The human IgG anti-carbohydrate repertoire exhibits a universal architecture and contains specificity for microbial attachment sites.

Despite the paradigm that carbohydrates are T cell-independent antigens, isotype-switched glycan-specific immunoglobulin G (IgG) antibodies and polysaccharide-specific T cells are found in humans. We used a systems-level approach combined with glycan array technology to decipher the repertoire of carbohydrate-specific IgG antibodies in intravenous and subcutaneous immunoglobulin preparations. A strikingly universal architecture of this repertoire with modular organization among different donor populations revealed an association between immunogenicity or tolerance and particular structural features of glycans. Antibodies were identified with specificity not only for microbial antigens but also for a broad spectrum of host glycans that serve as attachment sites for viral and bacterial pathogens and/or exotoxins. Tumor-associated carbohydrate antigens were differentially detected by IgG antibodies, whereas non-IgG2 reactivity was predominantly absent. Our study highlights the power of systems biology approaches to analyze immune responses and reveals potential glycan antigen determinants that are relevant to vaccine design, diagnostic assays, and antibody-based therapies.

On the Dark Side of Therapies with Immunoglobulin Concentrates: The Adverse Events

Therapy by human immunoglobulin G (IgG) concentrates is a success story ongoing for decades with an ever increasing demand for this plasma product. The success of IgG concentrates on a clinical level is documented by the slowly increasing number of registered indication and the more rapid increase of the off-label uses, a topic dealt with in another contribution to this special issue of Frontiers in Immunology. A part of the success is the adverse event (AE) profile of IgG concentrates which is, even at life-long need for therapy, excellent. Transmission of pathogens in the last decade could be entirely controlled through the antecedent introduction by authorities of a regulatory network and installing quality standards by the plasma fractionation industry. The cornerstone of the regulatory network is current good manufacturing practice. Non-infectious AEs occur rarely and mainly are mild to moderate. However, in recent times, the increase in frequency of hemolytic and thrombotic AEs raised worrying questions on the possible background for these AEs. Below, we review elements of non-infectious AEs, and particularly focus on hemolysis and thrombosis. We discuss how the introduction of plasma fractionation by ion-exchange chromatography and polishing by immunoaffinity chromatographic steps might alter repertoire of specificities and influence AE profiles and efficacy of IgG concentrates.

Diagnostic value of immunoassays for heparin-induced thrombocytopenia: a systematic review and meta-analysis.

Immunoassays are essential in the workup of patients with suspected heparin-induced thrombocytopenia. However, the diagnostic accuracy is uncertain with regard to different classes of assays, antibody specificities, thresholds, test variations, and manufacturers. We aimed to assess diagnostic accuracy measures of available immunoassays and to explore sources of heterogeneity. We performed comprehensive literature searches and applied strict inclusion criteria. Finally, 49 publications comprising 128 test evaluations in 15 199 patients were included in the analysis. Methodological quality according to the revised tool for quality assessment of diagnostic accuracy studies was moderate. Diagnostic accuracy measures were calculated with the unified model (comprising a bivariate random-effects model and a hierarchical summary receiver operating characteristics model). Important differences were observed between classes of immunoassays, type of antibody specificity, thresholds, application of confirmation step, and manufacturers. Combination of high sensitivity (>95%) and high specificity (>90%) was found in 5 tests only: polyspecific enzyme-linked immunosorbent assay (ELISA) with intermediate threshold (Genetic Testing Institute, Asserachrom), particle gel immunoassay, lateral flow immunoassay, polyspecific chemiluminescent immunoassay (CLIA) with a high threshold, and immunoglobulin G (IgG)-specific CLIA with low threshold. Borderline results (sensitivity, 99.6%; specificity, 89.9%) were observed for IgG-specific Genetic Testing Institute-ELISA with low threshold. Diagnostic accuracy appears to be inadequate in tests with high thresholds (ELISA; IgG-specific CLIA), combination of IgG specificity and intermediate thresholds (ELISA, CLIA), high-dose heparin confirmation step (ELISA), and particle immunofiltration assay. When making treatment decisions, clinicians should be a aware of diagnostic characteristics of the tests used and it is recommended they estimate posttest probabilities according to likelihood ratios as well as pretest probabilities using clinical scoring tools.

Intravenous Immunoglobulin with Enhanced Polyspecificity Improves Survival in Experimental Sepsis and Aseptic Systemic Inflammatory Response Syndromes.

Sepsis is a major cause for death worldwide. Numerous interventional trials with agents neutralizing single pro-inflammatory mediators have failed to improve survival in sepsis and aseptic systemic inflammatory response syndromes. This failure could well be explained by the widespread gene expression dysregulation known as "genomic storm" in these patients. A multifunctional polyspecific therapeutic agent might be needed to thwart the effects of this "storm". Licensed pooled intravenous immunoglobulin preparations seemed to be a promising candidate but they have also failed in their present form to prevent sepsis-related death. We report here the protective effect of a single dose of intravenous immunoglobulin preparations with additionally enhanced polyspecificity in three models of sepsis and aseptic systemic inflammation. The modification of the pooled immunoglobulin G molecules by exposure to ferrous ions resulted in their newly acquired ability to bind some pro-inflammatory molecules, complement components and endogenous "danger" signals. The improved survival in endotoxemia was associated with serum levels of pro-inflammatory cytokines, diminished complement consumption and normalization of the coagulation time. We suggest that intravenous immunoglobulin preparations with additionally enhanced polyspecificity have a clinical potential in sepsis and related systemic inflammatory syndromes.

Organisation of the equine immunoglobulin constant heavy chain genes. II. Equine cgamma genes.

The number of immunoglobulin G constant heavy chain genes (cgamma genes) varies broadly among mammalian species, reflecting structural and functional differences between expressed immunoglobulin G (IgG) isotypes and allotypes. Up to now equine IgG isotypes have been defined only at the biochemical and serological level. It is still not clear how many IgG isotypes exist in horses and whether there are any allotypes. Here, we describe the isolation and characterisation of equine cgamma genes. An equine genomic lambda phage library was screened with a human cgamma4 probe. Cross-hybridising equine cgamma sequences were cloned twice and characterised by restriction mapping with the human cgamma4 and a murine sgamma1 probe. Genomic equine DNA probes for both, cgamma genes and corresponding switch regions (sgamma), were isolated and used for a more detailed BamHI restriction analysis, comparing genomic DNA of various horses. This analysis reveals the existence of at least five, or probably six cgamma genes in the equine haploid genome. Beside the porcine system, this is the highest number of cgamma genes described for any mammalian species. Moreover, for two of these cgamma genes, BamHI restriction fragment length polymorphism became evident.

Quantitative Intercellular Localization of NADH-Dependent Glutamate Synthase Protein in Different Types of Root Cells in Rice Plants1

The quantitative analysis with immunogold-electron microscopy using a single-affinity-purified anti-NADH-glutamate synthase (GOGAT) immunoglobulin G (IgG) as the primary antibody showed that the NADH-GOGAT protein was present in various forms of plastids in the cells of the epidermis and exodermis, in the cortex parenchyma, and in the vascular parenchyma of root tips (<10 mm) of rice (Oryza sativa) seedlings supplied with 1 mm NH4+ for 24 h. The values of the mean immunolabeling density of plastids were almost equal among these different cell types in the roots. However, the number of plastids per individual cell type was not identical, and some parts of the cells in the epidermis and exodermis contained large numbers of plastids that were heavily immunolabeled. Although there was an indication of labeling in the mitochondria using the single-affinity-purified anti-NADH-GOGAT IgG, this was not confirmed when a twice-affinity-purified IgG was used, indicating an exclusively plastidial location of the NADH-GOGAT protein in rice roots. These results, together with previous work from our laboratory (K. Ishiyama, T. Hayakawa, and T. Yamaya [1998] Planta 204: 288–294), suggest that the assimilation of exogeneously supplied NH4+ ions is primarily via the cytosolic glutamine synthetase/plastidial NADH-GOGAT cycle in specific regions of the epidermis and exodermis in rice roots. We also discuss the role of the NADH-GOGAT protein in vascular parenchyma cells.

