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First evidence that gluten-free diet benefits asymptomatic patients with celiac disease blood markers

 

MD-FM Thursday May 29th, 2014


 

SARAH:

MD FM: the latest medical news from around the world. Here’s Peter Goodwin.

 

SEGMENT 1: CELIAC DISEASE: First evidence that gluten-free diet benefits asymptomatic patients

 

PETER:

Hello, to begin with: patients who test positive for celiac disease but don’t have any symptoms can benefit significantly from a gluten-free diet. Here’s Sarah Maxwell with more on these findings, reported in the journal Gastroenterology

 

SARAH:

Yes, these are from the first long-term study looking at asymptomatic patients: they didn’t have any of the common disturbing signs of the illness but they did test positive at antibody screening and small bowel biopsies revealed mucosal tissue damage –a lesion that’s typical of celiac disease:

 

KAUKINEN:

At the beginning of the study, they felt asymptomatic but they in fact had minor symptoms… People get used to minor symptoms, and they only recognize them afterwards, when these symptoms go away. Then they notice: “Well ok, in fact I did have this flatulence problem...” and “Oh yes, I did have this minor abdominal pain but I thought that this was normal!”

 

SARAH:

That was senior study author Katri Kaukinen, from the University of Tampere in Finland. Patients were randomized to a long-term gluten-free diet or a normal diet; and at one year, those on the gluten-free diet did significantly better:

 

KAUKINEN:

Those who were randomized to continue on the gluten –almost all of them developed worse small bowel mucosal lesions, also some of them had more symptoms. But those who were randomized to the gluten-free diet –their mucosa healed, antibodies disappeared and all these minor clinical symptoms... And also quality of life improved. It’s not easy to follow a gluten-free diet and we were quite surprised that, even if they had this restrictive diet, they felt that the total outcome was so positive.

 

SARAH:

And Professor Kaukinen told us that following a gluten-free diet might also have long-term beneficial effects:

 

KAUKINEN:

We know that in untreated celiac disease –these people suffer from osteopenia and osteoporosis and they might be at risk for bone fractures.

 

PETER:

So… Seeing as these patients were asymptomatic, should everyone now get tested then?

 

SARAH:

Well, no –not yet. The authors point out that the potential long-term benefits must first be evaluated but some at risk subgroups may clearly benefit from testing. We asked Sheila Crowe, who did not participate in the study, which ones:

 

CROWE:

It is worthwhile to screen for first and second-degree relatives, those with associated diseases like type-1-diabetes, autoimmune thyroid disease and a variety of other autoimmune disorders rather than just relying on symptoms of celiac disease. For example, in type-1-diabetes, not all individuals with present with GI symptoms, sometimes it’s poorer blood sugar control, possibly because of irregular absorption of their calories because of the enteropathy… But we have not come out to say that everybody should be screened for celiac disease.

 

SARAH:

That was Dr. Sheila Crowe, from La Jolla in California.

 

SEGMENT 2: Pharmacologic combination helps celiac disease patients avoid gluten ingestion

 

PETER:

And for patients with celiac disease whose symptoms don’t go away despite switching to a gluten-free diet, taking an oral mixture of two recombinant gluten-specific proteases further reduced small bowel mucosal injury. That’s according to another randomized phase-2 study by the same Finnish team, also published in the journal Gastroenterology. This is welcome news, as these patients need options because some of them end up ingesting at least trace amounts of gluten despite their best endeavors, especially from eating things like processed foods.

 

SEGMENT 3: Oophorectomy by age 35 strongly recommended to prevent cancer in BRCA1 mutation carriers

 

PETER:

Some experts say prophylactic oophorectomy by age 35 should become a universal standard for women with BRCA1 mutations, to reduce the risks of ovarian, breast, fallopian tube or peritoneal cancers...

 

SARAH:

That’s right and a clear-cut recommendation on this has now been made in the Journal of Clinical Oncology, by researchers who followed nearly 6,000 women with BRCA1 or 2 mutations. After a median 5.6 years, women had an 80 percent lower risk of cancer if they had their ovaries removed, and all-cause mortality was reduced by 77 percent. So the authors then tried to establish what is the optimal age for oophorectomy

 

PETER:

Current guidelines recommend having it done between the ages 35 and 40, when childbearing is complete, don’t they?

