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Introduction. Despite the high efficacy of direct acting antivirals (DAAs) in curing chronic HCV infection, there is a concern regarding a more aggressive phenotype of hepatocellular carcinoma (HCC) after DAA treatment. Although there are many clinical cohort studies that have evaluated the incidence and recurrence of HCC in these patients, data on the tumor characteristics of HCC after DAAs are not sufficient to establish a clear conclusion. A promising index was recently developed for the evaluation of HCC aggressiveness (AGI) which comprises 4 tumor-related parameters: maximum tumor diameter (MTD), number of tumor nodules, portal vein thrombosis (PVT) and serum AFP levels. Aim. We aimed to investigate the usefulness of AGI in assessing the pattern of HCV-related HCC after DAAs and the predictive value in survival. Material&methods. We carried out a retrospective comparative observational study in which we included patients treated with DAAs for HCV infection and diagnosed with HCC in the Institute of Gastroenterology and Hepatology from Iași, Romania, between January 1st, 2017 and December 31, 2019. Patients were matched based on age and sex with a historic cohort consisting of patients with HCV-related HCC without DAA therapy. Based on AGI, patients were divided into three aggressiveness classes: class A (low aggressiveness), B (intermediate aggressiveness) and C (high aggressiveness). Results. Among the 124 patients with chronic HCV infection diagnosed with HCC, 66 (53.2%) patients were males and 58 (46.8%) were female, with a mean age of 62.38 ± 9.88 years. According to DAAtreated and DAA-naive status, patients were divided into 2 groups: the DAA group included 30 treated patients and the non-DAA group included 94 DAAnaive patients. In the DAA group, the frequency of single HCC was much higher (73.3%) than in naïve patients (53.2%) (p = 0.052), as well as smaller tumor sizes (41.07 ± 18.116mm vs. 61.79 ± 34.477mm, p=0.001) and lower rates of malignant PVT (20% vs. 36%, p = 0.146). According to AGI, class B was the most frequently observed (42.6%) in DAA-naïve patients, followed by class A (31.9%) and class C (25.5%), whilst in DAA-treated patients the most frequent was class A (46.7%), closely followed by class B (40.0%), and class C in 13.3% of cases. The 3-year survival probability for AGI class A vs. B vs. C was 66.9% vs 40.2% vs 8.4%; p=0.001, from the time of diagnosis by Kaplan-Meier plot. There was a significantly higher survival rate in the DAA group compared to DAA-naïve patients (75.3% vs. 52.4%, p = 0.008). [ABSTRACT FROM AUTHOR]

Background: Despite numerous advances that have aimed to increase the safety of endoscopic retrograde cholangiopancreatography (ERCP), post-ERCP pancreatitis (PEP) still remains a major issue. We aimed to assess the rate of PEP as well as the relation to the cannulation techniques in our unit, a high-volume center in north-eastern Romania. Methods: ERCPs performed in our unit from March to August 2022 were retrospectively included. Data concerning demographic information, presence of difficult cannulation, the technique used for cannulation, as well as immediate complications, were gathered from the electronic database. Results: 233 ERCPs were included. PEP was diagnosed in 23 (9.9%) of cases. Precut sphincterotomy (PS), transpancreatic sphincterotomy (TPBS), and a combination of TPBS and PS were performed in 6.4%, 10.3%, and 1.7% of cases, respectively, while an Erlangen precut papillotomy was performed in one case. Both in patients with PS and TPBS the rate of PEP was 20%. When the two techniques were associated, the rate of PEP was 25%. TPBS and PS represented risk factors for PEP (OR 1.211 for a CI of 0.946–1.551, p = 0.041, and OR 1.124 for a CI of 0.928–1.361, p = 0.088, respectively). No PEP-associated deaths were found. Conclusions: Both PS and TPBS presented a similar risk of PEP. [ABSTRACT FROM AUTHOR]

Background & Aims: The burnout syndrome (BOS) is commonly seen in healthcare professionals, particularly in physicians who are exposed to a high level of stress at work and has a negative impact on the medical activity. Physicians with BOS manifest a negative attitude, a reduction in compassion at work, and suboptimal patient care experiences. These all can lead to absenteeism, poor performance and more frequent medical errors. We aimed to assess the level of BOS in a tertiary gastroenterology university center in Romania. Methods: This observational study involved 40 physicians from a tertiary gastroenterology university center. An online questionnaire assessed the presence of BOS using the Maslach Burnout Inventory. Results: A total of 40 physicians responded to the questionnaire. The prevalence of overall BOS of 87.5%. In terms of high burnout, 15 doctors (37.5%) had emotional exhaustion, 10 doctors (25%) had depersonalization, and 30 doctors (80%) scored low for personal achievement. Men presented more frequently emotional exhaustion and women lower personal achievement scores, but there was no significant statistical difference. No significant relationship was found between marital status or the number of children and BOS. We identified multiple risk factors associated to BOS, the most important one being strict internal regulations. Conclusions: Physicians presented an increased risk for BOS. The high rate of BOS among physicians found in our study requires careful attention. Further studies aiming to identify other factors that contribute to BOS and to identify measures to combat this syndrome are necessary. [ABSTRACT FROM AUTHOR]

