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Introduction There is a lack of studies on the optimal anti-tumor necrosis factor (anti-TNF) agent for postoperative prophylaxis of Crohn's disease (CD) recurrence. Therefore, we conducted a network meta-analysis (NMA) of prospective trials to compare the efficacy of anti-TNF agents in the prevention of postoperative endoscopic and clinical recurrence of CD following ileocolonic resection. Methods We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, and recent American gastroenterology association (AGA) meeting abstracts through August 2017. We selected prospective studies comparing anti-TNF agents among each other or to other agents in the setting of postoperative prevention of CD recurrence. We performed a NMA using a frequentist approach with generalized pairwise modeling and inverse variance heterogeneity method. Results We identified 9 studies, including 571 patients and 5 treatment agents, among which 2 anti-TNF drugs (adalimumab and infliximab). Compared with infliximab, our NMA yielded the following results for endoscopic recurrence: adalimumab [odds ratio (OR), 0.92; 95% confidence interval (CI), 0.18-4.75], thiopurines (OR, 4.11; 95% CI, 0.68-24.78), placebo (OR, 4.39; 95% CI, 0.70-27.68), and Mesalamine (OR, 37.84; 95% CI, 3.77-379.42). For clinical recurrence: adalimumab (OR, 1.03; 95% CI, 0.17-6.03), thiopurines (OR, 1.40; 95% CI, 0.20-10.02), placebo (OR, 1.77; 95% CI, 1.01-3.10), and mesalamine (OR, 16.54; 95% CI, 1.55-176.24). Conclusions On the basis of a NMA combining direct and indirect evidence either adalimumab or infliximab may be used in the postoperative prophylaxis of CD recurrence. There is currently a lack of evidence on the use of other anti-TNF agents in this setting.

Background: Adherence to therapy in chronic diseases such as inflammatory rheumatic diseases (CIRD), inflammatory bowel diseases (IBD) and psoriasis (Pso) is a major condition to achieve positive outcomes. Patient support programs (PSPs) were developed to improve the quality of care and enhance adherence to therapy. Objectives: To evaluate the perception of patients treated for inflammatory chronic diseases towards PSPs. Methods: All available PSPs were identified at the national level, and their services were classified into categories: financial, logistic, educational, and emotional support. Consecutive adult patients with CIRD, IBD and Pso, enrolled in a PSP for more than 3 months, were interviewed by a trained medical student. Demographic data, disease and treatment characteristics were collected at the physician’s clinic. Global satisfaction was estimated using a 5-points Likert scale, adherence to treatment was measured by the Compliance Questionnaire for Rheumatology (CQR), PSPs services were classified according to their importance to the patient using a 5-points Likert scale. An open questionnaire identified the patients’ perceptions qualitatively. Predictive factors of satisfaction were identified. Results: Forty-seven patients were included in the study, 53% were males, with a mean age of 49.8 years (SD 15.2) (Patients’ characteristics in Table 1). The majority declared that the PSP was very useful (95.7%) and were highly satisfied with the programs (97.9%). Higher attributes were assigned, by decreasing order, to: financial (copay program, providing of free samples), logistic (hotline, refrigerating box), educational (educational material) and emotional support. Nursing services and telephone reminders were rated as least important (Figure 1). Most open comments gave higher appreciation to financial support (54%), followed by education (38%) and logistics (8%). High appreciation of education was associated with lower age, type of treatment and PSP. Shorter treatment duration was associated with appreciation of educational material, emotional support and telephone reminders. Conclusion: Patients were highly satisfied with PSP programs, and ranked the financial support as the most important followed by logistics, whereas education, nursing services and telephone reminders were found less important. Lower age and shorter treatment duration were associated with higher appreciation of education and support. References [1] Rubin D, Mittal M, Davis M, et al. Impact of a Patient Support Program on Patient Adherence to Adalimumab and Direct Medical Costs in Crohn’s Disease, Ulcerative Colitis, Rheumatoid Arthritis, Psoriasis, Psoriatic Arthritis, and Ankylosing Spondylitis. J Manag Care Spec Pharm. 2017;23(8):859-67. [2] Gangi A, Clewell J, Shillington A. The impact of patient support programs on adherence, clinical, humanistic, and economic patient outcomes: a targeted systematic review. Patient Preference and Adherence 2016:10 711–725. [3] Van den Bosch F, Ostor A, Wassenberg S, et al. Impact of Participation in the Adalimumab (Humira) Patient Support Program on Rheumatoid Arthritis Treatment Course: Results from the PASSION Study. Rheumatol Ther (2017) 4:85–96. Disclosure of Interests: None declared

Objective Traumatic life events are important risk factors for eating disorders (ED). War has been associated, in military populations, with an increased post-service incidence of ED and an increased mean body mass index. We hypothesize that a modification of eating behavior (EB) related to stress during wartime may increase the risk of developing an ED later on among civilians exposed to war stress during adulthood. Methods This descriptive cross-sectional study was performed in a group of 303 undergraduate young adult students of both sexes from Lebanon, 6 months after the July 2006 war. Modification of EB during wartime, sociodemographic and other potential risk factors were assessed retrospectively. Students were then screened for ED using the SCOFF questionnaire. Results SCOFF was positive in 31.4% of the students, with a mean value 41.6% higher among subjects who reported an altered EB during the war. Among subjects with a positive SCOFF screening, 71% had experienced a change of EB during wartime. Alteration of EB during war was related to an odds ratio for a positive SCOFF screening of 2.6 (95% CI 1.54–4.34) and 1.8 (95% CI 1.01–3.21) for non-adjusted and adjusted analysis, respectively. Conclusions Modification of EB related to stress during wartime is associated with an increased risk of eating disorders. Early detection and treatment of eating disorders may be improved by routinely evaluation of EB modification in patients with a past history of war exposure.

The high prevalence of eating disorders in Arab countries indicates a need for an Arabic language screening tool. This study aimed to validate an Arabic version (A-SCOFF) of the British SCOFF questionnaire, a brief tool for the screening of eating disorders in primary health care. After translation and back-translation the A-SCOFF was given to 123 female patients [mean age 32 (SD 8.8) years] visiting primary health-care centres in Beirut. Each patient was evaluated by an eating disorders specialist blinded to A-SCOFF results. The validated Arabic version of the Mini International Neuropsychiatric Interview and the DSM-IV criteria for eating disorders were used as diagnostic references. The best diagnostic threshold for the A-SCOFF was found to be at 2 positive answers with a sensitivity of 80.0%, a specificity of 72.7% and an area under the curve of 80.0%. The A-SCOFF questionnaire is accurate and reliable for the early detection of eating disorders in this high-risk population.التحقق من صحة النسخة العربية لاستبيان سكوف (SCOFF) الخاص بتحري اضطرابات الأكل.انطوان عون، جاد عزام، فلورا الجبور، ساني حليس، داني دهام، شربل العم، خليل حنين، بيار دشلوت.إن ارتفاع معدل انتشار اضطرابات الأكل في البلدان العربية يجعل من الروري وجود أداة للتحري باللغة العربية. وقد هدفت هذه الدراسة إلى التحقق من صحة النسخة العربية (A-SCOFF) لاستبيان SCOFF البريطاني؛ وهي أداة مخترة لتحري اضطرابات الأكل في الرعاية الصحية الأولية. فبعد الترجمة والترجمة العكسية تم إعطاء A-SCOFF إلى 123 مريضة ]متوسط أعمارهن 32 (SD 8.8) سنة[ من اللواتي يَزُرْنَ مراكز الرعاية الصحية الأولية في بروت. وتم تقييم كل مريضة من قبل متخصص باضطرابات الأكل لا يعرف نتائج A-SCOFF. واستخدمت النسخة العربية المصادق عليها لمعاير المقابلة العصبية النفسية الدولية المصغرة ومعاير DSM-IV (الدليل التشخيصي الإحصائي الرابع) الخاصة باضطرابات الأكل كمراجع تشخيصية. فوجد أن أفضل عتبة تشخيصية لل A-SCOFF عى إجاباتن إيجابيتن كانت ذات حساسية مقدارها 80.0% وخصوصية مقدارها 72.7% ومنطقة تحت المنحنى مقدارها 80.0% . ولقد خلصنا أن الاستبيان A-SCOFF دقيق وموثوق للكشف المبكر عن اضطرابات الأكل لدى هذه الفئة السكانية ذات الخطورة العالية.Validation de la version en langue arabe du questionnaire SCOFF pour le dépistage des troubles alimentaires.La forte prévalence des troubles alimentaires dans les pays arabes indique la nécessité d’un outil de dépistage en langue arabe. La présente étude visait la validation de la version en langue arabe (SCOFF-A) du questionnaire SCOFF britannique, un outil succint pour le dépistage des troubles alimentaires en soins de santé primaires. Après traduction et rétrotraduction, le questionnaire SCOFF-A a été administré à 123 patientes (âge moyen 32 ans [ET 8,8 ans]) consultant dans des centres de soins de santé primaires à Beyrouth. Chaque patiente a été évaluée par un spécialiste des troubles alimentaires n’ayant pas eu connaissance des résultats au questionnaire SCOFF-A. La version en langue arabe validée du bref entretien neuropsychiatrique Mini International Neuropsychiatric Interview et les critères du DSM-IV pour les troubles alimentaires ont été utilisés en tant que références diagnostiques. Le meilleur seuil diagnostique pour le questionnaire SCOFF-A a été déterminé à deux réponses positives avec une sensibilité de 80,0 %, une spécificité de 72,7 % et une aire sous la courbe de 80,0 %. Le questionnaire SCOFF-A est précis et fiable pour le dépistage précoce des troubles alimentaires dans cette population à haut risque.

