Position statement on how can we can implement the Greendeal in our gastrointestinal and gastrointestinal endoscopy department in Belgium.

The importance to reach the target to be carbon net zero by 2050, as presented by the European Commission in the European Green Deal, cannot be overestimated. In a current endoscopy world, where single use has found its place and techniques are constantly evolving, it will be a challenge to reach these goals. How can we reconcile this evolution to a carbon neutral status by 2050 without compromising patients care, clinical standards and training needs? The European Society of Gastrointestinal Endoscopy (ESGE) together with the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) recently published a position statement (1) whereas in the UK there is the work from the green endoscopy group (2) in line with the strategy of the British Society of Gastroenterology (BSG) on sustainability (3). In Flanders, a project called "greendeal in duurzame zorg" had its kick off in March 2023 (4) so it is about time that we in Belgium, as gastroenterologists, start with tangible actions to a more sustainable daily practice. We wrote this position statement in cooperation with the Vlaamse Vereniging voor Gastro-Enterologie (VVGE), the Société royale belge de Gastro-entérologie (SRBGE) and the Belgian Society of Gastrointestinal Endoscopy (BSGIE). We will also work together in the coming years to continue to motivate our members to work on these initiatives and to co-opt new projects within the framework of the greendeal.

BSGIE survey on COVID-19 and gastrointestinal endoscopy in Belgium : results and recommendations.

BACKGROUND AND AIMS: With the first wave of the COVID-19 pandemic declining, activities in the gastrointestinal clinic are being recommenced after a period of stringent measures. Since a second COVID-19 wave is not entirely ruled out health care professionals might remain faced with the need to perform endoscopic procedures in patients with a confirmed positive or unknown COVID-19 status. With this report we aim to provide a practical relevant overview of preparation and protective measures for gastroenterologists based on the currently available guidelines and our local experience and results of a national Belgian survey, to guarantee a fast recall of an adequate infection prevention if COVID-19 reoccurs. METHODS: From the 23rd of March 2020 and the 13th of May 2020 we performed a Pubmed, Embase and Medline search, resulting in 37 papers on COVID-19 and endoscopy. Additionally, we combined these data with data acquired from the national BSGIE survey amongst Belgian gastroenterologists. RESULTS: Based on 72 completed surveys in both university and non-university hospitals, the results show (1) a dramatic (<20%) or substantial (<50%) decrease of normal daily endoscopy in 74% and 22% of the units respectively, (2) a difference in screening and protective measures between university and non-university hospitals. These findings were subsequently compared with the current guidelines. CONCLUSION: Based on new data from the BSGIE survey and current guidelines we tried to realistically represent the current COVID-19 trends in protective measures, screening and indications for endoscopy and to provide a practical overview as preparation for a possible second wave.

Tracking the sources of psychrotrophic bacteria contaminating chicken cuts during processing.

The major aim of the study was to establish the routes via which spoilage associated psychrotrophic bacteria contaminate poultry products at a large processing plant located in Belgium. Environmental samples were collected consisting of samples of air and swabs of food contact surfaces. Product samples were also collected consisting of modified atmosphere packaged (MAP) chicken wings and legs, which were analyzed microbiologically on the same day they were produced as well as after their sell-by date. Psychrotrophic bacteria from these samples were subsequently clustered and identified by means of MALDI-TOF MS and 16S rRNA gene sequencing. Carnobacterium maltaromaticum was determined to dominate the spoilage flora of both wings and legs. Other psychrotrophic bacteria able to grow on MRS which were identified on expired wings and legs included Carnobacterium divergens, Brocothrix thermosphacta, Lactobacillus curvatus, and Lactobacillus brevis. These were determined to arise from food contact surfaces such as cutting blades, leg hooks, Ertalon and polyurethane conveyor belts, working tables, and the hands of the operators. Importantly, it was determined that cleaning and disinfection was largely inadequate. Air was also determined to be an important vector of psychrotrophic bacteria in the processing environment, potentially contaminating the products directly or indirectly.

