Malignancy and mortality in a population-based cohort of patients with coeliac disease or "gluten sensitivity".

AIM: To determine the risk of malignancy and mortality in patients with a positive endomysial or anti-gliadin antibody test in Northern Ireland. METHODS: A population-based retrospective cohort study design was used. Laboratory test results used in the diagnosis of coeliac disease were obtained from the Regional Immunology Laboratory, cancer statistics from the Northern Ireland Cancer Registry and mortality statistics from the General Registrar Office, Northern Ireland. Age standardized incidence ratios of malignant neoplasms and standardized mortality ratios of all-cause and cause-specific mortality were calculated. RESULTS: A total of 13 338 people had an endomysial antibody and/or an anti-gliadin antibody test in Northern Ireland between 1993 and 1996. There were 490 patients who tested positive for endomysial antibodies and they were assumed to have coeliac disease. There were 1133 patients who tested positive for anti-gliadin antibodies and they were defined as gluten sensitive. Malignant neoplasms were not significantly associated with coeliac disease; however, all-cause mortality was significantly increased following diagnosis. The standardized incidence and mortality ratios for non-Hodgkin's lymphoma were increased in coeliac disease patients but did not reach statistical significance. Lung and breast cancer incidence were significantly lower and all-cause mortality, mortality from malignant neoplasms, non-Hodgkin's lymphoma and digestive system disorders were significantly higher in gluten sensitive patients compared to the Northern Ireland population. CONCLUSION: Patients with coeliac disease or gluten sensitivity had higher mortality rates than the Northern Ireland population. This association persists more than one year after diagnosis in patients testing positive for anti-gliadin antibodies. Breast cancer is significantly reduced in the cohort of patients with gluten sensitivity.

Anti-tissue transglutaminase antibodies and their role in the investigation of coeliac disease.

Coeliac disease (CD), caused by an inappropriate T-cell-mediated immune response to the ingestion of cereal proteins in genetically susceptible individuals, is a common disorder with a prevalence of about 1% in Caucasian populations. It has a strong association with other autoimmune disorders, particularly type 1 diabetes and autoimmune thyroid disease. Although primarily affecting the small bowel, CD is a multisystem disorder and the adult or child patient may initially present to a wide range of clinical specialties. The concept of the 'coeliac iceberg' has been used to emphasize that many cases currently remain undiagnosed. The identification of tissue transglutaminase (TGA)-2 as the antigen against which the autoantibodies are directed has led to a greater understanding of the pathogenesis of CD and to the development of improved serological tests. Enzyme-linked immunoassays using human tissue TGA as antigen have high diagnostic sensitivity and specificity for the detection of CD. This review examines the evidence for adopting IgA anti-tissue TGA as the first-line diagnostic test for CD. It recommends a laboratory algorithm for the use and interpretation of TGA to enable the clinical laboratory to play a full part in detecting and monitoring a disorder that is eminently treatable once the diagnosis has been considered and confirmed.

Cardiac evaluation of women distance runners by echocardiographic color Doppler flow mapping.

Echocardiographic color Doppler flow mapping was performed in 46 normal women to determine the normal flow phenomena across each of the four heart valves. Three groups were studied: Group I consisted of 15 highly trained long distance runners, mean age 27 years, running an average of 105 km/week, with a mean rest heart rate of 45 beats/min; Group II consisted of 14 moderately trained long distance runners, mean age 28, running an average of 60 km/week, with a mean rest heart rate of 53 beats/min; Group III consisted of 17 sedentary control subjects, mean age 28, with a mean rest heart rate of 77 beats/min. Color Doppler flow mapping showed that the ventricular inflow and outflow patterns were the same for each of the groups and identified a regurgitant flow pattern across each of the valves. A tricuspid regurgitant flow pattern was present in 14 subjects (93%) in Group I, 8 (57%) in Group II and 4 (24%) in Group III. A pulmonary regurgitant flow pattern was present in 13 subjects (87%) in Group I, 8 (57%) in Group II and 3 (18%) in Group III. A mitral regurgitant flow pattern was present in 4 subjects (20%) in Group I, 5 (35%) in Group II and 1 (17%) in Group III and an aortic regurgitant flow pattern was present in 1 subject (6%) in Group I. Patients in Group I had significantly more tricuspid and pulmonary regurgitant flow patterns than did patients in Group III (p less than 0.001). Heart rate and distance training in women appear to correlate with the frequency of tricuspid and pulmonary regurgitant flow patterns.(ABSTRACT TRUNCATED AT 250 WORDS)

Increasing numbers at a specialist coeliac clinic: contribution of serological testing in primary care.

