The Journal of Bucharest College of Physicians and the Romanian Academy of Medical Sciences

Lucian Negreanu

Lucian Negreanu

Treatment of Helicobacter Pylori – an Overview of Current Strategies of Diagnostic and Treatment

Helicobacter Pylori infection, responsible for ulcerous disease, atrophic gastritis,gastric cancer and MALT lymphoma (mucosa-associated lymphoid tissue) has a very high prevalence in the general population (approximately 50%). In Romania there are few data related to the prevalence of Helicobacter Pylori infection, as well as the resistance to antibiotic treatment, and the methods of patient surveillance are limited by costs and low accessibility. The aim of our paper is to recall the current possibilities of treatment and supervision of this category of patients, taking into account that the appropiate treatment and good monitoring of the patient can cure the complications of the disease and may prevent the occurrence of malignancies.

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Endoscopic Procedures In Patients Taking Novel Oral Anticoagulants

The use of direct oral anticoagulants (DOAC) for the treatment of atrial fibrillation and prevention of strokes is encouraged by their superior properties compared to vitamin K antagonists: predictable anticoagulant effect, greater patient compliance, few drug interactions, low risk of intracranial hemorrhages. Although practicing gastroenterologists may never prescribe a DOAC, they are likely to encounter DOAC-related GI adverse events (gastrointestinal bleeding), and they will need to manage DOACs around the time of endoscopy. The present paper aims to present the management possibilities of the patient treated with DOAC undergoing endoscopy, most studies performed so far focusing on the risk of spontaneous bleeding in this category of subjects. The current guidelines provided by the British Society of Gastroenterology and the European Society of Gastrointestinal Endoscopy orientate us, but endoscopic maneuvers should be preceded by a detailed analysis of the risks of secondary bleeding and thrombosis associated with DOAC users.

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Echo Intima-Media Thickness (IMT) in the Evaluation of Early Atherosclerosis in Inflammatory Bowel Disease (IBD) Patients – a Prospective Study

Introduction: Inflammatory bowel diseases (IBD) are accompanied by an early and accelerated atherosclerotic process. Previous studies showed that Doppler ultrasonography and intima-media thickness (IMT) is a reliable marker for early atherosclerosis diagnosis. The aim of our study was to evaluate the presence of early atherosclerosis in a group of subjects with inflammatory bowel diseases, using Doppler ultrasonography and intima-media thickness (IMT) as a marker of subclinical atherosclerosis. Methods: A case-control study was conducted on 61 patients with inflammatory bowel disease and 19 healthy individuals. The included patients had an established IBD diagnosis, based on clinical, endoscopic, and histological criteria for at least 12 months. Results: In our study echo IMT was not significantly higher in IBD patients than in matched healthy controls. We found no difference between Crohn’s disease and ulcerative colitis patients or between conventional or biologic treatment regarding the echo IMT. Severity of the disease and its duration were predictors of an increased IMT. We found that disease activity (measured by the endoscopic scores and CRP) correlates with higher values of echo IMT. Also the presence of anemia reached statistical significance and was correlated with increased echo IMT in the biologic treatment group. Conclusions: In our study we found an increased echo IMT in IBD patients versus control, but the values did not reach statistical significance. We found no difference between Crohn’s disease and UC, conventional or biologic treatment. Age and duration of disease were corelated with increased IMT. Disease that was not controlled (high endoscopic, clinical and biological markers of activity) was correlated with increased echo IMT. The limitations of our study are that in our patients therapy was started early in the course of the disease and that the majority of the patients were in remission when echography was made. Further studies are necessary to evaluate factors correlated with early atherosclerosis in IBD and how echo IMT can be used as a tool in the proactive evaluation of these patients.

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Thrombocytosis – a Valuable Parameter for Assessing Severity of Crohn's Disease Patients

Background and aim: Capsule endoscopy is the most sensitive method for evaluating mucosal lesions in Crohn’s disease and recent studies show that capsule endoscopy could be used for disease staging and for careful monitoring to evaluate endoscopic activity on a regular basis. Over time, many platelet changes have been described in IBD, including morphological and functional alteration and increased number. We determined whether platelets count correlates with the endoscopic activity measured using capsule endoscopy in Crohn’s disease patients from a single center.

Methods: This is a retrospective observational study. There were enrolled patients with suspected or known Crohn’s disease that underwent evaluation with capsule endoscopy in our department, between 2011 and 2021. For the evaluation with capsule endoscopy, Pillcam SB3 or Pillcam Colon2 were used. For the evaluation of endoscopic activity, we used Lewis score calculated using RAPID 8 capsule-reading software. Platelets level was
measured and correlated with the Lewis score, inflammatory biomarkers (C-reactive protein and fecal calprotectin) and anemic syndrome.

