Apply for a UEG Activity Grant to produce an online course

Developing an online course is not as complicated as you may think.

Ever wondered how a UEG star online course is born? Well, with the availability of a UEG Online Course Activity Grant, it could involve a rising ‘Lady Gaga’ (minus the drama) pairing with an expert ‘Bradley Cooper’ (minus the alcohol) to deliver a non-shallow, Oscar-winning performance.
I've been working with the UEG E-Learning team since early 2014 and feel tremendously proud of how much we have grown in terms of producing online courses. Basically, we just love doing them! But more importantly, the number of users enrolling in our (free!) online courses has risen immensely, and the feedback we've been getting is tremendously positive. Now, to expand the number and breadth of online courses available, UEG is offering an Activity Grant to fund the development and publication of high-quality online courses by individuals or societies. Here's why you, as a young gastroenterologist, should apply:
First, UEG's online courses are primarily taken by young GI specialists, so it makes sense that you get involved in their development. We also know that young GIs are great at coming up with the innovative, fresh and out-of-the-box ideas, which are needed to keep our online courses relevant and appealing.
Second, developing an online course is not as complicated as you may think. There are guidelines and criteria that need to be considered, but we have put a lot of effort in trying to make everything clear and simple. So, why not enjoy a 5-minute coffee break and go through the documents? You'll see that all the material is easy to follow and pretty straightforward, and that we have resources available to help you along the way (e.g. access to our art editor and recording studio). Plus, you can always contact the E-Learning team with any questions or for advice—we are here to help throughout the whole process.
So, where to start? Pick a ‘song’ that’s missing from our ‘playlist’ and find your ‘Bradley Cooper’. Indeed, I am sure a lot of you already have a specific topic in mind, something covered by the ESBGH Blue Book that is perhaps underrepresented in UEG’s Education Library, particularly in the form of an online course. Now all you have to do is think of a recognised expert on that topic with whom you would like to work, contact her or him and start the journey! I invite you to check our latest course on Autoimmune Pancreatitis to get a general idea of one possible format. We would love to hear what other ideas you have in mind! 
Please note that the Activity Grant application deadline of April 5th refers only to submission of the application form  (general concept for the course), a summary of planned costs, and CVs of the lead author and co-author(s). So, as you can see, there is really no excuse for not applying! In any case, for further information you should refer to the "Application for support of Online Courses” section on the Activity Grants page. We look forward to receiving your application!

Tough but doable

8 Tips for passing the European Specialty Examination in Gastroenterology and Hepatology

Anthea Pisani is a gastroenterology trainee in Mater Dei Hospital in Malta. She passed the European Specialty Examination in Gastroenterology and Hepatology in April 2018 and gave a talk about “Tough but doable: A personal view on the exam” in the Young GI Lounge at the subsequent UEG Week in Vienna. Her presentation was very much appreciated, so we asked Anthea to share her top tips for passing the exam in the GI Hive.


So, you have decided to sit for the European Specialty Examination in Gastroenterology and Hepatology.  Perhaps this was a voluntary decision on your behalf in order to broaden your horizons, or it may be a mandatory aspect of your training. It may be your first attempt or maybe a re-attempt and you might be at the beginning of your training or at the end of it. Either way, good luck with your preparations. Here are some points to help guide you towards becoming a European board certified Gastroenterologist. 

From bench to the UEG floor

A personal experience from an young gastroenterologist from Egypt and how UEG helped him to achieve his goals.

Mohammed Khorshid, a young gastroenterologist, tells us his personal success story of being invited to give an oral presentation at UEG Week. 

He realised that young GIs all face similar challenges, and explains how attending UEG Week every year and participating in the Young GI Network can help to overcome these. Back home, Mohammed supports his co-workers by sharing the new knowledge and serving as a role model. He encourages his colleagues from all over the world, but especially those from less prosperous countries, to submit their abstracts to UEG Week. All abstracts are peer reviewed and authors will get the chance to present their work, as well as receive abstract related awards and travel grants. 

Follow Mohammed’s example and submit your abstract to UEG Week by April 26, 2019. 
Register for UEG Week and participate in the Young GI Network activities!
Interviewer: Radislav Nakov

UEG Classroom Courses

These educational events are perfect opportunities to increase your GI knowledge.

Radislav Nakov, member of the YTG and the Education Committee explains what’s happening at UEG’s classroom courses and who should attend them.

These educational events are perfect opportunities to increase your GI knowledge but also to expand your professional network.  Find out more about the courses and how to apply. 

Work-life balance: 10 tips from the UEG Week 2018 experience 

A list of Dos and Dont's that came out of the Career Chat. 

Carolina Ciacci is a full Professor of Gastroenterology at University of Salerno (Italy), a member of the UEG Equality & Diversity Taskforce and a mother of two adult children. At UEG Week 2018, she participated in the session “Career Chat: Women as educators” and in the Facebook live chat “How to improve work-life balance for doctors?”. Based on these discussions and her own personal experience she shares her ten tips for work life balance in this edition of the GI Hive. 

The World Economic Forum Gender Gap Report of November 2017 indicated that it would take 100 years to close the gender gap at a world level1. While some academics are working towards closing the education gap, the intent to parity is yet to be translated into action on the representation and voice in other professional areas.
In the medical science field, the increasing number of women has not paralleled so far by a proportionate number of women in the leading positions, nor by a modification of the man-tailored traditional working environment in one more suitable to the modern model of family. It is believed that woman leadership can accelerate the process of women empowerment, via closing the education gap, translating the good intents into action, but mainly by identifying and removing barriers for women to succeed. 
United European Gastroenterology (UEG)’s  global vision is of promoting and providing equal opportunities and to be a place free of discrimination. The vision is supported by the UEG Equality & Diversity Task Force (E&D TF). During UEG Week 2018, the Equality & Diversity Task Force and the Young Talent Group of UEG organized the Career Chat and a Facebook live interview with the aim of supporting young gastroenterologists (GIs) to reach their goals and a satisfying work-life balance. 
Both initiatives were successful, and the discussion aimed to make both senior and young GIs conscious and creative in removing inherent barriers to succeed. It was recognized that the working set in most GI and endoscopy units is still man-modelled. However, young doctors felt the need to set up systems that help them to go through the natural life stage changes while having a satisfying career. The participants (both genders, but in the vast majority woman) expressed their need to find the right track in advancing women and making the workplace more gender-inclusive. 
In the Career Chat, was highlighted that the vast majority of the “leadership” or “career” challenges women GIs are facing are neither career nor profession related. They are emotional, often linked to the sense of guilt of not being a good parent because of the time and efforts spent at work. As a result women, especially mothers, have a sense of failure in achieving good results both at home and at work. The discussion between the senior and young participants of the Career Chat showed that to become successful and fully express their strengths and creativity, professionals independent of gender should strive to have some habits but might also need to give up some of them.

Here is a list of Do's and Dont's that came out of the Career Chat: 

  1. Make a careful analysis of your potential and find out how to empower yourself, both at work and within the family.   
  2. Set up your priorities, short and long-term goals.  Get the skills you need to succeed. Look around, find a spot for you in your working setting, fill up the empty space with expertise and knowledge.  Live up to your potential! 
  3. Choose your family partner carefully. This will help to share your family duties with him/her. Make a written list of each of your tasks. Try to set a routine for chores but know that you both need to be flexible. 
  4. Ask for help! Outsourcing is not a shame. It is hard to be on the same day on call, a mother, and a good housekeeper. Hire all the help you can afford, even if you have to pay a fee. 
  5. Make a careful plan of your expenses, since outsourcing is expensive. In some periods of your life, it is more important to spend less on entertaining and more on babysitting or housekeeping.
  6. Be efficient! Consider reducing commuting by living close to the workplace, or the kindergarten/ school. Find a gym next to your working place and go whenever you can. Check on your smartphone the time you spend on social media. You will be surprised how much time you waste scrolling the screen of your phone (yet it is sane to do that for some time!)
  7. Keep healthy! Eat well, train your body, and get a good night´s sleep. Don’t forget to look after your mind. Have a little quiet time alone. Enjoy small moments of harmony. It is vital to be fit for the daily challenges of your life.   
  8. Learn to say “no”! Saying “no” is difficult; however, you need to protect yourself from unnecessary and unfair demands that will add nothing to your personal growth and career. Be firm and protect your space.
  9. Failure is not an option (Gene Kranz, Apollo 13). Accept the possibility that sometimes in your life your career might slow down temporarily because of family engagements. Use your time at home cleverly; you might find a way to write a review or improve your knowledge in a particular field.  
  10. Do not mix up family and work. When you are at work, focus on what you are doing. Do not make unnecessary phone calls or waste time discussing your family life with your colleagues. Remember also that your colleagues may have supported you when you were on parental leave, so be helpful and available for them, too. On the other hand, if you are at home with your family limit checking your emails, or answering phone calls as much as possible. Multitasking will not work if you are striving for excellence in both fields.    
It seems that there is not a perfect recipe to achieve work-life balance. It will never be 50:50 because the amount of time and efforts to dedicate at work or at the family/social life will vary according to the personal priorities and also the times of life. In conclusion, senior and young GIs agreed with the idea that life as a physician is tough but rewarding. The recommendation is to refuse to give up being a woman and a mother. Life experience will give a woman leverage in being a physician, maybe a better one. Reference:
  1. World Economic Forum. The Global Gender Gap Report 2017

UEG Research Fellowship 

UEG YTG Member Gianluca Ianiro talks about this revolutional UEG grant for researchers.

We spoke with Gianluca Ianiro, a gastroenterologist at Policlinico Universitario A. Gemelli in Rome, and a member of the UEG Young Talent Group (YTG) and UEG Research Committee

Together with the Research Committee and the YTG, Gianluca developed a new UEG grant, the UEG Research Fellowship. In 2019, UEG will award a grant of € 50,000 to a researcher so that they can spend 12 months working with a renowned European principal investigator (PI). 
The Research Fellowship is suitable for clinical or basic researchers from Europe or the Mediterranean area. Those who are in training, have completed their training or PhD within the past 3 years or already have significant research experience are eligible to apply. The Research Fellowship is highly recommended for young researchers who want the opportunity to develop their ideas in a new working environment.
Download the detailed information and criteria, and apply by no later than January 18, 2019.

National young GI sections and the ECYG

Ivana Mikolasevic talks about the European Conference of Young Gastroenterologists

The GI Hive is a brand-new blog from the UEG Young Talent Group (YTG) that covers the most up-to-date information about life, career development, education and opportunities for young gastroenterologist in Europe. Interviews, infographics, WhatsApp conversations and videos with both junior and renowned gastroenterologists will all be published in the GI Hive on a regular basis.

Our latest guest in the GI Hive is Ivana Mikolasevic, a member of the UEG YTG and an associate professor in Rijeka, Croatia. In December 2018, Ivana and a group of young gastroenterologists from the Croatian Young GI section (Tomislav Bokun, Maja Mijić, Sanja Stojsavljević, Nadija Skenderević, Ana Ostojić, Viktor Domislović, Ivan Jakopčić, Petra Puž) are holding the first European Conference of Young Gastroenterologists in Zagreb, Croatia. Ivana is president of the organizing committee and shared a few words with us about the conference and the Croatian Young GI Section.

There are still countries in Europe without a young GI section and the YTG has published a paper on how to start one. Could you tell us how everything started in your country and about the organisation of the Croatian Young GI section and its activities?

We revived the inactive youth section of our national society of gastroenterology in 2013. We first started having meetings during national society meetings/congresses, following the organisation of dedicated sessions for young gastroenterologists when they presented their best scientific work. Then we took over the administration of our society's webpage and gradually the idea of having our own meeting grew. At the beginning of 2017 we organised the first three-day symposium dedicated to members of the youth section: it was a great success and was repeated early this year. To be honest, as we are a rather small community, we were sceptical about having our own meeting, but it eventually appeared to become almost like a necessity and the occasion all young members eagerly awaited—to meet each other and be able to discuss common interests and problems. Our senior colleagues have been extremely supportive of all our activities, so we would suggest that young gastroenterologists start activities for themselves in their own countries without fear, and that they ask for support of any kind from senior colleagues.

How did you decide to organise the first European Conference of Young Gastroenterologists (ECYG)?

So, I talked in front of our small ECYG team—Tomislav Bokun, Maja Mijić, Sanja Stojsavljević, Nadija Skenderević, Ana Ostojić, Viktor Domislović, Ivan Jakopčić, Petra Puž and me. The idea for the conference organisation was born within the Youth Section of the Croatian Society of Gastroenterology, with a desire to stimulate and strengthen international cooperation.  We already have annual meetings of the youth section when we discuss how to improve our education; we hold lectures about specific topics in digestive health and so on. We wanted to do the same thing with this conference but on a European level, because we have all had such good experiences making contact with colleagues from other countries who we met on courses and congresses we have attended during our education. Therefore, we wanted to create something that would be focused on young gastroenterologists and their networking, under the supervision of senior experts established in specific fields of gastroenterology. The idea of gathering together as many young GIs as possible so that we can make new contacts and share experiences made us enthusiastic, although, at first, none of us were probably aware of exactly what we were getting ourselves into. Then, once we put down all the assignments on paper, we rolled up our sleeves and started working.

What can young GIs learn by attending the ECYC?

This is the first conference targeting young gastroenterologist from all over Europe with the purpose of exchanging experience, knowledge and ideas with eminent professors and researchers. The main idea of the conference is for us, young gastroenterologists, to have a chance to present our most challenging clinical cases and discuss them with our peers and acknowledged experts in the field. Furthermore, ECYG gives us the opportunity to present our clinical and scientific work in a poster presentation form. Not only that, during hands-on sessions young delegates will be able to improve their manual skills in abdominal ultrasound, Colour Doppler, elastography and endoscopy. Moreover, this conference will enable us to initiate constructive and productive dialogues and to create a network for future collaboration with colleagues all over Europe. Finally, to enable us to achieve this goal, interaction will be encouraged and stimulated throughout the conference.

What are the most important messages from the conference?

Learn. Connect. Grow. It doesn’t matter if you come from a big or small country, region or hospital—if you try to give the best of yourself, as we, people from a small country, are trying to do by organising this conference, you can succeed in anything. Finally, our wish is that this project stimulates the awareness of young people about the need for teamwork, co-operation and education, both within their own centre and among other centres. Our small team wants to stress the importance of teamwork and collaboration needed in everyday practice to succeed.  Another important point is the apparent need for organising events and programs dedicated to young GIs. This conference is another 'proof of concept' for gathering young GIs in youth GI sections and organising events for them. We believe that every nation should have their own young GI section and all their own meetings, and we also call for close collaboration in organising hopefully future ECYGs. We invite you to view the YTG section of the UEG webpage for more information on activities for young GIs within UEG and to get into contact with the YTG and also Friends of YTG countries around Europe. We also invite you to share your experience about organizing events for young GIs as this could help us to improve the quality of ECYG. Fresh ideas are also warmly welcomed! To improve our knowledge, we have to work together and exchange our ideas, so we can approach complex medical problems from every angle. The future of the field lies with young gastroenterologists, but the knowledge lies with those who are less young. We want to transfer knowledge into the future.

What are your insights for the future of the conference?

Well, we want to do it all over again! Call us crazy, but so far this has been such a great experience and we are sure it will continue this way until and during the conference.  We hope that we will get good feedback and reviews, so we can show that a small country like Croatia can do something big as this when people work together.

Interviewer: Radislav Nakov

GI Hive, a brand new blog by the UEG Young Talent Group

Yasmijn van Herwaarden reveals more about the activities of young GIs within UEG. 

