Realigning values
A thoughtful reset for early-career physicians navigating evolving goals and responsibilities.
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02/01/2026
Dear friends,
Happy 2026! Did you know that New Year’s resolutions stemmed from the ancient Babylonians making promises of good behaviors and actions to the gods in return for an auspicious year ahead? This has evolved into personal goals of self-improvement for a fresh start.
This year, I challenged myself to a New Year’s realignment, as opposed to resolutions. It is less rigid and more reflective of how our values and goals may change over time. As an early-career faculty, I was just getting through my hectic schedule each day. I lost some joy in what I was doing and why I was doing it. I reassessed my day-to-day and refocused on what was important to me now, which had changed over the last few years alone! Here’s to a new year, but the same, more aligned, US!
In this issue’s “In Focus”, Drs. Mahesh Krishna and David N. Assis, provide an in-depth review of primary sclerosing cholangitis (PSC), including the approach to diagnosis and management. They artfully classify the management of PSC into understanding PSC’s relationship with malignancy, infection, liver fibrosis, spectrum of symptoms, and inflammatory bowel disease.
Dr. Rabia de Latour spearheaded her institution’s efforts in green endoscopy. In this issue’s, she reviews the various ways an endoscopy unit can take part in reducing waste in healthcare. In the “Early Career” section, Dr. Nicole Shen, a GI hospitalist, as well as co-founder and co-owner of Easy Belly, describes aspects of negotiating a job contract while protecting your entrepreneurship.
Dr. Raul Gonzalez, a professor of pathology and laboratory medicine at Emory University, describes what GI pathologists need to know from gastroenterologists, including providing key clinical information, obtaining adequate tissue, handling specimen appropriately, and understanding the limitations of pathology.
If you are interested in contributing or have ideas for future TNG topics, please contact me (jtrieu23@gmail.com) or Danielle Kiefer (dkiefer@gastro.org), Communications/Managing Editor of TNG.
Until next time, I leave you with a historical fun fact because we would not be where we are now without appreciating where we were: Marcello Malpighi was the first to use a microscope to describe the histologic layers of the intestine in the late 1600s; however, it wasn’t until 200 years later with better microscopes and histologic stains that gastrointestinal cells were differentiated.
Yours truly,
Judy A Trieu, MD, MPH
Editor-in-Chief
Assistant Professor of Medicine
Director of Therapeutic Endoscopy Research
Division of Gastroenterology & Hepatology,
University of North Carolina at Chapel Hill
Summary content
7 Key Takeaways
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Developed a paper-based colorimetric sensor array for chemical threat detection.
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Can detect 12 chemical agents, including industrial toxins.
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Production cost is under 20 cents per chip.
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Utilizes dye-loaded silica particles on self-adhesive paper.
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Provides rapid, simultaneous identification through image analysis.
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Inspired by the mammalian olfactory system for pattern recognition.
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Future developments include a machine learning-enabled reader device.
The guidelines emphasize four-hour gastric emptying studies over two-hour testing. How do you see this affecting diagnostic workflows in practice?
Dr. Staller: Moving to a four-hour solid-meal scintigraphy will actually simplify decision-making. The two-hour reads miss a meaningful proportion of delayed emptying; standardizing on four hours reduces false negatives and the “maybe gastroparesis” purgatory that leads to repeat testing. Practically, it means closer coordination with nuclear medicine (longer slots, consistent standardized meal), updating order sets to default to a four-hour protocol, and educating front-line teams so patients arrive appropriately prepped. The payoff is fewer equivocal studies and more confident treatment plans.
Metoclopramide and erythromycin are the only agents conditionally recommended for initial therapy. How does this align with what is being currently prescribed?
Dr. Staller: This largely mirrors real-world practice. Metoclopramide remains the only FDA-approved prokinetic for gastroparesis, and short “pulsed” erythromycin courses are familiar to many of us—recognizing tachyphylaxis limits durability. Our recommendation is “conditional” because the underlying evidence is modest and patient responses are heterogeneous, but it formalizes what many clinicians already do: start with metoclopramide (lowest effective dose, limited duration, counsel on neurologic adverse effects) and reserve erythromycin for targeted use (exacerbations, bridging).
Several agents, including domperidone and prucalopride, received recommendations against first-line use. How will that influence discussions with patients who ask about these therapies?
Dr. Staller: Two points I share with patients: evidence and access/safety. For domperidone, the data quality is mixed, and US access is through an FDA IND mechanism; you’re committing patients to EKG monitoring and a non-trivial administrative lift. For prucalopride, the gastroparesis-specific evidence isn’t strong enough yet to justify first-line use. So, our stance is not “never,” it’s just “not first.” If someone fails or cannot tolerate initial therapy, we can revisit these options through shared decision-making, setting expectations about benefit, monitoring, and off-label use. The guideline language helps clinicians have a transparent, evidence-based conversation at the first visit.
The guidelines suggest reserving procedures like G-POEM and gastric electrical stimulation for refractory cases. In your practice, how do you decide when a patient is “refractory” to medical therapy?
Dr. Staller: I define “refractory” with three anchors.
1. Adequate trials of foundational care: dietary optimization and glycemic control; an antiemetic; and at least one prokinetic at appropriate dose/duration (with intolerance documented if stopped early).
2. Persistent, function-limiting symptoms: ongoing nausea/vomiting, weight loss, dehydration, ER visits/hospitalizations, or malnutrition despite the above—ideally tracked with a validated instrument (e.g., GCSI) plus nutritional metrics.
3. Objective correlation: delayed emptying on a standardized 4-hour solid-meal study that aligns with the clinical picture (and medications that slow emptying addressed).
At that point, referral to a center with procedural expertise for G-POEM or consideration of gastric electrical stimulation becomes appropriate, with multidisciplinary evaluation (GI, nutrition, psychology, and, when needed, surgery).
What role do you see dietary modification and glycemic control playing alongside pharmacologic therapy in light of these recommendations?
Dr. Staller: They’re the bedrock. A small-particle, lower-fat, calorie-dense diet—often leaning on nutrient-rich liquids—can meaningfully reduce symptom burden. Partnering with dietitians early pays dividends. For diabetes, tighter glycemic control can improve gastric emptying and symptoms; I explicitly review medications that can slow emptying (e.g., opioids; consider timing/necessity of GLP-1 receptor agonists) and encourage continuous glucose monitor-informed adjustments. Pharmacotherapy sits on top of those pillars; without them, medications will likely underperform.
The guideline notes “considerable unmet need” in gastroparesis treatment. Where do you think future therapies or research are most urgently needed?
Dr. Staller: I see three major areas.
1. Truly durable prokinetics: agents that improve emptying and symptoms over months, with better safety than legacy options (e.g., next-gen motilin/ghrelin agonists, better-studied 5-HT4 strategies).
2. Endotyping and biomarkers: we need to stop treating all gastroparesis as one disease. Clinical, physiologic, and microbiome/omic signatures that predict who benefits from which therapy (drug vs G-POEM vs GES) would transform care.
3. Patient-centered trials: larger, longer RCTs that prioritize validated symptom and quality-of-life outcomes, include nutritional endpoints, and reflect real-world medication confounders.
Our guideline intentionally highlights these gaps to hopefully catalyze better trials and smarter referral pathways.
Dr. Staller is with the Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston.