Reviewer's report 
 Clinical and Histological Features of Nonalcoholic Steatohepatitis in Iranian Patients Title: 
Authors: 
Naser E Daryani MD ( nebrahim@sina.tums.ac.ir )
Dr Hossein Bahrami MD ( dr_Bahrami@hotmail.com )
Shahram Mirmomen MD ( mirmomen@ams.ir )
Babak Haghpanah MD ( babakhp@myrealbox.com )
 1  6 May 2003 Version: Date: 
 Claudio C Tiribelli Reviewer: 
 A paper whose findings are important to those with closely related research Level of interest: 
interests 
 Unable to decide on acceptance or rejection until the authors have Advice on publication: 
responded to the compulsory revisions 
This paper reports on the clinical and biochemical outline of Non Alcoholic Steatohepatitis (NASH) in 
Iran. To this end, 53 subjects with histologically proven NASH were examined. Almost all the NASH 
patients were somehow obese (from mild to severe) and more that were either dyslipidemic and/or 
diabetic, confirming that body weight, plasma lipids and glucose are important factors in inducing NASH. No correlation between the alteration in plasma activity of aminotransferases and the degree of fatty infiltration, fibrosis and/or inflammation was observed. The series is interesting as it derived 
from a Country where the alcohol consumption is much lower (theoretically zero) than in the 
Western countries. However the data are not providing any new hints on the mechanisms at the basis of this rapidly increasing clinical entity. 
1. Comments (Please number your comments and divide them into: discretionary revisions - which 
the authors can choose to ignore - and compulsory revisions - which the authors must address.) 
a) Discretionary revisions 
The term "transaminases" needs to be replace with "aminotransferases" 
Ref 5 is not a reference. Either delete or replace. 
b) Compulsory revisions 
The methods used in assessing the alcohol consumption (page 4, first para) need to be better specified. Was a questionnaire used and was the alcohol consumption somehow quantified? The study includes 53 cases deriving from a total of 86 who met the inclusion criteria. Out of these 
86, 74 were biopsied. What happened to the missing 21? Why they were discarded? This is 
important since this could introduce a selection bias hampering the conclusions. Full details should be provided. 
All the patients with "mild steatosis" (page 5, lines 4-5) were screened with a 3rd generation test for 
HCV and found to be negative. Were also the other subjects included in the study screened with 
RIBA for possible HCV infection?. If not, as I understand, this may further increase the selection bias. The detection of a fatty liver at US is reported to be only 51% (page 6, 3rd para). This is surprising 
since fatty liver is much higher in obese and dyslipedmic subjects (see Ann.Int.Med. 2000, 
132:112-117). Were all the US examinations performed by single operator? If yes, was the operator 
aware of the clinical and hystological findings of the subject? If multiple operators perform the US, 
were the criteria for "bright liver" defined beforehand according to the international standards. These 
details need to be provided. 
The discussion is focussed in explaining the sex difference observed when compared to other series 
previously reported. Though this is interesting, less emphasis is needed on this issue. More 
important seems to compare the clinical presentation of these patients (younger, with lover increase 
in AST and ALT acitivty) . 
Competing interests: 
None declared. 
Reviewer's report 
 Clinical and Histological Features of Nonalcoholic Steatohepatitis in Iranian Patients Title: 
Authors: 
Naser E Daryani MD ( nebrahim@sina.tums.ac.ir )
Dr Hossein Bahrami MD ( dr_Bahrami@hotmail.com )
Shahram Mirmomen MD ( mirmomen@ams.ir )
Babak Haghpanah MD ( babakhp@myrealbox.com )
 1  6 May 2003 Version: Date: 
 Claudio C Tiribelli Reviewer: 
 A paper whose findings are important to those with closely related research Level of interest: 
interests 
 Unable to decide on acceptance or rejection until the authors have Advice on publication: 
responded to the compulsory revisions 
This paper reports on the clinical and biochemical outline of Non Alcoholic Steatohepatitis (NASH) in 
Iran. To this end, 53 subjects with histologically proven NASH were examined. Almost all the NASH 
patients were somehow obese (from mild to severe) and more that were either dyslipidemic and/or 
diabetic, confirming that body weight, plasma lipids and glucose are important factors in inducing NASH. No correlation between the alteration in plasma activity of aminotransferases and the degree of fatty infiltration, fibrosis and/or inflammation was observed. The series is interesting as it derived 
from a Country where the alcohol consumption is much lower (theoretically zero) than in the 
Western countries. However the data are not providing any new hints on the mechanisms at the basis of this rapidly increasing clinical entity. 