GI Hive is a brand new blog edited by UEG Young Talent Group that combines the most up-to-date information about life, career development, education and opportunities for young GI specialists in Europe. Interviews, infographics, WhatsApp conversations and videos with both junior and renowned specialists will be regularly published in GI Hive.

The first bee in the GI Hive is Yasmijn van Herwaarden – UEG Young Talent Group (YTG) chair. Yasmijn is a resident at the Rijnstate hospital in Arnhem, the Netherlands and tries to finish her PhD thesis at the Radboud university hospital in Nijmegen. She is a 30-year old Sagittarius and loves painting, pilates and plants. 


Yasmijn, could you explain what is exactly Young Talent Group? What are the activities of the young GIs within UEG?

The Young Talent Group (YTG) was formed under the umbrella of the National Societies Committee to make the UEG and especially UEG Week more accessible and attractive for young specialists, residents, PhD students and post-docs working in digestive diseases. 
Within the YTG we are a group of nine from all over Europe who meet twice a year to plan our activities. We have a young representative in all other UEG committees to give the young perspective on all UEG activities. Next to the YTG we try to have a “friend of the YTG” in each national society connected to UEG. These Friends are our ambassadors and inform us on issues and activities from their country and they spread the word about our activities in each country. 
An important part of our activities take place during the UEG Week. We try to help guide first time visitors to the congress with for example the Young GI track in the congress app and the popular mentoring program. 
We try to facilitate informal networking in the young GI lounge were everyone under 40 is welcome for coffee and power outlets during the whole week and by organizing the Let’s Meet event on Sunday night each year. We also organize special sessions for young GI’s, for example this years “How to prepare a presentation” and the “Check your CV” informal meeting in the lounge. 

Among the most popular opportunities provided by YTG are the clinical and research fellowship programmes. Could you share with us a little bit more about them?

These fellowships were started to give young clinicians and researchers an opportunity to visit another European centre. We award € 1250 to spend at least two weeks in one of the participating centers. 
When rating the applications for this fellowship we are looking for young people with a specific plan of what they want to learn from the centre they will be visiting. So if you want to apply please make a good plan of what you want to learn and carefully pick the center you want to visit to match your plan. 
This year we completely changed the research fellowship compared to the previous years. We will be awarding more money, € 50.000, to spend 12 months with a European principal investigator to work on a research project. We want to support new and longer lasting research collaborations with this fellowship. 
You have to propose a plan of what you want to do and choose the principal investigator you want to visit. Of course you can draw inspiration from the list of centers participating in the clinical fellowships.

The YTG published a paper on the needs of young GI sections in UEG Journal. Can you explain what are the needs of young sections belonging to UEG National Societies?

We circulated a questionnaire among our Friends of the Young Talent Group to make an overview of the situation of young GI’s in each country. We learned that in many countries the young GI’s/residents are not organized and represented at a national level. We believe that it is important for young professionals to be represented and actually have a say in decisions that are made about their daily work and their future workplace. 
We are trying to help the young GI’s in different countries to get organized and have a young representative in the National Society. We already have some success stories, for example the newly formed young GI sections in Bulgaria and Spain. 

Why it is important for a young GI to send an abstract to UEG Week? 

For me submitting an abstract as a young researcher was always important because it was the opportunity to visit a conference and travel. I was fortunate that if the abstract was accepted for poster or oral presentation my department would pay for the travel costs and the conference fee. 
I always get new inspiration and also motivation to continue my research after a conference. Even during a poster presentation I have gotten tips from the audience that would make it into the final manuscript. But it is also just a lot of fun to visit another country with colleagues and make new friends. 

How can a young GI get involved with Young Talent Group and what is Young GI Network?

An easy way to stay in touch and hear about all our offers is to like the Young GI Network Facebook page. You can also subscribe to our mailing list and visit the UEG website to hear about the open calls we post. All the calls for the fellowships, other awards and grants and open calls for new positions in the YTG will be posted there. 
Very soon we will start offering a new way to get involved in the UEG: it will become possible to actively apply for our new UEG Talent Pool. From this pool we will actively promote young talents to all the UEG committees. 
The last two years we did a pilot for the talent pool with the Scientific Committee where young researchers could volunteer to chair a UEG Week session together with a senior chair. The reactions from both the junior chairs and the Scientific Committee were very positive seeing this as an excellent opportunity. We will post more information shortly and open the application on the UEG website.

Interviewer: Radislav Nakov

Personalised nutrition - food for thought

Developing tailored eating advice based on individual nutritional needs

‘Personalised nutrition’ represents any attempt to provide tailor-made healthy eating advice based on the nutritional needs of an individual, as dictated by their behaviour, phenotype and/or genotype and their interactions. Increasing evidence has shown the potential for integrating lifestyle habits, physiology, nutraceuticals, the gut microbiome and genetics into nutritional solutions, specific to the needs of each individual, for maintaining health and preventing disease. 

One area that has been gaining attention among both health professionals and the general public is nutrigenomics - the role of nutrients in gene expression. On a molecular level, nutrients work as messengers, transmitting signals that can be translated into changes in gene, protein, and metabolite expression and function, which may ultimately affect health outcomes. By employing molecular tools, nutrigenomics research identifies how nutrients and bioactive food compounds may alter gene expression, ultimately helping us to understand why people respond differently to the same diet and how genes and diet interact and predispose us to disease. 
Advances in nutrigenetics - how genes impact nutrient metabolism - and nutrigenomics do seem to encourage more personalised advice when it comes to food intake and nutritional supplements.1 
We are used to receiving generalized dietary guidelines and specific recommendations on food intake and nutrient supplements, based on age, gender and other requirements (e.g. during pregnancy or times of illness). For instance, many people will - at least intuitively - be familiar with some of the following daily nutritional recommendations for adults2:
  • 200 µg folic acid
  • 40 mg vitamin C
  • No more than 6 g salt
  • At least five portions of a variety of fruit and vegetables
  • No more than 11% of energy from saturated fat
Deficiencies in calcium, potassium, dietary fibre and vitamin D are also generally considered a public health concern.3 Some supplementation can be recommended. For example, folic acid taken during pregnancy to reduce the risk of malformations developing in the brain and spinal cord of the unborn child.  
By using information obtained from whole genome analysis, an individual’s genome can be scanned for polymorphisms (usually referred to as single nucleotide polymorphisms [SNPs]) in genes related to nutrient metabolism and disease development. For example, the methylenetetrahydrofolate reductase gene is associated with folate metabolism. If the common 677C-->T mutation (also known as the A222V mutation) is present in the methylenetetrahydrofolate reductase gene, it can result in an enzyme that has reduced activity. Should a person’s diet be low in folate, the presence of the 677C-->T mutation may lead to an increased risk of elevated homocysteine levels and a further moderate risk of cardiovascular disease.4,5 On a similar note, genetic variation may, at least in part, explain interindividual differences in plasma triacylglycerol concentrations on administration of polyunsatuared fatty acids, such as those found in fish oil,6 and it may also help explain why vitamin D might confer an increased risk of cancer development in some, while decreasing the risk in others.7 
So, is the future of gut (and general) health in personalised nutrition? How can we test it? Evidence-based medicine (EBM) relies on findings from randomized controlled trials to identify whether or not a given treatment or behaviour leads to a certain outcome. We have become used to EBM being critical to medical decision-making. A one-size-fits-all approach may appear inherently incompatible with the concept of personalised nutrition, and challenges arise when agreeing on the extent, quality and interpretation of evidence and consequent implications for dietary recommendations, particularly within the nutrigenomics arena. 
When will nutritional research be ready to be translated into public health action? Will personalized nutrition produce greater behaviour change and gains in health and wellbeing than can be achieved by conventional dietary advice?6 Although lowering the levels of dietary salt and saturated fats has had a positive effect on hypertension and lipid profiles, as demonstrated in clinical trials in healthy populations, limited trial data exist that prove a cause–effect relationship and a consequent reduction in disease by these dietary interventions.6 We also need to keep in mind that genes work together and not in isolation. This means that the presence of one SNP needs to be interpreted in the context of a person’s overall biochemistry, nutrition, and other lifestyle factors, such as activity, sleep and stress.
With advances in genetic testing, public awareness of personal genome testing and its potential is increasing. Companies are now offering affordable genetic testing options directly to the public. While there may be benefits to having your genetic information available, including the potential for personalised nutrition, there are also many risks and limitations that need to be highlighted and considered. These include, but are not limited to, whether there are sufficient regulations imposed on companies who perform genetic testing, interpretation and delivery of genetic information (via guidance of a health professional), ethical and social concerns, and privacy in terms of how DNA information is stored and used. 
Nutrigenomics and nutrigenetics, albeit an exciting area, is still relatively young and has not advanced enough to allow us to develop a diet based on a person’s entire genome–much more work is required before this can happen. Nonetheless, these tools have developed enough to highlight some nutrient–gene (and environment) interactions. So, for now, our advice is to watch this space as the field of personalised nutrition research continues to develop - who knows where we will find ourselves in the years to come!
Before you go, we would also like to guide your attention to the nutrition guidelines that are available in the UEG Standards & Guidelines Repository, including many from ESPEN and ESPGHAN! 
References 
  1. Fenech M, El-Sohemy A, Cahill L, et al. Nutrigenetics and nutrigenomics: Viewpoints on the current status and applications in nutrition research and practice. J Nutrigenet Nutrigenom 2011; 4: 69–89.
  2. Food Standards Agency. Nutrient and food based guidelines for UK institutions. https://www.ptdirect.com/training-design/nutrition/national-nutrition-guidelines-united-kingdom. (2007, revised October 2007, accessed 11 May 2018).
  3. Blumeberg JF, Bailey RL, Sesso HD, et al. The evolving role of multivitamin/multimineral supplement use among adults in the age of personalized nutrition. Nutrients 2018; 10: 248. 
  4. Kohlmeier M, De Caterina R, Ferguson LR, et al. Guide and position of the International Society of Nutrigenetics/Nutrigenomics on personalized nutrition: Part 2 – Ethics, challenges and endeavors of Precision Nutrition. J Nutrigenet Nutrigenom 2016; 9: 28–46.
  5. Liew SC and Gupta ED. Methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism: Epidemiology, metabolism and the associated diseases. Eur J Med Genet 2015; 58: 1–10.
  6. Görman U, Mathers JC, Grimaldi KA, et al. Do we know enough? A scientific and ethical analysis of the basis for genetic-based personalized nutrition. Genes Nutr 2013; 8: 373–381.
  7. Davis CD and Milner JA. Nutrigenomics, vitamin D and cancer prevention. J Nutrigenet Nutrigenom 2011; 4: 1–11.