Results: A total of 62 patients were included in the study, of whom 37 (59.67%) were with suspected Crohn’s disease and 25 (40.32%) were with known Crohn’s disease. Thrombocytosis was present in the majority of patients with severe endoscopic activity (Lewis score more than 790), elevated CRP, fecal calprotectin more than 250microg/g and anemic syndrome.

Conclusion: To our knowledge, this is the first study that assess the correlation between thrombocytosis and severity of Crohn’s disease, evaluated with capsule endoscopy. Our data suggests that platelet count is a valuable, non-invasive, easy to use biomarker that is a good predictor of severity of Crohn’s disease and could have a prognostic value. It correlates well with Lewis score, CRP, fecal calprotectin and anemia.

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Assessment of Treatment in Inflammatory Bowel Disease Patients Using Steroid Assessment Tool (SAT) in a Tertiary Center from Romania

Background and aims: The evolution of inflammatory bowel diseases was significantly improved during the last decade by the new therapeutic options. Classical medications as corticosteroids and 5-aminosalycilates (5-ASA) are still highly used. In order to evaluate the pattern of corticosteroid usage we used a dedicated online tool-the steroid assessment tool. Our purpose was to evaluate if this tool can permit a change in the therapeutic habits and an improvement of quality of care. We succeeded to outline a therapeutic profile for a series of IBD patients in a tertiary centre from Romania. Methods: Two consecutive assessments were made using an online tool named Steroid Assessment Tool (SAT). Corticosteroid pattern of use and all previous and current treatments were registered and analyzed. Also the epidemiological and clinical data were collected and analyzed. The statistical analysis was performed using SPSS® software. Results: Results showed that most of our IBD patients (90%) had been treated with 5-ASA, with 29.2% of CD patients and 54.3% of UC patients currently using 5-ASA. Also, we had more CD patients (78%) than UC patients (56.5%) treated with anti-TNF inhibitors. The rate of thiopurine use was small (2.3%) and of anti-integrin therapy, interleukin 12/23 inhibitors as well. The rate of corticosteroid use was 34% in 2019 and in 2020 it dropped to 25% while the rate of corticosteroid excess was 20.4% in 2019 with a statistically significant decrease in 2020 (p=0,01) when it was 5.95%.Discussion: We managed to draw a therapeutic profile of IBD patients in a tertiary IBD centre from Romania using an online tool named SAT. We noticed that the majority of patients were treated with 5-ASA. Even though 5-ASA are not recommended by recent therapeutic guidelines as treatment for CD, we have 29.2% of CD patients treated with this class of drugs, a rate smaller than other reports but still outside guidelines. In the same time, we have a higher rate of anti-TNF agents use compared to other studies, but a lower rate of thiopurine use. Corticosteroid use was higher the other reports, but we succeeded to lower the rate of corticosteroid use and the rate of corticosteroid excess.Conclusions: The therapeutic profile and habits of prescription in a tertiary IBD centre were analyzed twice using an easy-to-use online tool. The results obtained in our first evaluation led to a change in the therapeutic management, improving our adherence to guideline’s recommendations.

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The Impact of Hepatic Arterial Variations and Reconstructions on Arterial Complications in Liver Transplantation

Background: The purposes of the study were to determine the variations in hepatic arterial supply, to delineate the optimal methods of arterial anastomoses and reconstructions in liver transplantation and to analyse the incidence of arterial complications. Methods: The surgical anatomy of the extrahepatic arterial vascularization was investigated retrospectively in 209 donors and patients who underwent liver transplantation at Fundeni Clinical Institute (Bucharest, Romania) from January 1, 2015 to December 31, 2017. The vascular anatomy of the hepatic grafts was classified according to Michels’ description and other rare variations. Results: Anatomical variants of the classical pattern were detected in 26.3% of the livers (n = 55). The most common variant was a replaced right hepatic artery arising from the superior mesenteric artery (n = 17; 8.13%), followed by a common hepatic artery from superior mesenteric artery (n = 6; 2.87%). Arterial reconstructions were reported in 97 cases (45.5%). In recipients, used sites were intermediate: common hepatic artery (CHA) in 73.8% (n = 158), distal: proper hepatic artery (PHA) or common hepatic artery/gastro-duodenal artery bifurcation (CHA/GDA bifurcation) in 16.4% (n = 35) and proximal: coeliac trunk-splenic artery-aorta (CT–SA–A) in 9.3% (n = 20) of patients. Most common reconstructions were short graft artery (CT) on the recipient CHA (n = 33, 34.02%) and long graft artery: complex reconstruction between CT and superior mesenteric artery (SMA) - accessory right hepatic artery (RHA) from SMA on CHA (n = 12, 12.37%) and right hepatic graft artery on PHA or CHA/GDA bifurcation (n = 16, 16.49%). Conclusion: The information about the different hepatic arterial patterns, as well as establishing specific methods for arterial anastomoses and reconstructions is important in the determination of better outcomes.

