00:00:00: Pradeep Mundre: Hello everyone, welcome to this episode of the UEG podcast.

00:00:04: Pradeep Mundre: It's Pradeep Mundre here.

00:00:05: Pradeep Mundre: I'm a gastroenterologist from the UK and podcast host for this episode.

00:00:10: Pradeep Mundre: Now GI symptoms are very common and when these symptoms begin to interfere with patients' life, our daily life,

00:00:17: Pradeep Mundre: patients seek medical care and they're usually seen in clinic by gastroenterologists and we do various tests for these patients.

00:00:25: Pradeep Mundre: and when we don't find any organic cause for these persistent symptoms, often patients are told that there's nothing wrong.

00:00:33: Pradeep Mundre: and that's not a very good narrative I think and actually not true and the Rome Foundation has been working to change this narrative and have done a wonderful job.

00:00:44: Pradeep Mundre: and the Foundation has created a diagnostic symptom based criteria which has recently transformed the concept of functional GI disorders into disorders of gut-brain interaction

00:00:56: Pradeep Mundre: which is probably more accurate framework and that is sort of increasingly accepted and utilised globally.

00:01:05: Pradeep Mundre: and I guess this effort has legitimised these prevalent conditions and promoted development of new treatment and improved the quality of life for our patients.

00:01:16: Pradeep Mundre: and the outcomes and the Rome Foundation have now come up with their latest iteration, the Rome V.

00:01:23: Pradeep Mundre: Diagnostic and Therapeutic Standards and today's podcast is about this and we're going to discuss what's new in the Rome V edition, what are the new diagnosis that are added in here,

00:01:36: Pradeep Mundre: what changes the team have made to the existing condition definitions and briefly touch upon some of the principles of treatment.

00:01:45: Pradeep Mundre: and to discuss this today we have our wonderful guest Professor Maura Corsetti, Associate Professor of Gastroenterology at Nottingham University Hospitals in the UK.

00:01:56: Pradeep Mundre: Maura leads the Neurogastroenterology Unit there and the GI Motility Lab.

00:02:01: Pradeep Mundre: She's one of the board of directors of the Rome Foundation and one of the co-chairs of the Bowel Disorders Committee.

00:02:10: Pradeep Mundre: She also works with the UEG, representative of the UEG Scientific Committee and is chair of the postgraduate teaching course at the UEG.

00:02:20: Pradeep Mundre: Welcome to UEG Podcast, Maura.

00:02:21: Maura Corsetti: Thank you, Pradeep, and thank you for inviting me.

00:02:26: Pradeep Mundre: Excellent.

00:02:26: Pradeep Mundre: Well, let's kickstart.

00:02:28: Pradeep Mundre: The umbrella term, the disorders of gut-brain interaction, DGBI, let's call it, for the purpose of the podcast.

00:02:37: Pradeep Mundre: What does this include and why did you and your team change the name from previously known, you know...

00:02:45: Pradeep Mundre: I'm guilty of still using the term functional GI disorders, I have to say.

00:02:50: Maura Corsetti: So, well, let's say that this effort of changing the term from functional GI disorder to disorder of gut-brain interaction has started back in 2016,

00:03:00: Maura Corsetti: where it was recognised that the term functional attached to some kind of stigma for the patient,

00:03:07: Maura Corsetti: because when we say functional, we try to intend that this patient has no organic condition and we tend to say that it's not a real condition.

00:03:17: Maura Corsetti: So it's something that is really a psychologically driven kind of disorder.

00:03:22: Maura Corsetti: So we recognise that this was actually a problem for the patient.

00:03:26: Maura Corsetti: And also, I would say from the clinician, because of course, there was no understanding that over the time, our knowledge has improved.

00:03:34: Maura Corsetti: And now we know that these are indeed the disorder of gut-brain interaction because they involved evidence of visceral hypersensitivity, dysmotility,

00:03:44: Maura Corsetti: alteration in the way that our brain filtered the sensation, alteration in the permeability of the gut and all these kinds of factors are all together.

00:03:54: Maura Corsetti: So it's a more complex picture.

00:03:56: Maura Corsetti: And we think that indeed, the disorder of gut-brain interaction captured better this kind of complex pathophysiology and pathogenesis of symptoms.

00:04:06: Pradeep Mundre: Okay.

00:04:06: Pradeep Mundre: So essentially, you are moving away from kind of calling this absence of organic disease to a pathophysiological process related to all that you mentioned.

00:04:19: Pradeep Mundre: So you mentioned about motility.

00:04:20: Pradeep Mundre: Sorry, can you say that again?

00:04:21: Pradeep Mundre: What are the pathophysiological that comes under the umbrella of DGBI?

00:04:28: Maura Corsetti: So the research over the last 35 years has definitely demonstrated that this disorder of gut-brain interaction are indeed caused by a more complex mechanism

00:04:40: Maura Corsetti: that involve visceral hypersensitivity, alteration in the motility, alteration in the mucosal and immunology function, alteration in the microbiota,

00:04:52: Maura Corsetti: and also in the process, in the way that the brain process our sensation.

00:04:58: Maura Corsetti: So all these mechanisms together are really implicated in the pathophysiology of symptoms of this disorder.

00:05:05: Maura Corsetti: So that's why we believe that disorder of gut-brain interaction is a term that captures better the complex mechanism behind these disorders.

00:05:15: Pradeep Mundre: And Maura, let's say if you consider a particular diagnosis, is one of these factors involved or a combination of these things that you mentioned are involved in the pathophysiology?

00:05:27: Pradeep Mundre: I'm just trying to kind of gauge, depending on the diagnosis, just one function that is affected.

00:05:33: Maura Corsetti: No, no, no.

00:05:34: Maura Corsetti: Is all together playing a role.

00:05:38: Maura Corsetti: Of course, there are conditions where some alteration might be more prevalent than others, as far as we know at the moment.

00:05:46: Maura Corsetti: For example, I'm thinking about irritable bowel syndrome.

00:05:50: Maura Corsetti: The evidence are quite clear that the visceral hypersensitivity is one of the major factors in this condition,

00:05:58: Maura Corsetti: but they are likely to be all involved for each of these disorders altogether.

00:06:03: Maura Corsetti: Yes.

00:06:05: Pradeep Mundre: Yeah.

00:06:05: Pradeep Mundre: I guess in the future, we'll know more about how they interplay and all that.

00:06:10: Pradeep Mundre: I guess there's more and more research into understanding this, or more and more tests that are being developed and things.

00:06:18: Pradeep Mundre: Is that correct?

00:06:19: Maura Corsetti: Yes.

00:06:19: Maura Corsetti: Yes.

00:06:20: Maura Corsetti: If you are alluding at the fact that at the moment we don't have indeed a biological biomarker for this condition, we hope that in the future we will be able really to identify,

00:06:32: Maura Corsetti: and probably, for example, microbiota would be one of the things that might turn out to be one of the biomarker of this condition.

00:06:42: Maura Corsetti: But at the moment, I think that the research needs to really still continue, and hopefully we will come to this moment.

00:06:50: Maura Corsetti: But for sure, what we have understood over the years is that it's a complex interaction of all these factors,

00:06:58: Maura Corsetti: and therefore functional is not implying that the condition is related with psychological alteration, and that's it.

00:07:07: Maura Corsetti: This is not really reflecting the evidence.

00:07:11: Pradeep Mundre: Okay.

00:07:11: Pradeep Mundre: That's great.

00:07:12: Pradeep Mundre: Maura, let's talk about the Rome Foundation.

00:07:16: Pradeep Mundre: What is it, and what do they do?

00:07:19: Pradeep Mundre: And what's your role within the Rome Foundation.

00:07:23: Pradeep Mundre: Am I right or am I wrong?

00:07:24: Pradeep Mundre: Is it a myth that it's based in Rome, or is it based anywhere somewhere else?

00:07:29: Maura Corsetti: Well, it was established in 1990, actually, and is a nonprofit group of people that work together.

00:07:37: Maura Corsetti: Actually, I'm quite proud to say that everything started in Rome in Italy because it was Aldo Torsoli that was a professor of medicine at that time,

00:07:48: Maura Corsetti: who recognised that this kind of disorder was not legitimate because they were considered to be a disorder that without any diagnostic criteria, without a specific treatment.

00:08:01: Maura Corsetti: So it was the first they decided to put together a group of experts, international experts, to really define this condition.

00:08:08: Maura Corsetti: And from that point since now, we have been working really updating every time the research and the evidence really come up with the Rome V reiteration of this condition.

00:08:24: Maura Corsetti: So the Rome Foundation is really the association that tried to educate, to improve the education, the research,

00:08:31: Maura Corsetti: and the clinical care of these people and brought really to the legitimation of this condition.

00:08:38: Maura Corsetti: that after the work of Rome Foundation now, we have criteria that are used in clinical trial to define the response of some specific treatment.

00:08:48: Maura Corsetti: And we have really diagnostic criteria that are applied everywhere now also at global level to really define this condition.

00:08:58: Pradeep Mundre: Maura, you mentioned about the latest iteration, Rome V.

00:09:02: Pradeep Mundre: So you define various things from diagnostic criteria to therapeutic standards and all those things.

00:09:08: Pradeep Mundre: Why was there a need to change to Rome V?

00:09:12: Pradeep Mundre: Was there a real need for this?

00:09:14: Pradeep Mundre: And why did we need an update at this time?

00:09:18: Maura Corsetti: So take in mind that Rome IV criteria were released in 2016.

00:09:23: Maura Corsetti: So now we are 10 years later.

00:09:26: Maura Corsetti: And definitely we have more evidence from the science that really regarding the pathophysiology and the mechanism of this condition that have emerged.

00:09:35: Maura Corsetti: And also we are now, as I said before, more clear that these are disorders of the gut-brain interaction.

00:09:42: Maura Corsetti: So there was the need to really update all the diagnostic criteria and also the evidence about the pathophysiology and the treatment for this condition.

00:09:52: Maura Corsetti: And for example,

00:09:53: Maura Corsetti: there were also some conditions that before were not defined in the previous iteration and needed to be really defined this time because there was a need from the clinical practice.

00:10:04: Maura Corsetti: And maybe we can enter in detail of this in a minute.

00:10:08: Pradeep Mundre: Moving on, Maura, I was looking through the paper and essentially the disorders have been classified into six categories based on their anatomical site, as you alluded to.

00:10:18: Pradeep Mundre: Can you explain what they are in brief?

00:10:22: Pradeep Mundre: And maybe you can give us some examples just so that it gives us a little insight into whatever you choose.

00:10:29: Pradeep Mundre: We don't have time to go through all of them, but some of them that are of interest to you.

00:10:33: Maura Corsetti: Okay.

00:10:33: Maura Corsetti: So yes, we have the oesophageal disorder.

00:10:37: Maura Corsetti: And to give an example, for example, functional chest pain that is quite prevalent and is something that I think many clinicians are familiar with.

00:10:46: Maura Corsetti: Then we have the gastroduodenal disorders.

00:10:49: Maura Corsetti: And here I think that I can mention, for example, functional dyspepsia or cyclic vomiting syndrome.

00:10:55: Maura Corsetti: And that is also something that is frequently encountered in clinical practice.

00:11:00: Maura Corsetti: Then bowel disorder.

00:11:01: Maura Corsetti: And as I mentioned before, irritable bowel syndrome.

00:11:04: Maura Corsetti: The centrally mediated disorders, which I think are probably less recognised in clinical practice and people are not so familiar probably with this

00:11:13: Maura Corsetti: because we have a condition like the narcotic bowel syndrome or the centrally mediated abdominal pain.

00:11:19: Maura Corsetti: And maybe we can come back to this because I think that these are quite important condition that they are not really frequently reported in clinical practice.

00:11:28: Maura Corsetti: Then we have the gallbladder and sphincter of Oddi disorders.

00:11:32: Maura Corsetti: And here I think that the biliary sphincter of Oddi disorders is something that maybe in the past was more frequently reported than that more recently.

00:11:42: Maura Corsetti: And here there are some indeed evidence that of a change.

00:11:46: Maura Corsetti: Then the anorectal disorder.

00:11:48: Maura Corsetti: And here I think that many people are familiar with the term dyssynergic defecation, for example, that is frequent in our patient, but also faecal incontinence.

00:11:59: Maura Corsetti: And then we have, of course, all the chapter of the paediatric condition,

00:12:04: Maura Corsetti: where there now the change that had been made in Rome V is really that they have been aligned a little bit more with the adult diagnostic criteria,

00:12:13: Maura Corsetti: which I think was something that was necessary to make sure that the children are diagnosed in a similar way as the adults,

00:12:21: Maura Corsetti: especially this is important when we need to transition the children from the adult care.

00:12:28: Maura Corsetti: And I think that this was something that was needed.

