Clostridioides difficile infection in patients with and without COVID-19 during the pandemic: a retrospective cohort study from a tertiary referral hospital.

OBJECTIVES: This study aims to detect the prevalence and specific characteristics of Clostridioides difficile infection (CDI) during the COVID-19 pandemic. METHODS: In this retrospective observational study, conducted in a tertiary hospital in Greece between May 2021 and October 2022, patients with CDI from COVID-19 and Internal Medicine wards were enrolled and compared based on epidemiological and disease-associated data. RESULTS: In total, 4322 patients were admitted, and 435 samples for CDI were analyzed, with 104/435 (23.9%) sample positivity and 2.4% prevalence. We observed an increased prevalence of CDI compared to the beginning of the COVID-19 pandemic (prevalence= 1.7%, p=0.003). 35.6% of the CDI patients were hospitalized in the COVID-19 ward and 64.4% in the Internal Medicine ward. COVID-19 patients were younger (p=0.02) with a lower Charlson Comorbidity Index (CCI) compared to the Internal Medicine ward patients (p<0.001). With regards to the origin of CDI cases, in the Internal Medicine ward, 68.7% presented with Hospital-Onset CDI, 17.9% with Community Onset-Healthcare Associated CDI and 13.4% with Community Associated CDI, while in the COVID-19 ward, the respective percentages were 86.5%, 5.4% and 8.1%. Finally, there was an increased CDI-related CFR (Case Fatality Ratio) in the Internal Medicine ward compared to the COVID-19 ward (28.4% vs. 5.4%, p=0.001). CONCLUSIONS: Increased CDI prevalence and testing were observed compared to the beginning of the COVID-19 pandemic. Lower CDI-related CFR was observed in patients with COVID-19, which may be credited to the patients' significantly lower median age and CCI, as well as to the majority of deaths being due to respiratory failure.

Helicobacter pylori infection diagnosis and management: current practices of Greek gastroenterologists.

Background: The diagnosis and management of Helicobacter pylori (H. pylori) infection vary significantly, depending on country, area, and specialty. The aim of this study was to record the current practices of Greek gastroenterologists in the screening and treatment of H. pylori infection. Method: An anonymous questionnaire consisting of 19 questions about the management of H. pylori infection was sent with the aid of the Hellenic Society of Gastroenterology to all members of the Society. Results: The questionnaire was completed by 180 gastroenterologists, with a response rate of 31.4%. Diagnostic tests to confirm H. pylori infection are ordered by >90% of the gastroenterologists for patients with current peptic ulcer disease, gastric lymphoma, family history of gastric cancer, and an endoscopic appearance suggestive of gastritis. Most gastroenterologists (55.8%) also tested for H. pylori in patients with gastroesophageal reflux disease (GERD). Histopathology was the most preferred (60.6%) method when testing was decided during endoscopy, while urea breath test was the most preferred method (67.8%) regardless of endoscopy. Most gastroenterologists use quadruple eradication regimens supported by international guidelines (90%), while 65.6% of the physicians answered that they systematically recommend the addition of probiotics to standard therapy. Most physicians (82.8%) answered that they always confirm the eradication of the pathogen. Conclusions: The majority of Greek gastroenterologists conform to the recommendations of international guidelines regarding the diagnosis and management of H. pylori infection, except for the screening of patients with GERD. A considerable number of doctors use probiotics in addition to standard therapy.

The natural history of COVID-19 in patients with inflammatory bowel disease: a nationwide study by the Hellenic Society for the study of IBD.