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Improvement of Quality of Care in Inflammatory Bowel Disease: the Role of Steroid Assessment Tool (SAT) – Results from a Tertiary Center Trial

Background and aims: Corticosteroids play an important role in the treatment of inflammatory bowel disease patients. They are used for induction of remission but due to their numerous side-effects they are avoided in the long term treatments.In order to improve medical care for the IBD patients guidelines were developed to avoid steroid excess and to promote regular monitoring of corticosteroid use. The aim of this study was to evaluate corticosteroid treatment using an online tool in a tertiary IBD centre from Romania. Methods: An online monitoring tool – SAT (Steroid Assessment Tool) was used to assess disease characteristics, corticosteroid use, corticosteroid excess as defined by international guidelines and the use of bone protection medication associated to steroid treatment. Two successive evaluations of patients treated in a tertiary IBD center were made, the first one in March 2019 on 44 patients and the second one 12 month later, in March 2020, on 84 patients. Data were statistically analyzed with SPSS® software. Results: The results showed that in 2019 the rate of corticosteroid use was of 34%, while in 2020 there was a decrease of corticosteroid use up to 25%. Regarding steroid excess, in 2019 there were 20.4% of patients treated with steroids in excess, but we managed to reduce it to 5.95% in 2020, a decrease that was statistically significant. Bone protection medication was prescribed to only 6.6% of patients treated with corticosteroids in 2019, but a significant increase up to 95% was obtained in 2020. Discussions: Two SAT evaluations of a tertiary IBD centre from Romania revealed that despite new therapeutic options, the rate of steroid use was higher than that reported in other international studies. The objective evaluation of steroid use determined a change in managing IBD patients, thus we succeeded to decrease significantly the rate of steroid excess and increase the use of calcium and vitamin D associated to corticotherapy. Conclusions: The use of an objective tool for monitoring corticosteroid use determined an improvement in managing IBD patients and thus of quality of care.

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Type III Gastric Neuroendocrine Tumor - a Case Report

We present the case of a 71 year old female that was endoscopically diagnosed with type III neuroendocrine gastric tumor (NET). NETs are rare, slowly growing neoplasm originating in the neuroendocrine cells, that can occur anywhere in the body. Gastrointestinal forms account for more than a half of them. If type I and II gastric neuroendocrine tumors can be managed endoscopically, type III and IV have sugery as their main therapy. Because type III lessions have the greatest potential to generate metastasis, we did a CT scan on the patient and found distant metastasis located in the liver and also to the lymph nodes. Treatment options depend on the type of tumor, its location, signs and symptoms experienced by the patient, due to excess hormones produced by the tumor, and also if there is resectable metastatic disease or not. Altough our patient had a voluminous tumor, surgical resection was possible, followed by chemotherapy, with good evolution.

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Recent Advances in Colonic Preparation for an Accurate Colonoscopy - How to Improve Our Practice to Meet the Quality Criteria

Colorectal cancer (CRC) remains a major problem of global health. Screening colonoscopy is the gold standard in detection of CRC. A quality colonoscopy needs good indication, adequate bowel preparation, adequate examination time (30 to 45 minutes), a minimum 6 minutes time for mucosal examination during colonoscopy descent, a good centre adenoma detection rate. In 28-33% of the colonoscopies, the bowel preparation is unsatisfactory which leads to several hidden costs including the rise of preventable and treatable death rate regarding colorectal carcinoma. The ESGE (European Society of Gastrointestinal Endoscopy) recommends a maximum of 10% poor preparations, threshold that is difficult to reach in many centres. Newer low-volume laxative regimens for bowel cleansing are better in the fields of compliance and tolerability than the classic 4L PEG with 2L PEG-CS (Clensia ®) being one of the new promising low-volume formulas. The low fibre diet is now preferred due to better compliance and tolerability. Conclusions: One of the easiest ways to improve colonoscopy quality is through improved compliance. Two of the most effective measures are using newer laxative bowel cleansing formulas (like 2L PEG-CS) and a low-fibre diet.