00:12:30: Maura Corsetti: So these are the different categories that are considered.

00:12:35: Pradeep Mundre: Maura just mentioned the six different subcategories based on anatomical regions.

00:12:42: Pradeep Mundre: I'm assuming in clinical practice, you would see patients with overlap between different categories.

00:12:49: Pradeep Mundre: How common is that?

00:12:51: Pradeep Mundre: And is that correct?

00:12:52: Pradeep Mundre: So I'm assuming on the same basis patients will have multiple diagnosis labelled to them.

00:12:58: Maura Corsetti: Yes, definitely.

00:12:58: Maura Corsetti: This is the case.

00:12:59: Maura Corsetti: And the most recent evidence suggests that indeed 35% of the patient have an overlapping between the different conditions.

00:13:09: Maura Corsetti: For example, in IBS is not infrequent that IBS patient overlap with the functional dyspepsia.

00:13:15: Maura Corsetti: So they have symptoms from the upper GI and from the lower GI.

00:13:19: Maura Corsetti: And it's important to recognise this overlapping because it has been demonstrated that this patient tends to have more severe symptoms

00:13:26: Maura Corsetti: and have a quality of life that is more affected than patient with a single diagnosis.

00:13:31: Maura Corsetti: And so this is why it's quite important to know that this happens.

00:13:36: Maura Corsetti: And then when you assess the symptoms, really recognise that in this specific patient, you have two or more conditions that are overlapping.

00:13:46: Pradeep Mundre: Okay.

00:13:47: Pradeep Mundre: So more severe patients will have more overlapping symptoms related to different anatomical regions.

00:13:53: Pradeep Mundre: That's good to know.

00:13:54: Pradeep Mundre: And how strict are you in applying that criteria?

00:13:58: Pradeep Mundre: I read a few of them and things have changed a little bit.

00:14:02: Pradeep Mundre: It seems a bit relaxed this time compared to the previous one, especially in IBS maybe.

00:14:07: Pradeep Mundre: So how strict are you in applying the criteria and how does that vary?

00:14:11: Pradeep Mundre: Let's say research versus clinical practice.

00:14:14: Maura Corsetti: I have to say that I'm not applying in a strict way the criteria, meaning that I count for example,

00:14:21: Maura Corsetti: how many times the patient is reporting the episode of pain to make the diagnosis of IBS.

00:14:28: Maura Corsetti: Because in the new criteria, we know that abdominal pain or discomfort needs to happen at least three times a month.

00:14:36: Maura Corsetti: So I'm not really so strict in looking into this because this is something that in clinical practice, you cannot really apply in a really specific way.

00:14:47: Maura Corsetti: But of course, what I'm applying is the concept that to make a diagnosis, I need to have a patient with abdominal pain or discomfort.

00:14:55: Maura Corsetti: And this needs to be associated with an alteration in the bowel habit that can be constipation, diarrhoea or alternating bowel habit.

00:15:03: Maura Corsetti: And the key question that I use in clinical practice is to say,

00:15:07: Maura Corsetti: do you think that this pain gets better or get worse when you open the bowel or get worse when you are more constipated and more diarrhoeic?

00:15:15: Maura Corsetti: So this is a way to apply in clinical practice.

00:15:19: Maura Corsetti: The concepts that are important to make the diagnosis, of course, with the caveat that in clinical practice, you need to be more flexible and you cannot really be too specific.

00:15:30: Maura Corsetti: And of course, as you alluded about the duration, of course, I know that according to the Rome criteria, we need to have symptoms that started six months before.

00:15:40: Maura Corsetti: But I recognise that if I, for example, I'm a primary care physician, of course, I cannot wait six months before I can make the diagnosis.

00:15:49: Maura Corsetti: Of course, that's why some clinical criteria have been developed to say, of course, if you have a patient that developed the symptoms and has a duration of, let's say,

00:15:59: Maura Corsetti: eight weeks is already suggesting this condition.

00:16:02: Maura Corsetti: And then, of course, in primary care, we have a lot of our other information because the patient normally comes,

00:16:09: Maura Corsetti: we know better the patient than in secondary care when we see the patient after this patient has been followed up for four years from the GP.

00:16:17: Maura Corsetti: So I think that in secondary care, definitely we are in a better position.

00:16:22: Maura Corsetti: It's easier for us to say, okay,

00:16:24: Maura Corsetti: this is a patient with a disorder of gut-brain interaction because it arrives to us after another person really investigated or followed up for many years.

00:16:34: Maura Corsetti: And I think that the concept that I want to transmit is really that you need to know what are the symptoms that are suggesting the diagnosis.

00:16:42: Maura Corsetti: You need to know that the longer is the duration of the symptom, the more likely is that a patient has a disorder of gut-brain interaction.

00:16:50: Maura Corsetti: But of course, in clinical practice,

00:16:52: Maura Corsetti: we cannot expect people to know and remember each of the different criteria with the exact frequency of the symptom because this probably will never happen.

00:17:01: Maura Corsetti: So I think.

00:17:02: Pradeep Mundre: Yeah.

00:17:02: Pradeep Mundre: And it's a bit vague, isn't it?

00:17:04: Pradeep Mundre: And what's three times a month is... Yeah.

00:17:08: Pradeep Mundre: It doesn't make much difference.

00:17:09: Pradeep Mundre: I guess what you're trying to say is the quality of the symptoms matter, but the quantitative things that have been defined, you're a bit relaxed about this in clinical practice.

00:17:20: Maura Corsetti: Yes.

00:17:21: Maura Corsetti: Because then, well, when you are in research, you need to make sure that you, of course,

00:17:26: Maura Corsetti: enroll all the same people that have that characteristic and you need to make sure that you are not including patient that might not have this condition because otherwise.

00:17:37: Maura Corsetti: And this is, of course, a different situation in research.

00:17:41: Maura Corsetti: You need to be strictly applying this criteria, I think.

00:17:45: Pradeep Mundre: OK.

00:17:46: Pradeep Mundre: That leads on to my next point.

00:17:49: Pradeep Mundre: I want to ask is there was a subsection there mentioning about Rome clinical criteria.

00:17:55: Pradeep Mundre: Is that something that we follow as clinicians and the researchers follow the actual main criteria?

00:18:02: Pradeep Mundre: Is that what it's devised towards?

00:18:05: Maura Corsetti: The idea of creating some clinical criteria was because we recognise and well, with the help of the interaction with the primary care.