Introduction. Climate change and its impact on the environment are matters of high concern. Thus, recent European recommendations for environmental sustainability in endoscopy have been published. We aimed to assess the real-life perception of those recommendations as well as the level of implementation in a tertiary-care center in North-Eastern Romania. Methods. We included medical personnel from a tertiary-care center in North-Eastern Romania, namely senior and junior gastroenterologists, residents, and endoscopy nurses. An online survey was developed, that included the statements from the latest British Society of Gastroenterology (BSG), Joint Accreditation Group (JAG), and Centre for Sustainable Health (CSH) joint consensus on practical measures for environmental sustainability. Participants were asked to provide their opinion on the statements choosing their position from strong disagreement, disagreement, agreement, strong agreement, and no opinion. The results were collected confidentially and analyzed. Results. There were 29 participants, aged 36.9 ± 8.17 years old, mostly women (42.5%). Among the respondents 11 were senior gastroenterologists, 6 were junior gastroenterologists, 8 were residents, and 4 were endoscopy nurses. Most participants agreed that endoscopy was an important source of waste (65.5%) and that measures are needed to reduce the negative impact of endoscopy on the environment (62%). Concerning the need for strict adherence to professional guidelines when considering the indication for endoscopy 44.8% of the respondents strongly agreed while 34.5% agreed. Sustainable alternatives to conventional diagnostic endoscopy were favored however by only 48% of the respondents while 27.6% strongly disagreed. Trainee involvement based on methods including simulation and online image libraries was mostly disagreed upon (51.7%). All participants agreed that both upper and lower digestive endoscopies should be grouped on the same day and 86.2% of the respondents considered that the use of single-use endoscopes should be restricted to select indications. More than 50% of the participants strongly agreed on the need for sustainability in new decontamination units. Most participants agreed that the judicious use of sterile water is necessary to reduce the impact on the environment as well as the minimization of histopathology use. With one exception, all respondents agreed that endoscopy accessories should be carefully considered and planned pre-procedure to minimize waste. Over 50 % of the respondents strongly agreed that the judicious use of NO as well as paperless protocol use and optimization of PPE should be implemented. Over 60% agreed that, when possible, personnel should be able to work from home. However, most participants did not agree with the proposed lowflow devices on water taps. The use of renewable energy sources as well as energy-efficient lighting of the endoscopy unit was agreed upon by most participants as well as efficient waste management. All participants agreed that heating, ventilation, and air conditioning would be turned off when endoscopy rooms were not in use. Over 70% agreed that patients should bring their cups to the hospital. More than 80% considered that remote consultation could be the default means of providing post-endoscopy follow-up. However, only 25% considered that alternative investigations would eventually replace endoscopy. Concerning the implementation of these measures, only 34% agreed that they were already implemented in Romania, while over 50% considered that they could be implemented in our country. Conclusions. All in all, most of the proposed measures for environmental sustainability in endoscopy were agreed upon by the participants. There was however disagreement concerning the replacement of endoscopy by alternative investigations as well as the use of methods other than endoscopy for trainees to reduce the number of procedures. [ABSTRACT FROM AUTHOR]

Background. Burnout syndrome is a commonly seen in healthcare professionals, particularly in physicians who are exposed to a high level of stress at work and has a negative impact on the medical activity. The physicians who had have high burnout levels have been shown to commit more medical errors. Aim: To assess the level of the burnout syndrome in a tertiary university centre of gastroenterology in Romania. Methods. This observational study involved physicians from a tertiary gastroenterology university centre. An online questionnaire assessed the presence of burnout using the Maslach Burnout Inventory (MBI). Results. A total of 64 physicians responded to the questionnaire. In terms of high burnout, 11 doctors (17.18%) had emotional exhaustion, 13 doctors (20.3%) had depersonalization, and 58 doctors (90.62%) scored low for personal achievement. There were statistically significant correlations between the personal accomplishment and exhausting scores and between the personal accomplishment and depersonalization scores, respectively (P=0.007, and P<0.001, respectively). Conclusion. Physicians present an increased risk for burnout relative to workers in other fields. The high rate of burnout among physicians found by our study requires careful attention. Further studies aiming to identify other factors that contribute to burnout and as well as measures to combat burnout are necessary. Professional societies should get involved in studying the factors that generate burnout among physicians as well as to find solutions to reduce them. [ABSTRACT FROM AUTHOR]