Co-encapsulation of enzymes and antibodies for chemical deactivation of pathogens on paper

Le papier bioactif est obtenu par la modification de substrat du papier avec des biomolécules et des réactifs. Ce type de papier est utilisé dans le développement de nouveaux biocapteurs qui sont portables, jetables et économiques visant à capturer, détecter et dans certains cas, désactiver les agents pathogènes. Généralement les papiers bioactifs sont fabriqués par l’incorporation de biomolécules telles que les enzymes et les anticorps sur la surface du papier. L’immobilisation de ces biomolécules sur les surfaces solides est largement utilisée pour différentes applications de diagnostic comme dans immunocapteurs et immunoessais mais en raison de la nature sensible des enzymes, leur intégration au papier à grande échelle a rencontré plusieurs difficultés surtout dans les conditions industrielles. Pendant ce temps, les microcapsules sont une plate-forme intéressante pour l’immobilisation des enzymes et aussi assez efficace pour permettre à la fonctionnalisation du papier à grande échelle car le papier peut être facilement recouvert avec une couche de telles microcapsules. Dans cette étude, nous avons développé une plate-forme générique utilisant des microcapsules à base d’alginate qui peuvent être appliquées aux procédés usuels de production de papier bioactif et antibactérien avec la capacité de capturer des pathogènes à sa surface et de les désactiver grâce à la production d’un réactif anti-pathogène. La conception de cette plate-forme antibactérienne est basée sur la production constante de peroxyde d’hydrogène en tant qu’agent antibactérien à l’intérieur des microcapsules d’alginate. Cette production de peroxyde d’hydrogène est obtenue par oxydation du glucose catalysée par la glucose oxydase encapsulée à l’intérieur des billes d’alginate. Les différentes étapes de cette étude comprennent le piégeage de la glucose oxydase à l’intérieur des microcapsules d’alginate, l’activation et le renforcement de la surface des microcapsules par ajout d’une couche supplémentaire de chitosan, la vérification de la possibilité d’immobilisation des anticorps (immunoglobulines G humaine comme une modèle d’anticorps) sur la surface des microcapsules et enfin, l’évaluation des propriétés antibactériennes de cette plate-forme vis-à-vis l’Escherichia coli K-12 (E. coli K-12) en tant qu’un représentant des agents pathogènes. Après avoir effectué chaque étape, certaines mesures et observations ont été faites en utilisant diverses méthodes et techniques analytiques telles que la méthode de Bradford pour dosage des protéines, l’électroanalyse d’oxygène, la microscopie optique et confocale à balayage laser (CLSM), la spectrométrie de masse avec désorption laser assistée par matrice- temps de vol (MALDI-TOF-MS), etc. Les essais appropriés ont été effectués pour valider la réussite de modification des microcapsules et pour confirmer à ce fait que la glucose oxydase est toujours active après chaque étape de modification. L’activité enzymatique spécifique de la glucose oxydase après l’encapsulation a été évaluée à 120±30 U/g. Aussi, des efforts ont été faits pour immobiliser la glucose oxydase sur des nanoparticules d’or avec deux tailles différentes de diamètre (10,9 nm et 50 nm) afin d’améliorer l’activité enzymatique et augmenter l’efficacité d’encapsulation. Les résultats obtenus lors de cette étude démontrent les modifications réussies sur les microcapsules d’alginate et aussi une réponse favorable de cette plate-forme antibactérienne concernant la désactivation de E. coli K-12. La concentration efficace de l’activité enzymatique afin de désactivation de cet agent pathogénique modèle a été déterminée à 1.3×10-2 U/ml pour une concentration de 6.7×108 cellules/ml de bactéries. D’autres études sont nécessaires pour évaluer l’efficacité de l’anticorps immobilisé dans la désactivation des agents pathogènes et également intégrer la plate-forme sur le papier et valider l’efficacité du système une fois qu’il est déposé sur papier.

Co-encapsulation of enzymes and antibodies for chemical deactivation of pathogens on paper

