FMT: balancing scientific success with successful regulation

Eww! If the thought of gulping down helminth eggs in an effort to mitigate the symptoms of IBD, psoriasis and other autoimmune diseases wasn’t unpalatable enough, we now face the reality of having someone else’s faeces fertilizing our guts! Nevertheless, it appears that the incentive for using these types of ‘paleo’ therapeutic approaches is increasing, driven mainly by problems related to antimicrobial resistance, faltering immunological pathways and intestinal dysbiosis, all of which may be intrinsically linked. Meanwhile, authorities are struggling to develop regulations in the face of multiple trials supporting the efficacy of faecal microbiota transplantation (FMT) for the treatment of recurrent Clostridium difficile infections (CDI).

A few weeks ago, @Liz_Atchley uttered on Twitter “If I'm ever in need of a fecal transplant, just let me die”. Same week, @beardbrain went ‘"There Is No ‘Healthy’ Microbiome". So don't get that fashionable fecal transplant unless you really need it!”’ The last tweet refers to an article that appeared in the New York Times.1 What the article actually said was that it appears that there is no single healthy microbiome, that the microbiome in each individual may undergo dynamic changes, and that perfectly healthy people may differ greatly in terms of microbiota structure and diversity. In fact, each of us appears to have a unique gut microbiome that may, however, be perturbed (e.g. by antimicrobials or certain types of diets), leading to disease, possibly including metabolic syndrome. Meanwhile, there is solid scientific evidence that some patient groups, especially patients with recurrent CDI, benefit from FMT aiming to correct intestinal dysbiosis—microbiota alterations—by instilling fecal microorganisms from a healthy individual into the intestine of a patient. In the US, a total of 15%—20% of antibiotic-related cases of diarrhea and most cases of pseudomembranous colitis can be attributed to CDI, which is involved in three million cases of diarrhea and colitis per year, with many thousands succumbing to infection.2 Recurrence of CDI appears to be common, affecting around 15%—20% of cases. In their current CDI guidelines, The European Society for Clinical Microbiology and Infectious Diseases (ESCMID) recommends the use of FMT rather than vancomycin or fidaxomicin in patients who have experienced at least two CDI recurrences (i.e. three CDI episodes in a single patient).3,4 The EAGEN Gut Microbiota 2014 meeting took place in Rome in September, and some of the talks are now available in the UEG Education Library (please see below for the list of presentations). In one of the presentations, Dr Luca Pani from the Italian Medicines Agency not only ‘brutally’ explains the bread and butter of FMT and dishes out compelling facts on FMT success rates, but also expands on the vast potential applicability of FMT, which may prove valuable in preventing, mitigating, and/or treating complex disorders, such as multiple sclerosis, colorectal cancer, metabolic syndrome and disorders stemming from imbalances in the gut–brain axis.2 Moreover, Dr Pani importantly touches upon the intricate issues related to regulating FMT procedures, and asks several important questions. Should food and drug administrations control FMTs? Who are the FMT manufacturers? How about donor exclusions and testing of donor stool—which of the 40,000 species in stool should we allow to enter the recipient? Can single ‘active ingredients’ be identified or does the success of FMT rely on the combined actions/influence of diverse microbial communities? There have been discussions about whether FMTs are in fact tissue transplants or medicines, and there is also a continuum of varieties of FMT, from the infusion of donor faeces screened for pathogens prior to administration, to cocktails of enteric bacteria specifically chosen for and selectively grown on agar plates. Are we talking full-spectrum microbiota or defined microbiota ecosystems? Instead of FMT, are we moving towards ‘Next-Generation Microbiota Therapeutics’5 such as ‘RePOOPulate’, a synthetic stool produced by a ‘Robogut’6? Apparently, FMT regulations vary from being very strict, such as those developed by the US FDA, to being more or less absent in most other countries. In Austria, FMT is regarded as a therapeutic intervention that is not to be considered a pharmaceutical drug and is therefore exempt from regulation by the Austrian Medicines Act.4 As Dr Pani explains, the statistics on FMT for successfully treating C. difficile infections are clear—no need for P values anymore.2 Success stories keep coming in, which will eventually make FMT more palatable to the general public, and so it probably won’t be long before FMT will be triaged by health care professionals, medical companies, and national FDA agencies. Efforts aiming to relax regulations and ensure standardization as much as possible will be crucial in order to reduce the incidence of DIY-related mishaps and to quickly gain more insight into the therapeutic potential of FMT. Hungry for more? Then why not sit back and update yourself on FMT constituents, indications, feasibility, safety, practicality, and regulations, and—maybe first and foremost—examples of professional experience with FMT by having a look at the accepted articles section in Clinical Microbiology and Infection. I also recommend watching the talk on FMT and recurrent CDI by Lawrence Brandt given at the Gut Microbiota for Health 2nd World Summit.7
References
  1. Yong E. There Is No ‘Healthy’ Microbiome. The New York Times. November 1, 2014.
  2. Pani L. Microbial transplantation as a new therapy option in medicine: The views of the Italian Medicines Agency (AIFA). Opening lecture at EAGAN Gut Microbiota 2014.
  3. Debast SB, Bauer MP, Kuijper EJ, et al. European Society of Clinical Microbiology and Infectious Diseases: Update of the treatment guidance document for Clostridium difficile infection. Clin Microbiol Infect 2014; 20 (Suppl 2):1–26
  4. Kump PK, Krause R, Allerberger F, et al. Fecal microbiota transplantation—the Austrian approach. Clin Microbiol Infect Epub ahead of print 1 October 2014. DOI: 10.1111/1469-0691.12801
  5. Petrof EO and Khoruts A. From stool transplants to next-generation microbiota therapeutics. Gastroenterology 2014; 146; 1573–1582
  6. Petrof EO, Gloor GB, Vanner SJ, et al. Stool substitute transplant therapy for the eradication of Clostridium difficile infection: ‘RePOOPulating’ the gut. Microbiome 2013; 1:3
  7. Brandt L. Fecal Transplantation for the treatment of Clostridium difficile infection. Presentation at the Gut Microbiota for Health 2nd World Summit Madrid 2013.
EAGEN Gut Microbiota 2014 Presentations Pani L. Microbial transplantation as a new therapy option in medicine: the views of the Italian Medicines Agency (AIFA).  Putignani L. Gut bacteriome—Gut aerobs.  Delogu G. Gut bacteriome—Gut anaerobs.  Langella P. Gut bacteriome—Focus on Fecalibacterium prausnitziiCani P. Gut bacteriome—Focus on Akkermansia muciniphilia. Ianiro G. Gut mycome. Bruno R. Gut virome.  Gasbarrini A. The intestinal barrier in different physiological and pathological conditions.  Barbara G. Consequences of increased intestinal permeability.  Lopetuso L. Esophageal gastric barrier. Further UEG Education Resources Surawicz CM. Regulatory and safety issues. Presentation from Faecal microbial transplantation: An old therapy comes of age at UEG Week 2014 Mattila E. FMT for Clostridium difficile infection. Presentation from Faecal microbial transplantation: An old therapy comes of age at UEG Week 2014 Vermeire S. Modulation of the Intestinal Microbiota by Faecal Transplantation: What Can We Expect? Keynote Lecture at ESPGHAN Conference 2013. Further Reading Brandt LJ. American Journal of Gastroenterology Lecture: Intestinal microbiota and the role of fecal microbiota transplant (FMT) in treatment of C. difficile infection. Am J Gastroenterol 2013; 108: 177–185. DOI:10.1038/ajg.2012.450 Kapel N, Thomas M, Corcos O et al. Practical implementation of faecal transplantation. Clin Microbiol Infect Epub ahead of print 1 October 2014. DOI: 10.1111/1469-0691.12796 Kelly CR, Kunde SS and Khoruts A. Guidance on preparing an investigational new drug application for fecal microbiota transplantation studies. Clin Gastroenterol Hepatol 2014; 12: 283–288 Lagier JC. Fecal microbiota transplantation: from practices to legislation before considering industrialization. Clin Microbiol Infect Epub ahead of print 1 October 2014. DOI: 10.1111/1469-0691.12795 Singh R, Nieuwdorp M, Ten Berge IJ, et al. The potential beneficial role of faecal microbiota transplantation in diseases other than Clostridium difficile infection. Clin Microbiol Infect Epub ahead of print 7 November 2014. DOI: 10.1111/1469-0691.12799.

Medical mishaps

… mistakes also happen when providing health care.

Mistakes happen. This is the reason why my Volvo has large rubber bumpers and why pencils have rubbers. Indeed, I, amongst many others, may have been born for this very reason. It has long been recognised that mistakes also happen when providing health care. Of course, there are lots of reasons that such mistakes occur, including sleep deprivation, being rushed, having illegible hand writing, delivering complex care, language barriers and treating elderly patients who have lots of interacting comorbidities.