00:18:15: Maura Corsetti: And I mean, Pali Hungin from UK was one of the GP that was involved in this process.

00:18:20: Maura Corsetti: We recognise that clinicians find it a little bit difficult to understand and to follow the criteria of the foundation.

00:18:29: Maura Corsetti: And there were always some criticism that these were not easy to really apply in clinical practice.

00:18:34: Maura Corsetti: So that's why there was this need, which I think is quite important to make,

00:18:39: Maura Corsetti: to digest in some way the criteria for the clinician that is not expert or has no time to really actually apply and do the things as they are done, for example, in research.

00:18:52: Maura Corsetti: So that's why this was really something that was needed.

00:18:55: Maura Corsetti: And I think that was an important addition to the Rome V iteration.

00:19:01: Pradeep Mundre: So, Maura, let's unpick a couple of definitions, probably from the educational point of view,

00:19:06: Pradeep Mundre: probably just to give a bit of an essence as to how these are defined and what's written down there so that it helps us so that we can go back and reflect,

00:19:15: Pradeep Mundre: because it's impossible to remember all those things.

00:19:19: Pradeep Mundre: So you just pick whatever, you know, maybe IBS, rumination.

00:19:23: Pradeep Mundre: You mentioned about narcotic bowel syndrome.

00:19:24: Pradeep Mundre: Maybe you can talk about that.

00:19:26: Pradeep Mundre: So kind of if you just alluded to the definitions and how easy is that to understand and apply in clinical practice?

00:19:35: Maura Corsetti: So, well, I can probably start with an example of irritable bowel syndrome, because it was one of the criteria that we revised in our committee.

00:19:44: Maura Corsetti: And I think it's very important because it's one of the most prevalent condition that you encounter in clinical practice.

00:19:50: Maura Corsetti: And what has changed there is that we relaxed a little bit the criteria in the sense that before, to qualify for a diagnosis for IBS,

00:20:00: Maura Corsetti: you needed to have abdominal pain only and abdominal pain with a frequency of at least once per week.

00:20:09: Maura Corsetti: And then this was associated, as I said before, with the relation, with the defecation, with the altered bowel habit.

00:20:17: Maura Corsetti: But over the last 10 years, we realised that these criteria were too selective.

00:20:22: Maura Corsetti: We're selecting those people with IBS that had more severe pattern, because actually they were the patients that were presenting with these symptoms every week.

00:20:31: Maura Corsetti: But we were excluding all these patients that have a less severe presentation.

00:20:37: Maura Corsetti: And in particular, and this is the effort that was made with Rome V, to really take into account also on what is happening in the different continent of the world.

00:20:46: Maura Corsetti: Because we tend to concentrate on our experience in UK or in Western countries.

00:20:52: Maura Corsetti: But we forgot, for example,

00:20:54: Maura Corsetti: that in Asian countries, it was quite clear that IBS in those countries was not presenting in some, in a percentage of people, were not presenting with abdominal pain,

00:21:05: Maura Corsetti: but more with abdominal discomfort.

00:21:08: Maura Corsetti: So this is the reason why we introduced also the term abdominal discomfort.

00:21:14: Maura Corsetti: So the patient might present with abdominal pain or abdominal discomfort with a frequency that needs to be at least three times per month,

00:21:23: Maura Corsetti: but without the requirement of being once per week that was identifying this kind of more severe patient.

00:21:30: Maura Corsetti: And the other things that we added is also the fact that this pain needs to be not continuous.

00:21:36: Maura Corsetti: So I think that maybe you might be familiar with these patients that come to your clinic and say, well, doctor, I have pain every day for the entire day.

00:21:45: Maura Corsetti: And this is not changing, no matter what I'm doing.

00:21:49: Maura Corsetti: Well, this is a different patient from an IBS patient that has pain maybe every day, but is more an intermittent kind of pain that is associated with some of the physiological stimuli.

00:22:01: Maura Corsetti: So like getting worse after eating, or indeed, as I said, having the relation with the bowel habit or with the defecation.

00:22:10: Maura Corsetti: For example, in my experience, those people that come and are on long-term opioids,

00:22:15: Maura Corsetti: this tends to be the patient that have this kind of continuous pain that is constantly there as soon as they wake up.

00:22:23: Maura Corsetti: And it never gets better and can last, well, four months.

00:22:26: Maura Corsetti: This is a different kind of population.

00:22:28: Maura Corsetti: So with this non-continuous, we wanted to really make sure that we discriminate the two kinds of patients,

00:22:35: Maura Corsetti: which I think, well, we will see then with a future study whether we will achieve this aim, because of course, we need to confirm this.

00:22:44: Maura Corsetti: But from the validation study that has been done so far, it seems that there were at least 3% of the patients that were previously classified as IBS that probably have this kind

00:22:55: Maura Corsetti: of centrally mediated pain that is a different kind of presentation and is also a different treatment because normally, these people are more difficult,

00:23:04: Maura Corsetti: their pain is more difficult to treat as compared to the IBS one, for example.

00:23:10: Pradeep Mundre: Now, okay.

00:23:10: Pradeep Mundre: I guess the discrimination or the kind of teasing out different diagnosis is important because I think we will be guilty in clinical practice that everything gets labelled as IBS.

00:23:23: Maura Corsetti: Yes.

00:23:24: Pradeep Mundre: And this differentiation is important.

00:23:27: Pradeep Mundre: I guess that's because the therapeutic approach or management is different.

00:23:32: Pradeep Mundre: And maybe that reflects because the pathophysiology is different for different labels.

00:23:36: Pradeep Mundre: Is that what you're trying to say?

00:23:38: Maura Corsetti: Yes.

00:23:38: Maura Corsetti: Because for example, in my experience, I see that this patient on long-term opioids, you can thrive whatever you want in regard of neuromodulators.

00:23:49: Maura Corsetti: And they do not respond so well until you don't really decide to wean off your opioids.

00:23:56: Maura Corsetti: Because let's come also to the problem that is a big problem here in UK,

00:24:00: Maura Corsetti: that a lot of our patients are on long-term opioids without any clinical indication because we know that in the long-term, we should not be using opioids.

00:24:10: Maura Corsetti: And so probably, we need to really target this patient in a different way.

00:24:15: Maura Corsetti: While those patients with IBS, we need to also take into consideration the alteration in the bowel habit and then decide the treatment accordingly.

00:24:24: Maura Corsetti: So I think that definitely there is importance in recognising this.

