With the advent of the scientific realization that the microbiota of the gastrointestinal tract was more than the cells that exist in the body, the full importance of prebiotics and probiotics has come forth. The importance has been stressed and is available in the new textbook entitled, "The Microbiota in Gastrointestinal Pathophysiology: Implication for Human Health, Prebiotics, Probiotics and Dysbiosis." There is enough evidence published in the literature so that the scientific world now believes that prebiotics and probiotics are important in gastrointestinal disease.

This editorial wishes to emphasize the importance of the paper in this issue by Richardo Fernades and colleagues entitled “Effects of prebiotic and symbiotic supplementation on inflammatory markers and anthropometric indices after Roux-en-Y gastric bypass: a randomized, triple blind, placebo-controlled pilot study.”1 This paper focuses on the effect that the nutrients which feed the microbiota are potentially of major importance. It is written in extremely good details in both the data collection and the discussion sections. The nutrition staff is to be complimented for this work, which was done on gastric Roux-en-Y bypass patients, however, the implications and conclusions are applicable to the effect of the microbiota in all subjects. The randomized, triple-blind, placebo-controlled pilot study is on gastric bypass patients, but yet it demonstrates the effect of nutrients on the microbiota and the subsequent effects on the subjects which, in this case, are obese subjects. However, the conclusion may begin to be extrapolated to other subjects. That is the importance of the paper. The microbiota is fed by probiotics and other nutrients. There is all too little information available on the effect of the nutrients on the microbiota, so this paper is important because it focuses on that subject. Perhaps other investigators will begin to focus on studies that will measure the effect of different nutrients, such as probiotics, dietary fiber, and all microbiota nutrients. The laboratories1 of Dr Erasmo Benicio Santos de Moraes Trindade in Brazil at the Federal University of Santa Catarina and the authors are to be complimented for the detailed work, and the results are important.

Department of Internal Medicine/Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT The author declares that there is nothing to disclose. Address correspondence to: Martin H. Floch, MD, Department of Internal Medicine/Section of Digestive Diseases, Yale University School of Medicine, P.O. Box 208019, LMP 1080, New Haven, CT 06520-8019 (e-mail: [email protected]).

Dr Yehuda Ringel, Allan Walker, and I have just completed editing a large textbook of 43 chapters that will be published by Elsevier, The Microbiota in Gastrointestinal Pathophysiology: Implications for Human Health, Prebiotics, Probiotics, and Dysbiosis. One of my colleagues, interested in the clinical aspects of the microbiome, asked where do you get a patient tested to study their microbiome? That was a good question. Most of the published data come from research and research laboratories, and they do not do clinical work. I researched the problem and found that there were few places that do clinical studies. One is called American Gut, and the other is called Ubiome. Dr Rob Knight published a paper in AGA Perspectives,1 and he points out in his brief paper that it is a little early to use these data clinically. He compares his paper with some clinical studies, but those references are sparse. Another paper was just published in the Journal of Nutrition in which they studied the gastrointestinal flora of overweight pregnant women and related it to serum zonulin.2 They found that the richest composition of the microbiota can vary with the intake of food substances. Of course, this study is limited to overweight pregnant women, but it is a very important finding as they demonstrate that food intake can affect the clinical outcome.2 As we begin to learn more and more about the microbiota in various clinical states, the importance of food intake will become paramount. A chapter in our book, which has not been published yet, from the laboratory of Dr Ian Carroll, points out the depth of determining the microbiota from mucosa to lumen.3 It will be essential that studies tell us from where they collected their specimens to compare the data and determine whether we can alter the clinical states by altering the prebiotics or probiotics or food substances. It is very early in our understanding, but a very exciting time for us to begin to understand the pathophysiology and role of the intestinal microbiota.

Guidelines for diverticular disease management were last supported and published by the American Gastroenterology Association and the American College of Gastroenterology 2 decades ago. Guidelines have been published in other countries and by some societies. These guidelines are suggested as United States of America guidelines. In reality, they are what is practiced in Connecticut at Yale New Haven hospitals. The epidemiology and pathophysiology is described. This is still considered a dietary fiber-deficiency disease that results in high intracolonic pressure with resultant outpocketing of diverticula in the weakest point of the colon at the sites of vascular penetration with developing elastin deposition in the colon wall. The age and gender distribution is described. They are most common in the sigmoid. The guidelines of management are described according to accepted classification of the disease at all stages from onset, to early formation, to mild disease, to complicated disease, to rare specific states. The outcomes and mortality are discussed.

In the 19th century, Metchnikoff first clinically proposed probiotics to be helpful to human health. He proposed that aging was due to putrefaction in the colon and that its adverse effects may be overcome by changing the flora to that of a more saccharolytic metabolism.1 It was not until the late 20th and early 21st century that the use of probiotics became popular, so much so that it is now projected to be almost a $20 billion industry.2 Manufacturers make claims that their probiotic may improve immune status and digestive health, but because of regulatory controls they make no claims pertaining to its benefits in treatment of disease.3 However, literature analysis, systematic analysis, and meta-analysis have now permitted the health care field to recommend probiotics in many clinical and disease states.4–6 The review of the literature and recommendations have come to the conclusion that probiotics may be helpful in childhood diarrhea, certain allergic and eczema conditions, ulcerative colitis, pouchitis, and in the prevention of antibiotic-associated diarrhea but less so in the prevention of Clostridia difficile-associated diarrhea.7–12 Concomitant with this literature review, the observation that bacterial therapy or fecal microbial transplant (FMT) would be helpful in treating severe C. difficile diarrhea was made. Because C. difficile infection (CDI) has become epidemic and continues to be a major problem, other sources of therapy were sought.13 Recurrent CDI has been documented clearly in 15% to 30% of patients after an initial attack. Although standard antibiotic therapy has been helpful, the recurrence rate continues to be high, and both morbidity and mortality continue to be a problem. Consequently, the emergence of FMT was appealing to physicians and patients frustrated by the recurrence and the threatening mortality of this colitis. FMT was first used by Eiseman in 1958,14 and Brandt and Reddy15 have documented 275 cases in which it has been used with a cure rate of 89%. Most of the cases were treated by rectal or colonic installation of the transplant through colonoscopy or a rectal tube. However, Aas et al16 treated 18 patients with nasal gastric tube installation of the fecal slurry, and Garborg et al17 treated 40 patients using an upper endoscope. Hence, FMT has been used successfully following either the gastric or the colonic route. A further advance in this therapy has now been documented by Hamilton et al18 who performed FMT through a colonoscopy but used a standardized frozen preparation instead of freshly prepared fecal slurry. Their clinical experience with 43 patients revealed that frozen prepared specimens from volunteer donors produced a 95% success rate. Four patients required a second infusion, but a 1-year analysis of these patients revealed that 41 were cured. Their patient population was somewhat unique in that 30% had inflammatory bowel disease. The majority of patients with inflammatory bowel disease improved after successful CDI treatment. This work was carried out at the University of Minnesota, where they are continuing to develop their technique. They report that they will make recommendations on therapy in the near future.18 FMT permits the administration of over 500 strains of human organisms. They certainly fit the definition of a probiotic in that they are human organisms administered to benefit health. A question that can be raised now is whether therapy with a single organism can be as effective as therapy with multiple probiotic organisms. Certainly, we now have proof that CDI is better treated with 500 species. There are many papers in the literature that demonstrate a probiotic with 8 organisms—namely, VLS#3—which is effective in ulcerative colitis,19 pouchitis,20 and Irritable Bowel Syndrome.21 The question that does arise is whether multiple organism administration is better? This will have to be answered in the future. The use of frozen fecal material removes most of the social antitheses and will enable its use in other conditions. The use of 500 species is a form of “shotgun” therapy, but it enables total

The editorial board of most journals represents the intellectual and academic support of the editor. This editor assumed the position when we combined 2 journals—The Gastroenterologist and The Journal of Clinical Gastroenterology, maintaining the latter name in 2001. At that time, Dr Howard Spiro had retired as Editor, and as Editor of The Gastroenterologist I was selected to lead the combined journal. Fortunately, over the past decade, we have been able to bring this journal into the mainstream of leadership among gastroenterology journals. We have maintained an academic position and have continued to publish editorials, clinical reviews, research articles, an occasional case report, and letters to the editor. Our material has risen from approximately 400 articles per year to over 1100 manuscripts per year. Our publisher has given us unconditional, enthusiastic confidence in running the journal. Furthermore, over the past few years, we have aligned with the World Gastroenterology Organisation (WGO) and continue to develop that relationship. The journal is now truly an international journal. We have maintained our position and have improved both our Eigen factor and impact factor ratings. After a decade of running the journal, I thought it wise to review all aspects of the journal with a select committee of the Board and the publisher. This was done last September. We decided to revise the Editorial Board so that it more accurately represents what is done to assist the editor. There are many who have helped immeasurably at the onset and during their careers, for which this editor is extremely grateful. We now come to a point in time where the Board will be redesigned into the following categories: Senior Associate Editors: Dr Anil Nagar has been extremely helpful in leading the peer review program for the Alimentary Tract, and, similarly, Dr Joseph Lim has assumed that responsibility for the liver. I still choose the papers through an initial screening and make the final decision on publication, although Dr Lim is fully in charge of all hepatology manuscripts. The other senior associate editors will be Myron Lewis, who writes our biographies, and Michael Fried, who coordinates and represents the efforts with WGO. Advisory Associate Editors: This will include members who have been extremely helpful in advising the development of the journal and to whom I am deeply grateful. Donald Castell, Ken DeVault, Rosemarie Fisher, Irvin Modlin, and A Brian West. Section Editors: These editors will continue to work with the present editors who are responsible for soliciting and developing clinical review articles and making major decisions on reviews submitted to the journal. The rest of the Editorial Board will be divided into an Editorial Review Board, which will consist of those who do the major amount of reviewing, and the Editorial Board, which will consist of those who have selected societal and interdisciplinary responsibilities, although conducting less reviews. We feel strongly that creating a Review Board is important to maintain the high-quality peer review process. I am deeply appreciative to all members of the Board and the publishers who in the past have helped bring this journal to its outstanding reputation, maintaining it at a very high level. In addition, I am deeply grateful for the continued efforts in soliciting and reviewing major contributions. We believe that our place in the clinical and academic field of gastroenterology and hepatology is highly respected, and I am grateful to those who have helped us maintain this position in the world of journals and education.

Nutrition in Clinical PracticeVolume 27, Issue 2 p. 193-194 Invited Commentary Advances in Intestinal Microecology The Microbiome, Prebiotics, and Probiotics Martin H. Floch MD, Corresponding Author Martin H. Floch MD [email protected] Yale University School of Medicine, New Haven, ConnecticutMartin H. Floch, MD, Clinical Professor of Medicine, Yale University School of Medicine, Section of Digestive Diseases, 40 Temple St, Suite 1A, New Haven, CT 06510, USA; e-mail: [email protected].Search for more papers by this author Martin H. Floch MD, Corresponding Author Martin H. Floch MD [email protected] Yale University School of Medicine, New Haven, ConnecticutMartin H. Floch, MD, Clinical Professor of Medicine, Yale University School of Medicine, Section of Digestive Diseases, 40 Temple St, Suite 1A, New Haven, CT 06510, USA; e-mail: [email protected].Search for more papers by this author First published: 01 March 2012 https://doi.org/10.1177/0884533612439708Citations: 8Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume27, Issue2Pre‐ and ProbioticsApril 2012Pages 193-194 RelatedInformation

Yale University School of Medicine, Section of Digestive Diseases, New Haven, CT No funding. No conflict of interest.

Log in or Register Subscribe to journalSubscribe Get new issue alertsGet alerts Enter your Email address: Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. Subscribe to eTOC Secondary Logo Journal Logo All Articles Images Videos Podcasts Blogs Advanced Search Toggle navigation Subscribe Register Login Articles & Issues Current IssuePrevious IssuesPublished Ahead-of-Print CollectionsFor Authors Submit a ManuscriptInformation for AuthorsLanguage Editing ServicesAuthor Permissions Journal Info About the JournalEditorial BoardAdvertisingOpen AccessSubscription ServicesReprintsRights and Permissions All Articles Images Videos Podcasts Blogs Advanced Search

The microflora of the human gastrointestinal tract contain 10(14) organisms, more bacteria than make up the body. The largest number is in the colon, and the anaerobes outnumber the aerobes by 100 or 1000:1. The anaerobic species of Bacteroides. Eubacterium, and Bifidobacterium usually predominate, and usually the most common organism is Faecalibacterium prausnitzii. Other details are described in this study. Of note is that there are changes in the normal flora in patients suffering from inflammatory bowel disease and the irritable bowel syndrome. As diverticular disease and diverticulitis seem to have some chronic inflammatory component to their pathophysiology, it is suspicious that there is a dysbiosis, but we have not had studies published on the flora in diverticular disease. Further suspicion of the role of a dysbiotic flora is raised since the initial reports that both mesalamine, an anti-inflammatory agent, and probiotics, either Escherichia coli Nissle or Lactobacillus casei, have been effective in controlling recurrent attacks. The details of these studies are described.

Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT No conflict of interest. No funding.