Estimates vary, but the now famous Harvard Study concluded that 1% of hospital admissions result in an adverse event.1 I must admit to being sceptical about this figure, which would equate to more Americans being killed in US hospitals every 6 months than died in the entire Vietnam War. By contrast, on ward rounds it is clear to me that what actually kills people is being old, frail and diseased. And herein lies the root of my scepticism. The study takes no account of the expected risk of death in the absence of a medical error. A rarely quoted study by Hayward and Hofer,2 tried to examine care more objectively. The authors derived three interesting and illuminating conclusions. First, most deaths reportedly due to medical errors occurred at the end of life or in critically ill patients in whom death was likely regardless of the care received. Indeed, two-thirds of cases reviewed in their study had a "do-not-resuscitate" order in place at the time of death. Second, the level of agreement that a death was 'preventable' was poor (kappa value 0.25). The authors concluded, "…most of the 'errors' identified represent outlier opinions in cases in which the median reviewer believed either that an error did not occur or that it had little or no effect on the outcome." They dryly commented that if there were a large enough reviewer panel, there would always be someone of the opinion that each death was preventable. Third, the probability that an error definitely had contributed to a death was considered rare. The reviewing clinicians estimated that only 0.5% (95% CI, 0.3–0.7%) of patients who died would have lived an extra 3 months if their care had been optimal. This would represent roughly 1 patient per 10,000 admissions to the seven Veterans Affairs medical centres included in the study. The above conclusions will not be surprising to doctors who look after patients. But surely we should always be alert and pounce on every medical mishap to continuously improve practices and reduce the risk of further errors? The hunt for hospital mishaps may, however, have unforeseen consequences. I am aware of three problematic issues. The first issue is that identifying particular patterns of care that result in truly preventable deaths is difficult. It's far easier to identify 'minor' problems and the 'minor' individual responsible. For this reason nursing staff are the most frequently reprimanded team members. Paradoxically, nurses are the least likely not to internalise the reprimand and forgive themselves, and are the most likely to become depressed afterwards. I have seen nurses leave our NHS after a reprimand. There is already a national shortage of nurses because young people don’t want to spend a lifetime working shifts, doing physically and emotionally draining jobs in a punitive environment that comes down hard on every mistake. Qualified nurses don't need a push through the door; they are already leaving frontline services for less demanding jobs in the private sector. Personally, I regret not going into the financial sector where, for example, bringing your bank into financial ruin or the whole world into deep recession is rewarded with a warm handshake and a fat pension. Trying to fix problems in complex settings using hindsight and anecdotes is the second issue as it may lead to processes that worsen care. British nurses now seem to spend more time completing care plans and paperwork than directly caring for patients. To reduce prescription errors, we now have a bewildering 6-page colour coded prescription chart with a myriad of tiny boxes to prescribe anything from oxygen, to compression stockings, to drugs, with ample opportunity to get confused and make a mistake. In my opinion, almost all processes that are put in place to reduce risk, result in an increase in the complexity and time it takes to achieve the task. Surely, the reverse should be the case? Never before in the history of medicine have so many patients with so much disease been given such complex care by so few nurses within such a short space of time! The third and final issue is the overestimation of life expectancy. It is often lamented that doctors overestimate the life expectancy of their patients, but sick patients and their relatives have even more unrealistic expectations—they don't expect to die at all! Paradoxically, it is the elderly who have the least to gain from receiving numerous medical interventions, are the most likely to suffer an adverse event and the least likely to survive when something goes wrong. In spite of all this, when the 'unexpected' happens, it is presumed that it must be due to an error. The creeping mistrust is fuelled by our medical obligation to disclose every medical mishap. The relatives of an octogenarian who succumbs to a hospital acquired infection after a hip replacement will have little doubt that, "The reason my grandfather died was because the nurse didn't dress his wound on time/he didn't get his tablets in the evening/the hospital gave him pneumonia." How can we continuously reduce errors, encourage more young people to become healthcare professionals and provide sufficient time to complete every task, whilst encouraging the elderly to be realistic in their expectations? Unfortunately, this is a circle that cannot easily be squared. In the future, health care will undoubtedly be provided by robots! References 
  1. Brennan TA, Leape LL, Laird NM et al. Incidence of Adverse Events and Negligence in Hospitalized Patients — Results of the Harvard Medical Practice Study I. NEJM 1991; 324: 370–376.
  2. Hayward RA and Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA 2001; 286: 415–420. 

Endoscopic happenings at UEG Week 2014

I am limbering up for a dose of endoscopy at UEG Week. The ESGE has already sent me free complimentary access to their eLearning unit "Colonoscopy – the Basics". Clearly they are trying to tell me something.

Hopefully you have now downloaded the UEG Week 2014 App, which allows you to choose between 20 different pathways. The UEG Week Vienna Pathways Tool can also be downloaded. I am particularly looking forward to the endoscopy pathway. On Saturday during the postgraduate teaching programme there will be two live endoscopy sessions in the afternoon. The live endoscopists can then relax until Tuesday morning when there will be wall-to-wall live endoscopy in Hall A. These Live sessions do not always go to plan and they are a great opportunity to see experts get into and out of difficulties. Alex Meining is in charge and has told me that he has a record 36 cases lined up. He promises "polyps, polyps, polyps (small ones, ugly ones, polyps in the ileum, polyps in the rectum, polyps in Barrett's, polyps in the stomach), several IBD patients with strictures, new endoscopes (a new gastroscope and the three-lens screening colonoscope from FUSE, Olympus brand new extra-wide-angle scope, etc.). (Only) one ESD, a POEM, pancreatic cysts (with drainage, inspection of IPMN with Spy and confocal). In addition, there are pancreatic and biliary strictures of various types, contrast-enhanced EUS and various EUS-FNAs using various needles". Sounds like the kind of real-life stuff that is always interesting to see how other approach. Don't forget UEG Week Live and UEG 24/7—streaming many sessions as they happen and then making them available later on. Note, however, that none of the live endoscopy sessions are live streamed. On Monday, I'm looking forward to the acute upper GI bleeding therapy update in Hall D. I've got high hopes for the Hemospray device, which I hope will allow me to stay in bed when injection and thermal therapy has failed. In my mind the only outstanding question is "Do we need to organise an early re-check the next morning?" My guess is yes, that white powder will not stay on forever! We have two free paper sessions on new imaging and diagnostic modalities in upper and lower GI endoscopy on Monday afternoon. Not sure why the organisers haven't put the two sessions in the same hall though? Nevertheless, it's great to see that technology arms race is still in place. Sadly, there is a clash between the upper GI update and the update on gastro and duodenal endotherapy. I have the greatest respect for duodenal endotherapy, which is Tiger country indeed. It would be great if there were something that reduces the risk of late bleeding! For a large mucosal defect I spray thrombin, but this stuff is ridiculously expensive. On Tuesday morning Lars Aabakken and I will be hosting a session dedicated to the future of colorectal cancer screening. We'll give you an update on what to do with sessile serrated lesions, and presentations on the thorny issue of how to prevent and deal with local recurrences. Hopefully we can get a consensus on how many times we should try to get rid of a local recurrence before we give up. These are just some of the endoscopic happenings at UEG Week 2014. There are lots more to choose from including updates on Barrett's, EUS, ERCP, capsule and small bowel disease. Endoscopy continues to develop in numerous simultaneous directions driven by new technologies. I think that it has overtaken radiology in complexity, variety and colour! Please give us some feedback on which endoscopy sessions you're enjoying throughout the meeting. The easiest way may be to tweet using any of the hashtags: #UEGWeek #endoscopy #UEGEducation. Alternatively, just grab me for a chat!

Moving through the oesophagus at UEG Week 2014

If this is not your first time at UEG Week, you will already know that coffee breaks and lunch are on us! Just don’t spend too much time on them, as we have an extensive programme on the oesophagus and all things related waiting for you as well!

The postgraduate teaching programme on Sunday is your entrée. It starts with novel approaches and views on dysphagia and eosinophilic oesophagitis in patients with normal endoscopy, followed by a case presentation session on new options in gastro-oesophageal reflux disease (GORD). In the afternoon, you will be served an update on the management and outcomes of upper gastrointestinal bleeding (UGIB). Starting Monday, the oesophagus offering becomes truly 'buffet style' and you may want to take a look at the UEG Week Vienna Pathways Tool to help tailor your schedule to your appetite. For instance, this might be a good opportunity to get a therapy update on acute upper GI bleeding, starting at 11:00 in Hall D. Alternatively, you may walk into Hall B for views on the optimal management of patients with belching, aerophagia, rumination and hiccups. Can't decide? Here's a tip. Look for sessions with a 'Live' symbol. These will be streaming live on the UEG website and made available after the meeting via UEG 24/7. This is also a good day for you to grab your congress lunch and join Professor Mark Fox and colleagues in a round table discussion on dysphagia, based on a case presentation. Please come early though, as seats are limited. During the afternoon, there are two free paper sessions that might interest you: "Clinical and molecular factors in oesophago-gastric cancer outcomes", starting at 14:00 in Lounge 5, and "New diagnostic modalities in upper GI endoscopy", starting at 15:45 in Hall G/H. Continuing with your oesophageal main course, Tuesday kicks off with a therapy update on GORD, the implications of molecular pathogenesis on endoscopic therapy for Barrett's oesophagus, and a session on the risk factors and management of upper GI bleeding. If you are interested in novel endoscopic interventions in the oesophagus, please be sure to attend a free paper session on this topic at 11:00 in Hall O. Right after lunch at 14:00, you might want to join the discussion on whether function tests for the upper GI tract are indeed necessary or not (Hall B) or perhaps you might rather attend a free paper session on risk stratification and ablation in Barrett's oesophagus (Hall O). Moving towards the end of the day, a symposium on evidence-based treatment of achalasia takes place. No meal is complete without dessert! On Wednesday, the oesophagus pathway wraps up, starting with fresh and innovative views on the challenges and new frontiers in GORD and Barrett's oesophagus. You are also in for an integrated pathologist's versus endoscopist's view on oesophageal squamous cell carcinoma, early Barrett's neoplasia and early gastric carcinoma in the 11:00 symposium in Hall I/K. To return home with a sweet taste in your mouth, UEG Week 2014 ends with three cherries on top of the cake: a symposium on adenocarcinomas of the oesophago-gastric junction, another on endoscopic resection of upper GI tumours, and a free paper session on eosinophilic oesophagitis and other immune-mediated upper GI diseases.      We hope you enjoy the oesophagus 'course' at this year's UEG Week and look forward to your comments and tweets! (#UEGWeek #oesophagus #UEGEducation).

Spotlight on cancer—covering all bases at UEG Week 2014

Time is ticking away to UEG Week 2014 and if fighting cancer makes you tick, you are about to enjoy a full-course week, with servings from a cutting-edge research programme on cancer screening, diagnosis and prevention, and treatment.

If you're an early bird, you might decide to start your UEG Week 2014 experience on Saturday by attending the postgraduate teaching programme, with a mid-morning session dedicated to pancreatic adenocarcinoma, which covers endoscopic ultrasound, radiology and pathology for differential diagnosis, resectability and novel systemic treatment options. Sunday is a busy day and kicks off early morning with a session on colorectal cancer (CRC), focusing on early detection and local treatment, with talks on colonoscopy and non-invasive tests in population screening, and on recognition and diagnosis of early (T1) cancer: endoscopy, histopathological diagnosis and the use of ESD or TEM. This session is followed by one on terminal GI cancer, focused on symptom management and patient care (including case presentations). If you are only arriving on Monday, no worries! You are just in time to get in gear for the opening plenary session, which includes a talk on advances in the management of CRC, and is followed later in the morning by a free paper session focusing on the clinico-pathological features of GI cancer. During the lunch break you may want to electronically browse through the posters at the E-poster exhibition, and attend the new 'Poster Champ' sessions (from Monday to Wednesday), to select and award the best posters in each category. The afternoon programme includes plenty of sessions for you to choose from, starting with a free paper session on imaging techniques in colonoscopy, followed by another on new diagnostic modalities in upper GI endoscopy. In parallel, from a cancer treatment perspective, the session on late breaking digestive oncology abstracts is very appealing, and just prior to a session on the current and future perspectives in pancreatic cancer. Tuesday begins with a session on funding available for research under the EU research framework programme (H2020), followed by a 'Posters in the Spotlight' session on "Mechanisms underlying the development of GI cancer". This format is new for UEG Week 2014, in which hot topic research E-posters are presented on stage, and an oral free paper prize will be presented to the best poster. The afternoon kicks off with a free paper session on novel mechanisms and targets in CRC, followed by two sessions focusing on endoscopic management of early colorectal neoplasia and treatment of liver metastases. Wednesday wraps up this year's exciting and vibrant UEG Week, starting with novel approaches to rectal cancer from the viewpoint of the pathologist and the endoscopist. The final afternoon starts off with a round table discussion on molecular guided therapy for GI cancer, and ends with a session on the pancreas, in which an annual review of pancreatic cancer will be presented from basic and clinic viewpoints.  To make sure you're not missing out, please do complement this brief by browsing the complete programme online or by viewing the cancer pathway, which can be accessed online or via the UEG Week App.  We'd also love to hear what cancer content you find appealing throughout the meeting. Tweet to let us know! #UEGWeek #GIcancer #UEGEducation. On a footnote, since you can't physically be in two places at once (yet!), UEG will be livestreaming many of the sessions as they happen via UEG Week Live and all recorded talks will be made available via UEG 24/7.

Hepatobiliary highlights at UEG Week 2014

There is no doubt that 2014 is witnessing a revolution in the treatment of hepatitis C. You can find out all the latest information at this year's UEG Week, starting with a dedicated session during the postgraduate teaching programme on Saturday morning (Viral hepatitis: Cure by modern regimens?). The course will further offer you the opportunity to get an update on non-alcoholic fatty liver disease (NAFLD) and alcoholic liver disease, as well as on the endoscopic management of malignant biliary obstruction challenges, and will also feature a clinical case-based session on liver function assessments.

For further insights into hepatitis C management, be sure to attend the opening plenary session on Monday morning, which includes a talk by Professor Michael Manns, followed by an overview by Professor Heiner Wedermeyer of what's new in hepatology in clinical practice in 2014. After lunch, there will be a special free paper session on the lingering clinical challenges for hepatitis C therapy, followed by an update symposium on viral hepatitis therapies. Hepatitis C may be a lead actor in this year's UEG Week liver 'play', but much more besides is being covered. For example, why not join a round table discussion on non-obstructive jaundice on Monday lunchtime (please note that numbers are limited for these sessions)? Updates on NAFLD and liver cirrhosis (in the format of a free paper session and posters in the spotlight) are also featured in the afternoon, in parallel with a session on the immunopathogenesis of pancreatitis and hepatitis, as part of UEG’s two day "Today's Science; Tomorrow's Medicine" initiative. On Tuesday morning you might find yourself undecided on which session to attend. Will it be 'Clinical management of liver cirrhosis' or 'The liver as a central regulator of inflammation'? Shortly after, there's an update on alcoholic liver disease and novel aspects of biliary tract cancer to choose between. Finally, the afternoon has new concepts in management of biliary diseases and a free paper session on biliary tract cancer occurring simultaneously. Lucky for you, UEG has your back; all recorded sessions will be made available via UEG 24/7, with many of the sessions being made available as they happen, via UEG Week Live. For the final day of the meeting, there will still be plenty to learn about cholangiocellularcarcinoma (and neuroendocrine tumours), as well as diagnosis and management of both non-cirrhotic and cirrhotic liver nodules. And you may want to return home with some new insights on biliary stenting or on the interconnecting pathways linking viral hepatitis, cytokines and liver regeneration, which you can learn all about in the last two free paper sessions of the day. And don't forget there are poster sessions running throughout the whole meeting! Last but not least, we invite to visit the online program and search for your specific topic of interest—the word 'liver’ alone returns 355 matches! Or you might want to make use of the UEG Week Vienna Pathways Tool to make sure you’re not missing out! You can also download the UEG Week App for your mobile device and have all this information and more at your fingertips. We hope you enjoy the hepatobiliary pathway and would love to hear what you find interesting at this year's meeting! Please do comment or tweet to let us know by including one or more of the following hashtags: #UEGWeek #Hepatobiliary #UEGEducation. You can also visit the UEG Education Lounge located in Hall Z and talk to us personally. Have a great meeting!

UEG Week 2014 in transit: A view from the intestine

With UEG Week 2014 just around the corner, we have forged a brief summary for your perusal that might be of interest if you're into inflammatory bowel disease (IBD), irritable bowel syndrome (IBS) or other issues related to functional and organic bowel diseases.

Unsurprisingly, IBD is one of the major topics at UEG Week 2014. If IBD is your thing, then you should kick things off with the postgraduate teaching programme on Saturday and Sunday, when you can learn more about what's important for diagnosis, the challenges of refractory IBD and also skin lesions in IBD. And do make sure you're ready for Monday because it's jam-packed! The opening plenary session includes no fewer than two talks on 'How to translate basic immunology findings into clinical reality in IBD'. You may then want to stay put in Hall A to get updates on 'What's new in 2014' and to receive highlights from Digestive Disease Week 2014. However, you might prefer to stretch your legs and explore the convention centre. Why not look up environmental factors and IBD (Hall F2), conventional therapy for IBD (Hall I/K) or the free paper session on small bowel imaging and endoscopic interventions (Lounge 6), where you can get updates on everything from the diagnostic value of faecal calprotectin to the clinical usefulness of virtual enteroscopy for Crohn’s Disease. At lunchtime there's a round table discussion on treating IBD in patients with cancer and early in the afternoon there are parallel sessions on pathophysiology and new imaging tools. After all that, move to Hall E to be updated on the new European guidelines for diagnosing IBD or to Hall L/M to find out about new therapeutics for specific targets. Tuesday and Wednesday continue in the same vein, with more than ten other IBD sessions on offer—from management of complicated Crohn's disease to the best use of biologics, new biomarkers, new drugs, epidemiology and outcomes, targeting new pathways and what's new in 2014. In order to bone up on coeliac disease and wheat allergy, you should look up the postgraduate teaching programme session in Hall E on Sunday morning. Monday sees an afternoon session on 'New Challenges in Gluten Sensitivity: From Bench to Bedside', and includes a talk on triggers and drivers of autoimmunity. Look up 'Posters in the Spotlight' on Tuesday afternoon to learn about the applicability of serological tests for the diagnosis of coeliac disease in asymptomatic children. Speaking of those who are asymptomatic—should they be put on a gluten-free diet? Find out at the round table discussion on Wednesday lunchtime! To learn more about diet, food intolerance, and nutrition you'll probably want to secure a seat in Hall G/H Wednesday from 11:00am. Diet appears to be a major modulator of gut microbiota and this is one of the topics covered in the 'Today's Science Tomorrow's Medicine' session on 'Diet, immunity and systemic disease' in Hall R late on Monday morning. Moving on to bacteria, blooming blasters of bad bugs probably don't want to miss out on the postgraduate training programme on Saturday afternoon, which covers diagnosis, management and prevention of Clostridium difficile infections. Obviously, faecal microbial transplantation is bound to attract a lot of attention—make sure you secure your seat in Hall C on Tuesday afternoon! To learn more about the gut microbiota in health and disease, the symposium on altered intestinal microbiota composition in IBS on Monday morning in Hall G/H is an absolute must. Participate in the debate on whether gut microbiota alterations in patients with IBS are a cause or a consequence. To be updated on FODMAP and gluten-free diets for IBS patients you just have to look up Hall I/K and Hall Q on Monday afternoon, and if this is not enough, a panoply of talks on restrictive diets is in store for you in Hall E just before lunch on Tuesday. Next, hurry to Hall G/H to participate in the round table discussion on how to manage the difficult IBS patient, and then, immediately after this, Hall D is certainly the place to be on Tuesday afternoon if you want to continue learning how to manage IBS patients successfully. Please, however, be aware that there is also a Translational/Basic Science pathway session on normal and abnormal cross-talk at the mucosal border and the relevance of this for GI function and dysfunction taking place on Tuesday afternoon (Hall L/M). Faecal incontinence gets attention in the postgraduate teaching programme on Sunday, while constipation takes the stage on Tuesday afternoon—these two topics are also the focus of a free paper session in Hall R on Wednesday morning. Finally, don't forget the 'Neurogastroenterology and Motility: What’s new in 2014?' symposium in Hall 2 at 11:00–12:30 on Wednesday! With so much on offer, don't forget that there are plenty of tools available to help you make the most of UEG Week 2014. Downloading the UEG Week Vienna Pathways Tool is one way of getting acquainted with the entire conference programme. Or maybe you prefer to download the UEG Week App instead? The App includes the 'Pathways' feature that enables you to identify exactly which sessions might be of particular interest for your specialty. Many of the talks will be made available as they happen via UEG Week Live, which is great if you can't make the meeting in person. All recorded sessions will also be made available via UEG 24/7—perfect if you can't decide between parallel sessions!   We'd love to hear what intestine and motility content you find interesting throughout the meeting, so please do tweet to let us know by including the hashtag #UEGEducation and one or more of the following: #Intestine #IBS #IBD #motility #microbiota #FMT (faecal microbial transplantation) #Cdiff   Happy ruminating!

How to stomach H. pylori during UEG Week 2014

UEG Week 2014 is now just a few days away, and if your research or specialty involves upper GI diseases, such as gastric ulcers or gastric cancer, you're sure to get your fill at this year’s meeting.

With more than 35 sessions of relevance to choose from, we've selected a few that you might find interesting and informative, but do consider downloading the UEG Week Vienna Pathways Tool to make sure you're not missing out! The postgraduate teaching programme on Sunday has a lot in store for you. In the morning, there is a session on advanced endoscopic techniques, including gastrointestinal imaging and submucosal endoscopy. Around noon, you'll need to choose between three practical sessions that are supported by case presentations: learn more about managing and caring for patients with terminal GI cancer, progress in dysphagia and gastroparesis or whether we've solved all the problems associated with H. pylori infection. The afternoon is completed by a session on management and outcomes of upper GI bleeding, including endoscopic management, blood transfusion, pharmacological strategies for improving outcomes in acute upper GI bleeding, and information on the impact of novel oral anticoagulants on the gastroenterologist's case load. How H. pylori alters stem cell homeostasis by direct colonization of the gastric glands is the subject of a talk by Michael Sigal in Monday morning's opening plenary session in Hall A. If you choose to stay put in Hall A, you will certainly be able to find something to your liking in the 'What's new in 2014' session. Alternatively, you may want to proceed to Hall D if you're particularly interested in issues related to acute upper GI bleeding, or to Hall B if you’re more into topics related to belching, aerophagia, hiccups, rumination or cyclic vomiting. Of course, functional dyspepsia is also on the menu. Talks on diagnostic criteria and therapeutic approaches will surely attract quite a few attendants in a symposium dedicated to new thoughts in functional dyspepsia. This symposium also includes a talk on the role of food allergy in dyspepsia, and data on the association of serum adipocytokines and gut hormone levels with gastric emptying and symptoms in patients with functional dyspepsia will be presented. Monday finishes with talks and a panel discussion on 'quality endoscopy', including upper GI diagnosis, and should give rise to some interesting discussions based on experience and data from around the world. By the way, don't forget to season your Monday with some of the 'Best of DDW' from 14.00—15.30 in Hall A. There are two free paper sessions on offer if you're up and about bright and early on Tuesday morning: one on upper GI bleeding (risk factors and management) and the other on gastric carcinogenesis (new insights into pathogenesis and management). Tuesday morning is also H. pylori galore and offers an entire symposium on H. pylori-associated gastric carcinogenesis, covering everything on how H. pylori is able to induce gastric cancer. Unsurprisingly, there will be presentations on H. pylori-induced epigenetic changes, H. pylori-mediated miRNA regulation, proteolytic activity, and how iron deficiency may be involved in H. pylori-associated carcinogenesis. Later in the day, Hall B will also host talks on function tests for the upper GI tract and this session is a must for those interested in lactose intolerance and for those who do not really know what to make of oesophageal high-resolution manometry. If you're not full by the end of Tuesday, there's still plenty on offer on the final day of the meeting. On Wednesday lunchtime there are limited spaces available at two Round Table Discussions: one on the impact of long-term PPI use and one on molecular guided therapy for GI cancer. You also have your pick of two Wednesday afternoon symposia. In case you want to update yourself on advances in obtaining a mechanistic understanding of dyspepsia, Hall B is the place to be. Here you will also get a general update on dyspepsia, including data on new drugs, psychological therapies, and diagnostic tools. If adenocarcinoma of the oesophago-gastric junction sounds more alluring, then you should proceed to Hall F1. Here, different aspects of diagnosis and treatment will be dealt with, and the session highlights the relevance of taking a multidisciplinary approach to this particular disease. Finally, don't forget to check out the poster sessions on Monday, Tuesday and Wednesday, with 'Posters in the Spotlight' available for viewing in the E-poster lounge on those days. We'd love to hear what stomach and H. pylori content you find interesting throughout the meeting, so please do tweet to let us know by including one or more of the following hashtags: #UEGWeek #Stomach #Hpylori #upperGI #UEGEducation. In case you're not attending UEG Week in person, please note that many of the talks will be made available as they happen via UEG Week Live – just follow the livestream on the UEG website (www.live.ueg.eu/week). If you can't catch every talk as it happens (in person or via the livestream), then you're in luck because all recorded sessions will be made available via UEG 24/7 (www.ueg.eu/week/24-7). Bon appétit!

