The "Seventh International Symposium on Coeliac Disease" was held last September in Tampere, Finland. In the September 1996 issue of The Sprue-nik Press, we gave you an "eye-witness" account of the symposium, as dictated by Dr. Joseph Murray, transcribed and edited by Ann Whelan (publisher of Gluten-Free Living), and then "published" on the CELIAC Listserv on the internet.
At the symposium, abstracts of all the various studies and reports were handed out in a thick publication entitled simply, "Free Paper Abstracts". This document was edited by Drs. Pekka Collin and Markku Maki, internationally well-known celiac experts. Each of these half-page abstracts describe briefly the study's background, objective, results, and conclusions. Bill Elkus (one of the CELIAC Listserv administrators) gave me a copy of these abstracts, and I've been plowing through them every since.
This article is my attempt to summarize and in some cases interpret some of the more important information (as I judged it) covered in these abstracts. The reader should be aware that I do not have a medical background, so my attempts to summarize may result in oversimplification. Also, my interpretations could be just plain wrong (and I'll try to make it clear when I'm interpreting instead of just summarizing). Rest assured that this article was reviewed by our advisors (Dr. Alexander and Dorothy Vaughan), just as our newsletters are. In addition, Dr. Murray also reviewed this article.
Note: The abstracts are numbered sequentially in the document, A1 through A181. I will use the same numbers in brackets when I reference specific studies; for example: [A120]. A list of all referenced abstracts appears at the end of this article. Also, throughout this article, "treated celiacs" refers to celiac patients who are following a gluten-free (GF) diet, and "untreated celiacs" refers to celiac patients who are newly-diagnosed or who have not been following a GF diet.
USA: A Country Wearing Celiac Blinders?
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The USA is generally a world leader in medical research, but for some reason lags far behind in celiac-related research. This was very evident at the symposium. I went through all the various abstracts, and simply counted the number of studies that each country was involved in. The results were most illuminating (and for us depressing): The USA was involved in only two of the 181 studies presented at the symposium. Other countries involved in two studies included Algeria, Brazil, and Belgium. Countries such as Argentina, Israel, Switzerland, the Czech Republic, and the Netherlands all were involved in more studies than the USA. Distance was hardly an excuse: Our northern neighbor, Canada, with one-tenth the population of the USA, was involved in six of the studies presented at Tampere.
On the other end of the scale, we find Finland, Italy, and Sweden all were involved in 20 or more studies presented at the symposium. Ireland and the United Kingdom combined for 30. While these countries are traditionally thought to be celiac "hot spots", none of them have anywhere near the population and research funds of the USA.
It seems clear to me that there is a distinct bias against celiac research in the USA. Celiacs in this country have been saying this for some time now, and there was nothing at Tampere to refute this.
Prevalence of Celiac Disease
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One of the areas seemingly open to debate is the prevalence of CD. Studies in Finland [A27], Italy [A20, A25], Norway [A2], Sweden [A21], and the USA [A26] showed prevalence ratios varying from 1:560 to 1:75, which would indicate that celiac disease (CD) is fairly common. But two other studies, in Denmark [A22] and Germany [A23] suggest that CD is fairly rare; the prevalence ratios were 1:12,903 and 1:2,521 respectively. So which studies can we believe?
If you look closer at the two sets of studies, you find a fundamental difference. In the first set, a cross-section of some general population, such as blood donors or secondary school students, was tested for CD. The testing was done via serum antibody tests and (usually) follow-up biopsies when warranted. Since the antibody tests are 90+% accurate and specific, these studies are likely to have found most of the celiacs in the populations tested, while finding few "false positives". Therefore, the prevalence ratios from these studies are likely to be fairly accurate.
The studies done in Denmark and Germany compared previously-diagnosed celiacs against the overall population. There may be many other celiacs in these populations which have never been diagnosed; since the studies do not test the populations as a whole there is no way to really tell. The much lower prevalence rates found in these two studies may simply indicate the extent to which CD is under-diagnosed in those countries.
