Tania Gerarduzzi

Mass screening for coeliac disease using antihuman transglutaminase antibody assay

Aims: To determine coeliac disease prevalence by an anti-transglutaminase antibody assay in a large paediatric population; to evaluate acceptance of the screening programme, dietary compliance, and long term health effects. Methods: Cross-sectional survey of 3188 schoolchildren (aged 6–12) and prospective follow up of diagnosed cases. Main outcome measures were: prevalence of coeliac disease defined by intestinal biopsy or positivity to both human tissue transglutaminase and anti-endomysium antibodies in HLA DQ2-8 positive subjects; percentage of children whose families accepted screening; dietary compliance as defined by negativity for anti-transglutaminase antibodies; and presence of clinical or laboratory abnormalities at 24 month follow up. Results: The families of 3188/3665 children gave their consent (87%). Thirty biopsy proven coeliacs were identified (prevalence 1:106). Three other children testing positive for both coeliac related autoantibodies and HLA DQ2-8 but refusing biopsy were considered as having coeliac disease (prevalence 1:96). Of 33 cases, 12 had coeliac related symptoms. The 30 biopsy proven coeliacs followed a gluten-free diet. Of 28 subjects completing 18–24 months follow up, 20 (71.4%) were negative for anti-transglutaminase antibodies, while eight were slightly positive; symptoms resolved in all 12 symptomatic children. Conclusions: Prevalence of coeliac disease is high in Italian schoolchildren. Two thirds of cases were asymptomatic. Acceptance of the programme was good, as was dietary compliance. Given the high prevalence and possible complications of untreated coeliac disease, the availability of a valid screening method, and evidence of willingness to comply with dietary treatment population mass screening deserves careful consideration.

Fatal allergy as a possible consequence of long-term elimination diet

Urticaria is a commondisorder that affects as many as 20% of the population at some point during their lifetime. Factors believed to cause or aggravate urticaria include drugs, foods, additives, connective tissue disorders and infections. It is well established that hepatitis B virus causes urticaria (1). Whether hepatitis C infection causes urticaria or not is still debated. There have been conflicting reports both in favour of (2,3) and against (4,5) hepatitis C virus (HCV) causing urticaria. Kanazawa and colleagues (2) reported a positive relationship between hepatitis C and urticaria. Nineteen of 79 patients tested were found to be positive for HCV. Subsequent studies however did not confirm such an association (4,5). We describe here a case of chronic intermittent urticaria caused by HCV. A 49-year-old Caucasian man presented with a typical history of recurrent urticaria of several months duration. There were no clues in the history apart from promiscuity, and all routine screening investigations were negative apart from an approximately three times raised alanine aminotransferase (ALT). In view of a history of multiple sexual partners and raised ALT, hepatitis serology was requested. Hepatitis C antibody was reported to be positive by both enzymelinked immunosorbent assay (ELISA) and microparticle enzyme immune assay. Results of ELISA for hepatitis B were negative.We conclude that HCV infection may have caused urticaria in this patient. There does not appear to be any clearcut evidence to affirm or refute a direct link between chronic urticaria and HCV infection in the literature. We suggest that HCV status should be checked in patients presenting with urticaria in areas with a high prevalence. It may not be cost-effective to perform routine screening forHCVwhere the prevalence of this infection is low, but should be considered where the history or laboratory tests suggest this possibility. Further studies are needed to establish any definite association, possible aetiopathogenic role and the cost implications of screening and therapy of HCV in chronic urticaria.

Pretreatment with intravenous ketamine reduces propofol injection pain.

Background Paediatric procedural sedation using propofol has been shown to be safe and effective and is widely used. Pain at the injection site is a frequent complaint and can be particularly distressing for children, especially for those undergoing repeated procedures. Ketamine has analgesic properties and can diminish the incidence of propofol infusion pain in adults. The aim of the study was to investigate whether pretreatment with ketamine would reduce infusion line pain in propofol sedation in children.

Proton pump inhibitors in children: a review

Proton pump inhibitors are often used to treat disorders associated with gastric hypersecretion in children, despite the lack of pediatric formulations. They are highly effective in the treatment of ulcers, gastro-esophageal reflux disorders and hypersecretory diseases. They provide a high level of gastric acid inhibition with few adverse effects. The aim of this article is to review the available studies concerning the use of proton pump inhibitors in pediatric populations and to point out: indications for use in children, optimal dosage, risk of adverse effects and consequences of the mechanism of action, and drug interactions. We performed a Medline and Embase search of publications printed from January 1980 to December 2002 concerning the use of proton pump inhibitors in children. We consider the available randomised controlled trials and several other uncontrolled studies conducted in the pediatric population, including all available information concerning the pediatric use of proton pump inhibitors. In children as well as in adults, there are clinical conditions (i.e., severe esophagitis or eradication of Helicobacter pylori) in which proton pump inhibitors offer clear advantages over histamine-2 receptor antagonists. The relatively common use of acid inhibitors (proton pump inhibitors and histamine-2 receptor antagonists) in uncomplicated gastro-esophageal reflux disorders or in the prevention of non-steroidal anti-inflammatory drugs/steroid gastropathy is often unsubstantiated and should be limited to very specific situations. Multicentre randomised controlled studies are needed to better define the efficacy profile, the optimal dosage with respect to the different indications and the safety profile for chronic therapy of proton pump inhibitors in children.

Chronic urticaria and coeliac disease

We appreciated the paper by Levy et al published in this journal in June 2003.1 A number of the cases of chronic urticaria in children appear to be of unknown aetiology, and experiences such as the one reported by the authors indicate an autoimmune origin. In our opinion the model of association between thyroiditis and chronic urticaria may apply to the association between coeliac disease and chronic urticaria as well. Remarkably, …

Maturity-Onset Diabetes of the Young with Necrobiosis Lipoidica and Granuloma Annulare

Abstract:  We describe a 12‐year‐old white girl with granuloma annulare localized to both ankles since she was five, necrobiosis lipoidica in the left pretibial region since she was ten, and a recent history of weakness, migraine, and weight loss. After initial evaluation, high fasting blood glucose levels and high hemoglobin A1c were found. The family history for non‐insulin‐dependent diabetes was suggestive of maturity‐onset diabetes of the young. Coexistence of necrobiosis lipoidica and granuloma annulare, together with a family history of non‐insulin‐dependent diabetes, the age of onset, and the absence of ketosis, are specific features making possible, a clinical diagnosis. Genetic confirmation may not be so easily accessible or necessary.