1. Comments (Please number your comments and divide them into: discretionary revisions - which 
the authors can choose to ignore - and compulsory revisions - which the authors must address.) 
a) Discretionary revisions 
The term "transaminases" needs to be replace with "aminotransferases" 
Ref 5 is not a reference. Either delete or replace. 
b) Compulsory revisions 
The methods used in assessing the alcohol consumption (page 4, first para) need to be better specified. Was a questionnaire used and was the alcohol consumption somehow quantified? The study includes 53 cases deriving from a total of 86 who met the inclusion criteria. Out of these 
86, 74 were biopsied. What happened to the missing 21? Why they were discarded? This is 
important since this could introduce a selection bias hampering the conclusions. Full details should be provided. 
All the patients with "mild steatosis" (page 5, lines 4-5) were screened with a 3rd generation test for 
HCV and found to be negative. Were also the other subjects included in the study screened with 
RIBA for possible HCV infection?. If not, as I understand, this may further increase the selection bias. The detection of a fatty liver at US is reported to be only 51% (page 6, 3rd para). This is surprising 
since fatty liver is much higher in obese and dyslipedmic subjects (see Ann.Int.Med. 2000, 
132:112-117). Were all the US examinations performed by single operator? If yes, was the operator 
aware of the clinical and hystological findings of the subject? If multiple operators perform the US, 
were the criteria for "bright liver" defined beforehand according to the international standards. These 
details need to be provided. 
The discussion is focussed in explaining the sex difference observed when compared to other series 
previously reported. Though this is interesting, less emphasis is needed on this issue. More 
important seems to compare the clinical presentation of these patients (younger, with lover increase 
in AST and ALT acitivty) . 
Competing interests: 
None declared. 
Please review this paper.
user
Reviewer's report 
 Clinical and Histological Features of Nonalcoholic Steatohepatitis in Iranian Patients Title: 
Authors: 
Naser E Daryani MD ( nebrahim@sina.tums.ac.ir )
Dr Hossein Bahrami MD ( dr_Bahrami@hotmail.com )
Shahram Mirmomen MD ( mirmomen@ams.ir )
Babak Haghpanah MD ( babakhp@myrealbox.com )
 1  6 May 2003 Version: Date: 
 Claudio C Tiribelli Reviewer: 
 A paper whose findings are important to those with closely related research Level of interest: 
interests 
 Unable to decide on acceptance or rejection until the authors have Advice on publication: 
responded to the compulsory revisions 
This paper reports on the clinical and biochemical outline of Non Alcoholic Steatohepatitis (NASH) in 
Iran. To this end, 53 subjects with histologically proven NASH were examined. Almost all the NASH 
patients were somehow obese (from mild to severe) and more that were either dyslipidemic and/or 
diabetic, confirming that body weight, plasma lipids and glucose are important factors in inducing NASH. No correlation between the alteration in plasma activity of aminotransferases and the degree of fatty infiltration, fibrosis and/or inflammation was observed. The series is interesting as it derived 
from a Country where the alcohol consumption is much lower (theoretically zero) than in the 
Western countries. However the data are not providing any new hints on the mechanisms at the basis of this rapidly increasing clinical entity. 
1. Comments (Please number your comments and divide them into: discretionary revisions - which 
the authors can choose to ignore - and compulsory revisions - which the authors must address.) 
a) Discretionary revisions 
The term "transaminases" needs to be replace with "aminotransferases" 
Ref 5 is not a reference. Either delete or replace. 
b) Compulsory revisions 
The methods used in assessing the alcohol consumption (page 4, first para) need to be better specified. Was a questionnaire used and was the alcohol consumption somehow quantified? The study includes 53 cases deriving from a total of 86 who met the inclusion criteria. Out of these 
86, 74 were biopsied. What happened to the missing 21? Why they were discarded? This is 
important since this could introduce a selection bias hampering the conclusions. Full details should be provided. 
All the patients with "mild steatosis" (page 5, lines 4-5) were screened with a 3rd generation test for 
HCV and found to be negative. Were also the other subjects included in the study screened with 
RIBA for possible HCV infection?. If not, as I understand, this may further increase the selection bias. The detection of a fatty liver at US is reported to be only 51% (page 6, 3rd para). This is surprising 
since fatty liver is much higher in obese and dyslipedmic subjects (see Ann.Int.Med. 2000, 
132:112-117). Were all the US examinations performed by single operator? If yes, was the operator 
aware of the clinical and hystological findings of the subject? If multiple operators perform the US, 
were the criteria for "bright liver" defined beforehand according to the international standards. These 
details need to be provided. 
The discussion is focussed in explaining the sex difference observed when compared to other series 
previously reported. Though this is interesting, less emphasis is needed on this issue. More 
important seems to compare the clinical presentation of these patients (younger, with lover increase 
in AST and ALT acitivty) . 
Competing interests: 
None declared. 
assistant