00:24:27: Maura Corsetti: Like for example, recognising that a patient that has an epigastric pain stays there,

00:24:33: Maura Corsetti: and there's no relation with the alteration in the bowel habit, more likely, this patient is a functional dyspepsia patient rather than an IBS.

00:24:42: Maura Corsetti: And of course, if you don't have the alteration in the bowel habit, it's important because some medications are used regardless of whether the patient has diarrhoea or constipation.

00:24:52: Maura Corsetti: But some other medications can be used only in some specific bowel habit.

00:24:57: Maura Corsetti: So I think that taking this in consideration is quite important for the treatment.

00:25:02: Maura Corsetti: And this is why I always say that in this condition more than in others' condition, taking a good clinical history is the key.

00:25:10: Maura Corsetti: Because if you really understand how the symptoms are presenting and what is the duration of the symptoms, that is the key question,

00:25:18: Maura Corsetti: then you are already making your diagnosis just with the clinical history taken without even going to the investigation because you know already, well,

00:25:28: Maura Corsetti: the symptoms are characteristics of this condition, of course.

00:25:32: Maura Corsetti: Then you have few tests that you need to add.

00:25:34: Maura Corsetti: For example, in IBS, for sure, you will need to make sure that the patient is not anaemic, that the patient has no weight loss, that the patient has a normal CRP.

00:25:45: Maura Corsetti: But I mean, already from the clinical history taking, you can say, okay, my suspect is in this direction.

00:25:52: Maura Corsetti: Then your test will just confirm or disprove your suspect, I think.

00:25:58: Pradeep Mundre: So Maura, what are the new diagnosis that have been introduced in Rome V that didn't exist previously?

00:26:05: Pradeep Mundre: They must be, came across 1 or 2.

00:26:07: Pradeep Mundre: Can you explain what they are and sort of briefly see what the criteria were for diagnosing them?

00:26:14: Maura Corsetti: Yes.

00:26:14: Maura Corsetti: So I will touch mainly on the ones that are pertinent to the lower GI tract because I think you will have probably another podcast that was really dealing with the upper GI.

00:26:28: Maura Corsetti: But in any case, the inability to belch in the upper GI is definitely a new diagnosis that was introduced in Rome V.

00:26:36: Maura Corsetti: While in the lower GI tract, we have the abdominal migraine that was not present before and the anorectal sensory dysfunction disorder.

00:26:45: Maura Corsetti: So let me explain a little bit better what they are.

00:26:48: Maura Corsetti: So the abdominal migraine is a condition that was recognised many years ago in adults,

00:26:55: Maura Corsetti: but for some reason was more well recognised in children and was part of the Rome criteria in the children since ever,

00:27:05: Maura Corsetti: but never been really defined also for the adults.

00:27:09: Maura Corsetti: And this is a condition where the patient presents with this kind of stereotypical episode of pain that can last a few hours or even a few days.

00:27:20: Maura Corsetti: And then in between this episode, the patient is almost completely fine.

00:27:25: Maura Corsetti: And this pain is associated with some kind of other symptoms while this patient presents frequently also with migraine or with the family history of migraine.

00:27:39: Maura Corsetti: And they remind in some way those people with cyclic vomiting syndrome.

00:27:44: Maura Corsetti: So in the cyclic vomiting syndrome, the patient presents mainly with the episode of vomiting and between this episode, they are perfectly fine.

00:27:52: Maura Corsetti: Some of them might also have pain.

00:27:54: Maura Corsetti: So this is a condition that remember a little bit this kind of same pattern.

00:27:59: Maura Corsetti: And it's definitely something that affects quite a lot the quality of life of this patient

00:28:05: Maura Corsetti: because these are unpredictable episodes that disturb the possibility of functioning for this patient for a few days or even an entire week.

00:28:13: Maura Corsetti: So it's something that needed to be defined and recognised also in the adult population.

00:28:18: Maura Corsetti: And in this case, we were the adults that were actually learning from the paediatrics, not the other way around really to define this condition.

00:28:27: Maura Corsetti: The other condition that is the anorectal sensory disorder is something that over the years, we recognise that there are some patients that present with the hyposensitivity,

00:28:38: Maura Corsetti: in the rectum or hypersensitivity.

00:28:41: Maura Corsetti: So they have a threshold to report symptoms like urgency to defecate or symptoms like pain that is higher in this case,

00:28:49: Maura Corsetti: hyposensitivity or lower hypersensitivity when we test them with the anorectal manometry, for example,

00:28:57: Maura Corsetti: where we have this balloon that is standing inside the rectum and we study the sensitivity of the rectum.

00:29:04: Maura Corsetti: So of course, this is something that now is clear.

00:29:06: Maura Corsetti: For example, we know in chronic constipation, roughly 25% of the patient have an hyposensitivity to rectal distension.

00:29:16: Maura Corsetti: While, for example, in IBS, they tend to have an hypersensitivity of the rectum.

00:29:22: Maura Corsetti: And because these are conditions that you can actually treat with the biofeedback, you can actually teach a patient how to really improve the sensitivity of the rectum.

00:29:34: Maura Corsetti: And actually, with some medication, you can decrease the rectal sensitivity.

00:29:39: Maura Corsetti: We recognise that this is an important aspect that needed to be added to this criteria.

00:29:46: Maura Corsetti: And we will see in the future whether this will allow us to identify those patients that respond better to some specific treatment than the other.

00:29:54: Maura Corsetti: So I think that this is something that definitely was important to address.

00:30:00: Pradeep Mundre: I guess the fact that these new diagnosis are there, there'll be more knowledge gained on these conditions before the next iteration.

00:30:07: Pradeep Mundre: I guess that leads on to therapeutic changes for these patients.

00:30:10: Maura Corsetti: Yes, definitely.

00:30:12: Pradeep Mundre: So I've made a diagnosis and how would, let's say on a practical note, how would you in your clinic explain the diagnosis to the patients in simple terms?

00:30:23: Pradeep Mundre: You know, there's no point in giving the patient, oh, you have functional dyspepsia, so to say.

00:30:30: Pradeep Mundre: You have a functional disorder.

00:30:32: Pradeep Mundre: And I think we're not good at explaining this.

00:30:34: Pradeep Mundre: Maybe there must be some simple terminology that you would use.

00:30:37: Pradeep Mundre: That would probably help the clinicians more who treat these patients.

00:30:42: Maura Corsetti: Yes, definitely.

00:30:43: Maura Corsetti: And I have to say that more recently, I have been using a pocket card that I can post in the podcast.

