搜索结果：The American journal of gastroenterology

1. OVERVIEW The field of pediatric gastroenterology, hepatology, and nutrition (referred to subsequently as pediatric gastroenterology) continues to expand and evolve and is far different from 1999, when the previous guidelines on fellowship training in this field were published (1). Although still a relatively young field, this subspecialty is increasingly recognized and accepted throughout the world (2), albeit with varying degrees of medical resources and access to care. Tremendous medical advances, especially in the fields of genetics, infectious disease, pharmacology, and immunology, have changed our fundamental understanding of pathophysiology, and along with technological innovations, such as wireless imaging technology and intraesophageal impedance monitoring, have affected the way we diagnose and manage disease. At the same time, economic factors have become increasingly important in discussions of health care and graduate medical education (3). With rapidly escalating health care costs, care must be demonstrated to be not only high in quality but also cost-effective. Moreover, in response to pressure from the public to ensure practitioners are competent, accrediting agencies are imposing new and increasingly complex constructs for assessing the competency of our trainees. These factors demand that the training of pediatric gastroenterology fellows be continuously revised and reevaluated. It is not sufficient to focus exclusively on the clinical aspects of training, however. Although the primary mission of fellowship programs is to create competent clinicians, ensuring the health of future generations requires a broader training mission that recognizes that some of our trainees will choose careers as researchers and medical educators. Fellowship training, therefore, must provide individuals with the opportunity to pursue other essential career pathways. The necessity of providing this more inclusive training must be reconciled with evolving lifestyle expectations of trainees (4) and duty hour restrictions (5). In response to these enumerated factors, the Executive Council of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) charged its Training Committee with the task of updating the 1999 fellowship training guidelines. The goals outlined by the Steering Committee were to consider existing guidelines and seek consistency where possible; specifically incorporate the Accreditation Council for Graduate Medical Education (ACGME) competencies; create a framework that would permit consistent updating; reflect the unique aspects of pediatric gastroenterology, including the breadth of the field and unique nature of the patients, especially the changing presentation of disease as children develop; and respond to the practical needs of pediatric gastroenterology program directors. In addition to the original NASGPHAN guidelines, other existing guidelines were reviewed in the preparation of this document. Table 1 provides a list of the primary guidelines and the means to access them. ACGME's Residency Review Committee issues standards for fellowship training in pediatric gastroenterology and updates them every 5 years, with the most recent update in 2009 (6,7). ACGME establishes detailed training program requirements that are not included in these NASPGHAN guidelines. Requirements for training as a pediatric gastroenterologist in Canada are enumerated by the Royal College of Physicians and Surgeons in Canada (RCPSC) (8,9). The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) reviewed training issues and developed a curriculum for fellows in 2002 (2). The task force also reviewed the gastroenterology core curriculum generated by 4 adult gastroenterology societies that was updated in 2007 (10) and the recent guidelines for fellowship training in pediatric cardiology, a subspecialty with similar training issues, including procedure training and advanced training opportunities (11).TABLE 1: Guide to existing guidelinesUnique Characteristics of a Pediatric Gastroenterologist A pediatric gastroenterologist is expected to be an expert in the anatomy and physiology of a large segment of the human body that includes the esophagus, stomach, intestines, liver, biliary tree, and pancreas, as well as the diverse array of acute, subacute, and chronic illnesses that may affect these organs. Trainees must have the ability to analyze and integrate the clinical data, instead of limiting their thought processes to a particular organ or segment of the gastrointestinal (GI) tract. In pediatric gastroenterology, an assessment of growth and nutrition is an especially integral part of any patient's evaluation and care. Diseases of the digestive system can negatively affect the nutritional status of the child; conversely, the nutritional status of the child can profoundly affect the diagnostic evaluation of the patient. In addition, the practitioner must possess exemplary interpersonal and communication skills, because the field of pediatric gastroenterology is truly multidisciplinary and requires routine consultations and collaborations with myriad allied providers, including endoscopy suite and operating room personnel, nurses, dietitians, pharmacists, social workers, surgeons, intensivists, radiologists, pathologists, psychologists, and psychiatrists. Many of the diseases encountered by a pediatric gastroenterologist also are of relevance to other subspecialties, including endocrinology, rheumatology, pulmonology, and metabolism/genetics, necessitating collaborative relationships with these experts. A pediatric gastroenterologist, unlike an adult gastroenterologist, interacts extensively with both the patient and the patient's care provider(s). As such, it is imperative that the care not only be evidence-based and cost-effective but also be delivered in a compassionate manner that respects patients’ families and their cultures. The fiscal aspects of health care, especially in the United States, are undergoing seismic modifications and it is anticipated that events in the next 5 years will be characterized by vastly different reimbursement models and accountability in medicine. A pediatric gastroenterologist will need to be adept at demonstrating added value to health care dollars and strive for continuous quality enhancement of care. Knowledge of the dollar footprint of care will be imperative, especially as the subspecialist will have increasing access to an ever-expanding array of technological tools and diagnostic modalities, including medical genetic and pharmacogenetic testing. Furthermore, it is likely that as medical homes are established, pediatric subspecialists will need to develop new relationships with primary care providers. The other trend affecting fellowship programs is the juxtaposition of personal lifestyle choices and career choices. A subset of pediatric gastroenterologists works part-time for a variety of reasons, including needs for childcare, personal (or family) health issues, or other personal obligations or pursuits. Because these needs affect the training years, programs have increasingly adapted to trainee lifestyle requests. In the early years of this subspecialty, the majority of practitioners entered academic institutions, and this later expanded to private practice options. Presently, graduating trainees also consider hybrid practices in which they have an academic appointment with some role in trainee education, but otherwise maintain an independent practice. In summary, the field of pediatric gastroenterology is undergoing rapid transformation and these updated guidelines aim to address the changes occurring in the training of this subspecialty during the last decade and, more important, to prepare us for the future. Competencies ACGME was established in 1981 with a goal of developing a uniform set of guidelines that could be applied to ensure and improve the quality of resident and fellow education. As part of its Outcome Project, 6 core competencies that could serve as focal points in the development of residency and fellowship training program curricula were identified in 1999 and became part of program requirements in 2002 (12). Similarly, the RCPSC developed a set of core competencies that are an integral part of fellowship training program curricula (Canadian Medical Education Directives for Specialists, or CanMEDS competencies) (13). Although the CanMEDS competencies are not identical to those of the ACGME, their goals are similar (Table 2). Application of these core competencies and implementation of assessment tools by program directors of pediatric gastroenterology fellowship training are required for program certification by the ACGME and the RCPSC. Table 3 indicates how the ACGME competencies are presented in this guideline document.TABLE 2: ACGME and CanMEDS core competenciesTABLE 3: Mapping ACGME competencies to guidelinesThe competency of medical knowledge (CanMEDS Medical Expert and Scholar) requires that fellows demonstrate knowledge of relevant biomedical, clinical, epidemiological, and sociobehavioral sciences and their application to patient care. Areas that are particularly applicable to understanding the clinical manifestations and treatment of GI disease include developmental biology, pharmacology, host/microbial interactions, immunology, and genetics. Fellows should develop an understanding of the pathophysiology underlying the disorders that are encountered in ambulatory and inpatient settings. Medical knowledge should be obtained through didactic conferences, self-directed learning, and in the course of supervised clinical care. Concepts important for training in pediatric gastroenterology are included in the individual content areas. The competency of patient care (CanMEDS Medical Expert and Manager) is directed at ensuring that fellows are able to provide competent and compassionate care to their patients. They must be able to gather appropriate information via the performance of a complete clinical history and comprehensive physical examination, review of medical records, and appraisal of up-to-date scientific They must be able to develop and patient They must be able to diagnostic and and develop the clinical to Fellows also are expected to develop competency in the performance of GI that are essential for the practice of pediatric gastroenterology and should the and of in the evaluation of children with GI of the patient care required for training in pediatric gastroenterology is included in the individual patient content of this document. for training are reviewed in a of this and in more in the of these guidelines. The competency of and (CanMEDS Scholar) in this competency should fellows to develop a set of that will them to and reflect their and as clinicians, and to develop and goals to improve their clinical practice. includes the ability to incorporate by other health care providers, and patients. In addition, this of continuous requires the ability to information technology to their education and an understanding of the and application of evidence-based medicine. Fellows must which information their of patients, a and assessing the a competency also includes the development of that will permit fellows to and other and The competency of interpersonal and communication (CanMEDS more the performance of or Fellows should demonstrate interpersonal such as the ability to be in the of the of the relationships and for and as would to be and the to interpersonal on the needs of different and families Fellows must be able to create and and relationships with patients, to and with as a or of a health care must be able to and In addition, fellows should to the to their and with and other health care providers, both and in the of and are in in a multidisciplinary The competency of (CanMEDS includes training to ensure that fellows will be able to provide compassionate care to their in a manner that is to and is through a patient and on individual and appropriate It should include such as and and knowledge of for and continuous and in with of the health care and also are essential of Fellows should training in to them in complex such as or to provide care for their The content of this include of the application of this competency to disorders encountered in the course of pediatric gastroenterology practice. The competency of practice (CanMEDS and fellows to their clinical in a manner that is of high and cost-effective. requires that fellows different of medical practice and Fellows must that will them to for their and to from throughout the health care of training, the fellow should be able to demonstrate or understanding of the of of a multidisciplinary and how to a multidisciplinary that of complex such as disease or The content of this also include of the application of this competency to disorders encountered in the course of pediatric gastroenterology practice. A of can be to fellow and competencies may be through the application of different Medical knowledge may be with tools such as or competencies are a variety of including patient clinical patient and Although the particular of evaluation may from to it is essential that pediatric gastroenterology fellowship training programs develop a that the of and of to fellows in a manner that is and most likely to to their personal and career development is to the of these and to an At are expert in these A fundamental in assessing trainees on the ACGME competencies is that are to this the of clinical care and knowledge of the development of trainees A to this is the of to and are part of the essential must and to recognized of be and be and in its and of a in pediatric gastroenterology is the medical of the patient. provide a clinical in which to a in of the 6 by In this competency in practice could be in or ability to on a multidisciplinary and the competency in communication in or ability to provide compassionate and to the patient and and that could create a on 1 and the ACGME competencies that could to the on training, would the of a set by of the relevant program directors in the application of ACGME the content of this include the development of that in to appropriate In the guidelines for training in pediatric gastroenterology may be on a of ACGME and the American of a to the competencies and improve the assessment of The and a of developmental for Application of the to subspecialty training must and Training ACGME requirements for subspecialty training in pediatric gastroenterology that the training program should be 3 years in and ensure trainee as by their 6 competencies in the treatment of and with diseases of the GI the pancreas, the and RCPSC guidelines only years of fellowship for certification in pediatric gastroenterology of the enumerated for a training in Canada could an of fellowship or training their the increasing of pediatric gastroenterology practice and the ACGME we that at should be to clinical training in inpatient and ambulatory (Table of clinical training would still permit the fellow to be by training that clinical a clinical the majority of fellowship training in the inpatient that clinical pediatric gastroenterology is an should be to providing a of training in the ambulatory A care opportunity of at should be during the 3 years of the training duty should to the guidelines by ACGME and be of training fellow should increasing for clinical care and demonstrate increasing both in the inpatient and ambulatory during the course of the Fellows also should demonstrate increasing in the performance of routine diagnostic and GI Fellows have career goals that may affect their The of training should trainees with to clinical training, including training in such as and or liver, and the required of clinical a fellow to in such as or of training, to during the could be to this such training could of the pediatric gastroenterology as a or in a clinical practice. training should not with of the on the also should permit fellows are in academic careers to pursue advanced such as a in public health or clinical Trainees in a career in or would training during their fellows and programs should that the to as an requires that at 4 to 5 years of training is to a fellow to as an in or of this career is included as an 1 to years as a trainee or as on and of to training, and the individual needs of trainees. Table 5 of training for pediatric gastroenterologists different career training for different career and are an integral part of the practice of pediatric gastroenterology, and trainees are expected to demonstrate competency in the performance of a array of and such as and are in a of as a of technological in changes in other diagnostic and in the health care it important to guidelines for pediatric gastroenterology training programs that trainees are to in the most core of procedure training will important of the of Trainees must the appropriate and of both diagnostic and program must have for and development of in the performance of procedure on a trainees should maintain a and will the that must be to trainees throughout their training as to their of and they are expectations for their of Trainees are not expected goals should be in how to the of for their of training and the of to competency for procedure are in the endoscopy and procedure guideline for training that trainee not have to in of the but it is important that trainee become with every procedure and its and competency is recognized as a As such, it is recognized that some trainees will competency at a of because of and other factors that will more or to the same of Although that competency is the more appropriate review of the published for of that should be Trainees are expected to in the that they to of At of training, trainees have not in a procedure that they to will by an such as competency an essential of training programs is to ensure that trainee is to relevant which include diagnostic and GI diagnostic and of the endoscopy and and impedance monitoring, and the of the 1999 North American Society for Pediatric and Nutrition training guidelines the 2009 ACGME update from the list to the the including and was by the that some of the are increasingly by These will to affect the training of pediatric gastroenterologists and certification As a guidelines for procedure training will to the of the care of children with and nutritional disorders is the of disease and the development of new diagnostic and In addition, a understanding of the and processes the development and of the GI liver, and is essential to in disease and health during The of these requires the of individuals with training in clinical, and medical education, health and health in the subspecialty of pediatric gastroenterology must the of the field and be to the of new information on clinical care and practice evidence-based medicine. with ACGME and guidelines subspecialty training in pediatric gastroenterology must fellows must training in and in clinical, or or The of of other recognizes the of for the of the field of pediatric in this can be as 4 of academic The of the in original and clinical The of education the development of and assessment tools for the communication of knowledge to and the The of is with diverse such as the of communication technology in in or in patient care. The of application the of knowledge to of individuals and The of by this include clinical and Many are included the of and Trainees need to knowledge in aspects of through a of and in a with appropriate The must during the and throughout the of The requirements for the nature of the and its but it not the of that must be to this the goals established by the at of fellowship training should be to some such as a a at some of will be for of the these of the should be to Trainees must in a core curriculum in The curriculum should be presented in a that through the of diverse modalities, including and The curriculum should provide trainees with the opportunity to an understanding of clinical and of data, collaborative in social human and application of to clinical and evidence-based medicine. The curriculum also should include of and adult learning, curriculum and assessment of Trainees should the to information in and prepare for and of clinical and and complete and for Furthermore, the trainees should develop as of individuals and of in clinical and requirements fellows are to complete a supervised must be to the field of pediatric gastroenterology, hepatology, or with the to prepare trainees to become subspecialists and to to the of in the in the should to the development of to analyze the of gather and analyze new and and from a body of from and and The may include clinical, and medical education, health and health include clinical, and or review of the of health or and curriculum The must be or have and requires and of information or Trainees must and comprehensive knowledge of aspects of their Trainees should practice during the performance of the by the the of and to The is to to a for which trainees are for a of its of an are a a extensively a or complex a and a Fellowship training in is to be in a and Trainees must have the opportunity to and analyze their in conferences, and with other trainees and in a variety of provide an appropriate of the program must include with established in in different of clinical health health and education. Trainees should a to provide during their The is fundamental to the training and must to trainees during the of their The should have an established of in have in a field to pediatric gastroenterology, and be of the opportunities for trainees to for in conferences, and with in the subspecialty of pediatric The must ensure that the and required for the of the are to the fellow and must or and provide trainee is to have a by guidelines The in with the and program is for the of trainees through the of the and for the assessment of a and the of that the guidelines for The as by the is to at 3 individuals the with 1 from the subspecialty of pediatric The program can serve as a and in but or is not a of the The is to on a during the of training, at The is to trainees in the development of a course of to knowledge and those by the core curriculum to ensure of the The will in the of the and of the of the at its The will the program on during the training and the was and to the program and guidelines. Training the of knowledge and some pediatric gastroenterologists have their practices to clinical areas. to practice in these may training to develop the medical knowledge and clinical and technological to At the field of pediatric includes of and guidelines for training in of these were published in As the of pediatric gastroenterology it is likely that new will develop and will The goal of advanced training in pediatric gastroenterology is to provide clinical for subspecialty trainees would be expected in a fellowship training of in which advanced training can be appropriate include but are not to pediatric hepatology, and and and training could be obtained in 1 of 3 the of a of the requirements for clinical training and are during an of fellowship or in the course of practice. The only for advanced training in pediatric gastroenterology is that which for pediatric a of added in this subspecialty requires the of an of fellowship training in pediatric and a examination, by the and the American of Although the original NASPGHAN guidelines requirements for advanced training in other of subspecialty pediatric gastroenterology for advanced fellowship training not and, therefore, for this training were not included in this document. Furthermore, it is that the will be able to the expected of that NASPGHAN consider the requirements for programs that may advanced training in other pediatric and for fellowship training in these areas. of the Areas to the medical knowledge and clinical that trainees must develop to a field have in and detailed of In such have by program directors and of practical The Steering Committee established a of for the development of content areas. the that to be the of the content should be by and In the of medical of relevant is and learning, on a is an essential part of practice and should be goal was to create a that could be updated in response to changes in medical knowledge and practice. a to the ACGME competencies for content was thought to be important to aspects of trainee development that are to both and of practice. The Steering Committee identified of content that the breadth of pediatric gastroenterology in disease, of the GI GI GI and and GI nutritional and of these content were to task and they in to serve on these task The of content the role of the competencies in fellowship The of the content and the of the to the competencies are in Table The last of Table 6 the of the developmental in understanding the field of pediatric of the content The the role of the and especially the task force and for their in the content areas. and in the document. and the NASPGHAN with The also the NASPGHAN reviewed the and

The concept of beneficial microbes was first suggested by Elie Metchnikoff who postulated that lactic acid bacteria offered health benefits capable of promoting longevity. Disorders of the intestinal tract were frequently treated with viable nonpathogenic bacteria to change or replace the intestinal microbiota. The German professor Alfred Nissle isolated a nonpathogenic strain of Escherichia coli from the feces of a First World War soldier who did not develop enterocolitis during a severe outbreak of shigellosis. In Japan, Dr. Minoru Shirota isolated Lacticaseibacillus paracasei strain Shirota to battle diarrheal outbreaks. Today, a search of human clinical trials in PubMed shows that over 1500 trials have been published on probiotics. Although these studies are heterogeneous with regard to the strains and populations included, accumulated evidence supports the view that benefits are measurable across many different outcomes that have been assessed. This article is an update of a previous publication in the Journal of Clinical Gastroenterology,1 and is based on the guideline recently posted on the WGO website. Probiotics are live microorganisms that, when administered in adequate amounts, confer a health benefit on the host.2 Our glossary of terms is based on the definitions proposed by the International Scientific Association of Probiotics and Prebiotics. Lactobacilli, along with species of Bifidobacterium, have historically been common probiotics. In 2020, the genus Lactobacillus underwent a major restructuring to better address the wide diversity of microbes assigned to the genus. Twenty-three new genera were defined, including some with well-studied probiotic species (Table 1). TABLE 1 - New Names for Some Prominent Former Lactobacillus Probiotic Species. Still Included in the Lactobacillus Genus are Lactobacillus acidophilus, L. gasseri, L. crispatus, L. johnsonii, L. helveticus, and L. delbrueckii subsp. bulgaricus (Sometimes Abbreviated as L. bulgaricus). Former name New name Lactobacillus casei Lacticaseibacillus casei Lactobacillus paracasei Lacticaseibacillus paracasei Lactobacillus rhamnosus Lacticaseibacillus rhamnosus Lactobacillus plantarum Lactiplantibacillus plantarum Lactobacillus brevis Levilactobacillus brevis Lactobacillus salivarius Ligilactobacillus salivarius Lactobacillus fermentum Limosilactobacillus fermentum Lactobacillus reuteri Limosilactobacillus reuteri From the International Scientific Association for Probiotics and Prebiotics (ISAPP), “The big breakup of Lactobacillus,” available at https://www.nestlenutrition-institute.org/infographics/big-breakup-lactobacillus. GLOSSARY OF TERMS - Probiotics Live microorganisms that, when administered in adequate amounts, confer a health benefit on the host Prebiotic A selectively fermented ingredient that results in specific changes in the composition and/or activity of the gastrointestinal microbiota, thus conferring benefit(s) upon host health Synbiotics A mixture comprising live microorganisms and substrate(s) selectively utilized by host microorganisms that confers a health benefit on the host. There are 2 types of synbiotic: complementary (mixtures of probiotics and prebiotics) and synergistic (mixtures of live microbes selected to utilize a coadministered substrate for a health effect) Postbiotic A preparation of inanimate microorganisms and/or their components that confers a health benefit on the host The yeast Saccharomyces boulardii and some E. coli and Bacillus species are also used. Newcomers to the probiotic ranks include Clostridium butyricum, recently approved as a novel food in the European Union. Lactic Acid Bacteria, which have been used for the preservation of food by fermentation for thousands of years, may also potentially impart health benefits. However, the term “probiotic” should be reserved for live microbes that have been shown in controlled human studies to impart a health benefit. Fermentation is globally applied in the preservation of a range of raw agricultural materials, such as cereals, roots, tubers, fruit and vegetables, milk, meat, and fish. The prebiotic concept, first proposed by Gibson and Roberfroid in 1995,3 is a more recent one than probiotics. The key aspects of a prebiotic are that it is nondigestible by the host and that it leads to health benefits for the consumer through a positive influence on the resident beneficial microbes. The administration or use of prebiotics or probiotics is intended to influence the gut environment, which is inhabited by trillions of microbes, for the benefit of human health. Both probiotics and prebiotics have been shown to have beneficial effects that extend beyond the gut, but this guideline will focus on gut effects. Prebiotics typically consist of nonstarch polysaccharides and oligosaccharides, although other substances are being studied as candidate prebiotics—such as resistant starch, conjugated linoleic acid, and polyphenols. Most prebiotics are used as food ingredients in foods such as biscuits, cereals, chocolate, spreads, and dairy products. Commonly known prebiotics are: Oligofructose (fructooligosaccharide, FOS) Inulin Galactooligosaccharides (GOSs) Lactulose Breast milk oligosaccharides (human milk oligosaccharides or HMOs) Lactulose is a synthetic disaccharide used as a drug for the treatment of constipation and hepatic encephalopathy. The prebiotic oligofructose is found naturally in many foods, such as wheat, onions, bananas, honey, garlic, and leeks. Oligofructose can also be isolated from chicory root or synthesized enzymatically from sucrose. Fermentation of oligofructose in the colon may result in several physiologic effects, including: Increasing the numbers of bifidobacteria in the colon Increasing calcium absorption Increasing fecal weight Shortening gastrointestinal transit time Lowering blood lipid levels However, the extent to which these physiological effects may be experienced by a consumer varies due to a number of factors, including baseline gut microbiota and diet. It has been hypothesized that the increase in colonic bifidobacteria benefits human health by producing compounds that inhibit potential pathogens, by reducing blood ammonia levels, and by producing vitamins and digestive enzymes. Synbiotics were originally described as appropriate combinations of prebiotics and probiotics. More recently, the concept of synbiotics has evolved to include both complementary and synergistic synbiotics. A complementary synbiotic is defined simply as a mixture of probiotic(s) and prebiotic(s), where the 2 components meet the criteria defined for each, including proper characterization, and are used at a dose shown to provide a health benefit. However, a synergistic synbiotic has been described as a mixture of a live microbe selected to utilize a coadministered substrate, which together leads to a documented health benefit. The components of a synergistic synbiotic do not need to independently meet the criteria for a probiotic or prebiotic (Fig. 1).FIGURE 1: Composition of complementary and synergistic synbiotics. A complementary synbiotic combines a prebiotic and a probiotic, which work independently to elicit one or more health benefits. The prebiotic functions by modulating the resident microbiota to elicit a health benefit. The synergistic synbiotic is composed of a substrate that is utilized by the coadministered live microorganism, enhancing its functionality. Components of synergistic synbiotics work together (not independently) to bring about the resulting health benefits. (Reproduced from Swanson et al4 CC BY 4.0).Genera, Species, and Strains Used as Probiotics A probiotic strain is identified by the genus, species, subspecies (if applicable), and an alphanumeric designation that identifies a specific strain (Table 2). In the scientific community, there is an agreed nomenclature for genus, species, and subspecies names. Strain designations, product names, and trade names are not controlled by the scientific community. According to the guidelines of the World Health Organization (WHO) and Food and Agriculture Organization (FAO; http://www.fao.org/3/a-a0512e.pdf), probiotic manufacturers should deposit their strains in an internationally recognized culture collection. Such will an designation to shows a of strains and the names with TABLE 2 - Used for Probiotic Genus Strain designation International strain designation Strain name Lacticaseibacillus rhamnosus The product name shown in the may be used in some of Food and TABLE - of Probiotic and Prebiotic The and the can be by or in the Probiotics or Prebiotics Probiotics benefits to increase to and increase A both and to food benefits food and for with to an for to inhibit intestinal for with Prebiotics of absorption of host Strain for probiotics are the to probiotic evidence is to benefits as the specific gastrointestinal in this to specific strains or strain combinations of probiotics at the of in a clinical should specific strains to the benefits based on human Some strains will have that may for and However, an concept in the of probiotics is to that some of probiotic activity are different species, or probiotics may in a with regard to their to intestinal or microbiota. the to acid or in the colon may be a benefit by many different probiotic some probiotic benefits may be by different strains of well-studied species of probiotic It is common in the of probiotics for and to include Such an is of the different strains are to be for the benefit being assessed. such should focus on The functions of both probiotics and prebiotics for gastrointestinal are with the microbes that in the human Prebiotics are utilized by beneficial of the community, promoting health. probiotics and host or probiotics and resident microbes a key for the health. 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The microbiota and probiotics with the host in and and of and (Reproduced with from through the have been in many of the A range of product food through available (Table TABLE - of Probiotics of Food or health with for the consumer or health health or with or health or drug to or drug to or or and the bacteria in is specific to The that can be on these types of on in the Most probiotics and prebiotics are as foods or products. of or is to be and are at the health a specific in where the and the of the product for use in is From a scientific of a probiotic product as on the should species with nomenclature with recognized names Strain designation of strain at the of The which should be based on of the physiological of the physiological as by for and The for probiotics was at in to a It is that the probiotic will at an of to by through the of foods, and on the is a Most from is based on strains than product names, which can on the It can be to probiotic strains to specific and not are to this has been in and the by from and to available evidence and The of probiotic on the are not to may not to The that are to probiotic include of of typically by through the of that of and nomenclature used to the genus, species, and and a strain designation for strain in the The dose for probiotics varies on the strain and Although many in the range of some have been shown to be at levels, some subsp. was in the of at the dose of other probiotic is to It is not to a dose that is for the should be based on human studies a health benefit. probiotics are are to during product typically in that at the of the it not the on the manufacturers will the dose at the (not at the time of probiotic strains have the of to during However, evidence of the of that for probiotics. Probiotic on the have been shown in some to to meet the numbers and types of viable microbes in the from manufacturers is Most probiotics in use are from fermented foods or from the microbes a human and have been used in for the of the of in fermented as of the human and the of to their potential is to be by in the species a Most are intended by for the use in with or should be to the strains and with and for these as described in should meet the of as by et or use of isolated probiotics or known probiotics for new are and by an with food are for as of foods and for the and at levels used. the clinical for probiotics or prebiotics in are It should be that the a of clinical However, the effects of probiotics are and and for the effects are based on the specific for different on the of levels of and should be are as the of evidence for clinical However, to clinical trials with probiotics is with due to the of the of the probiotic the of the populations and the numbers in clinical Such can on but the of effects to be with on probiotics. on different probiotic strains a that of are the effects should be when the results to this with an of probiotic in clinical and probiotic and clinical in which have been found of Some probiotic strains are in reducing the and of in administration the of diarrheal in by of controlled clinical trials other probiotic strains have been published that that probiotics are to be and of In the of and there is evidence that probiotics can be in some specific A based on trials with a of that probiotics or with or administration of probiotics may be of In the of there is evidence of in or who are that probiotics may provide a for in and of A with that probiotics are in in Probiotic use in who are not or to be The also the need for but that the that who are at of benefit from being of the potential benefits and of probiotics. of The gut microbiota may an in by intestinal and intestinal A that probiotics may be beneficial in the and in the treatment of The on the of that probiotics have been shown to be in reducing gastrointestinal effects by and thus have a beneficial on the However, the of the evidence was and the of was There is evidence to the concept that a probiotic be probiotics to increase the by reducing effects to than through effects on and Prebiotics such as are used for the and treatment of hepatic encephalopathy. for 1 probiotic mixture that it can hepatic encephalopathy. A found that evidence from studies on the benefits of probiotics for with hepatic was of Although in the was the that probiotics may of and ammonia There is evidence that several probiotic strains and the prebiotic oligofructose are in the of has been in studies at in in and in studies that to There is evidence for the of a probiotic in an of and in the of with The probiotic is for and with of activity or as for in studies that probiotics may be and as as in and in to in both and However, a that evidence for the of in to was of and there was evidence that probiotics were in more severe of probiotics in have that there is evidence to that are beneficial for the or of of A in and as a result of probiotic is a in published some strains may and provide The that probiotics may and the of in with effects of probiotics on are shown in and L. reuteri and have been shown to time in with (Table and Lactobacillus delbrueckii subsp. bulgaricus and to This was in a number of controlled studies with with live Probiotic the of enterocolitis in of controlled trials have also shown a of in although not probiotic are The number to to 1 from by treatment with probiotics is to adequate in the probiotic product is for this of There was for of the and but was on severe The of probiotics as a treatment to has been through a number of clinical trials in and Probiotics in the outcomes of blood and and studies are to benefits. of There is evidence to the use of probiotics or synbiotics in in Although it is beyond the of this it may be of to to that probiotics and prebiotics have been shown to several clinical outcomes that are the of gastrointestinal evidence that gut microbiota may several a these and the gastrointestinal studies have shown that probiotics can in and and the and of common tract The benefit of probiotics during the in has to a World Organization on probiotic use during and in with a of Probiotics and prebiotics are also being for the of some of the including 2 and of for Probiotics and Prebiotics in and have the evidence for gastrointestinal the criteria used to the of TABLE - of in for in to the this from The of for A of trials trials with by a controlled or historically controlled may be on the of and not the of or the is The may be there is a or is to provide evidence than an The of of for and a number of gastrointestinal for which there is evidence from at 1 clinical that administration of a specific probiotic strain or a prebiotic is The of these is to the about the of studies that the and of the as some other on in the may not have been The the recent from major such as the European for and and the TABLE - of Probiotics and/or Prebiotics in Probiotic strain dose and treatment of Lactobacillus rhamnosus of probiotic of of in the Lactobacillus reuteri and L. reuteri 1 of of of in Lactobacillus rhamnosus L. and 1 a of of in of in Lactobacillus paracasei or L. rhamnosus Saccharomyces boulardii or with L. casei L. bulgaricus and 2 of in Lactobacillus and L. casei 2 of in clinical and Lactobacillus rhamnosus 1 of in clinical and Saccharomyces boulardii or 1 of in clinical and Lactobacillus reuteri of in Lactobacillus L. paracasei of in Lactobacillus and L. paracasei L. plantarum L. rhamnosus and L. salivarius of the of in Lactobacillus rhamnosus L. and subsp. and of in Lactobacillus acidophilus, Lactobacillus Lactobacillus and Lactobacillus delbrueckii subspecies and and salivarius subsp. of in of Clostridium of Lactobacillus and L. casei 2 with L. casei and L. bulgaricus and Saccharomyces boulardii or 2 Lactobacillus L. paracasei Lactobacillus 2 Oligofructose of for Lactobacillus rhamnosus 2 and treatment subsp. Lactobacillus rhamnosus 2 and treatment Lactobacillus reuteri and L. reuteri 1 of 2 and treatment Saccharomyces boulardii or 2 in effects and Bacillus 2 2 in effects and of with strains of Lactobacillus L. L. acidophilus, L. delbrueckii subsp. and salivarius subsp. on for Lactobacillus 2 on for Lactobacillus and on for Lactobacillus subsp. on for of with and Lactobacillus in with Bacillus was more than in reducing strains of Lactobacillus L. L. acidophilus, L. delbrueckii subsp. and salivarius subsp. of of in Lactulose 1 of hepatic and from hepatic strains of L. L. L. acidophilus, L. delbrueckii subsp. and salivarius subsp. of hepatic strains of Lactobacillus L. L. acidophilus, L. delbrueckii subsp. and salivarius subsp. hepatic with Lactobacillus L. acidophilus, bifidobacteria and L. casei hepatic Lactobacillus hepatic Lactobacillus plantarum a of hepatic Lactobacillus bulgaricus and with L. and in Lactobacillus L. L. acidophilus, and L. 2 in along with and of in and activity Lactobacillus paracasei L. plantarum L. and L. delbrueckii subsp. bulgaricus and in and activity with subsp. and in in and 1 2 in and also Lactobacillus plantarum 1 2 in of and Escherichia coli on of Lactobacillus rhamnosus L. plantarum L. and in in and Lactobacillus subsp. L. L. delbrueckii subsp. bulgaricus on of Saccharomyces boulardii 2 in 1 2 in of in fermented milk and Lactobacillus in in Lactobacillus 2 on of Lactobacillus rhamnosus L. rhamnosus 2 in of on of Galactooligosaccharides 2 on of Lactobacillus plantarum L. plantarum or in strains of Lactobacillus L. L. acidophilus, L. delbrueckii subsp. and salivarius subsp. of 1 of and of in Bacillus 2 in and in Lactobacillus and L. reuteri on of in Lactobacillus rhamnosus L. plantarum and subsp. on of in Saccharomyces of in and Bacillus Lactobacillus L. delbrueckii bulgaricus L. casei L. plantarum L. rhamnosus L. L. salivarius and 2 of in with Lactobacillus 1 of 1 of Lactobacillus and L. subsp. of and Lactobacillus casei L. plantarum subsp. of in on the of in on the constipation Lactobacillus L. rhamnosus and of and in Lactobacillus reuteri 1 2 of and Lactulose 1 Prebiotics are used as Oligofructose 1 of by and Lactobacillus paracasei L. rhamnosus L. and in and strains Lactobacillus acidophilus, and 1 of colonic transit and in with constipation subsp. subsp. 1 or 1 in in with than Lactulose Bacillus 2 to the time to constipation as to Lactobacillus L. casei L. and with and colonic transit time in with constipation Lactobacillus casei strain Shirota in fermented milk of or in the Lactobacillus casei subsp. 2 in in Lactobacillus paracasei in in Lactobacillus salivarius L. The probiotic in with the and more than treatment Lactobacillus reuteri 1 and with and in of Lactobacillus plantarum L. and dose of of Lactobacillus L. rhamnosus L. paracasei and of due to Lactobacillus casei strain Shirota in fermented milk the of Lactobacillus in fermented milk of the of the of strains of Lactobacillus L. L. acidophilus, L. delbrueckii subsp. and salivarius subsp. bacteria 2 of strains of Lactobacillus L. L. acidophilus, L. delbrueckii subsp. and salivarius subsp. bacteria 2 of clinical in strains of Lactobacillus L. L. acidophilus, L. delbrueckii subsp. and salivarius subsp. bacteria 2 of in Clostridium of in strains of Lactobacillus L. L. acidophilus, L. delbrueckii subsp. and salivarius subsp. bacteria of Escherichia coli Nissle viable bacteria 2 2 of viable Lactobacillus acidophilus, and 2 in the clinical to with with live of Lactobacillus delbrueckii subsp. bulgaricus and of strain of product 1 Lactobacillus 1 and Lactobacillus rhamnosus 1 Lactobacillus plantarum L. plantarum of of with with of TABLE - of Probiotics and/or Prebiotics in Probiotic strain dose Probiotics as a 1 the of the of on an including in L. rhamnosus for 1 of of and for 1 of L. reuteri 1 to for 1 of L. rhamnosus L. reuteri 2 for for 1 of for of L. paracasei and for of L. rhamnosus strains or for of but not of of L. delbrueckii L. acidophilus, for of L. rhamnosus and L. a for the of of and of Probiotics as a 1 of for the of treatment 1 of and L. rhamnosus for the of treatment 1 of and probiotic Lactobacillus Lactobacillus Lacticaseibacillus paracasei plantarum Lacticaseibacillus rhamnosus and Ligilactobacillus salivarius for the of treatment and for of but not The of L. rhamnosus and 2 for the of treatment of of 1 and of of L. rhamnosus for the of the 1 of of enterocolitis and of 1 Some specific strains of probiotic may be for L. rhamnosus From 1 to 1 and and to 1 and subsp. or L. reuteri or 1 1 this strain is by but not or subsp. L. with milk subsp. L. rhamnosus and Probiotics as a 1 and/or effects of treatment 1 it was the of and in reducing gastrointestinal effects with Lactobacillus plantarum subsp. and boulardii L. plantarum L. and boulardii for and effects milk L. casei for Probiotics as a 1 L. reuteri for at 1 and/or time in but its in is for 2 and/or time in with L. rhamnosus and L. reuteri in a dose of of of for and/or time in L. paracasei L. plantarum L. L. delbrueckii subsp. bulgaricus and and for in L. reuteri to for 1 time in both and 1 evidence for the use of probiotics a in with L. reuteri to 2 1 L. rhamnosus to 1 Probiotics as a 1 clinical in with A mixture of strains paracasei L. plantarum L. L. delbrueckii subsp. bulgaricus and as or in to 1 2 and of Escherichia coli Nissle or in to and is available for and of A mixture of strains paracasei L. plantarum L. L. delbrueckii subsp. bulgaricus and 1 2 in with and Lactobacillus in with other strains of or Lactobacillus may be beneficial for levels of and lipid and in with However, evidence not of the beneficial strain of probiotic 1 studies with the strain boulardii European and European for and not controlled and probiotics to be described by genus, species, and strain in studies the benefit. the strain was not the strain designation was not positive studies studies results for its were studies were not studies in which the results for the were not a of the probiotic strains or prebiotics found to have a beneficial is clinical evidence to a specific probiotic strain and/or prebiotic is should be the of the of the The of in the trials was not assessed. The may not be as the publication of new studies is other probiotics and/or prebiotics in controlled trials may be The of evidence may the different shown are used in the The of the is There is evidence from studies to the in terms of The do not provide of but levels of evidence to

