Author's response to reviews

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George Morrison
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1 Author's response to reviews Title: Trace gluten contamination may play a role in mucosal and clinical recovery in a subgroup of diet-adherent non-responsive celiac disease patients. Authors: Justin R Hollon (jhollon1@jhmi.edu) Pamela Cureton (pcureton@peds.umaryland.edu) Margaret L Martin (mlmartin@peds.umaryland.edu) Elaine L Leonard Puppa (epuppa@mbrc.umaryland.edu) Alessio Fasano (afasano@partners.org) Version: 5 Date: 5 February 2013 Author's response to reviews: see over

2 Dear Dr Giuseppe Chiarioni, Thank you for the feedback on our manuscript. We were pleased that the reviewers agreed with the importance of this topic. We have addressed the comments and suggestions of the reviewers and have detailed them below. Response to Reviewers: Editorial Board: 1) I am suggesting to increase the impact of the title (something like "Trace Gluten might be relevant on mucosal recovery in Celiac Disease") In reply: Thank you, we agree that a different title may better capture the essence of the manuscript and suggest, Trace gluten contamination may play a role in mucosal and clinical recovery in a subgroup of diet-adherent non-responsive celiac disease patients 2) add the high motivation needed by the patient on following the mentioned costly (in terms of money) diet advise to the limitations of the study. In reply: Good point; we have added these factors to the limitations discussion. 3) I also remember an old British case report on a Catholic woman where celiac disease was kept active by attending daily Catholic Services and I would like to see it mentioned on the References. In reply: We have added this to the background section (reference 19). 4) Since statements as" The GCED is an effective therapeutic option for gluten adherent NRCD patients" are simply not supported by the data presented (small sample size, absence of repeated biopsies in all of the study patients, etc), I am suggesting to significantly tempere your conclusions on both the abstract and the body of the paper. In reply: We agree and have revised both these sections. Referee #1 (Paola Iovino): 1) 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. In reply: We fully agree that, as with any retrospective chart review study, the greatest limitation is the study design itself. As stated in the conclusion, the next logical step for further evaluation of this treatment would be a multicenter prospective study.

3 2) 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. In reply: These concerns relate directly to the retrospective nature of the study as well and are acknowledged in the discussion (8 th paragraph). The symptoms recorded in the chart are those that are reported in Table 3; ideally, a prospective study would employ a symptom index with which to more accurately assess for changes in symptom severity, frequency etc. Likewise, a prospective study would allow for requiring biopsies on all study participates before and after treatment. 3) 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): ) 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. In reply: As mentioned in the discussion section, the systematic approach to the evaluation and diagnosis of NRCD has been well-published and the purpose of this study was not to duplicate this topic. Rather, this study focuses on those patients who have GFD-adherent NRCD, with particular emphasis placed on those with documented enteropathy (currently classified as RCD). Referee #2 (Geoffrey Holmes): 1) In the second paragraph conventional histology does not really separate RCD I and II and it would be better to mention immunological techniques that are in use. In reply: We corrected the second paragraph of the background section and also better clarified the immunological techniques used for immunophenotyping in the Methods section 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 alludes to this. In reply: We added a sentence specifically addressing this in the background section. This is also further discussed in paragraph 3 of the discussion section.

4 3) 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. In reply: This paragraph deals with the definitions set down prior to performing the study and this sentence in particular addresses how patients with RCD would be further subtyped if immunophenotyping occurred. Immunophenotyping was only performed in one patient (who failed to respond to the diet) and he was subsequently classified as RCD1 as demonstrated in Table 3. 4) 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. In reply: Agreed. We have made these corrections 5) 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. In reply: Patient 10, in Table 3, is the only patient who had immunophenotyping performed. We have fixed the Table heading alignment, thank you. 6) Did the authors encounter any patients with RCD II? In reply: Although we have had patients with RCD II under our care, none of these patients were placed on the GCED, nor do we believe that such a diet would have a beneficial effect. In fact, our fear is that this diet would only delay the diagnosis of RCD II, thus the recommendation that ruling out RCDII be the performed prior to GCED consideration. 7) 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? In reply: We agree that with any treatment based on dietary modification, success may be secondary to other factors not specifically targeted by the diet, such as other food intolerances or simply placebo effect. Although this diet does not avoid other common allergens such as unprocessed egg or soy, certainly it is a more natural diet and arguably the absence of processed food items may eliminate other poorly understood factors. Nonetheless, the majority of these patients also had a conversion in their celiac-specific serology which is quite suggestive that there is a gluten cause-and-effect relationship. And the high percentage of patients able to return to their normal GFD is also suggestive that this is not an issue of undiscovered intolerance. Referee #3 (Kamran Rostami):

5 1) Page 6 most of paragraph 2 should be in conclusion and discussion instead of introduction In reply: Agreed, we have removed this paragraph from the introduction and added a sentence to the discussion 2) line 10 methods: Response to GCED defined as normal villous architecture: as far as the current literature suggest, histological recovery is very slow, unrelated to symptoms and hardly ever completeld in coeliac patients. The definition of GCED therefore should be revised. Did some patients in this study truly completely normalised in their histology? i would suggest the authors to discuss their findings on histology correlated with the existence literature on mucosal recovery. In reply: By definition, Marsh 0-2 changes have normal villous architecture, and we draw a distinction between normal villous architecture and normal histology (Marsh 0). We have parenthetically added the Marsh 0-2 classification to this definition to avoid confusion. 3) ttg serology does (should be doesn't) In reply: Agreed, thank you for catching this error. Thank you for the opportunity to improve the manuscript. We look forward to your decision. Regards, Justin R. Hollon, MD

Level 2. Non Responsive Celiac Disease KEY POINTS:

Level 2. Non Responsive Celiac Disease KEY POINTS: Level 2 Non Responsive Celiac Disease KEY POINTS: Celiac Disease (CD) is an autoimmune condition triggered by ingestion of gluten leading to intestinal damage and a variety of clinical manifestations.