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Hepatitis D virus (HDV) infection is a global public health concern, especially because of its unique existence in the presence of hepatitis B virus infection. HDV infection is estimated to affect 12 million people globally. Having a clearer understanding of its prevalence in all regions of the world is essential for helping direct preventive and early interventional treatment. This mini-review assessed the literature over the last 10 years to determine the prevalence, diagnostic means and treatment guidelines available for HDV in the Middle East. The search found limited data available in 21 articles, of which 18 were studies focused on Iran. Prevalence rates ranged dramatically among the countries, and none of the 12 countries included in the search had specific HDV guidelines. This review highlights the urgent need for more precise data for the Middle East region to help establish early diagnosis and treatment options for HDV.

Ulcerative colitis and Crohn's disease are the main entities of inflammatory bowel disease characterized by chronic remittent inflammation of the gastrointestinal tract. The incidence and prevalence are on the rise worldwide, and the heterogeneity between patients and within individuals over time is striking. The progressive advance in our understanding of the etiopathogenesis coupled with an unprecedented increase in therapeutic options have changed the management towards evidence-based interventions by clinicians with patients. This guideline was stimulated and supported by the Emirates Gastroenterology and Hepatology Society following a systematic review and a Delphi consensus process that provided evidence- and expert opinion-based recommendations. Comprehensive up-to-date guidance is provided regarding diagnosis, evaluation of disease severity, appropriate and timely use of different investigations, choice of appropriate therapy for induction and remission phase according to disease severity, and management of main complications.

In the early twentieth century, the world witnessed important political, economic and social transformations and changes that had the greatest impact on the process of development of societies and defining their female characteristics and their distinctive features. The decade of the thirties was one of the most important historical periods in that period due to the characteristics and features it witnessed in political and social changes such as the collapse of the global stock exchange in The year 1929 led to the great global economic depression, which led to a period of austerity with the cessation of industrial business - commercial agriculture and the cessation of the movement of sale and purchase, unemployment, hunger and standing hours to get a loaf of bread, and the socio-historical method of studying art proved that there is a close connection between The political, economic and social conditions prevailing in a society.

Introduction: Hepatitis B virus (HBV) infection remains a worldwide public health problem. The last major review of the epidemiology and management of HBV in the Middle East was published in 2011. This paper aims to assess the current situation of the HBV care pathway in the United Arab Emirates (UAE), identify gaps in our knowledge and barriers therein, and recommend initiatives to be taken to improve the management of such patients. Methods: A literature search was conducted in PubMed as well as through free internet searches. Interviews and group discussions were held with key opinion leaders and HBV experts. Results: The national prevalence of HBV is estimated to be approximately 1.0–1.5%; however, prevalence is expected to be higher in those >25 years of age born before the introduction of the HBV vaccination programme. There is limited data on the burden of HBV-related hepatocellular carcinoma in the country. Discussion: Awareness of various aspects of the disease is perceived to be low among the general population and medium among healthcare providers. There are several mandated national screening structures present; however, there are no country-specific HBV guidelines regarding diagnosis, linkage-to-care, treatment, and follow-up. Improvements have been made in the past 30 years in the UAE, evident through a decline in prevalence. The burden attributable to HBV complication and the coverage of screening and treatment remain unclear. Conclusion: Key stakeholders in all areas of the HBV care pathway must reduce morbidity and mortality in the UAE population, and interventions should be supported by research.

Azathioprine (AZA) is commonly used in inflammatory bowel disease (IBD) patients. Lymphopenia is a recognized effect of this treatment, but lymphopenia-related complications in IBD patients have not been widely reported. The incidence and progression of AZA-induced lymphopenia in IBD patients is not well described. There is no consensus on its optimal management in this group.We assessed the incidence and progression of lymphopenia and its related complications in a cohort of IBD patients over a 14-month period in two large tertiary gastroenterology units. Analysis of prospectively collected data was performed.Fifty-two patients were studied prospectively with a median age of 34 years. Eighteen patients (34.6%) developed lymphopenia (1.0×10(9)/l) during the course of treatment and 10 of them had severe lymphopenia (0.6×10(9)/l). Lymphopenia lasted on average 85.4 days and spontaneously resolved in 13 patients. No lymphopenia related-complications were documented. Patients treated with steroids had a significantly higher rate of lymphopenia (83.3 vs. 44.1%, P=0.0083).Lymphopenia is common among IBD patients treated with AZA. However, it did not seem to be associated with a higher risk of opportunistic infections and spontaneously resolved in the majority of cases.

Long-term outcome in primary biliary cirrhosis (PBC) remains unclear. Whilst response to ursodeoxycholic acid (UDCA) is associated with good outcome, this effect is not universal. Early data from our group have suggested that one factor associated with a poorer outcome in PBC is fatigue. The aim of this study was to explore the inter-relationship between UDCA use, response, and fatigue in determining outcome over 9 years in a unique, comprehensive patient cohort.Longitudinal prospective study of a geographically-defined complete cohort of PBC patients in North-East England and matched community controls.Survival to death or transplant was significantly lower in PBC patients than in the case-control population (88/136 (65%) v 114/136 84% (p0.001 by log-rank test), with better survival in UDCA responders (defined using the Paris criteria) than in patients not treated with UDCA at study outset. Compared to the whole control group survival was reduced in PBC patients fatigued at study outset but not in those without fatigue (p0.0001); an effect independent of the beneficial effect of UDCA response and of conventional parameters of liver disease severity. UDCA responders without fatigue at the study outset had a 9 year survival which was identical to controls. Patients without fatigue at the study outset who developed fatigue during follow-up had significantly worse survival than patients who remained without fatigue throughout (p0.05). Fatigued controls had worse survival than non-fatigued controls (p = 0.05).Survival in a comprehensive cohort of PBC patients is substantially reduced compared with case-matched community controls. Development of fatigue and non-treatment with UDCA were specifically (and independently) associated with increased risk of death in PBC.

Patients with primary sclerosing cholangitis (PSC) frequently highlight the impact of fatigue on their life quality. The study aims were to evaluate fatigue and its associations in PSC and investigate whether overt autonomic dysfunction contributes to the expression of fatigue.All PSC patients under active follow-up at a regional liver centre were sent disease- and symptom-assessment tools. Three control groups were utilized; unselected community controls, patients with inflammatory bowel disease (IBD) without PSC, and cholestatic controls with primary biliary cirrhosis (PBC). A representative subgroup of PSC patients and normal controls underwent formal autonomic assessment.Symptom-assessment tools were returned by 40 non-transplanted patients. PSC patients had significantly worse fatigue than population controls (P = 0.005). Fatigue was significant compared to population controls whether or not patients had accompanying IBD, although was more marked in those with both PSC and IBD. In patients with PSC and IBD, fatigue severity and autonomic symptoms were significantly increased in those with prior significant surgical intervention. Clinically significant autonomic dysfunction was seen in 22.5% of PSC patients, and of those, 78% had significant fatigue. Neurally mediated hypotension was found in 60% of PSC patients compared to 8% in the control group. The PSC group had increased sympathetic activity and reduced parasympathetic activity.Fatigue is a significant problem in a minority of PSC patients and appears to be associated with autonomic dysfunction. Fatigued PSC patients should be screened for autonomic dysfunction and targeting such dysfunction represents a potential approach to treatment which warrants further exploration.

Background and aim Limited data suggests that pseudomembranes are uncommon in patients with inflammatory bowel disease (IBD) and C. difficile associated disease (CDAD), but the reason for this is unknown. We aimed to evaluate the rate of pseudomembranes in this population, identify predictive factors for pseudomembranes' presence and assess its clinical impact. Methods This was a sub-study of a retrospective European Crohn's & Colitis Organization (ECCO) multi-center study on the outcome of hospitalized IBD patients with C. difficile. The present study included only patients who underwent lower endoscopy during hospitalization, and compared demographic and clinical parameters in the group of patients with discernable pseudomembranes versus those without. Results Out of 155 patients in the original cohort, 93 patients underwent lower endoscopy and constituted the study population. Endoscopic pseudomembranes were found in 12 (13%) of these patients. Patients with pseudomembranes presented more commonly with fever (p = 0.02) compared to patients without pseudomembranes. No difference between the two groups was found with respect to the use of immunosuppressant drugs, background demographics or disease characteristics. Neither was there a difference between the group with or without pseudomembranes in the frequency of severe adverse clinical outcome or in the duration of hospitalization. On multi-variate analysis the presence of fever remained independently associated with the finding of pseudomembranes (OR 6, 95% CI 1.2–32, p = 0.03). Conclusions This study documents that hospitalized IBD patients with CDAD have low rate of endoscopic pseudomembranes, which is not accounted for by the use of immunosuppressant drugs. IBD patients with CDAD and discernable pseudomembranes more commonly present with fever, but their clinical outcome is similar to patients without pseudomembranes.

This paper proposes Utility Based Adaptive Frequency Hopping (UBAFH), an adaptive hopping technique implementing a new paradigm for frequency hopping systems. Traditional adaptive algorithms aim at identifying bad channels that are consequently removed from the hopset. UBAFH instead utilizes all the available frequencies but assigns different usage probabilities to different channels according to the experienced channel conditions. Opportune upper and lower limits are used in order to bound these usage probabilities and achieve a desired level of frequency diversity. We simulate the behavior of UBAFH over frequency selective fading channels and compare the achieved packet error rate and throughput with the ones of IEEE 802.15.1 and with the adaptive frequency hopping implementation proposed by IEEE 802.15.2 showing that UBAFH outperforms both approaches.

Introduction Patients with liver cirrhosis admitted to an ICU are believed to have a poor prognosis with high mortality despite significant use of resources. Most of the literature to date on this topic has been collected at hospitals with Specialist Liver Units and these results may not be representative of the outcome at general ICUs. A recent prospective study of cirrhotic patients admitted to a tertiary Liver ICU in the UK demonstrated an overall hospital mortality of 59%. The aim of this study was to determine the outcome of cirrhotic patients admitted to non-specialist ICUs. Methods Data was retrospectively collected from four hospitals in the NW region of the UK without specialist liver ICUs. Patients were identified using the Intensive Care National Audit and Research Unit (ICNARC) database. 61 patients with liver cirrhosis admitted to a general ICU between January 2010 and January 2012 were included in this study. Results Age range was 30 to 79 years (average 51 years). 80% of patients were male and alcohol was the commonest aetiology for liver cirrhosis (90%). The main reason for admission to ICU was for gastrointestinal bleeding (38%). 51% of patients had a Child Pugh score of C on admission to ICU. 46% of patients had a MELD score between 10 and 19 and 28% had a score between 20 and 29. 79% of patients required invasive ventilatory support, 49% required vasopressors and 21% needed renal replacement therapy. 51% developed further decompensation of their liver disease during their ICU stay. These included GI bleeding (21%), hepatic encephalopathy (15%), HRS (11%) and SBP (3%). 67% of patients had an ICU stay of Conclusion Patients with liver cirrhosis admitted to general ICUs have similar rates of mortality compared to those in tertiary liver ICUs. Therefore, admission to such units should not be deemed futile in cirrhotic patients and earlier admission may improve outcome. Disclosure of Interest None Declared

Corrigendum to ‘‘The independent effects of fatigue and UDCA therapy on mortality in primary biliary cirrhosis: Results of a 9 year cohort follow-up’’ J. Hepatol. 2010 Nov; 53(5):911–917 David E. Jones1,⇑, Ahmad Al-Rifai, James Frith, Imran Patanwala, Julia L. Newton Institute of Cellular Medicine, Newcastle University, Newcastle-upon-Tyne, UK; Institute for Ageing and Health, Newcastle University, Newcastle-upon-Tyne, UK

P129 The impact of concomitant treatment with immuno-modulators and antibiotics on the outcome of C. difficile-associated inflammatory bowel disease exacerbation: an ECCO multi-center retrospective study S. Ben-Horin1 *, M. Margalit2, P. Bossuyt3, J. Maul4, Y. Shapira5, D. Bojic6, I. Chermesh7, A. Al-Rifai8, A. Schoepfer9, M. Bosani10, M. Allez11, P.L. Lakatos12, F. Bossa13, A. Eser14, T. Stefanelli15, F. Carbonnel16, K. Katsanos17, D. Checchin18, I. Saenz de Miera19, Y. Chowers1, G.W. Moran20. 1Sheba Medical Center, Ramat-Gan, Israel, 2Haddassa Medical Center, Hebrew University, Jerusalem, Israel, 3University of Leuven Hospitals, Leuven, Belgium, 4Charite-Universitatsmedizin, Berlin, Germany, 5Tel-Aviv Medical Center, Tel-Aviv, Israel, 6Zvezdara University Medical Center, Belgrade, Serbia, 7Rambam Medical Center, Haifa, Israel, 8Salford NHS University Hospital, Manchester, United Kingdom, 9University Hospital of Bern, Bern, Switzerland, 10Sacco University Hospital, Milan, Italy, 11Saint-Louis Hospital, Paris, France, 12Semmelweis University, Budapest, Hungary, 13Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy, 14Medical University of Vienna, Vienna, Austria, 15Universita degli Studi di Milano, Milan, Italy, 16University hospital of Besancon, Besancon, France, 17Univeristy Hospital of Ioannina, Ioannina, Greece, 18University of Padua, Padua, Italy, 19Hospital General Yague, Burgos, Spain, 20University of Birmingham, Birmingham, United Kingdom