Several other studies [A1, A5, A73, A94] casually referred to CD prevalence ratios ranging from 1:675 to 1:250, as part of the background information. It is not just the European countries; an Algerian study [A73] cited a ratio of 1:474. Clearly the experts conducting these studies viewed these ratios as established fact in their respective countries. Only in a German study [A70] was CD cited as being relatively rare at 1:2,060.
Based on these studies, it is not unreasonable to conclude that CD has a prevalence of at least 1:500 among those of European descent; and it may be even more prevalent. The USA has a population of about 267 million people.(1) If we discount the non-Caucasian portion of the population (for which we don't have much information regarding CD), then that leaves about 221 million people.(2) If we use a conservative prevalence ratio of 1:500, then there are 442,000 Caucasian celiacs in the USA. But the prevalence is likely to be even higher, and there may be significant numbers of non-Caucasian celiacs. So one can conclude that there are between a half million and a million celiacs in the USA.
Prevalence in Families
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The familial incidence of CD was looked at in three studies (Italy [A98], Poland [A24], and Spain [A173]). In the first two studies, the prevalence of CD among first-degree relatives was found to be in the range of 5.5-6.0%. The third study found that 17.3% of the first-degree relatives had positive endomysial antibody tests, but it is not known how many of these were actually celiacs. Still, all three studies suggest routine screening for CD among the first-degree relatives of a diagnosed celiac.
Diagnosis on a Gluten-Free Diet
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One of the big problems that crops up over and over again has to do with people who are already on a GF diet, and who wish to get a valid medical diagnosis of CD. Currently, diagnosis of CD is accomplished by finding damage to the villi of the small intestine, followed by clinical response to the GF diet. But if you are already on a GF diet, then there is often no damage to find. So prior to being tested, you have to first go on a gluten-challenge, usually for several months to a year.
One of the big questions is: Is it possible to diagnose or verify CD in a patient that is already on a GF diet? Several of the studies attempted to determine whether there were any persisting differences in the immune response of celiacs on a GF diet. In each of the studies, some difference between celiacs and non-celiacs was found that was not dependent on the celiacs being on a gluten diet prior to testing. (However, bear in mind that these are all small-scale studies involving at most a few dozen celiacs and a few dozen controls, so much more testing would have to be done before any of these techniques would be generally available. In addition, these changes may also occur in other disease states so it may not be possible to determine that the changes are caused by CD only.) Comments in brackets [] are my own.
* Finland [A172]: In this study blood samples from both untreated and treated celiacs were analyzed, along with samples from family members (both with and without the HLA DQ2 gene associated with CD). They found that both treated and untreated celiacs had higher levels of certain lymphocytes than family members with the CD-related DQ2 gene. The level was somewhat lower in treated celiacs, but still markedly higher than the level for the non-celiacs. The level was the same for the non-celiacs, regardless of whether they had the CD-related DQ2 gene. [If these lymphocytes are specific to CD, then it might be possible to look for these when trying to diagnose someone already on the GF diet.]
* Switzerland & Germany [A147]: Biopsies were cultured for 24 hours in the presence or absence of gliadin peptides, and the effect on biosynthesis of several hydrolases was measured. In treated celiacs the gliadin prolamines resulted in a reduction of biosynthesis; in non-celiacs there was no reduction. [A larger study, involving both treated and untreated celiacs, would be a logical follow-up. Note that the technique used in this study, and all that follow in this section, still requires a biopsy; the difference is in how the biopsy samples are analyzed.]
* Belgium & France [A155]: Intraepithelial lymphocytes (IEL) and lamina propria lymphocytes (LPL) were isolated from mucosal biopsies. The frequency of IL-4 secreting IEL and LPL cells was measured. Non-celiacs were found to have a high frequency of IL-4 secreting IEL and LPL cells. Untreated celiacs were found to have a low frequency of both. However, treated celiacs were found to have a high frequency of IL-4 secreting LPL cells, but a low frequency of IL-4 secreting IEL cells. This suggests that a defect of IL-4 secretion by IEL cells could be the primary immune dysfunction in adult celiacs [which could help distinguish between non-celiacs, untreated celiacs, and treated celiacs].
