Review for 10.1186/1471-230X-11-136 (2011)

Reviewer's report
Title:Clinical benefit of gluten-free diet in screen-detected older celiac disease
patients
Version: 3Date:8 November 2011
Reviewer: Benjamin Lebwohl
Reviewer's report:
In this study, Vilppula and colleagues report on the effect of the gluten-free diet
(GFD) on older patients with screen-detected celiac disease (CD). The
investigators identfied 48 participants in the GOAL study who had an elevated
TTG antibody, comprising 1.7% of the GOAL cohort. 4 patients were already on
the GFD at the time of enrollment, 5 refused further workup of their positive TTG,
and 4 patients who underwent biopsy did not have villous atrophy, leaving 35
patients with newly-diagnosed screen-detected CD. 32 of the 35 agreed to
commence a GFD. The investigators found that, compared to controls, the
baseline GI symptom and psychological well-being score of CD patients was
similar, but that GI symptom scores improved while on the GFD. The
investigators also found that many of these screen-detected patients had a family
history of CD, a fracture history, or concomittant autoimmunity, suggesting that
case finding based on these criteria remains a viable strategy. Strengths of the
study include its nesting within a larger cohort (reducing the possibility of
selection bias), the use of validated symptom and well-being scores, the use of a
control group, and no loss to follow-up.
Overall this study adds to our knowledge regarding the utility of diagnosing CD in
older individuals.
Several suggestions:
There is very little discussion regarding how the 110 control subjects were
identified. Physicians offices? Another disease? Did they have a similar age and
gender distribution to the CD subjects? Were they part of the GOAL study?
The design of this study is similar to that of another study published by this group
(Ukkola, et al Clin Gastro Hepatol 2011), which evaluated symptoms and
well-being of newly-diagnosed CD patients, including screen-detected patients. It
is curious that this paper is not referenced and that the results of the current
study are not compared/contrasted to the previous study.
There is no discussion of limitations of this study. The authors should consider
mentioning limitations including: 1) a lack of laboratory values or bone density
measurement for the control group, precluding them from comparison for these
components of the study; and 2) questions of generalizability, as the availability
of gluten-free food in Finland is likely greater (and thus less likely to interfere with
quality of life) than in other European countries and the US.
Table 3: It appears that female CD patients have a decline in hemoglobin
(p=0.019) after starting the GFD. This is not pointed out or commented upon by
the authors.
Abstract: the improvement in GSRS is mentioned in the results section, but the
null PGWB finding is not mentioned-- as this was a major component of the
study, it should be included in the Abstract.
Discussion: The authors use the terms "elderly" and "older" interchangably, and
should probably minimize the use of the term "elderly" given many of the
referenced studies (and the present study) include patients in their 50's.
Discussion: The sentence "Mortality has not increased among elderly diagnosed
celiac disease patients," referencing Godfrey, et al. "elderly" should be changed
to "older" and (crucially) "diagnosed" should be changed to "undiagnosed."
Elsewhere in the Discussion "Godfrey" is misspelled.
Conclusion: would eliminate the clause "which would be enormously costly and
laborious"-- this study did not assess the cost of screening and so it would be
best to withhold judgment in this context.
Level of interest: An article of outstanding merit and interest in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests