Children with inflammatory bowel disease already have an altered arterial pulse wave.

Adults with inflammatory bowel disease (IBD) have an increased risk for vascular events. This study aims to evaluate arterial parameters in paediatric IBD. Carotid intima-media thickness (CIMT) was measured by ultrasound, and Arteriograph was used to assess aortic pulse wave velocity (PWVao), brachial and aortic augmentation indexes (AixBrach, AixAo), central systolic blood pressure (SBPao), and heart rate (HR). A total of 161 children were included; 55 (34%) children with newly diagnosed IBD (median age 14.35 (11.88-16.31) years, 53% males), 53(33%) in remission (median age 15.62 (13.46-16.70) years, 66% males), and 53 (33%) controls (median age 14.09 (11.18-14.09) years, 55% males) were recruited into a case-control study. Compared to controls, patients with active disease and those in clinical remission had significantly lower AixBrach and AixAo (P < 0.001, P = 0.009; P < 0.001, P = 0.003). PWVao and CIMT were still normal. HR was higher in both IBD groups than in controls (P < 0.001; P = 0.006). HR positively correlated with disease duration (P = 0.001). In the ordinary least squares regression models, anti-tumour necrosis factor (TNF) α treatment predicted lower peripheral and central systolic blood pressures, in contrast to aminosalicylates and methotrexate. Aminosalicylate treatment predicted increased HR.  Conclusion: Children with IBD have an increased heart rate, a lower augmentation index and, therefore, an altered pulse waveform. In paediatric IBD, arterial stiffness and CIMT are still normal, indicating the potential for adequate IBD treatment to preserve arterial health. What is Known: • Adult patients with inflammatory bowel disease (IBD) have increased carotid intima-media thickness and arterial stiffness, which positively correlates with cardiovascular risk and predicts mortality. Adequate treatment, especially anti-tumour necrosis factor (TNF) α medications, lower these risks. • Children with IBD have impaired endothelial function and reduced heart rate (HR) variability. What is New: • Children with IBD have impaired endothelial function and reduced heart rate (HR) variability. • Anti-TNFα treatment in children and adolescents with IBD lowers systolic pressure, whereas methotrexate and aminosalicylates have the opposite effect. Amiynosalyiciylate treatment also increases HR.

Quality of Diet of Patients with Coeliac Disease in Comparison to Healthy Children.

A lifelong strict gluten-free diet is the only available treatment for patients with coeliac disease (CD). As with any restrictive diet, it may potentially lead to nutritional deficits. Seventy-six patients with CD (mean age 9.0 ± 4.3 years, 57% female) and 590 healthy controls (HC) (mean age 9.9 ± 0.1 years, 54% female) were recruited and requested to keep a 3-day food record (3DFR). In HC patients, anthropometric data were determined at the time when 3DFRs were collected. In CD patients, anthropometric data were determined at two time points: at diagnosis and at the time of 3DFRs collection. Intake of energy, macronutrients, and micronutrients was determined using PRODI expert 6.9 software and expressed as a percentage of recommended daily intake. In CD patients, all measured anthropometric measures (body weight (BW), body height (BH), and body mass index (BMI) z-scores) increased significantly after the mean duration of 34.1 months of a GFD. Overall, CD patients had significantly lower BW and BH z-scores compared to healthy controls. Patients with CD were generally more compliant with the recommended dietary intakes of macronutrients and some micronutrients, as compared to HC. Three participants were not compliant with the GFD; 42.1% of participants took oral nutritional supplements at the start of their GFD. Our study showed that patients with CD have better compliance with dietary recommendations compared to healthy controls, showing that a well-balanced GFD diet can provide necessary macro- and micronutrients.

Severe Protein Loss in a 6-month-old Exclusively Breastfed Infant with Atopic Dermatitis.

Protein loss is often the result of kidney or intestinal disease (protein-losing enteropathy) and can cause a number of serious, potentially life-threatening complications such as hypotension, thrombocytosis, electrolyte imbalance, and cerebellar ischemia. Recent research suggests an association between extremely severe atopic dermatitis (AD) and allergic enteropathy. An exclusively breastfed 6-month-old infant was admitted to our institution due to failure to thrive, electrolyte imbalance, and severe AD (SCORing Atopic Dermatitis; SCORAD 40). On admission, the infant was in poor general condition, dehydrated, malnourished (bodyweight 4870 g, -3.98 z-score), with exudative erythematous morphs scattered throughout the body. Initial laboratory results showed microcytic hypochromic anemia, hypoalbuminemia, hypogammaglobinemia, thrombocytosis, hyponatremia, high values of total immunoglobulin E (IgE), and eosinophilia. Polysensitization to a number of nutritional and inhalation allergens was demonstrated, and an exclusive amino acid-based formula has been introduced into the diet. During the hospital course, the patient developed superficial thrombophlebitis and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Eosinophilia was found in a small intestine biopsy sample. Due to severe hypogammaglobulinemia, skin infections, and bacteremia, the differential diagnosis included primary immune deficiency (STAT3 deficiency, DOCK8 deficiency, PGM3 deficiency, IPEX), but all available immunological tests were unremarkable. Exclusive amino acid-based formula diet was continued in the infant, with topical corticosteroids under wet-dressing therapy and intravenous immunoglobulin replacement therapy. With the gradual improvement of the general condition, the introduction of solid foods was started according to the findings of allergy testing. At 17 months of age, the patient gained weight and his skin status has been improving, although frequent use of topical corticosteroids was necessary. There were no infections, no anemia or thrombocytosis, and albumin and immunoglobulin supplementation were no longer required. The main mechanism of protein loss in infants with extremely severe atopic dermatitis is probably due to damaged skin, and partially due to the eosinophilic inflammation of the small intestine. Immunoglobulin loss, potentiated by physiological or transient hypogammaglobulinemia in infants, poses a very high risk for severe, potentially life-threatening infections.

Point-of-Care Screening for Coeliac Disease in Schoolchildren Reveals Higher Disease Prevalence in Croatia.

Coeliac disease (CD) is an immune-mediated inflammatory disease triggered by dietary gluten and related proteins in genetically predisposed individuals. Point-of-care (POC) methods are non-invasive and easily performed tests, which could help to reduce the diagnostic delay of CD. The aim of our study was to determine the prevalence of CD using rapid POC test in first-grade schoolchildren in Zagreb, Croatia. A rapid qualitative immunoassay POC test designed for detection of immunoglobulin (Ig) A and IgG deamidated gliadin antibodies (DGP), as well as total IgA (to identify IgA deficient patients) in whole blood, was used to test healthy children on gluten containing diet. Out of 1404 tested children (51% female), 85 (6.05%) had a positive rapid POC test result and were referred to paediatric gastroenterologist. Finally, 7 children were diagnosed with CD (0.5%). There was no significant difference in children with CD and children with positive POC but negative serology in sex, BMI, or symptoms. However, children diagnosed with CD complained of abdominal pain significantly more often. The prevalence of CD in first-grade schoolchildren was 1:200 (0.5%), higher than in previous studies performed in Croatia. The results imply the possible benefit of IgA and IgG DGP-based POC tests in population screening.

Use of probiotics in the treatment of functional abdominal pain in children-systematic review and meta-analysis.

