Circulating antimyenteric autoantibodies in Tunisian patients with idiopathic achalasia.

The physiopathology of idiopathic achalasia is still unknown. The description of circulating antimyenteric autoantibodies (CAA), directed against enteric neurons in sera of patients, suggests an autoimmune process. Recent data showed controversies according to the existence and the significance of CAA. The aims of this study were to investigate whether CAA are detected in Tunisian patients with idiopathic achalasia and to look for associated clinical or manometrical factors with CAA positivity. Twenty-seven patients with idiopathic achalasia and 57 healthy controls were prospectively studied. CAA were assessed by indirect immunofluorescence on intestinal monkey tissue sections. Western blot on primate cerebellum protein extract and dot technique with highly purified recombinant neuronal antigens (Hu, Ri, and Yo) were further used to analyze target antigens of CAA. CAA were significantly increased in achalasia patients compared with controls when considering nuclear or cytoplasmic fluorescence patterns. (33% vs. 12%, P = 0.03 and 48% vs. 23%, P = 0.001 respectively). By immunoblot analysis, CAA did not target neuronal antigens, however 52/53 and 49 kDa bands were consistently detected. CAA positivity was not correlated to specific clinical features. The results are along with previous studies demonstrating high CAA prevalence in achalasia patients. When reviewing technical protocols and interpretation criteria, several discrepancies which could explain controversies between studies were noted.

Prognostic factors in Crohn's disease: a systematic review.

BACKGROUND: The natural history of Crohn's disease is associated with several factors that affect the prognostic of the patients. AIMS: To determine the most prognostic factors in Crohn's disease, based on a systematic review. METHODS: Literature review. RESULTS: The most important factors to consider in patients with Crohn's disease are the need for immunosuppressive therapy, the need for intestinal resection and disabling disease. Prognostic factors for these events are ileal involvement, perianal disease and initial treatment by corticosteroid. Other factors such young age, CRP level and smoking status, has not been found in all population-based studies. Protective role of anti-TNF drugs is strongly suggested but need to be confirmed in further studies. CONCLUSION: In a selected subgroup of patients with Crohn's disease characterized by the presence of these prognostic markers, the "topdown" strategy can be proposed.

Unbalanced bone remodeling in Tunisian patients with inflammatory bowel diseases.

BACKGROUND: Bone loss is an ignored complication in inflammatory bowel diseases. Its underling mechanisms are not fully elucidated. OBJECTIVES: To investigate bone turnover in patients with inflammatory bowel diseases. METHODS: The study included 67 patients with inflammatory bowel diseases and 54 age- and sex-matched healthy subjects. Urinary degradation products of C-terminal telopeptide of type I collagen, serum osteocalcin, parathyroid hormone, 25 hydroxy vitamin D and interleukin-6 were assessed. Bone mineral density was measured by dual energy-X-ray absorptiometry and osteoporosis was defined as T score < -2.5 SD. RESULTS: Patients showed significantly higher levels of C-terminal telopeptide of type I collagen and interleukin-6 and lower levels of 25 hydroxy vitamin D. Serum osteocalcin and parathyroid hormone were in normal range. In multivariate analysis, urinary degradation products of C-terminal telopeptide of type I collagen were associated with disease activity (p=0.04) and osteocalcin was associated with parathyroid hormone (p=0.04). Urinary degradation products of Cterminal telopeptide of type I collagen and interleukin-6 were significantly increased in inflammatory bowel disease patients with osteoporosis. No association was found between osteoporosis and serum osteocalcin, parathyroid hormone and 25 hydroxy vitamin D. CONCLUSION: Bone resorption rate is increased and is associated with osteoporosis in inflammatory bowel disease patients. Inflammation, malnutrition, and hypovitaminosis D may contribute to the bone loss.

[Onset of Crohn's disease induced by etanercept therapy: a case report]. / Le cas clinique du mois. Maladie de Crohn induite par l'Etanercept: à propos d'une nouvelle observation.

A 27-year-old-man was diagnosed as having ankylosing spondylitis (AS) in 2003 and received a treatment by etanercept. Typical symptoms of active Crohn's disease (CD) developed 11 months after initiation of etanercept therapy. At colonoscopy, lesions compatible with CD were found endoscopically and histologically. Etanercept was interrupted and CD responded to standard treatment. A switch to infliximab was decided to treat a flare up ofAS. New onset CD may be considered an immune mediated injury induced by etanercept, but the causative role of the latter has not been demonstrated at this stage.

