Ala I. Sharara

A systematic review of hepatitis C virus epidemiology in Asia, Australia and Egypt

Background: The hepatitis C pandemic has been systematically studied and characterized in North America and Europe, but this important public health problem has not received equivalent attention in other regions.

A Randomized Double-Blind Placebo-Controlled Trial of Rifaximin in Patients with Abdominal Bloating and Flatulence

AIMS:To study the efficacy of rifaximin, a nonabsorbable antibiotic, in relieving chronic functional symptoms of bloating and flatulence.METHODS:Randomized double-blind placebo-controlled trial consisting of three 10-day phases: baseline (phase 1), treatment with rifaximin 400 mg b.i.d. or placebo (phase 2), and post-treatment period (phase 3). Primary efficacy variable was subjective global symptom relief at the end of each phase. A symptom score was calculated from a symptom diary. Lactulose H2-breath test (LHBT) was performed at baseline and end of study.RESULTS:One hundred and twenty-four patients were enrolled (63 rifaximin and 61 placebo). Baseline characteristics were comparable and none had an abnormal baseline LHBT. Rome II criteria were met in 58.7% and 54.1%, respectively. At the end of phase 2, there was a significant difference in global symptom relief with rifaximin versus placebo (41.3%vs 22.9%, p= 0.03). This improvement was maintained at the end of phase 3 (28.6%vs 11.5%, p= 0.02). Mean cumulative and bloating-specific scores dropped significantly in the rifaximin group (p <0.05). Among patients with IBS, a favorable response to rifaximin was noted (40.5%vs 18.2%; p= 0.04) persisting by the end of phase 3 (27%vs 9.1%; p= 0.05). H2-breath excretion dropped significantly among rifaximin responders and correlated with improvement in bloating and overall symptom scores (p= 0.01). No adverse events were reported.CONCLUSIONS:Rifaximin is a safe and effective treatment for abdominal bloating and flatulence, including in IBS patients. Symptom improvement correlates with reduction in H2-breath excretion. Future trials are needed to examine the efficacy of long-term or cyclic rifaximin in functional colonic disorders.

A randomized single-blind trial of split-dose PEG-electrolyte solution without dietary restriction compared with whole dose PEG-electrolyte solution with dietary restriction for colonoscopy preparation

BACKGROUND Colonoscopy preparation regimens are poorly tolerated, requiring the use of a large volume of an unpalatable solution and diet restriction for adequate cleansing. The aim of this study was to compare the efficacy of two regimens of bowel preparation before colonoscopy: a whole dose of polyethylene glycol electrolyte solution (PEG-E), with diet restriction vs. a split dose with no diet restriction. METHODS A total of 141 patients (ages 20-84 years, 81 men) were randomly assigned to receive either 4 L PEG-E, along with a liquid diet the day before colonoscopy (Group A) or 2 L PEG-E with a regular diet the day before colonoscopy followed by another 2 L PEG-E on the day of the procedure (Group B). The quality of the preparation was graded by the endoscopist (poor to excellent), who was blinded to the type of preparation. Tolerability of the assigned preparation and adverse effects were recorded by an independent investigator by using a questionnaire administered before colonoscopy. Intra- and interobserver variability was studied by using randomly chosen videotapes of colonoscopies performed as part of the study. RESULTS There were 73 patients in Group A and 68 patients in Group B. The quality of the preparation was significantly better in Group B ( p = 0.011). The tolerability of the preparation regimen was not different overall between study groups in terms of side effects (except for bloating, which was more frequent in Group B, p = 0.039) or willingness to repeat the preparation. There was a nonsignificant trend toward improved adherence to the assigned preparation in favor of Group B ( p = 0.062). Inter- and intraobserver variability analysis showed good to excellent correlation among endoscopists. CONCLUSIONS Colonic preparation with split-dose PEG-E and no dietary restriction provides better quality colon cleansing than whole-dose preparation, with no significant impact on patient tolerability and side effects.

A randomized single-blind trial of standard diet versus fiber-free diet with polyethylene glycol electrolyte solution for colonoscopy preparation

