Exposure and resistance to anticoagulant rodenticides in invasive and endemic Chadian urban rodent species to develop a rational management strategy.

Rodent management involves the use of anticoagulant rodenticides (ARs). This use has resulted in the selection of numerous resistance alleles in the Vkorc1 gene, encoding the target enzyme of ARs. In Africa, although rodents are a major problem as a consequence of their transport and transmission of zoonotic pathogens, and damage to crops, the use of ARs and the spread of resistance alleles are poorly documented. We attempted to address both issues in Chad which is one of the largest countries in Africa. Owing to its location at the crossroads of central and northern Africa, Chad is representative of many African countries. METHODS: Using a sampling of nearly 300 rodents composed of invasive and endemic rodents collected in six of Chad's largest cities, exposure to ARs was analyzed by their quantification in the liver; the spread of AR resistance alleles was analyzed by Vkorc1 sequencing. RESULTS: We demonstrate the use of both ARs generations in Chadian cities and report the total sequencing of the Vkorc1 for 44 Mastomys natalensis with detection of two different haplotypes, the sequencing of the Vkorc1 for two other endemic rodent species, M. kollmannspergeri and Arvicanthis niloticus, and finally the detection of three new missense mutations - V29E, V69E and D127V - in R. rattus, potentially associated with resistance to ARs. DISCUSSION: These results should argue for the implementation of a reasoned management of rodent populations in Africa to avoid the spread of ARs resistance alleles. © 2023 The Authors. Pest Management Science published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

Interest of the faecal and plasma matrix for monitoring the exposure of wildlife or domestic animals to anticoagulant rodenticides.

Anticoagulant rodenticides (ARs), particularly second-generation compounds (SGAR), are known to be a potential threat to unintended species due to their tissue persistence. The liver is the storage tissue of ARs and is a matrix of choice in diagnosing exposure and intoxication of non-target fauna. However, it is only available on dead animals. Blood and faeces can be used on living animals. These two biological matrices were compared in terms of their relevance to exposure to ARs. In addressing this question, we compared the faecal, plasma and liver concentrations of bromadiolone, one of the SGAR frequently implicated in wildlife exposure. We studied this comparison at the individual level and at the population level, considering three influencing factors: dose, sex and time. Our findings demonstrate that faecal analyses are more valuable than plasma analyses for monitoring AR exposure of domestic and wild animals, even if faecal concentrations cannot be correlated with liver concentrations.

Investigation of anticoagulant rodenticide resistance induced by Vkorc1 mutations in rodents in Lebanon.

Anticoagulant rodenticides (AR) remain the most effective chemical substances used to control rodents in order to limit their agricultural and public health damage in both rural and urban environments. The emergence of genetically based resistance to AR worldwide has threatened effective rodent control. This study gives a first overview of the distribution and frequency of single nucleotide polymorphism in the vitamin K epoxide reductase subcomponent 1 (Vkorc1) gene in rodents in Lebanon. In the Mus genus, we detected two missense mutations Leu128Ser and Tyr139Cys, that confer resistance to anticoagulant rodenticides in house mice and a new missense mutation Ala72Val in the Mus macedonicus species, not previously described. In the Rattus genus, we found one missense mutation Leu90Ile in the roof rat and one missense mutation Ser149Ile in the Norway rat. This is the first study to demonstrate potential resistance to AR in Lebanese rodents and therefore it provides data to pest control practitioners to choose the most suitable AR to control rodents in order to keep their efficacy.

COVID-19 and Liver Dysfunction.

