Renal disease affects people of all ages and lead to considerable distress and early death for a significant number of persons. Kidney disease appears at all ages with newborn babies being affected with congenital and genetic problems, young children developing kidney problems as a primary condition or as a complication of other disease. The elderly, especially, are prone to develop kidney problems and renal failure as their health deteriorates.
Kidney diseases and renal failure are especially common in people with hypertension and diabetes. In the Arabian Peninsula these two diseases have had an exponential increase to epidemic proportions. In the future, with the high prevalence of hypertension and diabetes there will probably be an explosion of renal disease that will result in morbidity to a large number of persons but also the economic costs to the health system will be huge. Individuals will suffer and the families will be burdened the chronic illness of their family members. It is difficult to imagine the burden of the financial and social costs to the patients, families and society that could result from this marked increase in diseases of the kidneys which may well occur in the Arabian peninsula in the near future.
What can be done about the problem? This will take a combined effort of researchers; community medicine specialists and clinicians approaching the problems from may different angles. Work is being done and needs to continue in the understanding of the pathophysiology of kidney diseases, in the discovery and further development of treatments and in the long-term clinical care of patients with renal disease. Many individuals are contributing to these problems and encouragement is needed for those who have dedicated their working lives to studies in the field of kidney pathology and management.
The Sheikh Hamdan Grand Award for Medical Sciences will honour the individual who best exemplifies the dedication, research abilities and clinical contribution that will ultimately help to stop the devastating effects of renal disease and will give tremendous benefit to the citizens of the United Arab Emirates, the Arabian Gulf area and the world as a whole.
Open operations for chest and abdominal diseases carry inherent risks of morbidity and mortality because patients have to contend with the consequences of long incisions and wounds, which involve muscle cutting. Such wounds cause postoperative pain, which make it difficult for patients to be on their feet again quickly and require analgesic medication for several days after operation. In addition, because of wound discomfort, patients may be reluctant to breathe deeply and can develop chest infections which can be life threatening.
In the past decade there has been an explosion of interest worldwide amongst surgeons for so-called Minimally Invasive or ‘Keyhole Surgery’. This enables surgical procedures to be performed through tiny incisions with the operation undertaken by the surgeon using a small video camera to visualize internal organs looking at the video monitor. Thus, diagnosis and treatment of a wide range of diseases has become possible, including all the abdominal and chest organs. Advances in technology are now taking place, which will enable treatment of inflammatory conditions, trauma, degenerative diseases and cancer. These techniques enable some procedures to be undertaken with the patient only needing to spend one day in hospital instead of 7- 10 days after “open” surgery. This will enable a speedy recovery and may substantially reduce the risk of death from respiratory and other complications related to “open” wounds. In addition, considerable excitement has been generated by progress in information technology with the performance of “remote” keyhole surgery carried out by robotic arms, eg as in car manufacture, with the operating surgeon working at a nearby console, guiding the robotic arms. These robotic procedures are not yet routine but their development needs to be encouraged so that the best surgical expertise can be employed to treat patients far and wide. This has tremendous potential as, if the technology could be further developed, operations may be conducted in the future with a surgeon situated at a console and the actual operation on the patient being performed at another hospital and, indeed, even perhaps in another country.
Keyhole surgery has revolutionized surgical practice in the past decade and is now being extended to head and neck and limb surgery, to the benefit of patients worldwide. Developing this new technology needs strong and enthusiastic support of dedicated skilled surgeons who really are pioneers in this field.
In medicine, if prevention fails, at the end of the day you either cut (surgery) or prescribe drugs (applied pharmacology). With respect to GI disorders the unmistakable trend is nowadays away from surgery.
DUODENAL ULCER: Long gone are the days when ulcers used to be treated surgically by vagotomy and/or pyloroplasty. Actually the last PubMed entries to the topic are from the mid seventies. The decline of surgery in this area coincides with the discovery of histamine2-receptor blockers by Sir James Black and the introduction to the market of cimetidine (Tagamet) by Parson in 1974. While Tagamet, with the wisdom of hindsight, might not be the ideal drug, don’t tell that to the millions of grateful patients who experienced pain relief thanks to what at his introduction was a real wonder drug.