Temporal and Spatial Distribution of the Acetic Acid Bacterium Communities throughout the Wooden Casks Used for the Fermentation and Maturation of Lambic Beer Underlines Their Functional Role.

Few data have been published on the occurrence and functional role of acetic acid bacteria (AAB) in lambic beer production processes, mainly due to their difficult recovery and possibly unknown role. Therefore, a novel aseptic sampling method, spanning both the spatial and temporal distributions of the AAB and their substrates and metabolites, was combined with a highly selective medium and matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) as a high-throughput dereplication method followed by comparative gene sequencing for their isolation and identification, respectively. The AAB (Acetobacter species more than Gluconobacter species) proliferated during two phases of the lambic beer production process, represented by Acetobacter orientalis during a few days in the beginning of the fermentation and Acetobacter pasteurianus from 7 weeks until 24 months of maturation. Competitive exclusion tests combined with comparative genomic analysis of all genomes of strains of both species available disclosed possible reasons for this successive dominance. The spatial analysis revealed that significantly higher concentrations of acetic acid (from ethanol) and acetoin (from lactic acid) were produced at the tops of the casks, due to higher AAB counts and a higher metabolic activity of the AAB species at the air/liquid interface during the first 6 months of lambic beer production. In contrast, no differences in AAB species diversity occurred throughout the casks.IMPORTANCE Lambic beer is an acidic beer that is the result of a spontaneous fermentation and maturation process. Acidic beers are currently attracting attention worldwide. Part of the acidity of these beers is caused by acetic acid bacteria (AAB). However, due to their difficult recovery, they were never investigated extensively regarding their occurrence, species diversity, and functional role in lambic beer production. In the present study, a framework was developed for their isolation and identification using a novel aseptic sampling method in combination with matrix-assisted laser desorption ionization-time of flight mass spectrometry as a high-throughput dereplication technique followed by accurate molecular identification. The sampling method applied enabled us to take spatial differences into account regarding both enumerations and metabolite production. In this way, it was shown that more AAB were present and more acetic acid was produced at the air/liquid interface during a major part of the lambic beer production process. Also, two different AAB species were encountered, namely, Acetobacter orientalis at the beginning and Acetobacter pasteurianus in a later stage of the production process. This developed framework could also be applied for other fermentation processes.

The wrong end of the telescope: neuromuscular mimics of movement disorders (and vice versa).

The rapid advances in modern neurology have led to increased specialisation in clinical practice. Being an expert in a neurology subspecialty offers advantages for diagnosing and managing specific disorders. However, specialisation also risks tunnel vision: interpreting symptoms and signs within one's own framework of reference, while ignoring differential diagnostic options from other subspecialties. This is particularly relevant when the patient's presentation potentially belongs to different neurological subspecialties. We illustrate this challenge by highlighting a series of clinical features that partially overlap between two common subspecialties: movement disorders and neuromuscular disorders. An overlap in clinical presentation is not rare, and includes, for example, involuntary eyelid closure (which could be active eye closure due to blepharospasm, or ptosis due to weakness). Other overlapping features include abnormal postures, involuntary movements and gait changes. We describe two of these overlapping features in more detail and emphasise the possible consequences of 'looking through the wrong end of the telescope' in such patients, as this may lead to a wrong differential diagnosis, unnecessary investigations and a delayed treatment start.

The social contact hypothesis under the assumption of endemic equilibrium: Elucidating the transmission potential of VZV in Europe.

