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Editorials

A technological journey: specialty spotlights and beyond

Caralee Caplan
CMAJ November 02, 1999 161 (9) 1124-1127;
Caralee Caplan
MD
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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.

References

  1. 1.↵
    Rhodes P. An outline history of medicine. London (UK): Butterworths; 1988. p. 102.
  2. 2.↵
    Peitzman SJ. From dropsy to Bright's disease to end-stage renal disease. Milbank Q 1989;67(1 Suppl):16-32.
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Caralee Caplan
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