Introduction The pandemic of coronavirus disease 2019 (COVID-19) has caused over four million deaths, depleting resources and healthcare workers; therefore, in an attempt to stratify patients, the relationship between liver enzymes and clinical outcome was studied. This study aimed to assess the pattern and impact of liver enzymes on the clinical outcome of hospitalized patients with COVID-19 in Lebanon and look for possible confounding factors. Methodology This was a single-centered retrospective cohort study conducted between December 2020 and March 2021 on 230 patients diagnosed with COVID-19. Liver function tests (LFTs) and other laboratory values on admission and peak hospitalization were analyzed using SPSS. Results The prevalence of abnormal liver tests among the sample population with severe COVID-19 infection were as follows: aspartate aminotransferase (AST), 77%; alanine aminotransferase (ALT), 49%; alkaline phosphatase (ALP), 12%; and gamma-glutamyl transferase (GGT), 37%. A severe COVID-19 infection was more likely present in patients with abnormal levels of AST (p = 0.015), ALP (p = 0.03), and GGT (p = 0.022). ANOVA test revealed no significant relationship between AST levels at peak hospitalization and the treatments received by the patient. Conclusion Abnormal liver function tests of patients at admission may be an indicator of more severe disease. In the context of scarce resources created by the pandemic, it becomes essential to establish a reliable predictor for a severe outcome of COVID-19 infection and manage accordingly.

Comparative pharmacokinetics of difethialone stereoisomers in male and female rats and mice: development of an intra- and inter-species model to predict the suitable formulation mix.

The ecotoxicity of anticoagulants used for rodent pests' management is a major concern, particularly with second generation anticoagulants, which are more persistent in the body of rodents and therefore more likely to cause secondary exposure in their predators. One of the solutions envisaged to mitigate this risk is to use stereoisomers of these anticoagulants, each of which has particular pharmacokinetics. However, the few studies published to date have considered only one species and one sex. Here, we study the pharmacokinetics of the 4 stereoisomers of 3.4 mg/kg of difethialone in rats (Rattus norvegicus) and 3 mg/kg in mice (Mus musculus) in both sexes and propose a model to choose the optimal stereoisomer efficacy/ecotoxicity mixture for the management of all these animals. Our results show that while the most persistent stereoisomer (E3-cis) is common to both species and sexes, the pharmacokinetics of the other stereoisomers show marked differences between sexes and species. Thus, the area under curve (AUC) of E4-trans in male rats is four times lower than in females or mice, making it a priori unusable in male rats. Conversely, our modeling seems to show that the E1-trans stereoisomer seems to offer the best compromise AUC persistence. In conclusion, we highlight that studies on anticoagulants must necessarily integrate research on the effect of gender and species both on efficacy and with regard to the ecotoxicity of these molecules.

Incidence, Prevalence, and Clinical Epidemiology of Inflammatory Bowel Disease in the Arab World: A Systematic Review and Meta-Analysis.

OBJECTIVES: Despite the recent findings of the rising incidence of inflammatory bowel disease (IBD) in Arab countries, there are limited data on the characteristics of IBD patients and the disease course in the Arab world. This systematic review aimed to investigate the incidence and epidemiology of IBD in the Arab world. MATERIAL AND METHODS: We conducted a systematic literature review that utilized a comprehensive search of PubMed, Cochrane Central, SCOPUS, Google Scholar, and Web of Science from their inception till August 2020. We included cross-sectional, prospective, and retrospective studies that examined the prevalence and/or epidemiological characteristics of IBD in Arab countries. RESULTS: A total of 16 studies that examined IBD in Saudi Arabia, Egypt, Kuwait, the United Arab Emirates, Bahrain, Lebanon, and Oman were included. Generally, the included studies covered the period from the early 1990s to the late 2010s. A total of 1,627 ulcerative colitis (UC) patients and 1,588 Crohn's disease (CD) patients were included in this systematic review. The mean age at diagnosis ranged from 24.13 to 43.6 years in adult cases and from 4.5 to 16 years in pediatric cases. In most of the included studies, the majority of patients were male. The quantitative analysis revealed a pooled incidence rate of 2.33 (95% confidence interval [CI] 1.2-3.4) per 100,000 persons per year for UC in the Arab world. Likewise, the pooled incidence rate for CD in the Arab world was 1.46 (95% CI 1.03-1.89) per 100,000 persons per year. CONCLUSION: There is a growing incidence of IBD in the Arab world, while IBD patients from Arab countries may present with some different characteristics, compared to their counterparts in Europe.

Water vole management - Could anticoagulant rodenticides stereochemistry mitigate the ecotoxicity issues associated to their use?

