Downloaded from http://gut.bmj.com/ on November 15, 2015 - Published by group.bmj.com
PostScript factor for mortality in cirrhosis. The containment of development and further spread of MDR bacteria is an urgent clinical need. New strategies to face the emerging problem of MDR bacteria in cirrhosis are warranted. Oliver Waidmann,1 Volkhard A Kempf,2 Christian Brandt,2 Stefan Zeuzem,1 Albrecht Piiper,1 Bernd Kronenberger1 1
Medizinische Klinik 1, Schwerpunkt Gastroenterologie und Hepatologie, Universitätsklinikum Frankfurt, Goethe-Universität, Frankfurt/Main, Germany 2 Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Universitätsklinikum Frankfurt, Goethe-Universität, Frankfurt/Main, Germany Correspondence to Dr Oliver Waidmann, Medizinische Klinik 1, Schwerpunkt Gastroenterologie und Hepatologie, Universitätsklinikum Frankfurt, Goethe-Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt/Main, Germany; [email protected] Contributors OW and BK designed and performed the research, analysed the data and wrote the manuscript. VAK and CB analysed the data and critically revised the manuscript. AP and SZ critically revised the manuscript. Competing interests None. Ethics approval Institutional Review Board of the Goethe University Hospital Frankfurt. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Waidmann O, Kempf VA, Brandt C, et al. Gut 2015;64:1183–1184. Received 29 December 2014 Revised 3 January 2015 Accepted 8 January 2015 Published Online First 23 January 2015
▸ http://dx.doi.org/10.1136/gutjnl-2014-307526 Gut 2015;64:1183–1184. doi:10.1136/gutjnl-2014-309104
REFERENCES 1
2
3
4
Angeli P, Rodríguez E, Piano S, et al. for the CANONIC Study Investigators of the EASL-CLIF Consortium. Acute kidney injury and acute-on-chronic liver failure classifications in prognosis assessment of patients with acute decompensation of cirrhosis. Gut Published Online First: 13 Oct 2014. doi:10.1136/ gutjnl-2014-307526 Arvaniti V, D’Amico G, Fede G, et al. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis. Gastroenterology 2010;139:1246–56. Bajaj JS, O’Leary JG, Reddy KR, et al. Second infections independently increase mortality in hospitalized patients with cirrhosis: the North American consortium for the study of end-stage liver disease (NACSELD) experience. Hepatology 2012;56:2328–35. Kumarasamy KK, Toleman MA, Walsh TR, et al. Emergence of a new antibiotic resistance mechanism in
1184
5
India, Pakistan, and the UK: a molecular, biological, and epidemiological study. Lancet Infect Dis 2010;10:597–602. Fernández J, Acevedo J, Castro M, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology 2012;55: 1551–61.
British Society of Gastroenterology policy and processes for the development of guidelines We refer to two recently published guidelines in this journal from the British Society of Gastroenterology (BSG) on coeliac disease1 and Barretts oesophagus.2 We describe our BSG policy on the production of guidelines, which sets a sufficiently high quality benchmark such that we have been awarded National Institute of Health and Care Excellence (NICE) accreditation for our production process.3 The full policy and advice document are available on our website.4 Most guidelines are commissioned by the BSG clinical services and standards committee (CSSC). The formulation of guidelines are driven by a Guideline Development Group (GDG), include a writing committee, members of which are recognised authorities in the field, and others representing a range of relevant expertise, as well as patient representatives and those whose everyday practice will be influenced by the guidelines. The GDG chairman is usually chosen by the relevant specialty section, in consultation with the CSSC. All members of the GDG must complete a declaration of conflict of interests (COI) form. Whenever members have a potential COI with a particular section of the guideline, they may continue to be involved in the overall process but must withdraw their involvement from that area. In some cases, a COI may preclude membership of the GDG. Decisions with regard to these issues are made by the Chair of the GDG, in consultation with the head of the relevant BSG section and with the CSSC executive. All such decisions are documented and available for external review. Guidelines are developed in accordance with the principles laid down by the AGREE II instrument.5 An initial proposal from the GDG chairperson is submitted to the secretary of the CSSC and the relevant specialist section. This is also shared with relevant stakeholders including professional groups, patients and carers and their views sought. The final proposal should include the overall