* Two other studies, Italy [A148] and an unspecified country [A166], found differences in biopsy-obtained intraepithelial lymphocytes when treated celiacs were compared to non-celiacs.
Most celiacs are probably not aware of how endomysial antibody tests are done. Currently these tests are done using monkey esophagus tissue. This raises ethical issues due to the necessity of sacrificing a higher order animal for the tests, and it is of course quite costly. Several of the studies looked at using other tissues in place of monkey esophagus tissue.
There were ten different studies which tested human umbilical cord tissue as a substitute. The advantages are obvious: It is cheap and readily available at any hospital, and no life must be sacrificed to obtain it. The results were generally favorable when human umbilical cord tissue and monkey esophagus tissue were compared in performing antiendomysial tests:
* In two studies, human umbilical cord tissue did not work quite as well as monkey esophagus tissue [A105, A112].
* In one study, human umbilical cord tissue worked better than monkey esophagus tissue [A124].
Human appendix tissue was also tested and found to be effective, but only if histologically normal (healthy). The source would be appendices removed due to suspected [acute] appendicitis that were tested and found to be normal. [A106]
Autoimmune Disorders Linked to CD
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A study in Italy [A6] looked at the overall association between CD and autoimmune diseases, and found a four-fold increase in the prevalence of autoimmune diseases in CD patients, when compared to non-celiacs. Another study in Finland [A71] tested patients with multiple autoimmune endocrinologic diseases and found that in these patients the prevalence of CD was greater than 10%, a much higher rate than in the overall population.
Three studies [A80, A81, A107] looked at CD prevalence in Down's Syndrome (DS) patients. A noticeably higher prevalence of CD was found in DS patients in two studies [A80, A107]. However a study in Sweden [A81] found that elevated IgA AGA antibodies are often found in DS patients, even though only a small portion had mucosal damage consistent with CD. This suggests that the prevalence of CD in DS patients may be less than has previously been thought [or they may have "latent" CD--Dr. Alexander].
The link between Insulin-Dependent Diabetes Mellitus (IDDM) and CD has been well established. Studies in Algeria [A73], Germany [A70], and Greece [A67], as well as a multi-centric study [A72], show the prevalence of CD in IDDM patients to be 2.6-11.3%. For diabetics with CD, the GF diet often improves diabetic control. It is suggested in these studies that all IDDM patients should be screened for CD using the blood antibody tests, and the multicentric study [A72] recommends repeating the test every five years even if it comes back negative.
Other Problems Associated With CD
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The autoimmune problems discussed in the previous section have to do with genetics. The problems in this section have more to do with gluten-induced damage, either directly or indirectly.
One common problem faced by celiacs diagnosed at an older age is bone disease. Studies in Argentina [A8, A63] and Italy [A64] showed improvement in bone mineral density for newly-diagnosed celiacs after a year or more on the GF diet. Another study was done in Poland [A65] to determine the effect on young adult celiacs who abandon the GF diet for three or more years. These young adults fell within the normal limits in bone mineral density for their ages. [It is not clear if these young adults were off of the diet for a long enough time for bone problems to develop.--Dr. Alexander] Unfortunately this appears to support the false picture of good health that young adult celiacs often have when not on the GF diet. The other studies show clearly what happens down the road to celiacs that fail to follow the GF diet.
One of the biggest concerns among celiacs is the possibility of developing lymphoma or carcinoma. A study in Canada [A57] paints a bleak picture when CD is diagnosed in the elderly; in these cases there is a much higher risk of developing lymphoma or small intestinal adenocarcinoma. A study in France [A17] looked at refractory sprue cases and found the first evidence that refractory sprue is an early indicator for the onset of low-grade intraepithelial T-cell lymphoma. However, studies in Italy [A59] and England [A60] paint a brighter picture. The Italian study found that the risk of malignancy in those with undiagnosed CD is not much higher than the risk for non-celiacs. The English study found that risks of malignant conditions in the oral cavity are no higher for CD patients than for non-celiacs.