Cyclic water vole population explosions can be controlled in some European countries with anticoagulant rodenticides leading sometimes to wildlife poisonings due to the toxin's tissue persistence. Here, we analyzed the pharmacokinetics of rodenticide residues in voles and we explored potential ways of improving the mass application of these agents based on the concept of stereoisomers. We demonstrated the dramatic persistence of bromadiolone in vole tissues with a hepatic half-life of about 10-30 days, while the tissue persistence of chlorophacinone is rather short with a hepatic half-life of about one day. The dramatic persistence of bromadiolone is due to the trans-isomer group (the major compound in bromadiolone), while the cis-isomer group has a short half-life. Because of resistance to chlorophacinone, the cis-bromadiolone isomers may constitute an excellent compromise between efficacy and ecotoxicological risk to control voles. A mathematical model is proposed to favor the development of baits mixed with cis-isomer groups.

Prevalence of hepatitis B and anti-hepatitis C virus antibody among people who inject drugs in the Lebanese population.

BACKGROUND: People who inject drugs (PWIDs) are prone to a number of blood-borne viral infections. Hepatitis B virus (HBV) and hepatitis C virus (HCV) constitute an important public health concern in this high risk group. AIMS: We aimed to determine the prevalence of HBV and HCV antibody among PWIDs in Lebanon. METHODS: We conducted a prospective cross-sectional study between June 2015 and June 2016 on PWIDs recruited through Lebanese nongovernmental organizations in collaboration with the Lebanese Ministry of Public Health. The participants were tested for HBs antigen and HCV antibody using rapid test kits. The prevalence of each virus was then calculated. The correlation between both infections and other possible risk factors was also analysed. RESULTS: A total of 250 people were included in our study, of whom 98% were males. Mean age was 31.9 (standard deviation 8.7) years. The prevalence of HBsAg and anti-HCV among PWIDs was 1.2% and 15.6%, respectively. Older age, longer duration of drug use and lack of awareness were significantly correlated with a higher rate of HCV infection (P < 0.01). The high rate of needle sharing among our PWIDs significantly affected the prevalence of anti-HCVAb. CONCLUSION: PWIDs remain the subpopulation most affected with chronic HCV in Lebanon.

Biomarkers Potency to Monitor Non-target Fauna Poisoning by Anticoagulant Rodenticides.

The widespread use of pesticides to control agricultural pests is a hot topic on the public scene of environmental health. Selective pest control for minimum environmental impact is a major goal of the environmental toxicology field, notably to avoid unintended poisoning in different organisms. Anticoagulant rodenticides cause abnormal blood coagulation process; they have been widely used to control rodents, allowing inadvertent primary and secondary exposure in domestic animals and non-target predatory wildlife species through direct ingestion of rodenticide-containing bait or by consumption of poisoned prey. To report toxic effect, the most common approach is the measurement of liver or plasma residues of anticoagulant rodenticides in dead or intoxicated animals showing clinical symptoms. However, one major challenge is that literature currently lacks a hepatic or plasma concentration threshold value for the differentiation of exposure from toxicity. Regarding the variation in pharmacology properties of anticoagulant rodenticides inter- and intra-species, the dose-response relationship must be defined for each species to prejudge the relative risk of poisoning. Beyond that, biomarkers are a key solution widely used for ecological risk assessment of contaminants. Since anticoagulant rodenticides (AR) have toxic effects at the biochemical level, biomarkers can serve as indicators of toxic exposure. In this sense, toxicological knowledge of anticoagulant rodenticides within organisms is an important tool for defining sensitive, specific, and suitable biomarkers. In this review, we provide an overview of the toxicodynamic and toxicokinetic parameters of anticoagulant rodenticides in different animal species. We examine different types of biomarkers used to characterize and differentiate the exposure and toxic effects of anticoagulant rodenticide, showing the strengths and weaknesses of the assays. Finally, we describe possible new biomarkers and highlight their capabilities.

Epidemiological Study Assessing the Overuse of Proton Pump Inhibitors in Lebanese Population.

BACKGROUND Proton pump inhibitors (PPIs) are the most potent gastric agents for most acid-related disorders. Their effectiveness has led to their overutilization, leading to potential risks on patients and significant economic implications. The aim of this study was to determine the frequency of PPI overuse in Lebanon. Hence, the economic impact of this overutilization, if proven to be present, can be inferred. METHODS An epidemiological descriptive cross-sectional study was conducted in pharmacies all around Lebanese governorates over a 1-year period, using questionnaires handed out to 1000 participants coming to buy PPIs. Subjects taking PPIs for inappropriate indications or in inappropriate dosages or durations were considered abusing PPIs. PPIs are indicated for multiple gastric disorders and for prophylaxis of gastrointestinal injury when taking gastro-toxic medications. RESULTS 71.4% of subjects were overusing PPIs. Approximately 25 million US dollars were being wasted annually. Three categories of overuse were inferred (indication, dosage, and duration). Gastro protection was the most common reason for taking PPIs. Demographic variables and doctors' prescriptions did not influence PPI overuse. CONCLUSION PPIs are massively overused in Lebanon, leading to a huge burden on the health care system. Adhering to evidence-based guidelines and educational programs is highly recommended to enhance the quality and efficiency of prescriptions.

Complete Regression of Giant Inflammatory Polyp after Treatment with Adalimumab.

Giant inflammatory polyps (GIPs) are a rare complication of IBD resulting from chronic regenerative and healing processes leading to a polypoid formation on inflamed mucosa. We reported a case of GIP in a patient with long standing left-sided ulcerative colitis (UC); a well circumscribed sessile GIP was found during a colonoscopy for colorectal cancer screening on a normal colonic mucosa in the cecum. After a severe flare of the left-sided colitis and due to partial response to steroids patient was treated with adalimumab; new colonoscopy after 6 months shows complete disappearance of the GIP previously described. It is the first case report of GIP in normal macroscopic mucosa with complete disappearance after biologic treatment.

Hepatitis C in Lebanon: the burden of the disease and the value of comprehensive screening and treatment.

PURPOSE: To analyze the hepatitis C virus (HCV) burden in Lebanon and the value of comprehensive screening and treatment for different age groups and fibrosis stages. METHODS: We used a multicohort, health-state-transition model to project the number of HCV genotype 1 and 4 patients achieving a sustained virologic response 12 weeks after treatment or progressing to compensated cirrhosis (CC), decompensated cirrhosis (DCC), hepatocellular carcinoma (HCC), or liver-related death (LrD) from 2016 to 2036. In the low/medium/high screening scenarios, the proportion of patients screened for HCV was projected to increase to 60%/85%/99%, respectively, by 2036. We analyzed four treatment strategies: 1) no treatment, 2) all-oral direct-acting antivirals (DAAs) given to F3-F4 (CC) patients only, 3) all-oral DAAs to F2-F3-F4 (CC) patients, and 4) all-oral DAAs to all fibrosis patients. RESULTS: Low, medium, and high HCV screening scenarios projected that 3,838, 5,665, and 7,669 individuals will be diagnosed with HCV infection, respectively, from 2016 to 2036, or 40% of those aged 18-39 years, and 60% of those aged 40-80 years. With no treatment, the projected number of patients reaching CC, DCC, HCC, or LrD in 2036 was 899, 147, 131, and 147, respectively, for the 18-39 years age group. For the 40-80 years age group, these projections were substantially greater: 2,828 CC, 736 DCC, 668 HCC, and 958 LrD. The overall economic burden without treatment reached 150 million EUR. However, introducing DAAs for F0-F4 patients was projected to increase the proportion of remaining life-years spent in sustained virologic response 12 weeks after treatment by 43% and 62% compared to DAAs given at F2-F4 or F3-F4 only, respectively. CONCLUSION: An enhanced screening policy combined with broader access to DAAs can diminish the future clinical and economic burden of HCV in the Lebanese population and, for the middle-aged and elderly, provide the greatest health benefit with net cost savings.

Obstructive Giant Inflammatory Polyposis: Is It Related to the Severity or the Duration of the Inflammatory Bowel Disease? Two Case Reports.

We report two cases of giant inflammatory polyposis (GIP) with totally different presentation and evolution. The first patient had two giant pseudopolyps after one year of the diagnosis of UC. The second patient had one obstructive giant pseudopolyp secondary to CD at the level of the transverse colon, being totally asymptomatic years before the presentation. GIP is a rare complication of inflammatory bowel disease (IBD). It consists of numerous filiform polyps that look like a "mass of worms" or a "fungating" mass. Surgical resection is inevitable when GIP presents with obstructive symptoms.