A perfect storm

A record number of patient complaints for the 12-month.

The English Health and Social Care Information Centre recently reported a record number of patient complaints for the 12-month period from 1 April 2013—31 March 2014. The total tally was 174,872 complaints and the largest single source was complaints about inpatient care. In a country where people apologise for getting their feet stepped on, most patients do not complain about poor medical care and this figure is likely to be the tip of the iceberg.

So who is to blame for this epidemic? The West in general and the English National Health Service (NHS) in particular is seeing the beginning of a perfect storm in which several forces are converging. The first component is our increased life expectancy (lifespan), which has not been mirrored by an increase in healthy life expectancy (health span). People are now living longer in spite of accumulating health problems. Patients survive heart attacks, only to require multiple vascular interventions. Patients live with cancer longer, at huge expense, requiring close monitoring and frequent imaging. The second component of the perfect storm is patient expectation. It is paradoxical that although we now live longer than at any time before in history, we worry more about our health than ever. People are no longer content to see if that stubborn cough or sore throat will settle in a few days. After all, it may well be the beginning of something serious! Furthermore, they would rather have someone else, a 'qualified person', telling them that they have nothing to worry about. If their insomnia then turns out to be the first sign of a brain tumour, at least there is someone to sue. Many of the major IT companies are also developing smart watches with the ability to monitor health parameters and turn healthy people into nervous patients concerned about extra heart beats or poor quality of their REM sleep. In the case of the English NHS, the third component is that politicians are unwilling to pour further money into a health service that they see as inefficient. I guess that by throttling funds, they are hoping that a more efficient service will emerge. Sadly they are mistaken and instead services are increasingly managed on a shoestring. Wards are kept open with the bare minimum of nursing staff. Support services such as audiology, speech therapy, physiotherapy and occupational health are told that they have to cut expenditure by up to 20% As the above three factors are beginning to exert an irresistible force on the English health care system, managers' and politicians' eyes are increasingly turning towards the Pandora's box that is 'the marketplace'. When I first arrived in England some 30 years ago, hearing aids, dental care, retirement homes and eyesight tests were all free. However, it was soon realised that these services could be taken care of by private providers. As our creaking NHS is finding itself subjected to the unyielding effect of the above three forces, it is inevitable that this Pandora's box will be opened. Naturally, the NHS could never stop providing free emergency care for patients with serious acute disease or cancer, but this leaves plenty of scope for private providers in the marketplace. Why not ask pharmacists to see patients who develop a sore throat, wake up with a headache or simply feel tired? Pharmacists could charge patients either directly for giving them advice or indirectly by incurring a fee for the medicines that they recommend. Parents who find that their children have wonky teeth, can’t sit still in the classroom or simply don't seem to develop as well as their siblings, will in the future have to pay to have their children seen to. But why stop there? Why should the NHS provide joint replacements for free when instead it could supply patients with walking sticks? Why should the NHS provide free cataract extractions in both eyes when operating on just one eye is enough to allow people to read a book? Osteoarthritis and cataracts are neither emergency care nor cancer! Furthermore, why shouldn't patients pay for more expensive medication themselves? If patients don't like their angiotensin receptor blocker, they may opt for an angiotensin-II receptor blocker that has a different side effect profile! If patients are prepared to pay an extra €30.000 for a cytotoxic agent that gives them hope of an extra few months' survival, why stop them? The marketization of our lives is becoming omnipresent. Soon it will be possible to purchase everything. I can see three reasons why the free rein of market forces will be bad. Firstly, there will obviously be people who cannot afford care. Parents who do not have the funds or knowledge of 'the system' will not be able to obtain medication for ADHD or pay a psychologist for cognitive behavioural therapy. I predict that we will in the future see more evidence of what can go wrong when children are left unsupervised on our streets. Secondly, I would miss the fact that when I recommend a treatment to a patient, both of us know that I do not stand to gain personally from the advice. In most parts of the world, patients do not have this reassurance and may be tempted to seek an alternative and perhaps cheaper opinion. Patients seeking multiple opinions and then choosing the one that suits their own ideas best will not necessarily lead to better health outcomes. Thirdly, the 'haves' and the 'have-nots' will live completely separate lives. They will live in different parts of the city, their children will go to different schools, they will travel to work by different means and their leisure time will be spent in different places. I don’t think that this is good for society. Democracy itself will be under direct attack as those who can afford to pay for political influence and lobbyists will seek to buy the policies that favour them. Why not—it's the marketplace! In the meantime, I keep staring at those X-ray machines in the knowledge that when my own cataracts have reached maturity, and I can no longer read a book, my optician will swiftly point me in the direction of a private ophthalmologist without any involvement of the NHS. 

Cooperation and Reciprocity in Organ Transplantation

Surely one of the cornerstones of the survival of any species is how individuals participate by means of “Reciprocity” (Oxford dictionary; exchanging things or favours with others for mutual benefit) and “Cooperation” (the action or process of working together to the same end).

But what about those who try to cheat the system, deriving the benefit of others cooperating but without providing any reciprocity? I recall a study of seagulls which prune their own feathers but have to rely on other to prune their own heads. What if a pesky bird would accept others pruning its head but would rather spend his own pruning time catching more fish than pruning others in return? How does nature deal with the problem of the cheat? The observational study found that birds have a long memory and will not prune another bird if it had not returned the favour in the past.  I remembered this study when reading about the dwindling supply of organ donation. Safer cars have reduced supply and improved survival after heart attacks have increased demand for heart transplants. According to the NHS own website, between April 2011 and March 2012, 3,960 organ transplants were carried out in the UK thanks to the generosity of 2,143 donors. Unfortunately, another 7,593 people were still waiting for transplants at the end of the period. The ratio of 2.1 donors/ 3.9 organs is a little odd as in theory, one donor should provide organs for up to 6 transplantations.  There is a particular problem with tissue mismatch as Black and Asian people are three to four times more likely to develop kidney failure than the general population but are particularly unlikely to join the Organ Donor Register. This is particularly tragic as people from the same ethnic group are more likely to be a good tissue match.  To boost supply in England, a Bill has been proposed for an “opt-out transplant system” whereby everyone would automatically be included in the donor registry unless they ask to be taken off the register. Although the bill has already become law in Wales, I must admit that I am sceptical. People may still find a myriad of reasons why Nature’s law of cooperation and reciprocity does not apply to them and opt out of the donor registry. Indeed, Chile has seen an overall fall in the number of organ donors since they introduced an “active opt-out system” and evidence from other countries with an opt-out system indicates that the rise is small with only around 15 additional donors per country per year!  The Government’s proposed bill has received fierce opposition from Christian churches and from within the Muslim and Jewish communities. I would like to propose a solution which will retain people’s ability to exercise free choice, will not offend religious sensitivities and still provide a fair system, based on cooperation and reciprocity.  People will only be eligible to receive a donated organ IF they had already joined a donor registry! People would indicate which donor registry’s they would like to join and in turn be eligible to receive a transplanted kidney, liver, heart, lung, small bowel or pancreas.  It would work similarly to an insurance programme in which it would only be possible to get cover for a new disease. Without this clause, we will soon find cheats who quickly join the donor registry once they have received a diagnosis of cirrhosis. The only problem I can foresee is that of children or people with diminished capacity who are unable to choose. Perhaps in those cases, it would have to be their legal guardians who would have to make the choice on their behalf.  Wales will reassess the result of their new law in 5 years. Perhaps when they see the paltry number of extra donors, all from white middle classes rather than minorities, they will re-consider my proposal?

After the Summer School

Having returned from a hectic UEG Summer School in Prague, Bjorn has some reflections on Happiness

Professor Richard Easterlin found that more money does not make us more happy – the “Easterlin Paradox”.  This is because of “habituation” whereby the immediate thrill of buying something extravagant wears off. 

In fact, in spite of rising disposable incomes, people are less happy than they were 50 years ago.  Professor Robert Putnam blames the American unhappiness on television.  This is because the TV makes us less likely to go out and socialise and feel part of a community.  He also found, after studying some 30 000 Americans, that as communities became more diverse, people became less trusting of each other. 

Can Social Networks overcome our TV-induced isolation?  Well, Facebook may be better than TV (as a degree of communication is possible) but “competitive pressures” also increase. The “look what a fantastic life I have – effect” reduces happiness in others. 

Having spent a few fun days at the UEG Summer School in Prague, it’s clear to me that Putnam was right.  Nothing can beat meeting people face-to-face for building bridges across countries and continents.  As a total of 150 trainees and 20 specialists from 33 different countries mixed in the morning lecture theatre, afternoon workshops and over dinner an in nightclubs, a strong camaraderie developed.  