Le papier bioactif est obtenu par la modification de substrat du papier avec des biomolécules et des réactifs. Ce type de papier est utilisé dans le développement de nouveaux biocapteurs qui sont portables, jetables et économiques visant à capturer, détecter et dans certains cas, désactiver les agents pathogènes. Généralement les papiers bioactifs sont fabriqués par l’incorporation de biomolécules telles que les enzymes et les anticorps sur la surface du papier. L’immobilisation de ces biomolécules sur les surfaces solides est largement utilisée pour différentes applications de diagnostic comme dans immunocapteurs et immunoessais mais en raison de la nature sensible des enzymes, leur intégration au papier à grande échelle a rencontré plusieurs difficultés surtout dans les conditions industrielles. Pendant ce temps, les microcapsules sont une plate-forme intéressante pour l’immobilisation des enzymes et aussi assez efficace pour permettre à la fonctionnalisation du papier à grande échelle car le papier peut être facilement recouvert avec une couche de telles microcapsules. Dans cette étude, nous avons développé une plate-forme générique utilisant des microcapsules à base d’alginate qui peuvent être appliquées aux procédés usuels de production de papier bioactif et antibactérien avec la capacité de capturer des pathogènes à sa surface et de les désactiver grâce à la production d’un réactif anti-pathogène. La conception de cette plate-forme antibactérienne est basée sur la production constante de peroxyde d’hydrogène en tant qu’agent antibactérien à l’intérieur des microcapsules d’alginate. Cette production de peroxyde d’hydrogène est obtenue par oxydation du glucose catalysée par la glucose oxydase encapsulée à l’intérieur des billes d’alginate. Les différentes étapes de cette étude comprennent le piégeage de la glucose oxydase à l’intérieur des microcapsules d’alginate, l’activation et le renforcement de la surface des microcapsules par ajout d’une couche supplémentaire de chitosan, la vérification de la possibilité d’immobilisation des anticorps (immunoglobulines G humaine comme une modèle d’anticorps) sur la surface des microcapsules et enfin, l’évaluation des propriétés antibactériennes de cette plate-forme vis-à-vis l’Escherichia coli K-12 (E. coli K-12) en tant qu’un représentant des agents pathogènes. Après avoir effectué chaque étape, certaines mesures et observations ont été faites en utilisant diverses méthodes et techniques analytiques telles que la méthode de Bradford pour dosage des protéines, l’électroanalyse d’oxygène, la microscopie optique et confocale à balayage laser (CLSM), la spectrométrie de masse avec désorption laser assistée par matrice- temps de vol (MALDI-TOF-MS), etc. Les essais appropriés ont été effectués pour valider la réussite de modification des microcapsules et pour confirmer à ce fait que la glucose oxydase est toujours active après chaque étape de modification. L’activité enzymatique spécifique de la glucose oxydase après l’encapsulation a été évaluée à 120±30 U/g. Aussi, des efforts ont été faits pour immobiliser la glucose oxydase sur des nanoparticules d’or avec deux tailles différentes de diamètre (10,9 nm et 50 nm) afin d’améliorer l’activité enzymatique et augmenter l’efficacité d’encapsulation. Les résultats obtenus lors de cette étude démontrent les modifications réussies sur les microcapsules d’alginate et aussi une réponse favorable de cette plate-forme antibactérienne concernant la désactivation de E. coli K-12. La concentration efficace de l’activité enzymatique afin de désactivation de cet agent pathogénique modèle a été déterminée à 1.3×10-2 U/ml pour une concentration de 6.7×108 cellules/ml de bactéries. D’autres études sont nécessaires pour évaluer l’efficacité de l’anticorps immobilisé dans la désactivation des agents pathogènes et également intégrer la plate-forme sur le papier et valider l’efficacité du système une fois qu’il est déposé sur papier.

Prophylactic HPV vaccines: Underlying mechanisms

Human papillomavirus virus-like particles (HPV VLP) can be generated by the synthesis and self-assembly in vitro of the major virus capsid protein L1. HPV L1 VLPs are morphologically and antigenically almost identical to native virions, and this technology has been exploited to produce HPV L1 VLP subunit vaccines. The vaccines elicit high titres of anti-L I VLP antibodies that persist at levels 10 times that of natural infections for at least 48 months. At present the assumption is that the protection achieved by these vaccines against incident HPV infection and HPV-associated ano-genital pathology is mediated via serum neutralising Immunoglobulin G (IgG). However, since there have been very few vaccine failures thus far, immune correlates of protection have not been established. The available evidence is that the immunodominant neutralising antibodies generated by L1 VLPs are type-specific and are not cross-neutralising, although highly homologous HPV pairs share minor cross-neutralisation epitopes. Important issues remaining to be addressed include the duration of protection and genotype replacement. (c) 2006 Elsevier Ltd. All rights reserved.

Association of HIV-1 Envelope-Specific Breast Milk IgA Responses with Reduced Risk of Postnatal Mother-to-Child Transmission of HIV-1.