Three studies in Finland looked at oral mucosal lesions. [A83] found that the prevalence of CD in patients with oral mucosal lesions to be about 6%. Both [A83] and [A84] suggested that all patients with oral mucosal lesions should be screened for CD. In [A85] it was found that DH patients often have oral mucosal changes, even when on a strict GF diet.
Neurological problems were the focus of studies in England [A77] and Finland [A78]. In the English study it was found that neurological dysfunction is often the only symptom of gluten sensitivity. The Finnish study found that neurological problems were common in celiacs, and that patients with neurological symptoms often have atypical CD.
A Swedish study [A5] found a high prevalence of untreated CD among those seeking psychiatric advice. But none of the treated celiacs were diagnosed with anxiety disorders, suggesting an impact of the GF diet on factors which regulate mood in celiacs.
Short stature can be a symptom of untreated CD. A retrospective study in Algeria [A30] looked at this issue and found that early diagnosis of CD in children of short stature is critical, because it allows time for "catch-up" growth to occur, so that they may still attain their genetic potential.
A possible link between epilepsy and CD was studied in Lithuania [A79]. 71 epilepsy patients were randomly selected and assessed for CD, and none were found to have it. The study concluded that if a link exists, it may occur in children greater than ten years of age, who have had epilepsy for over two years.
An Italian study [A82] looked for CD in Williams' Syndrome patients. This is a curious situation. Williams' Syndrome is a rare genetic condition with a prevalence of 1:20,000. However, the genetic defect occurs on Chromosome #7(3), whereas the celiac-related genes appear to be on Chromosome #6(4). It would appear that there is no genetic connection between CD and Williams' Syndrome, and it seems clear that Williams' Syndrome is caused entirely by a genetic defect. Yet the study found that CD prevalence in Williams' Syndrome patients is very high (8.6%). It is not clear at this point where the link between the two conditions is; however, it is recommended that all Williams' Syndrome patients be tested for CD.
A Swedish study [A125] found the incidence of CD to be 1.7% among teenagers with iron deficiency. This suggests that CD should be screened for in cases of unexplained anemia.
A US study [A7] looked at post-bulbar duodenal strictures in five adult celiacs. In three of these, CD was not expected. However a biopsy of the duodenal stricture revealed villous atrophy, leading to a diagnosis of CD. These findings suggest that post-bulbar duodenal stenosis may herald the diagnosis of CD, whereas in the past it has previously been described as a rare complication of long-standing CD.
Finally, an Italian study [A76] looked at the effect of the GF diet on young celiac women. It determined that the GF diet may [favorably] influence menarche age, time for conception, and pregnancy outcome in celiac women. The study also found that pregnancy may trigger CD in previously undiagnosed women.
Oats: To Eat or Not To Eat?
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Several studies looked at the toxicity of oats for celiacs. Four studies of varying lengths, all involving adult celiacs, seem to indicate that oats may be safe for celiacs (Finland [A126, A129], Ireland [A10], and Sweden [A130]). In these studies, treated celiacs remained healthy after eating oats, and untreated celiacs who went on a GF diet that included oats recovered their good health. [A note of caution: The oats used in these studies were likely to be specially supplied and checked for gluten contamination. Such carefully checked oats are likely not available in the USA.]
Another Finland study [A127] looked at twelve adult dermatitis herpetiformis (DH) patients that began eating oats. After three months, five of them developed a slight rash on the knees, elbows, or scalp. Oddly enough, the study concludes that DH patients can remain symptom-free while eating oats daily, while conceding that further study needs to be done on the problem of the rash flaring up in some patients. My conclusion is somewhat different: I think this study shows that oats can be a problem for some (in this case nearly half) DH patients.
The most significant study regarding oats may very well have been done in Italy [A134]. In this study biopsy samples from treated celiacs were cultured for 24 hours either alone or in the presence of wheat gliadin or oat prolamines. After that time CD25+ lymphocytes were counted. It was found that in the presence of wheat or oat prolamines there were significantly more of these lymphocytes. The study concludes that these results suggest oat prolamines are able to activate a T-cell mediated mucosal immune systems response in the jejunum of celiacs; in other words, these results represent a warning against adding oats to the diet of a celiac.