Alcohol Awareness Month

April is the perfect time to discuss UEG’s actions on alcoholic liver disease.

Last October, on the occasion of UEG Week 2017, we had a chance to sit and talk with Professor Helena Cortez-Pinto, a member of UEG’s Public Affairs Committee and author of the UEG Education article “Mistakes in alcoholic liver disease and how to avoid them.” Now, in the middle of Alcohol Awareness Month, we highlight the main points of our discussion and make the video of the interview available.

During our interview, Helena conveyed the importance of several aspects related to state-of-the-art treatment for patients with alcoholic liver disease (ALD), such as the necessary involvement of multidisciplinary teams to deal with both the physical and psychological sides of the disease. She also touched on the specificities of performing a liver biopsy in ALD patients, as well as some of the alcohol-related issues the UEG Public Affairs Committee is trying to get onto the EU health agenda.

The current, evident disparity between ALD research and its burden, when compared with other liver diseases, was a key point mentioned by Helena during the interview. Supporting this point is evidence from Ramon Bataller and co-authors, who developed an Attention-to-Burden Index (ABI), comparing research activities during 2010–2014 with an estimate of disease burden for the four major liver diseases, namely hepatitis B and C, ALD and nonalcoholic fatty liver disease.1 Surprisingly (or not), they found that the mean research attention for ALD was only 5%, when its overall burden was 50%, highlighting the critical need to increase awareness of ALD in the liver research community. This need was also pointed out by Helena during her interview and is something she is working to convey to Members of the European Parliament, Representatives of the European Commission and Council, as well as other EU stakeholders, as part of her work on UEG’s Public Affairs Committee, which is chaired by Markus Peck-Radosavljevic.

In a related matter, earlier this year the “Alcohol and Digestive Cancers: Time for Change” report was published by UEG EU Affairs, highlighting the alarming scale of alcohol consumption across Europe and its direct and indirect impact on digestive cancers.

More information on the work of the UEG Public Affairs Committee can be found online, along with a copy of the “Mistakes in alcoholic liver disease and how to avoid them” article from Helena and co-author Pedro Marques da Costa and other articles in the “Mistakes in…” series.

We hope you enjoy the interview! Please be sure to let us know what you think, if there are any other issues we should be considering and if there’s anyone else you would like to see us interview in future. References
  1. Ndugga N, et al. Disparities between research attention and burden in liver diseases: implications on uneven advances in pharmacological therapies in Europe and the USA. BMJ Open 2017; 7: e013620.
Further reading
  • Singal AK, et al. ACG Clinical Guideline: Alcoholic Liver Disease. Am J Gastroenterol 2018; 113: 175–194. 
  • Marcellin P and Kutala BK. Liver diseases: A major, neglected global public health problem requiring urgent actions and large-scale screening. Liver Int 2018; 38 (Suppl 1): 2–6.
  • Spence AD, et al. Communication of alcohol and smoking lifestyle advice to the gastroenterological patient. Best Pract Res Clin Gastroenterol 2017; 31: 597–604.
  • Campbell EJ, Lawrence AJ and Perry CJ. New steps for treating alcohol use disorder. Psychopharmacology Epub ahead of print 25 March 2018. DOI: 10.1007/s00213-018-4887-7.

Thank you from UEG E-learning!

We wouldn’t be able to provide high-quality, valued content if not for our contributors.

This month has seen UEG E-learning reach a wonderful landmark, with 3,000 learners actively taking a UEG online course. Added to this are the thousands of pageviews attracted by our Mistakes in… series—more than 38,000 so far this year alone! Given UEG’s aim to enhance the education of young professionals in the field, we’re delighted that our content is being so well used.

Of course, we wouldn’t be in the position to provide such high-quality, valued content were it not for our contributors. Now, therefore, seems an appropriate time to say a big thank you to all our authors for their time, expertise and enthusiasm. Here, you’ll find a few UEG E-learning facts, figures and thoughts that demonstrate just how far the project has come in the past few years (since January 2014). At the end of this blog, you’ll find a list of the UEG E-learning content that’s currently available and the names of all our fantastic contributors. If you haven’t had a chance to look at our content then I recommend looking at the list and visiting the UEG Education website. Thank you, once more, to all our contributors—we truly appreciate your generosity and investment in UEG E-learning and look forward to working with you again in the future! Download the infographic

Alcohol, GI cancer and microbiota

To what extent might alcohol consumption drive or modify the relationship between gut microbiota and GI cancer?

In the ‘European Code Against Cancer', the International Agency for Research on Cancer (IARC) identify 12 ways to reduce the risk of developing cancer, one of which has to do with alcohol consumption.1 Indeed, the Code advises “If you drink alcohol of any type, limit your intake. Not drinking alcohol is better for cancer prevention.” This recommendation is perhaps not surprising given that alcohol has been identified as a cause of at least seven types of cancer, most of which are gastrointestinal (i.e. cancer of the mouth, pharynx, oesophagus, liver, colon and rectum).1

Working with clinical microbiology and microbiome analysis on a daily basis, I’m interested in the use of gut microbiota profiling for predicting human health and disease, including relationships between microbes and cancer. Dysbiosis and predominance of particular gut microbiota communities are thought to be involved in the development of, for example, colorectal cancer (CRC).2–4 But to what extent might alcohol consumption drive or modify such relationships? There may be several answers to this question, and, as exemplified by a recent study, they may not be black and white…5 In their study, Tsuruya et al. investigated the ecophysiological consequences of alcoholism on human gut microbiota.5 Detailing and corroborating the findings of others,6 they found that the gut microbiota of alcoholics were depleted in dominant obligate anaerobes (e.g. Ruminococcus) and enriched in aerotolerant (facultative anaerobic) groups, including Streptococcus and other minor species. That the distribution is skewed towards facultative anaerobes in alcoholics reflects—at least in part—the influence of oxidative stress due to ethanol-induced formation of reactive oxygen species by, for example, gut mucosal cells. The team go on to explain how the different major groups of bacteria metabolize ethanol under different ecological circumstances, which includes the production of acetaldehyde (the carcinogenic metabolite derived from alcohol that is thought to be critical to the development of ethanol-related CRC). While I strongly encourage you to acknowledge the complexity of these intricate relationships, what I find particularly intriguing is the extent to which it is possible to predict gut ecology (e.g. the level of oxidative stress) by microbiota profiling, since this could impact the way we manage and prevent cancers such as CRC. Strong epidemiological data suggest there is a dose–response relationship between alcohol consumption and the risk of CRC.7–10 And when it comes to alcohol (ab)use and the risk of developing and dying from CRC, it might be useful to look not only at the gut bacteria that are present and what they do, but also at those bacteria that are absent. For instance, the diet of individuals who consume excessive amounts of alcohol might favour gut microbiota changes that increase susceptibility to cancer development. Some bacteria produce short-chain fatty acids (SCFAs), which are most likely protective against the development of CRC.4,11 Such bacteria are established in the gut typically in relation to a diet rich in fibre. If the overall diet of alcoholics promotes (e.g. via malnutrition) a reduction in bacteria producing SCFAs, this could indirectly lead to an increased CRC risk. The possible opportunities here are manifold, but I will end by mentioning what I consider the two most important ones. First, microbiota profiling can be used as a noninvasive diagnostic/prognostic marker for various aspects of health and disease; stool analysis might in the future enable us to tell if a patient is an alcoholic, what type of food they eat (if you include profiling of eukaryotic cells in stool as well), and what the likelihood of, for example, CRC is in this patient. Second, microbiota manipulation—through diet, antibiotics, or gut microbiota transplantation—may be used with a view to reducing morbidity and mortality from cancer, not only CRC, but possibly also other types of cancer. References
  1. International Agency for Research on Cancer.  European Code Against Cancer (https://cancer-code-europe.iarc.fr/index.php/en/) [accessed March 21, 2017].
  2. Gagnière J, Raisch J, Veziant J, et al. Gut microbiota imbalance and colorectal cancer. World J Gastroenterol 2016; 22: 501–518.  
  3. Dulal S and Keku TO. Gut microbiome and colorectal adenomas. Cancer J 2014; 20: 225–231. 
  4. Vipperla K and O’Keefe SJ. Diet, microbiota, and dysbiosis: a ‘recipe’ for colorectal cancer. Food Funct 2016; 7: 1731–1740. 
  5. Tsuruya A, Kuwahara A, Saito Y, et al. Ecophysiological consequences of alcoholism on human gut microbiota: implications for ethanol-related pathogenesis of colon cancer. Sci Rep 2016; 6: 27923. 
  6. Mutlu EA, Gillevet PM, Rangwala H, et al. Colonic microbiome is altered in alcoholism. Am J Physiol Gastrointest Liver Physiol 2012; 302: G966–978. 
  7. Bailie L, Loughrey MB and Coleman HG. Lifestyle risk factors for serrated colorectal polyps: a systematic review and meta-analysis. Gastroenterology 2017; 152: 92–104.  
  8. Wang YM, Zhou QY, Zhu JZ, et al. Systematic review with meta-analyses: alcohol consumption and risk of colorectal serrated polyp. Dig Dis Sci 2015; 60: 1889–1902. 
  9. Bagnardi V, Rota M, Botteri E, et al. Alcohol consumption and site-specific cancer risk: a comprehensive dose-response meta-analysis. Br J Cancer 2015; 112: 580–593. 
  10. Cai S, Li Y, Ding Y, et al. Alcohol drinking and the risk of colorectal cancer death: a meta-analysis. Eur J Cancer Prev 2014; 23: 532-539. 
  11. Bultman SJ. Interplay between diet, gut microbiota, epigenetic events, and colorectal cancer. Mol Nutr Food Res 2017; 61. 
P.S. CRC awareness month takes place every March. Visit the Publications section [https://www.ueg.eu/publications/] of the UEG website to view several infographics on CRC, including one on ‘Alcohol and colorectal cancer’, or read the press release ‘Change through concrete policies: the case of EU alcohol policies and subsequent healthcare savings’ to find out more about the mortality attributable to major alcohol-attributable diseases, such as cancer and liver cirrhosis, and the strategy developed by the EU with a view to reducing alcohol-related morbidity and mortality.

Jointly organised by ESDO and ESGE

Early-bird registration for this UEG supported event is open until March 30, 2017.

Advice on Christmas Dinners...

A factual but fun article for the festive period from Mark Fox based on a Q&A session for his local newspaper

Advice on Christmas Dinners and its after effects

 “A factual but fun article for the festive period from Mark Fox based on a Q&A session for his local newspaper. Merry Christmas!”          

Nurse endoscopists

How have nurse endoscopists benefitted endoscopy services?

I remember the incredulity on the faces on my European colleagues 20 years ago when I told them that the UK was to start training nurse endoscopists. They doubted that it was desirable (or even possible!) to train nurses. Of course, by then the American Society for Gastrointestinal Endoscopy (ASGE) had for many years endorsed flexible sigmoidoscopy by ‘nonspecialists,’1,2 but little evidence of their effectiveness had been published.3

Unsurprisingly, it was the relentlessly increasing demand for endoscopy that made the introduction of nurse endoscopists necessary in the UK.  Some 20 years ago, the demand for gastroscopy approached 10 per 1,000 population per year and the demand for colonoscopy was expected to increase from an average of 2.5 to 10 colonoscopies per 1,000 population per year.4 In addition, the implementation of the NHS National Bowel Cancer Screening programme would further inflate the demand for endoscopy. For this reason, a British Society of Gastroenterology (BSG) Working Party5 gave the green light for nurse endoscopy, together with the United Kingdom Central Council (UKCC)6 and the General Medical Council (GMC). However, it was a cautious start because endoscopy was seen as a risky procedure that was associated with a 1:2,000 risk of death.7 The BSG, GMC and UKCC all agreed that nurse endoscopists were only to act as “technicians”. The responsibility for the patient’s management remained with “the supervising doctor” who had to be “immediately available within the hospital” (an oxymoron of course) in the event of complications or to give advice. Now we know that they were wrong and that the “interpretation of findings does not rely on the experience and training of an appropriately qualified doctor.”5 Endoscopy can be taught! Indeed, throughout the UK, nurse endoscopists now work independently, interpreting findings without the immediate supervision of a clinician. The uptake of nurse endoscopy has been steady in the past 20 years. In Leeds we have seven nurse endoscopists who undertake about 22% of our gastroscopies, 27% of our colonoscopies and all of our flexible sigmoidoscopies. ERCP, enteroscopy, EUS and most therapeutic endoscopy procedures that pose a significant risk of complications are carried out by consultants who are increasingly dedicating their time purely to endoscopy. Now we know more about the performance of nurse endoscopists. There is irrefutable evidence that the caecal intubation rate, adenoma detection rate, complication rate and patient satisfaction scores are comparable among nurses and doctors.8–10 In Leeds, the ‘raw’ caecal intubation rate for both our nurse endoscopists and consultants is 92% and the average polyp detection index (total number of polyps found/total number of patients) is also virtually identical (34.5 for nurses and 33.5 for consultants). In view of the reassuring published literature that has become available over the years, I was bemused to read a recent survey from New Zealand in which only 30% of doctors welcomed the introduction of nurse endoscopists.11 A huge majority believed that doctors would always deliver a better quality of endoscopy and that overall costs would spiral out of control if nurses were to be trained in endoscopy. Of course, endoscopy is a valued source of extra income for gastroenterologists in New Zealand, which makes me wonder if this may have had an influence on the outcome of the survey. Nevertheless, the statistics, reassuring as the may be, do not do nurse endoscopists justice. As a lead endoscopist, it is a relief to have a stable workforce that is fully committed to endoscopy. Most of my gastroenterology colleagues rush between ward rounds and outpatient clinics, phoning patients and their relatives in between. They have little time and energy to invest in endoscopy. By contrast, if an endoscopy list needs back filling, one of our nurse endoscopists will take it on. If an endoscopy audit is required, a nurse endoscopist can make the time. If there is an endoscopy-related problem, a nurse endoscopist will be willing to get involved. The truth is that without nurse endoscopists, endoscopy services will not be able to make the quantum leap from ‘Cinderella speciality’ to a core hospital service that is on an equal footing with radiology. My advice to any anxious colleagues who worry about the emergence of the nurse endoscopist is to welcome them, because with their help we can make endoscopy bloom! References 
  1. Maule WF. Screening for colorectal cancer by nurse endoscopist. NEJM 1994; 330(3):183–187. 
  2. DiSario JA and Sanowski RA. Sigmoidoscopy training for nurses and resident physicians. Gastrointest Endosc 1993; 39(1):29–32. 
  3. Committee on Training, Gross GWW, Bozymski EM, et al. Guidelines for training non-specialists in screening flexible sigmoidoscopy. Gastrointest Endosc 2000;51(6):783–785. 
  4. Barrison IG, Bramble MG, Wilkinson M, et al. Provision of endoscopy related services in district general hospitals: BSG Working Party Report 2001.
  5. British Society of Gastroenterology. Report of the British Society of Gastroenterology Working Party—The nurse endoscopist. 1994. 
  6. UKCC. The Scope Of Professional Practice. London UKCC 1992.
  7. Quine MA, Bell GD, McCloy RF, et al. Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods. Gut 1995; 36(3):462–467.
  8. Hui AJ, Lau JY, Lam PPY, et al. Comparison of colonoscopic performance between medical and nurse endoscopists: a non-inferiority randomised controlled study in Asia. Gut 2015; 64(7): 1058–1062. 
  9. Massl R, van Putten PG, Steyerberg EW, et al. Comparing quality, safety, and costs of colonoscopies performed by nurse vs physician trainees. Clin Gastroenterol Hepatol 2014; 12(3): 470–477. 
  10. Schoenfeld P; Lipscomb S; Crook J; et al. Accuracy of polyp detection by gastroenterologists and nurse endoscopists during flexible sigmoidoscopy: a randomized trial. Gastroenterology 1999; 117(2): 312–318. 
  11. Khan MI, Khan R and Owen W. Doctors and the nurse endoscopist issue in New Zealand. NZ Med J 2012; 125(1357): 88–97. 

Early Detection of Pancreatic Cancer—How?

What's the outlook for the development of biomarkers?

World Pancreatic Cancer Day is being held on November 13. It is estimated that 367,000 new cases of pancreatic cancer will be diagnosed worldwide in 2015 and the dismal survival rate means that only 2–10% of patients will be alive 5 years after diagnosis.

Globally, pancreatic cancer is the seventh most common cause of cancer-related death, and while death rates for many cancers are dropping, the death rate for pancreatic cancer is rising in Europe and the United States.1 The mortality of pancreatic cancer may, at least in part, be explained by the fact that early diagnosis is challenging. However, advances in the development of various biomarkers appear to hold promise for future screening of high-risk individuals, which—according to Cancer Research UK—includes patients with hereditary pancreatitis, a high incidence of pancreatic cancer in their family or a family history of at least one person with pancreatic cancer plus a linked cancer syndrome (e.g. a BRCA2 mutation).2 It has been reported that levels of serum cancer antigen 19-9 (CA19-9) are elevated in approximately 80% of patients with pancreatic cancer,3 and CA19-9 has been useful for therapeutic monitoring and early detection of recurrent disease after treatment in patients with known pancreatic cancer.4 However, CA19-9 is not a specific biomarker for pancreatic cancer. Moreover, patients who are negative for Lewis antigen a or b (approximately 10% of patients with pancreatic cancer) are unable to synthesize CA19-9. Although measurement of serum CA 19-9 levels is useful in patients with known pancreatic cancer, the use of this biomarker as a screening tool has yielded disappointing results.4 In addition to genetic alterations, dysregulation of specific epigenetic mechanisms is critical to tumour development. Comparing patients who have pancreatic cancer with healthy individuals and patients with chronic pancreatitis, Schultz et al. described differences in microRNA expression in whole blood with a view to identifying microRNA panels (classifiers) for diagnosing pancreatic cancer.3 microRNAs—non-coding 17–25-nucleotide-long RNAs that regulate gene expression—play important roles in tumour development and metastasis, and several have been described as specific to pancreatic cancer. Schultz and colleagues validated microRNA panels against CA19-9 sero-status and disease, and identified two panels for diagnosing pancreatic cancer using combinations of four and ten microRNAs in whole blood, respectively. The investigators call for further studies that could validate the use of these biomarkers as a screening tool for early-stage pancreatic cancer detection. More on the role of microRNAs in pancreatic tumour growth and progression can be found in a paper by Frampton and colleagues that was published in The Lancet in February 2015.5 Even more recently, in an article in Nature, Melo and colleagues6 suggested the use of a proteoglycan molecule (glypican-1 [GPC1]) anchored in the membrane of extracellular vesicles—exosomes—circulating in the bloodstream as a cancer biomarker. In particular, the team claimed that detection of GPC1+ exosomes in the blood could distinguish patients with early-stage and late-stage pancreatic cancer from patients with benign pancreatic disease and healthy individuals. The assay appeared more reliable than that based on CA19-9 detection. Compared with healthy donors, serum CA19-9 levels were increased in patients with cancer, but CA19-9 levels were also significantly increased in the serum of patients with benign pancreatic disease. Moreover, CA19-9 levels failed to distinguish patients with pancreatic cancer precursor lesions from healthy donors. An expanded interpretation of this important study, including a discussion of semantic issues, can be found in an accompanying News & Views article by Clotilde Théry.7 Apart from microRNAs, epigenetic features such as DNA methylation, satellite repeats and histone modifications might serve as biomarkers for early diagnosis of pancreatic cancer.8 Reviewing genes aberrantly methylated in pancreatic cancer, Henriksen and her team concluded that investigations into hypermethylated markers in cell-free DNA in plasma or serum are still limited by the availability of only a handful of small studies, which lack well-defined control groups, and that no single gene has been identified as a diagnostic marker.9 To read more about the many challenges related to identifying biomarkers for early diagnosis of pancreatic cancer, I recommend looking up a review by Jenkinson and colleagues.10 There are also a couple of interesting sessions from the recently concluded UEG Week 2015 in Barcelona that I’d like to highlight—all are available online. To learn more about ‘liquid biopsies’, including cell-free DNA, exosomes, and circulating tumour cells, you could look up the talk delivered by Aldo Scarpa, “Molecular diagnostics: From tissue biomarkers to liquid biopsies, single genes and panels”, which was part of the session “Pancreatic cancer: Where are we and what is the future?”11 There’s also an update session on therapy, including talks on chemotherapy, surgical resection, preoperative and palliative treatment, and neoadjuvant and adjuvant treatment.12 Finally, I would like to direct your attention to a talk that was given by Jean-Luc van Laethem, entitled “Pancreatic cancer in annual review”.13 Challenges aside, sensitive and specific biomarkers of early pancreatic cancer that can be obtained non-invasively appear critical to reducing the morbidity and mortality associated with pancreatic cancer. As we mark the 2015 World Pancreatic Cancer Day, we should set our hopes on it not being too long until one or more biomarkers prove valid for use in screening. References
  1. http://www.worldpancreaticcancerday.org/about/
  2. http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/pancreatic-cancer/risk-factors#heading-Eightteen
  3. Schultz NA, Dehlendorff C, Jensen BV, et al. MicroRNA biomarkers in whole blood for detection of pancreatic cancer. JAMA 2015; 311: 392–404.
  4. Hidalgo M. Pancreatic cancer. N Eng J Med 2010; 362: 1605–1617. 
  5. Frampton AE, Castellano L, Colombo T. Integrated molecular analysis to investigate the role of microRNAs in pancreatic tumour growth and progression. Lancet 2015; 385 Suppl 1: S37. 
  6. Melo SA, Luecke LB, Kahlert C, et al. Glypican-1 identifies cancer exosomes and detects early pancreatic cancer. Nature 2015; 523: 177–182. 
  7. Théry C. Cancer: Diagnosis by extracellular vesicles. Nature 2015; 523: 161–162. 
  8. Fukushige S, Horii A. Road to early detection of pancreatic cancer: Attempts to utilize epigenetic biomarkers. Cancer Lett 2014; 342: 231–237. 
  9. Henriksen SD, Madsen PH, Krarup H, et al. DNA hypermethylation as a blood-based marker for pancreatic cancer: A literature review. Pancreas 2015; 44: 1036–1045. 
  10. Jenkinson C, Earl J, Ghaneh P, et al. Biomarkers for early diagnosis of pancreatic cancer. Expert Rev Gastroenterol Hepatol 2015; 9: 309—315. 
  11. Pancreatic cancer: Where are we and what is the future? Session at UEG Week 2015. 
  12. Therapy update: Pancreatic cancer Session at UEG Week 2015.
  13. Pancreatic cancer in annual review Presentation by Jean-Luc van Laetham in the Pancreas: What’s new in 2015? Session at UEG Week 2015.