Background & Aims: The sofosbuvir (SOF) / velpatasvir (VEL) / voxilaprevir (VOX) combination has been evaluated in more than 800 patients enrolled in phase II and phase III studies, where it demonstrated excellent safety and efficacy, achieving overall sustained viral response (SVR) rates of more than 95%. We aimed to assess the efficacy and safety of SOF/VEL/VOX in a real-world study, including patients previously treated for genotype 1b hepatitis C virus (HCV) infection that did not obtain a sustained viral response with previous direct-acting antivirals (DAAs) therapy. Methods: In Romania, through a nationwide government-funded program in 2019-2020, 213 patients with chronic hepatitis C non-responders to previous DAAs therapy, received treatment with SOF/VEL/VOX 400/100/100 mg/day for 12 weeks. We performed a retrospective longitudinal study that included 143 individuals who were treated in Bucharest, Iași, Craiova and Constanța clinics, all with genotype 1b HCV infection. Efficacy was assessed by the percentage of patients achieving SVR 12 weeks post-treatment (SVR12). Serious adverse events (SAE) were registered. Results: Our cohort comprised 53% males with a median age of 60 years (27÷77); 47% were pre-treated with ombitasvir/paritaprevir/ritonavir+dasabuvir ± ribavirin, 40% with ledipasvir/SOF, 13% with elbasvir/grazoprevir. 42% of patients associated co-morbidities, 45% had compensated liver cirrhosis, 2% had treated hepatocellular carcinoma (HCC) and 1% had hepatitis B virus co-infection. SVR by intention to treat was reported in 139/143 (97.2%) and per protocol in 141/143 (98.6%). No predictive factors for SVR were identified. Rate of liver decompensation in patients with cirrhosis was 6% and was statistically associated in multivariate analysis with Child-Pugh score (p<0.01) and with severe steatosis (p=0.004). Occurrence of new HCC was reported in 3.6% of all patients with cirrhosis and was associated with poor liver function [higher Child-Pugh score (p=0.001) and low albumin levels (p=0.02)]. Serious adverse events related to therapy were reported in 1/143(0.7%). Conclusions: SOF/VEL/VOX was highly efficient in our population of patients with a 97.2% SVR. Liver decompensation occurred in 6% of cirrhotic patients at SVR, related to hepatic dysfunction. [ABSTRACT FROM AUTHOR]

Non-alcoholic fatty liver disease (NAFLD) is a common finding among patients with type 2 diabetes mellitus (T2DM). Between NAFLD and T2DM exist a bidirectional relationship. Patients with T2DM are at high risk for NAFLD, and evidence suggests that T2DM is linked to progressive NAFLD and poor liver outcomes. NAFLD promotes the development of T2DM and leads to a substantial increase in the risk of T2DM complications. This study aimed to assess the prevalence of liver steatosis and fibrosis in patients with T2DM from north-eastern Romania by using Vibration-Controlled Transient Elastography (VCTE) with Controlled Attenuation Parameter (CAP), which is a non-invasive method and can assess simultaneously liver steatosis and fibrosis. In total, 424 consecutive patients with T2DM were enrolled and evaluated using VCTE with CAP from January 2020 to January 2022. Clinical and laboratory data were recorded in all patients. For the CAP score, we used the following cut-offs: mild steatosis (S1)—274 dB/m, moderate steatosis (S2)—290 dB/m, and severe steatosis (S3)—302 dB/m. For liver fibrosis, to differentiate between fibrosis stages, the cut-off values were F ≥ 8.2 kPa for significant fibrosis (F2), F ≥ 9.7 kPa for advanced fibrosis (F3), and F ≥ 13.6 kPa for cirrhosis (F4). In total, 380 diabetic patients (72.6%) had liver steatosis (51.3% females, the mean age of 55.22 ± 10.88 years, mean body mass index (BMI) 29.12 ± 5.64 kg/m2). Among them, 26 (8.4%) patients had moderate liver steatosis (S2) and 242 (78.5%) patients had severe hepatic steatosis (S3). According to VCTE measurements, 176 (57.14%) patients had liver fibrosis, 36 (11.7%) of them had advanced fibrosis (F3), and 42 (13.6%) diabetic patients had cirrhosis (F4). Univariate analyses showed that severe steatosis was significantly associated with ferritin (β = 0.223, p = 0.022), total cholesterol (β = 0.159, p = 0.031), and HDL-cholesterol (β = −0.120, p = 0.006). In multivariate analyses, BMI (β = 0.349, p < 0.001), fasting plasma glucose (β = 0.211, p = 0.006), and triglycerides (β = 0.132, p = 0.044) were predictors of S3. Patients with T2DM have a high prevalence of severe steatosis and advanced fibrosis which can lead to the development and progression of complications with high morbidity and mortality rates. Hence, it is necessary to implement screening strategies to prevent advanced liver disease in patients with T2DM. [ABSTRACT FROM AUTHOR]

