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Storylines of family medicine Ⅻ:family medicine and the healthcare system

Family Medicine and Community Health 2024年第S3期12卷 109-118页

作者： William B Ventres Leslie A Stone Jeannette E South-Paul Kendall M Campbell Aerial R Petty Hima Ekanadham Kurt C Stange Rebecca S Etz William L Miller Robert L Ferrer Marianna Kong Thomas Bodenheimer Roger Strasser Sharon C M Reece Joshua freeman John M Westfall Family and Preventive Medicine University of Arkansas for Medical Sciences College of MedicineLittle RockArkansasUSA Meharry Medical College NashvilleTennesseeUSA Family Medicine University of Texas Medical Branch at Galveston School of MedicineGalvestonTexasUSA Family Medicine Residency Program New York-Presbyterian Columbia University Medical CenterNew YorkNew YorkUSA Center for Family and Community Medicine Columbia University Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA Center for Community Health Integration Case Western Reserve University School of MedicineClevelandOhioUSA Family Medicine and Population Health Virginia Commonwealth University School of MedicineRichmondVirginiaUSA Family Medicine Lehigh Valley Health NetworkAllentownPennsylvaniaUSA University of South Florida Morsani College of Medicine TampaFloridaUSA Family and Community Medicine UT Health San Antonio Long School of MedicineSan AntonioTexasUSA Family and Community Medicine University of California San Francisco School of MedicineSan FranciscoCaliforniaUSA Northern Ontario School of Medicine University SudburyOntarioCanada Family Medicine Baylor Scott and White HealthTempleTexasUSA Family Medicine University of Kansas School of MedicineKansas CityKansasUSA DARTNet Insitute AuroraColoradoUSA

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine,as interpreted by individual family physicians and medical educators in the USA and elsewhere around the ***‘Ⅻ:Family medicine and the future of the healthcare system’,authors address the following themes:‘Leadership in family medicine’,‘Becoming an academic family physician’,‘Advocare—our call to act’,‘The paradox of primary care and three simple rules’,‘The quadruple aim—melding the patient and the health system’,‘Fit-for-purpose medical workforce’,‘Universal healthcare—coverage for all’,‘The futures of family medicine’and‘The 100th essay.’May readers of these essays feel empowered to be part of family medicine’s exciting future.

关键词： system illustration family

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Limitations in assessment of mucosal healing in inflammatory bowel disease

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World Journal of Gastroenterology 2010年第1期16卷 15-20页

作者： Hugh James freeman Department of Medicine University of British Columbia

An emerging parameter to define the effectiveness of new therapeutic agents in clinical trials,and by extension,for use in day-to-day clinical practice has been labeled mucosal *** has been hypothesized that complete healing of the intestinal mucosa in inflammatory bowel diseases should result in reduced disease complications,reduced hospitalization and reduced surgical *** implication,the natural history of inflammatory bowel disease might then be altered. Measurement of mucosal healing,however,is largely observational,requiring repeated invasive endoscopic examinations,sometimes with mucosal *** indirect imaging methods may play a role in this assessment along with other surrogate markers,including intestinal *** measurements may have significant limitations that prohibit precise correlation with symptom-based disease activity indices in clinical *** likely reflects the dynamic nature of this evolving and individualized inflammatory process that tends to be focused,but not limited,to the mucosa of the intestinal tract.

关键词： Intestinal mucosa Digestive system endoscopy Clinical trials

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Surveillance for colitis-associated colon neoplasia

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World Journal of Gastroenterology 2010年第37期16卷 4646-4651页

作者： Hugh James freeman Department of Medicine University of British Columbia

The risk of developing colon cancer is increased in colitis patients, particularly if the disease is extensive and its duration long-standing. Endoscopic guidelines have been developed with the goal of detecting early neoplastic changes prior to development of advanced malignancy. Unfortunately, the natural history of this superimposed neoplastic process in colitis appears to be very heterogeneous and poorly understood. Moreover, there are numerous confounding variables in colitis patients that limit accurate assessment of the surveillance effectiveness of colonoscopy and multi-site biopsy protocols. Although the clinical challenge posed to even the most experienced clinicians remains significant, evolving methods of endoscopic imaging may facilitate better evaluation of this highly select group of patients.

