Reviewer ’s report  
 
Title: Diagnosis of celiac disease and applicability of ESPGHAN guidelines in Mediterranean  
countries: a real life prospective study  
 
Versio n: 0 Date: 31 Jul 2016  
 
Reviewer: Kalle Kurppa  
 
Reviewer's  report:  
 
The Study by Smarazzo et al. investigated the applicability of ESPGHAN CD guidelines in 
Mediterranean countries. It is a very large and important study and might thus be accepted for 
publica tion. However, it needs major revision before that:  
 
 
 
Abstract (+Discussion):  
 
1. The main aim was to assess how the diagnosis of CD is made, and how the new 
ESPGHAN guidelines can be applied in different countries. However, in the Conclusions 
the authors co ncentrate in the use of EmA and HLA (or the possibility of their 
avoidance). This was not the aim of the study, and due to the heterogeneity of the study 
cohort, I think the authors make too strong conclusions. The same problem can be seen in 
the discussio n. The text should be revised regarding this issue.  
 
 
 
 
Background:  
 
1. The use of dashes before sentences in the text is very clumsy and should be avoided  
 
 
2. In the 2nd paragraph it is said that 2 prospective studies have been performed, but then 3 
studies ar e referred (10 -12), which is correct?  
 
 
 
Methods (+Discussion):  
 
In general, the Methods -section is too unclear and sketchy. The used methods and study design 
should be described much more detailed, including:  
 
 
1. What methods were used in HLA determination (different commercial test etc.?). Not all 
HLA tests have 100% accuracy.  
 
 
2. Which tTG assays were used in different countries? There are major differences between 
the tests that may for instance explain some o f the potential cases. It must be understand 
that the tTG test kinetics are different and that the 10x UNL is in fact not the same with 
all tTG tests (see the ESPGHAN criteria, appendix)  
 
 
3. Which EmA -tests were used, antigen?  
 
 
4. How many biopsies were take n in each center, were bulb biopsies taken, how the biopsies 
were handled (see e.g. Taavela et al. PLOS One 2013). This is a major issue here, since it 
is very likely that the potential cases with tTG value >10X ULN do not have false 
positive serology, but  instead false negative histology (patchy lesion or wrongly 
orientated or interpreted biopsy).  
 
All the previously mentioned issues should be clarified in the M&M. In addition, as they 
may have major impact to the results, they should be thoroughly discusse d with 
references in the Discussion.  
 
 
 
Results:  
 
1. The use of P values, percentages, number of decimals etc. is inconsistent thorough the 
results. In general, the results are quite difficult to read.  
 
 
2. Three cases were considered to have CD despite negativ e serology but "equal to or higher 
than Marsh 2". This is interesting, in my opinion a potential celiac disease patient with a 
tTG 10X ULN is much more certainly a CD patient than a seronegative case with a 
Marsh 2 lesion. Can the authors provide any refer ences to back up their conclusions? I 
think that even the definition of Marsh 2 is rather unclear, and mild mucosal atrophy can 
be associated with other diseases than CD (Giardia, AIE etc.).  
 
 
3. It is interesting that the authors define all subjects with ne gative serology and Marsh 0 -1 
as "UCD", so are all these cases really having possible celiac disease and should thus be 
followed? Are there no such cases as "No celiac disease"? In particular if they have 
negative DQ2 and DQ8 (63 cases)?  
 
 
4. I think the pre gnancy; birth weight; breastfeeding etc. are not the main aim of the present 
study and are just confusing here. Further, several confounding factors were not 
considered, such as parental education, the fact that CD patients were not screened etc. I 
would c ompletely omit these issues from the paper.  
 
 
 
Discussion:  
 
1. In general, the Discussion is not very well written. Apart of the above -mentioned issues, 
it is lacking several recent papers investigating the new ESPGHAN criteria in CD 
diagnosis. In my opinion , the discussion needs major revision.  
 
