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We characterised the aetiology of non-responsive coeliac disease (NRCD) and provided contemporary mortality data in refractory coeliac disease (RCD) from our centre. We also measured urine gluten immunogenic peptides (GIPs) in patients with established RCD1 to evaluate gluten exposure in these individuals. Methods: This was a longitudinal cohort study conducted in Sheffield, UK. Between 1998 and 2019, we evaluated 285 adult (≥16 years) patients with NRCD or RCD. Patients with established RCD1 and persisting mucosal inflammation and/or ongoing symptoms provided three urine samples for GIP analysis. Results: The most common cause of NRCD across the cohort was gluten exposure (72/285; 25.3%). RCD accounted for 65/285 patients (22.8%), 54/65 patients (83.1%) had RCD1 and 11/65 patients (16.9%) had RCD2. The estimated 5-year survival was 90% for RCD1 and 58% for RCD2 (p = 0.016). A total of 36/54 (66.7%) patients with RCD1 underwent urinary GIP testing and 17/36 (47.2%) had at least one positive urinary GIP test. Conclusion: The contemporary mortality data in RCD2 remains poor; patients with suspected RCD2 should be referred to a recognised national centre for consideration of novel therapies. The high frequency of urinary GIP positivity suggests that gluten exposure may be common in RCD1; further studies with matched controls are warranted to assess this further.

Background & Aims\ud \ud Individuals with celiac disease (CD) can experience persisting gastrointestinal symptoms despite adhering to a gluten-free diet (GFD). This may be due to functional gastrointestinal disorders (FGIDs), although there is little data on its prevalence and associated factors.\ud \ud \ud \ud Methods\ud \ud An online health questionnaire was completed by adult members of Celiac UK in October 2018. The survey included validated questions on Rome IV FGIDs, non-gastrointestinal somatic symptoms, anxiety, depression, quality of life, healthcare use, GFD duration and its adherence using the celiac dietary adherence test score (with a value ≤ 13 indicating optimal adherence). The prevalence of FGIDs and associated health impairment in the celiac cohort was compared against an age- and sex- matched population-based control group.\ud \ud \ud \ud Results\ud \ud Of the 863 individuals with CD (73% female, mean-age 61 years) all were taking a GFD for at least 1 year, with 96% declaring that they have been on the diet for 2 or more years (2-4 years, 20%; ≥5 years, 76%). The adherence to a GFD was deemed optimal in 61% (n=523) with the remaining 39% (n=340) non-adherent. Those adhering to a GFD fulfilled criteria for a FGID in approximately a half of cases, although this was significantly lower than non-adherent subjects (51% vs. 75%, OR 2.0; p

Background and aim\ud \ud Gluten neuropathy (GN) is a common neurological manifestation of gluten sensitivity (GS), characterized by serological evidence of GS, while other risk factors for developing neuropathy are absent. The degree of small fiber dysfunction in GN has not been studied in depth to date. Small fiber involvement may lead to pain, thermal perception abnormalities, and sweat gland dysfunction. Sudomotor innervation refers to the cholinergic innervation of the sympathetic nervous system through small fibers in the sweat glands. The aim of our study was to assess the sudomotor function of GN patients.\ud \ud \ud \ud Methods\ud \ud Patients with GN were recruited. Clinical and neurophysiological data were obtained. HLA-DQ genotyping was performed. The skin electrochemical conductance (ESC) was measured with SUDOSCANTM.\ud \ud \ud \ud Results\ud \ud Thirty-two patients (25 males, mean age 69.5±10.2 years) were recruited. Thirteen patients (40.6%) had abnormal sudomotor function of the hands. Sixteen patients (50%) had abnormal sudomotor function of the feet. Twenty-one patients (65.6%) had abnormal sudomotor function of either the hands or feet.\ud \ud \ud \ud Sudomotor dysfunction did not correlate with the type of neuropathy (length-dependent neuropathy or sensory ganglionopathy), gluten-free diet adherence, severity of neuropathy, and duration of disease or HLA-DQ genotype. No differences in the ESC were found between patients with painful and patients with painless GN.\ud \ud \ud \ud Conclusion\ud \ud Sudomotor dysfunction affects two-thirds of patients with GN. The lack of correlation between pain and sudomotor dysfunction suggests different patterns of small fiber involvement in patients with GN.

We have previously shown that 67% of patients with newly diagnosed coeliac disease (CD) presenting to gastroenterologists have evidence of neurological dysfunction. This manifested with headache and loss of co-ordination. Furthermore 60% of these patients had abnormal brain imaging. In this follow-up study, we re-examined and re-scanned 30 patients from the original cohort of 100, seven years later. There was significant reduction in the prevalence of headaches (47% to 20%) but an increase in the prevalence of incoordination (27% to 47%). Although those patients with coordination problems at baseline reported improvement on the gluten free diet (GFD), there were 7 patients reporting incoordination not present at baseline. All 7 patients had positive serology for one or more gluten-sensitivity related antibodies at follow-up. In total, 50% of the whole follow-up cohort were positive for one or more gluten-related antibodies. A comparison between the baseline and follow-up brain imaging showed a greater rate of cerebellar grey matter atrophy in the antibody positive group compared to the antibody negative group. Patients with CD who do not adhere to a strict GFD and are serological positive are at risk of developing ataxia, and have a significantly higher rate of cerebellar atrophy when compared to patients with negative serology. This highlights the importance of regular review and close monitoring.