关键词： Ulcerative colitis Crohn’s disease Colon cancer Surveillance colonoscopy Colon biopsies

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Colorectal cancer risk in Crohn's disease

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World Journal of Gastroenterology 2008年第12期14卷 1810-1811页

作者： Hugh James freeman Department of Medicine (Gastro-enterology) University of British Columbia UBC Hospital Vancouver BC Canada

There is recognized increased risk for colorectal cancer in patients with inflammatory bowel disease, particularly in long-standing and extensive ulcerative colitis. There also appears to be an increased rate of intestinal cancer in Crohn's disease, including both colon and small bowel sites. In Crohn's disease, evidence suggests that detection of colorectal cancer may be delayed with a worse progno-sis. Some risk factors for cancer in Crohn's disease include the extent of inflammatory change within the colon and the presence of bypassed or excluded segments, inclu-ding rectal "stump" cancer. In addition, the risk for other types of intestinal neoplasms may be increased in Crohn's disease, including lymphoma and carcinoid tumors. Earlier detection of colorectal cancer based on colonoscopy scre-ening and surveillance may be achieved but, to date, this has not translated into a positive survival benefit. Moreo-ver, newer staining methods and evolving micro-endos-copic techniques show promise, but have not significantly altered management. Future research should focus on development of molecular or other bio-markers that might predict future dysplasia or cancer development in Crohn's disease.

关键词： Colon cancer Crohn's disease Surveillance Small bowel cancer

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Malignancy in adult celiac disease

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World Journal of Gastroenterology 2009年第13期15卷 1581-1583页

作者： Hugh James freeman Department of Medicine (Gastroen-terology) University of British Columbia Hospital

Prior studies have suggested that the incidence of some neoplastic disorders,particularly malignant lymphoma and small intestinal adenocarcinoma,are increased in celiac *** studies from the United Kingdom have also suggested a link between celiac disease and esophageal carcinoma,although this has not been confi rmed in North *** risk of other gastrointestinal cancers seems to be *** cancer does not appear to be detected more frequently,although direct endoscopic visualization of the upper gastrointestinal tract is now very common in patients with celiac *** cancer also appears to be limited in celiac disease,even in patients first diagnosed with celiac disease late in *** has led to the hypothesis that untreated celiac disease may be protective,possibly owing to impaired absorption of fat or fat-soluble agents,including hydrocarbons and putative co-carcinogens implicated in the pathogenesis of colon cancer,which may be poorly absorbed and rapidly excreted.

关键词： Adult Celiac disease Adenocarcinoma Lymphoma T cell enteropathy

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Adult celiac disease in the elderly

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World Journal of Gastroenterology 2008年第45期14卷 6911-6914页

作者： Hugh James freeman Department of Medicine (Gastroentero-logy) University of British Columbia

There is an increased awareness that celiac disease may occur in the elderly although presentations with either diarrhea, weight loss or both may be less common causing delays in diagnosis for prolonged periods. Higher detection rates also seem evident owing to active case screening, largely through serodiagnostic measures. In some elderly patients who are genetically predisposed, it has been hypothesized that celiac disease might be precipitated late in life by an antigen, possibly from an infectious agent. As a result, peptide mimicry or other poorly-defined mechanisms may precipitate an autoimmune gluten-dependent clinical state. Although diarrhea and weight loss occur, only isolated iron deficiency anemia may be present at the time of initial diagnosis. In addition, the risk of other autoimmune disorders, particularly autoimmune thyroiditis, and bone disease, are increased. Osteopenia may also be associated with an increased risk of fractures. Finally, elderly celiacs have an increased risk of malignant intestinal disease, especially lymphoma.

关键词： Celiac disease Elderly Lymphoma Silentceliac disease

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Complications of collagenous colitis

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World Journal of Gastroenterology 2008年第11期14卷 1643-1645页

作者： Hugh James freeman Department of Medicine(Gastroen-terology) University of British ColumbiaVancouver V6T 1W5Canada

Microscopic forms of colitis have been described, including collagenous colitis. This disorder generally has an apparently benign clinical course. However, a number of gastric and intestinal complications, possibly coincidental, may develop with collagenous colitis. Distinctive inflammatory disorders of the gastric mucosa have been described, including lymphocytic gastritis and collagenous gastritis. Celiac disease and collagenous sprue （or collagenous enteritis） may occur. Colonic ulceration has been associated with use of nonsteroidal anti-inflammatory drugs, while other forms of inflammatory bowel disease, including ulcerative colitis and Crohn＇s disease, may evolve from coUagenous colitis. Submucosal ＂dissection＂, colonic fractures or mucosal tears and perforation from air insufflation during colonoscopy may occur and has been hypothesized to be due to compromise of the colonic wall from submucosal collagen deposition. Similar changes may result from increased intraluminal pressure during barium enema contrast studies. Finally, malignant disorders have also been reported, including carcinoma and lymphoproliferative disease.

关键词： Colonic fractures Colonic perforation Celiac disease Collagenous gastritis Collagenous sprue Cat scratch colon Colon cancer Microscopic colitis

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Reproductive changes associated with celiac disease

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World Journal of Gastroenterology 2010年第46期16卷 5810-5814页

作者： Hugh James freeman Department of Medicine (Gastroenterology) University of British Columbia Hospital

Celiac disease is a mucosal disorder of the small intestine that may be triggered by dietary exposure to gluten in genetically-susceptible *** disorder is often associated with diarrhea,malabsorption and weight loss along with other extra-intestinal *** changes have been described,including impaired fertility and adverse pregnancy outcomes possibly related to immune-mediated mechanisms or nutrient *** possible pathogenetic factors that may alter placental function include maternal celiac disease autoantibodies binding to placental transglutaminase,and genetic mutations that may facilitate microthrombus *** noting activation during pregnancy or the puerperium may be important,and suggest that celiac disease may also be hypothetically precipitated by maternal exposure to one or more fetal antigens.

关键词： Celiac disease Infertility Pregnancy Post-partum celiac disease Fetal outcome

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Refractory celiac disease and sprue-like intestinal disease

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World Journal of Gastroenterology 2008年第6期14卷 828-830页

作者： Hugh James freeman Department of Medicine (Gastroenterology) University of British Columbia Vancouver BC Canada

Celiac disease is a gluten-dependent small intestinal mucosal disorder that causes malabsorption, often with diarrhea and weight loss. Diagnosis is based on detection of typical biopsy changes in the proximal small bowel, followed by evidence for an unequivocal response to a gluten-free diet. Refractoriness in celiac disease may be due to poor diet compliance, sometimes intentional, or consumption of ubiquitious sources of gluten. Alternatively, the original diagnosis may not be correct (eg., duodenal Crohn's disease), or a second cause for symptoms may be present (eg., collagenous colitis, functional bowel disorder). In some with recurrent symptoms, a complication may be present (eg., collagenous sprue, small bowel carcinoma, lymphoma). In some, a response to a gluten-free diet can not be unequivocally defined, and more precise historical terms have been used including "sprue-like intestinal disease" or "unclassified sprue". Although a "wastebasket diagnosis", these likely represent a heterogeneous group, and some, but not all, may develop lymphoma. Precise definition will be critical in the future as an array of new treatments, including biological agents, may emerge.

关键词： Refractory celiac disease Refractory sprue Unclassified sprue Celiac disease Intestinal lymphoma T-cell enteropabhy

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Pancreatic endocrine and exocrine changes in celiac disease

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World Journal of Gastroenterology 2007年第47期13卷 6344-6346页

作者： Hugh J freeman Department of Medicine (Gastroenterology) University of British ColumbiaVancouverBCCanada

Although there is a great deal of information on celiac disease and associated involvement of other non-intestinal sites,data on concomitant changes in the structure and function of the pancreas is limited. The present review critically examines pancreatic endocrine changes that have been well documented in the literature,including insulin-dependent diabetes mellitus. Pancreatic exocrine alterations may also occur,and if severe,marked malnutrition with pancreatic failure and ductal calcification have been observed. Finally,other pancreatic disorders have been recorded with celiac disease.

关键词： Celiac disease Gluten-sensitive enteropathy Diabetes mellitus Chronic pancreatitis Pancreatic function

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