Recent reductions in healthcare funding in the United States has pressured clinical laboratories to provide the same quality of diagnostic testing with fewer resources. Testing cascades have been developed to assist in the diagnosis of various illnesses, which use fewer tests and subsequently reduce costs. However, the cost effectiveness of a celiac disease (CD) testing cascade compared to a panel is currently unknown. Therefore, the purpose of this study was to determine if a CD testing cascade was equivalent to a panel in identifying patients deemed likely for CD, and to compare their cost effectiveness in a sample of symptomatic patients from Northeast Tennessee. A retrospective analysis using a CD testing cascade was performed on 933 outpatient samples referred to our laboratory from 2012 to 2017 with a request for a celiac disease serology panel. The seroprevalence of CD for the panel and the cascade were the same in this population (1.82%, 95% binomial confidence interval: 1.06% to 2.90%). The total cost of the CD cascade was 268% less than the cost of the panel resulting in a savings of $44,705, which translates to a savings of $47.92/patient. Based on these findings, we recommend utilization of the cascade to identify patients with likely CD. In the future, creative use of novel testing strategies can have significant contributions to healthcare reform and afford patients more cost-effective clinical diagnostic testing.

Health Tech company Dynamic Code AB provides a PCR test for determination of HLA DQ-genes connected to development of celiac disease. The PCR method is probe based and in real time and is at this time carried through on the, somewhat outdated, PCR instrument from Thermo Fisher/Applied Biosystems called 7300 Real-Time PCR System. The run time for this analysis on the instrument is 1 hour and 50 minutes. The Master Mix in use is TaqMan™ Gene Expression Master Mix, from the same manufacturer. Moving on to a more modern PCR instrument is a natural step for the company and is favourable in several regards, one of them being the run time that will be cut by 50 minutes, allowing for more samples to be analysed in the same amount of time. The objective is to move the HLA analysis to Thermo Fisher’s QuantStudio™ 6 and 7 Flex Systems and at the same time change the Master Mix to SolisFast® Probe qPCR Mix (Purple) from Solis BioDyne, in order to achieve better accuracy as this Master Mix is more compatible with the latter instrument, along with reducing reagent cost as it is less expensive. In order to find the optimal primer and probe concentration for each target included in the HLA analysis, their concentrations were varied and tested with the new Master Mix on the new instrument. PCR instrument transfer and Master Mix change was successful and validation experiments showed a 98,9% accuracy for the new method compared to the original method.

Celiac disease, a common autoimmune disease, affects ~1% of Americans. Treatment requires strict elimination of gluten, proteins found in wheat, rye, and barley. Individuals with celiac disease have been shown to have a lower quality of life than others without it. However, their quality of life has been known to improve with adherence to the gluten-free diet. Other than gluten-free diet adherence, little research has been completed on how specific eating patterns may impact the lives of individuals with celiac disease. In the general population, diet quality has been associated with health-related quality of life, where quality of life has been predictive of other outcomes, like mortality. Research in the general population has also shown an association between increased consumption of ultra-processed foods and adverse health outcomes, including obesity, cancer, and premature mortality, but none have explored its relation to quality of life. Among individuals with celiac disease, no studies have explored the relationship between diet quality or ultra-processing resulting from strictly adhering to a gluten-free diet and celiac disease-specific quality of life. This dissertation describes the eating patterns of a sample of 50 adults and 30 teens with celiac disease (the “sample”) to understand what they were eating, as well as the relationship between their diet quality and level of food processing to quality of life. Results were compared to a representative sampling of the population in the United States from the National Health and Nutrition Examination Survey (“NHANES”). The sample had room for improvement in their diet quality and levels of ultra-processing but performed favorably compared with NHANES. Using the Healthy Eating Index, the majority had scores considered suboptimal (mostly moderate scoring). However, using the Alternate Mediterranean Diet score, fewer had suboptimal scores (mostly moderate to high scoring). Differences between the measures’ scores reflected: (1) variations in measurement criteria, and (2) separate weights applied to those criteria. The sample had ultra-processed food consumption within the range associated with adverse health outcomes in some studies. With the exception of low folate and high lipids, most of the sample’s nutrient concerns reflected those in NHANES. The sample’s diet patterns were most similar to those in NHANES who had reported prior celiac disease diagnosis and were adhering to a gluten-free diet, with patterns significantly more favorable to other NHANES groups. In the general population, there was a consistent relationship with both higher Alternate Mediterranean Diet score and lower levels of ultra-processed food consumption as a percent of energy to better quality of life. Similar but less robust trends were found with the sample. Overall, results suggested that both higher adherence to healthier diet patterns (for example, more produce, legumes, nuts, whole grains, and less saturated fat) and lower levels of ultra-processing were associated with higher quality of life.

The aim of thesis was monitoring of changes in the content of gluten proteins in the biotechnological process of beer production. During the production process of wheat and barley beer, the samples were collected and analysed using the electrophoresis and immunoassay method. The results of the analyses were compared with commercial Czech beers. The theoretical part contains description and composition of gluten proteins, malt and beer technology, the changes that occur in this process, and methods of gluten proteins analysis. The experimental part contains procedures for laboratory production of barley and wheat beer and analyses of gluten proteins. To identify the individual gluteal protein fraction acid and SDS electrophoresis methods were used. For quantification, enzyme immunoassay was used and evaluated spectrophotometrically. The identification of the gluten‘s fractions by electrophoretic methods has been shown to be less specific for samples with lower content of gluten proteins and for barley specimens. A decrease in the concentration of gliadins and glutenins in the beer production process was demonstrated. A significant change was found during wort production with 98% decrease of gluten content compared to the feedstock and during the fermentation, when the gluten concentration dropped below 10 mg/kg. This value is acceptable from the legislation for products labelled „gluten-free“.

Zöliakie ist durch eine dysregulierte Immunreaktion auf die in Getreiden enthaltene Proteinfraktion Gluten charakterisiert. Die Assoziation der Erkrankung mit Polymorphismen in immunregulatorischen Genen weist auf eine Rolle von regulatorischen T-Zellen im Krankheitsgeschehen hin. Foxp3+ regulatorische T-Zellen haben eine essentielle Bedeutung für die Aufrechterhaltung der intestinalen Immunhomöostase und die Limitierung von Autoimmunität. In der vorliegenden Arbeit wurde eine 2005 bis 2010 diagnostizierte Gruppe von 51 Kindern und Jugendlichen mit Zöliakie untersucht. Diese Gruppe wurde mit 51 geschlechts- und altersadaptierten Kontrollen ohne Zöliakie verglichen. Es wurden anamnestische, paraklinische und histologische Daten mit der Verteilung von CD3+Foxp3+ regulatorischen T-Zellen in der Dünndarmschleimhaut untersucht. Patienten mit Zöliakie wiesen eine leichte Anämie, jedoch keine signifikante Wachstums- und Gewichtsentwicklung auf, was die oligosymptomatische Verlaufsform in der Gesamtkohorte unterstreicht. Es konnte gezeigt werden, dass CD3+Foxp3+ regulatorische T-Zellen bei Zöliakie-Patienten vermehrt in der Dünndarmschleimhaut akkumulieren. Weiterhin korreliert die Häufigkeit CD3+Foxp3+ regulatorischer T-Zellen sowohl mit dem Schweregrad der Schleimhaut-schädigung (gemessen an der Marsh-Oberhuber-Klassifikation, dem Zotten-Krypten Verhältnis oder der Zahl der intraepithelialen Lymphozyten) als auch mit den Titern Zöliakie-spezifischer Antikörper. Die Akkumulation CD3+Foxp3+ regulatorischer T Zellen lässt sich partiell als Folge einer Anreicherung von CD4+ T-Zellen auf Kosten CD8+ T-Zellen erklären. Die Daten weisen darauf hin, dass Foxp3+ regulatorische T Zellen sekundär als Folge des gluteninduzierten Entzündungsprozesses in der Schleimhaut akkumulieren, diesen offensichtlich aber nicht effektiv begrenzen. Die mögliche Assoziation der Immundysregulation der Zöliakie mit Foxp3+ regulatorischen T-Zellen ist damit nicht durch eine numerische Reduktion sondern wahrscheinlich durch partielle funktionelle Defekte bedingt.:Bibliographische Beschreibung 2 Inhaltsverzeichnis 3 Abkürzungsverzeichnis 5 1. Einleitung 6 1.1 Zöliakie 6 1.1.1 Epidemiologie 6 1.1.2 Äthiopathogenese 6 1.1.3 Diagnostik 10 1.1.4 Therapie 11 1.2 Regulatorische T-Zellen 12 1.2.1 Typen regulatorischer T-Zellen 13 1.2.2 Suppressionsmechanismen von CD4+CD25+Foxp3+ regulatorischen T-Zellen 14 1.3 Zielstellung der Arbeit 17 2. Material und Methoden 19 2.1 Ethikvotum 19 2.2 Ablauf der Studie 19 2.3 Rekrutierung der Studienpopulation 20 2.3.1 Gruppe der Zöliakie-Patienten 22 2.3.2 Kontrollgruppe 22 2.4 Telefoninterview – Erfassung anamnestischer Daten 23 2.5 Anthropometrische Daten 23 2.6 Klinische Chemie 24 2.7 Zöliakie - spezifische Antikörper 24 2.8 Färbungen der histologischen Schnitte 25 2.8.1 Vorbereitung der Gewebeproben 25 2.8.2 Hämatoxylin-Eosin (HE)-Färbung 25 2.8.3 Immunhistochemische Färbungen 26 2.8.4 Immunfluoreszenzfärbungen 27 2.8.5 Mikroskopie und Fotographie 28 2.9 Morphometrische Messung der histologischen Schnitte 28 2.9.1 Zotten- und Kryptenmessung 28 2.9.2 Bestimmung der Anzahl intraepithelialer Lymphozyten 29 2.9.3 Ermittlung von Zelldichten 29 2.10 Statistische Auswertung 30 3. Ergebnisse 31 3.1 Charakterisierung der Studienpopulation 31 3.1.1 Der Schweregrad der Schleimhautschädigung korreliert mit dem Geschlecht 31 3.1.2 Die Einführung glutenhaltiger Nahrung erfolgt bei Kindern mit Zöliakie früher 32 3.1.3 Keine Unterschiede in Körpergröße und Körpergewicht zwischen den Studiengruppen 36 3.1.4 Klinische Chemie - Leichte Anämie bei Kindern und Jugendlichen mit Zöliakie 39 3.1.5 Serologische Charakterisierung der Studienpopulation 41 3.2 Histologische Charakterisierung der Dünndarmschleimhaut 42 3.2.1 Das Zotten-Kryptenverhältnis sinkt mit zunehmendem Marsh-Stadium 42 3.2.2 Zunahme von intraepithelialen Lymphozyten bei Patienten mit Zöliakie 44 3.2.3 Erhöhte Infiltrationsdichte in der Lamina propria von Zöliakie-Patienten 46 3.3 Die Anzahl von CD3+Foxp3+ T-Zellen ist in der Dünndarmschleimhaut von Zöliakie- Patienten erhöht 48 3.4. Erhöhte CD4/CD8-Ratio in der Dünndarmschleimhaut von Zöliakie-Patienten 50 3.5 Dichte von regulatorischen Foxp3+ T-Zellen korreliert mit histologischen, hämatologischen und serologischen Parametern 52 4. Diskussion 56 4.1 Zöliakie – Umweltfaktoren und Immunregulation 56 4.2 Rolle von Foxp3+ T-Zellen bei Zöliakie 58 4.3 Immungenetik bei Zöliakie 63 4.4 Stärken und Schwächen der Studie 68 5. Zusammenfassung 69 Literaturverzeichnis 71 Appendix 84 Lebenslauf 85 Persönliche Daten 85 Danksagung 86 Erklärung über die eigenständige Abfassung der Arbeit 88