 
 
Are the methods appropriate and well described?  
If no t, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the co nclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistica l review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the  statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, fu nding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially fro m the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization th at 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above,  write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will b e included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as  confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title: Diagnosis of celiac disease and applicability of ESPGHAN guidelines in Mediterranean  
countries: a real life prospective study  
 
Versio n: 0 Date: 31 Jul 2016  
 
Reviewer: Kalle Kurppa  
 
Reviewer's  report:  
 
The Study by Smarazzo et al. investigated the applicability of ESPGHAN CD guidelines in 
Mediterranean countries. It is a very large and important study and might thus be accepted for 
publica tion. However, it needs major revision before that:  
 
 
 
Abstract (+Discussion):  
 
1. The main aim was to assess how the diagnosis of CD is made, and how the new 
ESPGHAN guidelines can be applied in different countries. However, in the Conclusions 
the authors co ncentrate in the use of EmA and HLA (or the possibility of their 
avoidance). This was not the aim of the study, and due to the heterogeneity of the study 
cohort, I think the authors make too strong conclusions. The same problem can be seen in 
the discussio n. The text should be revised regarding this issue.  
 
 
 
 
Background:  
 
1. The use of dashes before sentences in the text is very clumsy and should be avoided  
 
 
2. In the 2nd paragraph it is said that 2 prospective studies have been performed, but then 3 
studies ar e referred (10 -12), which is correct?  
 
 
 
Methods (+Discussion):  
 
In general, the Methods -section is too unclear and sketchy. The used methods and study design 
should be described much more detailed, including:  
 
 
1. What methods were used in HLA determination (different commercial test etc.?). Not all 
HLA tests have 100% accuracy.  
 
 
2. Which tTG assays were used in different countries? There are major differences between 
the tests that may for instance explain some o f the potential cases. It must be understand 
that the tTG test kinetics are different and that the 10x UNL is in fact not the same with 
all tTG tests (see the ESPGHAN criteria, appendix)  
 
 
3. Which EmA -tests were used, antigen?  
 
 
4. How many biopsies were take n in each center, were bulb biopsies taken, how the biopsies 
were handled (see e.g. Taavela et al. PLOS One 2013). This is a major issue here, since it 
is very likely that the potential cases with tTG value >10X ULN do not have false 
positive serology, but  instead false negative histology (patchy lesion or wrongly 
orientated or interpreted biopsy).  
 
All the previously mentioned issues should be clarified in the M&M. In addition, as they 
may have major impact to the results, they should be thoroughly discusse d with 
references in the Discussion.  
 
 
 
Results:  
 
1. The use of P values, percentages, number of decimals etc. is inconsistent thorough the 
results. In general, the results are quite difficult to read.  
 
 
2. Three cases were considered to have CD despite negativ e serology but "equal to or higher 
than Marsh 2". This is interesting, in my opinion a potential celiac disease patient with a 
tTG 10X ULN is much more certainly a CD patient than a seronegative case with a 
Marsh 2 lesion. Can the authors provide any refer ences to back up their conclusions? I 
think that even the definition of Marsh 2 is rather unclear, and mild mucosal atrophy can 
be associated with other diseases than CD (Giardia, AIE etc.).  
 
 
3. It is interesting that the authors define all subjects with ne gative serology and Marsh 0 -1 
as "UCD", so are all these cases really having possible celiac disease and should thus be 
followed? Are there no such cases as "No celiac disease"? In particular if they have 
negative DQ2 and DQ8 (63 cases)?  
 
 
4. I think the pre gnancy; birth weight; breastfeeding etc. are not the main aim of the present 
study and are just confusing here. Further, several confounding factors were not 
considered, such as parental education, the fact that CD patients were not screened etc. I 
would c ompletely omit these issues from the paper.  
 
 
 
Discussion:  
 
1. In general, the Discussion is not very well written. Apart of the above -mentioned issues, 
it is lacking several recent papers investigating the new ESPGHAN criteria in CD 
diagnosis. In my opinion , the discussion needs major revision.  
 
