ObjectiveEuropean Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines on coeliac disease (CD) recommend that children who have IgA-based antitissue transglutaminase (TGA-IgA) titre ≥10× upper limit of normal (ULN) and positive antiendomysial antibody, can be reliably diagnosed with CD via the no-biopsy pathway. The aim of this study was to examine the relationship between TGA-IgA ≥5×ULN and histologically confirmed diagnosis of CD.MethodsData including TGA-IgA levels at upper gastrointestinal endoscopy and histological findings from children diagnosed with CD following endoscopy from 2006 to 2021 were analysed. CD was confirmed by Marsh-Oberhuber histological grading 2 to 3 c. Statistical analysis was performed using χ² analysis (p<0.05= significant).Results722 of 758 children had histological confirmation of CD. 457 children had TGA-IgA ≥5×ULN and 455 (99.5%) of these had histological confirmation for CD; the two that did not had eventual diagnosis of CD based on clinicopathological features. 114 of 457 had between TGA-IgA ≥5×ULN and <10×ULN, all had confirmed CD. The likelihood of a positive biopsy with TGA-IgA ≥5×ULN (455/457) compared with TGA-IgA <5×ULN (267/301) has strong statistical significance (p<0.00001). The optimal TGA-IgA cut-off from receiver operating characteristic curve analysis was determined to be below 5×ULN for the two assays used.Conclusion99.5% of children with TGA-IgA ≥5×ULN had histological confirmation of CD, suggesting that CD diagnosis can be made securely in children with TGA-IgA ≥5×ULN. If other studies confirm this finding, there is a case to be made to modify the ESPGHAN guidelines to a lower threshold of TGA-IgA for serological diagnosis of CD.
patients (41/313) had a vitamin D level <25nmol/L (deemed deficient as per NICE guidelines).We reviewed 184 patients in-person/over the telephone in a 4 month period during the COVID pandemic and asked about their current supplementation. 49.45% (91/184) of patients reviewed reported taking 400 international units (IU) daily with 26% (48/184) taking >400IU daily. 12.5% (23/184) of these patients reviewed had a vitamin D level <25nmol/L. In those with a level <25nmol/L, 30.43% (7/23) were taking 400IU, 26% (6/23) were taking >400IU daily and 34.78% (8/ 23) were on no supplements at all. The average age was much higher at 16.86 years in this group compared to the overall average age of 12.34 years. Conclusions In our audit we established that 56.52% (13/23) patients reviewed in-person or over the telephone who were Vitamin D deficient as per the NICE definition (<25nmol/ L), were taking at least 400IU of Vitamin D daily (the recommended dose for children at increased risk of Vitamin D deficiency). This highlights the need for further studies and clearer international guidance re. prevention of and management of Vitamin D deficiency in these high risk SCD patients. The Sickle Cell Society and Public Health England (2019) guidelines recommend that Vitamin D deficiency be identified and treated according to local guidelines in all SCD patients. Those identified as Vitamin D deficient during the audit process were prescribed a higher dose of Vitamin D where possible with regular input from our hospital pharmacy team. We continued our policy of aiming to check Vitamin D levels twice per year with increased frequency of checks for those who required high dose Vitamin D treatment. Given the above findings, a plan was placed to make a more concerted effort to continuously ask patients re. vitamin D supplements during clinic and hospital visits.
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