Barriers in inflammatory bowel disease care in Central and Eastern Europe: a region-specific analysis.

Inflammatory bowel diseases (IBD), including Crohn's disease and ulcerative colitis, are chronic immune-mediated diseases with a high incidence and prevalence in Europe. Since these are diseases with associated disability, they require complex management and the availability of high-quality healthcare resources. We focused on the analysis of IBD care in selected countries of Central and Eastern Europe (Croatia, the Czech Republic, Hungary, Moldova, Poland, Romania and Slovakia) targeting the availability and reimbursement of diagnostic and therapeutic modalities, the role of IBD centers and also education and research in IBD. As part of the analysis, we created a questionnaire of 73 statements organized in three topics: (1) diagnostics, follow-up and screening, (2) medications and (3) IBD centers. The questionnaire was filled out by co-authoring IBD experts from individual countries, and then the answers and comments on the questionnaire were analyzed. We identified that despite the financial burden, which still partially persists in the region, the availability of some of the cost-saving tools (calprotectin test, therapeutic drug monitoring) differs among countries, mainly due to variable reimbursement from country to country. In most participating countries, there also remains a lack of dedicated dietary and psychological counseling, which is often replaced by recommendations offered by gastroenterologists. However, there is adequate availability of most of the currently recommended diagnostic methods and therapies in each participating country, as well as the implementation of established IBD centers in the region.

Impact of trainee involvement on the outcome of ERCP procedures: results of a prospective multicenter observational trial.

BACKGROUND: Training in advanced endoscopic techniques such as endoscopic retrograde cholangiopancreatography (ERCP) should be driven by key performance measures and standardized competence assessment in order to provide safe and high-quality interventions. We aimed to determine whether the involvement of trainees influences the outcome of the procedure and the incidence of ERCP-related adverse events. METHODS: This was an international, multicenter, prospective, observational study conducted at six high- and low-volume centers across Europe between October 2016 and October 2018, and included independent operators and their trainees. Standard report forms documenting indication, trainee involvement, technical outcome, and complications over a 30-day follow-up of consecutive ERCP procedures were included in the analysis. Technical success of the procedure and procedure-related adverse events were compared between procedures in the trainee group and the control group using bivariable and multivariable analysis. RESULTS: 21 trainees and 16 control endoscopists performed 1843 ERCPs during the study period. Trainee involvement in ERCP procedures did not decrease technical success (92.4 % vs. 93.7 %; P = 0.30) or increase the risk of adverse events (14.7 % vs. 14.6 %; P > 0.99). Conversely, there were significantly more moderate or severe adverse events in the control group compared with the trainee group (6.2 % vs. 3.4 %, P = 0.01). On multivariable analysis, only increased bilirubin levels, time to cannulation, and procedure difficulty level increased the risk of any procedure-related adverse event. CONCLUSION: Trainee involvement in ERCP interventions within a proper teaching setting is safe and does not compromise the success of the procedure.

Salmonella enterica Serovar Enteritidis Liver Abscess after Blunt Abdominal Trauma.

BACKGROUND: Salmonella enterica serovar Enteritidis is among the most reported serotypes of Salmonella species worldwide, but is rarely reported as the causative agent of a liver abscess. CASE REPORT: We present a patient with an abdominal blunt trauma. An initial abdominal computed tomography scan revealed a rupture of the right kidney and of the liver. Two days later, his physical state deteriorated and a new computed tomography scan was obtained. An extremely large 8-centimetre liver abscess was verified. Due to the unsatisfying response to antibiotic therapy and percutaneous drainage, we operated on the patient. An appendectomy, cholecystectomy and bisegmental liver resection were performed. An intraoperative swab from the abscess was positive for Salmonella enterica serovar Enteritidis. The patient was given intravenous ciprofloxacine. The post-operative course was complicated by a Coagulase-negative Staphylococcus infection of the wound, which improved with antibiotic therapy. CONCLUSION: Blunt abdominal trauma may initiate an unpredictable course of the disease in chronic Salmonella carriers.