BACKGROUND: Serological testing, using IgA class endomysial and tissue transglutaminase antibodies has high sensitivity and specificity for coeliac disease and allows case finding by clinicians other than gastroenterologists. We reviewed new coeliac patients seen over a 9-year period to determine how the availability of serology, particularly to primary care physicians, has changed rates and sources of diagnosis. METHODS: Files of patients attending a specialist coeliac clinic who were diagnosed from 1996 through 2004 were reviewed. Patients with villous atrophy consistent with gluten sensitive enteropathy (Marsh III) on duodenal biopsy were selected. Data analysed included clinical characteristics, endomysial and tissue transglutaminase antibodies status and source of request for serology. RESULTS: Over the study period 347 new coeliac patients, comprising adults and children aged 10 years and over, were identified, of whom 163 (47%) were identified by serological testing in primary care, 152 (44%) at the hospital gastroenterology department and 32 (9%) by other physicians in secondary care. Over three consecutive 3-year periods, the percentage of patients identified in primary care rose from 28% through 47% to 60%, with a rise in total numbers diagnosed from 93 through 118 to 136. There was no change in patient clinical characteristics over the study period. Though tissue transglutaminase antibodies were less sensitive than endomysial antibodies, combined testing obtained a sensitivity of over 90%. Patients identified in primary care were significantly younger and more likely to present with diarrhoea as a primary symptom. CONCLUSION: Currently over half of our coeliac patients are identified by serological testing in primary care, which has resulted in an overall rise in diagnosis rates. Primary care practitioners have an important role in the diagnosis of coeliac disease, particularly of patients who present with non-gastrointestinal symptoms. The contribution of specialists other than gastroenterologists in secondary care is disappointing and may improve with directed education.

Effects of intravenous methylprednisolone therapy on leukocyte and soluble adhesion molecule expression in MS.

Intravenous methylprednisolone (IVMP) may inhibit inflammatory cell recruitment to active MS lesions by effects on leukocyte or endothelial cell adhesion molecule expression. We investigated 15 MS patients in relapse receiving a 5-day course of IVMP (500 mg/day) and 15 normal subjects. Patients' blood samples were obtained pretreatment, at 6 and 24 hours after the first dose, and 48 hours after completion of therapy. Levels of L-selectin, leukocyte functional antigen 1 (LFA-1), Mac-1, and very late activation antigen 4 (VLA-4) expression were determined on alphabeta and gammadelta T cells and monocytes by dual-color immunofluorescent flow cytometry. Serum levels of soluble (s) L-selectin, sE-selectin, soluble intercellular adhesion molecule 1 (sICAM-1) and soluble vascular cell adhesion molecule 1 (sVCAM-1) were measured by ELISA. There was a marked decrease in the T-cell and monocyte counts at 6 hours after therapy, with recovery to baseline at 24 to 48 hours. Adhesion molecule expression was normal on circulating T cells and monocytes in active MS. IVMP resulted in significant changes in the percent adhesion molecule expression on monocytes: increased L-selectin expression at 24 hours, decreased Mac-1 expression at 6 hours, and decreased VLA-4 expression at 6 hours and 24 hours following treatment. T-cell adhesion molecule expression was unaffected by the therapy. Serum sE-selectin was reduced at 6 hours and 24 hours following treatment. IVMP alters the distribution and kinetics of monocyte adhesion molecule expression and endothelial cell release of E-selectin, which may limit monocyte recruitment to areas of tissue destruction in MS.

Elevated serum and CSF levels of soluble CD30 during clinical remission in multiple sclerosis.