Hepatitis C in Lebanon: burden of the disease and value of comprehensive screening and treatment.

INTRODUCTION: As few reliable data on the burden of hepatitis C virus (HCV) are available from the Middle East, we analyzed HCV burden in the Lebanese population and the value of comprehensive screening and treatment at different age groups and fibrosis stages. METHODOLOGY: A multi-cohort, health-state-transition model was developed to project the number of HCV patients achieving a sustained virologic response 12 weeks after treatment (SVR12) or progressing to compensated cirrhosis (CC), decompensated cirrhosis (DCC), hepatocellular carcinoma (HCC), and liver-related death (LrD) from 2016 to 2036. Epidemiology and mortality data were extracted from the Ministry of Health bulletin while costs were collected from insurance claims. The proportion of patients screened for HCV was projected to increase to 60%/85%/99% (low/medium/high screening scenarios) in 2036, with a new cohort being diagnosed each year. SVR12 rates were extracted from clinical trials. Separate models were used for 18-39 and 40- 80 age groups to account for different prevalence and screening rates. RESULTS: Low, medium and high HCV screening scenarios showed that 3,838, 5,665 and 7,669 individuals would be diagnosed with HCV infection from 2016 to 2036, 40% aged 18-39 and 60% aged 40-80. In the absence of treatment, the projected number of patients reaching CC, DCC, HCC and LrD in 2036 was 899, 147, 131 and 147 respectively for the 18-39 age groups. In the 40-80 age groups, these projections were substantially greater: 2,828 CC, 736 DCC, 668 HCC and 958 LrD. The overall economic burden of these complications would reach 150 million €. However, introducing direct-acting antivirals (DAAs) for F0-F4 patients would increase by 43% and 62% the proportion of remaining life-years (LYs) spent in SVR12 compared to DAAs given to F2-F4 or to F3-F4 only, respectively. Although DAAs for F0-F4 increase the cost of HCV treatment, they also provide the greatest health benefit and lowest cost per LY gained in SVR12. Compared to no treatment and screening, adopting the high screening variant and DAAs access to F0-F4 would cost an additional 1,957 € for every LY gained in SVR12 for patients aged 18-39 and -168 € for the 40-80 age group. CONCLUSION: An enhanced screening policy coupled with broader access to DAAs will diminish the future burden of HCV in the Lebanese population and provide the greatest health benefits among middle-aged and elder adults with net cost savings.

Prevalence of hepatitis B and hepatitis C among intravenous drug abusers in the Lebanese population.

INTRODUCTION: Injection drug users (IVDU) are prone to many blood born viral infections. Hepatitis B virus (HBV) and Hepatitis C virus (HCV) constitute an important public health concern in this high-risk group. The aim of the study is to calculate the prevalence of hepatitis B and C viruses among people who inject drugs (PWID) in Lebanon. METHODOLOGY: We conducted a prospective cross-sectional study between June 2015 and June 2016 on PWIDs recruited through the Lebanese non-governmental organizations in collaboration with the Lebanese ministry of public health. The participants were tested for HBs Antigen and HCV antibody using rapid test kits. The prevalence of each virus was then calculated. The correlation between both infections and other possible risk factors was also analyzed. RESULTS: A total of 250 people were included in our study. 98% were males. Mean age was 31.9-year-old. The prevalence of HBV and HCV among PWID was 1.2% and 15.6%, respectively. Older age, longer duration of drug use, and the lack of awareness were found to be significantly correlated with higher rate of HCV infection. We noted a relatively high rate of sharing needles among PWIDs without significantly affecting the prevalence of both viruses. CONCLUSION: IVDU remains a major public health concern in Lebanon, being one of the most prevalent subpopulations for chronic viral hepatitis namely the HCV. Appropriate screening strategies, targeted educational programs and adequate HBV vaccination are of extreme importance for further viral prevention among this high-risk group.

Real world experience with the all-oral interferon free regimen for the treatment of chronic hepatitis c virus infection in the Lebanese population.