OBJECTIVES: COVID-19 has evolved into a global health crisis, variably affecting the management of patients with chronic illnesses. Patients with inflammatory bowel disease (IBD) may represent a vulnerable population due to frequent administration of immune-modifying treatments. We aimed to depict the natural history of COVID-19 infection in Greek patients with IBD at a nationwide level via unbiased reporting of all cases that were registered during the sequential waves of the pandemic. METHODS: Following a national call from the Hellenic Society for the study of IBD, we enrolled all IBD patients with established diagnoses of COVID-19. Clinical and epidemiological data, including COVID-19 modifying factors and IBD-associated therapies, were analyzed against adverse outcomes (hospitalization, ICU admission and death). RESULTS: We identified 154 IBD patients who were diagnosed with COVID-19 (men: 58.4%; mean age=41.7 years [SD = 14.9]; CD: 64.3%). Adverse outcomes were reported in 34 patients (22.1%), including 3 ICU admissions (1.9%) and two deaths (1.3%). Multivariate logistic regression analysis showed that age (OR = 1.04, 95% CI, 1-1.08) and dyspnea at presentation (OR = 7.36, 95% CI, 1.84-29.46) were associated with worse outcomes of COVID-19 infection. In contrast, treatment with biologics, in particular anti-TNF agents, exerted a protective effect against an unfavorable COVID-19 disease course (OR = 0.4, 95% CI, 0.16-0.99). Patients on subcutaneous biologics were more likely to halt treatment due to the infection as compared to those on intravenous biologics. CONCLUSIONS: IBD patients who developed COVID-19 had a benign course with adverse outcomes being infrequent. Treatment with anti-TNF biologics had a protective effect, thus, supporting continuation of therapy during the pandemic.

Primary gastric melanoma of unknown origin: a case report and short literature review.

Though being usually a cutaneous tumor, melanomas can occur in several extracutaneous sites. Primary mucosal melanomas are rare, and primary gastric mucosal melanomas are considered extremely rare. Compared with cutaneous and ocular melanoma, mucosal melanomas have the lowest five-year survival. High level of suspicion of such rare condition may be the only way for early detection, diagnosis and chance for successful management of similar cases. In the present report, a case of a primary gastric melanoma in a 73-year-old man is described, along with a short review of the literature.

Differences between fellows and fellowship program directors in their perception of the impact of the COVID-19 pandemic on gastroenterology training: results from a nationwide survey in Greece.

BACKGROUND: Lockdown measures applied during the SARS-CoV-2 outbreak caused a significant disturbance to hospital routine. We assessed trainees' and fellowship directors' perceptions regarding the impact of the pandemic on gastroenterology fellowship training. METHODS: A web-based survey was anonymously disseminated to all Greek gastroenterology fellows and fellowship program directors. Participants completed electronically a questionnaire comprised of 5 domains that assessed participants' perception of: 1) overall impact on training; 2) impact on training in gastroenterology-specific fields (endoscopy, inflammatory bowel disease, hepatology); 3) impact on different aspects of endoscopy training; 4) impact on academic training; and 5) training perspectives for the post-pandemic era. RESULTS: A total of 77/128 fellows (60.1%) and 18/28 fellowship program directors (64.3%) responded. More fellows reported that the COVID-19 pandemic would have an adverse impact on fellowship training compared to their fellowship program directors (81.8% vs. 55.6%, P=0.038). This concern was mainly focused on endoscopy training (83.1% vs. 27.8%, P<0.001), with no difference regarding training in gastroenterology's other specific fields. The difference was consistent for technical skills (79.2% vs. 38.9%, P=0.001), and for the performance of basic diagnostic (70.1% vs. 22.2%, P<0.001) and emergency (48.1% vs. 11.1%, P=0.004) procedures. Fellows and fellowship program directors identified the unknown timeframe of measure implementation and the postponement of scheduled endoscopic procedures as the main factors that negatively affected training. Extension of the fellowship training program was deemed the optimal option by fellows for addressing the training decrement in the post-pandemic era, while fellowship program directors favored an increase in workload. CONCLUSION: Fellows and their fellowship program directors do not share the same concerns about the impact of COVID-19 pandemic on training programs and they propose different measures to remedy its effects.

Endoscopic sedation practices of Greek gastroenterologists: a nationwide survey.

