, representative of primary schoolchildren of our region, demonstrated that CD prevalence is growing in Italy, with a modified clinical spectrum and iceberg deepness.

Duodenal bulb in celiac adults: The "whether biopsying" dilemma

Background: Celiac disease (CD)-related lesions were described in duodenal bulb of celiac patients. Goal: Our aim was to evaluate the morphology of bulb mucosa in adult celiac patients and in controls to evaluate its usefulness for CD diagnosis. Study: We studied 43 celiac patients (10 male, median age: 35.2 y) at diagnosis and 43 gastroenterological controls (10 male, median age: 37.8 y), submitted to upper endoscopy for gastroenterological complaints. Histologic lesions were assayed by an experienced pathologist according to the Marsh modified classification. Antiendomysium antibodies and antitransglutaminase antibodies-tTGAb (ELISA and/or RIA) have been tested. In selected patients, DNA was typed for DRB1, DQA1, and DQB1 genes by sequence-specific primer polymerase chain reaction. Results: In all celiac patients lesions were present in the bulb mucosa. One female with thyroiditis, who had a CD daughter, showed lesions only in the duodenal bulb. Patchy villous atrophy was found in another patient. All celiacs were antiendomysium and/or tTGAb positive. DQ2 heterodimer was present in 5 CD patients. The gastroenterological controls showed normal mucosa in the duodenum. Conclusions: This study demonstrates that CD-related histologic lesions are present in duodenal bulb of adult patients. Moreover, the normal aspect of this mucosa in gastroenterological controls implies the high negative predictive value of this finding. Therefore, we suggest taking at least 1 biopsy on the bulb area and 1 from the distal duodenum for CD diagnosis, in all the patients submitted to upper endoscopy, to avoid missed or delayed diagnosis.

Seven Percent Hypertonic Saline—0.1% Hyaluronic Acid in Infants With Mild-To-Moderate Bronchiolitis

Our study was aimed to evaluate the efficacy of 7% hypertonic saline and 0.1% hyaluronic acid (7% HS–HA) given by inhalation, in infants hospitalized for mild‐to‐moderate bronchiolitis.

Celiac disease in a large cohort of children and adolescents with recurrent headache: A retrospective study.

BACKGROUND The clinical picture of celiac disease is changing with the emergence of subclinical forms and growing evidence reporting associated neurological disorders. AIMS To establish the prevalence of celiac disease in children suffering from recurrent headache. METHODS In our retrospective study we collected charts from 1131 children attending our tertiary care Centre for Paediatric Headache over the period 2001-2012. They were screened for celiac disease and positive patients were referred to our Operative Unit for Coeliac disease and confirmed positive children underwent upper endoscopy with multiple duodenal biopsies. Celiac children started a gluten-free diet. RESULTS 883 children (481 females; median age, 9.8 years, range 3-19) performed celiac disease screening, and among them, 11 children (7 females; median age, 8.2 years, range: 4.8-13.9) were diagnosed with celiac disease. Seven children (5 females, median age, 11.9 years, range: 10.3-13.9) had been diagnosed as celiac prior to the neurological evaluation. The prevalence of celiac disease in our sample is 2.04% vs. 1.2% of the general population (p=0.034). CONCLUSIONS Our study demonstrates, on a large series, that celiac disease prevalence is doubled in patients with chronic headache. Screening for celiac disease could be advised as part of the diagnostic work-up in these paediatric patients, particularly among pharmacological non-responders.

Immediate effect on fertility of a gluten-free diet in women with untreated coeliac disease

In a recent paper in Gut , describing a Swedish population-based cohort, Zugna et al found that women with coeliac disease had normal fertility, but their fertility had decreased in the 2 years preceding the diagnosis of coeliac disease.1 This study provides important answers to fertility problems in patients with coeliac disease by analysing a nationwide database. The results, however, must be interpreted with caution. This paper may be considered confusing because the role of coeliac disease as one of the causes of infertility has been underestimated taking into account population studies in general. Infertility, spontaneous abortion and delayed puberty represent subclinical coeliac disease presentations …

Endoscopic and Histological Gastric Lesions in Children With Celiac Disease: Mucosal Involvement Is Not Only Confined to the Duodenum