Keywords: Candida; hepatic candidiasis; kidney;liver; mycosis; transplantationThe incidence of hepatic candidiasis is difficultto estimate because of diagnostic difficulties. Itsfrequency was 7% in a study of 562 adult patientswith leukaemia [1]. Hepatic candidiasis (HC), alsoreferred to as chronic disseminated candidiasis,hepatosplenic candidiasis and granulomatous hepaticcandidiasis, affects almost exclusively patients under-going remission induction chemotherapy or bonemarrow transplantation for acute leukaemia [2].It occurs on recovery following prolonged episodesof bone marrow dysfunction and neutropenia [1].Theliver,spleenandsometimesthekidneysareinfectedwith Candida. Occasionally, patients with other typesof immunosuppression (aplastic anaemia, lymphoma,sarcoma or liver transplantation) may develophepatosplenic candidiasis [3]. This is the first reportedcase of HC in a kidney transplant recipient.

Drug-induced liver injury (DILI) represents liver damage from various therapeutic drugs. Antimicrobials are among the most common causes of DILI. We report a case of hepatic toxicity due to Trimethoprim-sulfamethoxazole (TMP-SMX) in a patient who underwent renal transplantation. Diagnosis has been made after a careful history taking, exclusion of competing etiologies and reversal of biochemical abnormalities after withdrawal of the antibiotic. TMP-SMX liver toxicity is well known but remains unpredictable and is rarely reported.

We are reporting the rare case of splenic artery aneurysm of 4 cm of diameter presenting as a sub mucosal lesion on gastro-duodenal endoscopy. This aneurysm was treated by endovascular coil embolization and stent graft implantation. The procedure was uneventful. On day 1, the patient presented an acute severe epigastric pain and cardiovascular arrest. Abdominal computed tomography scan showed an active leak of the intravenous contrast dye in the peritoneum from the splenic aneurysm. We performed an emergent resection of the aneurysm, and peritoneal lavage. Postoperatively, hemorrhagic choc was refractory to large volumes replacement, and intravenous vaso-active drugs. On day 2, he presented massive hematochezia. We performed a total colectomy with splenectomy and cholecystectomy for ischemic colitis, with spleen and gallbladder infarction. Despite vaso-active drugs and aggressive treatment with Factor VIIa, the patient died after uncontrolled disseminated intravascular coagulation.

To study the epidemiology of HCC in Lebanon and prognostic factors predictive of early mortality.An observational follow-up cohort study of HCC cases diagnosed over a five-year period was carried out. Multivariate analysis was conducted to identify prognostic factors in comparison to Cancer of the Liver Italian Program (CLIP) score. Multiple variables including the etiology of underlying liver disease, the demographic characteristics of patients, and the severity of liver disease evaluated by the Child-Pugh score were studied. Tumor parameters included the time of diagnosis of HCC, alpha-fetoprotein level, number and size of nodules, presence of portal vein thrombosis, and treatment modalities. Death or loss of follow-up was considered as an end-point event.Ninety-two patients (mean 60.5 +/- 22.3 years) were included. Etiology of underlying disease was hepatitis B, C, and alcohol in 67%, 20%, and 23.5% respectively. Child-Pugh class at diagnosis was A, B, and C in 34.8%, 39.3% and 25.8% respectively. Overall survival was 44.8%, 32.8% and 17.6% at 1, 2 and 3 years respectively (mean F/U 40.2 +/- 23.5 mo). Multivariate analysis identified three predictors of early mortality (6 mo): bilirubin3.2 mg/dL (P0.01), HCC as first presentation of liver disease (P = 0.035), and creatinine1 mg/dL (P = 0.017). A score based on these variables outperformed the CLIP score by Cox proportional hazard. ROC curve showed both models to be equivalent and moderately accurate.HBV is the leading cause of HCC in Lebanon. Independent predictors of early mortality are elevated bilirubin, creatinine and HCC as first manifestation of disease. Prospective validation of a score based on these clinical parameters in predicting short-term survival is needed.