 
 
Are the methods appropriate and well described?  
If no t, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the co nclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistica l review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the  statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, fu nding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially fro m the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization th at 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above,  write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will b e included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as  confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title: Diagnosis of celiac disease and applicability of ESPGHAN guidelines in Mediterranean  
countries: a real life prospective study  
 
Versio n: 0 Date: 31 Jul 2016  
 
Reviewer: Kalle Kurppa  
 
Reviewer's  report:  
 
The Study by Smarazzo et al. investigated the applicability of ESPGHAN CD guidelines in 
Mediterranean countries. It is a very large and important study and might thus be accepted for 
publica tion. However, it needs major revision before that:  
 
 
 
Abstract (+Discussion):  
 
1. The main aim was to assess how the diagnosis of CD is made, and how the new 
ESPGHAN guidelines can be applied in different countries. However, in the Conclusions 
the authors co ncentrate in the use of EmA and HLA (or the possibility of their 
avoidance). This was not the aim of the study, and due to the heterogeneity of the study 
cohort, I think the authors make too strong conclusions. The same problem can be seen in 
the discussio n. The text should be revised regarding this issue.  
 
 
 
 
Background:  
 
1. The use of dashes before sentences in the text is very clumsy and should be avoided  
 
 
2. In the 2nd paragraph it is said that 2 prospective studies have been performed, but then 3 
studies ar e referred (10 -12), which is correct?  
 
 
 
Methods (+Discussion):  
 
In general, the Methods -section is too unclear and sketchy. The used methods and study design 
should be described much more detailed, including:  
 
 
1. What methods were used in HLA determination (different commercial test etc.?). Not all 
HLA tests have 100% accuracy.  
 
 
2. Which tTG assays were used in different countries? There are major differences between 
the tests that may for instance explain some o f the potential cases. It must be understand 
that the tTG test kinetics are different and that the 10x UNL is in fact not the same with 
all tTG tests (see the ESPGHAN criteria, appendix)  
 
 
3. Which EmA -tests were used, antigen?  
 
 
4. How many biopsies were take n in each center, were bulb biopsies taken, how the biopsies 
were handled (see e.g. Taavela et al. PLOS One 2013). This is a major issue here, since it 
is very likely that the potential cases with tTG value >10X ULN do not have false 
positive serology, but  instead false negative histology (patchy lesion or wrongly 
orientated or interpreted biopsy).  
 
All the previously mentioned issues should be clarified in the M&M. In addition, as they 
may have major impact to the results, they should be thoroughly discusse d with 
references in the Discussion.  
 
 
 
Results:  
 
1. The use of P values, percentages, number of decimals etc. is inconsistent thorough the 
results. In general, the results are quite difficult to read.  
 
 
2. Three cases were considered to have CD despite negativ e serology but "equal to or higher 
than Marsh 2". This is interesting, in my opinion a potential celiac disease patient with a 
tTG 10X ULN is much more certainly a CD patient than a seronegative case with a 
Marsh 2 lesion. Can the authors provide any refer ences to back up their conclusions? I 
think that even the definition of Marsh 2 is rather unclear, and mild mucosal atrophy can 
be associated with other diseases than CD (Giardia, AIE etc.).  
 
 
3. It is interesting that the authors define all subjects with ne gative serology and Marsh 0 -1 
as "UCD", so are all these cases really having possible celiac disease and should thus be 
followed? Are there no such cases as "No celiac disease"? In particular if they have 
negative DQ2 and DQ8 (63 cases)?  
 
 
4. I think the pre gnancy; birth weight; breastfeeding etc. are not the main aim of the present 
study and are just confusing here. Further, several confounding factors were not 
considered, such as parental education, the fact that CD patients were not screened etc. I 
would c ompletely omit these issues from the paper.  
 
 
 
Discussion:  
 
1. In general, the Discussion is not very well written. Apart of the above -mentioned issues, 
it is lacking several recent papers investigating the new ESPGHAN criteria in CD 
diagnosis. In my opinion , the discussion needs major revision.  
 
 
 
Are the methods appropriate and well described?  
If no t, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the co nclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistica l review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the  statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, fu nding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially fro m the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization th at 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above,  write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will b e included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as  confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant