Romanian Guidelines for the Diagnosis and Treatment of GERD-induced Respiratory Manifestations.

BACKGROUND AND AIMS: Gastroesophageal reflux disease (GERD) is a common condition present in daily practice with a wide range of clinical phenotypes. In this line, respiratory conditions may be associated with GERD. The Romanian Societies of Gastroenterology and Neurogastroenterology, in association with the Romanian Society of Pneumology, aimed to create a guideline regarding the epidemiology, diagnosis and treatment of respiratory conditions associated with GERD. METHODS: Delphi methodology was used and eleven common working groups of experts were created. The experts reviewed the literature according to GRADE criteria and formulated 34 statements and recommendations. Consensus (>80% agreement) was reached for some of the statements after all participants voted. RESULTS: All the statements and the literature review are presented in the paper, together with their correspondent grade of evidence and the voting results. Based on >80% voting agreement, a number of 22 recommendations were postulated regarding the diagnosis and treatment of GERD-induced respiratory symptoms. The experts considered that GERD may cause bronchial asthma and chronic cough in an important number of patients through micro-aspiration and vagal-mediated tracheobronchial reflex. GERD should be suspected in patients with asthma with suboptimal controlled or after exclusion of other causes, also in nocturnal refractory cough which needs gastroenterological investigations to confirm the diagnosis. Therapeutic test with double dose proton pump inhibitors (PPI) for 3 months is also useful. GERD induced respiratory conditions are difficult to treat; however,proton pump inhibitors and laparoscopic Nissen fundoplication are endorsed for therapy. CONCLUSIONS: This guideline could be useful for the multidisciplinary management of GERD with respiratory symptoms in current practice.

Romanian Guidelines for Nonpharmacological Therapy of IBS.

BACKGROUND AND AIMS: The nonpharmacological therapy in irritable bowel syndrome (IBS) is expanding rapidly. Practitioners and medical educators need to be aware of progress and changes in knowledge of this topic. The Romanian Society of Neurogastroenterology aimed to create guidelines based on best evidence on the use of nonpharmacological therapy in IBS. METHODS: A group of experts was constituted. This was divided in eleven subgroups dedicated to eleven categories of nonpharmacological therapy. The subgroups searched the literature and formulated statements and recommendations. These were submitted to vote in order to obtain consensus. RESULTS: The outcome of this activity is represented by the guidelines of the Romanian Society of Neurogastroenterology, presented in this paper. The recommendations are seen as complementary to the pharmacological therapy and are not intended to recommend avoiding pharmacological drugs. CONCLUSIONS: These guidelines were elaborated by a Delphi process and represent a useful tool for physicians managing patients with IBS.

How the Internet influences the relationship between outpatients and gastroenterologists: A multicenter study.

BACKGROUND/AIMS: The Internet offers a lot of non-filtered medical information which may interfere with the patient-doctor relationship. The aim of the present study was to assess the influence of the Internet on the classical doctor-patient relationship in gastroenterological outpatient settings. MATERIALS AND METHODS: A multicenter study was conducted, including a representative sample selected from five major regional medical centers throughout Romania. We designed a questionnaire which had two parts. One had to be filled out by adult patients on their first visit to a gastroenterology clinic and the other by physicians, stating the diagnosis and giving a doctor-patient collaboration score. RESULTS: From a total of 485 patients (49.9% females, mean age 50.42 years), 64.9% had Internet access, 75% out of whom searched for their symptoms online. University graduates searched for their symptoms online more often than secondary school graduates (80% vs. 31.1%, p<0.05). Most patients stated that they used the Internet to identify the most appropriate medical specialist for their condition. Internet users were less likely to visit a general practitioner (GP) before coming to a specialist (85.3% vs. 92.2%, odds ratio (OR) 0.491, 95% confidence interval (CI) 0.24-0.98, p<0.05). Patients who had searched for their symptoms online were less likely to follow the treatment prescribed by the GP (53.6% vs. 67.5%, p=0.004), but they received a better collaboration score (OR 1.12, 95% CI 1.05-1.36, p<0.05). CONCLUSION: The Internet exerts a positive influence on specialist doctor-patient relationship, but it might burden the health system with the incorrect tendency to replace the role of the GP.

Gastrointestinal endoscopy in patients on direct oral anticoagulants. A consensus paper of the Romanian Society of Gastroenterology and Hepatology.