The basic reproduction number R0 and the effective reproduction number R are pivotal parameters in infectious disease epidemiology, quantifying the transmission potential of an infection in a population. We estimate both parameters from 13 pre-vaccination serological data sets on varicella zoster virus (VZV) in 12 European countries and from population-based social contact surveys under the commonly made assumptions of endemic and demographic equilibrium. The fit to the serology is evaluated using the inferred effective reproduction number R as a model eligibility criterion combined with AIC as a model selection criterion. For only 2 out of 12 countries, the common choice of a constant proportionality factor is sufficient to provide a good fit to the seroprevalence data. For the other countries, an age-specific proportionality factor provides a better fit, assuming physical contacts lasting longer than 15 min are a good proxy for potential varicella transmission events. In all countries, primary infection with VZV most often occurs in early childhood, but there is substantial variation in transmission potential with R0 ranging from 2.8 in England and Wales to 7.6 in The Netherlands. Two non-parametric methods, the maximal information coefficient (MIC) and a random forest approach, are used to explain these differences in R0 in terms of relevant country-specific characteristics. Our results suggest an association with three general factors: inequality in wealth, infant vaccination coverage and child care attendance. This illustrates the need to consider fundamental differences between European countries when formulating and parameterizing infectious disease models.

Relative distribution of gastrin-, CCK-8-, NPY- and CGRP-immunoreactive cells in the digestive tract of dorado (Salminus brasiliensis).

The endocrine cells (ECs) of the gastrointestinal mucosa form the largest endocrine system in the body, not only in terms of cell numbers but also in terms of the different produced substances. Data describing the association between the relative distributions of the peptide-specific ECs in relation to feeding habits can be useful tools that enable the creation of a general expected pattern of EC distribution. We aimed to investigate the distribution of ECs immunoreactive for the peptides gastrin (GAS), cholecystokinin (CCK-8), neuropeptide Y (NPY), and calcitonin gene-related peptide (CGRP) in different segments of the digestive tract of carnivorous fish dorado (Salminus brasiliensis) by using immunohistochemistry procedures. The distribution of endocrine cells immunoreactive for gastrin (GAS), cholecystokinin (CCK-8), neuropeptide Y (NPY), and calcitonin gene-related peptide (CGRP) in digestive tract of dorado S. brasiliensis was examined by immunohistochemistry. The results describe the association between the distribution of the peptide-specific endocrine cells and feeding habits in different carnivorous fish. The largest number of endocrine cells immunoreactive for GAS, CCK-8, and CGRP were found in the pyloric stomach region and the pyloric caeca. However, NPY-immunoreactive endocrine cells were markedly restricted to the midgut. The distribution pattern of endocrine cells identified in S. brasiliensis is similar to that found in other carnivorous fishes.

Susceptibility-weighted imaging improves the diagnostic accuracy of 3T brain MRI in the work-up of parkinsonism.

BACKGROUND AND PURPOSE: The differentiation between Parkinson disease and atypical parkinsonian syndromes can be challenging in clinical practice, especially in early disease stages. Brain MR imaging can help to increase certainty about the diagnosis. Our goal was to evaluate the added value of SWI in relation to conventional 3T brain MR imaging for the diagnostic work-up of early-stage parkinsonism. MATERIALS AND METHODS: This was a prospective observational cohort study of 65 patients presenting with parkinsonism but with an uncertain initial clinical diagnosis. At baseline, 3T brain MR imaging with conventional and SWI sequences was performed. After clinical follow-up, probable diagnoses could be made in 56 patients, 38 patients diagnosed with Parkinson disease and 18 patients diagnosed with atypical parkinsonian syndromes, including 12 patients diagnosed with multiple system atrophy-parkinsonian form. In addition, 13 healthy controls were evaluated with SWI. Abnormal findings on conventional brain MR imaging were grouped into disease-specific scores. SWI was analyzed by a region-of-interest method of different brain structures. One-way ANOVA was performed to analyze group differences. Receiver operating characteristic analyses were performed to evaluate the diagnostic accuracy of conventional brain MR imaging separately and combined with SWI. RESULTS: Disease-specific scores of conventional brain MR imaging had a high specificity for atypical parkinsonian syndromes (80%-90%), but sensitivity was limited (50%-80%). The mean SWI signal intensity of the putamen was significantly lower for multiple system atrophy-parkinsonian form than for Parkinson disease and controls (P < .001). The presence of severe dorsal putaminal hypointensity improved the accuracy of brain MR imaging: The area under the curve was increased from 0.75 to 0.83 for identifying multiple system atrophy-parkinsonian form, and it was increased from 0.76 to 0.82 for identifying atypical parkinsonian syndromes as a group. CONCLUSIONS: SWI improves the diagnostic accuracy of 3T brain MR imaging in the work-up of parkinsonism by identifying severe putaminal hypointensity as a sign indicative of multiple system atrophy-parkinsonian form.