objective of the guideline, the target population of patients, who the target users are and the main clinical questions to be addressed. The clinical questions are usually grouped into sections. The process used is usually the patients, interventions, controls and outcomes system, in which these four critical components are predefined as precisely as possible. The GDG develops a systematic, comprehensive, transparent and reproducible strategy to search for evidence on which management recommendations are based. The overall strategy is decided by the GDG as a whole and must be described in adequate detail (if necessary in an appendix). Libraries generated by keyword searches are stored to allow excluded references to be traced. For assessing the quality of evidence, the GRADE system6 is recommended. The cost and service implications of implementing the guideline and the potential facilitators and organisational barriers to doing so are considered. Guidelines normally include a statement as to how the implementation of the guideline will be assessed. On completion, the guideline is reviewed by two BSG council members, two members of the CSSC and sent to all CSSC members for comments and posted on the BSG website for comments from the members. All feedback is sent to the lead author for amendments to the guideline and if these are satisfactory, the guideline is then submitted to Gut for the usual peer review process by four to eight internationally renowned authorities. We believe that the BSG has set high quality standards for guideline development, which we encourage other organisations to follow. Tony CK Tham, Dermot Gleeson, Simon M Greenfield, Adam Harris, Simone Cort Clinical Services and Standards Committee, British Society of Gastroenterology, London, UK Correspondence to Dr. Tony C K Tham, Ulster Hospital, Belfast BT16 1RH, UK; [email protected] Contributors All authors contributed to the development of the guidelines policy, and reviewed the contents of the letter. Funding This research received no specific funding. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
Gut July 2015 Vol 64 No 7
Downloaded from http://gut.bmj.com/ on November 15, 2015 - Published by group.bmj.com
PostScript To cite Tham TCK, Gleeson D, Greenfield SM, et al. Gut 2015;64:1184–1185. Received 9 January 2015 Accepted 21 January 2015 Published Online First 9 February 2015 Gut 2015;64:1184–1185. doi:10.1136/gutjnl-2015-309164
REFERENCES 1
2
3 4
5
6
Ludvigsson JF, Bai JC, Biagi F, et al. BSG Coeliac Disease Guidelines Development Group; British Society of Gastroenterology. Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology. Gut 2014;63:1210–28. Fitzgerald RC, di Pietro M, Ragunath K, et al., British Society of Gastroenterology. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett’s oesophagus. Gut 2014;63:7–42. NICE accreditation. http://www.nice.org.uk/about/ what-we-do/accreditation BSG guidelines advice document. http://www.bsg.org. uk/images/stories/docs/clinical/guidelines/general/bsg_ guidelines_advice_2014.doc Brouwers M, Kho ME, Browman GP, et al., for the AGREE Next Steps Consortium. AGREE II: Advancing guideline development, reporting and evaluation in healthcare. Can Med Assoc J. 2010;51:421–4. Available online July 5, 2010. Guyatt GH, Oxman AD, Vist G, et al. for the GRADE Working Group. Rating quality of evidence and strength of recommendations GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924–6.
Altered microbiota in microscopic colitis Recently, Shin et al1 reported that Akkermansia spp had a beneficial effect on glucose homeostasis in obese mice. Mucin degrading Akkermansia—promoting mucin degradation and turnover—is associated with a healthy mucosa. In IBD, a deranged microbiota is reported while findings in microscopic colitis (MC) are lacking. MC is a disorder characterised by chronic non-bloody diarrhoea, predominantly affecting elderly smoking women. Despite frequent diarrhoea, laboratory anomalies are seldom seen. Since an altered microbiota is reported in several immune mediated diseases and since MC affects the gut, our hypothesis was that the microbiota would be altered in patients with MC. A group of 10 female patients (mean age 48 years, range 43–68 years) with onset of MC collected as previously described2 donated faecal samples that were compared with samples from seven healthy control women (mean age 50 years, range 45–65 years) with respect to their faecal microbiota. The bacterial microbiome was analysed by DNA sequencing (Illumina Hiseq 2000) Gut July 2015 Vol 64 No 7
Figure 1 Occurrence of bacterial species in the microbiota in patients with microscopic colitis compared with healthy controls.
