Review for 10.1186/1471-230X-12-136 (2012)

Reviewer's report
Title:Use of health care services and pharmaceutical agents in coeliac disease:
a prospective nationwide study
Version: 1Date:30 April 2012
Reviewer: Umberto UV Volta
Reviewer's report:
The present paper deals with a relevant topic in coeliac disease (CD)
represented by the use of health care services and pharmaceutical agents in
untreated and treated gluten sensitive enteropathy (one year prior to the
diagnosis and after the initiation of gluten-free diet). Unrecognized CD was
associated with an increased health care service use and consumption of drugs,
whereas dietary treatment resulted in a diminished burden to health care system
and a lower use of drugs.
The goal posed by the Authors is well defined and methods are appropriate and
well described. Results are convincing with an appropriate discussion and valid
conclusions in line with the data produced in the manuscript. References are
complete and previous studies on this topic are thoroughly discussed in the text.
The title and abstract of the paper express clearly what has been found and the
paper has been written very well.
I have no major remarks, but only some suggestions in order to clarify some
points and to improve the clinical message of the manuscript.
1) In the Discussion Section the Authors should underline that the decreased use
of health care services and pharmaceutical agents determined by the discovery
and dietary treatment of CD results in a decrease of costs for public heath care
system. Even though it is not the goal of the paper, the Authors should stress
that the cost/benefit ratio for CD diagnosis is largely advantageous (add
reference Greco L, World Journal of Gastroenterology 2011) since costs for
diagnosis are limited (serology and duodenal biopsy) and benefits allowing to
save money (see advantages demonstrated in this paper) are largely superior.
Also from a ethical point of view, it should be mentioned how many unuseful
invasive procedures (bone biopsy for unexplained anaemia, colonoscopy for
abdominal pain, computed tomography for suspected inexistent neoplasms) are
performed in these patients before they are recognized as coeliacs. And it should
not be forgotten the unuseful blood transfusions performed (luckily very rare at
present) in many cases of severe iron deficiency anaemia caused by iron
malabsorption at duodenal level.
2) Discussion, page 11, 2nd paragraph: I suggest to add to the text that the
impaired helath-quality of life of CD patients irrespective of a strict gluten-free
diet due to frequent gastrointestinal complaints can be explained by the frequent
coexistence of irritable bowel syndrome and reflux esophagitis (add reference
Kurien M, APT 2011).
3) Discussion, page 12, 3rd paragraph: I agree that the use of vitamins,
micronutrients and mineral salts increases significantly in CD patients after the
diagnosis, but very often this is the result of a medical prescription: The Authors
should mention that gluten-free commercial products do not contain vitamins,
micronutrients and mineral salts, so the use of these products can cause a
deficiency of these elements and very often the CD specialists must prescribe
this treatment (add one or more references about the low content of vitamins and
mineral salts of commercial gluten-free products).
Umberto Volta
Director of Coeliac Disease Unit
St. Orsola-Malpighi Hospital
University of Bologna
President of the Scientific Board of
Coeliac Disease Italian Association
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I have no competing interests.
Umberto Volta