Journal of Palliative MedicineVol. 3, No. 1 Innovations in End-of-Life CareTaking a Spiritual History Allows Clinicians to Understand Patients More FullyDr. Christina Puchalski and Anna L. RomerDr. Christina Puchalski and Anna L. RomerPublished Online:19 Apr 2005https://doi.org/10.1089/jpm.2000.3.129AboutSectionsPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byVerbalizing spiritual needs in palliative care: a qualitative interview study on verbal and non-verbal communication in two Danish hospices4 January 2022 | BMC Palliative Care, Vol. 21, No. 1Implementation of an Educational Toolkit to Increase Nurse Competence in Spirituality and Spiritual Care of Oncology Patients8 November 2022 | Journal of Holistic Nursing, Vol. 5Posicionamento sobre a Saúde Cardiovascular nas Mulheres – 2022Arquivos Brasileiros de Cardiologia, Vol. 119, No. 5Experiences of German health care professionals with spiritual history taking in primary care: a mixed-methods process evaluation of the HoPES3 intervention15 October 2022 | Family Practice, Vol. 29Religious and spiritual journeys of LGBT older adults in rural Southern Appalachia25 October 2021 | Journal of Religion, Spirituality & Aging, Vol. 34, No. 4The CASH assessment tool: A window into existential suffering19 May 2021 | Journal of Health Care Chaplaincy, Vol. 28, No. 4Integrating religion/spirituality into professional social work practice27 July 2022 | Journal of Religion & Spirituality in Social Work: Social Thought, Vol. 41, No. 4The Concept of Spirituality in the Health Sector: Contributions from the Study of Religion27 September 2022 | International Journal of Latin American Religions, Vol. 12Systematic review: The relationship between religion, spirituality and mental health in adolescents who identify as transgender13 September 2022 | Journal of Gay & Lesbian Mental Health, Vol. 26„Des Lebens Ruf an uns wird niemals enden“ – Sinnzentrierte Interventionen im Überblick30 August 2022 | Zeitschrift für Palliativmedizin, Vol. 23, No. 05Case discussion: The critically ill older adult in spiritual distressGeriatric Nursing, Vol. 47Australian Patient Preferences for the Introduction of Spirituality into their Healthcare Journey: A Mixed Methods Study3 August 2022 | Journal of Religion and Health, Vol. 27Religion, Spirituality, and Ethics in Psychiatric Practice30 March 2022 | Journal of Nervous & Mental Disease, Vol. 210, No. 8Spiritual distress in dialysis: A case report21 July 2022 | Progress in Palliative Care, Vol. 211Interprofessional communication training to address spiritual aspects of cancer care19 July 2022 | Journal of Health Care Chaplaincy, Vol. 29Spirituality in Serious Illness and HealthJAMA, Vol. 328, No. 2What is the role of spiritual care specialists in teaching generalist spiritual care? 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Psikoterapilerdeki Dini İzler15 December 2018 | Cumhuriyet İlahiyat Dergisi, Vol. 22, No. 3Women's Perceptions of Using Short Films to Integrate Spirituality in TherapyJournal of Systemic Therapies, Vol. 37, No. 4Content Validation of Advanced Illness Criteria of a Palliative Care Screening Tool Lauren C. DiLello, Karen Mulvihill, Jennifer Delli Carpini, Riddhi Shah, Julia Hermanowski, and Damanjeet Chaubey29 October 2018 | Journal of Palliative Medicine, Vol. 21, No. 11Understanding, assessing, and in the spiritual of medical and October 2018 | Theology, Vol. 11, No. and of in Living with October 2018 | Journal of & Social Services, Vol. No. for the spirituality as October 2018 | Revista de Vol. 71, No. An of an aged psychiatry March 2018 | Psychiatry, Vol. 26, No. de de vida de de Vol. 25, No. support and with in Care in the Care A Narrative June | Journal of Care Medicine, Vol. No. Care in Cancer: in the of of Clinical Oncology Educational Vol. 3, No. religion/spirituality in clinical practice: A among social and and October | Journal of Clinical Psychology, Vol. 74, No. Spirituality in Care December | Journal of Religion and Health, Vol. 57, No. of to spiritual care at the of a phenomenological exploration from the of palliative care February 2018 | Journal for the Study of Spirituality, Vol. 8, No. Existential Distress in Pediatric Cancer December and Patient Spiritual in the through October of Spirituality in November Psychological/Psychiatric, Social, and Spiritual Problems and July and End-of-Life Care in Cancer in Oncology Nursing, Vol. No. Care in Hospice and Palliative Journal of Hospice and Palliative Care, Vol. 20, No. and Spirituality: Literature review and Journal of Counseling, Vol. 18, No. of the tool existential communication between and cancer August | European Journal of General Practice, Vol. 23, No. Education and of Christian Nursing, Vol. 34, No. Care Interventions in to and Therapy C. and D. September | Journal of Palliative Medicine, Vol. 20, No. in Patients with A Qualitative September | Journal of Research in Nursing and Vol. 14, No. theory on the and in an exploratory case study September | Vol. 69, No. of the of Spirituality and Palliative Care Research and of Pain and Symptom Management, Vol. No. of a spiritual care training program for staff on November | Palliative and Supportive Care, Vol. 15, No. 4Spiritual distress and spiritual care in advanced heart July | Reviews, Vol. and Spiritual Patient Simulation in Nursing, Vol. No. Vol. 42, No. 4The impact of a spiritual in patients with and and their support December | Vol. 26, No. 3The Importance of a Spiritual History in Healthcare Vol. No. About Substance Use DisordersJournal of Psychosocial Nursing and Mental Health Services, Vol. No. and Spiritual Beliefs of April | Journal of Religion and Health, Vol. No. Care Perceptions of and With of Hospice & Palliative Nursing, Vol. 19, No. in Substance Use What to Know to Practice30 November | in Mental Health Nursing, Vol. 38, No. End-of-Life Care to Religious and Vol. No. of Social Education, Vol. 53, No. Nursing Care and of Christian Nursing, Vol. 34, No. 1The of taking a religious and spiritual July | Psychiatry, Vol. 24, No. religion and spirituality in Vol. No. the role of religious in the at the of of Vol. No. care spiritual March | Supportive Care in Cancer, Vol. 24, No. Spiritual Care and the Role of An Review of Literature and April | Journal of Religion and Health, Vol. No. of the Spiritual Needs of of with Is in the June | Journal of Palliative Medicine, Vol. 19, No. Impact of a Tool for Comprehensive Assessment of Palliative Care on Assessment at and of Pain and Symptom Management, Vol. No. from Healthcare Students to Understand Spiritual Assessment in Clinical Practice29 October | Journal of Religion and Health, Vol. No. Spirituality in January | Journal of Religion and Health, Vol. No. 3Development and of to Assess Nurse Provision of Spiritual August 2014 | Journal of Holistic Nursing, Vol. 34, No. and Validation of the Practice Assessment September 2014 | Research on Social Practice, Vol. 26, No. and the Medical A of July | Journal of Health Care Chaplaincy, Vol. 22, No. history taking in palliative care: A controlled September | Palliative Medicine, Vol. 30, No. Is Is Using A and the Life With American in Spiritual March | Journal of in Mental Health, Vol. 11, No. and spiritual in September | International Journal of and Mental Health, Vol. No. 1The of Hospital to and Patients’ Spiritual A May | Journal for the Study of Spirituality, Vol. No. 1The and to March End-of-Life Spiritual March in Holistic Patient Journal of Nursing, Vol. No. of spiritual assessment for older September 2014 | and Vol. No. und der der Care, Vol. No. Spirituality and A for Holistic January | Journal of Religion and Health, Vol. No. and Belief, in Care spiritual history tool by C. M. Puchalski as an for an interdisciplinary in January | Journal for of and Social Vol. 21, No. the of Spiritual A Pain and Palliative Care Service Quality of Pain and Symptom Management, Vol. No. of Spiritual Assessment in September | Vol. No. the of Christian Nursing, Vol. 32, No. 4Spiritual care: is the assessment tool for palliative Journal of Palliative Nursing, Vol. 21, No. und Spiritualität in der September | Vol. 60, No. of September of spirituality assessment in palliative care patients in November 2014 | Progress in Palliative Care, Vol. 23, No. 4The for Spiritual A Mixed-Methods July | Oncology Nursing Vol. 42, No. 4The Integration of Religion and Spirituality in Social Practice: A May | Social Vol. 60, No. 3The and Educational of a Spiritual Life Review for Patients with and June 2014 | Journal of Cancer Education, Vol. 30, No. in Geriatric Palliative in Geriatric Medicine, Vol. No. An for Spiritual Well-Being May | Journal of Religion & Spirituality in Social Work: Social Thought, Vol. 34, No. Spiritual Assessment March | Journal of Health Care Chaplaincy, Vol. 21, No. American on Mental Health, and Help April | and Vol. 60, No. of Christian Nursing, Vol. 32, No. the Spiritual Needs and of Oncology Patients in Nursing Practice, Vol. 29, No. Care Training to Healthcare Professionals: A Systematic April | Journal of Pastoral Care & Counseling: Advancing theory and professional practice through scholarly and reflective publications, Vol. 69, No. analysis of spiritual