Functional abdominal pain is a very frequent functional gastrointestinal disorder but still without adequate treatment options. Therefore, the main aim of this systematic review and meta-analysis was to evaluate strain-specific probiotic effects on functional abdominal pain in children. This was a systematic review and meta-analysis of randomized controlled trials published in a period up to 1st of April 2020 that analyzed probiotic interventions for pediatric functional abdominal pain. We included 9 randomized controlled trials (a total of 702 children, 506 with functional abdominal pain; 4 to 18 years); 8 studies were available for meta-analysis (a total of 641 children). Lactobacillus rhamnosus GG and Lactobacillus reuteri DSM 17938 were the only two probiotic strains investigated. Significant reduction in pain intensity (6 trials, n = 380, mean difference - 1.24, 95% CI - 2.35 to - 0.13) and increase in number of days without pain (2 trials, n = 101, mean difference 26.42, 95% CI 22.67 to 30.17) were found in children taking L. reuteri DSM 17938. For all other outcomes, there were no significant differences between probiotic and placebo.Conclusion: Based on the available evidence, no firm conclusions can be given; however, L. reuteri was proven to decrease the pain intensity in children with functional abdominal pain. Further trials regarding long-term outcomes, possibly involving longer interventions, are needed. What is Known: • Previously published systematic reviews have suggested that probiotics may have an effect on the pain in children with functional gastrointestinal disorders, but limited data exist on strain-specific effects. What is New: • This systematic review provides evidence on the probiotic use on the strain-specific level. • This systematic review showed that the use of Lactobacillus reuteri DSM 17938 modestly reduces the pain intensity in children with functional abdominal pain.

Lactobacillus reuteri DSM 17938 is effective in the treatment of functional abdominal pain in children: Results of the double-blind randomized study.

BACKGROUND & AIMS: Possible therapeutic effect of Lactobacillus (L.) reuteri DSM 17938 has been reported in children with functional abdominal pain (FAP) but data are inconclusive. METHODS: This is a randomized double-blinded controlled trial (RCT) which assessed effect of L. reuteri DSM 17938 (dose 108 CFU/day) in children (age 4-18 years) on FAP during an intervention period of 12 weeks and follow-up of 4 weeks. This study was performed after the interim analysis and had different labeling of products and a new randomization. Data presented here are results of this RCT and pooled data from both RCTs (before and after interim analysis). RESULTS: This RCT included 46 children (median age 10.1 vs 10.6 years; 11 vs 13 girls). Abdominal pain was less severe in intervention group during the 4th month of the study and there was significant increase in the number of days without pain. Pooled data from both parts of the study included 101 children. Number of days without pain was significantly higher in the L. reuteri group (mean difference 26.42 days, 95% CI 22.47-30.17). Significant difference in the pain intensity was found after 2nd, 3rd and 4th month of the intervention. There was no difference between groups in the number of children in whom symptoms completely ceased (Risk Ratio 1.09, 95% CI 0.75-1.58). CONCLUSION: Administration of L. reuteri DSM 17938 was associated with the reduction in the intensity of pain and with significantly increase in pain-free days in children with FAP.

Alternative Splicing Rescues Loss of Common Gamma Chain Function and Results in IL-21R-like Deficiency.

Inborn errors in interleukin 2 receptor, gamma (IL2RG) perturb signaling of the common gamma chain family cytokines and cause severe combined immunodeficiency (SCID). Here, we report two brothers suffering from chronic cryptosporidiosis, severe diarrhea, and cholangitis. Pan T, B, and NK cell numbers were normal, but immunophenotyping revealed defective B cell differentiation. Using whole exome sequencing, we identified a base pair deletion in the first exon of IL2RG predicted to cause a frameshift and premature stop. However, flow cytometry revealed normal surface expression of the IL-2Rγ chain. While IL-2, IL-7, and IL-15 signaling showed only mild defects of STAT5 phosphorylation in response to the respective cytokines, IL-4- and IL-21-induced phosphorylation of STAT3 and STAT6 was markedly reduced. Examination of RNA isoforms detected alternative splicing downstream of IL2RG exon 1 in both patients resulting in resolution of the predicted frameshift and 16 mutated amino acids. In silico modeling suggested that the IL-2Rγ mutation reduces the stabilization of IL-4 and IL-21 cytokine binding by affecting the N-terminal domain of the IL-2Rγ. Thus, our study shows that IL2RG deficiency can be associated with differential signaling defects. Confounding effects of alternative splicing may partially rescue genetic defects and should be considered in patients with inborn errors of immunity.

One-year outcomes in children with eosinophilic esophagitis.