[Efficacy and safety of Adalimumab in Crohn's disease]. / Indications et résultats de l'adalimumab au cours de la maladie de Crohn.

BACKGROUND: Adalimumab is the first subcutaneously self administered fully human anti-TNFa. AIM: To determine efficacy and safety of Adalimumab therapy in Crohn disease. METHODS: Literature review. RESULTS: Adalimumab has been evaluated for its effect in inducing and maintaining remission and its steroid-sparing effect of refractory Crohn's disease. In addition, it offers a significant treatment option in patients who have lost response to or become intolerant to Infliximab. Results also suggest efficacy of Adalimumab in fistulising Crohn's disease but more studies are needed. Adalimumab was well tolerated and studies show that all anti-TNF inhibitors have similar safety profiles.

Metabolic syndrome is associated with gastroesophageal reflux disease based on a 24-hour ambulatory pH monitoring.

Several studies have focused on the relationship between metabolic syndrome and gastroesophageal reflux disease (GERD). They were based on GERD complications, whereas little is known about the association between metabolic syndrome and objectively measured esophageal acid exposure. The aim of our study was to assess the relationship between metabolic syndrome and GERD based on a 24-hour pH testing. It was a cross-sectional study including 100 consecutive patients who underwent a 24-hour pH-metry monitoring and were assessed for the five metabolic syndrome components as well as for body mass index (BMI). Among the 100 patients, 54 had a pathological acid GERD. The 46 GERD-free patients represented control group. Sex distribution was comparable between both groups but GERD patients were older than controls (44.59 vs. 37.63 years, P= 0.006) and more often obese or with overweight (83.3 vs. 60.9%, P= 0.01). Frequency of metabolic syndrome as a whole entity was higher among patients with GERD than those without GERD (50 vs. 19.56%; P= 0.002) with a crude odds ratio of 4.11 (95% confidence interval: 1.66-10.14). Multivariate regression analysis showed that metabolic syndrome as well as an age ≥ 30 years were independent factors associated to GERD but not BMI and sex. Abnormal waist circumference and fasting glucose level ≥ 100 mg/L were the only independent factors among the five components of metabolic syndrome. Metabolic syndrome but not BMI was an independent factor associated to GERD. These results confirm the hypothesis that central obesity is associated to GERD.

[Transuterine migration of intrauterine contraceptive devices]. / Migration transutérine des dispositifs intra-utérins.

UNLABELLED: The intrauterine contraceptive device (IUCD) is frequently used. The use of IUCD can be responsible of serious complications as transuterine migration. In this study, we evaluate the physiopathology, the strategy of diagnosis and treatment of the IUCD translocation. MATERIAL AND METHODS: We conducted a retrospective study of nine cases of IUCD migration having occurred between 2004 and 2009. We discussed the age, the type of IUCD, the risk factors, the mechanisms of migration, the circumstances and methods of diagnosis, the treatment and the evolution of IUCD migration. Mean age of the patients was 35 years. The risk factors were: multiparity, anteversus uterus, scarred uterus, IUCD postpartal insertion, inexperience of the operator. Most patients were asymptomatic. Two patients had urinary symptoms. The diagnosis of an extrauterine device was confirmed by abdominal X-ray and ultrasound results in all patients. The endoscopic treatment was successful in 66% of cases. All patients had an uneventful recovery. Transuterine migration remains one of the least common but most serious complications associated with the use of an IUCD. This complication could be controlled if thorough gynaecological exam was performed, if risk factors were delineated, if the IUCD was technically well inserted and a rigorous surveillance was performed.

Association of chemokine and chemokine receptor polymorphisms with activity degree of IBD in Tunisian patients.