Small things, vast impact: gut microbiota in health & disease

All things microbiota related at UEG Week 2015!

The relevance of manipulating gut microbiota—that is using gut microbiota (e.g. faecal microbiota transplantation [FMT]), components thereof, or diet (including probiotics)—with a view to ameliorating or potentially treating diseases and syndromes is currently subject to intense scrutiny.

The number of conditions that could potentially benefit from gut microbiota manipulation is vast, ranging from autoimmune diseases, such as inflammatory bowel disease (IBD) and multiple sclerosis, to functional bowel diseases (e.g. irritable bowel syndrome [IBS]), antibiotic-induced gut dysbiosis (e.g. recurrent Clostridium difficile infection) and metabolic syndrome. Others include mental health diseases/personality disorders, including anxiety, depression, autism, and schizophrenia. Through my own research, I have discovered that some intestinal microbes are much more common in healthy individuals than in patients with infectious diarrhoea, functional or inflammatory bowel diseases. Just to be clear, I’m not talking about Akkermansia muciniphila or Faecalibacterium prausnitzii, in fact, I’m not even talking about bacteria! I’m referring to a couple of intestinal protists (Blastocystis sp. and Dientamoeba fragilis) that once were thought by many to be gut pathogens. Well, a lot of recent data not only suggest that they are not gut pathogens, but that they also appear to be much more common than previously anticipated. At our lab, we have developed and are currently validating a gut microbiota profiling tool that enables unprecedented and exhaustive interrogation of ribosomal genes from bacteria, yeasts, moulds, and parasites (protists and helminths) in complex samples, such as stool samples. In other words, we will be able to identify all gut colonising/infecting organisms present in a stool sample to at least genus level, and very often to species level. Given my background and interests, I was very pleased to learn that UEG Week 2015 has a specific “Gut Microbiota” pathway. I’m going to adhere to it as much as I can! Not only am I interested in being able to pin down every single organism squatting our guts, I also want to know what they do! You’ll definitely find me in Room E2 at the “From omics to better understanding of pathogenesis” session, which is being chaired by my fellow Web Editor, Rui Castro. Here, Loris Lopetuso will present and compare data on gut microbiota composition (16S NGS data) in patients with IBD, IBS, diverticular disease and healthy controls. If you’re new to research into gut microbiota, you’d do well to attend the talk by Paul O’Toole on “Microbiota: What gastroenterologists should know.” This talk is part of the symposium “Microbiota: Evolving concepts in GI disorders” that takes place in Room F1 on Tuesday 27 October (14:00–15:30). Also in this session, you’ll be able to listen to Patricia Lepage discussing the fundamental issue of causation versus correlation in research into IBD-associated microbiota. Harry Sokol will reveal whether FMT for non-infectious GI diseases is “ready for prime time”, and Gerardo Nardone will deliver a talk with the title, “Microbiota and upper GI diseases: What is the clinical relevance?”  “Brain–gut interactions in health and disease” is the title of a Round Table Discussion taking place in Room E4 on Tuesday 27 October (14:00–15:30). As Peter Andrey Smith says, referring to the gut-brain axis, “…the mechanisms by which gut microbes and the brain might communicate are unclear, but there are several tantalising leads for researchers to follow.” In a recent News Feature in Nature, he provides some examples as to how differences in gut microbiota may lead to differences in brain development and behaviour. Butyrate, one of the short-chain fatty acids apparently produced by gut bacteria in those of us who are not on the FODMAP diet (for more information, see my previous blog), fortifies the blood–brain barrier by tightening connections between cells, hence influencing the basic physiology of the blood–brain barrier. I’m also really looking forward to the “Abstracts on Fire: Gut microbiota in lower GI diseases” session, which will be chaired by Antonio Gasbarrini and Herbert Tilg, and takes place at the UEG Hotspot on Wednesday 28 October (8:30–10:30). This free paper session provides us with no less than 12 talks, focusing on topics such as recurrent C. difficile infection and FMT. Among these, we will be spoiled with two talks from Gianluca Ianiro, who is going to try to convince us that surgery is no longer required in patients with C. difficile infection after FMT performed in an academic tertiary care centre. If you’d like to come and talk to me about gut microbiota in health and disease in general, research communication, or about UEG E-learning, I’ll be at the Young GI Network “Let’s Meet” event on Sunday evening and at the UEG Booth on Monday (13:00–14:00) and Tuesday (15:30–15:45). See you there!

E-learning adventures at UEG Week 2015

Getting ready for a busy few days in Barcelona!

UEG Week 2015 is just around the corner and the UEG E-learning team is getting ready for a busy few days in Barcelona! As well as meeting to plan future UEG Education online courses and content, we’ll be spending time at the UEG Booth and the Young GI Lounge in Hall 8.0 during many of the session breaks on Monday, Tuesday and Wednesday. We’ll also be attending the “Young GI Network—Let’s Meet” reception on Sunday evening. If you’d like to meet the team to find out more about what we do, discuss how we can best serve you and how you might be able to get involved, then please do come and say hello!

