Reviewer's report
Title:Successful modified dietary treatment of non-responsive celiac disease:
Not all resistance to a strict gluten-free diet is refractory sprue.
Version: 3Date:3 January 2013
Reviewer: PAOLA IOVINO
Reviewer's report:
Summary
This is a retrospective study. From 2005 through 2011, a total of 29 patients all
gluten free diet-adherent non-responsive celiac disease (NRCD patients) who
attended the University of Maryland Center for Celiac Research in Baltimore
were instructed on the Gluten Contamination Elimination Diet (GCED) i.e. a 3-6
month diet of whole, unprocessed foods. Of the 17 compliant patients, 82%
responded to the GCED and 79% successfully returned to a traditional gluten
free diet (GFD) without resurgence of symptoms.
The Authors concluded that the GCED is an effective therapeutic option for
GFD-adherent NRCD patients. Furthermore, this diet can prevent an inaccurate
diagnosis of refractory celiac disease (RCD1) and avoid immunotherapy.
I have the following comments:
This is an interesting study because it gives another therapeutic option for
GFD-adherent NRCD patients and, moreover identifies a subgroup of patients,
previously classified as RCD1, that is not truly refractory to dietary treatment.
I have some concerns about the methodological approach.
Firstly, the retrospective design represents the main limitation because it reduces
the accuracy of information that prospective investigations permit to obtain.
Secondly, the detailed description of all symptoms referred for a clear definition
of symptom resolution should be mandatory. In fact, NRCD is defined as failure
of symptomatic or histological improvement with a presumed GFD. Then, the
Authors stated that EGDS with biopsies should be performed as the first
investigation in GFD adherent NRCD patients to differentiate those with celiac
enteropathy, and therefore possibly RCD, from those without persistent mucosal
disease. But, in this study the data collected are few because only 5 patients
being biopsied after completing the GCED.
Lastly, I found very intriguing the belief that the majority of such patients are
continuing to react to miniscule amounts of gluten cross-contamination, however
I have a concern about the lack of a systematic approach to diagnose GFD
adherent NRCD patients as recently described (Mooney PD et al J Gastrointestin
Liver Dis 2012, 2(2):197-203) and, also about the influence of other dietary
compounds (for example the quality and the quantity of grains, the fruits and
vegetable, the dairy products) on symptoms resolution.
Further studies especially multicenter studies that allow to include a larger
number of GFD adherent NRCD patients should be performed.
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:
no competing interests
Reviewer's report
Title:Successful modified dietary treatment of non-responsive celiac disease:
Not all resistance to a strict gluten-free diet is refractory sprue.
Version: 3Date:3 January 2013
Reviewer: PAOLA IOVINO
Reviewer's report:
Summary
This is a retrospective study. From 2005 through 2011, a total of 29 patients all
gluten free diet-adherent non-responsive celiac disease (NRCD patients) who
attended the University of Maryland Center for Celiac Research in Baltimore
were instructed on the Gluten Contamination Elimination Diet (GCED) i.e. a 3-6
month diet of whole, unprocessed foods. Of the 17 compliant patients, 82%
responded to the GCED and 79% successfully returned to a traditional gluten
free diet (GFD) without resurgence of symptoms.
The Authors concluded that the GCED is an effective therapeutic option for
GFD-adherent NRCD patients. Furthermore, this diet can prevent an inaccurate
diagnosis of refractory celiac disease (RCD1) and avoid immunotherapy.
I have the following comments:
This is an interesting study because it gives another therapeutic option for
GFD-adherent NRCD patients and, moreover identifies a subgroup of patients,
previously classified as RCD1, that is not truly refractory to dietary treatment.
I have some concerns about the methodological approach.
Firstly, the retrospective design represents the main limitation because it reduces
the accuracy of information that prospective investigations permit to obtain.
Secondly, the detailed description of all symptoms referred for a clear definition
of symptom resolution should be mandatory. In fact, NRCD is defined as failure
of symptomatic or histological improvement with a presumed GFD. Then, the
Authors stated that EGDS with biopsies should be performed as the first
investigation in GFD adherent NRCD patients to differentiate those with celiac
enteropathy, and therefore possibly RCD, from those without persistent mucosal
disease. But, in this study the data collected are few because only 5 patients
being biopsied after completing the GCED.
Lastly, I found very intriguing the belief that the majority of such patients are
continuing to react to miniscule amounts of gluten cross-contamination, however
I have a concern about the lack of a systematic approach to diagnose GFD
adherent NRCD patients as recently described (Mooney PD et al J Gastrointestin
Liver Dis 2012, 2(2):197-203) and, also about the influence of other dietary
compounds (for example the quality and the quantity of grains, the fruits and
vegetable, the dairy products) on symptoms resolution.
Further studies especially multicenter studies that allow to include a larger
number of GFD adherent NRCD patients should be performed.
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:
no competing interests
Please review this paper.
user
Reviewer's report
Title:Successful modified dietary treatment of non-responsive celiac disease:
Not all resistance to a strict gluten-free diet is refractory sprue.
Version: 3Date:3 January 2013
Reviewer: PAOLA IOVINO
Reviewer's report:
Summary
This is a retrospective study. From 2005 through 2011, a total of 29 patients all
gluten free diet-adherent non-responsive celiac disease (NRCD patients) who
attended the University of Maryland Center for Celiac Research in Baltimore
were instructed on the Gluten Contamination Elimination Diet (GCED) i.e. a 3-6
month diet of whole, unprocessed foods. Of the 17 compliant patients, 82%
responded to the GCED and 79% successfully returned to a traditional gluten
free diet (GFD) without resurgence of symptoms.
The Authors concluded that the GCED is an effective therapeutic option for
GFD-adherent NRCD patients. Furthermore, this diet can prevent an inaccurate
diagnosis of refractory celiac disease (RCD1) and avoid immunotherapy.
I have the following comments:
This is an interesting study because it gives another therapeutic option for
GFD-adherent NRCD patients and, moreover identifies a subgroup of patients,
previously classified as RCD1, that is not truly refractory to dietary treatment.
I have some concerns about the methodological approach.
Firstly, the retrospective design represents the main limitation because it reduces
the accuracy of information that prospective investigations permit to obtain.
Secondly, the detailed description of all symptoms referred for a clear definition
of symptom resolution should be mandatory. In fact, NRCD is defined as failure
of symptomatic or histological improvement with a presumed GFD. Then, the
Authors stated that EGDS with biopsies should be performed as the first
investigation in GFD adherent NRCD patients to differentiate those with celiac
enteropathy, and therefore possibly RCD, from those without persistent mucosal
disease. But, in this study the data collected are few because only 5 patients
being biopsied after completing the GCED.
Lastly, I found very intriguing the belief that the majority of such patients are
continuing to react to miniscule amounts of gluten cross-contamination, however
I have a concern about the lack of a systematic approach to diagnose GFD
adherent NRCD patients as recently described (Mooney PD et al J Gastrointestin
Liver Dis 2012, 2(2):197-203) and, also about the influence of other dietary
compounds (for example the quality and the quantity of grains, the fruits and
vegetable, the dairy products) on symptoms resolution.
Further studies especially multicenter studies that allow to include a larger
number of GFD adherent NRCD patients should be performed.
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:
no competing interests
assistant