OBJECTIVE: To ascertain the presence of the Th2 response in MS patients by evaluating the level of soluble (s) CD30 across the clinical spectrum of MS and during relapse and remission. BACKGROUND: MS is considered a T-cell-mediated disorder with the immune attack dominated by a Thl cytokine response. Elevated levels of sCD30 have been associated with CD4+ cells that secrete Th2-type cytokines. METHODS: Levels of sCD30 were determined in the serum and CSF of patients with primary progressive MS, secondary progressive MS, relapsing-remitting MS (RRMS), both in relapse and remission, and in patients with other inflammatory neurologic disease (IND) and noninflammatory neurologic disease (NIND). None of the patients were on immunomodulatory treatment. RESULTS: Higher serum levels of sCD30 were detected in all MS subgroups and IND patients compared with NIND patients. RRMS patients in remission had significantly higher levels than those in relapse (median, 45.7 U/mL versus 18.3 U/mL; p = 0.04). Significantly higher CSF levels were also found in all groups, except those with RRMS in relapse compared with NIND patients. Again, RRMS patients in remission had higher CSF sCD30 levels compared with those in relapse (median, 4.0 U/mL versus 3.0 U/mL; p = 0.08). CONCLUSIONS: Serum and CSF levels of sCD30 are increased in MS, particularly during remission. The results provide additional evidence for the presence of a Th2 response and indicate that sCD30 may be of value as a marker of lesion resolution.

T-cell receptor alpha, beta, gamma, and delta chain gene microsatellites show no association with multiple sclerosis.

Genetic predisposition to multiple sclerosis (MS) is determined, in part, by certain HLA genotypes, but the contribution of T-cell receptor (TCR) germline polymorphisms to MS susceptibility is less clear. Reports of disease associations with restriction fragment length polymorphisms of TCR alpha and beta chain genes have been difficult to confirm, and little data is available on the influence of the TCR gamma delta germline in MS. We investigated the TCR alpha, beta, gamma, and delta chain genes of Northern Irish patients with MS using four microsatellite markers of high heterozygosity. There were similar allele frequencies in patients and controls for all microsatellites studied. We conclude there is no convincing evidence for an association of MS with TCR alpha, beta, gamma, and delta chain gene polymorphisms.

Increased incidence of IgM class smooth muscle antibody in patients after renal transplantation.

Autoantibodies were examined in 70 patients with renal failure, before acceptance on a hemodialysis program, during the program, and up to 3 months after renal transplantation. Smooth muscle antibody (SMA) in the IgM class was detected in 76% of the patients after transplantation compared with 14% before transplantation. This increase was significant at the 5% level. Furthermore, two groups of patients were distinguished on the basis of a 4-fold or greater increase or no demonstrable increase in the titer of IgM SMA after transplantation. Rejection episodes occurred more frequently amongst patients from this former group (67%) compared with the latter group (35%).

Raised CSF levels of soluble adhesion molecules across the clinical spectrum of multiple sclerosis.

Endothelial activation is considered an important step in multiple sclerosis (MS) lesion formation, elevated cerebrospinal fluid (CSF) and serum levels of certain adhesion molecules being associated with varying stages of disease activity and clinical course. CSF and serum sVCAM-1, sICAM-1, sE-selectin and sL-selectin were measured by ELISA in 16 primary progressive (PPMS), 16 secondary progressive (SPMS) and 43 relapsing-remitting MS patients (RRMS) and compared with 20 inflammatory (IND) and 46 non-inflammatory neurological disease (NIND) controls. CSF sVCAM-1 and sICAM-1 were increased in all MS groups vs. NIND with no significant differences between the MS groups. CSF sE-selectin (p = 0.007) and the sE-selectin index (p = 0.01) were elevated in PPMS vs. RRMS in relapse, whilst serum sE-selectin was significantly raised in PPMS compared to RRMS in remission (p = 0.005), RRMS in relapse (p = 0.004), NIND (p = 0.03) and IND (p = 0.05). Adhesion molecule levels in both progressive MS groups were similar. These results provide evidence for a distinct inflammatory component in PPMS and for immunological heterogeneity between the clinical subgroups of MS.

Serum and cerebrospinal fluid levels of soluble adhesion molecules in multiple sclerosis: predominant intrathecal release of vascular cell adhesion molecule-1.