Thirty years ago, responding to the growing interest, rapid expansion, and increase in research in pediatric gastroenterology and nutrition, we established the Journal of Pediatric Gastroenterology and Nutrition (JPGN). The editorial of the first edition began, quo vadis? (1). Thirty years later, we are asking the same question. What should the vision of JPGN be? It seems mandatory to provide the pediatric gastroenterologist with research and knowledge of gastrointestinal ontogenic function and malfunction during early life. It was hoped that the Journal would serve as an intellectual stimulus and an international forum for the presentation and discussion of advances and controversies within the discipline. The findings of differential timing of the expression of the genes controlling various small intestinal disaccharidases, pancreatic exocrine enzymes, and so on, led to a new practical paradigm on gut development (2). The paradigm included interaction of genetic endowment, gene expression, intrinsic biological clocks, endogenous regulatory mechanisms of the hypothalamic-hypophysial-thyroid-adrenal axis, gastrointestinal receptors and mediators, and environmental influences. The environmental influences affecting gut ontogeny included intrauterine growth retardation and malnutrition early in life (2). Barker (3) hypothesized that the effect of intrauterine growth retardation increases the risk of later-onset disease, particularly cardiovascular disease, hypertension, and type 2 diabetes mellitus in adults (3). The ontogeny of gut enzymes in early infancy and the recognition of pancreatic amylase deficiency and the early appearance of intestinal α-glucosidases and salivary amylase led to another ontogenic paradigm of alternate pathways of digestion and absorption in early infancy. The pragmatic outcome of ontogenic research was to use α-glucosides, such as sucrose, maltose, maltodextrins, and short polymers of glucose, during the neonatal period and for the compromised infant. Studies focused on the investigation and clinical applications of gastrointestinal ontogeny exemplify the early emphasis of JPGN. The potential for new therapeutic modalities attributable to age-related changes in the gut can stimulate clinical and basic research. The human genome project, the availability of stem cell biology, advances in molecular mechanisms of growth and development, and discoveries of mucosal growth factors and receptors that occurred as a result of the inception of JPGN have led to dramatic expansion of the basic, translational, and clinical studies in the Journal. We aspired to be one of the journals that publish original articles on gut ontogeny. In addition, we decided to invite ontogenic review articles that provided a basis for understanding the importance of gut ontogeny. Conversely, we were successful publishing age-related clinical studies in pediatric gastroenterology, with an emphasis on early life. An example of clinical disorders that we began to address successfully is celiac disease (CD). Clinical studies in CD emerged in the Journal, including global prevalence and high prevalence of silent preschool- and school-aged children, association with autoimmune disorders, Down syndrome, type 1 diabetes mellitus, and atypical presentations. Mechanistic studies of the effect of several genetic factors together with an environmental trigger were published. The genetic predisposition to CD was studied as a complex of HLA-DQA1*05/DQB1*02 and HLA-DQA*0301/DQB*0302 genes as major factors. Two strategies of genetic research—linkage and association studies—led to the discovery of several susceptibility loci and genes such as a region on 5q, MYO9B, and CTLA4. In addition, a genomewide association study identified 8 new risk regions, 7 of which harbour genes controlling the immune response. Again, we solicited review articles on genetic molecular biology research and the pathogenesis of CD. Another example for specific age-related clinical presentation and therapeutic considerations is failure to gain weight and short stature associated with pediatric inflammatory bowel disease (IBD). Pediatric IBD is different in some major aspects from adult IBD. Early-onset IBD has a distinct phenotype with disease manifestations that are primarily colonic with severe perianal disease and extragastrointestinal manifestations. Furthermore, early-onset IBD is unique in its association with metabolic diseases, neutrophil defects, immunodeficiency states, chronic granulomatous disease, and leukocyte adhesion defects. IBD is thought to result from a complex interplay of multiple genes and environmental factors. Large-scale genotyping techniques have resulted in identification of >30 IBD-associated genes. Pediatric IBD management must consider lifelong disease and treatment. Twenty-five percent of patients with IBD develop the disease in childhood and adolescence. Clinicians need to weigh the risks and benefits of selected therapies, particularly the effects of medications, such as steroids, on growth and development and lifetime of exposure. For the last 30 years, the Journal has published a significant number of articles addressing issues specifically focused on pediatric IBD. We realized that the greatest challenge facing JPGN was reaching out to the world in general and developing countries in particular. We solicited articles from developing countries and found worthwhile clinical observations, but we were challenged by the flaws of study design, such as inclusion and exclusion criteria, sample size, and statistical analyses; data presentation; results; and conclusions. We were confronted with English and grammatical mistakes, leading us to correct and rewrite articles, provided they had a sound scientific message for the pediatric gastroenterology community. A new dimension of the Journal was added when the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition started to develop and update clinical practice guidelines and recommendations (4,5). Overall, it is apparent that JPGN has evolved to become an important cornerstone for the discipline and a reference journal for the societies of pediatric gastroenterology, hepatology, and nutrition. My suggestion for the future is that the clinical research emphasizes acute and chronic gut diseases, all the while continuing to consider the effect of the ontogeny of the gut. In the quest to improve the knowledge of pediatric gastroenterology and nutrition, we should develop new areas of focus and analysis, perspectives, policy forums, and technical comments, similar to the journal Science. Presentation of the basic science news on the ontogeny of the gut, including cell biology, genetics, and immunology, should be a stimulus for inquiry and research to advance the frontiers of pediatric gastroenterology.

AIM: To determine whether the relative American contribution to gastroenterology research, as determined by authorship in journals, decreased from 1980 to 2005. METHODS: Country of residence for authors was manually determined for 8,251 articles, encompassing every gastroenterologic article published in 1980 and 2005 in nine gastroenterology and four leading medical journals (8 American and 5 European journals). Country of residence was also determined for all editorial board members for the same years in the same journals. RESULTS: In all eight analyzed American journals, the relative frequency of non-American authors significantly and sharply increased from 1980 to 2005, and of American authors correspondingly decreased. The effect was invariant: (a) regardless of journal field: general medicine (e.g., N Engl J Med, from 10.1% in 1980 to 27.2% in 2005, odds ratio [OR] 3.34, OR confidence interval [CI] 2.40-4.62, P < 0.0001) versus general gastroenterology (e.g., Am J Gastroenterol, from 20.8% in 1980 to 51.9% in 2005, OR 4.29, OR CI 2.81-6.55, P < 0.0001); (b) regardless of journal gastroenterology subspecialty (e.g., Hepatology vs Endoscopy); (c) regardless of journal circulation: high circulation (e.g., Ann Intern Med, OR 3.50, OR CI 2.05-5.96, P < 0.0001) versus lower circulation (e.g., J Clin Gastroenterol, OR 6.88, OR CI 2.86-16.5, P < 0.0001); (d) regardless of journal impact factor: high impact (e.g., N Engl J Med, see above) versus lower impact (e.g., Dig Dis Sci, OR 3.06, OR CI 2.08-4.51, P < 0.0001); (e) regardless of article topic within a journal (e.g., colon vs upper gastrointestinal tract); (f) regardless of article length within a journal; (g) regardless of number of authors per article or order of authorship; and (h) regardless of whether international representation on the journal's editorial board increased (e.g., Am J Gastroenterol) or decreased (J Clin Gastroenterol) from 1980 to 2005. Contrariwise, in three of five analyzed European journals, the opposite effect occurred: the relative frequency of non-American authors statistically significantly decreased from 1980 to 2005 (e.g., Aliment Pharmacol Ther, from 87.9% in 1980 to 75.9% in 2005, OR 0.43, OR CI 0.20-0.94, P < 0.033), and of Americans authors correspondingly increased. The same trend generally held for the editorial boards of analyzed journals: the relative frequency of non-American board members significantly increased in five American journals (e.g., Am J Gastroenterol, from 4.2% in 1980 to 31.3% in 2005, OR 10.5, OR CI 1.68-63.5, P= 0.006), and decreased in all five analyzed European journals. Interstate and transnational collaborations (coauthorship) increased in publications from 1980 to 2005 (e.g., transnational, from 2.8% in 1980 to 14.1% in 2005 in N Engl J Med, OR 5.62, OR CI 3.25-9.73, P < 0.0001). CONCLUSIONS: From 1980 to 2005, American representation in American gastroenterologic journals significantly declined, whereas American representation in European gastroenterologic journals moderately increased. The latter finding, together with increased transnational collaboration and increased international representation in editorial boards, suggests that increasing globalization of information, partly due to computers and the Internet, may be an important etiologic factor. This may result in an improving quality of research performed outside America. Other potential etiologic factors include improving standard of living outside America and increasing clinical volume of academic gastroenterologists in America.

BACKGROUND: A survey of journals published in the field of Gastroenterology conducted 5 years ago showed marked variability in reporting of conflicts of interest or funding sources in these journals. AIM: To re-examine reporting of conflicts of interest and funding sources for original articles and editorials in Gastroenterology and Hepatology journals. METHODS: We evaluated all original articles and editorials in 15 leading journals (determined by impact factor-Thomson Reuter Science Citation Index) devoted to Gastroenterology and Hepatology for disclosures of conflicts and for editor's self disclosures. We examined each journal's editorial policy by contacting the journal directly if the information was not revealed on the Web site or print versions of the journal. RESULTS: Of the 1574 articles evaluated, a total of 1207 (77%) reported the presence or absence of a potential conflict of interest and 1047 (67%) reported the presence or absence of funding sources. A total of 3 of the 15 (20%) journals (American Journal of Gastroenterology, Gastroenterology, and Alimentary Pharmacology and Therapeutics reported the presence or absence of funding sources in all their published original articles. Only 5 of 15 (33%) journals (Gut, Gastrointestinal Endoscopy, American Journal of Gastroenterology, Neurogastroenterology & Motility and Alimentary Pharmacology and Therapeutics) publicly disclosed the conflicts of interest of the editors. CONCLUSIONS: (i) Funding sources and conflicts of interest are still reported variably in the GI literature. (ii) Editorials and review articles are influential, but have poor reporting of conflicts of interest. (iii) Editors of many journals still do not report their conflicts of interest.