Objective: This study aimed to assess if there is secondary care medical inertia towards coeliac disease (CD).\ud \ud \ud \ud Design: Group (1): Time from primary care presentation to diagnostic endoscopy was quantified in 151 adult patients with a positive endomysial antibody test and compared with 92 adult patients with histologically proven inflammatory bowel disease (IBD). Group (2): Across four hospitals, duodenal biopsy reports for suspected CD were reviewed (n=1423). Group (3): Clinical complexity was compared between known CD (n=102) and IBD (n=99) patients at their respective follow-up clinic appointments. Group (4): 50 gastroenterologists were questioned about their perspective on CD and IBD.\ud \ud \ud \ud Results: Group (1): Suspected coeliac patients waited significantly longer for diagnostic endoscopy following referral (48.5 (28–89) days) than suspected patients with IBD (34.5 (18–70) days; p=0.003). Group (2): 1423 patients underwent diagnostic endoscopy for possible CD, with only 40.0% meeting guidelines to take four biopsies. Increased diagnosis of CD occurred if guidelines were followed (10.1% vs 4.6% p

Background and Aims\ud Seronegative villous atrophy (SNVA), raised intraepithelial lymphocytes (IELs), and crypt hyperplasia on duodenal histology can be secondary to celiac disease (CD) or other causes such as medications or infections. Our aims were to assess the role of small-bowel capsule endoscopy (SBCE) in these patients and to ascertain whether findings on SBCE at diagnosis can predict disease outcome.\ud \ud Methods\ud Patients (n = 177) with SNVA, IELs, ± crypt hyperplasia on duodenal histology were studied. These patients all had an equivocal diagnosis of CD.\ud \ud Results\ud Overall, 56 patients (31.6%) had a positive SBCE. Thirty-three patients (58.9%) had disease affecting the proximal third of the small bowel (SB). The diagnostic yield of SBCE was 40.0% (22 patients), 51.4% (18 patients), 27.0% (10 patients), and 14.0% (7 patients) in patients with an unknown cause for SNVA (SNVA-UO), patients with SNVA who responded to a gluten-free diet (SNVA-CD), patients with a known cause for SNVA, and patients with railed IELs ± crypt hyperplasia, respectively. In SNVA-UO, SBCE at diagnosis was more likely to be positive in patients with persistent SNVA (10, 90.9%) and persistent SNVA with lymphoproliferative features (4, 80.4%) than patients with spontaneous resolution of SNVA (8, 20.5%) (P = .0001). All patients in the SNVA-CD group who eventually developed adverse events had a positive SBCE (P = .022). They also had more extensive SB disease than those without adverse events (50% vs 1% P = .002). More extensive SB disease on SBCE correlated with a higher SNVA-related mortality in patients with SNVA-UO and SNVA-CD (P = .019). Severity of histology did not correlate with mortality (P = .793).\ud \ud Conclusions\ud A positive SBCE at diagnosis predicts a worse outcome. More importantly, more extensive disease in these patients is associated with poor survival. Targeting patients with extensive disease at diagnosis with more aggressive therapy can help to improve prognosis.

Coeliac disease is a common small intestinal enteropathy which manifests following ingestion of gluten in genetically susceptible individuals. Since gluten was identified as the driving factor in coeliac disease, the gluten-free diet (GFD) has remained the mainstay of treatment. While most individuals will display improvement in symptoms and signs of coeliac disease following institution of the GFD, up to 30% will continue to experience symptoms and/or have persisting intestinal inflammation. These individuals can be classified as having non-responsive coeliac disease (NRCD), which may be associated with dietary indiscretion, slow healing, refractory coeliac disease, and/or an alternative condition. The purpose of this review is to provide an overview of the causes of NRCD in adults, highlight a systematic approach to investigate these patients, and appraise the latest management aspects of this subset of coeliac disease.

Background & Aims\ud Celiac disease is an autoimmune disorder induced by ingestion of gluten that affects 1% of the population and is characterized by gastrointestinal symptoms, weight loss, and anemia. We evaluated the presence of neurologic deficits and investigated whether the presence of antibodies to TG6 increases the risk of neurologic defects in patients with a new diagnosis of celiac disease.\ud \ud Methods\ud We performed a prospective cohort study at a secondary-care gastroenterology center of 100 consecutive patients who received a new diagnosis of celiac disease based on gastroscopy and duodenal biopsy. We collected data on neurologic history, and patients were evaluated in a clinical examination along with magnetic resonance imaging (MRI) of the brain, MR spectroscopy of the cerebellum, and measurements of antibodies against TG6 in serum samples. The first 52 patients recruited underwent repeat MR spectroscopy at 1 year after a gluten-free diet (GFD). The primary aim was to establish if detection of antibodies against TG6 can be used to identify patients with celiac disease and neurologic dysfunction.\ud \ud Results\ud Gait instability was reported in 24% of the patients, persisting sensory symptoms in 12%, and frequent headaches in 42%. Gait ataxia was found in 29% of patients, nystagmus in 11%, and distal sensory loss in 10%. Sixty percent of patients had abnormal results from the MRI, 47% had abnormal results from MR spectroscopy of the cerebellum, and 25% had brain white matter lesions beyond that expected for their age group. Antibodies against TG6 were detected in serum samples from 40% of patients–these patients had significant atrophy of subcortical brain regions compared to patients without TG6 autoantibodies. In patients with abnormal results from MR spectroscopy of the cerebellum, those on the GFD had improvements detected in the repeat MR spectroscopy 1 year later.\ud \ud Conclusions\ud In a prospective cohort study of patients with a new diagnosis of celiac disease at a gastroenterology clinic, neurological deficits were common and 40% had circulating antibodies against TG6. We observed a significant reduction in volume of specific brain regions in patients with TG6 autoantibodies, providing evidence for a link between autoimmunity to TG6 and brain atrophy in patients with celiac disease. There is a need for early diagnosis, increased awareness of the neurological manifestations amongst clinicians and reinforcement of adherence to a strict GFD by patients in order to avoid permanent neurological disability.