INTRODUCTION: The treatment of hepatitis C has dramatically improved since the introduction of the new Direct-Acting Antivirals (DAAs). The aim of this study is to assess the effectiveness and safety of all oral DAAs with or without ribavirin in the treatment of hepatitis C virus (HCV) in treatment naïve and experienced Lebanese population. METHODOLOGY: We reviewed all cases approved for hepatitis C treatment with DAAs according to the Lebanese guidelines for treatment of HCV at the Ministry of Public Health from October 2015 till December 2016. Available data concerning age, sex, mode of transmission, genotype (GT) and subtype, fibrosis stage, previous treatment (if present), new DAAs treatment, and sustained virological response at week 12 (SVR12) were collected. RESULTS: During a period of 15 months (October 2015 to December 2016), 186 patients were treated with DAAs. 57% were male and the mean age was 54.3 years. The source of infection was unknown in 51% of cases and blood transfusion in 35.5% of cases. Genotype 1 was the most predominant genotype (45%), followed by GT4 (34%) and GT3 (12%). 71.6% of patients had advanced fibrosis before starting DAAs and 57% were cirrhotic. 42% of patients were treatment experienced (85% pegylated interferon and ribavirin). Different DAAs regimens were used according to the Lebanese guidelines for treatment of HCV: Ledipasvir/Sofosbuvir (38.7%), Sofosbuvir/Daclatasvir (16.1%), Sofosbuvir/Velpatasvir (1.6%), Sofosbuvir/RBV (7.5%), Ombitasvir/Paritaprevir/Ritonavir (17.5%) and Ombitasvir/Paritaprevir/Ritonavir -Dasabuvir (18.8%). Ribavirin was used in 51.6% of cases. SVR12 was achieved in 93% of patients (relapse in 4%, loss of follow up and/or severe adverse effect in 3%). SVR 12 was achieved in 93%, 96% and 94% of GT1, GT3 and GT4 cases respectively. SVR12 was seen in 91.3% of cirrhotic patients vs. 98.7% of F0-F3 patients. (p = 0.047).  There was no difference in SVR12 between treatment naïve and experienced patients. Hepatocellular carcinoma developed in 5 patients (2.9%) during the study period. CONCLUSION: This is the first real world Lebanese data of HCV treatment with DAAs. The study population was significant for a large number of patients with cirrhotic (50%) and treatment experienced patients (42%). SVR12 was achieved in 93% of patients with no difference between treatment naïve and experienced patients. SVR12 was lower in patients with cirrhosis compared to patients with lower stage of fibrosis (91.3% vs. 98.7%).

Prevalence of hepatitis C virus genotypes and subtypes in Lebanese population and major high risk groups.

BACKGROUND AND STUDY AIMS: The prevalence of hepatitis C in Lebanon is low. It is estimated at 0.2% of the total population. The aim of our study is to evaluate the exact prevalence of each genotype on a large scale population and in each potential source of infection. PATIENTS AND METHODS: We reviewed all the data in the Ministry of Public Health related to patients who have submitted their file for treatment during a period of 9years ranging from January 2005 till December 2013. RESULTS: The genotype distribution in 1031 Lebanese patients was as following: Genotype 1 was the most predominant representing 47% followed by genotype 4 representing 34% then genotype 3 representing14%. Concerning sex distribution and routes of infection, there was a male predominance in intravenous drug users (IVDU), whereas approximately equal distribution was noted in haemodialysis and transfusion groups. A female predominance was noted in the "unknown" mode of infection. Concerning age distribution and routes of infection, a mean age of 27 was noted in the IVDU group, whereas mean age of 60 in the transfusion group and 50 in the haemodialysis group. In patients who acquired the infection post transfusion or during haemodialysis, genotype 1 was the most predominant, whereas in IVDU, genotype 3 was the most predominant. Concerning sub-genotyping: subtype 1b was the most predominant (84%) in genotype 1. in genotype 2 subtype b with 75%, all genotype 3 were subtype a, in genotype 4 subtype a represents 50% of genotype followed by subtype e in 30%. CONCLUSION: Our data concerning Lebanese population demonstrate that genotype 1 is the most prevalent genotype followed by genotype 4. In IVU, we noted genotype-3 and -1 being the most prevalent in relation to clustering in this high risk group. This distribution differs from most surrounding countries and all other Arab countries.