and sequences were aligned to a catalogue of sequenced genomes from the National Center for Biotechnology Information and hmpdacc.org to determine the composition of the microbiota. Sequences were aligned with Bowtie to the sequenced species catalogue of 2382 genomes. Alignments with the fewest number of mismatches were counted. Relative abundance was calculated by calculating the ratio of aligned reads of each genome to the total number of aligned reads. Details about the bioinformatics methods, MEDUSA pipeline, have been described previously.3 Patients with MC had a marked reduction of Veruccomicrobia (Akkermansia spp) compared with healthy individuals (figure 1), with a difference approaching 2–3 log (p=0.02; Wilcoxon rank-sum test). In other species (Bacteroides
and Prevotella), some differences could be noticed although not reaching statistical significance. The notion that patients with MC had a significantly lower amount of Akkermansia was further strengthened with specific Akkermansia spp. PCR performed on the 10 patients and 7 controls and on an additional 5 female patients with MC (total mean age 50 years, range 43–65 years) and 7 female controls (total mean age 51 years, range 45–73 years) (figure 2). Although the number of patients with MC was low, it should be noted that the smokers had extremely low levels of Akkermansia. Akkermansia is one of the most prevalent bacterial strains in the large intestine. It has been shown in mice that Akkermansia thickens the mucin layer, and thus may protect
Figure 2 Occurrence of Akkermansia muciniphila in the microbiota in patients with microscopic colitis compared with healthy controls. Smokers are marked in black circles and non-smokers are marked in white circles. 1185
Downloaded from http://gut.bmj.com/ on November 15, 2015 - Published by group.bmj.com
British Society of Gastroenterology policy and processes for the development of guidelines Tony CK Tham, Dermot Gleeson, Simon M Greenfield, Adam Harris and Simone Cort Gut 2015 64: 1184-1185 originally published online February 9, 2015
doi: 10.1136/gutjnl-2015-309164 Updated information and services can be found at: http://gut.bmj.com/content/64/7/1184
These include:
References Email alerting service
This article cites 4 articles, 3 of which you can access for free at: http://gut.bmj.com/content/64/7/1184#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
PostScript factor for mortality in cirrhosis. The containment of development and further spread of MDR bacteria is an urgent clinical need. New strategies to face the emerging problem of MDR bacteria in cirrhosis are warranted. Oliver Waidmann,1 Volkhard A Kempf,2 Christian Brandt,2 Stefan Zeuzem,1 Albrecht Piiper,1 Bernd Kronenberger1 1
Medizinische Klinik 1, Schwerpunkt Gastroenterologie und Hepatologie, Universitätsklinikum Frankfurt, Goethe-Universität, Frankfurt/Main, Germany 2 Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Universitätsklinikum Frankfurt, Goethe-Universität, Frankfurt/Main, Germany Correspondence to Dr Oliver Waidmann, Medizinische Klinik 1, Schwerpunkt Gastroenterologie und Hepatologie, Universitätsklinikum Frankfurt, Goethe-Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt/Main, Germany; [email protected] Contributors OW and BK designed and performed the research, analysed the data and wrote the manuscript. VAK and CB analysed the data and critically revised the manuscript. AP and SZ critically revised the manuscript. Competing interests None. Ethics approval Institutional Review Board of the Goethe University Hospital Frankfurt. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Waidmann O, Kempf VA, Brandt C, et al. Gut 2015;64:1183–1184. Received 29 December 2014 Revised 3 January 2015 Accepted 8 January 2015 Published Online First 23 January 2015
▸ http://dx.doi.org/10.1136/gutjnl-2014-307526 Gut 2015;64:1183–1184. doi:10.1136/gutjnl-2014-309104
REFERENCES 1
2
3
4
Angeli P, Rodríguez E, Piano S, et al. for the CANONIC Study Investigators of the EASL-CLIF Consortium. Acute kidney injury and acute-on-chronic liver failure classifications in prognosis assessment of patients with acute decompensation of cirrhosis. Gut Published Online First: 13 Oct 2014. doi:10.1136/ gutjnl-2014-307526 Arvaniti V, D’Amico G, Fede G, et al. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis. Gastroenterology 2010;139:1246–56. Bajaj JS, O’Leary JG, Reddy KR, et al. Second infections independently increase mortality in hospitalized patients with cirrhosis: the North American consortium for the study of end-stage liver disease (NACSELD) experience. Hepatology 2012;56:2328–35. Kumarasamy KK, Toleman MA, Walsh TR, et al. Emergence of a new antibiotic resistance mechanism in
1184
5
India, Pakistan, and the UK: a molecular, biological, and epidemiological study. Lancet Infect Dis 2010;10:597–602. Fernández J, Acevedo J, Castro M, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology 2012;55: 1551–61.
British Society of Gastroenterology policy and processes for the development of guidelines We refer to two recently published guidelines in this journal from the British Society of Gastroenterology (BSG) on coeliac disease1 and Barretts oesophagus.2 We describe our BSG policy on the production of guidelines, which sets a sufficiently high quality benchmark such that we have been awarded National Institute of Health and Care Excellence (NICE) accreditation for our production process.3 The full policy and advice document are available on our website.4 Most guidelines are commissioned by the BSG clinical services and standards committee (CSSC). The formulation of guidelines are driven by a Guideline Development Group (GDG), include a writing committee, members of which are recognised authorities in the field, and others representing a range of relevant expertise, as well as patient representatives and those whose everyday practice will be influenced by the guidelines. The GDG chairman is usually chosen by the relevant specialty section, in consultation with the CSSC. All members of the GDG must complete a declaration of conflict of interests (COI) form. Whenever members have a potential COI with a particular section of the guideline, they may continue to be involved in the overall process but must withdraw their involvement from that area. In some cases, a COI may preclude membership of the GDG. Decisions with regard to these issues are made by the Chair of the GDG, in consultation with the head of the relevant BSG section and with the CSSC executive. All such decisions are documented and available for external review. Guidelines are developed in accordance with the principles laid down by the AGREE II instrument.5 An initial proposal from the GDG chairperson is submitted to the secretary of the CSSC and the relevant specialist section. This is also shared with relevant stakeholders including professional groups, patients and carers and their views sought. The final proposal should include the overall
objective of the guideline, the target population of patients, who the target users are and the main clinical questions to be addressed. The clinical questions are usually grouped into sections. The process used is usually the patients, interventions, controls and outcomes system, in which these four critical components are predefined as precisely as possible. The GDG develops a systematic, comprehensive, transparent and reproducible strategy to search for evidence on which management recommendations are based. The overall strategy is decided by the GDG as a whole and must be described in adequate detail (if necessary in an appendix). Libraries generated by keyword searches are stored to allow excluded references to be traced. For assessing the quality of evidence, the GRADE system6 is recommended. The cost and service implications of implementing the guideline and the potential facilitators and organisational barriers to doing so are considered. Guidelines normally include a statement as to how the implementation of the guideline will be assessed. On completion, the guideline is reviewed by two BSG council members, two members of the CSSC and sent to all CSSC members for comments and posted on the BSG website for comments from the members. All feedback is sent to the lead author for amendments to the guideline and if these are satisfactory, the guideline is then submitted to Gut for the usual peer review process by four to eight internationally renowned authorities. We believe that the BSG has set high quality standards for guideline development, which we encourage other organisations to follow. Tony CK Tham, Dermot Gleeson, Simon M Greenfield, Adam Harris, Simone Cort Clinical Services and Standards Committee, British Society of Gastroenterology, London, UK Correspondence to Dr. Tony C K Tham, Ulster Hospital, Belfast BT16 1RH, UK; [email protected] Contributors All authors contributed to the development of the guidelines policy, and reviewed the contents of the letter. Funding This research received no specific funding. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
Gut July 2015 Vol 64 No 7
Downloaded from http://gut.bmj.com/ on November 15, 2015 - Published by group.bmj.com
PostScript To cite Tham TCK, Gleeson D, Greenfield SM, et al. Gut 2015;64:1184–1185. Received 9 January 2015 Accepted 21 January 2015 Published Online First 9 February 2015 Gut 2015;64:1184–1185. doi:10.1136/gutjnl-2015-309164
REFERENCES 1
2
3 4
5
6
Ludvigsson JF, Bai JC, Biagi F, et al. BSG Coeliac Disease Guidelines Development Group; British Society of Gastroenterology. Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology. Gut 2014;63:1210–28. Fitzgerald RC, di Pietro M, Ragunath K, et al., British Society of Gastroenterology. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett’s oesophagus. Gut 2014;63:7–42. NICE accreditation. http://www.nice.org.uk/about/ what-we-do/accreditation BSG guidelines advice document. http://www.bsg.org. uk/images/stories/docs/clinical/guidelines/general/bsg_ guidelines_advice_2014.doc Brouwers M, Kho ME, Browman GP, et al., for the AGREE Next Steps Consortium. AGREE II: Advancing guideline development, reporting and evaluation in healthcare. Can Med Assoc J. 2010;51:421–4. Available online July 5, 2010. Guyatt GH, Oxman AD, Vist G, et al. for the GRADE Working Group. Rating quality of evidence and strength of recommendations GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924–6.