UNLABELLED: Infants born to HIV-1-infected mothers in resource-limited areas where replacement feeding is unsafe and impractical are repeatedly exposed to HIV-1 throughout breastfeeding. Despite this, the majority of infants do not contract HIV-1 postnatally, even in the absence of maternal antiretroviral therapy. This suggests that immune factors in breast milk of HIV-1-infected mothers help to limit vertical transmission. We compared the HIV-1 envelope-specific breast milk and plasma antibody responses of clade C HIV-1-infected postnatally transmitting and nontransmitting mothers in the control arm of the Malawi-based Breastfeeding Antiretrovirals and Nutrition Study using multivariable logistic regression modeling. We found no association between milk or plasma neutralization activity, antibody-dependent cell-mediated cytotoxicity, or HIV-1 envelope-specific IgG responses and postnatal transmission risk. While the envelope-specific breast milk and plasma IgA responses also did not reach significance in predicting postnatal transmission risk in the primary model after correction for multiple comparisons, subsequent exploratory analysis using two distinct assay methodologies demonstrated that the magnitudes of breast milk total and secretory IgA responses against a consensus HIV-1 envelope gp140 (B.con env03) were associated with reduced postnatal transmission risk. These results suggest a protective role for mucosal HIV-1 envelope-specific IgA responses in the context of postnatal virus transmission. This finding supports further investigations into the mechanisms by which mucosal IgA reduces risk of HIV-1 transmission via breast milk and into immune interventions aimed at enhancing this response. IMPORTANCE: Infants born to HIV-1-infected mothers are repeatedly exposed to the virus in breast milk. Remarkably, the transmission rate is low, suggesting that immune factors in the breast milk of HIV-1-infected mothers help to limit transmission. We compared the antibody responses in plasma and breast milk of HIV-1-transmitting and -nontransmitting mothers to identify responses that correlated with reduced risk of postnatal HIV-1 transmission. We found that neither plasma nor breast milk IgG antibody responses were associated with risk of HIV-1 transmission. In contrast, the magnitudes of the breast milk IgA and secretory IgA responses against HIV-1 envelope proteins were associated with reduced risk of postnatal HIV-1 transmission. The results of this study support further investigations of the mechanisms by which mucosal IgA may reduce the risk of HIV-1 transmission via breastfeeding and the development of strategies to enhance milk envelope-specific IgA responses to reduce mother-to-child HIV transmission and promote an HIV-free generation.

Ischemic Stroke as the Initial Manifestation of Neurosyphilis in a Young Adult Patient Positive for Human Immunodeficiency Virus

A 31-year-old man with pontine infarction was referred to our hospital for further evaluation and treatment. At admission, his neurological examination was unremarkable. No lymphadenopathy or skin lesions were found. The Treponema pallidum haemagglutination test, rapid plasma regain test and fluorescent treponemal antibody absorption test of immunoglobulin G were positive in both serum and cerebrospinal fluid (CSF). CSF analysis showed lymphocytic pleocytosis. The patient had male-to-male sexual contact and was found to be HIV positive. Physicians should be aware that acute ischaemic stroke may be the first manifestation of neurosyphilis in a young adult, especially with HIV infection.

Design and validation of a novel generic platform for the production of tetravalent IgG1-like bispecific antibodies

International audience

Infección por virus sincitial respiratorio y su relación con valores de IGG en niños críticos

Antecedente: La infección por el virus sincitial respiratorio (VSR) representa una elevada morbimortalidad, y en algunos casos necesidad de manejo en unidades de cuidado intensivo pediátrico (UCIP). La respuesta inmunológica influye de manera directa en la expresión de la severidad y pronóstico de los pacientes con infección respiratoria. Metodología: Estudio de una cohorte retrospectiva de pacientes con infección respiratoria grave secundaria a VSR, sin historia de inmunodeficiencia, atendidos en la UCIP del Hospital Universitario Clínica San Rafael. Se realizó análisis descriptivoglobaly de acuerdo a la categorización de las prueba de IgG. Resultados: De 188 pacientes que ingresaron a la UCIP, 13% presentaron infección por VSR (24), con una edad promedio de 7,3 (DE=3,6) meses. Pertenecían al sexo masculino79,83%. Se encontró que 12,5% tenían un valor de IgGbajo para su edad, 58,33% tenían valores en límite inferior y el 29,17% dentro de rangos normales para su edad. En los pacientes con IgG baja, fue mayor la presentación de choque séptico que no responde a líquidos (100 vs 92 vs 86%), la mediana de días de ventilación mecánica fue mayor (8 vs 6 vs 5 respectivamente), así como la mortalidad (67 vs 7,1 vs 0%). Conclusión: Nuestra serie encontró que aquellos pacientes con niveles bajos o valores en el límite inferior de IgG sérica tuvieron mayor compromiso sistémico, mayor duración de ventilación mecánica y mayor mortalidad. Se necesitan estudios prospectivos que relaciones niveles bajos de IgG con severidad y pronostico en estos pacientes con infección grave por VSR.

