César Yaghi

Osteoprotegerin in relation to body weight, lipid parameters insulin sensitivity, adipocytokines, and C-reactive protein in obese and non-obese young individuals: results from both cross-sectional and interventional study.

OBJECTIVE We analyzed the relation of osteoprotegerin (OPG) with insulin sensitivity, lipid profile, serum glutamic pyruvic transaminase (SGPT), adipocytokines, and C-reactive protein (CRP) in obese and non-obese subjects. METHODS In the study, 170 subjects (106 obese and 64 non-obese, sex ratio female/male=2.03) were included. Thirty-two obese subjects were reevaluated 6 months after the weight loss induced by bariatric surgery. RESULTS OPG did not differ between obese and non-obese subjects (respective mean values 5.17 and 4.96 pmol/l) or according to gender, but was positively correlated with age (P<0.0001 for both groups). OPG was statistically higher in 18 obese diabetic subjects compared with non-diabetics (P=0.03). After adjustment for age, no significant correlation was found between OPG and body mass index (BMI), waist, systolic and diastolic blood pressure, cholesterol, triglycerides, high density lipoprotein (HDL) cholesterol, leptin, and adiponectin in both the obese and non-obese subjects. However, OPG was positively correlated with homeostasis model assessment (HOMA) index and SGPT levels in obese subjects at baseline (r=0.295, r=0.20, P<0.05) and after adjustment for age (r=0.28, r=0.20, P<0.05). OPG was also significantly correlated with CRP; this correlation persisted after adjustment for age in obese subjects (r=0.30, P<0.01). In a multivariate analysis in the obese group, HOMA index and CRP were independent predictors of OPG while SGPT was not. Six months post-surgery, OPG did not change, despite a significant reduction in glucose, SGPT, cholesterol, triglycerides, CRP, and leptin values (P=0.02, P=0.006, P=0.007, P<0.001, P<0.001, P<0.001 respectively) and a significant increase in adiponectin and HDL values (P<0.001 for both variables). CONCLUSION Our results show that in obese subjects, OPG is not related to BMI. However, we describe new relationships between OPG and both HOMA index and CRP.

Serum proteomic profiling of obese patients: correlation with liver pathology and evolution after bariatric surgery

Objective: Chronic liver diseases, including cirrhosis, may develop in obese patients. Steatosis and non-alcoholic steatohepatitis (NASH) are risk factors for progression to fibrosis. To date, diagnosis of steatosis and NASH relies on liver biopsy. The aim of the study was to identify serum markers of steatosis and NASH in obese patients using SELDI–TOF ProteinChip. Patients: Eighty obese non-alcoholic patient candidates for bariatric surgery and devoid of hepatitis B and C infection were selected. Serum samples were collected before surgery and at 6 months after surgery for 33 of these patients. Wedge liver biopsy was performed at the time of bariatric surgery. Twenty-four serum samples from healthy blood donors served as controls. The protein profiles of each serum were assessed using SELDI–TOF ProteinChip technology and were compared according to liver histological lesions. Results: Twenty-four obese patients (30%) had non-significant liver lesions, 32 (40%) had significant steatosis and 24 (30%) had NASH. Comparison of serum protein profiles according to liver lesions identified three peaks (CM10-7558.4, CM10-7924.2 and Q10-7926.9) the intensity of which significantly increased according to the severity of the liver lesions (steatosis and NASH) and returned to normal after bariatric surgery. None was correlated with either liver function tests or metabolic parameters. Identification using immunoSELDI assay characterised these peaks as the double charged ions of α- and β-haemoglobin subunits. Conclusion: The differential proteomic method demonstrated changes in serum protein profiles in obese patients according to severity of liver lesions. Free haemoglobin subunits may serve as a serum biomarker of the severity of liver damages.

Influence of acetaminophen at therapeutic doses on surrogate markers of severity of acute viral hepatitis.

OBJECTIVES Data on the influence of acetaminophen intake on acute viral hepatitis is scarce, but it could play a role in the worsening of this disease. The aim of this study was to determine whether the intake of acetaminophen at therapeutic doses affects the severity of acute viral hepatitis. METHODS This was a prospective study concerning 37 consecutive patients hospitalized for acute viral hepatitis. Acetaminophen consumption and time since last intake were assessed by a questionnaire. Parameters of severity were studied in comparison to time related serum concentrations of acetaminophen. RESULTS Patients hospitalized for acute viral hepatitis (18 male, 19 female patients) had a mean age of 29.2 +/- 11.5 years. The causal virus was HAV (n=23), HBV (n=7) and other viruses (n=8). The mean cumulated dose of acetaminophen was 7.7 +/- 5.65 g. The daily dose did not exceed the therapeutic dosage and the mean was 1.95 +/- 0.81 g (1-3 g). Patients who received 7.5 g of acetaminophen or more had a lower prothrombin index 52.4 +/- 30.3% vs 74.2 +/- 17.2% (P=0.039), and a lower factor V 54.7 +/- 33.2% vs 83.3 +/- 19.6% (P=0.033). Prothrombin index and bilirubinemia were negatively correlated with time related plasma acetaminophen concentrations. CONCLUSIONS The use of acetaminophen at therapeutic doses was associated with greater alterations of surrogate markers of the severity of acute viral hepatitis especially hepatitis A. This was related to cumulated dosages and correlated to the time related acetaminophen plasma concentrations. Acetaminophen use should be interrupted when acute hepatitis is suspected.

