Prof. Manuela Merli (Figure 1) is Associate Professor at the Department of Clinical Medicine, Sapienza University of Rome, Italy. She’s a member of many prestigious associations, including European Association for the Study of Liver Disease, Italian Association for the Study of the Liver, Italian Society of Gastroenterology, European Society of Enteral and Parenteral Nutrition and Italian Society for Transplant Organs. Prof. Merli’s main research interests are in the fields of liver cirrhosis, pathogenesis and treatment of portal hypertension and nutrition and metabolic abnormalities in patients with chronic liver disease.
It’s our honor to do an interview with Prof. Manuela Merli. We greatly appreciate her for her time and sharing her experiences and perspectives with us.
HBSN: Do you and your team have any research being conducted? Are there any interesting findings?
Prof. Merli: I am working in Sapienza University of Rome and interested in hepatology and liver transplantation. I am often involved in the management of complications of chronic liver diseases, which means that I often deal with patients with portal hypertension and variceal bleeding. Our team performed one of the first trials on transjugular intrahepatic portosystemic shunt for cirrhotic patients with gastrointestinal bleeding or refractory ascites. We also participated in a trial on the use of glypressin and albumin vs. midodrine and octreotide in patients with hepatorenal syndrome.
Recently, I am much involved in studying the problems of infections in hospitalized cirrhotic patients. We have published a lot of interesting data and one important finding is that, in these patients, the increase in multi-drug resistant bacteria mainly happens in health care-associated infections. It means that, for example, when a cirrhotic patient comes to hospital for a bacterial infection, this should not be always classified as community-acquired infection. If the patient was hospitalized in the last three months or was in contact with the health care system for procedures or intravenous therapies, the infection may derive from germs that have been selected in the hospital setting. These germs are much more resistant to antibiotic therapy and need a different empirical approach. We have conducted a control study about antibiotic therapies for health care related bacterial infections in hospitalized cirrhotic patients, which showed very interesting results.
Last but not least, I’ve been involved in nutrition for many years, and now we take more care about nutrition in patients with end stage liver diseases or those before or after liver transplantation.
HBSN: Is sarcopenia an important nutritional index for patients with severe liver diseases? Are there any measures that can be taken to prevent sarcopenia or slow its progression?
Prof. Merli: Yes, sarcopenia is certainly a crucial point, and its importance has been recognized widely.
For sure we can prevent sarcopenia by giving adequate amount of proteins. Probably we also need to make the muscle “work”. There was a great mistrust of promoting a moderate physical exercise in patients with cirrhosis because it was shown that this could increase portal hypertension. But nowadays we are more confident that a balanced physical exercise can be proposed in cirrhotic patients to ameliorate muscle mass and function without being harmful. We still need more work on this to know what is more suitable for these patients considering the illnesses severity. Probably we will be able to reach better results by studying the pathophysiology of sarcopenia. Now we have a number of beautiful molecular studies showing, among others, the role of myostatin on sarcopenia in cirrhotic patients: this may also lead, in the future, to new therapeutic approaches.
Obviously we can also give testosterone to these patients but, as you know, it may increase the rate of hepatocellular carcinoma (HCC). So there is caution in giving this hormone, although there have been trials on its utilization in cirrhotic patients.
HBSN: Do you have any suggestions on the current medical education?
Prof. Merli: I think the current study system in Italy gives great priority to studying “with the brain”. It means that students should stay on the books and have solid theoretical capacity. Frequently I ask my students to apply their knowledge into practice as early as they can because the possible defect in this way of studying is that they learn a lot but they are weak in doing skills and having interrelationship with the patients. I think this is the great role of “tutors”. Students need to discuss later on with their tutors what they have done. And this is the way they move more into becoming a doctor.
HBSN: Do students in Italy have many opportunities to practice knowledge they learn in school?
Prof. Merli: The problem is the ratio between teachers and students. It’s not difficult to put many students in a course and give them a lecture. But when they go to practice, teachers need to have them in small groups. At this time, the number of students may be a limited factor because if a teacher has many students, he or she cannot have a good relationship with all of them. This is the main limitation.
Otherwise we now have enrolled some mannequins. It means that students are not necessarily close to the patients at the beginning. They can start from doing things on the models. They can practice putting nasogastric tubes inside them, or performing fine-needle aspiration of blood. So they can understand how they should do this, and then, when they go to the hospital, they are well prepared.
HBSN: As an author, if you would like to submit a paper to a journal, which aspects of a journal will you pay attention to?
Prof. Merli: There are many aspects. Of course the first is if it is on PubMed and if it has good quotation. Another aspect is that it doesn’t take much time to get the articles published. Also, sometimes, they ask you to pay a lot to have the paper online. Of course, this is important because more people can have free access to the paper. However the costs should be mitigated.
HBSN: And as a reader instead of an author, are there any different aspects of the journal you will pay attention to?
Prof. Merli: If I am a reader, of course I will pay attention to the availability of the journal. Also, I like journals that show new and original information. Some papers now keep reviewing and reviewing, adding nothing to the knowledge. I mean, frequently this is only repetition of things we already know. I think original data are very important.
Conflicts of Interest: The authors have no conflicts of interest to declare.
(Science Editors: Cecilia Jiang, Cindy Hao, HBSN, firstname.lastname@example.org)