Ancillary investigations to diagnose parkinsonism: a prospective clinical study.

Various ancillary investigations can assist clinicians in the differential diagnosis of patients with parkinsonism. It is unknown which test offers greatest diagnostic value in clinical practice. We included 156 consecutive patients with parkinsonism, but with an initially uncertain diagnosis. At baseline, all patients underwent extensive clinical testing and the following ancillary investigations: brain magnetic resonance imaging (MRI); (123)I-iodobenzamide single photon-emission computed tomography (IBZM-SPECT); analysis of cerebrospinal fluid (CSF); and anal sphincter electromyography (EMG). The final diagnosis was established after 3-year follow-up by two movement disorder specialists, according to international consensus criteria. We determined the diagnostic value by comparing the baseline clinical parameters and ancillary studies with the final diagnosis. Out of a potential 138 parameters, univariate analysis identified 35 parameters that discriminated Parkinson's disease (PD, n = 62) and atypical parkinsonism (AP, n = 94), with AUC of 0.55-0.81. Stepwise logistic regression showed that the combination of tandem gait, axial UPDRS subscore, slow saccadic eye movements and dysphagia yielded an AUC of 0.93, adjusted for optimism. The combination of tandem gait and axial UDPRS subscore yielded an AUC of 0.90. None of the ancillary investigations alone or in combination with clinical testing improved this clinically based diagnostic accuracy, not even in a subgroup of patients with the greatest diagnostic uncertainty at baseline. Our study demonstrates that a comprehensive set of clinical tests provides good accuracy to differentiate PD from AP. Our results also suggest that routine MRI, IBZM-SPECT, CSF analysis and anal sphincter EMG do not improve this diagnostic accuracy. Future work should evaluate the possible diagnostic value of more advanced diagnostic tests.

Surgical management of gastrointestinal stromal tumours: a single centre experience during the past 17 years.

BACKGROUND: Gastrointestinal stromal tumour (GIST) is a rare tumour that can arise anywhere within the gastrointestinal tract. OBJECTIVES: Our objective was to present our experience managing this rare tumour of the gastrointestinal tract. We reviewed the clinico-pathological and morphological features, our experience with surgical treatment, and the outcome GIST in our centre. PATIENTS AND METHODS: The current retrospective analysis included 64 patients with GIST observed between February 1995 and September 2012. RESULTS: There were 39 males and 25 females. The mean age was 63.2 (range 36-83). The GISTs were located in the stomach in the majority of patients (60 patients, 94.0%). The tumour was asymptomatic in 14 (21.9%) patients. The tumour size varied from 0.4 to 25 cm with a mean size of 7.9 cm. Five patients showed peritoneal or liver metastasis at diagnosis. All patients had surgery. Five patients had a R2 resection and in one patient the resection-free margin was uncertain. In our cohort we had 5 patients with metastasis at diagnosis who received adjuvant imatinib. Four patients developed metastasis in the follow-up period. Three patients died due to GIST, three other patients died due to other disease. CONCLUSIONS: Gastric GIST were more common than GIST at other locations. Surgical treatment was the main therapeutic option. Tyosine kinase receptor inhibitors was used as a first line treatment in patients with metastatic GISTs or in patients with recurrence of the disease.

Gastrointestinal stromal tumor of the stomach: progresses in diagnosis and treatment.

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal smooth muscle neoplasms that can arise anywhere within the gastrointestinal tract. Approximately 60-70% are located in the stomach. Once considered variants of smooth muscle tumors, they are now understood as originating from the interstitial cells of Cajal or their stem cell precursors. The majority of GISTs (approximately 95%) express the CD117 antigen (KIT), a proto-oncogene product ; 85-95% of these neoplasms have mutations in the c-KIT gene; only 5-7% has mutations in platelet-derived-growth factor a (PDGFRa). GISTs can be asymptomatic and incidentally found during examination for other pathologies or at autopsy. The most common symptoms of gastric GIST are abdominal pain and bleeding. Diagnostic work up consists of endoscopy with ultrasonography and cross-sectional imaging studies (computed tomography and/or magnetic resonance imaging). Surgery remains the first-line treatment for localized gastric GISTs. Both open and laparoscopic operations have been shown to reduce recurrence rates and improve long-term survival. The use of small-molecule selective tyrosine kinase receptor inhibitors has revolutionized the treatment of advanced GISTs.

Small bowel metastases from melanoma: does videocapsule provide additional information after FDG positron emission tomography?

Finding small bowel metastases of melanoma can be important because surgical removal of unique small bowel metastasis of melanoma could improve survival. In this study, we evaluated if capsule endoscopy provides additional information after Pet CT has been performed. In this series of 9 patients collected from 3 university centers, capsule endoscopy influenced the therapeutic decision (to perform or not a surgical segmental resection) in 2/9 patients. All metastatic lesions were found in the proximal bowel. Capsule identified jejunum metastases in one case while Pet CT was negative, and identified metastases while Pet CT result was not conclusive. In one case PET CT identified mesenteric metastases while capsule was negative. SBCE influenced therapeutic decision in 2/9 patients concerning the decision of performing small bowel resection or not. In 1 patient SBCE changed the stage of the disease without affecting medical therapeutic strategy. The prognosis of patients with positive PET and/or capsule findings is very limited (2/3 died within the year). In selected patients, capsule endoscopy can provide complementary information once PET CT has been performed.

Validation of MALDI-TOF MS for rapid classification and identification of lactic acid bacteria, with a focus on isolates from traditional fermented foods in Northern Vietnam.

AIMS: To evaluate the potential use of MALDI-TOF MS for fast and reliable classification and identification of lactic acid bacteria (LAB) from traditional fermented foods. METHODS AND RESULTS: A total of 119 strains of LAB from fermented meat (nem chua) were analysed with both (GTG)(5)-PCR fingerprinting and MALDI-TOF MS. Cluster analysis of the profiles revealed five species represented by a single isolate both in (GTG)(5)-PCR and in MALDI-TOF MS; five species grouped alike for (GTG)(5)-PCR and for MALDI-TOF MS; however, differences in minimal similarity between the delineated (GTG)(5)-PCR and MALDI-TOF MS clusters could be observed; three species showed more heterogeneity in their MALDI-TOF MS profiles compared to their (GTG)(5)-PCR profiles; two species, each represented by a single MALDI-TOF cluster, were subdivided in the corresponding (GTG)(5)-PCR dendrogram. As proof of the identification potential of MALDI-TOF MS, LAB diversity from one fermented mustard sample was analysed using MALDI-TOF MS. PheS gene sequencing was used for validation. CONCLUSIONS: MALDI-TOF MS is a powerful, fast, reliable and cost-effective technique for the identification of LAB associated with the production of fermented foods. SIGNIFICANCE AND IMPACT OF THE STUDY: Food LAB can be identified using MALDI-TOF MS, and its application could possibly be extended to other food matrices and/or other food-derived micro-organisms.

CSF α-synuclein does not differentiate between parkinsonian disorders.

Differentiating between Parkinson's disease (PD) and atypical Parkinsonism (AP) is clinically relevant but challenging. A timely and correct diagnosis might result in better targeted treatment strategies, adequate patient counseling, and early recognition of disease-specific complications. We aimed to investigate whether cerebrospinal fluid (CSF) concentrations of α-synuclein are of additional diagnostic value. We examined 142 consecutive patients with parkinsonism, mean disease duration 39.7 mo (Parkinson's disease (PD), n = 58; MSA, n = 47; dementia with Lewy bodies (DLB), n = 3; VaP, n = 22; progressive supranuclear palsy (PSP), n = 10; CBD, n = 2). Gold standard was the clinical diagnosis established after 2 years of clinical follow-up. CSF concentrations of α-synuclein, blood pigments and the erythrocyte count were determined. No differences between CSF α-synuclein concentrations of patients with PD with the reference values from our laboratory were observed. We neither found significant differences between patients with PD and AP nor between AP subgroups. Adjustment for age, disease severity or presence of erythrocytes or blood pigments in CSF did not alter these results. Our results imply that CSF α-synuclein is currently unsuitable as biomarker to differentiate between PD and AP.

Estimating the force of infection for HCV in injecting drug users using interval-censored data.

Injecting drug users (IDUs) account for most new HCV infections. The objectives of this study were: to estimate the force of infection for hepatitis C virus in IDUs within the interval-censoring framework and to determine the impact of risk factors such as frequency of injection, drug injected, sharing of syringes and time of first injection on the time to HCV infection. We used data from the Amsterdam Cohort Study collected in The Netherlands and focused on those individuals who were HCV negative upon entry into the study. Based on the results, the force of infection was found to vary with time of first injection. The risk of infection was higher in the first 3 years of an IDU's career, implying estimates based on single cross-sectional studies could be biased. Frequency of injection and type of drug injected were found to be highly significant predictors, whereas sharing syringes was not.

Durable remission of inoperable liver metastasis from rectal cancer after hepatic arterial infusion of oxaliplatin and 5-fluorouracil in combination with intravenous cetuximab.

At diagnosis of a cT3N0M1 adenocarcinoma of the rectum with synchronous inoperable liver metastases, a 59-year-old man was treated with preoperative radiotherapy (5×5 Gy), followed by laparoscopy-assisted anterior resection of the rectum with total mesorectal excision. At the first postoperative evaluation, a new lung metastasis was detected. First-line chemotherapy with folfiri (5-fluorouracil, irinotecan, leucovorin) resulted in transient stabilization of the metastatic liver disease. At progression, oxaliplatin and 5-fluorouracil-folinic acid were administered by intrahepatic arterial infusion, in combination with intravenous cetuximab. A partial radiologic response was obtained, with complete metabolic response on fluorodeoxyglucose positron-emission tomography, and normalization of carcinoembryonic antigen values. The solitary lung metastasis was sequentially treated with radiotherapy and resection. Five years after the initial diagnosis, this patient remains free from progression, with residual cystic remnants of the liver metastases visible on conventional computed tomography imaging, but not enhancing with fluorodeoxyglucose positron-emission tomography.

Cerebrospinal fluid tau and phosphorylated tau protein are elevated in corticobasal syndrome.

Differentiating corticobasal syndrome (CBS) from progressive supranuclear palsy (PSP) and idiopathic Parkinson's disease (PD) can be difficult. To investigate the additional value of cerebrospinal fluid (CSF) biomarkers in the diagnostic differentiation of parkinsonism, we analyzed the CSF concentrations of total protein, lactate and brain specific proteins amyloid-ß(42) protein, tau protein (t-tau), and tau protein phosphorylated at Thr181 (p-tau), in CSF samples from patients with PSP (n = 21), CBS (n = 12), and PD (n = 28). CBS patients demonstrated higher concentrations of t-tau and p-tau compared with PSP and PD patients. In discriminating CBS and PD, t-tau offered the best combination of sensitivity (75%) and specificity (90.9%), followed by p-tau (sensitivity 87.5% and specificity 75%). The p-tau/t-tau ratio resulted in sensitivity of 84.2% and specificity of 66.7% in discriminating PSP and CBS. In conclusion, our results suggest that CSF parameters are of additional value in the diagnostic differentiation of CBS and PD.