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Quality of Care in Inflammatory Bowel Disease: the Role of Steroid Assessment Tool (SAT) - a Review

Corticosteroids have an important role in induction of remission in inflammatory bowel disease, but they are not an indicated for maintenance treatment as they are associated with many side effects. Despite new efficient therapeutic options for maintaining remission, there is an excess in prescribing steroids in inflammatory bowel disease. Corticosteroid use was evaluated in international cohorts given that steroid free remission and avoiding serious side-effects of corticosteroids is a desirable goal. We discuss the role and the evidences on a secure web-based steroid assessment tool (SAT) which can be used as an instrument of evaluation of corticosteroid use, a quality indicator in inflammatory bowel disease.

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Case Presentation: a Facial Ulceration in a Patient with Ulcerative Colitis

We present the case of a patient with severe ulcerative colitis treated with infliximab that was admitted for an extensive facial ulceration located on the left cheek. Pyoderma gangrenosum, bacterial, mycobacterial and fungal infection were taken into account. The patient was diagnosed with a Klebsiella abscess originating from a tooth infection. Infectious complications might arise more frequently in IBD patients treated with anti TNF and adequate diagnosis and therapy is required.

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An Angiographic Treatment for a Pancreatic Pseudoaneurysm

Interventional radiology has made significant progress to the care of severe acute pancreatitis complications with the introduction of percutaneous procedures. More recently, radiologic intervention has become the gold standard in treating a rare condition like pancreatic pseudoaneurysms. We report the case of an 40 years old male, heavy drinker and smoker, at the second episode of acute pancreatitis that developed an pseudoaneurysm cured through angiographic embolotherapy.

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The Bucharest College of Physicians’ Study on Burnout Amongst Healthcare Professionals in Romania’s Capital City

Since its fi rst description in 1980 by Freudenberger, the phenomenon of burnout has been studied intensively by many scholars in the past decades and stakeholders are getting more and more aware of the problematic burnout poses in the professional fi eld, as well as the healthcare threat it poses. It is well known today that when it comes to the fi eld of healthcare workers, burnout plays a signifi cant role in regards to physicians’ well-being. The Bucharest College of Physicians wanted to evaluate this phenomenon amongst doctors working in Romania’s capital city and launched a survey addressing its’ members. The study revealed a rather high number of physicians suffering from at least one kind of burnout. The numbers were highest in the fi eld of personal and professional burnout – 55% and 52% of respondents respectively. In regards to burnout caused by the nature of their work (working with patients), a still high number of 36% of respondents showed signs of burnout. Participants in the study named the increasing number of bureaucratic tasks as one of the major stressors at the job and suggested that by eliminating some bureaucracy, one could improve their level of stress on the job. The results of the study conducted by the Bucharest College of Physicians fall in line with other studies regarding healthcare workers around the globe. The alarmingly high numbers of burnout cases and increased levels of stress should signal stakeholders in the healthcare system to take action in order to improve physicians’ well-being.

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Identification of Osteoarthritis with Multiple Joint Involvement in Elderly Institutionalized Patients Concomitant with...

Related to the rehabilitation of patients with osteoarthritis, kinesiotherapy addresses the methods, procedures and methodology that will be used depending on the anatomic, functional and clinical stage of the disease and its location after setting treatment goals. Furthermore, priorities of the rehabilitation program are established considering both medical issues and also paramedical and social aspects [1].
The kinesiotherapeutic opera tional strategy in rehabilitating patients with osteoarthritis is planned according to the characteristic comorbidities of elderly patients [2]. Clinical trials highlight that cardiovascular mortality is reduced when sedentary individuals become moderately active [3,4].

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The Rehabilitation of Elderly Institutionalized Patients with Osteoarthritis (Multiple Joint Involvement) Using...

Osteoarthritis, as a major cause of disability and due to the high prevalence among chronic diseases, represents one of the most important public health problems worldwide [1]. The limitation of physical function and the restriction of independence produce negative effects on the mental status of patients suffering from osteoarthritis, namely the emergence of depression and decreased self-confidence [2,3].
Developing a kinesiotherapeutic strategy based on the clinical, anatomical and functional stage of the disease and other comorbidities, as well as exploiting psychological and psychopedagogical resources will improve the physical performance and increase the independence of these patients [4,5].

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