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Critical Issues in Gastroenterology

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Critical Issues in Gastroenterology. Edited by Gitnick G. (Pp 132; £23.50). UK: Williams and Wilkins Europe Ltd, 1998. ISBN 0-683-30555-7.

The breathless hype “the lastest [sic] vital gastroenterology information on strategies, therapies, equipment” and the out of focus cover artwork give an unfortunate rushed feel to this portable volume, which is indeed rather heterogeneous in content. There are six chapters covering strategic planning for managed care, proton pump inhibitors (PPI), irritable bowel syndrome (IBS), emerging therapies for hepatitis C, colorectal cancer and polyp surveillance, and evolving therapies for colon cancer. Most of the chapters are from the UCLA School of Medicine, some from the East coast and one from Monash (PPIs). Readers who are seeking an evidence-based medicine approach will find some of the chapters circumlocutory and lacking detail of treatment regimens and supporting research evidence. The text is entirely unreferenced and a list of “recommended readings” is given instead. One has the impression that certain chapters, notably the quite comprehensive review of IBS by Lembo, Chang and Mayer, were written with references which were subsequently expunged by the editor.

Fullerton’s chapter on strategic planning for managed care will be an eye opener for most British gastroenterologists, and is required reading for those of us who are anticipating a role in negotiating with primary care groups and health authorities. This is medi-business in which a business planning approach is applied to practice based clinical trials, outcomes research, clinical practice guidelines, and disease management. This systems approach to the treatment of diseases uses the disease itself as the unit of analysis and not the traditional NHS measures of new referrals or inpatient episodes. A worked example of a disease management programme for inflammatory bowel disease (IBD) is given. Reading this Californian future evokes a Rawhide image of the health manager rounding up gently moving herds of patients with IBD, although we know that each case is a potential maverick or bucking bronco.

The chapter on PPI use is extremely conversational and seems almost to have been taken by surprise by theHelicobacter pylori story. This is in contrast to the discussion of IBS, which thoroughly examines the pathophysiology and reviews the spectrum of drug, psychological and behavioural treatment. This section would have been strengthened by a synthesis of the approach to the patient with IBS and guidance on choosing between the confusing variety of treatment modalities described.

Emerging therapies for hepatitis C are comprehensively covered, and the chapter on colorectal cancer and polyp surveillance by Bond is perhaps the most authoritative in the volume. He does at least make plain where his position on endoscopic surveillance of patients with colorectal cancer or IBD is evidence-based. In discussing evolving therapies for colon cancer Rosen has thoroughly reviewed the variety of chemotherapeutic trials.

Critical Issues in Gastroenterology does provide an interesting read in parts but falls short of its target “to prepare you to solve the challenging problems you face daily in gastroenterology”. This is particularly so in the field ofH pylori where bland statements of the increasing awareness of the need to treat H pylori infection effectively are out of step with the European perception of the need to boldly go where the evidence is pointing.

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