BACKGROUND AND AIMS: Despite rising incidence of eosinophilic esophagitis (EoE), data on the follow-up and treatment outcomes in pediatric patients are scarce. Therefore, the aim of this study was to present data on the treatment outcomes in children diagnosed with EoE who were treated in a tertiary medical center. PATIENTS AND METHODS: A retrospective study involving patients younger than 18 years who were diagnosed with EoE in our center between January 2011 and June 2017. RESULTS: Thirty-two patients met inclusion criteria and were followed up for a mean of 3 years (range 0.5-6.8). Six months after the diagnosis, 28 (87.5%) children were still followed up; 21 (75%) were in clinical remission, including 10 (36%) who were in histological remission. After 12 months, 27 patients were still followed up; 21 (78%) achieved clinical remission, including 10 (37%) with histological remission. During follow-up, three patients developed gastroesophageal reflux disease (GERD). There was no difference in body mass index (BMI) Z score between baseline and 12 months follow-up (median - 0.3 vs - 0.3 SD, p = 0.862). CONCLUSIONS: Absence of symptoms does not indicate mucosal healing; therefore, patients should be followed up endoscopically. Additionally, despite restricted diet, nutritional status remains unaffected. Finally, patients with EoE can develop significant GERD even years after the EoE diagnosis.

Lack of Benefit of Lactobacillus reuteri DSM 17938 as an Addition to the Treatment of Functional Constipation.

The aim of this study was to investigate the role of Lactobacillus reuteri DSM 17983 in the treatment of functional constipation in children. The trial was a single-center randomized, double-blind, placebo-controlled study. Patients were allocated into the 2 groups; intervention group which received L reuteri DSM 17983 and lactulose and placebo group which received placebo and lactulose. Due to small recruitment rate study was terminated prematurely; therefore, only 33 children (12 girls, median age 4.5 years, range 2-16) were randomized. There was no difference between groups in the stool frequency, stool consistency, pain, soiling rate and dose of the lactulose. This study found that L reuteri DSM 17938 adds no benefit to the treatment of constipation in children. Due to small sample size, these results, however, should be interpreted with caution.

Anterior Cutaneous Nerve Entrapment Syndrome in Children: A Prospective Observational Study.

OBJECTIVE: Anterior cutaneous nerve entrapment syndrome (ACNES) is often an overlooked cause of abdominal pain. Data for pediatric patients, especially with regard to the treatment modalities are scarce. The aim of this study was to present a treatment modality of ACNES with combined local subfascial anesthetic and corticosteroid injection in a prospectively collected cohort of pediatric patients. METHODS: This was a prospective observational long-term study that included pediatric patients who were diagnosed with ACNES in a tertiary care pediatric center and who were followed-up for at least 12 months (median: 1.7 y; range: 1 to 2.7 y). All children were treated by ultrasound-guided subfascial injection of 40 mg 1% lidocaine and 4 mg dexamethasone into the rectus abdominis muscle in the place of the most severe pain (trigger point infiltration). RESULTS: The study included 38 children (28, 73.7% female; median age: 15 y). The majority of patients had pain in the lower right abdominal quadrant and were diagnosed in a median of 6 (range: 0.5 to 50) months after symptoms started. Overall, 24 (63%) patients achieved sustained symptom-free remission after a median of 1 (mean: 1.6; range: 1 to 5) trigger point infiltration during the first treatment session. Five (13%) children were surgically treated because of a lack of long-term response. Children who were surgically treated required a higher number of block applications during the first session of treatment, compared with children who were successfully treated conservatively. DISCUSSION: ACNES in children can be successfully treated by a combined local subfascial anesthetic and corticosteroid trigger point infiltration.

Lactobacillus reuteri DSM 17938 in the Treatment of Functional Abdominal Pain in Children: RCT Study.