Altered microbiota in microscopic colitis Recently, Shin et al1 reported that Akkermansia spp had a beneficial effect on glucose homeostasis in obese mice. Mucin degrading Akkermansia—promoting mucin degradation and turnover—is associated with a healthy mucosa. In IBD, a deranged microbiota is reported while findings in microscopic colitis (MC) are lacking. MC is a disorder characterised by chronic non-bloody diarrhoea, predominantly affecting elderly smoking women. Despite frequent diarrhoea, laboratory anomalies are seldom seen. Since an altered microbiota is reported in several immune mediated diseases and since MC affects the gut, our hypothesis was that the microbiota would be altered in patients with MC. A group of 10 female patients (mean age 48 years, range 43–68 years) with onset of MC collected as previously described2 donated faecal samples that were compared with samples from seven healthy control women (mean age 50 years, range 45–65 years) with respect to their faecal microbiota. The bacterial microbiome was analysed by DNA sequencing (Illumina Hiseq 2000) Gut July 2015 Vol 64 No 7
Figure 1 Occurrence of bacterial species in the microbiota in patients with microscopic colitis compared with healthy controls.
and sequences were aligned to a catalogue of sequenced genomes from the National Center for Biotechnology Information and hmpdacc.org to determine the composition of the microbiota. Sequences were aligned with Bowtie to the sequenced species catalogue of 2382 genomes. Alignments with the fewest number of mismatches were counted. Relative abundance was calculated by calculating the ratio of aligned reads of each genome to the total number of aligned reads. Details about the bioinformatics methods, MEDUSA pipeline, have been described previously.3 Patients with MC had a marked reduction of Veruccomicrobia (Akkermansia spp) compared with healthy individuals (figure 1), with a difference approaching 2–3 log (p=0.02; Wilcoxon rank-sum test). In other species (Bacteroides
and Prevotella), some differences could be noticed although not reaching statistical significance. The notion that patients with MC had a significantly lower amount of Akkermansia was further strengthened with specific Akkermansia spp. PCR performed on the 10 patients and 7 controls and on an additional 5 female patients with MC (total mean age 50 years, range 43–65 years) and 7 female controls (total mean age 51 years, range 45–73 years) (figure 2). Although the number of patients with MC was low, it should be noted that the smokers had extremely low levels of Akkermansia. Akkermansia is one of the most prevalent bacterial strains in the large intestine. It has been shown in mice that Akkermansia thickens the mucin layer, and thus may protect
Figure 2 Occurrence of Akkermansia muciniphila in the microbiota in patients with microscopic colitis compared with healthy controls. Smokers are marked in black circles and non-smokers are marked in white circles. 1185
Downloaded from http://gut.bmj.com/ on November 15, 2015 - Published by group.bmj.com
British Society of Gastroenterology policy and processes for the development of guidelines Tony CK Tham, Dermot Gleeson, Simon M Greenfield, Adam Harris and Simone Cort Gut 2015 64: 1184-1185 originally published online February 9, 2015
doi: 10.1136/gutjnl-2015-309164 Updated information and services can be found at: http://gut.bmj.com/content/64/7/1184
These include:
References Email alerting service
This article cites 4 articles, 3 of which you can access for free at: http://gut.bmj.com/content/64/7/1184#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