Management of patients undergoing endoscopy and under treatment with the newer direct oral anticoagulants (DOACs) is a common and a complex clinical issue that gastroenterologists have to face more and more often these days. The increasing use of DOACs in patients requiring both short- and long-term anticoagulation is mostly due to the advantages these agents offer, among which the lack of monitoring requirements and the reduced need of dose adjustments are perhaps the most important ones. Managing these patients in the peri-endoscopic period implies balancing the risk for thrombosis that a certain patient carries and the bleeding risk associated with the endoscopic procedure itself. The Romanian Society of Gastroenterology and Hepatology decided to create a consensus paper to serve to practitioners and teachers. After reviewing the available published data and existing recommendations, a Delphi consensus process was carried out involving the leaders of opinion in this field. After reaching expert consensus, we provide herein guidance for a practical approach of DOACs therapy management in patients with endoscopic interventions.

Psychological Interventions for Irritable Bowel Syndrome.

Irritable bowel syndrome (IBS) patients often present psychoform symptoms or psychiatric disorders. Among the psychological factors studied in IBS patients, two seem to influence mostly its severity: catastrophizing and somatization. Somatization is an independent risk factor for IBS. In addition, somatization more than the severity of IBS influences the way the patients perceive their illness, the outcome and the efficacy of treatment. Irritable bowel syndrome patients demonstrate greater catastrophizing scores than controls, and pain catastrophizing is a significant predictor of gastrointestinal symptoms related to pain. In this context we analysed the data regarding the efficacy of two psychological treatments in IBS: cognitive behavioral therapy and hypnosis. Cognitive behavioral therapy is focused on replacing maladaptive coping strategies with more positive cognitions and behaviors. Several studies showed that cognitive behavioral therapy is effective in reducing bowel symptoms in IBS, both post-treatment and short-term follow-up. Gut-directed hypnotherapy has beneficial short-term effects in improving gastrointestinal symptoms of patients with IBS, and the results are maintained after one year in half of the patients. Psychological treatments are a suitable option for selected IBS patients.

Role of comorbidities in caring for chronicly ill elderly patients with and without dementia.

BACKGROUND AND AIM: The aim of this study is to highlight the presence of co-morbidities and their role in caring for chronicly ill patients with and without dementia. PATIENTS AND METHODS: The study was performed on a group of 213 chronic patients. We used CIRS-G (Cumulative Illness Rating Scale in Geriatric Population) and IADL (Instrumental Activity Daily Living) scales. We compared the scores of severity and dependency. RESULTS: The most frequent co-morbidities in the study group were cardiac, vascular, locomotor, sensory organs and metabolic diseases. For the study group, the highest medium score of severity according to the CIRS-G scale was represented by cardiovascular diseases. For patients with dementia, psychiatric, cardiac, vascular, metabolic, genitourinary, sensory organs and locomotion domains had the highest score of severity and dependency. CONCLUSIONS: The health status of chronic patients with and without dementia is characterized by multiple pathologies with various degrees of severity and dependency.

The Relationship between Serum Lipid Fractions and Heart Rate Variability in Diabetic Patients with Statin Therapy.

BACKGROUND AND AIMS: The aim of this study is to identify and highlight the relationship between serum lipid fractions and heart rate variability in diabetic patients receiving statin therapy. PATIENTS AND METHODS: The study was performed in a group of 87 type 2 diabetic patients on statin associated therapy. All patients were on Holter ECG 24 hours monitored with three channel monitor (Labtech ECG Holter monitor), and data were analyzed on a commercially available software (Cardiospy PC SW/EV 5.02.06.02). Concentrations of biochemical parameters were determined using specific enzymatic assays on an autoanalyzer Olympus AU 680. In the studied patients, we analyzed Holter/24 hours monitoring reports with respect to heart rate variability indexes, arrhythmic events and myocardial ischemia. RESULTS: It was noticed that the mean values of serum TG were slightly elevated, TC levels were close to the limits specified by the guidelines for diabetic patients and for patients with cardiovascular diseases, with no significant differences between males and females. After analyzing the HRV in both time and frequency domains, we found no strong correlations between any of the HRV indexes and any of the lipid fractions. CONCLUSIONS: The results suggest that statin therapy may reduce the autonomic impairment secondary to dyslipidemia.

Effects of simvastatin in patients with viral chronic hepatitis C.

BACKGROUND/AIMS: A geranyl-geranylated protein is synthesized during chronic hepatitis C virus replication; statins can inhibit this synthesis. We aimed at studying the effects of administrating simvastatin to patients who finished the standard antiviral therapy and who did not have hepatic cytolysis. METHODOLOGY: A total of 101 patients were divided into 3 groups. Those without liver cytolysis were divided as follows: In group A1 patients were treated with simvastatin for 3 months and in group A2 the patients were non-treated controls. Those patients with hepatic cytolysis were placed in group B and treated for 3 months with simvastatin. The patients were biologically monitored monthly and the initial viremia was compared with the final one. The results were then statistically analysed. RESULTS: Significant changes of viremia were not observed in the patients from groups A1 and A2. In 24 patients in group B (58.54%) the viremia was significantly reduced (p=0.018), and in 6 patients (39.02%) it increased insignificantly. After 1 and 2 months of treatment, the cholesterolemy and the serum alkaline phosphatase significantly decreased to the patients from group B. CONCLUSIONS: In this study, more than half of the patients chronically infected with the hepatitis C virus, who had hepatic cytolysis and were treated with simvastatin, showed a significant reduction in the level of viremia.

