Genomic medicine in gastroenterology: A new approach or a new specialty?

Throughout history, many medical milestones have been achieved to prevent and treat human diseases. Man’s early conception of illness was naturally holistic or integrative. However, scientific knowledge was atomized into quantitative and qualitative research. In the field of medicine, the main trade-off was the creation of many medical specialties that commonly treat patients in advanced stages of disease. However, now that we are immersed in the post-genomic era, how should we reevaluate medicine? Genomic medicine has evoked a medical paradigm shift based on the plausibility to predict the genetic susceptibility to disease. Additionally, the development of chronic diseases should be viewed as a continuum of interactions between the individual’s genetic make-up and environmental factors such as diet, physical activity, and emotions. Thus, personalized medicine is aimed at preventing or reversing clinical symptoms, and providing a better quality of life by integrating the genetic, environmental and cultural factors of diseases. Whether using genomic medicine in the field of gastroenterology is a new approach or a new medical specialty remains an open question. To address this issue, it will require the mutual work of educational and governmental authorities with public health professionals, with the goal of translating genomic medicine into better health policies.     

Current status of gene therapy in gastroenterology

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Quality of life measurement in gastroenterology: what is available?

Monitoring and enhancement of a patient's health-related quality of life (HRQL) is an important element of research and medical care. In a previous article, we provided an overview of HRQL measurement. Now we will review the structure and properties of the most commonly used generic and digestive disease-specific HRQL instruments and illustrates their use in the gastroenterology and hepatology literature. Generic measures have been used to study specific diseases as well as to compare HRQL in GI and nongastrointestinal disease. Disease specific instruments have been developed for inflammatory bowel disease, irritable bowel syndrome, dyspepsia, gastroesophageal reflux disease, liver disease, and GI malignancy. Further work is needed to compare disease-specific instruments and to define the most appropriate uses of HRQL measurement in clinical trial and community practice settings.     

Do gender disparities persist in gastroenterology after 10 years of practice?

BACKGROUND: Cross-sectional studies confirm gender disparity in many aspects of the practice of medicine and surgery. Some data suggest the disparities diminish after 10 yr of practice. This study aims to examine gender discrepancies in income, social, and professional status of gastroenterologists after 10 yr of practice.
METHODS: Prospective, observational, cohort study of gastroenterologists incepted upon graduation from a U.S. GI fellowship program in 1993 and 1995. A 36-item questionnaire was sent to the cohort at 3, 5, and 10 yr after graduation from GI fellowship training. The following are the results of the final, 10th year survey.
RESULTS: A total of 168 men and 25 women (mean age 45.5 yr) responded. Men and women were equally likely to be board certified and married, however, women had fewer children. Men earned a mean annual gross income of $375,000 versus $245,000 for women ( P = 0.001). After adjusting for practice setting, work hours, practice-ownership, free endoscopy center practice, and vacation time, female gastroenterologists earned $82,000 (22%) less per year than their male colleagues (95% CI $34,000–130,000, P = 0.001). Women were more frequently in academic practice (38% vs 17%), but were less likely to hold the most advanced academic positions.
CONCLUSIONS: After 10 yr of practice, significant economic, professional, and social disparities persist between male and female gastroenterologists in this cohort. Women were more likely to practice in a setting with flexible work hours, a family leave provision, and in a practice with other women. Initiatives to equalize pay and ensure opportunities for professional advancement for women may diminish the significant practice disparities incurred by women in gastroenterology.     

What is the role of diagnostic laparoscopy in a gastroenterology unit?

Background Diagnostic laparoscopy is known to be a relatively safe invasive procedure. However, its use has decreased owing to the development of imaging techniques, and fewer gastroenterologists now practice diagnostic laparoscopy. Our aim was to examine the role of diagnostic laparoscopy in a gastroenterology unit in the era of advanced imaging techniques. Methods We retrospectively reviewed 855 diagnostic laparoscopy cases. Its safety and efficacy were evaluated for various indications. Results No mortality was observed, and complications were noted in ten patients (1.2%). Among the indications were evaluation of chronic liver disease (n = 673), liver tumor (n = 15), ascites of unknown origin and peritoneal disease (n = 142), and staging of intra-abdominal malignancy (n = 25). In patients with chronic liver disease, 461 were diagnosed as having chronic viral hepatitis, based on clinical data including imaging studies, but the diagnosis was changed to cirrhosis after a laparoscopic exam in 69 patients (15.0%). In patients with ascites of unknown origin and peritoneal disease, the diagnostic yield was 87.2% (123/141). In 24 (19.5%) of the 123 patients, the diagnosis changed or the less probable diagnosis was confirmed after laparoscopic examination. The confirmed diagnoses were mainly primary peritoneal disease, including peritoneal tuberculosis, in 17 patients, peritoneal metastatic carcinoma in five, and mesothelioma in two. Conclusions Diagnostic laparoscopy in a gastroenterology unit is safe and useful, especially for confirmation of liver cirrhosis and primary peritoneal disease evaluation.     