OBJECTIVES: Beneficial therapeutic effect of probiotics has been reported in children with the irritable bowel syndrome (IBS) but not consistently in other functional abdominal pain-related disorders. The aim of the present study was to investigate the effect of Lactobacillus reuteri DSM 17938 in the treatment of functional abdominal pain (FAP) and IBS in children. METHODS: Children (age 4-18 years) referred to pediatric gastroenterologist at Children's Hospital Zagreb from May 2012 to December 2014, diagnosed as FAP or IBS, were randomized to receive L reuteri DSM 17938 108 CFU daily or placebo. The study was a prospective, randomized, double-blind, placebo-controlled parallel study. Symptoms were evaluated using Wong-Baker FACES pain rating scale for pain and Bristol scale for stool shape and consistence. RESULTS: Data were analyzed for 55 children (26 in the intervention group and 29 in the placebo group). Children in the intervention group had significantly more days without pain (median 89.5 vs 51 days, P = 0.029). Abdominal pain was less severe in children taking probiotics during the second month (P < 0.05) and fourth month (P < 0.01). The 2 groups did not differ in the duration of abdominal pain, stool type, or absence from school. Both groups experienced significant reduction in the severity of abdominal pain from first to fourth month, with the reduction more prominent in the intervention group (P < 0.001 vs P = 0.004). CONCLUSIONS: Administration of L reuteri DSM 17938 was associated with a possible reduction of the intensity of pain and significantly more days without pain in children with FAP and IBS.

Methotrexate is an efficient therapeutic alternative in children with thiopurine-resistant Crohn's disease.

OBJECTIVE: This study aimed to investigate the role of methotrexate (MTX) in the maintenance of clinical remission and mucosal healing in children with Crohn's disease (CD), in whom azathioprine (AZA) treatment failed. MATERIALS AND METHODS: This was a retrospective, longitudinal cohort study which included all children who were diagnosed with CD during a period of 10 years and who received MTX for ≥12 months after failed AZA treatment. Remission was assessed clinically, defined by Pediatric Crohn's Disease Activity Index as a score of ≤10 and no need for the reintroduction of the remission induction therapy. In the subset of patients with sustained clinical remission, the rate of mucosal healing was endoscopically assessed. Endoscopic lesions were assessed by Simple Endoscopic Score for CD. Each patient served as his or her own historical control. RESULTS: Of the 32 included patients, 22 (68.7%) remained in the stable clinical remission after a period of 12 months and 14 (43.8%) did not experience relapse during the whole follow up (median duration 2.9 years; range 1-4.8 years). From all patients who were in clinical remission during the entire follow up (n = 14), endoscopy was performed in eight (57%) patients and showed complete mucosal healing macroscopically (Simple Endoscopic Score for CD score of 0) and microscopically in seven out of eight (87.5%) patients. CONCLUSION: MTX was found to be an efficient therapeutic alternative in the thiopurine-resistant patients, enabling the complete mucosal healing.

Diagnosis of coeliac disease in children younger than 2 years.

BACKGROUND AND AIM: To diagnose coeliac disease (CD) in children younger than 2 years, the old ESPGHAN criteria based on 3 small bowel biopsies were recommended until recently. The aim of the present study was to investigate the applicability of only 1 small intestinal biopsy plus positive serology for the diagnosis of CD in children younger than 2 years. METHODS: A prospective cohort study included 81 patients younger than 2 years with symptoms suggestive of CD, who all completed the diagnostic procedure based on 3 small bowel biopsies. According to the finding of the third biopsy, patients were divided into group A-CD confirmed (N = 44), and group B-CD not confirmed, after the gluten challenge (N = 37). RESULTS: At the time of the first biopsy, total villous atrophy (Marsh IIIc) was found more often in group A than in group B (77% vs 27%, P < 0.01). Also, all of the studied antibodies were more frequently positive in group A than in group B (P < 0.01 for all of the tested antibodies). Positive anti-endomysial antibodies and Marsh IIIc finding were the best discriminators between the group A and the group B and considerably contributed to the prediction of CD. CONCLUSIONS: The second and the third biopsies (before and after the gluten challenge) may also be avoided when diagnosing CD in children younger than 2 years provided that the child, at the time of presentation, has positive anti-endomysial antibodies and Marsh IIIc on the small bowel biopsy. A gluten challenge should be still considered in all other children younger than 2 years.

Antibiotic resistance of Helicobacter pylori in pediatric patients -- 10 years' experience.