Out of programme (OOP) opportunities are to be encouraged. This article gives an insightful view of the Sheffield Clinical Research Fellowship Programme. Unique trainee feedback is provided. The take home message is clear - trainees should grab OOP experiences with both hands! For consultants the logistics described are potentially transferrable to their own regions.

Objectives Lower gastrointestinal symptoms are not well characterized in people with type 1 diabetes, and the effects on quality of life and glycemic control are unknown. This study aimed to determine the prevalence of lower gastrointestinal symptoms and the effects on glycemic control and quality of life, and to investigate for underlying causes.\ud \ud \ud Research design and methods This is a prospective, cohort study in secondary care. Patients with type 1 diabetes completed a gastrointestinal symptom questionnaire and the Short Form 36 V.2 quality of life questionnaire and had their hemoglobin A1c measured. Patients with diarrhea were offered reassessment and investigation as per the national guidelines. Controls without diabetes were used to compare symptom prevalence and quality of life scores.\ud \ud \ud Results 706 with type 1 diabetes (mean age 41.9 years) and 604 controls (mean age 41.9 years) were enrolled. Gastrointestinal symptoms were significantly more frequent in type 1 diabetes compared with controls, in particular constipation (OR 2.4), diarrhea (OR 2.5), alternating bowel habit (OR 2.1), abdominal pain (OR 1.4), floating stools (OR 2.7), bloating (OR 1.4) and flatulence (OR 1.3) (all p

BACKGROUND: Celiac disease (CD) is associated with an increased risk of developing epilepsy, a risk that persists after CD diagnosis. A significant proportion of CD patients have persistent villous atrophy (VA) on follow-up biopsy. This study's objective was to determine whether persistent VA on follow-up biopsy affects long-term epilepsy risk and epilepsy-related hospital emergency admissions. METHODS: Nationwide Cohort Study. We identified all people in Sweden with histological evidence of CD who underwent a follow-up small intestinal biopsy (1969-2008). We compared those with persistent VA to those who showed histological improvement, assessing the development of epilepsy and related emergency hospital admissions (defined according to relevant ICD codes in the Swedish Patient Register). Cox regression analysis was used to assess outcome measures. RESULTS: Of 7590 people with CD who had a follow-up biopsy, VA was present in 43%. The presence of persistent VA was significantly associated with a reduced risk of developing newly-diagnosed epilepsy (hazard ratio [HR] 0.61; 95% confidence interval [CI] 0.38-0.98). On stratified analysis this effect was primarily amongst males (HR 0.35; 95 CI 0.15-0.80). Among the 58 CD patients with a prior diagnosis of epilepsy, those with persistent VA were less likely to visit an emergency department with epilepsy (HR 0.37; 95%CI 0.09-1.09). CONCLUSIONS: In a population-based study of CD individuals, persisting VA on follow up biopsy was associated with reduced future risk of developing epilepsy but did not influence emergency epilepsy-related hospital admissions. Mechanisms as to why persistent VA confers this benefit requires further exploration.

OBJECTIVES: Mucosal healing is important in celiac disease (CD) for the prevention of complications. However, obtaining duodenal biopsies is invasive, and there is currently no reliable surrogate marker for histological remission in clinical practice. We aimed to assess the role of a point-of-care test (POCT) based on IgA/IgG-deamidated gliadin peptide, in detecting persistent villous atrophy (VA) in CD. \ud \ud METHODS: We prospectively recruited patients with CD attending endoscopy for the assessment of histological remission. All patients had IgA-endomysial (EMA) antibodies, IgA-tissue transglutaminase (TTG) antibodies, and the POCT performed, and completed a validated dietary adherence questionnaire. A gastroscopy was performed in all patients, with four biopsies taken from the second part of the duodenum and one from the duodenal bulb. We compared the diagnostic performance of the surrogate markers against duodenal histology as the reference standard. \ud \ud RESULTS: A total of 217 patients with CD (70% female, age range 16-83 years, median age 53 years) on a gluten-free diet (median duration 6 years) were recruited from 2013 to 2017. Eighty-five (39.2%) patients had persistent VA. The sensitivities of the POCT, TTG, EMA, and the adherence score in detecting VA were 67.1%, 44.7%, 37.7%, and 24.7% respectively (P=0.0005). The combination of the POCT and adherence score only marginally increased the sensitivity to 70.6% (59.7-80.0%). \ud \ud CONCLUSIONS: The sensitivity of the POCT was higher than the other surrogate markers in predicting VA. A POCT may provide the additional advantage of an immediate objective assessment of mucosal healing at the time of an office-based follow-up consultation.