The last century has given us cars, telecommunication and globalisation.  These are firmly anchored in an economical “growth strategy” in which countries compete to continuously increase Productivity and GDP.  This is associated with depleting resources, global warming and a reduction in overall happiness.   In contrast to having more stuff, I predict that in the next 100 years, people will want and expect improved health and longevity.  In Prague I was privileged to meet some of the people who will deliver it. 

Do you have what it takes?

Every year we are hosting a one year’s Endoscopy Fellowship in Leeds. The aim is to provide one of our senior Gastroenterology Trainees with a grounding in advanced therapeutic endoscopy.

Unfortunately, it has become apparent that not every trainee is comfortable with advanced therapeutic endoscopy.  They have a problem with the unpredictability of neoplasia and therapeutics.  Sometimes the resection goes to plan but at other times there is pain, immediate bleeding, delayed bleeding or even perforations.  Unpredictability is an inherent part of endoscopic therapeutics.  In fact, it is one of the reasons that I love it.  Not two cases are the same!

However, some of our trainees find this new role deeply unsettling.  Up to this point in their careers, they have never found themselves to be the reason why their patient ends up on the ITU or admitted for live saving emergency surgery or readmitted with a haemoglobin level of 40.  

A few years ago the Christmas edition of the BMJ published a tongue-in-cheek piece of research which clearly identified the "Therapeuticians” from the “Diagnosticians” (those who dare from those who duck).  A plucky researcher hid in the car park of a large hospital and secretly timed how long it took for surgeons to park their cars compared to the medics.  There was a clear divide, whereby surgeons would park their cars 20% faster than their medical counterparts.  The reason was not that the medics were driving larger cars but because they were far more cautious.  They would pull up to a free slot but bail out because it looked a little tight, or was close to a bend or required reversing into the slot etc.  The surgeons had more confidence in their abilities and were less concerned about what could go wrong (scratched paintwork). 

I now try to dissuade the trainees from applying who are the least likely to be comfortable in a life of therapeutic endoscopy.  It is easy to identify them. They will not miss an opportunity to phone you for advice, craving reassurance that they are doing the right thing. They feel uncomfortable making decisions, particularly if it has to be based on a “best guess” rather than a treatment protocol.   Paradoxically, I regard our ability to assess large amounts of partially contradictive and confusing information and provide a sensible and educated guess, is what separates us from nurses.  This is what we are trained for! 

I do ask trainees if they think that they would be happy in a professional life of removing large and scary lesions.  Unfortunately, most trainees have little insight into their own comfort zones.   Perhaps I should change my approach and simply time how long they take to park their cars. 

Get checked out - have a full body CT?

Since my teenage years I have been afraid of radiation. Two phrases stuck in my mind: 1) “there is no safe limit for radiation exposure”, 2) “the DNA damage is cumulative and never goes away” ...

Indeed this is why I see little point in radiology for disease which can be assessed by endoscopic means.  For the same reason I am incredulous when people voluntarily expose themselves to ionising radiation as part of a health check-up.

During ERCP I diligently carried my personal radiation exposure meter for many years.  Although the device was issued for “exposure prone activities”, such as ERCP, I decided to always carry the meter with me at work.  After all, the ionising radiation is even more significant when not shielded by a lead apron. 

Last year I had an Eureka moment and also started to wear the dosimeter during flights.  In the UK the average annual background radiation dose is 2.2 millisieverts (mSv).  However, at cruising altitude (35.000 feet), the hourly radiation may be up to 50 times greater than at the surface.  In addition, those body scanners which are replacing metal detectors at airports also emit radiation.

Your precise dose depends on the number of hours spent at high altitude and the latitude of the flight.  Latitude is important as earth's magnetic field deflects charged particles. The shielding is most effective at the equator where earth's magnetic lines are parallel to earth’s surface. Conversely, the magnetic shielding disappears over the poles where the magnetic lines point perpendicular to the surface.  Not sure how do penguins manage to cope with the large amount of radiation they receive at the South Pole?  Perhaps they don't live long enough to get cancer? 

For every 200 hours in the air, you receive 1 mSv of radiation exposure (look for yourself by clicking this link).  I was therefore surprised that our radiation protection officer did not phone me after I had travelled with my radiation exposure meter for year.  It turns out that most of the radiation received in an aircraft is from neutrons which can not be detected with classical dosimeter!

Official calculations estimate that for each 1 mSv of radiation exposure (above background radiation), will give rise to another 6.3 cancers per 100.000 people/year.  It is for this reason that EU-based air crews are limited to a maximum of 100 mSv of exposure in every 5 year period.  Nevertheless, there is evidently no safe radiation limit as pilots have been found to have an increased risk of cancer. 

My Radiologist friend tried his best to reassure me and pointed out that these radiation figures must be put into context.  “For example, a trip to Mars, will give you a total of 1000 mSv  which will give you a 1:20 extra risk of dying from cancer”.   In comparison, one of our abdominal CT studies only generate some 10mSv of radiation and will not cause more than one extra cancer in 400-500 exposures…

Reassuring words indeed !

A couple of years ago, I was invited to spend a long weekend in an African city.

It was part of an initiative to teach endoscopy to the locals. Anticipating trouble, I cautiously announced to my wife that this “would provide a great opportunity to see some of the marvellous continent.” My wife agreed: “Yes this is a great opportunity, just a shame that you will NOT be going!” She continued, “it’s far too dangerous and what these poor people need is clean water and a comprehensive vaccination programme not blooming endoscopies!” As a paediatrician, my wife felt that she could speak with some authority on the needs of Africa. “And goats, lots of goats”, I retorted remembering a friend who on getting married declined wedding presents but accepted donations of goats. One of my friends thought that I gave in far too easily. “You know, if you allow your wife to cocoon you like this, with ever tighter wraps, you’ll suffocate”. I was somewhat taken aback. For me, defiance was unthinkable but this guy seemed to do as he pleased with impunity! Living with a formidable wife and three strong daughters, I had been outnumbered for more than a decade. Furthermore, I spent every working day in the company of women. Last year I concluded that the testosterone levels at home needed a boost. I bought a 50Kg male brute of a dog. At the previous owners, he used to bark gruffly at passing cars. Sadly he quickly adapted to his new surroundings and within three weeks, the dog stopped barking and became frightened of umbrellas, balloons and plastic bags. I don’t blame the poor dog, fear was inevitable. I am still OK with balloons and umbrellas but I have become afraid of my wife. After 30 years I have even come to believe that it’s the secret behind a long and successful marriage.

Whilst most would make resolutions of things to do in 2014, I am more certain of things that I may not do ...

