The future of gastroenterology—The next 25 years

Summary Gastroenterology frequently has been considered a backward, undeveloped specialty of clinical medicine, albeit one that deals with many and frequently occurring diseases and has many interested practitioners. In the past few years increasing numbers of young basic medical scientists have turned with keen interest to this almost virgin clinical field and have brought with them the techniques of their respective disciplines. Research in gastroenterology, which has lagged until now, is also receiving increasing pecuniary support. One can predict that in the next 25 years the development of scientific knowledge of the gastrointestinal tract and of diagnosis and therapeutic measures will move on apace.The development of means to quantitate many of the functions of the gastrointestinal tract in health and disease and the use of newer techniques, such as those offered by anatomic, biochemical, and physiologic scientists, should help greatly to expand our knowledge of diseases of the alimentary system. The electron microscope, the determination of the amounts and kinds of enzymes in the blood and cells, studies of motor function and standardization of results, newer techniques of biopsy of liver and intestinal mucosa, and clear definitions and understanding of absorption are all among the factors that will influence and develop this specialty.Ways to control acid and enzyme secretion, how to govern the motor activity of the gastrointestinal tract, development of a better understanding of parenteral nutrition and of the relation of nutritional disturbances to disease of the liver—these are some of the boons to therapy that can be looked for in the quarter-century ahead.The clinical gastroenterologist in the future will stand on an increasingly firm foundation of scientific medicine. The need for a carefully taken history and of a sympathetic and understanding physician who can properly interpret what the scientific studies of his patient have shown will in fact be as great as if not greater than before.     

The Quality of Colonoscopy Services—Responsibilities of Referring Clinicians

Primary care clinicians initiate and oversee colorectal screening for their patients, but colonoscopy, a central component of screening programs, is usually performed by consultants. The accuracy and safety of colonoscopy varies among endoscopists, even those with mainstream training and certification. Therefore, it is a primary care responsibility to choose the best available colonoscopy services. A working group of the National Colorectal Cancer Roundtable identified a set of indicators that primary care clinicians can use to assess the quality of colonoscopy services. Quality measures are of actual performance, not training, specialty, or experience alone. The main elements of quality are a complete report, technical competence, and a safe setting for the procedure. We provide explicit criteria that primary care physicians can use when choosing a colonoscopist. Information on quality indicators will be increasingly available with quality improvement efforts within the colonoscopy community and growth in the use of electronic medical records.     

The dynamics of the emergency medical readmission — The underlying fundamentals

BackgroundHospital readmissions are a perennial problem. We reviewed readmissions to one institution (2002–2015) and investigated their dynamics.Methods96,474 emergency admissions (in 50,701 patients) to an Irish hospital over a 15-year period were studied, and patterns surrounding early (< 28 days) and late (any other) readmissions determined. Univariate and logistic or truncated Poisson regression methods were employed.ResultsEarly readmission rate averaged 9.6% (95% CI: 9.4, 9.8) with a low/high of 8.4% (95% CI: 7.8, 9.1) and 10.3% (95% CI: 9.6, 11.0) respectively with no overall time trend. Early readmissions represented 20.1% (95% CI: 19.8, 20.5) of emergency medical readmissions. Median time to first readmission was 55 weeks (95% CI: 13, 159), time to second was 35 weeks (95% CI: 9, 98); by the 7th/8th readmissions, intervals were 13 weeks (95% CI: 4, 36) and 11 weeks (95% CI: 4, 30). Readmissions were older 67.1 years (95% CI: 48.3, 79.2) vs. single admissions 53.9 years (34.3, 72.4) and stayed longer — 5.8 days (2.7, 10.6) vs. 3.9 days (1.5, 8.0). Readmissions had more Acute Illness Severity, Charlson Co-Morbidity and Chronic Disabling Disease. Between 2002 and 2015 the logistic adjusted model of 30-day in-hospital mortality reduced from 6.1% (95% CI: 5.7, 6.5) to 4.4% (95% CI: 4.1, 4.7) (RRR 30.4%).ConclusionEarly hospital readmission rate did not change over 15 years despite improvements in hospital mortality outcomes. Readmissions have a consistent pattern related to patient illness and social characteristics; the fundamentals are driven by disease progression over time.     

The burden of musculoskeletal disease—a global perspective

Musculoskeletal diseases are one of the major causes of disability around the world and have been a significant reason for the development of the Bone and Joint Decade. Rheumatoid arthritis, osteoarthritis and back pain are important causes of disability-adjusted-life years in both the developed and developing world. COPCORD studies in over 17 countries around the world have identified back and knee pain as common in the community and are likely to increase with the ageing population. Musculoskeletal conditions are an enormous cost to the community in economic terms, and these figures emphasise how governments need to invest in the future and look at ways of reducing the burden of musculoskeletal diseases by encouraging exercise and obesity prevention campaigns.Presented at the ILAR Lecture at EULAR 2005 and published in part electronically in Rheuma 21st July/August 2005 (Rheuma21st.com).     

Early Experience of Transaortic TAVI—The Future of Surgical TAVI?

BackgroundTrans-catheter aortic valve implantation (TAVI) is now a well recognised procedure for the high risk surgical patient with native or bioprosthetic aortic valve stenosis. Transfemoral and transapical implantation techniques are well described. With increasing referral of more marginal transapical patients, we describe our experience of a transaortic TAVI approach which we believe reduces the postoperative wound pain, respiratory complications, operative risk and hospital stay.MethodsPatients referred for surgical TAVI underwent trans-catheter aortic valve implantation via an upper sternotomy and direct cannulation of the ascending aorta.ResultsThirteen patients with a mean age of 81 years underwent transaortic Edwards SAPIEN valve implantation. There was no in hospital mortality in our series. One patient required insertion of a permanent pacemaker for complete heart block. There were no aortic cannulation complications.ConclusionThe transaortic TAVI approach provides good exposure of the distal ascending aorta, a familiar cannulation site for cardiac surgeons. Our initial experience demonstrates the approach to be a safe technique with the potential for faster and less complicated recovery in patients undergoing surgical TAVI procedures. With further experience and greater acceptance, the transaortic approach may ultimately become the procedure of choice for patients unsuitable for a transfemoral approach.     

The value of early intervention in RA—a window of opportunity

Rheumatoid arthritis (RA) is associated with progressive joint destruction, with functional status influenced by both disease activity and radiographic progression. The case for early aggressive treatment of RA is based on large amounts of good data in many countries. Studies with conventional disease-modifying anti-rheumatic drugs in early RA have shown improved outcomes compared with later treatment, especially if an aggressive approach with combinations of drugs is used. Early intervention with tumour necrosis factor (TNF) inhibitors has been shown to improve clinical outcomes, induce remission and prevent radiographic progression. It also improves patients’ functional status, health-related quality of life, and reduces fatigue. Patients with RA have reduced productivity, an increased number of lost work days and retire early; enabling patients to work should be at the core of a therapy’s cost-effectiveness. Introduction of anti-TNF therapy early in RA has been shown to decrease job loss and reduce the amount of working time missed. Although the drug costs of initial treatment with combination therapy including a TNF inhibitor are high, these may be compensated by the reduction in lost productivity, making such a strategy cost-effective overall. In addition, some patients who respond well to combination therapy may be able to stop the TNF inhibitor. It is important to assess the benefits of any intervention not just to healthcare costs but to society as a whole, and physicians should be advocates for optimal access to effective therapies for their patients.     

The natural history of achalasia: Evidence of a continuum—“The evolutive pattern theory”

BackgroundIt is currently unclear if the three manometric patterns of esophageal achalasia represent distinct entities or part of a disease continuum. The study’s aims were: a) to test the hypothesis that the three patterns represent different stages in the evolution of achalasia; b) to investigate whether manometric patterns change after Laparoscopic-Heller-Dor (LHD).MethodsWe assessed the patients diagnosed with achalasia who underwent LHD as their first treatment from 1992 to 2016. Their symptoms were scored using a detailed questionnaire for dysphagia, food-regurgitation, and chest pain. Barium-swallow, endoscopy, and esophageal-manometry were performed before and 6 months after surgery.ResultsThe study population consisted of 511 patients (M:F = 283:228). Patients’ demographic and clinical data showed that those with pattern III had a shorter history of symptoms, a higher incidence of chest pain, and a less dilated gullet (p < 0.001). All patients with a sigmoid-shaped mega-esophagus had pattern I achalasia. One patient with a diagnosis of pattern III achalasia developed pattern II at a follow-up manometry before surgery.At a median follow-up of 30 months (IQR 12–56), the outcome of surgery was positive in 479 patients (91.7%).All patients with pattern I preoperatively had the same pattern after LHD, whereas more than 50% of patients with pattern III before treatment showed pattern I or II after surgery.ConclusionsThis study supports the hypothesis/theory that the different manometric patterns represent different stages in the evolution of the disease—where pattern III is the earliest stage, pattern II an intermediate stage, and pattern I the final stage.     

The molluscicidal effect of a new insecticide——Sha Chong Huan.

Sha Chong Huan is a new agricultural insecticide. This paper deals with its mol-luscicidal effect on Oncomelonia hupensis and its toxicity on fish and plants. Snailswere immersed in a solution of Sha Chong Huan in the concentration of 2 ppm at