The aim of this study was to assess the pattern of evolution of resistance to antibiotics in Helicobacter pylori isolated from children who underwent upper endoscopy with antral biopsy during a 10-year period (2001-2010). We retrospectively analyzed data of all children (n = 3,008) who underwent upper endoscopy during the observed period at the Children's Hospital Zagreb, a university tertiary medical center. We calculated the rate, antibiotic susceptibility and risk factors for the H. pylori infection in our cohort. Antral biopsy was performed in 2,313 (76.89%) patients. Altogether, 382 (16.51%) children had positive biopsy for H. pylori (histology and/or culture). There was no significant difference in the incidence of H. pylori during 10 years of observation (p = 0.21). Infected children compared to non-infected group were older (p = 0.005), and had more often antral nodularity (p < 0.0001), and duodenal ulcer (p = 0.002). Altogether, 22.4% of treatment-naïve patients had strains resistant to tested antibiotics: majority to azithromycin (17.9%), followed by clarithromycin (11.9%), metronidazole (10.1%) and amoxicillin (0.6%). In the eradication failure group, 9/11 of children had strains resistant to tested antibiotics, mostly to metronidazole (7/11), followed by azithromycin (3/11) and clarithromycin (1/11). No correlation was found between age or gender and antibiotic resistance (p = 0.32, for both). In conclusion, our data strongly support current guidelines which recommend antibiotic susceptibility testing prior to eradication therapy. Based on our results we recommend the use of amoxicillin-metronidazole-based regimen as the first-line therapy in our study population.

Our experiences with the use of atopy patch test in the diagnosis of cow's milk hypersensitivity.

Atopy patch test has been recognized as a diagnostic tool for the verification of food allergies in infants and small children suffering from atopic dermatitis. The test also has a role in the diagnosis of food allergies characterized by clinical signs associated with the digestive system. Yet, in spite of numerous studies, the test itself has hitherto not been standardized. Our study enlisted 151 children less than two years of age, who exhibited suspect skin and/or gastrointestinal manifestations of food allergy to cow's milk, and in whom tests failed to prove early type of allergic reaction. Atopy patch test was positive in 28% of the children with atopic dermatitis, 43% of the children with suspect gastrointestinal manifestation and 32% of the children with skin and gastrointestinal manifestations of food allergy. In our experience, atopy patch test is an excellent addition to the hitherto used tests for the diagnosis of food allergies. It targets specifically delayed type hypersensitivity reactions, which are difficult to confirm with other diagnostic tools. It is furthermore simple to perform, noninvasive and produces a minimum of undesired side effects. For these reasons, it should become part of the routine diagnostic toolset for food allergies to cow's milk in infants and children, and applied before a food challenge test.

Compliance with gluten-free diet in children with coeliac disease.

OBJECTIVES: Coeliac disease (CD) is a lifelong disorder with gluten-induced manifestations in different organs. Gluten-free diet (GFD) is required to achieve remission and prevent complications; however, study reports on GFD growth effect are not consistent. METHODS: Compliance with GFD was estimated according to current body mass and height; presence of anaemia and other signs and symptoms; and attitude toward GFD. RESULTS: Seventy-one patients with CD (mean age = 12 years; mean age after CD diagnosis = 9 years) were examined and their blood sampled for determination of endomysial antibodies (EMA), haemoglobin, and red blood cell count. Questionnaire analysis revealed 42 (59.1%; 4 EMA positive) patients to be on strict GFD, 19 (26.8%; 5 EMA positive) were taking small amounts of gluten, and 10 (14.1%; all EMA positive) were not on a diet at all. The patients on strict GFD had greatest body height, yet the difference was not significant. These patients also had a higher mean body mass (P = 0.05) and significantly higher mean haemoglobin and mean cell haemoglobin levels (P = 0.05 and P < 0.05, respectively). Apart from chronic fatigue in patients on partial diet (P = 0.05), patient groups did not differ significantly in the frequency of symptoms. Anaemia and delayed puberty were recorded only in noncompliers (P < 0.01 and P < 0.05, respectively). Noncompliers often found the specific diet to pose a major life burden (P < 0.01) and did not visit a gastroenterologist on a regular basis (P < 0.01). CONCLUSIONS: Almost half of the coeliac patients were likely to abandon GFD without experiencing major symptoms, thus increasing the risk for developing complications later in life. An active attitude is required in the follow-up of patients with CD.