Last year my wife was called to attend for breast cancer screening.  Seeing the spectre of “small shadow” -> “inconclusive histology” -> “extended lumpectomy” -> “still not sure”,  playing out in my mind, I suggested that it may be wiser not to attend.  Of course she ignored me and of course a small “probably a calcified node” was found.  She attended for a targeted biopsy whilst I got on with another endoscopy list.  To my surprise she phoned after the biopsy to ask me to pick her up as she felt unable to drive home!?  When I collected her she described how they had spent an hour, repeadedly poking deep into her breast with an increasingly blunt biopsy needle.  She had been locked into some sort of frame to keep her still in the X-ray machine. Once freed from this fixation device, she collapsed on the floor with a vaso-vagal attack.  She apologised for fainting and vomiting on the floor of the X-ray department and asked if there was anywhere to lay down and recover.  Cheerfully the staff assured her that this happened all the time and that she may just as well stay on the floor as there were nowhere else to recover!  Seeing all my worst fears coming true, I anxiously waited for the histology (which I was sure would be inconclusive).  Luckily histology was a clear-cut calcified tiny lump and the screening programme scored another “success”.   The tenderness and bruising lasted a month. Most screening programmes were started with little evidence as they simply seemed a good idea.  Unfortunately, after a screening programme has been launched, there is no way of determining if it is doing any good.  The reason for this includes “lead-time bias”, “length-bias” and “healthy volunteer bias”.  Take screening for Barrett’s dysplasia as an example.  We have done it for decades without a shred of evidence.  The brave “UK BOSS trial”  is turning the clock back and will hopefully provide some evidence in support.  If the benefit of a screening programme is not confirmed (by a prospective randomised trial) before it is launched, sooner or later concerns about expense, lack of benefit or even harm may start to emerge.  Without solid trial evidence gathered before launch, costs may become difficult to justify and the issue of benefit vs. harm impossible to weigh up. Breast cancer screening is a good example. A Danish review (BMJ 2010;340:c124), found that the mortality of breast cancer was falling at a similar rate in both screened and unscreened women. A year later, a retrospective analysis looked at the breast cancer mortality in Europe to compare the timing of the reduction in countries starting screening at different times (BMJ 2011;343;d4411). The authors concluded that screening did not seem to play a direct part in the reduction in breast cancer mortality. Fifteen years ago, the same concerns were put forward regarding screening for early gastric cancer by Tony Axon (Lancet 1998;351:1350-2). Luckily, screening for colorectal cancer has been thoroughly studied.  We all know that a centrally organised, National comprehensive screening programme reduces an individual’s risk of dying from colorectal cancer.  Surprisingly, I did not have a reply at my fingertips when a patient asked me, “OK, I understand that my lifetime risk of dying from bowel cancer is 1:50 but what will my risk be if I now send my poo off for testing ?”  With the UK guaiac FOB kit, presumably the answer is 1:75?   You may be surprised to hear that 25 years ago, my wife got my genes checked out.  This was in a pilot screening trial open to pregnant women searching for the “delta 508 mutation” responsible for most cases of Cystic Fibrosis in the UK.  A month later, we were surprised to hear that she was a carrier.  Subsequently, I tested negative for the delta 508 mutation.  I thought that this was reassuring but the research team was less clear-cut in their assessment;   “We are not sure about the CF mutations which occur in Scandinavians…”, “there are hundreds of mutations which can all cause the disease…”, “you may have some other mutation which will interact with your wife’s mutation…”, The risk of your child being born with cystic fibrosis is probably no greater than 1:300… we hope“. Rapid DNA sequencing using powerful machines has now brought down the time and cost so that a complete map of your DNA can be delivered for less than $1000 and within just a few days.  The problem is that we don’t have the faintest idea of what the data means.  Furthermore, the “epigenetics” of how genes are silenced and switched on, in response to environmental triggers, is also unknown.  Interestingly, the setting of these switches can be transmitted to our children and grandchildren! Perhaps the reason why your wife is afraid of dogs is that her great grandmother was bitten by one? Naturally, enthusiasts are lining themselves up to praise the rapid march of the technology from research bench, to clinical practise and soon the supermarket checkout.  Nobody has paused to consider than having someone’s complete genome sequenced opens a can of worms;   “Did you know that you carry these 20 lethal recessive genes?”  “Another 350 of your genes have been linked to Alzheimer’s, early heart disease or rapidly progressive cancer or psychiatric disease”  “but we think that some of these risk may only be of relevance if you have red hair or eat a lot of bacon or marry the wrong person”, “Sorry but we can’t advice you any further”.  “We should now really screen your partner and your children and your children’s children“. The screenee will suddenly have many legitimate questions;  “Will this data be cross matched with other databases such as the insurance industry, the police or International Research databases – “for the benefit of others?”  Will I have any say in this?  One thing is certain, once your genome has been entered into the “DECIPHER Consortium database” or the “Leiden Open Variation Database” or the “Locus Reference Genomic Collaboration database” (to mention just a few) you will spend your remaining life completing lifestyle forms and replying to upsetting letters asking if you have noticed any chest pains, deterioration in memory, suicidal thoughts or any funny lumps in the last 6 months. Finally, I am resolved not to accept a blood transfusion unless my life depends on it.  This is not because of any religious convictions. My concerns are twofold; first there is evidence from our armed forces that liberal transfusion of wounded on the battlefield leads to worse outcomes. In fact, soldiers who get shot “in theatre” (this is what the military calls the dusty backstreets where wars are nowadays fought) receive just enough fluids to have a detectable radial pulse.  During the helicopter transfer to the nearby field hospital they get their blood analysed by “thromboelastography”, to guide red cell+/-plasma+/-platelet replacement to replenish oxygen carriage and pre-empt coagulopathy.  Within an hour they undergo “Damage Limitation Surgery”. The outcomes are impressive as fewer than 10% of soldiers die from their injuries.  In contrast, patients with a bleeding upper GI lesion are managed with liberal transfusions, not guided by anything (at least not thromboelastography) and the “emergency endoscopy” is carried out sometime in the next 24 hours!  The outcomes are less than impressive in that you are more likely to die from a bleeding ulcer in the suburbs than of a high velocity bullet in Helmand.   Apart from worsening outcomes associated with liberal transfusion, there is also ”Transfusion-related immunomodulation” (TRIM) to consider.  Forty years ago, it was discovered that patients who had previously received a transfusion where far less likely to reject their renal transplant (NEJM 1973;5:253-9).  The reason for this is that donor white cells somehow damage immune systems causing impaired natural killer cell function, decreased phagocytosis and suppression of lymphocyte production and antigen presentation.   This is one of the reasons why transfusion services are trying to remove as many white cells as possible.    Another reason is the outbreak of “new variant Creutzfeld-Jacob disease” (nvCJD) in the UK. To prevent the spread of “prions”, virtually all our endoscopy accessories are now disposable and certain operations such as tonsillectomies are no longer carried out.  In 2004, a study  (Lancet 2004;364:527-9) confirmed that the condition could also be transmitted by blood transfusions.  The UK government has now banned anyone who have received a blood transfusion since January 1980 from donating blood.  Most other countries have gone further and have banned blood donations from anyone who set foot in the UK between 1980 - 1996.  Even sperm donations are banned!   How the mysterious “prion protein” causes our brains to rot is unknown. But it makes me wonder, what other mysterious proteins, currently floating around in seemingly healthy blood donors, remain to be discovered?

Some musings over traditional family values, happiness, consumption and the perils of having children late in life.

In the lead-up to Christmas, I came across a survey which asked people how much their happiness depended on material belongings rather than other things.  The Brits found themselves quite high up in the survey.  Unicef believes that this is the reason why British kids are unhappy .  Their analysis found child well-being in the UK at the bottom of a league of developed nations whilst the Swedes were second to the top.  The Unicef researchers concluded that British parents work all hours to increase family income but are too exhausted and busy to give their children attention.  Naturally, the children themselves would prefer time with their parents to consumer goods.  What can you expect in a country where the average age of having children is 30 (the highest on record until we see next years figures).  The Unicef finding are little wonder as British parents in their late 30’s and 40’s find themselves cash-rich and time-poor. The researchers commented that;  “We were struck by the volume of toys in the UK…”. “Our ethnographers observed boxes and boxes of toys, many of which were broken, and children appearing to 'rediscover' toys which they had even forgotten that they owned. Parents spoke of having to have 'clear-outs' of children's toys in order to make room for new things…”.  “One mother in the UK felt that she had bucked the trend because as she told us, “I don’t buy something for the girls every time I go out”.  It's all about values and the "World Values Survey", has monitored these values for a long time.  Of particular interest is the “Inglehart-Welzel” graph.  In this graph “survival values” are plotted close to the intersection of the X-axis (which places a priority of security over liberty, disapproval of homosexuality, acceptance of repressive, authoritarian regimes, distrust in outsiders etc) and “self-expression values” (acceptance of homosexuality, democracy, trust in outsiders) at the right hand end of the X-axis.  At the Y-axis there are “traditional values” (religiosity, national pride, respect for authority, obedience and marriage) close to the intersect and “secular-rational values" (secularism, cosmopolitan orientation, non-violent protest and individualism) at the top end of the Y-axis.  They concluded that values of a society moves from the bottom left part of the plot towards the top right as peoples sense of security increases and societies move from agricultural to industrial and then to “knowledge societies”.  Interestingly, the advance from bottom left to top right is also mirrored by the empowerment of women and increasing happiness. However, in the above survey it was the Chinese who were the most likely to link material belongings with happiness.  I must admit that this did not surprise me. I recall a conversation I had with a Chinese girl from Singapore.  On asking what she looks for in a man, she answered “the 5 C’s of course – every Singapore girl knows these”.  Innocently, I proposed that these would be;  “Cheerful”, “Colourful”, “Cerebral”, “Charming” and “Clean” (an inspired guess as Singapore is a very clean place).  No, she replied, the Five C’s are: “Credit Card”, “Club Membership”, “Condominium”, “Cash” and “Car !”. These C’s are largely wasted on a Swede as the above survey found that Swedes were the least likely to link material goods with happiness.  This must be why I have little enthusiasm for buying Christmas presents.  Luckily my wife has stepped into the breech and now does all the Christmas Shopping. Unfortunately, she steadfastly refuses to buy her own! Merry Christmas and a Happy New Year to all of you !

Discovering a forgotten letter triggered some ambivalent recollections of different times.