Final Thoughts
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As you can see, there really is a lot of celiac-related research taking place--it's just that most of it is happening outside our country. Still, we have seen an increase in celiac-related research in this country in the last few years, with the CD Prevalence Study at the University of Maryland School of Medicine being the most recent to be announced. So take heart: Things are slowly beginning to change on the celiac "front" in the USA.
Keep in mind that all the studies you have read about here represent cutting-edge research. No matter how exciting some of them may sound, don't expect to see anything you've read about to be in use anytime soon. Most of these studies involved a small number of patients, which means they need to be verified by larger studies conducted at multiple sites. This means more funds, and none of it happens overnight. But if you are patient you should eventually see some of the results from these studies in action.
References
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(1) US Census Bureau, "Current U.S. Population Count", from the internet: http://www.census.gov/, obtained June 22, 1997
(2) US Census Bureau, "Population Data", from the internet: http://www.census.gov/population/www/estimates/nation3.html, obtained June 22, 1997.
(3) Williams Syndrome Association, "Facts About Williams Syndrome", from the internet: http://www.williams-syndrome.org/facts.htm, obtained June 23, 1997.
(4) Martin Kagnoff, MD, in a talk entitled "Genetics and What's New in Research", summarized in The Sprue-nik Press, Dec. 1995, pg. 5.
Abstracts referenced in this article
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[A1] "Coeliac Disease Has a Multifactorial Etiology", A Ivarsson, L Persson, O Hernell, Umea University, Sweden
[A2] "Coeliac Disease in Norwegian Blood Donors", N Hovdenak, E Hovlid, et al, Deaconess' Hospital and Haukeland Hospital, Bergen, Norway
[A5] "Psychiatric Illness in Adult Coeliac Disease", C Hallert, B Bengtsson, et al, University Hospital of Linkoping, Linkoping, Sweden
[A6] "Autoimmune Disorders in Coeliac Disease", A Ventura, G Magazzu (coordinators),et al, University of Bologna, Messina, Modena, Napoli, Palermo, Pisa, Trieste, Italy
[A7] "Post-Bulbar Duodenal Stenosis in Celiac Disease", J Murray, G Schweiger, University of Iowa College of Medicine, Iowa City, Iowa, USA
[A8] "Long-Term Effect of Gluten Restriction on Bone Mineral Density (BMD) of Patients with Celiac Disease", J Bai, D Gonzalez, et al, Gastroenterology Hospital and Clinical Hospital, Buenos Aires, Argentina
[A10] "Absence of Oats Cereal Toxicity in Adult Coeliac Disease", U Srinivasan, N Leonard, et al, St. James' Hospital and St. Vincent's Hospital, Dublin, Ireland
[A17] "Intraepithelial Clonal T Cell Profileration in the Gut of Patients with Refractory Sprue", C Cellier, N Patey, et al, Hopital Laennec and Hopital Necker, Paris, France
[A20] "Coeliac Disease: How Big Is the Iceberg", M Dotti, A Montanelli, et al, General Hospital of Palazzolo, University of Brescia, and University of Ancona, Italy
[A21] "High Prevalence of Coeliac Disease Among Swedish Adults", O Hernell, A Ivarsson, et al, Umea University, Sweden
[A22] "Regional Danish Coeliac Disease", B Weile, P Krasilnikoff, University of Copenhagen, Gentofte and Hvidovre Hospitals
[A23] "Incidence of Coeliac Disease in Northern Germany", U Peters, H Kayser, A Jung, H Erbersdobler, University of Kiel, Germany