OBJECTIVE: The stability and composition of intestinal flora plays a vital role in human wellbeing throughout life from as early as birth. Over the past 50 years, several studies have been conducted to evaluate the effect of probiotic administration in pediatric gastroenterology. This document aims to provide a recommendation score on probiotic utilization in pediatric gastroenterology, together with a review of current knowledge concerning its benefits, tolerability, and safety. STUDY DESIGN: Published literature was selected without study design restriction: clinical guidelines, meta-analyses, randomized controlled trials (RCTs), cohort studies, outcomes research and case-controlled studies were selected using the following MESH-validated terms: probiotics, diarrhea, acute diarrhea, antibiotic-associated diarrhea, traveler's diarrhea, bacterial diarrhea, nosocomial diarrhea, prophylactic diarrhea, Helicobacter pylori infection, colic, infantile colic, necrotizing enterocolitis (NEC), inflammatory bowel disease, constipation, and allergy. Once the validity and the quality of results were evaluated, a recommendation score and level of evidence were assigned for pediatric gastrointestinal-related conditions, according to the updated Evidence-Based Medicine guidelines: 1a for systematic review (SR) of RCTs, 1b for individual RCT, 1c for SR and individual RCT, 2a for SR of cohort studies, 2b for individual cohort studies, 2c for outcomes research, and 3a for SR of case-control studies. RESULTS AND CONCLUSIONS: The Latin American Expert group consensus recommends the use of the following probiotics for pediatric gastrointestinal conditions: prevention of acute infectious diarrhea (AID): 1b for Bifidobacterium lactis, Lactobacillus rhamnosus GG (LGG), and L. reuteri; prevention of nosocomial diarrhea: 1 b for B. lactis Bb12, B. bifidum, LGG and Streptococcus thermophiles; treatment of AID: 1a for LGG and S. boulardii, 1b for L. reuteri; prevention of antibiotic-associated diarrhea: 1b for LGG and S. boulardii; prevention of traveler's diarrhea: 1b for S. boulardii; prevention of infantile colic: 1a for L. reuteri DSM 17938; treatment of infantile colic: 1b for L. reuteri DSM 17938; prevention of NEC: 1a for B. breve, mixtures of Bifidobacterium and Streptococcus, LGG, L. acidophilus and L. reuteri DSM 17938; induction and maintenance of remission in ulcerative colitis: 1b for VSL#3; improving symptoms of irritable bowel syndrome: 2c for LGG and VSL#3.

Functional dyspepsia (FD) is a common disorder of gut-brain interaction, affecting approximately 7% of individuals in the community, with most patients managed in primary care. The last British Society of Gastroenterology (BSG) guideline for the management of dyspepsia was published in 1996. In the interim, substantial advances have been made in understanding the complex pathophysiology of FD, and there has been a considerable amount of new evidence published concerning its diagnosis and classification, with the advent of the Rome IV criteria, and management. The primary aim of this guideline, commissioned by the BSG, is to review and summarise the current evidence to inform and guide clinical practice, by providing a practical framework for evidence-based diagnosis and treatment of patients. The approach to investigating the patient presenting with dyspepsia is discussed, and efficacy of drugs in FD summarised based on evidence derived from a comprehensive search of the medical literature, which was used to inform an update of a series of pairwise and network meta-analyses. Specific recommendations have been made according to the Grading of Recommendations Assessment, Development and Evaluation system. These provide both the strength of the recommendations and the overall quality of evidence. Finally, in this guideline, we consider novel treatments that are in development, as well as highlighting areas of unmet need and priorities for future research.

BACKGROUND AND AIM: To appraise the current reporting methodological quality of meta-analyses in five leading gastroenterology and hepatology journals, and to identify the variables associated with the reporting quality. METHODS: We systematically searched the literature of meta-analyses in Gastroenterology, Gut, Hepatology, Journal of Hepatology (J HEPATOL) and American Journal of Gastroenterology (AM J GASTROENTEROL) from 2006 to 2008 and from 2012 to 2014. Characteristics were extracted based on the PRISMA statement and the AMSTAR tool. Country, number of patients, funding source were also revealed and descriptively reported. RESULTS: A total of 127 meta-analyses were enrolled in this study and were compared among journals, study years, and other characters. Compliances with the PRISMA statement and the AMSTAR checklist were 20.8 ± 4.2 out of a maximum of 27 and 7.6 ± 2.4 out of a maximum of 11, respectively. Some domains were poorly reported including describing a protocol and/or registration (item 5, 0.0%), describing methods, and giving results of additional analyses (item 16, 45.7% and item 23, 48.0%) for PRISMA and duplicating study selection and data extraction (item 2, 53.5%), and providing a list of included and excluded studies (item 5, 14.2%) for AMSTAR. Publication in recent years showed a significantly better methodological quality than those published in previous years. CONCLUSIONS: This study shows that methodological reporting quality of MAs in the major gastroenterology and hepatology journals has improved in recent years after the publication of the developed PRISMA statement, and it can be further improved.

Background Lenvatinib demonstrated a treatment effect on overall survival by the statistical confirmation of noninferiority to sorafenib for the first-line treatment of uHCC. The objective of this study was to evaluate the cost-effectiveness of lenvatinib compared with sorafenib for patients with uHCC in Japan. Methods A partitioned-survival model was developed to estimate the cost-effectiveness of lenvatinib versus sorafenib when treating uHCC patients over a lifetime horizon and considering total public healthcare expenditure. Efficacy and safety data were extracted from the REFLECT trial. Utility values were derived from the European Quality-of-Life 5-Dimension Questionnaire, conducted with patients enrolled in the REFLECT trial. Direct medical costs, such as primary drug therapy, outpatient visits, diagnostic tests, hospitalization, post-progression therapy, and adverse-event treatments, were included. Cost parameters unavailable in the clinical trial or publications were obtained based on the consolidated clinical standards from a Delphi panel of four Japanese medical experts. Results For lenvatinib versus sorafenib, the incremental cost was -406,307 Japanese Yen (JPY), and the incremental life years and quality-adjusted life years (QALYs) were 0.27 and 0.23, respectively. Thus, lenvatinib dominated sorafenib, due to the mean incremental cost-effectiveness ratio falling in the fourth quadrant, conferring more benefit at lower costs compared with sorafenib. The probabilistic sensitivity analysis showed that 81.3% of the simulations were favorable to lenvatinib compared with sorafenib, with a payer's willingness-to-pay-per-QALY of 5 million JPY. Conclusions Lenvatinib was cost-effective compared with sorafenib for the first-line treatment of uHCC in Japan.

