Auteur Topic: An Expert Interview (met Dr. Murray van Mayo Clinic)  (gelezen 2270 keer)


  • Gold Member
  • *****
  • Berichten: 1157
An Expert Interview (met Dr. Murray van Mayo Clinic)
« Gepost op: februari 25, 2014, 21:37:37 »
Dr. Murray is verbonden aan de Mayo Clinic in Amerika en heeft veel artikelen over Coeliakie op zijn naam staan alsmede zijn er ook video's (uitleg etc.) te zien m.b.t. Coeliakie.

An  Expert Interview With Joseph A. Murray, MD
February 13, 2014

Which Guideline for Celiac Disease Is Best?
The Guidelines
Guidelines for the care of patients with suspected or known celiac disease are changing rapidly as new research leads to new understanding of the pathophysiology, assessment, and management of this increasingly common condition. Medscape spoke with Joseph A. Murray, MD, a member of several guideline panels and current President of the North American Society for the Study of Celiac Disease, about the current evidence underlying standards for care.

About the Interviewee
Dr. Murray is Professor of Medicine and Consultant in the Division of Gastroenterology and Hepatology and the Department of Immunology and Director of the Celiac Disease Program at the Mayo Clinic in Rochester, Minnesota.
Dr. Murray's research interests focus on celiac disease and esophageal disorders. A research program, sponsored by the National Institutes of Health and the Centers for Disease Control and Prevention, focuses on clinical epidemiology of celiac disease, the role of genetics in predicting disease, clinical trials, the development of animal models for the disease and its associated dermatologic condition, and dermatitis herpetiformis. These studies encompass complications of celiac disease including small bowel cancer and intersect with programs in the Mayo Comprehensive Clinical Cancer Center and the Clinical Research Unit and complement the celiac disease clinic activity.

Background to the Interview
Celiac disease is recognized to be an inflammatory disorder of the small intestine with an autoimmune component and strong heritability. Once viewed primarily as a disease of childhood, occurring mainly in white persons, it is now understood to occur in people of any age and in populations outside Europe and North America. Previously considered a rare disease, the prevalence of celiac disease is currently estimated at 1 in 100-300 in most parts of the world, [1] and the incidence and prevalence have been increasing markedly over the past few decades. [2-5]
It has also become clear that celiac disease is associated with many other nongastrointestinal signs and symptoms and strongly associated with autoimmune diseases such as type 1 diabetes.
As a result of advances in the understanding and diagnosis of celiac disease, major guidelines have been updated recently, including those issued by the American College of Gastroenterology (ACG), [6] European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN), [7] the British Society of Pediatric Gastroenterology, Hepatology, and Nutrition/Coeliac UK, [8] and the World Gastroenterology Organisation. [1] The US and European guidelines differ in their emphasis on the relative importance of serologic, genetic, and histologic testing in diagnosis, but all of the recommendations aim at achieving high diagnostic accuracy and improving rates of diagnosis.
The detection and management of celiac disease increasingly involve general practice. At the same time, diagnostic algorithms are becoming more complicated, requiring specialized knowledge apart from procedures and biopsies. [9]
To further assist primary care providers (PCPs), Dr. Murray spoke to Medscape about the guidance provided by the latest guidelines for diagnostic strategies in the primary care setting for patients with suspected celiac disease. Management after diagnosis, with particular attention to strategies used in primary care, was  
etc. etc.

The Interview -- Diagnosis
Medscape: With the increasing prevalence of celiac disease in Western countries, have you noticed increases in any particular subgroup, such as the young or elderly, or it is occurring in the broad population?
Dr. Murray: New-onset celiac disease is occurring at all ages, although the most dramatic increases are in older people, by which I mean those in their 40s and 50s and beyond. It is remarkable that those are people who have eaten gluten their entire lives without getting celiac disease. A Finnish study in subjects over the age of 50 years showed that there was substantial occurrence of celiac disease in people who previously tested negative, [12] suggesting that you can get celiac disease at any age, even a relatively advanced age, despite a lifetime's exposure to gluten. I think that observation and another study from Maryland, [13] almost more than anything else, have to change our approach to celiac disease in general. That is why there is the current profusion of guidelines and an effort to make PCPs understand that celiac disease is a condition they really have to be aware of now. Twenty years ago, it was usual to regard celiac as a rare condition, and we could wait until someone demonstrated severe malabsorptive disease in childhood before considering the possibility of celiac disease. Now we can no longer ignore it; it is becoming much  
etc. etc.

Diagnostic Confirmation
Medscape: How should the PCP usually proceed to confirm a diagnosis?
Dr. Murray: Detection is only the first stage in diagnosis. A single immunoglobulin A (IgA) anti-tissue transglutaminase (TTG) antibody test is probably the single most accurate detection test. When you get a positive result for a test, how you respond is very important because that single positive does not mean that your patient has the disease. It means that the patient has a much higher probability of having the disease; a single serologic test result does not constitute a diagnosis. You have done the first step, and that may be all you need to do as a PCP. Next, refer the patient to a specialist who can confirm the diagnosis. In the United States, you usually refer to a gastroenterologist. In the United Kingdom, it may be referral to a local celiac clinic, depending on available resources.
An important issue for every practitioner who uses these types of blood tests is not to be a slave to a threshold. We have cut-offs. Let us say the cut-off is 10; if the result is 10.1, we call that positive; and if it is 9.9, we call that negative. But in truth, when you compare them in the laboratory, they are indistinguishable. So I think we have to be cognizant that somebody whose test result is quite close to the negative threshold is less likely to have the disease, but somebody who is at the very top end of the negative threshold but not quite positive, in the right circumstances, might actually have the disease. There are some intercontinental differences in how testing is used. There is a different philosophy about how blood tests are expected to perform outside the United States. In Ireland, where I have worked, blood tests have generally been used with the goal of maximizing sensitivity, not wanting to miss people with the disease. When you increase the sensitivity, you accept some loss of specificity because you know you can send the patient for confirmation, and the patients do not usually pay out of pocket for their confirmation tests. In the United States, on the other hand, there is an expectation of higher specificity, maybe even at the expense of some sensitivity. You want to emphasize specificity because you know that doctors and patients are going to place more reliance on positive tests, and patients may not go on to get further testing because of the personal financial cost.  
etc. etc.

The Interview -- Management
Medscape: Life-long adherence to a gluten-free diet is the only option for patients with confirmed celiac disease, but what about follow-up after they have started on the diet? You and your colleagues have reported a study in which the quality of follow-up of celiac patients was found to be poor. [19]
Dr. Murray: There was poor follow-up, at least in that particular community (Olmsted County, Minnesota), but I don't think that is anything unusual. That is a community with one of the highest concentrations of doctors in the world, but we are not doing a very good job of following up with patients with celiac disease.
Medscape: The ACG guideline makes the point that a dietitian is effective in follow-up. In the United Kingdom, patients have been reported as preferring to consult a dietitian, only seeing a physician when necessary. [20] What do you think the role of a dietitian should be in follow-up?
Dr. Murray: Dietitians have a role beyond simply enabling and verifying adherence to a gluten-free diet. An important point for management that I think we now need in 2014 is to emphasize that just because something is gluten-free doesn't mean it is healthy. If it is full of fat and sugar, whether it is gluten-free or not, it is    
etc. etc.