[A24] "Familial Incidence of Coeliac Disease in Poland", Z Grzenda-Adamek, J Stopyrowa, A Pituch-Noworolska, W Miezynski, Polish-American Institut of Pediatrics Collegium Medicum Jagiellonian University, Krakow, Poland
[A25] "A Population Based Study of Coeliac Disease in a European Country: The San Marino Study", F Biagi, M Andreani, et al, Universita dell'Aquila, Universita di Bologna, Divisione di Medicina Generale Repubblica di San Marino, Clinica Medica dell'Universita Cattolica di Roma
[A26] "Coeliac Disease Risk in U.S.A.: High Prevalence of Antigliadin and Antiendomysium Antibodies in Healthy Blood Donors in the U.S.A.", T Not, K Horvath, et al, University of Trieste, Messina, Italy; University of Maryland, USA; and Blood Transfusion Service, Helsinki, Finland
[A27] "High Prevalence of Celiac Disease Among Healthy Children and Young Adults in Finland", K-L Kolho, H Akerblom, J Viikari, E Savilahti, Children's Hospital, University of Helsinki, Helsinki; and University of Turku, Turku, Finland
[A30] "Gluten Free Diet (GFD) Effects on the Growth Prognosis of Coeliac Children Diagnosed Lately and Followed at Long Term", G Boudraa, M Benbouabdellah, et al, Service de Pediatrie C. 9, Oran, Algeria
[A57] "Neoplastic Disorders in 100 Consecutive Patients with Adult Celiac Disease (CD)", H Freeman, University of British Columbia, Vancouver, Canada
[A59] "How Much is Coeliac Disease (CD) Prevalence Increased in Patients with Malignancy?", E Fabiani, S Ricci, et al, University Depts. of Pediatrics, Oncology, Internal Medicine, Ancona, Italy
[A60] "Is There an Increased Incidence of Oral Premalignant and Malignant Lesions in Patients with Coeliac Disease?", S Rao, I Hutchison, P Kumar, St. Bartholomew's Hospital, London, England
[A63] "Longitudinal Study on the Impact of Long-Term Treatment on Body Composition and Anthropometry of Celiac Disease Patients", E Smecuol, D Gonzalez, et al, Gastroenterology Hospital, Salvador University and Clinical Hospital, Buenos Aires University, Buenos Aires, Argentina
[A64] "Propeptide of Type I Procollagen is Predictive of Post-Treatment Bone Mass Gain in Adult Coeliac Disease", M Di Stefano, R Jorizzo, et al, Catholic University of Roma, University of L'Aquila, University of Bologna, Maggiore Hospital, Bologna, Ricerca in Medicina
[A65] "Spine and Total Bone Mineral Density in Young Adults with Neglected Celiac Disease", P Dziechciarz, A Talajko, A Radzikowski, Warsaw University Medical School, Child Health Center, Warsaw, Poland
[A67] "Celiac Disease in Diabetic Children and Adolescents: Screening with IgA-Antigliadin Antibodies", T Karagiozoglou-Lampoudi, O Lekidou, et al, Central Hospital, Aristotelian University, Thessaloniki, Greece
[A70] "The Coexistence of Insulin Dependent Diabetes Mellitus and Celiac Disease", J Henker, S Munstermann, K Conrad, University of Dresden, Germany
[A71] "Coeliac Disease and Endocrinologic Disorders", K Kaukinen, P Collin, et al, Tampere University Hospital and University of Tampere, Finland
[A72] "Celiac Disease (CD) and Insulin Dependent Diabetes Mellitus(IDDM): A Multicentric Study", I De Vitis, S D'Addesa, G Ghirlanda, P Cotroneo, G Gasbarrini (coordinators)
[A73] "Coeliac Disease (CD) and Insulin-Dependent Diabetes Mellitus (IDDM) in Children of West Algeria", G Boudraa, M Benbouabdellah, et al, Service de Pediatrie C. 9, Oran
[A76] "Obstetric and Gynaecological Problems and Coeliac Disease", G Magazzu, E Fragale, et al, University of Messina, Italy