BACKGROUND: Sedation in gastrointestinal endoscopy is rapidly evolving worldwide. However, this has led to significant disagreements, especially regarding the use of propofol by non-anesthesiologists. The aim of this study was to document the practices of Greek gastroenterologists regarding sedation and compare them to previous surveys. METHODS: The study was conducted in 2 periods, December 2015 and June 2018. In each period, the same online questionnaire regarding endoscopic sedation practices was sent to all registered Greek gastroenterologists (509 and 547 gastroenterologists, respectively). RESULTS: The response rates were 38.3% and 47.1%, respectively. In each period, 25.1% and 16.7% of physicians did not use sedation. Most gastroenterologists (approx. 70% in both instances) answered that they "almost never" collaborate with an anesthesiologist during endoscopy. Midazolam was by far the most popular sedation agent, used by almost 90% of physicians in both periods. Propofol was used by 30.8% and 27% of physicians, respectively. Physicians using propofol were significantly more satisfied with the sedation than other physicians, while propofol was the agent selected by most physicians if they were to undergo endoscopy themselves. Most physicians cited medicolegal reasons and inadequate training as chief reasons for not using propofol. CONCLUSIONS: Sedation use is widespread among Greek gastroenterologists. Although midazolam is the most commonly used agent, propofol is preferred (theoretically) by most physicians and achieves the best satisfaction. The introduction of a strict training curriculum for endoscopic sedation can effectively eliminate the barriers preventing gastroenterologists from administering propofol, while at the same time ensuring optimal patient safety during endoscopy.

Cultural factors and the circadian rhythm of ST elevation myocardial infarction in patients in a Mediterranean island.

INTRODUCTION: The circadian rhythm of onset of myocardial infarction shows an increased risk during the morning hours. However, it is not clear whether habits, culture and sunshine hours differentiate circadian rhythm. The aim of this study was to investigate the influence of cultural factors on the circadian rhythm of acute myocardial infarction with ST segment elevation in a Mediterranean island. METHOD: The study was a retrospective correlational survey. It included 123 patients with ST elevation myocardial infarction (mean age 60.7±12.6; 82% men). The 24 h of a day were divided into four six-hour periods of time for study purposes (00:01-06:00; 06:01-12:00; 12:01-18:00; and 18:01-24:00) and the chi-square test was used for the analysis. RESULTS: A morning peak of symptoms onset of ST-elevation myocardial infarction was detected during the period 06:01-12:00 (p=0.044). In patients who were smokers, a bimodal pattern involving a morning (06:01-12:00) and an afternoon-to-night peak (18:01-24:00) (p=0.005) was detected. For patients with a history of hypertension, a morning peak of their symptoms was also detected (p=0.028). Different circadian variations were found between patients over the age of 60 years old and patients under the age of 60 years old (p=0.025). CONCLUSIONS: Patients with ST elevation myocardial infarction seem to follow a circadian rhythm with a peak of onset of symptoms in the morning. In the smokers' subgroup, a different circadian pattern was found. The habit of smoking is likely to affect the circadian rhythm of the onset of ST elevation myocardial infarction in the Mediterranean area and culture.

Effects of antiviral treatment on the risk of hepatocellular cancer in patients with chronic viral hepatitis.

Hepatocellular carcinoma (HCC) is a major complication of chronic hepatitis B (CHB) and chronic hepatitis C (CHC). Accumulating data suggest that antiviral treatment in both CHB and CHC reduces the incidence of HCC. Evidence is more consistent for interferon-based treatment in both CHB and CHC and for lamivudine in patients with CHB. However, more limited data suggest that other nucleos(t)ide analogues might also reduce the risk of HCC. In contrast, conflicting data have been reported on the effects of direct-acting antivirals on the incidence of HCC.

Is propofol the optimal sedative in gastrointestinal endoscopy?