Effects of lovastatin and pentoxyphyllin in nonalcoholic steatohepatitis.

BACKGROUND/AIMS: Today, there is no ideal treatment for nonalcoholic steatohepatitis. The present study intended to make a multicentric prospective study about the efficiency of lovastatin and pentoxyphyllin administered in patients with nonalcoholic steatohepatitis. METHODOLOGY: 87 patients were included in the present study. The patients diagnosed with nonalcoholic steatohepatitis and dislypidemia were treated for 4 months with lovastatin 10 mg/day and those without dislypidemia with pentoxyphyllin, 400 mg x 3/day. The patients were evaluated clinically and biochemically monthly. RESULTS: Regarding the lovastatin-treated group, transaminases significantly decreased (p < 0.05), after the first and second month, as well as cholesterolemia (p < 0.001), and the APRI score after 2 months (p = 0.03). In the pentoxyphyllin-treated group, transaminases significantly decreased after 1 month (p < 0.05), and the Forns index after 2 months (p < 0.05). CONCLUSIONS: Both drugs significantly decreased the transaminases. Lovastatin reduced the cholesterolemia in the dislipidemic patients. The decrease of the APRI score suggests that both medicines have benefic effects on the hepatic histology, too.

Lovastatin and fluvastatin reduce viremia and the pro-inflammatory cytokines in the patients with chronic hepatitis C.

BACKGROUNDS/AIMS: Certain statins interfere with the mechanism of the hepatitis C virus replication. We aimed at studying the effect of statins on the level of viremia and of the pro-and anti-inflammatory cytokines in the patients with chronic hepatitis C. METHODOLOGY: We took in our study all the patients with chronic hepatitis C placed in the evidence of the clinics of internal medicine of the Emergency County Clinical Hospitals of Brasov, Oradea and Sibiu, who had been identified with viremias. The patients were treated with fluvastatin 40 mg/day or lovastatin 20 mg/day for 28 days. The level of viremia, hemoleukogram, hepatic biochemical tests and the pro and anti-inflammatory hepatic cytokines were analysed before and after the treatment. The final results were compared with the initial ones, as well as between the 2 groups. RESULTS: Regarding those 99 analysed patients, the initial average viremia was of 2376074 +/- 3427596 UI/ml, while the final one was of 1321136 +/- 1343570 UI/ml (p = 0.000987). Both, in the group treated with lovastatin, as well as in that treated with fluvastatin, the decrease of viremia was significant from the statistics point of view (p = 0.032, respectively p = 0.00092). Lovastatin administration resulted in the significant decrease of the pro-inflammatory cytokines IL-6 and TNF-alfa, while that of fluvastatin brought about the significant decrease of the serum levels of IL-6, IL-8 and TNF-alfa. There were no significant differences, statistically speaking, between the 2 determinations, regarding the levels of IL-10 (anti-inflammatory cytokine) and those of erythropoietin. Transaminases average level did not vary significantly after those 4 weeks of statins treatment. CONCLUSIONS: Lovastatin and fluvastatin, significantly decrease the level of viremia, of IL-6 and TNF-alpha in the patients with chronic hepatitis C.

Genetic determination of irritable bowel syndrome.

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder. According to the Rome III criteria, IBS is defined as recurrent abdominal pain or discomfort for at least 3 d per month during the previous 3 mo associated with two or more of the following symptoms: improvement with defecation, onset associated with a change in the frequency of stool and/or onset associated with a change in form or appearance of stool. There is growing evidence regarding the genetic contribution in IBS, however the precise etiology of IBS is still unknown. The evaluation of the genetic influence is based on twin studies, familial aggregation and genetic epidemiological investigations. Most studies showed a concordance for IBS significantly greater in monozygotic than in dizygotic twins. The majority of the studies have shown that familial aggregation may represent exposures to a similar environment, as well as the influence of genetic factors. Whereas no specific gene has been identified in association with IBS, recent studies have noticed the importance of polymorphisms in the promoter region of the serotonin reuptake transporter gene, G-protein beta 3 subunit gene (C825T), cholecystokinin receptor (CCKAR gene 779T>C), and high-producer tumor necrosis factor genotype. Further studies are necessary to determine how genetic factors influence the clinical manifestations and therapeutical response in IBS patients.