Changes in Age at Diagnosis and Nutritional Course of Celiac Disease in the Last Two Decades.

The frequency of celiac disease (CD) has increased along time, with relevant changes reported in geographical variations, clinical presentation and nutritional repercussions. In recent years, some celiac patients are presenting overweight/obesity, but it is unclear how frequent this is and to what extent undernutrition remains a concern. This is relevant because CD tends to be overlooked in overweight patients. With this in mind, we assessed age at diagnosis, clinical characteristics and nutritional status of 155 celiac patients diagnosed between 1994-2017 in four pediatric hospitals in Santiago, Chile. Since 2003, the number of patients diagnosed has increased (p < 0.0033), coinciding with antitransglutaminase and antiendomysial antibodies becoming available to public health systems. In 2000, 4.5% of patients were asymptomatic at diagnosis, suggesting that active search is not routinely applied. Gastrointestinal symptoms plus failure to thrive were significantly more frequent under 2 years (p = 0.0001). Nutritional status has improved at diagnosis and during follow up, but undernutrition remains more frequent in children <2 and <5 years (p < 0.002 and p < 0.0036, respectively). Overweight at diagnosis was reported in 2002 and obesity in 2010. After initiating treatment, since 2010, patients changing from undernourishment to overweight has sometimes been observed after only 6 months on a gluten-free diet.

Avoiding Small Intestinal Biopsies for Diagnosis of Celiac Disease in Children: A Reliable Strategy for All Patients?

BACKGROUND: Current reports applying ESPGHAN exception criteria (EEC) to diagnose celiac disease (CD) without duodenal biopsies indicate that a high percentage of patients with CD may be identified when applied correctly in specialized settings. Application of the EEC, however, in "daily life conditions" at the different levels of medical services is not clear. METHODS: EEC was applied to 130 pediatric patients evaluated for CD at 5 public hospitals in Santiago, Chile, during 2010 to 2015. Clinical presentation, serum anti-tissue transglutaminase 2 and anti-endomysium antibodies (EMA), genotyping, and small intestinal histology were obtained from clinical charts. RESULTS: A total of 78 of 130 patients reviewed had some of the data required for analysis, but EMA was determined in 54% and genotyping in 2.3% of patients, limiting the study. After offering free genotyping, only 12 of 78 (15%) had all data required for EEC application. In this small group, 10 of 12 (83.3%) patients could avoid duodenal biopsies and 2 (16.7%) with potential CD were misdiagnosed. Main reasons for not doing EMA and genotyping were that they are expensive, unavailable in the local health care center, and considered "not necessary" for diagnosis. CONCLUSION: Limited resources in clinical settings reduce availability of EMA and genotyping, making application of EEC criteria difficult and only possible only in 15% of our patients. Within this subgroup, biopsies could be avoided in 83.3%, and 16.7% of patients with potential CD were misdiagnosed. Insufficient studies and incorrect interpretation of EEC contributed to incomplete assessment in 52 of 130 (40%) patients. The Chilean public health system is likely representative of several others present in developing and developed countries.

Micronutrient deficiencies in patients with typical and atypical celiac disease.

OBJECTIVE: The extent of the digestive/absorptive involvement in atypical presentation of celiac disease (CD) is not always clear. The aim of the study was to assess nutritional status of iron (Fe), copper (Cu), and zinc (Zn) in patients with typical CD (TCD) and atypical CD (ACD). PATIENTS AND METHODS: A cross-sectional study was done in patients with TCD, ACD, and healthy controls (HC). Hemoglobin, serum ferritin, free erythrocyte protoporphyrin, Fe, Cu, ceruloplasmin, Zn, anti-endomysial antibodies, and anti-tissue transglutaminase antibodies were measured. Data were analyzed by Kruskal-Wallis, principal component analysis, and linear discriminant analysis. RESULTS: : One hundred nine individuals were studied (54 TCD, 19 ACD, 36 HC); mean age  ±  standard deviation was 23 ± 15.8 (range 1.6-75.4) years. Median and range of hemoglobin were 12.8 g/dL (8.1-17.6) in TCD, 12.4 g/dL (10.5-14.5) in ACD, and 13.6 g/dL (11.1-16.7) in HC (P < 0.0001); serum ferritin was 17.7 µg/L (2.9-157), 10.8 µg/L (2.7-39.8), and 28.7 µg/L (4.5-127.2), respectively (P < 0.01). Cu was 105 µg/dL (60-185), 97.5 µg/dL (40-130), and 125 µg/dL (80-205), respectively (P < 0.05). Ceruloplasmin was 21.6  mg/dL (14.2-73.2), 22.6  mg/dL (0.9-34.3), and 32.1 mg/dL (5.8-72.6), respectively (P < 0.01). There were no differences in Fe, free erythrocyte protoporphyrin, and Zn. Principal component analysis showed that 58% of observed variability was explained by Fe and Cu indicators. Linear discriminant analysis revealed differences between CD and HC (P < 0.0001), with high values of correct classification for TCD (73%) and HC (72%), but not ACD (16%), which were mostly classified as TCD (79%). CONCLUSIONS: Deficiency of micronutrients was found both in typical as well as in atypical cases.

Amerindian mtDNA haplogroups and celiac disease risk HLA haplotypes in mixed-blood Latin American patients.