BACKGROUND & AIMS: Gastrostomies are widely used to provide long-term enteral nutrition to patients with neurological conditions that affect swallowing (such as following a cerebrovascular accident or for patients with motor neuron disease) or with oropharyngeal malignancies. The benefits derived from this intervention are uncertain for patients and caregivers. We conducted a prospective, multicenter cohort study to determine how gastrostomies affect health-related quality of life (HRQoL) in recipients and caregivers. METHODS: We performed a study of 100 patients who received gastrostomies (55% percutaneous endoscopic gastrostomy, 45% radiologically inserted) at 5 centers in the United Kingdom, 100 caregivers, and 200 population controls. We used the EuroQol-5D (EQ-5D, comprising a questionnaire, index, visual analogue scale) to assess HRQoL for patients and caregivers before the gastrostomy insertion and then 3 months afterward; findings were compared with those from controls. Ten patients and 10 caregivers were also interviewed after the procedure to explore quantitative findings. Findings from the EQ-5D and semi-structured interviews were integrated using a mixed methods matrix. RESULTS: Six patients died before the 3-month HRQoL reassessments. We observed no significant longitudinal changes in mean EQ-5D index scores for patients (0.70 before vs 0.710 after; P=.83) or caregivers (0.95 before vs 0.95 after; P=.32) following gastrostomy insertion. The semi-structured interviews revealed problems in managing gastrostomy tubes, social isolation, and psychological and emotional consequences that reduced HRQoL. CONCLUSIONS: We performed a mixed methods prospective study of the effects of gastrostomy feeding on HRQoL. HRQoL did not significantly improve after gastrostomy insertion for patients or caregivers. The lack of significant decrease in HRQoL after the procedure indicates that gastrostomies may help maintain HRQoL. Findings have relevance to those involved in gastrostomy insertion decisions and indicate the importance of carefully selecting patients for this intervention, despite the relative ease of insertion.

Coeliac disease is a common digestive disorder that affects 1% of adults. It is characterised by mucosal damage of the small intestine caused by dietary gluten. The main treatment for coeliac disease is a lifelong gluten-free diet, which can reduce morbidity and mortality and also improve quality of life. Despite the benefits, adhering to this diet is often challenging, with patients often struggling to sustain dietary restriction. Structured follow-up for coeliac disease is recommended in international guidelines for improving adherence and for detecting complications;however, uncertainty exists concerning exactly who should be administering this follow-up care. Here, we undertake a review of the current approaches described in the literature to follow-up patients with coeliac disease, and assess the efficacy of these differing models. We also explore future directions for the care of these patients in the context of the UK National Health Service (a publicly funded healthcare system). Although the focus of this review pertains to follow-up within the UK healthcare system, these problems are recognised to be international, and so the findings of our review are likely to be of interest to all healthcare professionals seeing and managing patients with coeliac disease.

BACKGROUND: Seronegative villous atrophy (SNVA) is commonly attributed to coeliac disease (CD). However, there are other causes of SNVA. More recently angiotensin-2-receptor-blockers (A2RBs) have been reported as an association but data on SNVA have been limited to centres evaluating complex case referrals and not SNVA in general. OBJECTIVES: To provide clinical outcomes and associations in a large prospective study overseeing all newcomers with SNVA. DESIGN: Over a 15-year period (2000-2015) we evaluated 200 adult patients with SNVA at a UK centre. A diagnosis of either seronegative CD (SNCD) or seronegative non-CD (SN-non-CD) was reached. Baseline comparisons were made between the groups, with 343 seropositive CD subjects serving as controls. RESULTS: Of the 200 SNVA cases, SNCD represented 31% (n=62) and SN-non-CD 69% (n=138). The human leucocyte antigen (HLA)-DQ2 and/or DQ8 genotype was present in 61%, with a 51% positive predictive value for SNCD. The breakdown of identifiable causes in the SN-non-CD group comprised infections (27%, n=54), inflammatory/immune-mediated disorders (17.5%, n=35) and drugs (6.5%, n=13; two cases related to A2RBs). However, no cause was found in 18% (n=36) and of these 72% (n=26/36) spontaneously normalised duodenal histology while consuming a gluten-enriched diet. Following multivariable logistic regression analysis an independent factor associated with SN-non-CD was non-white ethnicity (OR 10.8, 95% CI 2.2 to 52.8); in fact, 66% of non-whites had GI infections. On immunohistochemistry all groups stained positive for CD8-T-cytotoxic intraepithelial lymphocytes. However, additional CD4-T helper intraepithelial lymphocytes were occasionally seen in SN-non-CD mimicking the changes associated with refractory CD. CONCLUSIONS: Most patients with SNVA do not have CD, in particular those who are not white. Furthermore, a subgroup with no obvious aetiology will show spontaneous histological resolution while consuming gluten. These findings suggest caution in empirically prescribing a gluten-free diet without investigation.

OBJECTIVES: Non-coeliac gluten sensitivity (NCGS) refers to patients with primarily gastrointestinal symptoms\ud without enteropathy that symptomatically benefi t from gluten-free diet (GFD). Little is known about\ud its pathophysiology, propensity to neurological manifestations, and if these differ from patients with\ud coeliac disease (CD). We investigated the clinical and immunological characteristics of patients\ud presenting with neurological manifestations with CD and those with NCGS.\ud METHODS: We compared clinical, neurophysiological, and imaging data of patients with CD and NCGS\ud presenting with neurological dysfunction assessed and followed up regularly over a period of\ud 20 years.\ud RESULTS: Out of 700 patients, 562 were included. Exclusion criteria included no bowel biopsy to confi rm\ud CD, no HLA type available, and failure to adhere to GFD. All patients presented with neurological\ud dysfunction and had circulating anti-gliadin antibodies. Out of 562 patients, 228 (41%) had\ud evidence of enteropathy (Group 1, CD) and 334 (59%) did not (Group 2, NCGS). The most common\ud neurological manifestations were cerebellar ataxia, peripheral neuropathy, and encephalopathy. There\ud was a greater proportion of patients with encephalopathy in Group 1 and with a greater proportion\ud of neuropathy in Group 2. The severity of ataxia did not differ between the two groups. Patients in\ud Group 1 had more severe neuropathy. All patients from both groups responded to gluten-free diet.\ud Anti-tissue transglutaminase (TG2) antibodies were found in 91% of patients in Group 1 and in\ud 29% of patients in Group 2. Comparison between those patients in Group 2 with HLA-DQ2/DQ8 and\ud those without as well as those with positive TG2 compared with those with negative TG2 antibodies\ud identifi ed no differences within these subgroups. Serological positivity for TG6 antibodies was similar\ud in the two groups (67 and 60%).\ud CONCLUSIONS: The neurological manifestations of CD and NCGS are similar and equally responsive to a GFD\ud suggestive of common pathophysiological mechanisms.