Chronic hepatitis C virus (HCV) infection induces hepatic steatosis due to viral and host factors. However, information regarding the effects of direct-acting antivirals (DAAs) therapy on liver steatosis and fibrosis is limited. Vibration-controlled transient elastography (VCTE) with a controlled attenuation parameter (CAP) represents a non-invasive method, which has been used in the last few years for the detection of hepatic steatosis and fibrosis before and at a sustained virological response at 12 weeks (SVR12). The aim of this study was to assess the modifications of liver steatosis and fibrosis in HCV-infected patients who achieved SVR12. Consecutive patients with chronic HCV infection that were treated with DAAs in a tertiary gastroenterology center from Romania were included. Demographics, laboratory data, and VCTE evaluation were recorded in all patients. Patients with previous hepatic decompensation and those who did not achieve SVR were excluded. Two hundred and eighty patients (67.1% females) who achieved SVR12 were included. Regarding the changes in biological parameters, including liver enzymes such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST), reduced to normal levels at SVR12 compared to the baseline (28.72 ± 24.71 U/L vs. 40.72 ± 27.34 U/L for ALT, p < 0.013 and 27.21 ± 11.15 U/L vs. 33.35 ± 23.37 U/L for AST, p = 0.029). On the contrary, the levels of triglycerides increased significantly from the baseline to SVR12 (124.03 ± 113.49 mg/dL to 153.78 ± 94.53, p = 0.004). Regarding hepatic steatosis by CAP evaluation, at SVR12, 186 (66.4%) of the individuals had a CAP score of ≥248 dB/m, an increase of 4.6% from the baseline. After viral eradication with DAAs, we observed an increase in hepatic steatosis. Hence, a long-term follow-up is mandatory to identify HCV-infected patients with hepatic steatosis post-SVR and the risk factors for more severe outcomes. [ABSTRACT FROM AUTHOR]

Background & Aims: Identifying the risk factors for extraintestinal manifestations (EIMs) in inflammatory bowel diseases (IBD) may optimize the therapeutic decision. We aimed to assess the prevalence of EIMs in IBD patients in Romania and to determine the risk factors. Methods: We analyzed 2,626 patients registered in the Romanian IBD Prospect National Registry. We performed a descriptive cross-sectional study to assess the point prevalence of EIMs, calculating global prevalence and analyzing the different types of EIMs and their respective frequencies were carried out. Demographic and clinical risk factors were researched as possible predictors for EIMs development, based on the results of the univariate and multivariate logistic regression analysis. Results: The overall point prevalence of EIMs was 16.3%. A significantly higher frequency of EIMs in Crohn's disease (CD) was noted in comparison to ulcerative colitis (UC) and IBD unclassified (IBDU) (23.2% vs 11.3% and 16.3%, respectively, p<0.001). The most frequent type of EIM was peripheral arthropathy (8.3%), significantly associated with CD (p<0.001). Univariate analysis highlighted the significant independent common predictive risk factors for EIMs, in both CD and UC patients: female gender, patient's urban area of origin, anemia, hypoalbuminemia, and high level of C-reactive protein (CRP), while significant independent IBD phenotype-related risk factors were ileocolonic location and concomitant involvement of upper gastrointestinal tract for CD, non-smoker status and both moderate and severe disease activity for UC (p<0.05). Multivariate analysis determined that female CD patients with moderate or severe disease activity, with other than isolated ileal disease, and female UC patients with moderate or severe extensive colitis are the most likely to develop EIMs. Conclusions: IBD patients are experiencing EIMs in a large proportion, with higher rates for CD. As EIMs negatively affect patient outcomes, foreseeing the risk by identifying independent and associated predictive factors could be a first step to optimal work-up and treatment [ABSTRACT FROM AUTHOR]

