A year ago the editors at CMAJ joined the international community of general medical journals in deciding to devote a November issue to the impact of new technologies in medicine. We soon discovered that the greatest challenge lay in defining "technology." After several MEDLINE searches and brainstorming sessions, I still felt unsure about how CMAJ ought to approach this subject. I decided to ask the 21 members of our editorial board and several of our peer reviewers with a stated interest in technology how they would interpret our theme.
In less than a week, all of the board members and reviewers had offered enthusiastic and thoughtful responses to my email query. In addition to musing on the ethical, political and economic issues related to new technologies in general, these physicians - representing a wide range of specialties and interests - described in some detail the emergence of new technologies in their fields. They opened before me an extraordinary and sometimes bizarre world of high-powered machines, biological tools, designer drugs and medical gadgetry. From this initial foray, I realized how powerful our email system and computerized reviewer database - both relatively simple technologies - could be as information-gathering tools. In moments I could travel across the country or the world to access the insights and experience of clinicians who work daily in today's technologic environment.
Creating specialty listservs - that is, lists of email addresses for each of the clinical specialties - I tossed out a query, like a message in a bottle, to hundreds of physicians practising in 34 specialty areas: What did they believe to be the most important or exciting new technologies in their fields, and what Canadian authority would they recommend to describe that technology for us? Over the next few weeks 150 email responses washed up on our shore (some, interestingly, from physicians who had received the survey as messages forwarded from colleagues) and roughly 30 more came by telephone and post. Ultimately, more than 180 specialists listed almost 400 technologies and Canadian experts to describe them. As a final step, I contacted some of these experts, asking them to write about a new technology in their area of expertise and to provide additional material, such as Web site URLs, photographs and video clips. The end result is the Specialty Spotlights section that follows (p. 1131) and an enhanced online edition of this special technology issue (www.cma.ca/cmaj).
The responses to my query, summarized in the accompanying list, reveal important trends in contemporary medical technology. Although a remarkable variety of technologies are available to today's practitioner, certain key technologies were mentioned over and again by our reviewers, suggesting that there is considerable agreement among specialists as to which innovations are the most promising. Although medical and surgical specialists tended to emphasize different technologies - medical specialists focusing on DNA diagnostics and gene therapy, and surgical specialists citing endoscopy and minimally invasive surgical procedures as key advances - some technologies transcended specialties. The overwhelming consensus was that advances in computer technology, imaging techniques and molecular biology are changing the face of clinical medicine.
Computer technology was described as important in a variety of areas, ranging from diagnosis and treatment to research and education. Respondents said that computers generally increased efficiency through automation in laboratory medicine, advanced informatics in emergency medicine and critical care, and improved monitoring and drug delivery in anesthesia. Computers were also cited as providing new ways of accomplishing old tasks, such as modelling for drug development and collecting survey information on sensitive topics in psychiatry. Another reported function of computer technology was, of course, communication, with large databases and links enabling, for example, worldwide tracking and coordination of infection control and easy retrieval of information for patients and physicians.
New imaging techniques have changed the way we see disease in virtually all specialties. Some, such as positron emission tomography scanning to determine myocardial perfusion, represent new applications of known technologies; others, such as magnetoencephalography for localization of epileptic foci, are relatively new on the scene. In the case of intraoperative MRI, a well-known technology has moved into a new environment.
It seems clear from the respondents that, along with new imaging techniques, no technology has had a greater impact on medical diagnostics than advances in molecular biology. These advances have fed progress in genetics and pharmacology - preclinical specialties whose wide-ranging contributions to clinical medicine warranted inclusion in the list. Not surprisingly, the development of new biological markers, genetic screening tests and tools for the treatment of cancer were cited as crucial advances in hematology and oncology. But nephrologists, neurologists, pharmacologists, respirologists and urologists alike credited the unprecedented explosion of knowledge in molecular biology with improving accuracy and speed of diagnosis and providing new targets for therapy.
These new diagnostic technologies promise to reveal the body's hidden truths; at the same time, they force us to see more from farther away. With the expanded sensory capacity provided by these innovations, medical practice has become less tactile and immediate. In the 19th century, when Laënnec invented the stethoscope, he called his method "mediate auscultation" to emphasize the interposition of a device between the physician and the patient.1 The gap between physician and patient may widen as our vision becomes increasingly mediated by machines, as surgery becomes less invasive, and as investigations become virtual rather than real. Moreover, technology is increasingly defining the illness experience itself: renal failure, for example, once a hopeless condition defined by the symptoms of "dropsy," has been redefined by dialysis and the new set of difficulties that this technology brings.2
It is easy to imagine that the social and ethical issues surrounding contemporary technology represent uncharted territory in the history of medicine. But just as pathology, radiology and microbiology grew out of the recognition that autopsies, x-rays and the microscope could render the body transparent, today's specialties continue to be defined by their technologies and to challenge our notion of what we ought to see and do. As CT scans and genetic testing allow us to see ever more deeply into the core of what makes each of us human, the question remains: How should our vision be used, and how can we, as physicians and as a society, integrate new technologies humanely into patient care?
Evidence-based methods and technology assessment are examples of medicine's efforts to answer this fundamental question. So, in a small way, are the Specialty Spotlights in this issue. These brief and lively reports attempt to shed light, for both the specialist and the general practitioner, on the history, problems and promise of established and emerging technologies. As a group, together with the other articles in this issue, they illuminate the larger landscape of scientific, political, social, ethical and economic issues that medical technologies necessarily create.
Current technologies in medicine
Anesthesia
Cerebral monitoring to detect awareness under anesthesia
Monitoring during cardiopulmonary bypass
Depth-of-anesthesia devices: bispectral index, auditory-evoked responses
Transesophageal echocardiography
Transcranial Doppler
Cardiology and cardiac surgery
PET scanning for myocardial perfusion and metabolism
Contrast echocardiography and harmonic imaging
SPECT and 3-D imaging
Digitalization of full-motion images in echocardiography, angiography
Intravascular ultrasonography and intravascular pressure/flow measurements
MRI of heart
Molecular cardiology
Gene identification in familial atrial fibrillation
Implantable cardiac monitoring devices and cardioverter defibrillator
New potent antiplatelet drugs (glycoprotein IIb/IIIa inhibitors)
Gene therapy for angiogenesis and coronary artery disease
Immunologic manipulation
Mechanical heart
New arterial conduits (e.g., radial artery) for bypass surgery
Intracoronary radiation
Ablation treatment for atrial fibrillation
Port access minimally invasive cardiac surgery
Ventricular assist devices for treatment of heart failure
Xenotransplantation
Bridging strategies, cardiomyoplasty
Robotic surgery
Angioplasty and stenting for carotid stenosis
Left ventricular remodelling surgery
Telemedicine
Database and patient chat line on congenital heart disease
Critical care
Recognition of new mediators of acute inflammation in adult respiratory distress syndrome (ARDS) and sepsis
New treatments for ARDS
Monoclonal antibody therapy directed against IgE antibodies and cytokines in sepsis
Inhaled nitric oxide for hypoxemic respiratory failure
Noninvasive ventilation, including liquid ventilation
Brain protective drugs
New drug delivery systems
Home telemetry with ST-segment monitoring and alarm to signal unstable angina or myocardial infarction to critical care team
Blood substitutes and transfusion therapy in ICU
Continuous renal replacement therapy in ICU
Dermatology
Photodynamic therapy (laser light and porphyrins) for treatment of skin cancer and retinal degeneration
Laser surgery
Telemedicine
Emergency medicine
Bedside ultrasonography
Mini-CT and MRI
Point-of-care laboratory testing
Ultrasound examination of fractures
Rapid-sequence intubation
Home treatment of deep vein thrombosis with low-molecular-weight heparin
Home treatment of cellulitis and pneumonia
New observation units
Procedural sedation
Endocrinology
Bone densitometry
New blood glucose monitoring devices
Noninvasive detection of diabetes complications
New insulins, including inhaled insulins
Computer analysis of blood glucose levels with insulin adjustments
Forensic medicine
DNA evidence
Toxicology
CT and MRI imaging for dating of child abuse injuries
Gunshot wound technologies
Portable x-ray machines to identify position of bullets at crime scene
Laser fingerprinting
DNA typing for confirmation of sexual assault
Gastroenterology and general and colorectal surgery
Endoscopy and endoscopic ultrasonography
"Virtual" colonoscopy
Population screening for colorectal cancer
Molecular genetics of colonic neoplasia, hemochromatosis, cystic fibrosis
Urea breath test and new treatments for Helicobacter pylori
Probiotic treatment for GI disease
Designer drugs for inflammatory bowel disease
Computer modelling for drug development
Antitumour necrosis factor treatment for Crohn's disease
Photodynamic therapy
Small-bowel transplantation
Minimally invasive surgery, including laparoscopy
Cryosurgery
Robotic surgery
Harmonic scalpel
New uses of ultrasonic energy in surgery
Biliary stenting
Transjugular intrahepatic portal-systemic shunts
Angiographic control of GI bleeding
Pancreas and islet cell transplantation in brittle type 1 diabetes
Radiofrequency ablation of liver tumours
Living-related liver transplants
Xenotransplantation
Genetics
Human Genome Project and molecular diagnosis and screening
DNA chip technology and high-speed DNA sequencing for mutation analysis
Fluorescence in-situ hybridization (FISH) and spectral karyotype analysis for rapid diagnosis of syndromes, prenatal diagnosis and use in cancer genetics
Tandem mass spectrometry for newborn screening and diagnosis of metabolic diseases
Positional cloning
Expressed sequence tags searchable using information technology
Analysis of fetal cells in maternal blood and preimplantation diagnosis
Bioinformatics and computational biology
Integrative studies of gene-gene and protein-protein interactions
New ways to apply information from model organisms to humans
Gene therapy for muscular dystrophy
Cloning for tissue and organ replacement
Hematology/oncology and surgical oncology
Genetic identification of people at risk for cancers
Identification of genetic abnormalities and translocations in pediatric cancers
DNA diagnostics for thalassemia and subcategorization of lymphomas
PCR for more sensitive detection of viruses
Molecular markers for diagnosis of solid tumours
Identification of new risk factors for venous thrombosis (e.g., Factor V Leiden mutation) using molecular methods
Advances in hematopoietic transplantation, including mini-transplants and nonmyeloablative allogeneic peripheral blood stem-cell transplants for older patients and mismatched donors
New drugs for graft-versus-host disease
Manipulated hematopoietic grafts for diseases in which tumour cells contaminate grafts
Immunomodulatory therapy for leukemia
Conformal radiotherapy with 3-D computerized treatment planning
Precision radiotherapy using sensor technology
Gene therapy and manipulation of viruses for treatment of hematologic and other cancers
Application of methylene blue and solvent detergent to virally inactivate plasma
Storage of cord blood from newborns in the event leukemia develops later
Leukoreduction filters to decrease virus transmission and transfusion reactions
Anti-angiogenesis-based treatments (e.g., thalidomide)
Tumour vaccines
Antibody therapy (e.g., Herceptin, B-cell monoclonal antibodies conjugated to radiolabelled iodine and CD20 [Rituximab] for low-grade lymphomas)
Brachytherapy
New treatments for pediatric thromboembolism
Dedicated CT simulation
Infectious disease, microbiology and virology
Automated and molecular diagnosis of infections (e.g., chlamydia, gonorrhea, HIV, HCV, HBV)
HIV viral load assays
Anti-sense nucleic acid sequences and bacteriophages
Nucleic amplification to detect changes in cellular cytokines in chronic inflammatory diseases
Prokaryotic PCR for detection of new pathogens (e.g., agents responsible for cat-scratch and Whipple's disease)
Representational differential analysis of virulence factors
New antivirals and antiretrovirals
HIV vaccines
Recognition of virus-coded proteins that interact with receptors
New antibiotics for infections due to multidrug-resistant bacteria
Laboratory medicine and pathology
Point-of-care testing
Molecular diagnosis of infectious diseases and cancer, including molecular hybridization for human papillomavirus testing
Molecular screening
Laboratory automation
Liquid-based cytology
Automated cytology using artificial intelligence for cervical cancer screening
PCR for determining diagnosis and prognosis in anatomic pathology and to detect B- or T-cell clones in lymphoma and microbial antigens in infections
FISH for determining diagnosis and prognosis in anatomic pathology
Neonatology
Dual-photon x-ray absorptiometry in evaluation of whole body and regional fat, muscle and bone mass
Technological advances in assessment of fetal well-being
Somatic gene therapy for inherited disorders
Genetic engineering
Surfactant and steroid therapy for respiratory distress syndrome
Developmental homeostasis in the treatment of thromboembolic disease
Laparoscopic surgery
Nephrology
Online monitoring using biosensors during hemodialysis
New transplantation methods, including pig kidney transplantation
New drugs to prevent transplant rejection
Nocturnal hemodialysis
Molecular biology and cloning
Neurology, neurosurgery and vascular surgery
Functional MRI
Intraoperative MRI
Magnetic resonance spectroscopy
SPECT scans for vascular disease
Magnetoencephalography for localization of epileptic foci
Genetic analysis
Pharmacogenetics in treatment of Alzheimer's disease
New drugs for epilepsy, Parkinson's disease and multiple sclerosis
New intravenous and intra-arterial thrombolytic therapies for stroke
Implanted infusion pumps for severe spasticity due to spinal cord trauma or multiple sclerosis
Deep brain stimulation for Parkinson's disease and dystonia
Vagus nerve stimulation by implanted pacemaker for epilepsy
Surgery and transplantation for Parkinson's disease
Surgery for epilepsy and stroke
Stereotactic surgery for arterial venous malformations, epilepsy, vestibular schwannoma, movement disorders, pain
Endovascular coiling/stenting of aneurysms
Ventriculoscopy, neuroendoscopy
Nutrition
MRI to measure fat deposition
Identification of risk gene profiles to allow targeted diet modification
Food irradiation
Genetic alteration of food
Obstetrics and gynecology
New ultrasound techniques for imaging uterine contents
Prenatal diagnosis in first trimester by ultrasound and maternal serum screening
In vitro fertilization and other new infertility treatments
Multifetal pregnancy reduction
New treatments for abnormal menstrual bleeding
Specific estrogen receptor modulators
Human papillomavirus vaccines
Tension-free vaginal tape for urinary incontinence
Laparoscopic Burch procedure
Microwave endometrial ablation
Orthopedic surgery
Alternative bearing surfaces (e.g., ceramic components) in total joint arthropasty
Bone graft substitutes
Use of growth factors
New cartilage replacement strategies
Minimally invasive spinal surgery
Thermal capsular shrinkage for treatment of unstable shoulder
Minimal access fracture fixation
Palliative care
Subcutaneous infusion pumps to administer pain drugs
New drugs for pain control
New palliative radiotherapy methods
Pharmacology
Magnetic resonance spectroscopy
Sodium-hydrogen exchange inhibitors to limit damage from cardiac reperfusion
New drugs for male sexual dysfunction
Biosensors and continuous immunoassays with digital read-outs
Designer drugs interacting with newly discovered receptors (e.g., glycoprotein IIb/IIIa receptor blockers)
Transfection of endothelial cells with virus-carrying genes for vascular endothelial growth factor in treatment of atherosclerosis
Prediction of drug interactions and effects through knowledge of drug enzyme systems
Combinational chemistry
Psychiatry
PET, SPECT and MRI to determine drug occupancy at receptor sites
New computerized neurocognitive assessment batteries
Genetic mapping of childhood disorders
Tryptophan deprivation to determine appropriate timing of discontinuation of SSRIs
Computerized, structured diagnostic interviews
Transmagnetic stimulation for resistant depression
Designer drugs for psychosis and depression
Eye movement desensitization and reprocessing
Computerized analysis of patient characteristics, treatment regimens and course of care
Telepsychiatry
Respirology, thoracic surgery and otolaryngology
PCR-based diagnostics
DNA fingerprinting in study of TB transmission
Rapid diagnosis of TB
Sputum induction and differential cell counts for asthma and other lung disorders
Spiral computerized tomography
Virtual bronchoscopy
New sleep study equipment, including methods to detect increased upper airway resistance
Oximetry and rapid blood gas analysis
Gene therapy for cystic fibrosis
Autotitration of continuous positive airway pressure (CPAP) for sleep apnea
CPAP for congestive heart failure
Noninvasive ventilation for chronic obstructive pulmonary disease
Nonfluorocarbonated inhalers for drug delivery
Thorascopic surgery and peritonoscopy
Lung-volume-reduction surgery for emphysema
Mandibular advancement devices for sleep apnea
Aerosol delivery of nonpulmonary therapeutic agents
Bone-anchored hearing aids
Laser-assisted surgery of upper airway
Endoscopic sinus surgery
Rheumatology
Bone densitometry and other new methods for measuring bone mass
Biologic treatment for rheumatoid arthritis and systemic lupus erythematosis
Anti-tumour-necrosis-factor-alpha antibodies for rheumatoid arthritis
Autologous cartilage cells for treatment of local cartilaginous defects in osteoarthritis
Urology
New treatments for prostate cancer, renal calculus disease and impotence
Sacral neuromodulation for voiding dysfunction
Holmium laser
Competing interests: None declared.
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