 

SARAH:

Yes they do and for carriers of the BRCA2 mutation, the authors appear to agree with this recommendation. But that’s not the case for carriers of the BRCA1 mutation, since almost all of the risk reduction observed in these patients in the study resulted from early intervention:

 

NAROD:

For BRCA1, we had only one percent of the patients get cancer by age 35. But if we were to tell a 35 year-old woman that she could wait until age 40 to have preventive surgery, she would have a four percent risk of being diagnosed with ovarian cancer. And for some women, they may wish to accept that risk --some women wish to preserve their fertility beyond their thirties and most women wish to prevent menopause for as long as possible but, for me, that risk seems a little bit high… So, as a practitioner, I think the recommendation for oophorectomy at age 35 for BRCA1 carriers is well justified.

 

SARAH:

That was lead study author, Dr. Steven Narod, from the University of Toronto in Canada.

 

SEGMENT 4: Chronic fatigue syndrome appears to stem from brain inflammation

 

PETER:

There’s been confirmation that, chronic fatigue syndrome (CFS) could be triggered by brain inflammation –This is in findings reported in the journal PLoS One:

 

SARAH:

Yes, CFS is a somewhat mysterious illness characterized by extreme exhaustion, muscle and joint pain and cognitive problems. In this study, MRI imaging showed that patients with CFS had reduced activity in the basal ganglia –a region of the brain connected with fatigue and motivation. Lead study author Andrew Miller:

 

MILLER:

Interestingly, that reduced neuronal activity that we saw in the basal ganglia correlated with symptoms of fatigue. So the lower the activity in that brain region, the greater the amount of fatigue in those chronic fatigue syndrome individuals. We saw no relationship between those two things in the control population.

 

SARAH:

Dr. Andrew Miller, from Emory University in Atlanta, Georgia. And he explained to MDFM that the basal ganglia are primary brain targets during inflammation:

 

MILLER:

There’s been a lot of discussion about whether or not chronic fatigue syndrome is related to a viral infection. And the studies that we’ve done, previously, have shown that one of the inflammatory molecules, called interferon alpha, has been shown to target the basal ganglia. And interestingly interferon alpha is an inflammatory cytokine that is antiviral in nature.

 

SARAH:

And Dr. Miller said this finding could open up new therapeutic avenues for these patients, who currently have no standard of care:

 

MILLER:

What we’re experimenting with now are anti-cytokine therapies that are used to treat inflammatory and autoimmune disorders like psoriasis like rheumatoid arthritis, to tease out whether these inflammatory cytokines are actually the culprits. If that works, and we’ve then proven that inflammation is the direct cause of these changes, then we can go in with more sophisticated agents…

 

SARAH:

Andrew Miller, from Atlanta.

 

IN BRIEF 1: Benefits of using hypertonic saline vs. normal saline for children with bronchiolitis still unclear

 

PETER:

Finally, in brief: For infants with bronchiolitis, two randomized trials, published in JAMA pediatrics, report conflicting results on the use of inhaled hypertonic saline vs. normal saline. One study suggested that using the more concentrated saline in the emergency room led to fewer clinical improvements, while the other said it decreased subsequent hospital admissions. Experts concluded that practitioners should not use hypertonic saline on a routine basis in the emergency room, since the optimal concentration, dosing frequency and duration of therapy are still unclear.

 

IN BRIEF 2: First pediatric miniaturized cardio-renal dialysis emergency machine for neonates and small infants

 

PETER:

Researchers have designed the first pediatric miniaturized cardio-renal dialysis emergency machine –tailored specially for neonates and small infants. According to a report in The Lancet the machine was safe and effective for treating neonates with hemorrhagic shock, multiple organ dysfunction or severe fluid overload. Such a machine could help reduce the range of indications for peritoneal dialysis, and it could perhaps widen the range of indications for continuous renal replacement therapy and make this less traumatic.

 

PETER:

And that's all from MDFM for now. Sarah Maxwell and I will be back with more next week. So until then, from me Peter Goodwin, goodbye!

 

 

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