Propofol is a sedative agent commonly used for sedation in gastrointestinal endoscopy. Its pharmacologic properties render propofol an almost ideal drug to achieve and maintain the targeted level of sedation in even complex gastrointestinal procedures. When compared with other sedative agents, propofol is associated with better patient and endoscopist satisfaction and shorter recovery times. Furthermore, propofol can be combined with other sedatives to reduce the total dosage required to achieve the targeted sedation. Its safety is demonstrated by multiple studies, in which adverse events occurred very rarely. Nevertheless, the use of propofol by non-anesthesiologists is illegal in many countries and in those permitted, a structured curriculum with clinical training must first be successfully completed. However, various studies have shown that non-anesthesiologist administration of propofol is comparable in efficacy and safety to administration by an anesthesiologist and more cost-effective. The results of numerous studies indicate that propofol is superior in many aspects compared with traditional sedative agents.

Common ABCB1 polymorphisms in Greek patients with chronic hepatitis C infection: A comparison with hyperlipidemic patients and the general population.

BACKGROUND: Hepatitis C virus infectivity and replication efficiency appears to be dependent on the lipid content and organization of the plasma membrane of the host cell, as well as of the intracellular membranous web. As there is increasing awareness of a role played by the efflux pump ABCB1 (p-glycoprotein, P-gp) in lipid homeostasis, its function could be a determinant of chronic HCV infection. The aim of the present study was to examine and compare the distribution of common ABCB1 genotypes in patients with chronic HCV infection (n=168), hyperlipidemic patients (n=168) and a control group (n=173), all from Greece. METHODS: Participants were genotyped for the ABCB12677G>T/A and 3435C>T polymorphisms with previously reported PCR-RFLP methods. Genotype and allele frequency distributions were compared between the three groups with the χ(2) test of independence. RESULTS: The ABCB1 2677GG (ancestral) genotypes were significantly over-represented in patients with chronic hepatitis C compared to controls (39.3% vs. 26.6%, p=0.015 according to the dominant model). A similar result was obtained when hyperlipidemic patients were compared to controls (45.2% vs. 26.6%, p<0.001 according to the dominant model). Comparison of ABCB1 3435C>T genotype and allele distributions provided similar but not as significant differences. Genotype and allele distributions for both ABCB12677G>T/A and 3435C>T were very similar between HCV patients and hyperlipidemic patients. CONCLUSION: Our findings imply an influence of ABCB1 polymorphisms on HCV infectivity, possibly through an effect on lipid homeostasis.

The Greek version of the 9-item European Heart Failure Self-care Behaviour Scale: a multidimensional or a uni-dimensional scale?

OBJECTIVES: To evaluate the dimensionality of the Greek version of the European Heart Failure Self-care Behaviour Scale (Gr9-EHFScBS) in a Greek-Cypriot population. BACKGROUND: EHFScBS is a valid and reliable scale which is widely used for assessing heart failure (HF) patients' self-care behaviors. METHODS: EHFScBS was translated into Greek and was administered to 128 Greek-Cypriot HF patients. The internal consistency, construct validity and discriminant validity of the scale were assessed. RESULTS: Confirmatory factor analysis failed to capture the proposed theoretical structure. Further exploratory factor analysis provided a three-factor solution accounting for 53.35% of the variance, though the scale is better used as a whole. Cronbach's alpha was moderate 0.66, but deletion of any item decreased the alpha coefficient. Discriminant validity was supported by the poor correlation between EHFScBS and Minnesota Living with Heart Failure Questionnaire scores. CONCLUSION: Even though results do not conform to the multidimensionality of the scale, assessment of the tool provided acceptable validity and reliability measures to support its usage among Greek speaking populations.

Educational challenges to the health care professional in heart failure care.

The purpose of this review is to discuss the educational challenges faced by health care professionals in the care and management of patients with heart failure (HF). Self-care is a vital component in HF management, and promotion of self-care through education is a fundamental aspect of patient-centered care and supports patients' right to autonomy. The ultimate goal is not simply to convey knowledge, but to promote patients' understanding and to enhance their self-care skills by assuming an active role in their care. As such, health care professionals are confronted with a number of patient-related issues as they strive to provide high-quality education. Beyond assessing patients' individual information needs and preferences, they are tasked with addressing several obstacles that impede patients' ability to engage in self-care. Factors such as cognitive impairment and low health literacy have a major impact on patients' ability to understand, absorb, and recall information. Moreover, the existence of negative beliefs, which are strong determinants of patients' attitudes towards their disease and treatment, may also influence their response to educational messages. Health care professionals must not only identify and overcome these obstacles, but they must act effectively within the limitations of their working environment and of the health care system.

Pegylated interferon alfa-2b pen device and ribavirin treatment for patients with chronic hepatitis C: an evaluation of patient satisfaction.

OBJECTIVE: The aim of this study was to evaluate the satisfaction of patients with chronic hepatitis C who used the pegylated interferon α-2b pen device. METHODS: Patients from multiple centers in Greece were recruited to participate in this noninterventional, observational study. Patients received pen device training for at least 6 weeks before treatment and used questionnaires to provide feedback (rating scale: 1-4, negative; 5-7, positive) on training, medication preparation and injection, and appreciation of the device. Results were analyzed with standard statistical analysis and multivariate logistic regression. RESULTS: In total, 507 patients (mean age, 43.5 years), 77.4% of whom were treatment naive, participated in the study. Overall, 84.2% of patients rated training positively, 67.4% of patients rated medication preparation positively, and 88.3% of patients rated medication injection positively. Appreciation of the pen device treatment method was rated positively by 82.2% of patients. Intravenous drug users were more likely to rate medication injection positively (P=0.0284) and to appreciate this method of drug delivery (P=0.0328) than other patients. Patients with lower levels of education were less likely to rate training positively (P=0.0202) and showed less appreciation for this route of drug delivery (P=0.0341) than other patients. Treatment-naive patients were more likely to provide positive responses about the overall procedure than were treatment-experienced patients (odds ratio: 1.932; P=0.032). Adverse events were reported by 6.4% (29 of 453) of patients. CONCLUSION: Patients were satisfied with the pegylated interferon α-2b pen device; therefore, good treatment adherence is expected with its use.

Peginterferon alfa-2b as monotherapy or in combination with lamivudine in patients with HBeAg-negative chronic hepatitis B: a randomised study.

BACKGROUND: The efficacy of pegylated interferon alfa-2b alone or in combination with lamivudine for the treatment of patients with hepatitis B e antigen (HBeAg) negative (-) chronic hepatitis B (CHB) is understudied. MATERIAL/METHODS: One hundred twenty-six patients with HBeAg(-)chronic hepatitis B received pegylated interferon alfa-2b > or =1.5 micro g/kg/wk for 48 weeks. Ninety of those subjects were randomly selected to receive concomitant treatment with lamivudine 100 mg/d. The coprimary end points were the subjects' virologic (hepatitis B virus deoxyribonucleic acid [HBV DNA] <60 IU/mL) and biochemical (normalization of alanine aminotransferase levels) responses 24 weeks after treatment cessation. RESULTS: The scores for necroinflammatory activity and fibrosis in patients randomly assigned to receive monotherapy were statistically significantly lower than those in patients receiving combination therapy. HBV DNA levels were statistically significantly higher and alanine aminotransferase levels were statistically significantly lower in patients receiving monotherapy than in those receiving combination therapy. Virologic responses in the monotherapy and combination therapy groups were similar at weeks 48 and 72 (59.1 vs 42.9%). The biochemical response at week 72 was also similar in the treatment groups. The results of multiple regression analysis showed that the virologic response at week 72 was independently correlated with the pegylated interferon alfa-2b dose and that the biochemical response was independently correlated with necroinflammatory activity, the pegylated interferon alfa-2b dose, and lamivudine therapy. CONCLUSIONS: These data support the use of pegylated interferon alfa-2b in patients with HBeAg(-) chronic hepatitis B; however, the concomitant use of lamivudine produced no additional clinical benefit.