Objectives: Lymphocytic gastritis (LG) has been reported in patients with celiac disease (CD). The aim of the present study was to evaluate gastric mucosa involvement in celiac children and gastroenterological controls (GC). Methods: In a retrospective study on 226 patients with CD (82 M; median age: 5.7years) at diagnosis and 154 GC (66 M; median age: 7.4 years), the evaluation of gastric and duodenal mucosa was performed. CD was diagnosed according to the North America Society for Pediatric Gastroenterology, Hepatology, and Nutrition criteria. Gastric lesions were classified according to Updated Sydney System. Anti-gastric parietal cell antibodies (GPCA) were assayed by enzyme-linked immunosorbent assay. Results: A total of 21.2% and 7% of patients with CD showed chronic superficial gastritis (CSG) and LG, respectively. Helicobacter pylori (Hp) infection was found in 6 (2.7%) children with CD (66.7% had CSG, 16.7% LG, and 16.7% interstitial gastritis). CSG was present in 21.4% of controls. No control subject showed LG. Hp infection was found in 24 (15.6%) children with GC (91.7% had CSG). Among patients with CSG, Hp infection was more frequent in controls than in celiac children (P < 0.0001). Ten of 90 patients with CD and 1 of 29 controls were positive for GPCA. Conclusions: Gastritis is a common finding in children with CD and adolescents. In celiac subjects, CSG is the most frequently detected. Our data suggest the hypothesis that LG may be related to a longer exposure to gluten. The presence of GPCA may suggest the presence of an underlying autoimmune process.

Bronchiolitis: Analysis of 10 consecutive epidemic seasons

Bronchiolitis is the leading cause of hospitalization in infants under 12 months. Our aims were to analyze epidemiological characteristics of infants with bronchiolitis over 10 consecutive seasons and to evaluate whether there are any clinical differences between infants hospitalized for bronchiolitis during epidemic peak months and infants in non‐peak months. We enrolled consecutive enrolled 723 previously healthy term infants hospitalized at the Paediatric Emergency Department, “Sapienza” University of Rome over the period 2004–2014. Fourteen respiratory viruses were detected from nasopharyngeal aspirates by molecular methods. Clinical and demographic data were extracted from clinical charts. Viruses were detected in 351 infants (48.5%): RSV in 234 (32.4%), RV in 44 (6.1%), hBoV in 11 (1.5%), hMPV in 12 (1.6%), co‐infections in 39 (5.4%), and other viruses in 11 (1.5%). Analyzing the 10 epidemic seasons, we found higher incidence for bronchiolitis every 4 years with a peak during the months December–January. Infants hospitalized during peak months had lower family history for asthma (P = 0.003), more smoking mothers during pregnancy (P = 0.036), were slightly higher breastfed (0.056), had lower number of blood eosinophils (P = 0.015) and had a higher clinical severity score (P = 0.017). RSV was detected mostly during peak months, while RV was equally distributed during the seasons. We found some variations in bronchiolitis incidence during epidemics, and discriminative characteristics in infants hospitalized for bronchiolitis during peak months and in non‐peak months, that might reflect two different populations of children. Pediatr Pulmonol. 2016;51:1330–1335.

Risk Factors for Virus-induced Acute Respiratory Tract Infections in Children Younger Than 3 Years and Recurrent Wheezing at 36 Months Follow-up After Discharge

Background: We sought to know more about how 14 common respiratory viruses manifest clinically, and to identify risk factors for specific virus-induced acute respiratory tract infections (ARTIs) in children younger than 3 years old and for wheezing at 36-month follow-up. Methods: We retrospectively studied the clinical records for 273 full-term children (median age, 2.9 months; range, 0.26–39; boys, 61.2%) hospitalized for ARTIs, whose nasopharyngeal specimen tested positive for a respiratory virus and 101 children with no history of respiratory diseases (median age, 8 months; range, 0.5–36.5; boys, 58.4%). At 12, 24 and 36 months after children’s discharge, all parents were interviewed by telephone with a structured questionnaire on wheezing episodes. Results: The most frequently detected viruses were respiratory syncytial virus in bronchiolitis, human rhinovirus in pneumonia and human bocavirus in wheezing. Multivariate analysis identified, as risk factors for virus-induced ARTIs, the presence of siblings [odds ratio (OR): 3.0 (95% confidence interval [CI]: 1.8–5.2)], smoking cohabitants (OR: 2.3 (95% CI: 2–4.2)] and breastfeeding lasting less than 3 months [OR: 0.5 (95% CI: 0.3–0.9)]. The major risk factor for respiratory syncytial virus–induced ARTIs was exposure to tobacco smoke [OR: 1.8 (95% CI: 1.1–3.2)]. Risk factors for human rhinovirus–induced ARTIs were attending day-care [OR: 5.0 (95% CI: 2.3–10.6)] and high eosinophil blood counts [OR: 2.6 (95% CI: 1.2–5.7)]. The leading risk factor for recurrent wheezing was exposure to tobacco smoke [OR: 2.5 (95% CI: 1.1–15.6)]. Conclusions: Each respiratory virus leads to a specific clinical manifestation. Avoiding exposing children to tobacco smoke might restrict viral spread from sick parents and siblings to younger children, prevent severe respiratory diseases, and possibly limit sequelae.