Crohn's disease (CD) and ulcerative colitis (UC) have complex genetic background that is characterised by more than one susceptibility locus. To detect a possible association between the functional polymorphisms of the chemokine receptors CCR5, CCR2 and MCP-1 genes and susceptibility to CD and UC in Tunisian population, polymorphisms of CCR5-delta32, CCR5-59029-A/G, CCR2-V641 and MCP-1-2518-G/A were analysed in 194 Inflammatory bowel disease (IBD) patients and 169 healthy blood donors using PCR-RFLP and PCR-SSP methods. The patients were classified in 126 patients with CD and 68 patients with UC. The genotypic and allelic frequencies of all polymorphisms studied, did not reveal significant differences between patients and conrols and among CD and UC patients. However, analysis of CD patients revealed that those without homozygosous G/G genotype are more frequently in remission compared to those with this genotype (OR: 0.4, 95% CI: [0.174-0.928]; p = 0.03). Also, the frequency of the CCR2-641 muted allele was statistically higher in CD patients in remission disease than those in active form (OR: 0.267 95% CI: [0.09-0.78]; p = 0.01). Adjustment for known covariates factors (age, gender and immunosuppressive regimen) confirmed these univariate findings and revealed that the CCR5-59029-A/G and CCR2-V64I genotype were associated to remission form of CD (OR: 263; 95% CI: [1.01-6.80]; p = 0.047 and OR: 4.64; 95% CI: [1.01-21.31]; p = 0.049 respectively). In conclusion, the present study supports the involvement of chemokine receptor (CCR2 and CCR5) polymorphisms in activity degree of the IBD disease in Tunisian patients.

Effect of pantoprazole in patients with chronic laryngitis and pharyngitis related to gastroesophageal reflux disease: clinical, proximal, and distal pH monitoring results.

Few studies had evaluated the results of proton pump inhibitors on distal and proximal pH recording using a dual-channel probe. The aim of this study was to determine the clinical and pH-metric effect of treatment with pantoprazole 80 mg for 8 weeks in patients with ear, nose, and throat (ENT) manifestations of gastroesophageal reflux disease associated with pathological proximal acid exposure. We conducted a prospective open study. Patients included had to have chronic pharyngitis or laryngitis, and a pathological gastroesophagopharyngeal reflux. All patients received treatment with pantoprazole 80 mg daily for 8 weeks. One week after the end treatment, patients had a second ENT examination and a 24-hour pH monitoring using dual-channel probe. We included 33 patients (11 men, 22 women). A pathological distal acid reflux was found in 30 patients (91%). After treatment, the improvement of ENT symptoms was found in 51.5% of patients. Normalization of 24-hour proximal esophageal pH monitoring was observed in 22 patients (66%). After treatment, the overall distal acid exposure, the number of distal reflux events, and the number of reflux during more than 5 minutes were significantly decreased (respectively: 19.4% vs 7.2% [P < 0.0001], 62.7 vs 28.4 [P < 0.0001], and 10.4 vs 3.9 [P < 0.0001] ). Similarly, in proximal level, the same parameters were significantly decreased after treatment (respectively: 6.8% vs 1.6% [P < 0.0001], 32.6 vs 8.1 [P < 0.0001], and 3.4 vs 0.6 [P= 0.005] ). Treatment with pantoprazole reduced the frequency and severity of gastroesophagopharyngeal acid reflux in patients with chronic pharyngitis and laryngitis.

Seroprevalence of Helicobacter pylori among Tunisian blood donors (outpatients), symptomatic patients and control subjects.

OBJECTIVES: Helicobacter pylori is a worldwide infection, although little data are available in the Tunisian population. The aims of our study were to detect the prevalence of H. pylori in a blood-donor population (n=250) and in another population of hospital-consulting patients comprising 87 symptomatic patients and 59 controls, and to determine the factors that influence the prevalence. MATERIALS AND METHODS: Study subjects answered a standardized questionnaire, and IgG anti-H. pylori and anti-cag were detected by ELISA. In the second population, culture and cagA polymerase chain reaction were performed. RESULTS: The seroprevalence of H. pylori in blood donors was 64%, and 11% had anti-cag. All patients positive for anti-cag were also positive for anti-H. pylori antibodies. The seroprevalence of H. pylori was 99.3% in the hospital-consulting patients, of whom 55.5% were positive for anti-cag. The difference between the anti-cag and symptomatic patients (66.7%) and controls (39%) was significant. Symptomatic patients had a higher rate of anti-cag (66.7%) compared with the controls (39%) and blood donors (11%). CONCLUSION: H. pylori seroprevalence in blood donors is low (64%) compared with symptomatic patients (99.3%), and anti-cag was statistically associated with symptomatic patients and pathology. Also, some environmental factors were correlated with H. pylori seroprevalence.

Antibiotics and chronic kidney disease: Dose adjustment update for infectious disease clinical practice.