The next step in the prevention and non-invasive therapy of upper GI tract ulcers was the introduction of the Proton Pump Inhibitors (PPI) in the early eighties. While daily maintenance treatment with the anti-secretory H2 receptor blocker controls duodenal ulcer effectively and markedly reduce relapse rate at one year after treatment from about 75 percent to 25 percent, PPIs further lower the relapse rate to fewer than 10 percent.
The link between Gl tract ulcera and Helicobacter infection is well established. Modern therapy of this condition includes various antibiotics. Furthermore there is an epidemiologically positive association between H. pylori status and the risk for gastric cancer. In addition to the epidemiological evidence, animal experiments have shown that H. pylori infection elevates the risk for gastric cancer.
GASTROESOPHAGEAL REFLUX DISEASE: The prevalence of GRD seems to be rising and is now probably the commonest acid-peptic disease encountered in the West. The PPIs have revolutionized the treatment of GRD. In clinical trials they have proven markedly superior to the H2 receptor blockers in healing (at eight weeks, 80 to 90 percent vs. 50 to 60 percent), symptom relief, prevention of relapse on maintenance therapy and cost-effectiveness. The ideal profile of an anti-secretory drug for intermittent treatment would combine rapid onset of action (similar to H2 receptor blockers) with powerful effect (as with PPI). The new class of drug, the reversible PPI (e.g., BY841) approaches this requirement.
GASTROKINETIC AGENTS: Cisapride probably contributed more to our understanding of GI tract physiology than to relieving patient suffering, but the new generation of serotonin receptor agonists (renzapride & mosapride) is just around the corner. Furthermore the good old macrolide erythromycin is serving as a template for the new class of motilin agonists. Erythromycin increases antral contractility by two mechanisms: an inotropic effect acting on smooth muscle motilin receptors, and, at lower doses, a cholinergic chronotropic effect mediated through neuronal motilin receptors.
ULCERATIVE COLITIS: The treatment of ulcerative colitis requires careful review of the medical and surgical options. The surgical procedure of choice is proctocolectomy with ileal pouch-anal anastomosis. However pharmacological treatment is gaining upper hand, mainly due to new therapeutic options.
Smoking is protective against developing ulcerative colitis. Nicotine is the cause of this protective effect. Controlled trials have demonstrated efficacy of transdermal nicotine for active ulcerative colitis. Topical administration of nicotine to the colon reduces nicotine blood concentrations and side effects, and may be of clinical benefit. Despite the use of high-dose intravenous corticosteroids, 20-30% of patients will make a poor response and will require urgent surgery. The use of intravenous immuno-supressants (cyclosporin) has proved effective at reducing the immediate surgical rate in this group of unresponsive patients and appears safe.
CROHN’ S DISEASE: Infliximab is a chimeric monoclonal antibody that binds to tumor necrosis factor-alpha (TNFalpha) and neutralizes its effects. TNFalpha plays an important role in the development of both Crohn's disease and rheumatoid arthritis. In a large, double blind, randomized study involving patients with active, refractory Crohn's disease, significantly more recipients of intravenous infliximab, compared with placebo, achieved a clinical response after 4 weeks' follow-up. Moreover, infliximab administration was associated with a rapid improvement in endoscopic and histological findings in clinical trials involving patients with active, refractory Crohn's disease.
The possibility, and to a certain extent the reality, of non-surgical treatment for serious diseases which used to “belong to the knife” is a "hot topic" in medical science. The consequences of this trend, if fully implemented are indeed phenomenal and of immense public health relevance. One can indeed assume that the face of 21st century medicine will be changed beyond recognition.
Taken together, all the mentioned aspects emphasize the importance of the selected topic, and make it a very good choice for the prestigious Sheikh Hamdan Award.