AN EPIDEMIOLOGICAL STUDY OF THIOPURINE-METHYLTRANSFERASE VARIANTS IN A CROATIAN INFLAMMATORY BOWEL DISEASE PATIENT COHORT.

Thiopurine S-methyltransferase (TPMT) is an enzyme that converts thiopurine drugs into inactive metabolites. Over 20 variant TPMT-encoding alleles, which cause reduced enzymatic activity, have been discovered so far. Our aim was to investigate the frequencies of variant alleles, i.e. genotypes in inflammatory bowel disease (IBD) patients and healthy individuals and to compare these frequencies with selected world populations. The most common variant alleles TPMT*2, TPMT*3A, TPMT*3B and TPMT*3C were analyzed with polymerase chain reaction-based assays and allele-specific polymerase chain reaction-based assays in 685 participants including 459 IBD patients and 226 healthy volunteers. Study results revealed 434/459 (94.55%) IBD patients and 213/226 (94.25%) healthy subjects to be homozygous for the wild-type allele (TPMT*1/*1). TPMT*1/*2 and TPMT *1/*3C genotypes were found in 4/459 (0.87%) and 7/459 (1.53%) IBD patients, respectively; in healthy volunteers they were not found. TPMT*1/*3A genotype was found in 14/459 (3.05%) IBD patients and 13/226 (5.75%) healthy subjects. Variant genotypes were statistically significantly more common in Crohn's disease subgroup than in ulcerative colitis subgroup. The prevalence of variant genotypes was 23/338 (6.80%) in Crohn's disease subgroup as compared with 2/121 (1.65%) in ulcerative colitis subgroup (χ2 = 4.59; p = 0.032). In conclusion, the most frequently occurring nonfunctional TPMT allele in Croatian population is TPMT*3A. The overall frequency of mutant alleles in our population is statistically nonsignificantly lower when compared with other populations of Caucasian origin. The Crohn's disease group had more mutant alleles than the ulcerative colitis group.

[ABNORMALITIES OF HEMOSTASIS IN PATIENTS WITH LIVER CIRRHOSIS].

Until the beginning of the 90ies, it was believed that patients with liver cirrhosis were auto-anticoagulated and thus protected from thromboembolic events. However, new discoveries have broken the longstanding paradigm. In deranged hepatic function there is a reduced synthesis of procoagulants and endogenous anticoagulants, however, extrahepatally synthesized hemostatic and fibrinolytic factors are disproportionately affected. In stable disease hemostatic system is "rebalanced'' but fragile, therefore, even a minimal stress can promote bleeding or thrombosis. Also, there are many concomitant factors, such as hemodynamic changes, other organ affection, namely kidney, and predisposition to infection, that shift the balance towards either bleeding or thrombosis. Conventional laboratory tests are not sufficient for evaluation of the bleeding risk, prothrombotic risk factors are not clearly identified, and safety profile of antithrombotic drugs is not precisely evaluated since cirrhotic patients are mainly excluded from big clinical trials. For all that is said, the diagnostic and therapeutic approach in this context is complex and requires teamwork of a hepatologist, hematologist and in a phase of operative treatment, the anesthesiologist. In this review article, we will discuss mechanisms of hemostatic and fibrinolytic abnormalities of liver cirrhosis, the incidence of thromboembolic events as well as prophylactic and therapeutic options in the setting of conservative treatment.

Waist circumference does not correlate with functional lung capacity in moderate and severe chronic obstructive pulmonary disease.