Vaccination policies in Europe: Common goals, diverse approaches and public doubts

As Desiderius Erasmus (1466–1536) said (presumably in Latin) “prevention is better than cure”. Amongst the disease prevention methods that we have at our disposal vaccination is arguably one of the greatest, but is currently under attack from an array of detractors. The use of vaccination to limiting spread of an infectious disease was introduced in Europe in early 18th Century from Africa and Asia. Variolation, the practice of inoculating a child with smallpox in order to prevent full-blown attacks, was not wholly benign or safe: 2–3% of those variolated died of smallpox in contrast to the 20–30% who died after contracting smallpox naturally. In addition, variolated individuals could pass smallpox to others. How variolation worked is not exactly clear. Possibly, infection passed deliberately from one person to another via the skin is less lethal than natural infection because of the route or dose. An early account of the use of variolation was from the renowned traveller and explorer Lady Mary Montagu, who had witnessed the use of variolation in her eastern travels. She asked Dr Charles Maitland to variolate her two-year-old daughter and her advocacy of the use of variolation attracted considerable criticism. However, the practice slowly began to spread as its ability to protect against full-blown smallpox became apparent. In seeking a more benign method of prevention, Edward Jenner (1749–1823, already famous for his description of the parasitic egg-laying lifestyle of the cuckoo, leading to his election as a Fellow of the Royal Society in 1788) learnt of the benefits of infection with cowpox from farmers whose milkmaids had pockmark-free skin, having avoided the ravages of smallpox. Encouraged by his mentor the great experimentalist John Hunter (1728–93) Edward Jenner (1749–1823) performed the experiment of inoculating fluid discharged from a fresh cowpox lesion into the skin of an 8 year old boy. Two months later he attempted to infect the child with fresh discharge from smallpox lesion and showed that the child did not develop a variolation lesion or disease. Jenner published his findings in 1796 and used his considerable political and persuasive skills to popularise the practice [1]. The use of animal poxviruses to prevent smallpox improved in both efficacy and safety, so that by 1980 smallpox was officially declared to have been globally eradicated. The major struggle that Jenner faced was in convincing a sceptical public of the benefits of vaccination.

Vernal Keratoconjunctivitis and immune-mediated diseases: One unique way to symptom control?

Health Organization, 2006. 3. Choquet-Kastylevsky G, Vial T, Descotes J. Allergic adverse reactions to sulfonamides. Curr Allergy Asthma Rep 2002: 2: 16–25. 4. Lin D, Li WK, Rieder MJ. Cotrimoxazole for prophylaxis or treatment of opportunistic infections of HIV/AIDS in patients with previous history of hypersensitivity to cotrimoxazole. Cochrane Database Syst Rev 2007: 2: CD005646. 5. Moreno-Ancillo A, L opez-Serrano MC. Hypersensitivity reactions to drugs in HIV-infected patients. Allergic evaluation and desensitization. Clin Exp Allergy 1998: 28: 57–60. 6. Absar N, Daneshvar H, Beall G. Desensitization to trimethoprim/ sulfamethoxazole in HIV-infected patients. J Allergy Clin Immunol 1994: 93: 1001–5. 7. Brockow K, Romano A, Blanca M, Ring J, Pichler W, Demoly P. General considerations for skin test procedures in the diagnosis of drug hypersensitivity. Allergy 2002: 57: 45–51. 8. Kletzel M, Beck S, Elser J, Shock N, Burks W. Trimethoprim-sulfamethoxazole oral desensitization in hemophiliacs infected with human immunodeficiency virus with a history of hypersensitivity reactions. Am J Dis Child 1991: 145: 1428–9. 9. Palusci VJ, Kaul A, Lawrence RM, Haines KA, Kwittken PL. Rapid oral desensitization to trimethoprimsulfamethoxazole in infants and children. Pediatr Infect Dis J 1996: 15: 456–60. 10. Nagarajan R, Nelson RP, Day NK, Good RA. Trimethoprim-sulfamethoxazole sensitivity and desensitization in HIVinfected children. J Allergy Clin Immunol 1995: 95: 287.