A 31 year old woman presented with vaginal faecal discharge and anal pain. Her past medical history was significant for a 20 year history …

Anomalous pancreaticobiliary junction with cystic dilatation of the biliary tract is usually associated with carcinoma arising from the cyst wall. We report an extracystic location of biliary carcinoma in the presence of anomalous pancreaticobiliary junction and cysts in a patient with obstruction of the origin of the left hepatic duct who underwent hepatobiliary resection. Cholangiocarcinoma was found to have arisen in a noncystic left hepatic duct, in conjunction with cystic dilatation involving both the cystic and common bile ducts. The present case supports a relationship between anomalous pancreaticobiliary junction and biliary carcinogenesis that may affect the extracystic biliary tree.

t m n w a m 39-year-old man presented with a 6-year history of ecurrent episodes of nonfebrile, diffuse, crampy, abominal pain, nausea, and bloating, with normal bowel ovement. These episodes occurred 1 to 2 times per ear, lasting 36 hours, and resolved spontaneously. In the revious 6 months he noted an increase in frequency and everity of recurrences along with a weight loss of 6 kg 10% of body weight). He had an unremarkable past edical history without any abdominal surgery or liver isease, and he wasn’t taking any medication. On examnation, the abdomen was flat with mild nonspecific iffuse tenderness. There was no palpable mass. Bowel ounds were weak. Routine blood analysis was normal. pper gastrointestinal endoscopy and colonoscopy with erminal ileoscopy were normal. Contrast-enhanced CT of the abdomen showed a hickening of the last 20 cm of the distal jejunum surounded by a moderate dilatation of the proximal jejuum and by a conglomeration of ileal loops (A). The last 0 cm of the ileum were normal, as was the colon. A mall-bowel followthrough revealed a bowel wall thickning of a distal jejunal loop without mucosal abnormalties followed by a “cauliflower-like” disposition of the leum loops situated 10 cm above the ileocecal valve (B, rrowheads). An abdominal MRI confirmed the images f the CT scan. f

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.

Background Colonoscopy has a great impact on diagnosis and management of the diseases of the colon. In general it's 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. It's an audit of a single tertiary French affiliated hospital. It does not necessarily reflect what's 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.

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. …

A 17 year old woman presented to the emergency room after accidental ingestion of a toothbrush. The patient tearfully admitted that she had been self inducing vomiting to control her weight for the …

A 52 year old man with a known history of renal stones presented with symptoms and signs of right renal colic. No fever or infectious signs were noted. Right ureteral …

A 55 year old woman with no significant past medical history presented with abdominal pain and vomiting. She was totally asymptomatic before this episode. Twenty four hours prior …

A 45 year old woman presented with longstanding dyspepsia associated with oedema and a 4 kg weight loss over the previous six months. She gave no history of haematemesis or blood in stool, …

A 24 year old woman was admitted for severe and recurrent vomiting. Her complaints began 12 months earlier when she started by having occasional postprandial vomiting …

Pancreatic tuberculosis is an extremely rare form of extrapulmonary disease. The diagnosis preoperatively is difficult because clinical, laboratory and radiologic findings are nonspecific. Published data indicate that these lesions mimic cystic neoplasms of the pancreas and the confirmation of clinical suspicion could only be obtained by an open surgical biopsy. Recently, fine needle aspiration cytology has been shown to be a safe, reliable and cost-effective alternative. We report a new case of a peripancreatic tuberculosis in a 52 year old woman and review the relevant literature, paying special attention to the usefulness of endoscopic ultrasound guided-fine needle aspiration in the diagnosis of abdominal tuberculosis.