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:15 January 2013
Reviewer: Geoffrey Holmes
Reviewer's report:
Patients with non-responsive coeliac disease (NRCD) present a challenge to
carers. The commonest cause is the ingestion of gluten either accidentally or by
design. In some co-morbidity is responsible. The remainder have been labelled
refractory coeliac (RCD). This group can be sudivided into RCD I and II
depending on the clonality of intraepithelial lymphocytes. Those with RCD I have
a good prognosis and I behave little differently from other coeliacs while those
with RCD II have a poor prognosis with a propensity to develop lymphoma.
The authors, in this interesting paper, address the question whether those
labelled RCD I who are are taking a gluten free diet (GFD) remain unwell
because they are in fact ingesting small amount of gluten in a conventional GFD
so are not suffering from RCD 1 at all. This turns out to be true for some cases of
NRCD and RCD1 because when given a gluten contamination elimination diet
(GCED) they get better and once over the hill some could return to a GFD.
I have suspected that those with RCD I might be very sensitive to gluten and so
are ill and this paper documents evidence for this. It will be of value to those
managing CD
Abstract. Fine
Backgound. This is a good summary.
Minor essential revisions
1. In the second paragraph conventional histology does not really separate RCD
I and II and it would be better to mention immunological techiques that are in use.
2. In this section I would add somewhere that elimination of co-morbidities in
those with NRCD is necessary before a diagnosis of RCD can be given. The
legend of Fig 1 aludes to this.
Methods
Minor esential revisions
1. The authors define RCD as persistent or relapse of symptoms and villous
atrophy. They have not used other lab tests as far as I can see so in the second
paragraph the sentence beginning, If polymerase chain reaction .... is out of
place. This is more of a comment.
Results
These are well laid out in text and tables.
Minor essenatial revisions
1. At the beginning of the Histology section villous blunting is an odd description.
Marsh 3 is more than blunting. Atrophy would be a better term and this also
applies to the 4th paragraph of the Discussion.
Discussion
This is well laid out.
Table 3. RCD1 is mentioned in the legend but in the body of the Table is only
RCD.
On my copy the Table headings were out of alignment.
Satisfactory reference list
Did the authors ancounter any patients with RCD II?
Have the authors considered that those who did not respond might have had
other food intolerances such as eggs and soy protein, elimination of which can
improve the symptoms of some CD patients?
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have 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:15 January 2013
Reviewer: Geoffrey Holmes
Reviewer's report:
Patients with non-responsive coeliac disease (NRCD) present a challenge to
carers. The commonest cause is the ingestion of gluten either accidentally or by
design. In some co-morbidity is responsible. The remainder have been labelled
refractory coeliac (RCD). This group can be sudivided into RCD I and II
depending on the clonality of intraepithelial lymphocytes. Those with RCD I have
a good prognosis and I behave little differently from other coeliacs while those
with RCD II have a poor prognosis with a propensity to develop lymphoma.
The authors, in this interesting paper, address the question whether those
labelled RCD I who are are taking a gluten free diet (GFD) remain unwell
because they are in fact ingesting small amount of gluten in a conventional GFD
so are not suffering from RCD 1 at all. This turns out to be true for some cases of
NRCD and RCD1 because when given a gluten contamination elimination diet
(GCED) they get better and once over the hill some could return to a GFD.
I have suspected that those with RCD I might be very sensitive to gluten and so
are ill and this paper documents evidence for this. It will be of value to those
managing CD
Abstract. Fine
Backgound. This is a good summary.
Minor essential revisions
1. In the second paragraph conventional histology does not really separate RCD
I and II and it would be better to mention immunological techiques that are in use.
2. In this section I would add somewhere that elimination of co-morbidities in
those with NRCD is necessary before a diagnosis of RCD can be given. The
legend of Fig 1 aludes to this.
Methods
Minor esential revisions
1. The authors define RCD as persistent or relapse of symptoms and villous
atrophy. They have not used other lab tests as far as I can see so in the second
paragraph the sentence beginning, If polymerase chain reaction .... is out of
place. This is more of a comment.
Results
These are well laid out in text and tables.
Minor essenatial revisions
1. At the beginning of the Histology section villous blunting is an odd description.
Marsh 3 is more than blunting. Atrophy would be a better term and this also
applies to the 4th paragraph of the Discussion.
Discussion
This is well laid out.
Table 3. RCD1 is mentioned in the legend but in the body of the Table is only
RCD.
On my copy the Table headings were out of alignment.
Satisfactory reference list
Did the authors ancounter any patients with RCD II?
Have the authors considered that those who did not respond might have had
other food intolerances such as eggs and soy protein, elimination of which can
improve the symptoms of some CD patients?
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have 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:15 January 2013
Reviewer: Geoffrey Holmes
Reviewer's report:
Patients with non-responsive coeliac disease (NRCD) present a challenge to
carers. The commonest cause is the ingestion of gluten either accidentally or by
design. In some co-morbidity is responsible. The remainder have been labelled
refractory coeliac (RCD). This group can be sudivided into RCD I and II
depending on the clonality of intraepithelial lymphocytes. Those with RCD I have
a good prognosis and I behave little differently from other coeliacs while those
with RCD II have a poor prognosis with a propensity to develop lymphoma.
The authors, in this interesting paper, address the question whether those
labelled RCD I who are are taking a gluten free diet (GFD) remain unwell
because they are in fact ingesting small amount of gluten in a conventional GFD
so are not suffering from RCD 1 at all. This turns out to be true for some cases of
NRCD and RCD1 because when given a gluten contamination elimination diet
(GCED) they get better and once over the hill some could return to a GFD.
I have suspected that those with RCD I might be very sensitive to gluten and so
are ill and this paper documents evidence for this. It will be of value to those
managing CD
Abstract. Fine
Backgound. This is a good summary.
Minor essential revisions
1. In the second paragraph conventional histology does not really separate RCD
I and II and it would be better to mention immunological techiques that are in use.
2. In this section I would add somewhere that elimination of co-morbidities in
those with NRCD is necessary before a diagnosis of RCD can be given. The
legend of Fig 1 aludes to this.
Methods
Minor esential revisions
1. The authors define RCD as persistent or relapse of symptoms and villous
atrophy. They have not used other lab tests as far as I can see so in the second
paragraph the sentence beginning, If polymerase chain reaction .... is out of
place. This is more of a comment.
Results
These are well laid out in text and tables.
Minor essenatial revisions
1. At the beginning of the Histology section villous blunting is an odd description.
Marsh 3 is more than blunting. Atrophy would be a better term and this also
applies to the 4th paragraph of the Discussion.
Discussion
This is well laid out.
Table 3. RCD1 is mentioned in the legend but in the body of the Table is only
RCD.
On my copy the Table headings were out of alignment.
Satisfactory reference list
Did the authors ancounter any patients with RCD II?
Have the authors considered that those who did not respond might have had
other food intolerances such as eggs and soy protein, elimination of which can
improve the symptoms of some CD patients?
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests
assistant