Predicting changes in clinical status of young asthmatics: Clinical scores or objective parameters?

Preventing asthma exacerbation is an important goal of asthma management. The existing clinical tools are not good in predicting asthma exacerbations in young children. Childhood Asthma Control Test (C‐ACT) was recently published to be a simple tool for assessing disease control in young children. This study investigated C‐ACT and other disease‐related factors for indicating longitudinal changes in asthma status and predicting asthma exacerbations. During the same clinic visit, asthma patients aged 4–11 years completed the Chinese version of C‐ACT and underwent exhaled nitric oxide and spirometric measurements. Blinded to these results, the same investigator assigned Disease Severity Score (DSS) and rated asthma control according to Global Initiative for Asthma. Asthma exacerbations during the next 6 months were recorded. Ninety‐seven patients were recruited, with their mean (standard deviation [SD]) age being 9.2 (2.0) years. Thirty‐six (37.1%) patients had uncontrolled asthma at baseline. C‐ACT, DSS, and FEV₁ differed among patients with different control status (P < 0.001 for C‐ACT and DSS; P = 0.028 for FEV₁). Thirty‐two patients had asthma exacerbations during the 6‐month follow‐up. Changes in patients' C‐ACT scores correlated with changes in asthma control status, DSS, and FEV₁ (P = 0.019, 0.034, and 0.020, respectively). C‐ACT score was lower among patients with asthma exacerbations (mean [SD]: 22.9 [4.2] vs. 24.5 [2.1]; P = 0.015). Logistic regression confirmed that the occurrence of asthma exacerbations was associated only with baseline C‐ACT (B = ?0.203, P = 0.042). In conclusion, C‐ACT is better than DSS and objective parameters in reflecting changes in asthma status and predicting asthma exacerbations in young children. Pediatr Pulmonol. 2009; 44:442–449. © 2009 Wiley‐Liss, Inc.     

What’s in a Label? Is Diagnosis the Start or the End of Clinical Reasoning?

Diagnostic reasoning has received substantial attention in the literature, yet what we mean by “diagnosis” may vary. Diagnosis can align with assignment of a “label,” where a constellation of signs, symptoms, and test results is unified into a solution at a single point in time. This “diagnostic labeling” conceptualization is embodied in our case-based learning curricula, published case reports, and research studies, all of which treat diagnostic accuracy as the primary outcome. However, this conceptualization may oversimplify the richly iterative and evolutionary nature of clinical reasoning in many settings. Diagnosis can also represent a process of guiding one’s thoughts by “making meaning” from data that are intrinsically dynamic, experienced idiosyncratically, negotiated among team members, and rich with opportunities for exploration. Thus, there are two complementary constructions of diagnosis: 1) the correct solution resulting from a diagnostic reasoning process, and 2) a dynamic aid to an ongoing clinical reasoning process. This article discusses the importance of recognizing these two conceptualizations of “diagnosis,” outlines the unintended consequences of emphasizing diagnostic labeling as the primary goal of clinical reasoning, and suggests how framing diagnosis as an ongoing process of meaning-making might change how we think about teaching and assessing clinical reasoning.     

Evaluation of Clinical Innovation: A Gray Zone in the Ethics of Modern Clinical Practice?

BACKGROUND

Various stakeholders can have differing opinions regarding ethical review when introducing new procedures with patients.

OBJECTIVE

This pilot study examines the way in which Research Ethics Boards (REBs; Institutional Review Boards) and clinical biochemists (CBs; laboratory medicine specialists) differ in their interpretation of what is research and what should be considered common practice versus innovation versus experimentation when introducing new procedures with patients. It also explores whether these groups agree on who is responsible for the ethical review of new procedures.

METHODS

A validated case scenario for the introduction of a new diagnostic test into clinical practice was sent to CBs and REBs across Canada. Participants were asked to determine whether the scenario constituted research; whether the test procedure should be considered as experimental, innovative, or commonly accepted care; and whether the project required approval by a REB and, if not, who should be responsible for ethical review.

RESULTS

Results showed 81% of 37 CBs and 52% of 27 REBs identified the scenario as research. Responsibility for ethical review was assigned to REBs by 44% of REBs and 54% of CBs. Of all participants, 53% classified the test procedure as ‘innovative’, 8% as ‘experimental’, whereas 17% classified it as ‘commonly accepted’.

CONCLUSIONS

This pilot study indicates a substantial variation in the ethical assessment of innovation in clinical care. This suggests the need to further elaborate on the types of innovation in health care and categorize the nature of the risks associated with each.