Background. Specific Baveno VII consensus recommendations are based on the reliability of noninvasive criteria to rull out or rull in clinically significant portal hypertension (CSPH). Aim. We aimed to assess the translation into the real-world clinical practice of the main Baveno VII consensus recommendations. Material and Methods. We launched a brief online survey, and we invited physicians to respond to several questions related to advanced chronic liver disease patients' care (the use of non-invasive criteria to avoid endoscopy when CSPH is rulled out, the prevention of decompensation when CSPH is rulled in, and the type of non-selective beta-blocker). Results. 108 gastroenterologist and hepatologist practitionners answered our survey. According to the type of the medical unit in which they developed their clinical activity, there was an uniform distrubution between municipal, county and universitary hospitals. For clarity and reproducibility, we present the questions and answers as they were originally formulated. Question A. Do you perform an upper gastrointestinal endoscopy for variceal screening to patients with Thrombocyte count <150.000/mmc and liver stiffness measurement < 15 kPa? Answers: 1. Yes: 67 (62%); 2. No: 41 (38%). Question B. Do you initiate non-selective beta-blockers to your patients when liver stifness measurement is more than 25 kPa, for the prevention of the decompensation? Answers: 1. Yes: 99 (85%); 2. No: 9 (15%). Question C. If yes, what NSBB do you prefer? Answer: 1. Carvedilol: 92 (85%); 2. Propranolol: 16 (15%). Conclusions. Baveno VII consensus recommendation regarding avoidance of UGIE in patients with NIT rulling out CSPH is not generally adopted in the clinical practice. The majority of gastroenterologists and hepatologists preffer however performing UGIE, which can be explained by the fear of possibly missing oesophageal varices, and also by the wide acessibility of UGIE in Romania, both in general hospitals, but especially in universitary centers. However, the NSBB (Carvedilol being the most frequently the first choice) are generally recommended by non-invasive criteria, proving the awareness of the practitioners regarding the prevention of decompensation BAVENO VII takeaway message. [ABSTRACT FROM AUTHOR]

Introduction. In order to meet the requirements of the WHO, namely - the eradication of viral hepatitis by 2030, UMF "Grigore T. Popa" from Iasi together with ARAS and the Hospital "St. Spiridon" from Iasi, carries out since 2020 the project "LIVE(RO) 2 - Integrated regional program for prevention, early detection (screening), diagnosis and targeting treatment of patients with chronic liver disease secondary to viral infections with liver viruses B/D and C in the North-East and South-East regions". This study aimed to assess the epidemiological characteristics of the vulnerable population in the eastern part of the country diagnosed with chronic B/D and C viral infection. Materials and Methods. Between July 2021 and December 2022, we performed a prospective screening of chronic viral hepatitis B/D and C in vulnerable people in the counties of North-East and South-East of Romania, within the national program LIVE(RO) 2 - EST. Rapid diagnostic tests were used to detect HBs antigen (HBsAg) and anti-HCV antibodies (HCVA): HBV (Wama Immuno-Rapid HBV®) and HCV (Wama Immuno-Rapid HCV®). Rapid test-positive patients were tested for HBV DNA and HCV RNA and those eligible under the national protocol were treated with antivirals. Results. The study included 55593 individuals tested rapidly, of which 2160 (3.8%) patients were tested positive (1120 women, 1040 men, mean age 55.86 ± 6.023 years, predominantly rural background - 76.19%). Of these, 1077 (49.8%) were HBsAg positive, 918 (42.5%) with HCV positive needle, 37 (1.7%) HBV/HCV coinfection and 128 (5.9%) HBV/VHD coinfection. HBV-DNA was performed in 724 (67.3%) individuals, of which 452 (62.5%) subjects > 2,000 children/ml. Also, 518 (54.3%) patients with HCV-positive Ac had detectable HCV RNA, of which 375 (72.3%) received antiviral treatment. Depending on the ethnicity, the prevalence of viral infection was 4.29% in Roma people and 3.23% in Romanian people. Among the vulnerable groups determined by work, inactive people (27.7%), uninsured people (11.2%), unskilled people (1.87%), unemployed people (0.6%) and people working in agriculture (0.59%) were predominantly tested. Among the special vulnerable groups, people with disabilities (3.99%), people addicted to alcohol (2.43%) and people with a minimum income (1.21%) were predominantly tested. Conclusions. The high prevalence of B/D and C viral infection in the vulnerable population tested in the North-East and South-East Region of Romania compared to the rest of the population, indicates the significant viral spread of the infection in these people, a condition that requires further testing and the need for policies public health in vulnerable groups to promote access to existing health services and early initiation of optimal antiviral treatment. [ABSTRACT FROM AUTHOR]