Celiac disease is a common autoimmune disease triggered by gluten-containing foods (wheat, barley and rye) in genetically predisposed individuals. We present a patient with celiac disease complicated by severe aphthous stomatitis resulting in impairing swallowing, chewing and speaking. This led to weight loss, psychosocial problems as well as inability to perform her work. A variety of topical and systemic medications used resulted in either no improvement or only partial alleviation of the patient's symptoms. After informed consent, etanercept was initiated and resulted in complete remission of aphthous stomatitis, decrease in arthralgia and fatigue and considerable improvement in her quality of life. The use of newer biological agents for selected and severe manifestations of celiac disease may lead to improved morbidity in these patients, but more studies are needed to determine long-term efficacy as well as safety of these drugs in the mucosal and/or systemic complications of this disease.

Celiac disease is a common autoimmune disease triggered by gluten-containing foods (wheat, barley and rye) in genetically predisposed individuals. We present a patient with celiac disease complicated by severe aphthous stomatitis resulting in impairing swallowing, chewing and speaking. This led to weight loss, psychosocial problems as well as inability to perform her work. A variety of topical and systemic medications used resulted in either no improvement or only partial alleviation of the patient's symptoms. After informed consent, etanercept was initiated and resulted in complete remission of aphthous stomatitis, decrease in arthralgia and fatigue and considerable improvement in her quality of life. The use of newer biological agents for selected and severe manifestations of celiac disease may lead to improved morbidity in these patients, but more studies are needed to determine long-term efficacy as well as safety of these drugs in the mucosal and/or systemic complications of this disease.