NOD2/CARD15 mutations in Croatian patients with Crohn's disease: prevalence and genotype-phenotype relationship.

BACKGROUND: Crohn's disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract with variations in localization and behaviour. Mutations in the NOD2/CARD15 gene on chromosome 16q have been implicated in the pathogenesis of the disease and three main sequence variants, all single nucleotide polymorphisms (SNPs), have been identified in North American and European populations. AIMS AND METHODS: As no data exist in the Croatian population, we consecutively collected a cohort of 136 CD patients and 91 healthy controls to determine the prevalence of NOD2/CARD15 mutations and their association with phenotypic expression of the disease. All patients and controls were genotyped for Arg702Trp (Hugot SNP8), Gly908Arg (Hugot SNP12), and Leu1007fsinsC (Hugot SNP13) and allele frequencies were compared between the Crohn's patients and controls. The correlation of NOD2/CARD15 genotypes with the phenotypic expression of Crohn's disease was further assessed by logistic regression analysis. RESULTS: NOD2/CARD15 variants were found in 38/136 CD patients (27.9%) compared to 10/91 (10.9%) healthy controls (P = 0.0022). Allele frequencies in patients with CD were 13.97%, 4.4% and 11.76%, respectively, for SNP8, 12 and 13, compared to 5.49%, 1.12% and 4.40% in controls (P = 0.041, P = 0.162, P = 0.055). Six CD patients carried double mutations and, remarkably, we identified two homozygous mutants amongst the healthy control group. Surgery over the course of the disease and a younger age at onset of the disease were significantly more frequent in patients who were carriers of NOD2/CARD15 mutations. CONCLUSIONS: This report on NOD2/CARD15 mutations in Croatian patients with CD demonstrates that this gene is also implicated in susceptibility to CD in the Croatian population. Phenotypic association showed a younger age at diagnosis and a higher need for surgery in patients carrying NOD2/CARD15 mutations. However, the prevalence is somewhat lower compared to other reports, likely due to a more prominent colonic inflammation.

Gluten-free diet has a beneficial effect on chromosome instability in lymphocytes of children with coeliac disease.

OBJECTIVES: Children with coeliac disease (CD) have an increased number of chromosome aberrations in peripheral blood lymphocytes. Whether genetically determined or a secondary phenomenon in CD, chromosome abnormalities may be involved in the predisposition to cancer in CD patients. The aim of the study was to follow a group of children with CD in whom the initial frequency of chromosome aberrations at diagnosis was known and to measure the same variable after a minimum of 2 years on a gluten-free diet. METHODS: Chromosome aberrations in peripheral blood lymphocytes were determined in 17 patients with CD, before and after at least 24 months of a gluten free diet (mean, 33 months), and in 15 healthy children. The differences in the frequency of aberrations were analyzed by Mann-Whitney U test and Wilcoxon matched-pairs signed-ranks test. RESULTS: Twelve patients adhered to the diet and had a significantly lower frequency of chromosome aberrations than did 5 patients not following the diet (0.16% v 1.2%; P = 0.03), whereas at presentation there had been no difference (1.54% v 1.2%; P = 0.09). The frequency of aberrations at follow-up in patients who were diet adherent was significantly lower than at presentation (1.54% v 0.16%; P = 0.02) and remained unchanged in patients who were not diet adherent (1.2% v 1.2%; P = 1). After at least 24 months of a gluten-free diet, children with CD did not differ from healthy control subjects (0.16% v 0.27%; P = 0.54), whereas children not following the diet had an increased frequency of aberrations (1.2% v 0.27%; P = 0.05). CONCLUSIONS: The frequency of chromosome aberrations in peripheral blood lymphocytes of patients with CD decreased significantly on a gluten-free diet. We conclude that genomic instability is a secondary phenomenon, possibly caused by chronic intestinal inflammation.