BACKGROUND: Endoscopic balloon dilatation (EBD) is recognised treatment for symptomatic Crohn's strictures. Several case series report its efficacy. A systematic analysis for overall efficacy can inform the design of future studies. \ud \ud AIM: To examine symptomatic (SR) and technical response (TR) and adverse events (AE) of EBD. Stricture characteristics were also explored. \ud \ud METHODS: A systematic search strategy of COCHRANE, MEDLINE and EMBASE was performed. All original studies reporting outcomes of EBD for Crohn's strictures were included. SR was defined as obstructive symptom-free outcome at the end of follow-up, TR as post-dilatation passage of the endoscope through a stricture, and adverse event as the presence of complication (perforation and/or bleeding). Pooled event rates across studies were expressed with summative statistics. \ud \ud RESULTS: Twenty-five studies included 1089 patients and 2664 dilatations. Pooled event rates for SR, TR, complications and perforations were 70.2% (95% CI: 60-78.8%), 90.6% (95% CI: 87.8-92.8%), 6.4% (95% CI: 5.0-8.2) and 3% (95% CI: 2.2-4.0%) respectively. Cumulative surgery rate at 5 year follow-up was 75%. Pooled unweighted TR, SR, complication, perforation and surgery rates were 84%, 45%, 15%, 9% and 21% for de novo and 84%, 58%, 22%, 5% and 32% for anastomotic strictures. Outcomes between two stricture types were no different on subgroup meta-analysis. \ud \ud CONCLUSIONS: Efficacy and complication rates for endoscopic balloon dilatation were higher than previously reported. From the few studies with 5 year follow-up the majority required surgery. Future studies are needed to determine whether endoscopic balloon dilatation has significant long-term benefits.

Background: Endoscopic balloon dilatation (EBD) is recognised treatment for symptomatic Crohn's strictures. Several case series report its efficacy. A systematic analysis for overall efficacy can inform the design of future studies. \ud \ud Aim: To examine symptomatic (SR) and technical response (TR) and adverse events (AE) of EBD. Stricture characteristics were also explored. \ud \ud Methods: A systematic search strategy of COCHRANE, MEDLINE and EMBASE was performed. All original studies reporting outcomes of EBD for Crohn's strictures were included. SR was defined as obstructive symptom-free outcome at the end of follow-up, TR as post-dilatation passage of the endoscope through a stricture, and adverse event as the presence of complication (perforation and/or bleeding). Pooled event rates across studies were expressed with summative statistics. \ud \ud Results: Twenty-five studies included 1089 patients and 2664 dilatations. Pooled event rates for SR, TR, complications and perforations were 70.2% (95% CI: 60-78.8%), 90.6% (95% CI: 87.8-92.8%), 6.4% (95% CI: 5.0-8.2) and 3% (95% CI: 2.2-4.0%) respectively. Cumulative surgery rate at 5 year follow-up was 75%. Pooled unweighted TR, SR, complication, perforation and surgery rates were 84%, 45%, 15%, 9% and 21% for de novo and 84%, 58%, 22%, 5% and 32% for anastomotic strictures. Outcomes between two stricture types were no different on subgroup meta-analysis. \ud \ud Conclusions: Efficacy and complication rates for endoscopic balloon dilatation were higher than previously reported. From the few studies with 5 year follow-up the majority required surgery. Future studies are needed to determine whether endoscopic balloon dilatation has significant long-term benefits.

Background: The mechanisms of cerebellar degeneration attributed to prolonged and excessive alcohol intake remain unclear. Additional or even alternative causes of cerebellar degeneration are often overlooked in suspected cases of alcohol-related ataxia. The objectives of this study were two fold: (1) to investigate the prevalence of gluten-related serological markers in patients with alcohol-related ataxia and; (2) to compare the pattern of brain involvement on magnetic resonance imaging between patients with alcohol and gluten ataxias.\ud \ud Materials & Methods: Patients diagnosed with alcohol and gluten ataxias were identified from a retrospective review of patients attending a tertiary clinic. HLA genotype and serological markers of gluten-related disorders were recorded. Cerebellar volumetry, MR spectroscopy and voxel-based morphometric analyses were performed on patients and compared with matched control data.\ud \ud Results: Of 904 registered patients, 104 had alcohol ataxia and 159 had gluten ataxia. 61% of the alcohol ataxia group and 70% of the gluten ataxia group had HLA DQ2/DQ8 genotype compared to 30% in healthy local blood donors. 44% of patients with alcohol ataxia had antigliadin antibodies compared to 12% in the healthy local population and 10% in patients with genetically confirmed ataxias. None of the patients with alcohol ataxia and antigliadin antibodies had celiac disease compared to 40% in patients with gluten ataxia. The pattern of structural brain abnormality in patients with alcohol ataxia who had antigliadin antibodies differed from gluten ataxia and was identical to that of alcohol ataxia.\ud \ud Conclusions: Alcohol related cerebellar degeneration may, in genetically susceptible individuals, induce sensitization to gluten. Such sensitization may result from a primary cerebellar insult, but a more systemic effect is also possible. The duration and amount of exposure to alcohol may not be the only factors responsible for the cerebellar insult.