[A77] "Gluten Sensitivity: Exploring the Neurological Iceberg", M Hadjivassiliou, A Gibson, et al, Royal Hallamshire Hospital, Sheffield, UK
[A78] "Nervous System Manifestations in Patients with Coeliac Disease", L Luostarinen, P Collin, et al, Tampere University Hospital and University of Tampere
[A79] "Coeliac Disease and Epilepsy", V Urbonas, D Bajoriene, A Jucaite, Vilnius University Children's Hospital Centre of Paediatrics, Vilnius, Lithuania
[A80] "Down's Syndrome and Coeliac Disease: The Prevalence of IgA-Antigliadin Antibodies and Anti-Endomysial Antibodies", A Carlsson, B Lindberg, et al
[A81] "Anti-gliadin and Anti-endomysium Antibodies in Children with Down's Syndrome", T Hansson, A Dannaeus, et al, Uppsala University Hospital, Uppsala, Sweden
[A82] "Celiac Disease in Williams' Syndrome", B Papadatou, C Digilio, et al, Ospedale Pediatrico Bambino Gesu, Roma
[A83] "Coeliac Disease in Patients with Oral Mucosal Symptoms", J Jokinen, U Peters, et al, Tampere University Hospital and University of Tampere
[A84] "Oral Mucosal Changes in Patients with Coeliac Disease", H Lahteenoja, A Toivanen, et al, University of Turku, Turku, and University of Tampere, Tampere, Finland
[A85] "Oral Mucosa is Frequently Affected in Patients with Dermatitis Herpetiformis", H Lahteenoja, A Toivanen, et al, Turku University Hospital, MediCity Research Laboratory, and University of Turku
[A94] "Gut Permeability in Adults With Clinical and Silent Celiac Disease", E Grodzinsky, M Strom, et al, Linkoping University and University Hospital, Linkoping, Sweden
[A98] "Screening of Relatives of Patients with Coeliac Disease by Means of Serum Anti-endomysium Antibodies", A De Alessandri, P Montagna, et al, Istituto "G. Gaslini"; Universita' di Genova
[A99] "Human Umbilical Vein Endothelial Cells: A New Easily Available Substrate for Detecting Endomysial Antibodies in Patients with Coeliac Disease", A Whelan, R Willoughby, D Weir, Trinity College and St. James Hospital, Dublin
[A100] "Antiendomysium Antibody on Human Umbilical Cord Vein: A Cheap and Sensitive Diagnostic Tool for the Screening of Celiac Disease", T Not, A Citta, et al, Clinica Pediatrica-Istituto per l'Infanzia, Trieste, Italy
[A102] "Human Umbilical Cord Tissue: A Suitable Substrate for Endomysial Antibody Detection", C Feighery, C Liddy, et al, St. James's Hospital, Dublin; and City University, Birmingham, U.K.
[A103] "Endomysium Autoantibodies on Human Umbilical Cord in Coeliac Disease", S Sulkanen, A Marttinen, et al, University of Tampere, Tampere, Finland
[A104] "Human Umbilical Cord-Derived Fibroblasts as Antigen in Whole Cell ELISA for Coeliac Disease Antibodies", S Sulkanen, T Halttunen, et al, University of Tampere, Tampere, Finland
[A105] "Connective Tissue Substrates in Serum Screening for Coeliac Disease (CD)", C Keilmann, I Wascher, et al, University Children's Hospital, Tubingen, Germany
[A106] "Same Substrate for Anti-Endomysium, Anti-Jejunum and Anti-Reticulin Assay", I Korponay-Szabo, J Kovacs, et al, Heim Pal Children's Hospital, Budapest, Hungary
[A107] "Endomysium Antibodies (EmA) and Detection of Silent Coeliac Disease", C Farre, F Mallolas, P Vilar, V Varea, Hosp.Universitario S.Joan de Deu, Barcelona, Spain
[A108] "Human Umbilical Cord Antibodies (HUC-Ab) for CD-Screening", C Farre, V Rico, A Mestres, M Hernandez, Hosp.Universitario S.Joan de Deu, Barcelona, Spain
[A109] "Endomyosial Antibodies in Relation to Celiac Disease (CD) Activity in Lamina Propria of Jejunal Mucosa", R Kotalov,a, J Nevoral, J Smidova, Z Lojda, !st Paediatric Clinic of Charles University, Laboratory for Histochemistry of Charles University, Prague
[A112] "Human Liver - Suitable Antigen for Reticulin Antibody Determination. A Prospective Study", O Pozler, Z Nozicka, P Dedek, Charles University, Hradec Kralove, Czech Republic
[A114] "Chronic Liver Disease May Be a Cause of False Positive AntiEndomysium Antibody Assay", H Gillett, A Ferguson, et al, University of Edinburgh, Edinburgh, Scotland, UK
[A119] "Screening Test for Coeliac Disease Using Antiendomysium Antibody on Human Umbilical Cord Section", M Polgar, Madarasz Children's Hospital, Budapest, Hungary
[A124] "Human Umbilical Cord Tissue: Substrate for the Detection of Endomysial Antibodies", E Barry, C Collins, et al, St. Vincent's Hospital, University College Dublin; and St. James' Hospital, Dublin, Ireland
[A125] "Screening for Coeliac Disease Among 15- and 16-Years Old Adolescents with Gliadin and Endomysial Antibodies", L Hulthen, L Hallberg, et al, Goteborg University, Goteborg, Sweden
[A126] "Five Year Follow-Up Study: Use of Oats and Adherence to Gluten-Free Diet", T Kemppainen, E Janatuinen, et al, University of Kuopio, Kuopia, Finland
[A127] "Oats for Patients with Dermatitis Herpetiformis", T Reunala, P Collin, et al, University Hospitals, Tampere and Helsinki, Finland
[A129] "Adult Patients with Coeliac Disease Have No Antigliadin or Antireticulin Antibody Response to Oats", E Janatuinen, T Kemppainen, et al, Kuopio University Hospital, Kuopio, Finland
[A130] "The Oat-Coeliac Study in Gothenburg", S Storsrud, R Lenner, A Kilander, Sahlgrenska University Hospital, Goteborg, Sweden [A134] "Oats Prolamines In Vitro Activate Intestinal Cell-Mediated Immunity in Coeliac Disease", N Leone, G Mazzarella, et al, Univ Federico II, Naples; Istituto di Scienze dell'Alimentazione CNR, Avellino; and Istituto Superiore di Sanita, Rome; Italy
[A147] "The Organe Culture of Human Intestinal Biopsies as an In Vitro-Model for Coeliac Disease in Remission", D Kreft, H-P Hauri, et al, University of Bonn, Geneva, Berne; University of Basle; University of Dusseldorf
[A148] "Integrins and Coeliac Disease", K Pittschieler, B Ladinser, Dept.of Paediatrics, Gastroenterology, Bozen, Italy
[A155] "Deficit in Spontaneous IL-4 Secretion by Intra-Epithelial (IEL) and Lamina Propria (LPL) Lymphocytes from Adult Coeliac Patients", A Lambrechts, M Carol, et al, Hopital Erasme, Brussels, Belgium; CH of Valenciennes and CHU of Lille, France
[A158] "Leukocyte Aggregation and Celiac Disease", A Porcella, F Bamonti Catena, R Marino, M Bardella, Istituto di Scienze Mediche, University of Milan, IRCCS Ospedale Maggiore, Milan, Italy
[A166] "Quantification of Intraepithelial Lymphocytes (IEL) Subsets by Flow Cytometry Analysis (FCA)", P Eiras, C Camarero, E Roldan, F Olivares, A Bootello, G Roy
[A172] "Circulating CD45RO+TcR[alpha][delta] Cells in Coeliac Disease (CoD) Patients and Their Healthy Family Members", T Kerttula, K Holm, et al, Tampere University Hospital, University of Tampere, Tampere and Finnish Red Cross Blood Transfusion Service, Helsinki, Finland
[A173] "HLA-DQ2 as a Marker of Potential Coeliac Disease Among First-Degree Relatives of Coeliac Patients", E Arranz, J Telleria, et al, Universidad de Valladolid, Spain
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