Bakgrund: Celiaki är en autoimmun sjukdom som påverkar två delar av tunntarmen. En autoimmun reaktion påbörjas vid intag av gluten (gliadin) som främst finns i sädesslagen vete, korn och råg. De sociala situationer som personer med Celiaki upplever är komplexa. Sjuksköterskans stöd till personer med Celiaki är viktigt för att bidra till en ökad livskvalité och kan även stödja till att bibehålla, främja och återfå hälsa. Syfte: Var att belysa personer med Celiakis behov av stöd ur ett omvårdnadsperspektiv. Metod: Studien genomfördes som en allmän litteratur studie och åtta resultatartiklar framkom. Resultatartiklarna granskades, bearbetades och sammanställdes till tre teman. Resultat: De teman som framkom var: Sjuksköterskans stöd- Att vara en del av ett sammanhang, Sjuksköterskans roll- Att dela erfarenheter, Sjuksköterskans betydelse- Att ge stöd för personer med Celiaki. Det framkom från resultatet att personer med Celiaki påverkades både psykiskt och socialt och därmed i behov av stöd. Konklusion: Från resultatet framkom det att personer med Celiaki är i behov av stöd. En okunskap om sjukdomen från allmänheten påverkar personer med Celiaki i sociala sammahang. / Background: Celiac disease is an autoimmune disease that affects two parts of the small intestine. An autoimmune reaction is initiated by consuming gluten (gliadin) which is mainly found in wheat, barley and rye. The social situation that people with Celiac disease experience is complex. The nurse's support for people with Celiac disease is important to contribute to an increased quality of life and can also help maintain, promote and regain health. Purpose: To highlight people with Celiac disease's need for support from a nursing perspective. Method: The study is conducted as a general literature study and eight result articles appeared. The eight results articles was reviewed, processed and compiled into three themes. Results: The themes that emerged was: The nurse's support- To be part of a context, The nurse's role- To share experiences, The nurse's importance of providing support for people with Celiac disease. It emerged from the results that people with Celiac disease were affected both mentally and socially and thus are in need of support. Conclusion: The results showed that people with Celiac disease are in need of support. The lack of knowledge by the general public of the disease affects people with Celiac disease in the social context

Celiac disease (CD) is a highly prevalent autoimmune disease in which intestinal inflammation is induced by dietary gluten. The means through which gluten-specific CD4+ T cell activation culminates in intraepithelial T cell (T-IEL) mediated intestinal damage remain unclear. Here, we performed multiplexed-single cell analysis of intestinal and gluten-induced peripheral blood T cells from patients with different celiac disease states and controls. Untreated, active CD (ACD) and potential CD (PCD) were associated with an enrichment of activated intestinal T cell populations including CD4+ follicular T-helper (TFH) cells, regulatory T cells (Tregs), and Natural CD8+ αβ and γδ T-IELs. Natural CD8+ αβ and γδ T-IELs expressing activating Natural Killer Cell Receptors (NKRs) exhibited a distinct TCR repertoire in CD and persisted in patients on a gluten-free diet (GFD) without intestinal inflammation. Our data further show that NKR-expressing cytotoxic cells, which appear to mediate intestinal damage in CD, arise from a distinct NKR-expressing memory population of T-IELs. Following gluten ingestion, both αβ and γδ T cell clones from this memory population of T-IELs circulated systemically with gluten-specific CD4+ T cells and assumed a cytotoxic and activating NKR-expressing phenotype. In patient-derived organoid (PDO) model of CD, gluten exposure induced the presence of this cytotoxic, NKR-expressing population exclusively in PDOs generated from CD patients. The increased abundance of cytotoxic, NKR-expressing T-IELs following gluten exposure corresponded to histologic observations of altered organoid morphology including degenerated organoid structures and the presence of infiltrating immune cells co-localized with apoptotic epithelial cells. Collectively, these findings suggest that these cytotoxic, NKR-expressing T cells in CD are rapidly mobilized in parallel with gluten-specific CD4+ T cells following gluten ingestion to mediate the destruction of intestinal epithelial cells in CD.

The purpose of this qualitative descriptive study was to examine parental experiences and challenges raising children with both T1DM and CD. Twenty-six families, including 30 parents (25 mothers, 4 fathers, and one custodial grandmother), participated in a 30-60 minute audio-recorded interview designed to explore parental experiences raising children with both T1DM and CD. Participants were asked IRB approved open-ended questions about their experiences raising a child with both diseases. Direct quotations best representing categories/sub-categories were identified through selective coding. Analysis revealed seven main themes: Six themes parents are concerned about, including (a) their child's health complications, b) the challenges of daily disease management, c) the time, resources, and expense required to manage both diseases, d) their child's emotional/mental health, e) support from healthcare providers, f) community support/understanding, and lastly (observed by the researcher) g) how positive versus negative experiences and adaptation influence the way parents and children meet their challenges and perceive the future. Parents raising children with both T1DM and CD face many daily challenges as they learn to manage both lifelong chronic diseases. They need access to and support from healthcare providers for up-to-date education, treatment options, and community resources. Positive provider relationships were identified as: being responsive to parent's questions, willing to listen to parents, creating an open and honest dialogue with parents, having a personal relationship with the child, and being a patient advocate. Future research should examine broader ethnic and socioeconomic populations. A quantitative study design could also be used to assess the level of caregiver burden, in order to compare different ethnic and socioeconomic groups.