Activated cerebral vascular endothelial cells express leukocyte, vascular cell, and intracellular adhesion molecules (E-selectin, VCAM-1 and ICAM-1) which facilitate leukocyte adhesion to endothelium and migration into inflammatory lesions. Paired serum and cerebrospinal fluid (CSF) levels of soluble (s) E-selectin, sVCAM-1 and sICAM-1 were determined by ELISA in patients with clinically definite MS in relapse, and patients with other inflammatory (IND) and non-inflammatory neurological disease (NIND). CSF levels of sVCAM-1 and sICAM-1 were significantly increased in MS patients compared to IND and NIND patients. Elevation of CSF sVCAM-1 in MS patients was the most marked finding (P = 0.0001) and an increased sVCAM-1 index indicated that this was due to intrathecal release of sVCAM-1. There were no differences in serum and CSF sE-selectin levels between the study groups. Measurement of the sVCAM-1 index may provide a marker of disease activity in patients with clinically definite MS.

Serum and cerebrospinal fluid soluble Fas levels in clinical subgroups of multiple sclerosis.

Elevated sFas levels have been described in multiple sclerosis (MS) patients with active disease. The aim of this study was to assess the diagnostic potential of serum and cerebrospinal fluid (CSF) sFas measurements in differentiating clinically defined MS patient subgroups. Levels of sFas and sFas indices were determined in patients with stable relapsing-remitting MS (RRMS), active RRMS, primary progressive MS (PPMS), secondary progressive MS (SPMS) and patients with inflammatory (IND) and noninflammatory neurological diseases (NIND). Serum sFas modulation over 32 weeks IFN-beta1a therapy was also investigated. Serum and CSF sFas levels and sFas indices were elevated in MS compared to NIND and IND patients. Within the MS group, serum and CSF sFas levels were highest in PPMS, with active RRMS patients demonstrating the highest sFas indices. This may reflect an ongoing disease process which is occurring acutely (active disease) or incessantly (progressive disease). IFN-beta1a induced a transient increase in circulating sFas following initiation of therapy. Whilst evidence was provided for variable sFas expression in clinical subgroups of MS, there was insufficient definition between the respective groups to advocate sFas measurements as a diagnostic marker of clinical subgroups of MS.

Interferon-beta1a administration results in a transient increase of serum amyloid A protein and C-reactive protein: comparison with other markers of inflammation.

Putative markers of inflammation such as serum beta2-microglobulin and neopterin have been shown to be transiently upregulated following interferon-beta (IFN-beta) administration to multiple sclerosis (MS) patients. However, to date the role of the important inflammatory mediators serum amyloid A protein (SAA) and C-reactive protein (CRP) have not been described. Here we show that SAA but not CRP is elevated in relapsing-remitting MS patients compared to normal healthy individuals, and furthermore that both are transiently upregulated following intramuscular injection with IFN-beta1a (Avonex). This pattern of expression was found to parallel that of beta2-microglobulin and neopterin following injection and was mirrored by a selective activation of peripheral monocytes with respect to upregulation of receptors known to be involved in the inflammatory response (HLA-DR, CD16 and CD86). Injection of saline solution intramuscularly to six healthy control individuals did not produce a similar upregulation of any of the inflammatory markers investigated. Following IFN-beta1a injection, all inflammatory responses were attenuated at week 12 of therapy in comparison to those following the initial injection in a group of follow-up patients. In addition, IFN-beta1a injected on a weekly basis did not produce a sustained modulation of any of the markers investigated in patients treated for 32 weeks.

Evaluation of five commercial kits to detect dsDNA antibodies.

Experiments were performed to evaluate five commercial kit assays used for the detection of antibodies to dsDNA. The kits were compared using a performance index score as recommended by the guidelines of the European Committee for Clinical Laboratory Standards. The highest performance score was obtained using the radioimmunoassay from Immunodiagnostic Services Ltd, with the Amersham kit second, the immunofluorescence test using Crithidia luciliae third, the Walker ELISA kit fourth, and the haemagglutination assay fifth. The results showed that none of the kits was outstanding, each appeared to detect a different anti-DNA antibody type as different results were obtained using each kit in assays of quality control sera, linearity of the method, antibody detection in various patient groups, and interference by various substances. It is suggested that laboratories using commercial assay kits for the detection of antibodies to dsDNA should decide which is the most appropriate to their particular needs and that a performance index scoring system may be useful in the comparison of assay evaluations between different laboratories.

Transthyretin values correlate with mucosal recovery in patients with coeliac disease taking a gluten free diet.