Thyroxine and reserpine-induced changes in metabolic profiles of rat urine and the therapeutic effect of Liu Wei Di Huang Wan detected by UPLC-HDMS

The promise of metabonomics, a new "omics" technique, to validate Chinese medicines and the compatibility of Chinese formulas has been appreciated. The present study was undertaken to explore the excretion pattern of low molecular mass metabolites in the male Wistar-derived rat model of kidney yin deficiency induced with thyroxine and reserpine as well as the therapeutic effect of Liu Wei Di Huang Wan (LW) and its separated prescriptions, a classic traditional Chinese medicine formula for treating kidney yin deficiency in China. The study utilized ultra-performance liquid chromatography/electrospray ionization synapt high definition mass spectrometry (UPLC/ESI-SYNAPT-HDMS) in both negative and positive electrospray ionization (ESI). At the same time, blood biochemistry was examined to identify specific changes in the kidney yin deficiency. Distinct changes in the pattern of metabolites, as a result of daily administration of thyroxine and reserpine, were observed by UPLC-HDMS combined with a principal component analysis (PCA). The changes in metabolic profiling were restored to their baseline values after treatment with LW according to the PCA score plots. Altogether, the current metabonomic approach based on UPLC-HDMS and orthogonal projection to latent structures discriminate analysis (OPLS-DA) indicated 20 ions (14 in the negative mode, 8 in the positive mode, and 2 in both) as "differentiating metabolites".

A novel serogenetic approach determines the community prevalence of celiac disease and informs improved diagnostic pathways

Background: Changing perspectives on the natural history of celiac disease (CD), new serology and genetic tests, and amended histological criteria for diagnosis cast doubt on past prevalence estimates for CD. We set out to establish a more accurate prevalence estimate for CD using a novel serogenetic approach.Methods: The human leukocyte antigen (HLA)-DQ genotype was determined in 356 patients with 'biopsy-confirmed' CD, and in two age-stratified, randomly selected community cohorts of 1,390 women and 1,158 men. Sera were screened for CD-specific serology.Results: Only five 'biopsy-confirmed' patients with CD did not possess the susceptibility alleles HLA-DQ2.5, DQ8, or DQ2.2, and four of these were misdiagnoses. HLA-DQ2.5, DQ8, or DQ2.2 was present in 56% of all women and men in the community cohorts. Transglutaminase (TG)-2 IgA and composite TG2/deamidated gliadin peptide (DGP) IgA/IgG were abnormal in 4.6% and 5.6%, respectively, of the community women and 6.9% and 6.9%, respectively, of the community men, but in the screen-positive group, only 71% and 75%, respectively, of women and 65% and 63%, respectively, of men possessed HLA-DQ2.5, DQ8, or DQ2.2. Medical review was possible for 41% of seropositive women and 50% of seropositive men, and led to biopsy-confirmed CD in 10 women (0.7%) and 6 men (0.5%), but based on relative risk for HLA-DQ2.5, DQ8, or DQ2.2 in all TG2 IgA or TG2/DGP IgA/IgG screen-positive subjects, CD affected 1.3% or 1.9%, respectively, of females and 1.3% or 1.2%, respectively, of men. Serogenetic data from these community cohorts indicated that testing screen positives for HLA-DQ, or carrying out HLA-DQ and further serology, could have reduced unnecessary gastroscopies due to false-positive serology by at least 40% and by over 70%, respectively.Conclusions: Screening with TG2 IgA serology and requiring biopsy confirmation caused the community prevalence of CD to be substantially underestimated. Testing for HLA-DQ genes and confirmatory serology could reduce the numbers of unnecessary gastroscopies. © 2013 Anderson et al.; licensee BioMed Central Ltd.