Background & Aims\ud Patients with celiac disease have been reported to be at increased risk for pancreatitis and pancreatic insufficiency, but the risk might have been overestimated because of patient selection and limited numbers of patients for analysis. Furthermore, no distinction has been made between patients with gallstone-related and non–gallstone-related pancreatitis. We performed a nationwide study to determine the risk for any pancreatitis or subtype of pancreatitis among patients with biopsy-verified celiac disease.\ud \ud Methods\ud We analyzed data from patients in Sweden with celiac disease (n = 28,908) who were identified on the basis of small intestinal biopsy records from 28 pathology departments (those with villous atrophy, Marsh 3). Biopsies were performed from 1969 to 2008, and biopsy report data were collected from 2006 to 2008. Patients with pancreatitis were identified on the basis of diagnostic codes in the Swedish Patient Register and records of pancreatic enzyme use in the Swedish Prescribed Drug Register. Data were matched with those from 143,746 individuals in the general population; Cox regression was used to estimate hazard ratios (HRs) for pancreatitis.\ud \ud Results\ud We identified 406 patients with celiac disease who were later diagnosed with pancreatitis (and 143 with expected pancreatitis) (HR, 2.85; 95% confidence interval [CI], 2.53–3.21). The absolute risk of any pancreatitis among patients with celiac disease was 126/100,000 person-years, with an excess risk of 81/100,000 person-years. The HR for gallstone-related acute pancreatitis was 1.59 (95% CI, 1.06–2.40), for non–gallstone-related acute pancreatitis HR was 1.86 (95% CI, 1.52–2.26), for chronic pancreatitis HR was 3.33 (95% CI, 2.33–4.76), and for supplementation with pancreatic enzymes HR was 5.34 (95% CI, 2.99–9.53). The risk of any pancreatitis within 5 years of diagnosis was 2.76 (95% CI, 2.36–3.22).\ud \ud Conclusions\ud Based on an analysis of medical records from Sweden, patients with celiac disease have an almost 3-fold increase in risk of developing pancreatitis, compared with the general population.

Functional gastrointestinal disorders remain a rather obscure and vague chapter of medicine, clouded with discordant, or even completely contradictory findings and opinions, depending on the different researchers and studies. The two main etiological hypotheses are an alteration of the brain-gut axis with visceral hypersensitivity, or a microscopic inflammation of the gastro-intestinal mucosa. However, what appears to link these and other hypotheses is the evidence that the symptoms reported by patients, both in adults and in the pediatric age, are very often presented in association with the intake of specific foods. To further complicate this heterogeneous situation, several authors have reported cases of patients without the celiac disease (CeD) or wheat allergy (WA) criteria, who referred a marked improvement in gastro-intestinal functional symptoms on a gluten-free diet (GFD). This condition was initially defined as ‘gluten sensitivity’ (GS), only to be changed to ‘non-celiac gluten sensitivity’ (NCGS), to better differentiate it from CeD, and finally redefined as ‘non-celiac wheat sensitivity’ (NCWS), as it is still not certain even today which of the components of wheat is the real culprit of this pathology. To date, this is one of the most studied and controversial areas of research in the gastroenterological field, with data that, at least in part, seem to indicate that NCGS/NCWS in adults could represent a form of non-IgE-mediated allergic reaction that has its roots in some clinical reactions already in the pediatric age

ObjectiveWe aimed to determine the predictive capacity and diagnostic yield of a 10-fold increase in serum IgA antitissue transglutaminase (tTG) antibody levels for detecting small intestinal injury diagnostic of coeliac disease (CD) in adult patients.DesignThe study comprised three adult cohorts. Cohort 1: 740 patients assessed in the specialist CD clinic at a UK centre; cohort 2: 532 patients with low suspicion for CD referred for upper GI endoscopy at a UK centre; cohort 3: 145 patients with raised tTG titres from multiple international sites. Marsh 3 histology was used as a reference standard against which we determined the performance characteristics of an IgA tTG titre of ≥10×ULN for a diagnosis of CD.ResultsCohort 1: the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 54.0%, 90.0%, 98.7% and 12.5%, respectively. Cohort 2: the sensitivity, specificity, PPV and NPV for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 50.0%, 100.0%, 100.0% and 98.3%, respectively. Cohort 3: the sensitivity, specificity, PPV and NPV for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 30.0%, 83.0%, 95.2% and 9.5%, respectively.ConclusionOur results show that IgA tTG titres of ≥10×ULN have a strong predictive value at identifying adults with intestinal changes diagnostic of CD. This study supports the use of a no-biopsy approach for the diagnosis of adult CD.

How to cite this article: Holdoway A. & Sanders D.S. (2012) The Inaugural Digestive Disorders Federation Meeting: a collaborative and multidisciplinary approach to medical and nutrition education? J Hum Nutr Diet. 25, 101–102.