Eosinophilic gastroenteritis: Approach to diagnosis and management.

Eosinophilic gastroenteritis (EGE) is a rare and benign inflammatory disorder that predominantly affects the stomach and the small intestine. The disease is divided into three subtypes (mucosal, muscular and serosal) according to klein's classification, and its manifestations are protean, depending on the involved intestinal segments and layers. Hence, accurate diagnosis of EGE poses a significant challenge to clinicians, with evidence of the following three criteria required: Suspicious clinical symptoms, histologic evidence of eosinophilic infiltration in the bowel and exclusion of other pathologies with similar findings. In this review, we designed and applied an algorithm to clarify the steps to follow for diagnosis of EGE in clinical practice. The management of EGE represents another area of debate. Prednisone remains the mainstay of treatment; however the disease is recognized as a chronic disorder and one that most frequently follows a relapsing course that requires maintenance therapy. Since prolonged steroid treatment carries of risk of serious adverse effects, other options with better safety profiles have been proposed; these include budesonide, dietary restrictions and steroid-sparing agents, such as leukotriene inhibitors, azathioprine, anti-histamines and mast-cell stabilizers. Single cases or small case series have been reported in the literature for all of these options, and we provide in this review a summary of these various therapeutic modalities, placing them within the context of our novel algorithm for EGE management according to disease severity upon presentation.

Epidemiology of hepatitis B and hepatitis C in Lebanon.

BACKGROUND AND STUDY AIMS: Hepatitis B and C are two potentially life threatening liver infections. Lebanon is ranked as a zone of moderate endemicity. This study aimed to determine the prevalence of hepatitis B and C in Lebanon and their distribution according to age, region and sex. PATIENTS AND METHODS: This national prospective cross-sectional study was conducted from January 2011 till December 2012 in the six Lebanese Governorates in collaboration with municipalities, the Ministry of Public Health, Health Centres and dispensaries. An upcoming screening for hepatitis B and C was announced? in different districts of each Governorate. All individuals presenting to local laboratory, not known to have chronic hepatitis, were asked for a blood sample and answered a questionnaire addressing sex, age, place of birth and residence. Screening tests were "Abbots" for hepatitis B and "Human Hexagon" for hepatitis C. PCR testing was used to confirm the positivity of the previous tests. RESULTS: Of 31147 individuals screened, 542 had a rapid test positive for HBV (prevalence 1.74%, 95% CI 1.6-1.89) with a male to female ratio of 1.08. This prevalence was higher in the South and Nabatieh (1.9%) compared to Beirut (0.73%). Of 31,147 individuals screened, 64 had a rapid test positive for HCV (prevalence 0.21%, 95% CI 0.16-0.27) with a male to female ratio of 0.85. This prevalence was higher in Nabatieh (0.61%) compared to Mount Lebanon (0.08%). CONCLUSIONS: The prevalence of HBV and HCV in Lebanon is 1.74% and 0.21%, respectively with a higher prevalence in South and Nabatieh districts. These data rank Lebanon amongst countries with low endemicity for both viruses. Decrease in the prevalence of HBV is due to awareness campaign as well as success of the MOPH National Hepatitis Program in vaccinating all new born since 1998 and in screening and vaccinating high risk groups.

Protein Loosing Enteropathy Secondary to Strongyloidiasis: Case Report and Review of the Literature.

Strongyloidiasis is a helminthic disease which affects millions around the world resulting in a significant burden in certain high risk groups. It is rarely reported in the Lebanese population probably due to the low index of suspicion in common practice. We are reporting a case of strongyloidiasis that was found in an elderly patient presenting initially with dyspnea followed by skin rash, protein loosing enteropathy, diarrhea, and abdominal pain while on corticosteroid therapy. The diagnosis was suspected based on clinical presentation in addition to peripheral eosinophilia. We will also describe the upper and lower endoscopic aspects of the disease, as well as histologic findings on duodenal and colonic biopsies.