BACKGROUND AND STUDY AIMS Colonoscopy preparation usually involves the intake of large volumes of polyethylene glycol electrolyte solution (PEG-ES) in combination with a clear-liquid diet (CLD). Liberalization of the diet might enhance the tolerance to PEG-ES without compromising the quality of the preparation. The primary aims of this study were to evaluate the efficacy and tolerability of PEG-ES given with a CLD compared with a fiber-free diet (FFD) for colonoscopy preparation. The incidence of adverse events among patients in the two diet groups was also assessed as a secondary outcome. METHODS This was a single-center randomized, prospective, single-blind study. A total of 200 patients undergoing colonoscopy were randomized to either CLD or FFD in addition to PEG-ES. RESULTS Patients in the FFD group were able to drink more PEG-ES (mean +/- SD, 3.9 +/- 0.3 L) compared with those in the CLD group (3.3 +/- 0.7 L) ( P < 0.01). The quality of the preparation was significantly better in the FFD group, with more patients having satisfactory preparations than those in the CLD group (81.4 % vs. 52.0 %; P < 0.001). Tolerance to the preparation was higher in the FFD group compared with the CLD group, with significantly more patients adhering to the FFD regimen ( P < 0.001). There were more adverse events experienced in the CLD group, with odds ratios of 1.9 for nausea (95 % confidence interval [CI] 1.0 - 3.6), 3.8 for vomiting (95 % CI 1.3 - 11.3), and 3.0 for headache (95 % CI 1.5 - 5.9). CONCLUSION FFD given with PEG-ES on the day before colonoscopy is a more effective regimen than the standard CLD regimen, and is better tolerated by patients.

Clinical epidemiology of inflammatory bowel disease in Lebanon

Background: The objectives of this study were to determine the prevalence and incidence of inflammatory bowel disease (IBD) in a representative Lebanese cohort and to describe practice prevalence trends, disease characteristics, and impact on quality of life (QoL) of IBD patients in Lebanon. Methods: All of a university‐based health programs 2000–2004 computerized records that listed a diagnosis of Crohns disease (CD) or ulcerative colitis (UC) were reviewed. In addition, data on patients seen in the gastroenterology clinics and data from the IBD registry at the American University of Beirut Medical Center (AUBMC) from the same period were analyzed. Results: Of 15,073 insured individuals, 8 had a diagnosis of CD and 16 of UC, giving an age‐adjusted prevalence of 53.1 per 100,000 people for CD and 106.2 per 100,000 people for UC. The mean age at diagnosis for patients with CD and UC was 28.8 ± 11.1 and 32.0 ± 13.4 years, respectively, and there was a slight female predominance. The mean annual incidence was 4.1 per 100,000 people for UC and 1.4 per 100,000 people for CD (range, 0–6.9/100,000 for both). Of the 10,383 patients seen in the gastroenterology clinic from 2000 to 2004, 251 (2.4%) had IBD (142 UC, 100 CD, and 9 indeterminate), a ratio that trended upward over time (range, 1.8%–2.7%). The median IBD Quality‐of‐Life (IBDQ) questionnaire score was 124.9 ± 30.5, indicating that the disease had a moderately severe impact on QoL. Conclusions: The prevalence of IBD in this representative Lebanese cohort falls in the intermediate range of that reported for white populations in Europe and North America. Future studies are needed to examine local risk factors, disease genotypes and phenotypes, and epidemiologic time trends. The psychosocial burden of IBD in Lebanon appears significant.

A randomized, controlled, double-blind trial of the adjunct use of tegaserod in whole-dose or split-dose polyethylene glycol electrolyte solution for colonoscopy preparation

BACKGROUND Problems of compliance, quality, and safety of colon preparation regimens have prompted continued investigation with alternative forms of cleansing. OBJECTIVE To evaluate the efficacy of tegaserod as an adjunct to a polyethylene glycol electrolyte solution (PEG-E), given as a whole dose or split dose, in colonoscopy preparation. DESIGN Randomized, placebo-controlled, double-blind trial. SETTING A single university-based hospital. PATIENTS Patients who were undergoing elective colonoscopy. INTERVENTIONS A 4-arm randomization scheme that compared tegaserod with a placebo, each with whole-dose or split-dose PEG-E preparation. MAIN OUTCOME MEASUREMENTS Efficacy of colon cleansing was the primary outcome. Secondary outcomes included adherence, tolerability, adverse effects, and patient perceptions of their preparation quality. RESULTS A total of 382 patients completed the trial. Patients who received the split-dose preparation had significantly better colon cleansing than those who received the whole-dose preparation (88.9% vs 42.6%, P < .001). The addition of tegaserod did not significantly improve the overall colonoscopy preparation quality compared with a placebo. However, there were fewer poor preparations in the whole-dose PEG-E group (12.4% vs 1.1%, P = .002, Bonferroni correction removes significance) and more excellent preparations in the split-dose group (53.3% vs 38.3%, P = .035, Bonferroni correction removes significance) in favor of tegaserod. Interobserver and intraobserver variability analysis showed substantial agreement among endoscopists. Adherence was significantly lower in the whole-dose group versus the split-dose PEG-E group (68.8% vs 91%, P < .001), independent of the use of tegaserod. Adverse effects were not different between study groups. LIMITATIONS A 4-arm randomization and the single-center nature of the study. CONCLUSIONS Tegaserod has a marginal effect on the quality of colonoscopy preparation when used as an adjuvant to PEG-E. The split-dose PEG-E was superior to the whole-dose PEG-E and resulted in better colon cleansing, adherence, and tolerance.