Tomer, Rui and Bjorn will also be chairing sessions and, as one of this year’s UEG Rising Stars, Rui will be presenting his work on microRNAs in NASH in Room E1 during the first session on Wednesday morning. The team will also be attending many of the sessions to get their annual updates across the breadth of the field, and below are a few highlights that everyone is looking forward to. Charlie’s choice: As usual there is so much excellent content that the problem will be fitting it all in. I'll certainly be attending the Rising Stars session, highlighting the best of our researchers from Europe and the USA—this is always an inspiring session. I'll also be playing close attention to the IBD free paper sessions. Like Rune, I'm looking forward to attending the microbiota-focused sessions. And for all the rest there is UEG Week Live! Bjorn’s choice: My pick of the sessions would be “Endoscopic management of benign oesophageal strictures.” I am convinced that in treatment-resistant cases a “stricturoplasty”—whereby the stricture is cut with an endoscopic knife—can turn failure into victory. I would like to discuss this option with the presenters! Tomer’s choice: There are many attractive learning options at the upcoming UEG Week, ranging from basic science to practical patient management. I am looking forward to “Introducing the omics: A guide for clinicians” on Monday morning, as part of the Today’s Science; Tomorrow’s Medicine lectures. This field has evolved greatly and I am looking to hear an update on the implications for clinicians.  I am also glad the Postgraduate Teaching Programme has a session dedicated to lower GI bleeding, a topic that applies to our everyday practice. Rui’s choice: I am particularly interested in the hepatobiliary pathway, featuring different session formats on liver cirrhosis and cholestasis. And I always love the Today’s Science; Tomorrow’s Medicine sessions, showing just how much can be achieved from a well-sustained and rational basic-to-translational/clinical research plan. And speaking of research, I am also looking forward to a great panel discussion at the “How to do research?” Hotspot Symposia! Rune’s choice: The impact of the intestinal microbiota on human health and disease is something that never ceases to fascinate me, and of course, I’ll be giving priority to the gut microbiota pathway. I’m especially looking forward to the session chaired by my colleague Mirjana Rajilic-Stojanovic and Giovanni Barbara on evolving microbiota concepts in GI disorders on Tuesday. Here, Paul O'Toole will deliver a talk with the title “Microbiota: What gastroenterologists should know.” Natalie’s choice: I love a bit of controversy, so I’m really looking forward to visiting the UEG Week Hotspot to see some of the new session formats—Abstracts on Fire, Clinical Trials Revisited and Hotspot Symposia—in action! Coming from a basic research background, I’m also particularly interested in the sessions on the ‘omics’ and learning more about what difference they are making to practical patient care and what they might allow us to achieve in the future. Don’t forget to look out for tweets from all of the team (@CharlieMuz, @Bjorn_Rembacken, @Eukaryotes, @RuiCastroHD, @adartom and @nataliewood06) during UEG Week (#uegweek)! Why not join the dialogue and tell us what’s got your attention? And if you like twitter debates then make sure you’re online for the #WeekChat on Sunday with Mark Hull (@mark_tbh; Diet, microbiota and colonic disease) and on Tuesday with Chris Hawkey (@chrishawkey; Updates on stem cell research in gastroenterology). There will also be three Decide on the Spot cases published in the UEG Week News and online during UEG Week (on Saturday, Monday and Tuesday)—the answer and explanation for each case will be posted online the following day. Those of you who view the case online, sign in to myUEG and post a comment or answer in the comments section will qualify for a complimentary UEG Education Power Bank, which is perfect for charging your mobile devices on the go! To receive your UEG Education Power Bank, simply come and show us your post on the laptop at the UEG booth in Hall 8.0. Please note that comments on social media don’t count, participants are entitled to a maximum of one Power Bank and the number of Power Banks available each day is limited! Wishing you all an enjoyable and productive time in Barcelona! 

Time to change a treatment paradigm

Models of care and malnourished patients

In the past 10 years we have seen the expansion of a cadre of gastroenterologists who have a sub-specialty interest in nutrition. As a result, we have seen nutrition rightfully taking centre stage in our hospitals. Indeed, in the UK hospital mealtimes are now ‘protected’ and malnourished patients have their food served on red trays.

Our nutrition experts have more directly been involved in a transformation of the care of patients who have short bowels. This group of patients is a complex mix, in which every patient is different depending on how much small bowel is left, what type of anastomosis was constructed and the underlying disease. Such patients may suffer high morbidity and mortality because the malabsorption of macronutrients, micronutrients, electrolytes and water can result in impaired growth, premature aging, sudden hypotension, renal failure, arrhythmias, fits, infections, liver failure and impaired healing. The increased survival of these desperately ill patients has been achieved by meticulous attention to detail. A tiny shift in a patient’s serum magnesium level triggers an adjustment. As the 2003 AGA review put it: “Vitamin and mineral status should be monitored regularly, and supplementation should be customized for each patient.”1 Of course, it takes a particular type of meticulous doctor to tirelessly manage a patient’s micronutrient intake. I am not sure that I could manage to pay such careful daily attention to every patient’s zinc, copper, magnesium and selenium levels. Luckily, gastroenterologists with a specialist interest in nutrition are self-selected, thorough doctors and their patients with intestinal failure benefit greatly. Most UK hospitals now have a nutrition team, which is headed up by a gastroenterologist with a specialist interest in nutrition. Initially these teams only cared for patients with intestinal failure. Subsequently their remit enlarged to include patients with malabsorption and more recently came to include all those who are malnourished. The most severely malnourished patients in our hospitals are those with anorexia nervosa. The nutrition of these patients is now often looked after by gastroenterologists with an expertise in intestinal failure. Just as intestinal failure is at the sharp end of gastroenterology, anorexia nervosa is at the sharp end of psychiatry. Not only does the condition have the highest mortality rate of any mental illness,2 the management is complicated by a lack of reliably successful treatments. The National Institute for Health and Care Excellence (NICE) has reviewed the therapies available and awarded only “grade C level evidence” for 74 of the 75 therapies for eating disorders.3 As we start to see severely malnourished patients who have eating disorders on our gastroenterology wards, it is becoming apparent that simply focusing on a patient’s nutritional needs does not work. Care may be reduced to a battle of wills in which patients pull out their feeding tubes as quickly as doctors put them back down. Furthermore, in spite of opiates, botox injections, naso-gastric feeding, venting PEGs, gastric pacemakers and parenteral nutrition, many patients remain just as debilitated. Personally, I believe that the key to understanding why many patients with the most severe eating disorders do not seem to be greatly improved by pipes and pills is because we practise the “Medical Model” of care. This model focuses on ‘curing’ patients, whereby ‘cure’ is defined by the absence of symptoms and a return to normal, pre-morbid health.4 Of course, such a model is entirely appropriate for treating reflux oesophagitis, a peptic ulcer or an exacerbation of colitis. However, when managing patients who have functional bowel disease, alcohol addiction or eating disorders this model of care may be less helpful. In all areas of psychiatry, the Medical Model of care is being superseded by the “Recovery Model”. Indeed, the Recovery Model of care has been integrated into public mental health policy in many countries, including Australia, New Zealand, USA, Canada, Ireland and the UK.5 The Recovery Model emphasises the personal experience of recovery, involving hope, rebuilding connections with family, friends and supporting patients in rebuilding a fulfilling life in spite of ongoing illness. In contrast to the Medical Model, this model aims for ‘recovery’, defined as enabling a return of hope, personal responsibility, control and empowerment.6 Supporting patients with functional bowel disease, alcohol addiction and eating disorders on their journey towards recovery involves understanding their agenda, active listening, empathy and the setting of realistic goals in equal partnership with patients and their families. Unfortunately, this model of care is unfamiliar to many gastroenterologists, and perhaps particularly to those with a sub-speciality interest in intestinal failure. For this reason we may have to train a new cadre of gastroenterologists with particular expertise in functional disease. This new gastroenterological subspeciality would protect vulnerable patients against repeated cycles of inappropriate investigations and increasingly invasive interventions and instead focus on supporting them on a road towards recovery and a living a fulfilling life. References
  1. Buchman AL, Scolapio J and Fryer J. AGA technical review on short bowel syndrome and intestinal transplantation. Gastroenterology 2003; 124: 1111–1134. 
  2. Beumont PJ and Touyz SW. What kind of illness is anorexia nervosa? European Child and Adolescent Psychiatry 2003; 12: i20–i24. 
  3. National Institute for Health and Clinical Excellence. Eating disorders. NICE clinical guideline 9. January 2004.
  4. Roberts G and Wolfson P. The rediscovery of recovery: open to all. Advances in Psychiatric Treatment 2004; 10: 37–49.
  5. Andresen R, Oades LG and Caputi P. Psychological Recovery: Beyond Mental Illness. Chichester, UK: Wiley-Blackwell 2011 
  6. Schrank B and Slade M. Recovery in psychiatry. Psychiatric Bulletin 2007; 31: 321–325.
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