AIMS: To assess changes in indicators of nutrition and iron deficiency as possible non-invasive markers of mucosal recovery in patients with coeliac disease on a gluten free diet. METHODS: Concentrations of transthyretin, retinol binding protein, soluble transferrin receptor, IgA anti-gliadin, and IgA anti-transglutaminase, and titres of IgA anti-endomysial antibody were measured in 36 newly diagnosed adult patients with coeliac disease and duodenal villous atrophy before (T0) and after one year (T1) on a gluten free diet. Duodenal biopsies taken at T0 and T1 were compared and graded as no improvement (no change in initial grade of villous atrophy) or improvement. RESULTS: Twenty two patients showed histological improvement and 14 showed no improvement. Transthyretin values increased in all patients with mucosal improvement and decreased in all patients showing no improvement. However, transthyretin values did not correlate with the degree of villous atrophy at T0 and T1 when assessed separately. Changes in retinol binding protein and soluble transferrin receptor values did not correlate with mucosal improvement. Coeliac disease associated antibodies (to gliadin, endomysium, and transglutaminase) decreased in most patients between T0 and T1, irrespective of mucosal recovery. CONCLUSIONS: Serial but not single measurements of transthyretin may be used as a non-invasive test to monitor mucosal recovery and therefore reduce the need for, or frequency of, follow up biopsies in treated patients with coeliac disease.

Effect of low to moderate levels of smoking and alcohol consumption on serum immunoglobulin concentrations.

AIM: To determine the effect of low to moderate levels of smoking and alcohol consumption on immunoglobulin concentrations. METHODS: Serum samples from 1787 subjects with approximately equal numbers in each five year group from 15 to 64 years were obtained from a large random population survey in Northern Ireland. Details were available on each subject concerning the number of units of alcohol consumed per week and the number of cigarettes smoked per day. IgG, IgM, and IgA concentrations were measured by laser nephelometry on all serum samples. RESULTS: Low to moderate consumption of alcohol was associated with a decrease in IgG and IgM median concentrations in contrast to an increase in IgA median concentrations. The decrease in IgM and especially IgG median concentrations appeared to be related to the smoking habits of the subjects. Alcohol consumption alone was associated with increased IgA median concentrations whereas cigarette smoking alone was associated with reduced IgG median concentrations. CONCLUSION: Low levels of alcohol consumption and cigarette smoking influence IgG, IgM, and IgA serum concentrations. This should be borne in mind when selecting subjects for use in research and clinical settings.

Evaluation of formulae for CSF IgG synthesis using data obtained from two methods: importance of receiver operator characteristic curve analysis.

AIMS: To determine the clinical performance of three cerebrospinal fluid (CSF) IgG synthesis formulae using data obtained from two quantitation methods. METHODS: Receiver operator characteristic (ROC) analysis and decision index plots were used to compare a rate nephelometric (RN) and a rocket immunoelectrophoretic (RIEP) method for quantitating albumin and IgG for use in CSF IgG synthesis formulae. Further analysis was used to determine the most clinically accurate of these formulae for a diagnosis of multiple sclerosis with regard to technical accuracy and cost effectiveness. RESULTS: Values for albumin and IgG determined by RN gave better sensitivities and specificities than the RIEP method when applied to all three formulae; however, when the 95% confidence limits were considered, the difference was not significant. Using the RN method with an agreed "rule in" threshold value of 90% specificity, the IgG index gave the best clinical performance. CONCLUSION: ROC curve analysis and decision index plots provide valuable tools in assessing and comparing the clinical performance of new and existing laboratory assays.

Diversity of autoantibodies in patients with antimitochondrial antibody and their diagnostic value.

A retrospective analysis of clinical and laboratory features of 102 patients, whose sera contained antibody to mitochondria, showed that primary biliary cirrhosis was diagnosed in 50% of them. Immunofluorescence showed that the sera of the patients with primary biliary cirrhosis all had the M2 antimitochondrial antibody staining pattern. A new staining pattern, designated M2(1), which could be mistaken for the M2 pattern, was not found in any patients with either primary biliary cirrhosis or chronic active hepatitis. Other serological variables such as antibody to mitochondria in IgM class, to multiple nuclear dots, and to the XR antigen, were associated with primary biliary cirrhosis, and taken in association with antimitochondrial antibody of M2 type, contribute to the diagnosis of the disease.