Proizvodnja lubenice u Hrvatskoj posljednjih godina raste, godišnje se lubenicom zasije 3 000 ha s prosječnim prinosom od 23, 1 t/ha (FAO 1998, prema Lešić, 2002). Područja sa sumom srednjih dnevnih temperatura iznad 3000 oC, u bezmraznom razdoblju, prikladna su za uzgoj lubenice, takve uvjete nalazimo u većini naših krških polja (Lešić i sur., 2002). Na naše tržište najranije dolazi lubenica proizvodena u dolini Neretve, a nadopunjuje je proizvodnja u Ravnim kotarima i ostalim krškim poljima. Primjena suvremenih tehnologija u uzgoju omogućava raniji dolazak na tržište, te povećanje prinosa (Borošić, 1997). Posljednjih godina kao rezultat intenzivne selekcije na tržištu je prisutan veliki broj dobrih kultivara. Pri izboru kultivara za uzgoj treba voditi računa o prinosu, otpornosti na bolesti, adaptabilnosti, dužini vegetacije te potrebama tržišta (Roberts, 1996). Zbog blizine tržišta i turističke sezone proizvodnja lubenice na području Drniša i Imotskog stalno raste, stoga je cilj ovog rada bio ispitati karakteristike novih kultivara u tim agroekološkim uvjetima. Poljski pokus s devet kultivara lubenice (Crimson Glory, Eureka, Royal Majesty, Suger Delicata, Paladin, Farao, Top Gun, Crimson Sweet i Sultan) postavljen je na obiteljskim gospodarstvima u Petrovom polju 1999. i 2000. godine te u Imotskom polju 2000. Presadnice su uzgojene u lončićima u stakleniku, a posađene su u polje 16.5.1999. i 17.5.2000. u Drnišu i 15.5.2000. u Imotskome, na malch od crne PE-folije uz sustav za navodnjavanje kapanjem. Pokus je postavljen po slučajnom bloknom rasporedu s pet ponavljanja, razmak sadnje je bio 2 m između redova, 1 m unutar reda. Pri osnovnoj obradi tla u obje godine u Drnišu parcela je pognojena zrelim stajskim gnojem (30 t/ha) i kompleksnim mineralnim gnojivom NPK 5-20-30 (600 kg/ha). U Imotskome u 2000. godini u osnovnoj obradi dodano je 40 t/ha zrelog stajskog gnoja i 600 kg/ha NPK 5-20-30. Fertirigacijom su obavljene četiri prihrane s ukupno 300 kg/ha AN-om (33, 5%N) u obje godine i na obje lokacije. Zaštita je obavljana tijekom vegetacije te su preventivno su upotrebljeni Ridomil MZ 72 WP, Rubigan EC, Chess 25 WP, Demitan SC dok su kurativno primijenjeni Aliette WP, Chromosul 80 and Actellic 50 EC. Berbe su obavljene ručno, dinamikom dozrijevanja plodova prema vanjskim pokazateljima zrelosti, odnosno u trenutku kad je vitica najbliža plodu uvenula te se boja dijela koji dotiče tlo promijenila iz bijele u žutu (Marr, 1998). Berba u Drnišu u 1999. je bila od 4. kolovoza do 24. kolovoza, a u 2000. od 27. srpnja do 3. kolovoza. U Imotskom je berba bila od 26. srpnja. 2000. do 11. kolovoza 2000. Plodovi su vagani pojedinačno te je izmjeren ukupan prinos, prosječna masa ploda te udio netržišnih plodova (< 4.5 kg). Podaci su statistički obrađeni analizom varijance, a srednje vrijednosti su uspoređene Duncan testom. Prinos tržišnih plodova bio je najveći u Drnišu u 1999. godini i kretao se od 72, 823 t/ha do 35, 247 t/ha, u 2000. godini prinos bio također veći na lokaciji u Drnišu u odnosu na Imotski, osim kod kultivara Top Gun i Crimson Sweet (Tablica 1). Značajno najveći prinos u obje godine istraživanja u Drnišu imao je kultivar Royal Mayesty (72, 823 i 44, 721 t/ha), ali u 2000. godini nije bilo značajne razlike u odnosu na kultivare Paladin (43, 744 t/ha) i Sultan (42, 875 t/ha), ostali kultivari su imali značajno manji prinos. U Imotskom je najveći prinos zabilježen kod kultivara Crimson Sweet (38, 061 t/ha), ali nije bilo značajne razlike u odnosu na kultivare Farao (36, 404 t/ha) i Royal Mayesty (35, 254 t/ha) dok su ostali kultivari imali značajno manji prinos. Najmanji prinos u obje godine u Drnišu imao je kultivar Eureka (35, 247 i 29, 004 t/ha), dok je u Imotskome najniži prinos zabilježen kod kultivara Sugar Delicata (22, 391 t/ha) (Tablica 1). Utjecaj lokacije i godine uzgoja na prinos lubenice je očit iz dobivenih rezultata, slična zapažanja dobivena su i u radovima drugih autora (Duval i NeSmith, 1999 ; NeSmith, 1999 ; Sanders i sur., 1999). Pored varijabilnosti u prinosu zabilježena je i varijabilnost u prosječnoj masi ploda koji su kod većine kultivara bili u klasi srednje krupnih plodova (Tablica 2). Najveća prosječna masa ploda zabilježena je 1999. godine u Drnišu kod kultivara Farao (10, 95 kg), ali nije bilo značajne razlike s kultivarima Crimson Glory (10, 84 kg), Paladin (10, 78 kg), dok su ostali kultivari bili značajno lošiji. U 2000. godini u Drnišu najveću prosječnu masu ploda imao je kultivar Sultan (7, 84 kg) ) dok su ostali kultivari bili značajno lošiji. U Imotskom je najveća prosječna masa bila zabilježena kod kultivara Farao (7, 43 kg), no opravdana razlika je zabilježena samo u odnosu na kultivare Eureka, Royal Mayesty i Sugar Delicata (Tablica 2). Važan pokazatelj prinosa je i postotak tržišnih plodova koji je u Drnišu u 1999. bio najveći kod kultivara Royal Mayesty (99, 15%), a u 2000 kod kultivara Sultan (94, 15%) (Tablica 1). U Imotskom se postotak tržišnih plodova kretao od 82, 4% (Sugar Delicata) do 100% kod (Crimson Glory). Najveći postotak netržišnih plodova zabilježen je kod kultivara Sugar Delicata u obje godine i na obje lokacije. Tehnologija uzgoja u velikoj mjeri utječe na prinos i komponente prinosa lubenice (Borošić i sur., 1997 ; Duval i NeSmith, 1999 ; NeSmith, 1999 ; Sanders i sur., 1999), pored relativno zadovoljavajućih rezultata dobivenih u ovom istraživanju očito je da je poželjan daljnji rad na poboljšanju tehnologije uzgoja lubenice na našim obiteljskim gospodarstvima. Tablica 1. Tržišni prinos lubenice (t/ha) i udio netržišnih plodova (%) na lokacijama u Drnišu i Imotskom u 1999. i 2000. Lokacija Drniš '99 Drniš '00 Imotski '00 Kultivar t/ha % t/ha % t/ha % Crimson Glory 36, 449de 1, 49 30, 654d 8, 55 29, 331d 0, 00 Eureka 35, 247e 2, 75 29.004d 15, 86 28, 586d 8, 49 Royal Mayesty 72, 823a 0, 84 44, 721a 9, 24 35, 254abc 11, 29 Sugar Delicata 44, 852cd 2, 85 32, 046cd 16, 01 22, 391e 17, 58 Paladin 54, 177b 1, 77 43, 774ab 7, 66 30, 578cd 5, 33 Farao 60, 331b 1, 27 38, 394bc 10, 32 36, 404ab 3, 47 Top Gun 55, 866b 1, 13 31, 683d 11, 59 33, 042bcd 4, 63 Crimson Sweet 45, 469c 1, 43 32, 813cd 13, 29 38, 061a 6, 53 Sultan 54, 343b 2, 44 42, 875ab 5, 84 32, 084bcd 3, 35 Tablica 2. Masa ploda (kg) lubenice na lokacijama u Drnišu i Imotskom u 1999. i 2000. Lokacija Kultivar Drniš '99 Drniš '00 Imotski '00 Crimson Glory 10, 84 ab 7, 31b 7, 09abc Eureka 9, 46d 6, 31d 6, 87c Royal Mayesty 9, 65cd 6, 80c 6, 91bc Sugar Delicata 8, 45f 6, 59cd 6, 10d Paladin 10, 78 ab 7, 39b 7, 32a Farao 10, 95a 7, 36b 7, 43a Top Gun 8, 70ef 6, 69cd 7, 18abc Crimson Sweet 9, 17de 6, 57cd 7, 26ab Sultan 10, 23bc 7, 84a 7, 23abc Zaključak Rezultati pokusa pokazuju da se kultivari lubenice razlikuju po prinosu i prosječnoj masi ploda u ispitivanim agroekološkim uvjetima, također uočen je utjecaj izbora lokacije i godine uzgoja a navedena svojstva. Obzirom na prinos u Drnišu možemo istaknuti kultivar Royal Mayesty (72, 823 t/ha) i Farao (60, 331 t/ha) u 1999. godini te Paladin (43, 774 t/ha) i Sultan (42, 875 t/ha) u 2000. godini. U Imotskom je najveći prinos zabilježen kod kultivara Crimson Sweet (38, 061 t/ha). Kultivar Farao se posebno istakao obzirom na prosječnu masu ploda koja se kretala od 7, 36 kg do 10, 95 kg. Udio netržišnih plodova je bio veći u godinama s lošijim prinosom, međutim bio je najveći kod kultivara Sugar Delicata u svim uvjetima. Literatura Borošić J., Romić D., Klačić Ž., Žutić I., Romić M. i Prtenjača V., (1997). Utjecaj malčiranja tla i navodnjavanja na rast i prinos lubenica. Zbornik sažetaka XXXIII znanstvenog skupa hrvatskih agronoma, Opatija, 105. Duval J. R., NeSmith D.S., (1999). Stand survival, establishment and yield of a diploid and a triploid watermelon transplants of different ages and sizes. HortTechnology 9(4) Lešić R., Borošić J., Butorac I., Ćustić M., Poljak M. i Romić D., (2002). Povrćarstvo, Zrinski, Čakovec Marr C.W., Tisserat N., (1998). Commercial vegetable production watermelon. Kansas State University. No. 1107: 1-7 NeSmith D.S., (1999). Root distribution and yield of direct seeded and transplanted watermelon. J.Amer. Soc. Hort. Sci. 124(5):458-461. Roberts W., Motes J., Edelson J., Damicone J., Duthie J., (1996). Watermelon production. Oklahoma State University, F-6236:1- 6 Sanders D.S., Cure, J.D., Schultheis, J.R., (1999). Yield response of watermelon to planting density, planting pattern and polyethylene mulch. HortScience 34(7):1221-1223.