00:30:50: Maura Corsetti: I can post the link to the Rome Foundation pocket card part where you can actually use this.

00:30:57: Maura Corsetti: And it's very simple because it helps you to explain to the patient why this condition is a condition of disorder of gut-brain interaction.

00:31:06: Maura Corsetti: So basically with this pocket card,

00:31:08: Maura Corsetti: there is an illustration that is quite easy to understand where you have the brain and you have the gut and you have the spinal cord that connects the two actually parts.

00:31:19: Maura Corsetti: And then you have two different arrows, one that is green and the other one that is red.

00:31:24: Maura Corsetti: And I normally explain that in normal condition, myself, that I don't have IBS, I have my gut that is constantly sending information to my brain.

00:31:35: Maura Corsetti: My brain is able to filter the sensation and is really allowing only the sensation that I need to be conscious of to arrive to the brain.

00:31:46: Maura Corsetti: So this is telling us that this sensation that goes up with the red arrow are continuously happening, but the brain is filtering this with the green arrow that goes down.

00:31:59: Maura Corsetti: So the concept of the gate and the filtering of the brain.

00:32:03: Maura Corsetti: So in IBS, I explained that normally the red arrow is very active while the green one is inactive because and this is related to evidence that we have in the literature

00:32:15: Maura Corsetti: that the filtering activity of the brain is not functioning so well in patients with the disorder of gut-brain interaction.

00:32:24: Maura Corsetti: So normally then I explain, you know, this imbalance, you can treat this imbalance using some medication like for example,

00:32:33: Maura Corsetti: neuromodulators that tend to sort out this balance and make these two pathways again functioning properly.

00:32:41: Maura Corsetti: Or you can also use no pharmacological treatment like for example,

00:32:45: Maura Corsetti: hypnotherapy or cognitive behavioural treatment where we try to use the strength of our brain to control the physical symptoms.

00:32:55: Maura Corsetti: And in this way, in one explanation, in a few minutes, you show them a picture that they like.

00:33:01: Maura Corsetti: They normally like to take a picture of this card because it's very easy to understand.

00:33:08: Maura Corsetti: They can see the name of the Foundation, so it's not Maura Corsetti that developed this card and is inventing this data.

00:33:16: Maura Corsetti: And if they want, they can go back and check.

00:33:19: Maura Corsetti: And this really relates with the evidence in the literature.

00:33:24: Maura Corsetti: So we are saying something that is true, but using more simple way of explaining and also to represent this kind of imbalance between the gut and the brain.

00:33:35: Maura Corsetti: And in my experience, this works normally because then if they know and they go on the internet,

00:33:40: Maura Corsetti: then they will see that this condition are called disorder of gut-brain interaction and they will say, okay, then make sense.

00:33:47: Maura Corsetti: All fit with the explanation that they gave me.

00:33:50: Pradeep Mundre: Maura, that's an amazing way of explaining this because I think we tend to be very dismissive.

00:33:56: Pradeep Mundre: We just tend to say, okay, your scans are normal.

00:33:59: Pradeep Mundre: There's not much, it's just functional.

00:34:02: Pradeep Mundre: But the way you explain it, you're actually acknowledging the issue here.

00:34:07: Pradeep Mundre: And I guess that's very important for the patients rather than being dismissive.

00:34:11: Pradeep Mundre: I guess that builds that relationship that you have with the patients and that in itself is therapeutic for the patients.

00:34:17: Pradeep Mundre: Right.

00:34:17: Pradeep Mundre: Because you don't need to, do you treat, let's say, do you have to give drugs or do you have to send them to some sort of gut-directed therapy?

00:34:26: Pradeep Mundre: And how many of the patients do need treatment?

00:34:31: Pradeep Mundre: I'm assuming most patients don't need management as such, just an explanation.

00:34:36: Maura Corsetti: Yeah.

00:34:36: Maura Corsetti: So while taking mind that, of course, I work in a centre and I'm the referral for sometimes very difficult patient.

00:34:43: Maura Corsetti: And one of the problem is that they probably are explaining this concept too late.

00:34:49: Maura Corsetti: After many years of frustration, I've been told, well, you don't have anything, you don't have a cancer, but this is not what they want to hear.

00:34:56: Maura Corsetti: They want to understand, okay, I don't have a cancer, but what is the reason of my symptoms?

00:35:00: Maura Corsetti: And probably if we could start this earlier, and I was impressed this week, I had a patient that came referred by the GP and actually was the GP that explained all this concept.

00:35:11: Maura Corsetti: And the patient came to me saying, well, I have been told that this is a disorder of gut-brain interaction.

00:35:16: Maura Corsetti: I said, yes.

00:35:17: Maura Corsetti: And I just confirmed this.

00:35:18: Maura Corsetti: So I think that if we could start probably all together to really give this explanation in our clinic, also after an endoscopy, because it takes five minutes to say this.

00:35:29: Maura Corsetti: And with this pocket card, I can tell you, it's so easy.

00:35:32: Maura Corsetti: Then the patient go home, reflect on this.

00:35:34: Maura Corsetti: We will save a lot of endoscopy that are requested for nothing.

00:35:38: Maura Corsetti: And a lot of consultations that are just caused by the fact that we are really, we don't take the time to explain something that is quite simple.

00:35:47: Maura Corsetti: But of course, to explain this, you need to believe to this.

00:35:51: Maura Corsetti: Because the other problem is that I think one of the problem is, and we can probably discuss this a little bit more if you like, is also the education.

00:36:00: Maura Corsetti: And it's really, of course, I'm passionate about my work because I have been studied this since ever.

00:36:06: Maura Corsetti: But I think that just a little bit of more knowledge about the evidence that we have in the literature will make a massive difference to the care of our patient.

00:36:17: Maura Corsetti: And just explaining sometimes really, reassure the patient, and I normally add to this explanation, that this condition are chronic.

00:36:24: Maura Corsetti: We cannot treat, but we cannot cure, but we can treat this.

00:36:28: Maura Corsetti: And I add also that they are not attached with any increased risk of any increased more mortality, but of course they affect the quality of life.

00:36:37: Maura Corsetti: So I acknowledge something that the patient don't ask frequently.

00:36:41: Maura Corsetti: The fact that they are afraid about having a cancer, but they are not really telling us this.

00:36:47: Maura Corsetti: So if you say upfront, then it's something that you give in five minutes, all the important information, and then hopefully they will be reassured.

00:36:58: Maura Corsetti: Maybe not at the first consultation, maybe you need to repeat in some cases more times, but this is definitely better than organising a colonoscopy that will never change the symptoms

00:37:08: Maura Corsetti: and actually might also make worse the symptoms after the bowel preparation and all the discomfort that they have during the investigation, I think.

00:37:18: Pradeep Mundre: I guess what matters there is not just the symptoms.

00:37:22: Pradeep Mundre: What is more important is the impact the symptoms have on the quality of life.

00:37:27: Pradeep Mundre: And that probably determines how far you push in terms of treatment or further appointments and things.

00:37:36: Pradeep Mundre: So what are the general principles?

00:37:38: Pradeep Mundre: Because I don't think so.

00:37:39: Pradeep Mundre: There's one magic pill that works for these patients.

00:37:41: Pradeep Mundre: So you need a very comprehensive approach to managing these patients.

00:37:46: Pradeep Mundre: Can you explain briefly what are the basic principles of management of such patients?

00:37:51: Pradeep Mundre: And what's more important, maybe the most important ones you can look to?

00:37:55: Maura Corsetti: Yeah.

00:37:56: Maura Corsetti: So well, the first important thing is to make a diagnosis.

00:37:59: Maura Corsetti: So don't say to the patient, you don't have a cancer, but tell to the patient, OK?

00:38:03: Maura Corsetti: I think you have a disorder of gut-brain interaction.

00:38:06: Maura Corsetti: If you are not able to make a specific diagnosis, at least this, I think, is something important.

00:38:12: Maura Corsetti: Because the patient then will know that there is a diagnosis.

00:38:15: Maura Corsetti: Then explain what this disorder are, because this is part of the treatment.

00:38:20: Maura Corsetti: In all the guidelines, this is the first step that is quite important.

00:38:24: Maura Corsetti: Then you need to revise also the lifestyle of your patient, because there are patients that do not recognise that some of their habits might have also a role.

00:38:35: Maura Corsetti: I don't know if a patient is not managing the stress and recognise the stress is one of the factors that can make the symptoms worse.

00:38:45: Maura Corsetti: This is something that they can work around to really improve the symptoms.

00:38:50: Maura Corsetti: The same with the diet.

00:38:51: Maura Corsetti: It's very easy to assess and try to understand whether the patient is following some diet without any clinical indication.

00:38:59: Maura Corsetti: And this can help them already to correct some of the easy factors.

00:39:04: Maura Corsetti: And then, of course, you need to explain also to the patient what are the options.

00:39:09: Maura Corsetti: I normally offer the patient all the options, saying, OK, I can refer you first to the dietitian if I recognise that there is something that might be changing the diet.

00:39:20: Maura Corsetti: I can propose you a medication.

00:39:22: Maura Corsetti: And of course, depending on what the patient has tried before, I can select some first-line treatment like antispasmodics or medication like this.

00:39:32: Maura Corsetti: Or I can go directly to neuromodulators if the patient has more severe and has tried already the first-line treatment.

00:39:40: Maura Corsetti: Then, as regard to the non-pharmacological treatment like CBT or hypnotherapy, of course, unfortunately, this depends on what you have available in your centre.

00:39:52: Maura Corsetti: Because still we have a big problem that we are not able to offer all the patients.

00:39:57: Maura Corsetti: We would like this non-pharmacological treatment.

00:40:00: Maura Corsetti: A lot of patients now would like to really have a treatment like this rather than a medication.

00:40:07: Maura Corsetti: But of course, this is not possible every time.

00:40:11: Maura Corsetti: If we have this possibility, I would offer this at the very beginning.

00:40:15: Maura Corsetti: Because we don't need to refer only the refractory patient to this treatment.

00:40:20: Maura Corsetti: Because as I explained already before,

00:40:23: Maura Corsetti: the psychological aspect or also how to control and manage our stress is something that will be useful regardless of which kind of severity of symptoms you have.

00:40:35: Pradeep Mundre: OK.

00:40:35: Pradeep Mundre: And I think what you said, explained there, is acknowledging is very important.

00:40:40: Pradeep Mundre: But a few things that I picked up from that explanation is acknowledging the symptoms, acknowledging that they have disorders, gut-brain interaction is important.

00:40:51: Pradeep Mundre: And then you said to kind of unpick the trigger of things and then focus on the management.

00:40:56: Pradeep Mundre: Now, what harm does unnecessary repeated tests have on these patients rather than instead of acknowledging maybe earlier on that they have disorders, gut-brain interaction,

00:41:07: Pradeep Mundre: if you keep on doing repeated tests for these patients, does it cause any harm to them or does it cause worsening of symptoms in these patients?

00:41:16: Maura Corsetti: I think that the most important things that we need to consider is that continuously repeating tests gives the patient the message that we are not sure about our diagnosis.

00:41:27: Maura Corsetti: Because when you repeat another test, you are basically saying, well, I think that someone really missed something there.

00:41:35: Maura Corsetti: So how the patient can trust you if you continue to really request another investigation to be sure?

00:41:43: Maura Corsetti: And then, of course, if you are repeating always the same investigation at the certain moment, of course, they will get the message, OK, where are we going?

00:41:51: Maura Corsetti: Are my symptoms changing or not?

00:41:53: Maura Corsetti: They don't see the benefit, even though they like probably to have investigation because they think that this reassure them.

00:42:00: Maura Corsetti: There are evidence of the opposite because there are studies demonstrating that having doing a colonoscopy does not reassure the patient

00:42:09: Maura Corsetti: and is not really sorting out the fear of having something there.

00:42:14: Maura Corsetti: So at the certain moment, you need to show the patient that you are confident that sometimes what I do in my clinical practice, well,

00:42:22: Maura Corsetti: we assume that the patient remember all the investigation that they have done and they know the meaning of this investigation.

00:42:30: Maura Corsetti: Well, this is not the case.

00:42:31: Maura Corsetti: So in my clinical letter, and this is something that I think is a good trick for any clinician,

00:42:37: Maura Corsetti: is important to list all the previous investigation and then sometimes stop a minute and say, listen, let me remember you what you have done so far.

00:42:45: Maura Corsetti: And then you realise that they have done two gastroscopy, three colonoscopy, three CT scan.

00:42:52: Maura Corsetti: And at the end, you say, you see, we investigated everything.

00:42:55: Maura Corsetti: And according to my knowledge, I can be assured that I'm confident.

00:43:01: Maura Corsetti: I'm taking the risk of saying I'm confident about my diagnosis.