BACKGROUND AND OBJECTIVE: Risk haplotypes have been described in celiac disease (CD), but the influence of native genes on CD in Hispanic Americans is unknown. The aim of the study was to measure the frequency of Amerindian mitochondrial DNA (mtDNA) haplogroups (inherited by the maternal line) in mixed-blood patients with CD from Chile, Argentina, and Uruguay, and to assess the relation between these and human leukocyte antigen (HLA) alleles and haplotypes and clinical presentations. PATIENTS AND METHODS: Clinical history, histological data, and genetic studies were conducted following 2 protocols: a case-control study of 72 Chilean patients with CD and controls, and an assessment of 43 (additional) samples of celiac patients from Chile, 96 from Argentina, and 57 from Uruguay, compared with the mtDNA frequency in the corresponding country. HLA typing was performed by a commercial kit, and mtDNA was determined by means of polymerase chain reaction and restriction fragment length polymorphisms analysis. RESULTS: A total of 73.6% of cases had typical presentations. The most frequent HLA alleles were HLA-DQB*201 and 202. No-DQ2/DQ8 HLA haplotypes were found in 7% of cases. mtDNA frequencies for typical Amerindian haplogroups were found in 71% of cases and 64% of controls (P χ2 = 0.016); in the comparative analysis, mtDNA distribution was not different from the figures reported for the respective general country population. No relation was found between haplotypes or haplogroups and clinical presentations. CONCLUSIONS: mtDNA haplogroups A/B/C/D were frequently found in celiac patients and controls, but no relations appeared between haplogroups, haplotypes, and clinical presentations.

Alternativas a la cirugía: sonda nasoyeyunal y sonda nasogástrica / Alternatives to surgery: probe nasoyeyunal and nasogastric tube

The central nervous system damage is associated with a major dysfunction of gastrointestinal tract, whose magnitude is variable. The rehabilitation of disabled children should be confronted by a multi-professional team and beginning the most early as possible, with the aim of impacting so positive on morbidity and mortality associated with their condition. Enteral nutrition is a valuable tool when the indication is right, the first approach is to establish the form of food safer and less expensive according to the clinical circumstances of each case. When the nutritional rehabilitation can be achieved in the short term, the nutrition through probes both gastric as post-pyloric, are alternative for quick and easy access, often in stages prior to establish definitive food routes.

El daño del sistema nervioso central se asocia a una disfunción importante del tracto gastrointestinal, cuya magnitudes variable. La rehabilitación del niño discapacitado debe ser enfrentada por un equipo multiprofesional e iniciada lo más precozmente posible, con el objetivo de impactar de manera positiva en la morbimortalidad asociada a su condición. La nutrición enteral es una herramienta valiosa cuando la indicación es la adecuada, la primera aproximación es establecer la forma de alimentación más segura y menos costosa de acuerdo a las condiciones clínicas de cada caso. Cuando la rehabilitación nutricional se puede alcanzar en un corto plazo, la nutrición a través de sondas tanto gástricas como post pilóricas, son alternativas de fácil y rápido acceso, en muchas ocasiones en etapas previas a establecer rutas de alimentación definitivas.

Comprendiendo las percepciones de los usuarios adictos a drogas, respecto a su experiencia en psicoeducación / Understanding drug addicted perceptions about their experience in psychoeducation

Las adicciones a drogas (alcohol e ilicitas) son un problema grave y crónico que aumenta cada día. Los pacientes que logran comprometerse con un tratamiento tienen mayor probabilidad de éxito en lograr abstinencia y rehabilitarse. El modelo de tratamiento y rehabilitación que aplica la Unidad de adicciones de la Pontificia Universidad Católica de Chile, contempla varias estrategias entre las cuales se encuentra la psicoeducación, basada en el modelo cognitivo conductual, que pretende crear consciencia racional de enfermedad a través del trabajo grupal de temas previamente establecidos. Esta investigación se propuso explorar las percepciones de los usuarios adictos a drogas respecto a su experiencia de psicoeducación en ese centro, para construir una comprensión que rescate las experiencias más significativas en este proceso. Se realizó un grupo focal con 8 participantes y al análisis de los testimonios, se identificaron 5 categorías principales: Percepción de las características del método: se reconoce como método no tradicional obligatorio, que enseña conceptos de enfermedad adictiva, es complementario a las otras estrategías del tratamiento y tiene credibilidad

Hígado en la diabetes / Liver and diabetes

Se revisa la bibliografía en relación con el compromiso hepático atribuible a la diabetes misma como sólo asociadas a ellas o a la terapia con antidiabéticos y en particular a las drogas hipoglicemiantes orales. Entre las alteraciones hepáticas observadas en diabéticos destacan la hepatomegalia, el hígado graso, el aumento de glicógeno hepático, la cirrosis y la hepatitis. En esta última se encuentra esteatosis, inflamación lobular o portal, colagenosis y aún sustancia hialina similar a la de la hepatitis alcohólica. Las alteraciones del laboratorio hepático son inespecíficas en la diabetes y el compromiso del órgano sólo puede asegurarse mediante la biopsia. Los hipoglicemiantes orales y en especial la clorpropamida son potencialmente productores de daño hépatico