Antibiotic prescription in chronic kidney disease patients poses a twofold problem. The appropriate use of antibacterial agents is essential to ensure efficacy and to prevent the emergence of resistance, and dosages should be adapted to the renal function to prevent adverse effects. SiteGPR is a French website for health professionals to help with prescriptions to chronic kidney disease patients. A working group of infectious disease specialists and nephrology pharmacists reviewed the indications, dosing regimens, administration modalities, and dose adjustments of antibiotics marketed in France for patients with renal failure. Data available on the SiteGPR website and detailed in the present article aims to provide an evidence-based update of infectious disease recommendations to health professionals managing patients with chronic kidney disease.

Correlation between levels of C-reactive protein and clinical activity in Crohn's disease.

AIMS: To determine the factors associated with an increased C-reactive protein level in Crohn's disease patients and to seek a correlation between the C-reactive protein value and the Crohn's disease activity index. METHODS: We prospectively studied 103 Crohn's disease patients, 76% of whose disease was active at the time of inclusion. C-reactive protein measurement was carried out on all patients. An increased C-reactive protein level was defined as >/=10mg/L. RESULTS: The median C-reactive protein rate was 53.9mg/L (ranging from 1 to 228mg/L). An increased C-reactive protein was found in 77 patients (75%). By univariate analysis, ileocolic localization, severity of the flare, erythrocyte sedimentation rate, leukocyte and platelet count, fibrinogen, albumin, serum calcium and Crohn's disease activity index were found to be associated to elevated C-reactive protein values. By multivariate analysis, independent factors associated with an increased C-reactive protein level were: ileocolic localization (p=0.02; OR [95% CI]: 2.84 [1.25-9.52]) and moderate or severe disease activity (p=0.001; OR [95% CI]: 4.20 [1.92-8.64]). A statistically significant association between the Crohn's disease activity index score and the C-reactive protein level was found in our study (r=0.302; p=0.001). The optimal C-reactive protein threshold value that separates patients with moderate to severe disease (Crohn's disease activity index>220) from the others was calculated to be 19mg/L with a sensitivity of 76.4% and a specificity of 56.2%. CONCLUSION: The C-reactive protein level is correlated to disease activity in Crohn's disease. Its role seems to be essential in predicting moderate and severe disease activity.

[A previously unreported late complication of Finney strictureplasty]. / Une complication tardive et inédite d'une stricturoplastie à la Finney.

We report the case of a 23 year old woman, treated for Crohn's disease for 11 years. She was operated on for multiple obstructing jejuno-ileal strictures using strictureplasty technique. Nine stricturoplasties of Heineke-Mikulicz type and one Finney type were performed without immediate postoperative complication. The patient received Imurel(R) and remained in remission for 15 months. Peritonitis due to a perforation of the Finney strictureplasty required re-operation; an ileostomy was performed. Such a late complication of a strictureplasty has not previously been reported in the literature. Although this complication was severe, the indication for this procedure in the surgical management of Crohn's complications should not be modified.

[Colonic expression of gamma-interferon and interleukin-10 in Crohn's disease and ulcerative colitis]. / Expression colique de l'interféron-gamma et de l'interleukine-10 au cours de la maladie de Crohn et de la rectocolite ulcéro-hémorragique.

OBJECTIVE: The aim of this study was to investigate mucosal expression of INF-gamma and IL-10 in patients with Crohn's disease (CD) or ulcerative colitis (UC). METHODS: Fourteen patients with CD and 11 patients with ulcerative colitis participated and 7 healthy subjects were also included. Study of the mucosal expression of INF-gamma and IL-10 was conducted using biopsies from healthy and damaged colons, using the inverse transcription and genetic amplification (RT-PCR) technique in real time (Taqman). Our results were expressed as ratio between messenger cytokine (mRNA) levels and ribosomal RNA level of a reference molecule (rRNA 18S), then multiplied by 108. RESULTS: In the cases of Crohn's disease, the mucosa expressed increased INF-gamma and IL-10 compared with controls (respective medians: 23.03 vs. 1.87 p=0.04 and 20.61 vs. 2.13 p=0.08). A strong positive correlation was found in the mucosal expression of IL-10 and INF-gamma during CD (r=0.9 p<0.0001). In contrast, in patients with UC, the expression of INF-gamma and IL-10 were comparable to those observed in the controls (7.18 vs. 2.18 p=0.36 and 3.66 vs. 1.87 p=0.44). CONCLUSION: During Crohn's disease, the expression of both IL-10 and INF-gamma was increased and strongly correlated, compared with the controls.

Ochratoxin A in human plasma in Morocco: a preliminary survey.