Antibodies specific for measles virus envelope antigens and autoantibodies in patients with chronic active hepatitis.

Distinctly increased levels of antibodies to measles virus envelope antigens haemolysin and haemagglutinin were found in the sera of patients with chronic active hepatitis compared with a normal control group, using immunofluorescence and functional tests. Similarly, a higher incidence of smooth muscle antibody of both IgG and IgM classes was observed in the patients and an important correlation was found between haemolysin antibodies specific for measles virus and smooth muscle antibody of IgG and IgM classes. In contrast, there was no such correlation between the virus specific haemolysin antibodies and antinuclear antibodies. The increased levels of antibodies to measles virus envelope antigens and of autoantibodies may reflect defects in immunoregulation rather than persistent infection with measles virus.

Coeliac disease detected by screening is not silent--simply unrecognized.

Coeliac disease (CD) is associated with a wide spectrum of clinical presentation and may be overlooked as a diagnosis. There is some evidence that untreated CD is associated with a doubling of mortality, largely due to an increase in the incidence of malignancy and small intestinal lymphoma, which is decreased by a strict gluten-free diet. We studied the clinical features of screening-detected coeliacs compared to age- and sex-matched controls as a 3-year follow-up to a population screening survey, and followed-up subjects who had had CD-associated serology 11 years previously to determine whether they have CD or an increased mortality rate compared to the general population. Samples of the general population (MONICA 1991 and 1983) were screened for CD-associated serology and followed-up after 3 and 11 years, respectively, and assessed by a clinical questionnaire, screening blood tests and jejunal biopsy. Mortality rates for 'all deaths' and 'cancer deaths' were compared in subjects with positive serology in 1983 with reference to the general population. Thirteen coeliacs were diagnosed by villous atrophy following screening, compared to two patients with clinically detected CD, giving a prevalence of 1:122. Clinical features or laboratory parameters were not indicative of CD compared to controls. Subjects with positive serology followed up after 11 years did not have an excess mortality for either cancer deaths or all causes of death. Screening-detected CD is rarely silent and may be associated with significant symptoms and morbidity. In this limited study with small numbers, there does not appear to be an increased mortality from screening-detected CD, although the follow-up may be too short to detect any difference.

Serum soluble adhesion molecules in multiple sclerosis: raised sVCAM-1, sICAM-1 and sE-selectin in primary progressive disease.

Leucocyte invasion into the central nervous system in multiple sclerosis (MS) is complex, involving T-cell/endothelium interaction dependent upon initial adhesion mediated by molecules such as E-selectin, L-selectin, intracellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-(VCAM-1). Circulating levels of these can be measured by sensitive enzyme-linked immunoassay (ELISA) techniques. To assess whether serum concentrations of soluble adhesion molecules vary across the spectrum of patients with relapsing-remitting (RR), secondary progressive (SP) and primary progressive (PP) MS, we measured circulating levels of soluble (s)E-selectin, sL-selectin, sICAM-1 and sVCAM-1 in serum obtained from 78 PPMS patients, 71 patients with RRMS, 65 patients with SPMS and 66 patients with other neurological disease using commercially available ELISA systems. Levels of serum sVCAM-1 were significantly elevated in PPMS compared with RRMS in remission (P = 0.0001) and in relapse (P = 0.0001), whilst sICAM-1 was significantly elevated in PPMS compared with all other MS groups (vs SPMS, P = 0.006; vs RRMS in relapse, P = 0.003; vs RRMS in remission, P = 0.0001). Serum sE-selectin levels were significantly higher in PPMS compared with all other groups except inflammatory neurological disease (IND) [vs SPMS, P = 0.029; vs RRMS in relapse, P = 0.002; vs RRMS in remission, P = 0.001; vs non-inflammatory neurological disease (NIND), P = 0.002; vs IND, P = 0.076]. In PPMS there was no correlation between levels of any adhesion molecule and disability or disease duration. These results provide evidence for significant immunological heterogeneity in MS and suggest that different leucocyte/endothelial cell interactions may be active in various MS subgroups. It also challenges the hypothesis that PPMS is a less inflammatory form of the disease.