Discovering a forgotten letter triggered some ambivalent recollections of different times, when doctors where seen as omnipotent and patients suffered for it. It is a rare occurrence that I tidy my desk.  There are usually more pressing tasks.  But I couldn’t put it off any longer and after filing away paperwork, one foot deep, I came across a hand written letter from my previous boss, Tony Axon.  Tony gave each of his juniors a nice handwritten letter of support and Best Wishes when he retired after 40 years service.  Tony developed Gastroenterology in Leeds from humble beginnings some 40 years ago.  In those days, gastroenterology, and endoscopy in particular, were not seen as “worthy” medicine.  It didn’t help that medics and surgeons in Leeds were at a war footing, with fisticuffs in the corridors.  In this infertile soil, Tony Axon built a comprehensive gastroenterology firm which included cutting edge technologies such as ERCP.  I wonder if Tony felt any unease over handing over “the keys to the Firm” to his young apprentices. Sadly any feeling of responsibility to “the firm” has now long disappeared from the National Health Service.  Most of our young trainees work a full shift pattern with little sense of being united in the workings of a “firm”.  They understand that they are nothing but small wheels within a larger machine.  In contrast, in my generation, we thought that we were the machine.  Of course, the old system had to change.  I do remember the 110 hours of continuous on call, covering all medical admissions from Friday morning to Monday afternoon.  If you did grab some sleep, the nurses would phone you with the latest urinary outputs or ask if it would be OK to give a couple of paracetamols.   Each ward you covered had “IV’s”, which you had to make up and administer.  The nurses wouldn’t lift a finger as “it was not part of the nursing model of health care provision”. The result was not no IV’s were given on time and “slow intravenous infusions” were 10 second injections. I was surprised to learn that ringing in the ears was not an inevitable side effect of IV Frusemide.  Perhaps it was wrong to tell patients that “you have to choose between hearing and breathing  - you can’t have both!” “See one, Do one and Teach one”, was the way you learnt day-to-day procedures.  And we did EVERYTHING! Urinary catheters, suprapubic catheters, arterial lines, central lines, lumbar punctures, chest drains, liver biopsies, pleural biopsies, temporary pacing, shocking people out of AF, Swan-Ganz measurements, blood gases and chemotherapy.  The ECG machines were particularly challenging.  The leads ended with small suckers and these little buggers would always fall off at the crucial moment.  With skill you could press the start button and then quickly but gently drape both hands over as many of the suckers as possible to keep them in place.
I now realise, that my generation is unique.  The generation before me, had very few practical procedures and doctoring largely involved furrowed brows, a limited number of blood tests and lots of bed rest.  Conversely, the generation after me has delegated the responsibility for procedures to other departments.  Now the liver biopsies are ultrasound guided.  Chest drains are only placed by respiratory physicians.  Pacing is done by cardiologists. But it wasn’t all bad.  I fondly remember the after-wardround coffees when we would laugh and exchange anecdotes.  I remember the story of the vagrant having a VF arrest in A&E.  When the defibrillator shock was administered, all his flies jumped out of his hair, in beautiful synchrony!  I recall the patient who had a VF arrest in the middle of a sentence. He fell back unconscious onto the pillow. Glancing at the cardiac monitor, I gave him a thump in the chest. To my surprise he immediately sat up again and shouted “OUCH - WHAT DID YOU DO THAT FOR!?!”.  Our camaraderie translated into a deep sense of loyalty.  Nobody took any sick leave.  Absence would land colleagues in impossible situations.  If you didn’t come to work, your colleagues would have to pick up twice their normal workload, see twice as many patients in clinics  or the ward round would last 6 hours instead of 3 hours.  Acute medical takes were busy, usually with 20-30 medical admissions.  This was an era when patients were stockpiled on trolleys in A&E and women gave birth in corridors next to heart attacks and acute abdomens. I recall feeling particularly rough in the middle of a Medical Take, I checked my temperature to find it to be 38.7 ⁰C.  I phoned my wife for a moan and ask for her opinion about taking some ampicillin.  “Don’t be an idiot, take a paracetamol and GET ON WITH IT!!!”, was the reply.  What did I expect from a doctor?

Well another successful UEG Week draws to its conclusion

The feedback has been excellent and another milestone has been passed - for the first time in the history of the World, the European Gastroenterology Society meeting has overtaken the DDW meeting in size and scope.  The Postgraduate Course on Saturday and Sunday was very well attended.  I have been told that the format will change a little next year with the afternoons having more, smaller “breakout sessions”. The tandem talks have also been well received.  Preparation is particularly important with these as ideally, the two presenters should liaise closely and try to merge their respective talks into a single coordinated delivery. The new stuff has also been great.  The live feed on the UEG Week is fantastic (first proposed by me in 2010).  There were some teething problems but after “boosters” were put in to allow more internet traffic, the signal has been stable and more people have been able to patch in with their smartphones and tablets.  The ClipCube video clips have been hilarious and a welcome contrast to serious academia.  The Conference App has been good although I am missing a “Right Now” button to show me what is currently going on in the different lecture halls. All the talk of change and improvements in the UEG Week, is in stark contrast to our personal lives were we value stability and status-quo over change.  I recently returned from a meeting abroad to join my wife, (I was a little late), at a party.  Gazing across a large group, she had to be pointed out to me.  Unknown to me, she had changed her hair, got a deep brown (spray) tan and a sharp new light green dress.  She looked great, but the transformation left me a vague feeling of unease.   The simple fact remains that when a woman decides that it’s time for something new, her partner/husband remains part of the old.  She addressed my concerns in her usual direct manner; “Bjorn, imagine that I have three options, boxes if you wish.  Imagine that I really want what is inside one of the boxes but I don’t know which box it is hidden in.  I choose box 1 but then someone shows me that box 2 is empty.   Should I now change my mind and select box 3?  Not sure if there were husbands inside these imaginary boxes, I proposed that she should stick with her first choice.  “Wrong”, she cried, you should change your mind and choose box 3!  The odds that box 3 is correct, is now 2/3 !

I still don’t get it but hopefully this is only true in our Professional Lives !

Voter apathy is well recognised phenomenon. No doubt caused by our pulverisingly boring politicians.

Paradoxically politics should not be boring. It should be about passion!  A passion to change things for the better, for the majority, for the country, or for humankind. 

The reason why you have not heard of “medical meeting apathy” is because I just made the term up. I have seen it creeping in over the last 20 years.  Many past colleagues and research compatriots are nowadays never seen at medical meetings. Perhaps they feel that they can keep up to date by reading journals and looking up the occasional guideline on the BSG website? No doubt, the institutions they work for are happy to keep their noses firmly pressed against the rockface. Furthermore, partners and young children are rarely pleased to see you go away.  How is little John going to get back from Rugby camp on Sunday? Who is going to take young Phillippa back from her dance classes on Tuesday? 

Taking a little “me time”, away from the coalface not only make us better doctors, but also more fulfilled human beings.  Furthermore, a larger membership base makes it more difficult to ignore Gastroenterological issues in Brussels, Whitehall or wherever the corridors of power lie.

So how can we claw back some territory lost to “medical meeting apathy”?  The UEG Week 2013 has several new features attempting to do just this. Naturally, you can still ask questions using your mobile telephone, but you can now also linger after presentations for a more in-depth discussion with speakers.  Daily, round table discussions have also been introduced.  To encourage participation, there is even a free lunch!  Will more tedious topics such as viral hepatitis, be provided with a better lunch?  In addition, there are more “tandem talks”, whereby two presenters thrash out the ins and outs of some topic.  For the Postgraduate Course, I have been paired up with Dieter Hahnloser to debate the “Management of Dysplasia in Colitis”.  We have put something special together. 

Some other controversial topics have been juxtaposed such as Guy Boeckxstaens who argue that refractory GORD is all about the acid pocket, versus Ronnie Fass who believes that it’s all in the brain (does he mean in the mind?).  Fernando Azpiroz talks about functional disorders being part of the lifestyle versus Robin Spiller who believes that it is post-infective. Naively, I am surprised that there is nobody arguing that its usually in the patients head. I guess that its no accident that I am an endoscopist. There is also a session looking into non-invasive monitoring of liver disease (biomarkers vs elastography).  Can’t help to think that we can get all the prognostic information in reply to 3 simple questions: a) Do you have a Job?  b) Do you have a Drivers License? c) Do you have a Wife?  If the patient replies "No" to all 3 questions, the prognosis is grim!

For those poor people left behind, manning the coalface, there is “live streaming” from 2-3 sessions every day. Furthermore, 3 sessions will be recorded and published online by Tuesday 15 October; “Multidisciplinary management of IBD”, “Non-invasive testing and staging in GI and Liver Disease” and the Monday morning Opening Plenary Session. Finally, your friends and colleagues can monitor your social activities on the new Live UEG Social Wall.

By the way, don’t miss an opportunity to see my latest, hot dance moves in the "Wasserwerk" on Sunday evening! 
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