Waist circumference is a good predictor of the risk of heart diseases, but data on the relationship between waist circumference and pulmonary diseases are sparse. The aim of this study was to investigate its influence on pulmonary function regarding exercise capacity in moderate and severe chronic obstructive pulmonary disease (COPD), according to Global Initiative for Lung Diseases (GOLD) stages. During 2009, a total of 70 COPD patients aged 33 to 80 years were stratified into GOLD 2 and GOLD 3 stages. Diagnostic separation between COPD severity groups was made upon percentage of predicted forced expiratory volume in 1 second. Anthropometric measures, lung function testing and prognostic scoring systems were assessed. Logistic regression analysis was used to make comparisons while taking into account the possible confounding factors. Waist circumference did not show substantial variations between GOLD 2 and GOLD 3 stages (p > 0.5). There was a weak positive correlation between waist circumference and percent of predicted 6-minute walking distance (r = 0.237; p = 0.001). Another parameter, suprailiac skinfold, was significantly different between GOLD 2 and GOLD 3 stages (19.41 vs. 15.32 mm; p = 0.047). Although waist circumference is a meaningful marker of abdominal obesity, which influences pulmonary function, we failed to prove its importance in correlation with functional lung capacity in a selected COPD population. However, suprailiac skinfold deserves greater attention and further evaluation.

Hemoptysis as an early symptom of abdominal actinomycosis with thoracic extension ten years after cholecystectomy with retained gallstone.

BACKGROUND: Thoracoabdominal actinomycosis is rare, especially in the context of readily available medical facilities. METHODS: Case report and review of the literature. CASE REPORT: A 54-year-old male patient was admitted because of hemoptysis and a pulmonary infiltrate in the left lower lobe. His history was unremarkable except for chronic gastritis and an elective laparoscopic cholecystectomy performed 10 years earlier. Following persistent hemoptysis, elevated inflammatory markers, and a non-revealing bronchoscopy, a computed tomography scan of the thorax and upper abdomen revealed a tumor in the upper part of the left kidney spreading directly to the adjacent diaphragm and left lower lobe. Laparotomy revealed a granulomatous mass containing a gallstone, as well as orange granular content. The treatment involved surgical removal of the mass, splenectomy, excision of the infiltrated part of the left hemidiaphragm, and decortication of the left lower lobe. Because of a prolonged post-operative low-grade fever and radiologically confirmed encapsulation in the lingula, the patient was given ceftriaxone. Repeat bronchoscopy revealed Actinomyces meyeri. The initial antibiotic therapy was replaced with amoxicillin-clavulanic acid, after which the patient's health improved. CONCLUSION: Actinomycosis is still a highly intriguing disease, as initial symptoms often mislead clinicians. It is important to consider the disease whenever we are challenged diagnostically or when risk factors are present.

MDR1 polymorphisms are associated with inflammatory bowel disease in a cohort of Croatian IBD patients.

BACKGROUND: Inflammatory bowel diseases (IBD) are chronic diseases of unknown etiology and pathogenesis in which genetic factors contribute to development of disease. MDR1/ABCB1 is an interesting candidate gene for IBD. The role of two single nucleotide polymorphisms, C3435T and G2677T remains unclear due to contradictory results of current studies. Thus, the aims of this research were to investigate the association of MDR1 polymorphisms, C3435T and G2677T, and IBD. METHODS: A total of 310 IBD patients, 199 Crohn's disease (CD) patients and 109 ulcerative colitis (UC) patients, and 120 healthy controls were included in the study. All subjects were genotyped for G2677T/A and C3435T polymorphism using RT-PCR. In IBD patients, review of medical records was performed and patients were phenotyped according to the Montreal classification. RESULTS: Significantly higher frequency of 2677T allele (p=0.05; OR 1.46, 95% CI (1.0-2.14)) and of the 3435TT genotype was observed among UC patients compared to controls (p=0.02; OR 2.12; 95% CI (1.11-4.03). Heterozygous carriers for C3435T were significantly less likely to have CD (p=0.02; OR 0.58, 95% CI (0.36-0.91)). Haplotype analysis revealed that carriers of 3435T/2677T haplotype had a significantly higher risk of having UC (p=0.02; OR 1.55; 95% CI (1.06-2.28)). CONCLUSION: MDR1 polymorphisms are associated with both CD and UC with a stronger association with UC.