Available epidemiological information seems to indicate that Balkan endemic nephropathy is associated with consumption patterns involving foodstuffs contaminated with ochratoxin A (OTA) and with a higher frequency of OTA-positive blood samples. The aim of this preliminary study was to assess OTA concentrations in human plasma in Morocco. Therefore, samples from 309 healthy volunteers (213 males, 96 females) were analysed. The analyses revealed that 60% of the human plasma sampled was positive for OTA (61.5% in the male and 56% in the female population), and an average concentration of 0.29 ng/mL (0.31 ng/mL in males, 0.26 ng/mL in females). The highest concentration found was 6.59 ng/mL. The results suggest that the Moroccan population is exposed to OTA, even though the OTA plasma levels are lower than that reported in some North African countries.

[Study of malabsorption of lactose by the hydrogen breath test in a population of 70 Tunisian adults]. / Etude de la malabsorption du lactose par le test respiratoire à l'hydrogène dans une population de 70 adultes tunisiens.

Lactose malabsorption was studied by the hydrogen breath-test in 23 adults suffering from irritable bowel syndrome (group A) and in 47 healthy subjects (group B). The concentration of hydrogen in end-expired alveolar samples was measured after ingestion of 25 g of lactose. Among the 70 subjects, 6 (8.5 p. 100) were not hydrogen producers and were excluded from the study. Lactose malabsorption was shown in 51 of the remaining 64 subjects (79.6 p. 100). Among these 51 patients, 36 were healthy and 15 had an irritable bowel syndrome. The frequency of lactose malabsorption among the 43 healthy hydrogen producers was 83 p. 100. This value is similar to those observed in other studies (greek and italian). Our results suggest that lactose malabsorption is frequent among the tunisian adult population.

[Effect of the increase of the caloric load of a meal on gastric emptying of its solid and liquid phases]. / Effet de l'augmentation de la charge calorique d'un repas sur la vidange gastrique de ses phases solide et liquide.

Caloric regulation of gastric emptying was mainly assessed with artificial liquid meals. We thus studied the effects of glucidic and lipidic caloric loads on gastric emptying of a solid-liquid meal (400 ml; 480 kcal), measured by an isotopic technique. Sixteen healthy subjects were separated in 3 groups; solutions of identical volume (400 ml) were added to the meal: water in group I (N = 6), glucose polymers (Caloreen; 400 kcal) in group II (N = 5), and triglycerides (Intralipide; 400 kcal) in group III (N = 5). Gastric emptying was dramatically slower in groups II and III than in group I, whatever the parameter considered. The magnitude of this caloric brake was identical for the 2 caloric loads tested and concerned both phases of the meal. Therefore, 3 h after the end of the meal, intragastric percentages of ingested liquids were 50 +/- 4 in group II, 52 +/- 5 in group III, vs 14 +/- 1 p. 100 in group I (p less than 0.001); for solids these percentages were 56 +/- 6 and 68 +/- 2 vs 11 +/- 3 p. 100 (p less than 0.001). In all groups, emptying of solids was slower than that of liquids, but the kinetics of this discrimination was modified by the increase of caloric load. The pyloric output of calories, estimated for the 3 h of the study was close to 2 kcal/min for the 3 groups studied. Thus, the 2 fold increase of the caloric concentration in groups II and III as compared to group I, did not modify the delivery rate of energy to small bowel.(ABSTRACT TRUNCATED AT 250 WORDS)

[Malignant lymphoma on a gastric stump]. / Lymphome malin sur moignon gastrique.

We report a case of lymphoplasmocytic and immunoblastic gastric remnant lymphoma occurring in a 51 year-old male. This patient had undergone subtotal gastrectomy for a gastric peptic ulcer at age 37. Histologic findings in the initial gastric specimen showed a dense lymphoid infiltrate surrounding the ulcer within the gastric mucosa. This proliferation was grouped into distinct follicles, and was compatible with pseudo-lymphoma. The progression of pseudo-lymphoma to malignant lymphoma is suggested.

[Minimal deviation adenocarcinoma of the uterine cervix in a woman with Peutz-Jeghers syndrome. Report of a case]. / Adénocarcinome à déviation minime du col utérin chez une femme porteuse d'un syndrome de Peutz-Jeghers. A propos d'une observation.

We report a case of minimal deviation adenocarcinoma of the uterine cervix in a 32 year old women who present a Peutz Jeghers syndrome. This patient also had fibroadenoma of the breast and dystrophic mastopathy. This case represent an example of predisposition to developing tumors of the Peutz Jeghers syndrome.