OBJECTIVE: To develop a new evidence-based, pharmacologic treatment guideline for rheumatoid arthritis (RA). METHODS: We conducted systematic reviews to synthesize the evidence for the benefits and harms of various treatment options. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence. We employed a group consensus process to grade the strength of recommendations (either strong or conditional). A strong recommendation indicates that clinicians are certain that the benefits of an intervention far outweigh the harms (or vice versa). A conditional recommendation denotes uncertainty over the balance of benefits and harms and/or more significant variability in patient values and preferences. RESULTS: The guideline covers the use of traditional disease-modifying antirheumatic drugs (DMARDs), biologic agents, tofacitinib, and glucocorticoids in early (<6 months) and established (≥6 months) RA. In addition, it provides recommendations on using a treat-to-target approach, tapering and discontinuing medications, and the use of biologic agents and DMARDs in patients with hepatitis, congestive heart failure, malignancy, and serious infections. The guideline addresses the use of vaccines in patients starting/receiving DMARDs or biologic agents, screening for tuberculosis in patients starting/receiving biologic agents or tofacitinib, and laboratory monitoring for traditional DMARDs. The guideline includes 74 recommendations: 23% are strong and 77% are conditional. CONCLUSION: This RA guideline should serve as a tool for clinicians and patients (our two target audiences) for pharmacologic treatment decisions in commonly encountered clinical situations. These recommendations are not prescriptive, and the treatment decisions should be made by physicians and patients through a shared decision-making process taking into account patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

In the United States, colorectal cancer (CRC) is the third most common cancer diagnosed among men and women and the second leading cause of death from cancer. CRC largely can be prevented by the detection and removal of adenomatous polyps, and survival is significantly better when CRC is diagnosed while still localized. In 2006 to 2007, the American Cancer Society, the US Multi Society Task Force on Colorectal Cancer, and the American College of Radiology came together to develop consensus guidelines for the detection of adenomatous polyps and CRC in asymptomatic average-risk adults. In this update of each organization's guidelines, screening tests are grouped into those that primarily detect cancer early and those that can detect cancer early and also can detect adenomatous polyps, thus providing a greater potential for prevention through polypectomy. When possible, clinicians should make patients aware of the full range of screening options, but at a minimum they should be prepared to offer patients a choice between a screening test that is effective at both early cancer detection and cancer prevention through the detection and removal of polyps and a screening test that primarily is effective at early cancer detection. It is the strong opinion of these 3 organizations that colon cancer prevention should be the primary goal of screening.

AIM: In addition to respiratory symptoms, COVID-19 can present with gastrointestinal complaints suggesting possible faeco-oral transmission. The primary aim of this review was to establish the incidence and timing of positive faecal samples for SARS-CoV-2 in patients with COVID-19. METHODS: A systematic literature review identified studies describing COVID-19 patients tested for faecal virus. Search terms for MEDLINE included 'clinical', 'faeces', 'gastrointestinal secretions', 'stool', 'COVID-19', 'SARS-CoV-2' and '2019-nCoV'. Additional searches were done in the American Journal of Gastroenterology, Gastroenterology, Gut, Lancet Gastroenterology and Hepatology, the World Health Organization Database, the Centre for Evidence-Based Medicine, New England Journal of Medicine, social media and the National Institute for Health and Care Excellence, bioRxiv and medRxiv preprints. Data were extracted concerning the type of test, number and timing of positive samples, incidence of positive faecal tests after negative nasopharyngeal swabs and evidence of viable faecal virus or faeco-oral transmission of the virus. RESULTS: Twenty-six relevant articles were identified. Combining study results demonstrated that 53.9% of those tested for faecal RNA were positive. The duration of faecal viral shedding ranged from 1 to 33 days after a negative nasopharyngeal swab with one result remaining positive 47 days after onset of symptoms. There is insufficient evidence to suggest that COVID-19 is transmitted via faecally shed virus. CONCLUSION: There is a high rate of positive polymerase chain reaction tests with persistence of SARS-CoV-2 in faecal samples of patients with COVID-19. Further research is needed to confirm if this virus is viable and the degree of transmission through the faeco-oral route. This may have important implications on isolation, recommended precautions and protective equipment for interventional procedures involving the gastrointestinal tract.

Our patients spend most of their lives far away from an examination room. If we are truly going to capture our patients' attention and engage them in their care, then we must reach beyond the four walls of the clinic, hospital, or endoscopy suite. This is the vision of the digital health movement-an effort to monitor patients remotely and dynamically with mobile health ("mHealth") smartphone applications, electronic health record portals, social media, and wearable biosensors to improve health care outside of the clinical trenches. This article explores how advances in digital health may improve health-care delivery, focusing on gastroenterology and hepatology. It describes how technology can monitor patients remotely, improve face-to-face care, drive clinical decisions, and offer value to health-care organizations, their patients, and their staff. The article also describes pitfalls and shortcomings of digital technologies and concludes by describing a new model for how digital health can be deployed at scale to improve coordination and outcomes of care.

In the United States, colorectal cancer (CRC) is the fourth most common cancer diagnosed among adults and the second leading cause of death from cancer. For this guideline update, the American Cancer Society (ACS) used an existing systematic evidence review of the CRC screening literature and microsimulation modeling analyses, including a new evaluation of the age to begin screening by race and sex and additional modeling that incorporates changes in US CRC incidence. Screening with any one of multiple options is associated with a significant reduction in CRC incidence through the detection and removal of adenomatous polyps and other precancerous lesions and with a reduction in mortality through incidence reduction and early detection of CRC. Results from modeling analyses identified efficient and model-recommendable strategies that started screening at age 45 years. The ACS Guideline Development Group applied the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in developing and rating the recommendations. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends (qualified recommendations) that: 1) average-risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. The options for CRC screening are: fecal immunochemical test annually; high-sensitivity, guaiac-based fecal occult blood test annually; multitarget stool DNA test every 3 years; colonoscopy every 10 years; computed tomography colonography every 5 years; and flexible sigmoidoscopy every 5 years. CA Cancer J Clin 2018;68:250-281. © 2018 American Cancer Society.

These guidelines provide a practical and evidence-based resource for the management of patients with Barrett's oesophagus and related early neoplasia. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was followed to provide a methodological strategy for the guideline development. A systematic review of the literature was performed for English language articles published up until December 2012 in order to address controversial issues in Barrett's oesophagus including definition, screening and diagnosis, surveillance, pathological grading for dysplasia, management of dysplasia, and early cancer including training requirements. The rigour and quality of the studies was evaluated using the SIGN checklist system. Recommendations on each topic were scored by each author using a five-tier system (A+, strong agreement, to D+, strongly disagree). Statements that failed to reach substantial agreement among authors, defined as >80% agreement (A or A+), were revisited and modified until substantial agreement (>80%) was reached. In formulating these guidelines, we took into consideration benefits and risks for the population and national health system, as well as patient perspectives. For the first time, we have suggested stratification of patients according to their estimated cancer risk based on clinical and histopathological criteria. In order to improve communication between clinicians, we recommend the use of minimum datasets for reporting endoscopic and pathological findings. We advocate endoscopic therapy for high-grade dysplasia and early cancer, which should be performed in high-volume centres. We hope that these guidelines will standardise and improve management for patients with Barrett's oesophagus and related neoplasia.

This consensus statement from the members of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine recommends a standardized method for measuring gastric emptying (GE) by scintigraphy. A low-fat, egg-white meal with imaging at 0, 1, 2, and 4 h after meal ingestion, as described by a published multicenter protocol, provides standardized information about normal and delayed GE. Adoption of this standardized protocol will resolve the lack of uniformity of testing, add reliability and credibility to the results, and improve the clinical utility of the GE test.

For routine EUS-guided sampling of solid masses and lymph nodes (LNs) ESGE recommends 25G or 22G needles (high quality evidence, strong recommendation); fine needle aspiration (FNA) and fine needle biopsy (FNB) needles are equally recommended (high quality evidence, strong recommendation).When the primary aim of sampling is to obtain a core tissue specimen, ESGE suggests using 19G FNA or FNB needles or 22G FNB needles (low quality evidence, weak recommendation).ESGE recommends using 10-mL syringe suction for EUS-guided sampling of solid masses and LNs with 25G or 22G FNA needles (high quality evidence, strong recommendation) and other types of needles (low quality evidence, weak recommendation). ESGE suggests neutralizing residual negative pressure in the needle before withdrawing the needle from the target lesion (moderate quality evidence, weak recommendation).ESGE does not recommend for or against using the needle stylet for EUS-guided sampling of solid masses and LNs with FNA needles (high quality evidence, strong recommendation) and suggests using the needle stylet for EUS-guided sampling with FNB needles (low quality evidence, weak recommendation).ESGE suggests fanning the needle throughout the lesion when sampling solid masses and LNs (moderate quality evidence, weak recommendation).ESGE equally recommends EUS-guided sampling with or without on-site cytologic evaluation (moderate quality evidence, strong recommendation). When on-site cytologic evaluation is unavailable, ESGE suggests performance of three to four needle passes with an FNA needle or two to three passes with an FNB needle (low quality evidence, weak recommendation).For diagnostic sampling of pancreatic cystic lesions without a solid component, ESGE suggests emptying the cyst with a single pass of a 22G or 19G needle (low quality evidence, weak recommendation). For pancreatic cystic lesions with a solid component, ESGE suggests sampling of the solid component using the same technique as in the case of other solid lesions (low quality evidence, weak recommendation).ESGE does not recommend antibiotic prophylaxis for EUS-guided sampling of solid masses or LNs (low quality evidence, strong recommendation), and suggests antibiotic prophylaxis with fluoroquinolones or beta-lactam antibiotics for EUS-guided sampling of cystic lesions (low quality evidence, weak recommendation). ESGE suggests that evaluation of tissue obtained by EUS-guided sampling should include histologic preparations (e. g., cell blocks and/or formalin-fixed and paraffin-embedded tissue fragments) and should not be limited to smear cytology (low quality evidence, weak recommendation).