00:43:05: Maura Corsetti: So let's now think about helping you because if I do another investigation, then you will wait six months for another investigation.

00:43:13: Maura Corsetti: And how long you will be reassured for?

00:43:15: Maura Corsetti: Probably just two months is better that you try to really understand.

00:43:19: Maura Corsetti: And I think that sometimes taking the time and listing all the previous investigation works because then the patient say, OK.

00:43:27: Maura Corsetti: And then I explain, well, faecal calprotectin is to exclude inflammation.

00:43:31: Maura Corsetti: FIT test is to exclude the risk of a cancer.

00:43:34: Maura Corsetti: So, you know, then you target all the different fear that they have.

00:43:39: Maura Corsetti: And I don't say I think.

00:43:42: Pradeep Mundre: Maura, I've come across some patients who, you know, you see the patients and you, they deny the role of psychosocial factors in their illness.

00:43:51: Pradeep Mundre: You know, you ask them whether they have any of these contributing and they deny these things and they consistently seek repeated tests, repeated investigations.

00:43:59: Pradeep Mundre: And they usually not willing to engage or explore these other gut, brain gut behavioural treatments.

00:44:06: Pradeep Mundre: How do you approach those patients?

00:44:09: Pradeep Mundre: And are they the more severe and a spectrum?

00:44:11: Pradeep Mundre: Are they more milder patients?

00:44:13: Maura Corsetti: So I think that while this is an important subject, probably people that work like us in more secondary or tertiary care hospitals tends to see more frequently.

00:44:25: Maura Corsetti: This indeed are patients where it's difficult sometimes to really explain and make them believe in what you are saying.

00:44:33: Maura Corsetti: What I found in my clinical practice is again, taking the time with these people, as I said before, to explain,

00:44:39: Maura Corsetti: because mind be that and it's not infrequent that these people have never been explained before.

00:44:45: Maura Corsetti: What is a disorder of gut-brain interaction?

00:44:48: Maura Corsetti: And I try not to really, even though I recognise that this patient might have an important psychological component, I try to always focus on the.

00:44:59: Maura Corsetti: relation between the gut and the brain rather than saying that most of their symptoms are probably well related to this psychological distress.

00:45:10: Maura Corsetti: And I try to really work and maybe can take more than one consultation to reach this point.

00:45:16: Maura Corsetti: It can also be that collaborating with other colleagues, for example, if I refer to a dietitian, the dietitian of my team will repeat some concept and is really the repetition.

00:45:27: Maura Corsetti: For example, yes, recently I've done a study really looking at, well,

00:45:33: Maura Corsetti: one of my fellow did a study really looking at how the patient perceive our input and the input of the primary care in understanding their symptoms.

00:45:44: Maura Corsetti: And I find out that is really the number of years of frustration of being not explained this condition that is what is really making these people arriving to your care and then say,

00:45:56: Maura Corsetti: well, I don't trust anymore anyone.

00:45:59: Maura Corsetti: So maybe it's really the time to stop and try to work with all the other colleagues together.

00:46:05: Maura Corsetti: Sometimes they say, okay, I don't believe you.

00:46:07: Maura Corsetti: I want to have another consultation, another second opinion.

00:46:11: Maura Corsetti: Then here in Nottingham, we develop a system where if they go to another one, of course they will assess whether I miss anything because I'm not perfect.

00:46:20: Maura Corsetti: It can be that I miss anything, but they tend to really repeat the concept so that the patient finds some consistency rather than going to another colleagues

00:46:29: Maura Corsetti: and be ordered another investigation that this will not help.

00:46:33: Maura Corsetti: Definitely, I think.

00:46:35: Maura Corsetti: So it's really be patient and explain again and again and again.

00:46:39: Pradeep Mundre: Yeah, I guess that we will refer you to the card that you mentioned.

00:46:43: Pradeep Mundre: I'm assuming that, I don't know, we will be putting a link of that at the bottom page of the podcast.

00:46:52: Pradeep Mundre: We should probably bring it to the close, Maura.

00:46:54: Pradeep Mundre: Any final thoughts before we close this?

00:46:58: Maura Corsetti: Well, so as I alluded before,

00:47:01: Maura Corsetti: I think that one of the things that at the moment are really missing for us and for all the healthcare system is really proper educational course that really teach the basic.

00:47:17: Maura Corsetti: So how to really start from the symptoms and recognise the different condition and being able and confident in making a diagnosis and then prepare a plan for your patient.

00:47:29: Maura Corsetti: So with the BSG, we have been developing a basic course where we are going to teach how to make the diagnosis of the most frequent condition, IBS,

00:47:40: Maura Corsetti: functional dyspepsia, cyclic vomiting syndrome, chronic constipation and also give an idea of the clinician, what means a dietary treatment,

00:47:51: Maura Corsetti: what means using the brain gut behavioural treatment and also what are the communication skills that you need.

00:47:59: Maura Corsetti: to develop in general because these are patients that are probably more difficult for a clinician because we don't have a biological marker and we cannot take a biopsy and say, okay,

00:48:10: Maura Corsetti: I can make you the diagnosis.

00:48:12: Maura Corsetti: So you need to learn how to make the diagnosis using the clinical history.

00:48:18: Maura Corsetti: And I hope that this will help in the future.

00:48:21: Maura Corsetti: And we are working with Rome Foundation really to have more of this educational courses to make available this early in the career.

00:48:30: Maura Corsetti: For example, here in Nottingham, I started an undergraduate course on disorder of gut-brain interaction for the third year students.

00:48:39: Maura Corsetti: And I think that we need to expose the students during the medical course before they become consultant to understand that this condition exists

00:48:48: Maura Corsetti: and are actually the most prevalent condition in our practice, in every speciality, also in rheumatology, in neurology.

00:48:55: Maura Corsetti: So you need to know this condition from the beginning.

00:48:59: Pradeep Mundre: Yeah, desperately needed, I think.

00:49:03: Pradeep Mundre: I think these need to be included in the curriculum of the trainees in a more stronger way rather than learning from the guidelines or whatsoever.

00:49:12: Maura Corsetti: From experience, or from experience, from bad experience, learning from bad experience because then...

00:49:20: Pradeep Mundre: Yeah, Maura, thanks for your time today and see you soon.

00:49:24: Maura Corsetti: Thank you.

00:49:25: Maura Corsetti: Thank you for asking me to be here.

00:49:26: Maura Corsetti: Thank you, bye bye.