Efficacy and tolerability of peginterferon alpha-2a with or without ribavirin in thalassaemia major patients with chronic hepatitis C virus infection

Thalassaemia patients with genotype 1 or 4 chronic hepatitis C virus (HCV) infection were randomised to receive peginterferon alpha‐2a 180 mg/week ribavirin for 48 weeks. Primary efficacy variable was sustained viral response (SVR) at 72 weeks. Thirty‐two patients were evaluated; 20 enrolled. Baseline characteristics were comparable. SVR occurred in four of 12 and five of eight patients in the monotherapy and combination groups (30% and 62·5%; P = 0·19), respectively. Undetectable RNA at 12 weeks and age <18 years were associated with improved SVR (P < 0·05). Transfusion requirements rose by 34% in the combination arm (P = 0·08). Peginterferon/ribavirin was effective in thalassaemics with HCV and moderate iron overload.

Hepatitis C in pregnancy

Objective To review the epidemiology and clinical course of hepatitis C virus (HCV) infection, to examine current data on the vertical transmission of HCV to neonates, and to develop recommendations for intrapartum and postpartum follow-up of neonates born to HCV-infected mothers. Data Sources The English-language medical literature from 1988 to 1996 was reviewed through MEDLINE. Methods of Study Selection Case series evaluating vertical transmission of HCV infection in neonates, determined by HCV RNA testing, after delivery and breast-feeding were reviewed and summarized. Tabulation, Integration, and Results Vertical transmission of HCV infection was examined with respect to maternal human immunodeficiency virus (HIV) status (as heterosexual transmission of HCV is enhanced in HIV-positive patients) and chronicity of HCV infection. Vertical transmission of HCV from HIV-negative mothers with chronic hepatitis C ranged from 0 to 18%. The risk of HCV vertical transmission from HIV-negative mothers with acute hepatitis C may be higher than that from mothers with chronic HCV infection. Vertical transmission of HCV was proportional to maternal HCV RNA levels; no transmission was noted in women without HCV RNA, whereas the greatest transmission was noted in women with HCV RNA greater than 1 million copies/mL. Vertical transmission of HCV from HIV-positive mothers with chronic hepatitis C ranged from 6 to 36%. In colostrum, HCV RNA was found to be present in low titers. No studies have documented transmission of HCV infection to infants via breast-feeding. Conclusion Vertical transmission of HCV complicates up to 18% of pregnancies in HCV-positive, HIV-negative women and 6–36% in HCV-positive, HIV-positive women. The highest rates of vertical transmission of HCV were noted in women with high HCV RNA or concurrent HIV infection. Breast-feeding has not been associated with vertical transmission of HCV infection.

Endemic Gastrointestinal Anthrax in 1960s Lebanon: Clinical Manifestations and Surgical Findings

Anthrax is an ancient disease caused by the gram-positive Bacillus anthracis; recently, it has gained much attention because of its potential use in biologic warfare. Anthrax infection occurs in three forms: cutaneous, inhalational, and gastrointestinal. The last type results from ingestion of poorly cooked contaminated meat. Intestinal anthrax was widely known in Lebanon in the 1960s, when a series of >100 cases were observed in the Bekaa Valley. We describe some of these cases, introduce the concept of the surgical management of advanced intestinal anthrax, and describe some of the approaches for treatment.

Safety and Effectiveness of 100 mg/kg/day Deferiprone in Patients with Thalassemia Major: A Two-Year Study

Deferiprone at a dose of 75 mg/kg/day is not sufficiently effective to maintain iron stores at a level which has been considered safe in all patients with iron overload. Our main aim was to determine the safety of long-term therapy with high-dose (100 mg/kg/day) deferiprone. A secondary aim was to determine the efficacy of this high dose. Twelve thalassemia major patients received deferiprone at a dose of100 mg/kg/day over 2 years. Transient aspartate aminotransferase increase (8 patients), gastrointestinal discomfort (3 patients) and arthralgia (2 patients) were the most commonly reported side effects. None of the patients discontinued therapy. The mean serum ferritin level fell from 3,901 ± 3,618 to 1,790 ± 2,205 µg/l after 2 years (p < 0.05). Five of the 12 patients continued to receive deferiprone for an additional 3 years. No new side effects were encountered. The mean serum ferritin level in this subgroup was initially 2,510 ± 332 µg/l and dropped to 1,511 ± 664 µg/l after 5 years (p < 0.05). Liver iron levels at the end of the 2-year study ranged from 1.0 to 30.9 mg/g dry weight, 3 of the patients having levels above 15 mg/g.