Isolated fever induced by mesalamine treatment

Adverse reactions to mesalamine, a treatment used to induce and maintain remission in inflammatory bowel diseases, particularly ulcerative colitis, have been described in the literature as case reports. This case illustrates an unusual adverse reaction. Our patient developed an isolated fever of unexplained etiology, which was found to be related to mesalamine treatment. A 22-year-old patient diagnosed with ulcerative colitis developed a fever with rigors and anorexia 10 d after starting oral mesalamine while his colitis was clinically resolving. Testing revealed no infection. A mesalamine-induced fever was considered, and treatment was stopped, which led to spontaneous resolution of the fever. The diagnosis was confirmed by reintroducing the mesalamine. One year later, this side effect was noticed again in the same patient after he was administered topical mesalamine. This reaction to mesalamine seems to be idiosyncratic, and the mechanism that induces fever remains unclear. Fever encountered in the course of a mesalamine treatment in ulcerative colitis must be considered a mesalamine-induced fever when it cannot be explained by the disease activity, an associated extraintestinal manifestation, or an infectious etiology.

Unusual etiology of epigastric pain.

BACKGROUND Epigastric pain is a common presenting complaint encountered in urgent care settings. Although peptic, biliary, and pancreatic pathologies are the most frequent findings, other rare diagnoses also can be found. OBJECTIVES We report an unusual case of acute epigastric pain in which abdominal ultrasound was of great support in revealing the diagnosis. CASE REPORT A 64-year-old man presented to the Emergency Department after rapid onset of acute epigastric pain. Abdominal ultrasound showed a multi-cystic heterogeneous mass between the stomach and the liver. Abdominal computed tomography scan confirmed the gastric origin of the mass and showed torsion signs. Urgent laparotomy was performed with tumor excision. The diagnosis of pedunculated exophytic gastric stromal tumor was made and long-term follow-up was arranged. CONCLUSIONS Acute presentation revealed the presence of the tumor, which was excised surgically.

Pheochromocytoma: a tumour not to be trusted

A 59-year-old male with liver cirrhosis secondary to non-alcoholic steatohepatitis, and prior history of aesophageal variceal bleeding underwent abdominal magnetic resonance imaging (MRI) for increasing a-fetoprotein plasma levels. He was also known to have long-lasting diabetes mellitus. His medication included propranolol for prevention of rebleeding. The examination was performed on a Signa 1.5 Tesla (General Electric, Milwaukee, WI, USA) machine. It showed a dysmorphic but otherwise unremarkable liver, mild splenomegaly, moderate ascitis and a well-circumscribed, heterogeneous, highly enhancing extra-adrenal mass, measuring 5.8 cm, located to the right side of the aorta under the renal hilum (Figs 1–3). Extra-adrenal pheochromocytoma, or paraganglioma, was the first proposed diagnosis. However, because biological markers were normal (serum catecholamines, 24 h urinary catecholamines and urinary vanillylmandelic acid (VMA) levels), other diagnoses were suggested including retroperitoneal sarcoma and adenopathy secondary to hypervascular primary tumour such as neuroendocrine, melanoma, kidney, breast, thyroid or colon. Percutaneous computed tomography (CT)-guided biopsy was performed without premedication and without any side effect. During this procedure carried out without intravenous contrast injection, the highest density in the tumour was 23 Hounsfield units. Histology concluded to a pheochromocytoma. A surgery was planned, and, because the tumour was clinically and biologically silent and because biopsy was not complicated, it was decided not to prepare the patient with a-blockers. Unfortunately the patient developed a hypertensive crisis with a systolic blood pressure reaching 230 mmHg when the surgeon touched the tumour. The blood pressure was rapidly controlled, and the tumour was completely removed. The patient had unremarkable post-operative recovery. Most pheochromocytomas occur in the adrenal gland. However, extra-adrenal or ectopic pheochromocytomas do occur in 15–20% of cases and can be located in any organ containing chromaffin cells, mainly in the abdomen. The diagnosis of pheochromocytoma is easy when clinical signs and biological markers such as elevation of plasmatic concentration of catecholamines and 24-h urinary concentration of VMA are present, and the role of imaging is to localise the tumour prior to surgical removal. However, in about 10% of patients, there may be no or few symptoms and physical signs as in our

Prospective Audit of Colonoscopy Practice in a Lebanese University Hospital

Background Colonoscopy has a great impact on diagnosis and management of the diseases of the colon. In general its a safe and accurate procedure. No evaluation has been done of any endoscopic practices in a country where the practice of medicine is totally private. Objectives Prospective audit of technical success and complication rates of both therapeutic and diagnostic colonoscopy. Setting One endoscopy unit of a Lebanese university hospital. Patients and design 407 consecutive colonoscopies were evaluated over a 6-month period. Data were recorded for age and sex of the patients, indication of the colonoscopy, presence of comorbidities, patients risk stratification, administrated dose of anesthetic drugs. Data concerning the procedure itself were also monitored. Intervention Completion rate as well as complications reported during or post colonoscopy. All patients were called back by phone 48 hours and 1 month later to identify any related post-procedural complication. Results 407 patients underwent colonoscopy. All patients were sedated with midazolam, propofol and fentanyl. The overall caecal intubation rate was 99.99%. 70 snare polypectomies and 29 cold forceps excision were performed as well as 5 coagulations with Argon Plasma Coagulation. The most important post-procedural complication was chemical colitis in 2 cases. Limitations Patients and endoscopists satisfaction was not evaluated. Its an audit of a single tertiary French affiliated hospital. It does not necessarily reflect whats really happening on a national level. Conclusion This audit enabled us to change some of our practices; i.e. rinsing method of endoscopes. It stimulated the team to keep a high performance level without neglecting the risk of potential complications.

An unusual internal pile

A 60 year old female underwent total colonoscopy for recurrent painless haematochezia. She reported no past medical history of abdominal or anorectal symptoms. Physical examination was unremarkable. …