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An Overview of the Survey
GASTROENTEROLOGY 69: 1053- 1057, 1975 Copyright © 1975 by The Williams & Wilkins Co.
Vol. 69, No. 5 Printed in U.S.A.
An Overview of the Survey
I. Why the survey was done . II. How the survey was done A. Work groups B. Executive group C. Cancer of digestive organs D. Human experimentation III. Comments A. Recurrent themes B. General concerns IV. Specific recommendations V. Follow-up efforts I. Why the Survey Was Done Digestive diseases account for a large fraction of all sickness, but only a small fraction of all the dollars for research and training are spent on them. That was and is the contention of a number of leaders in the gastroenterological community. About a decade ago these leaders embarked upon a campaign to document this contention and to use that documentation in an attempt to get redress. The fruits of this decade of effort have been summarized at the two Conferences on Digestive Disease as a National Problem. 1• 2 Material presented at the first conference, held in 1967, established unequivocally that digestive diseases did indeed account for a major fraction of all sickness. While the first conference called for greater research support in digestive diseases, no explicit, comprehensive description of research opportunities and needs was presented. Research support cannot be justified merely because a problem is important; it must also be shown that promising avenues are available for exploitation. In preparation for the second conference, held in 1973, the Digestive Disease Program of the National Institute of Arthritis, Metabolism and Digestive Diseases, National Institutes of Health (NIAMDD/ NIH), initiated a program to conduct a survey to identify future needs and opportunities in digestive disease research. The
reports presented here are the fruits of that survey. These reports show that there are abundant promising opportunities in digestive diseases research. They can serve both to justify increased support for research in digestive diseases and to indicate some of the priorities in the use of such additional funds. These reports should prove useful in the planning activities of the Administration, the Congress, scientific societies and individual scientists, and lay organizations. II. How the Survey Was Done This assessment of needs and opportunities in digestive diseases research was based upon a series of papers* prepared by scientists actively engaged in research in this field. These investigators were asked to identify areas in which too little research effort has been expended, as well as un* Copies of the individual papers submitted to each of the Work Groups can be obtained from the Digestive Diseases Program, National Institute of Arthritis, Metabolism and Digestive Diseases, Room 603, Westwood Building, National Institutes of Health, Bethesda, Maryland 20014. Copies will 'be available to the public at cost of duplication (ten cents per page, per fee schedules published as Notice of Proposed Amendments to the Department of Health, Education and Welfare Regulation on Availability of Records to the Public, pursuant to 5 U.S.C. 552 and 42 U.S.C. 1306, Federal Register, 40, p. 4439, January 30, 1975).
1053
1054
OVERVIEW OF SURVEY
Vol. 69, No . 5
tapped areas which show promise of gener- R. Johnson, who provided initial scientific ating new, useful information. The papers editing of each report and coordinated subwere criticized and modified by other sci- sequent revisions by chairmen of the Work entists to ensure that the recommendations Groups and members of the Executive were a useful mix between the obvious Group. directions that require pursuit and genu C . Cancer of Dif{estive Organs inely new proposals. The Work Group on Cancer of Digestive A. Work Groups Organs found an extensive overlap of their The field of gastroenterology was arbi- efforts with the National Cancer Plan detrarily divided into areas (Work Groups), veloped by the National Cancer Institute. each chaired by an active scientist of Therefore, they did not issue a separate recognized accomplishment. The chairman report . The absence of a report on cancer selected the members of his Work Group, should not be construed to mean that who then divided their area into as many gastroenterologists feel that research on subareas as they thought appropriate. cancer of the digestive tract is unimportant Opinions about the needs and the promise or that gastroenterologists should not parof research in each subarea were solicited ticipate in such research. The Work Group from active scientists throughout the on Cancer of Digestive Organs strongly United States and abroad. More than 300 recommended that there be increased liaiscientists contributed data and ideas in son with the National Cancer Institute to this phase of the effort. An invitation to determine the role of the gastroenterologist participate in the effort was issued to the in cancer research. It is recognized that general scientific community via several although gastroenterologists diagnose and scientific journals. Summaries of past re- treat gastrointestinal malignancies, they search efforts or reviews of the "state of the do very little of the research on cancer of art" were limited to material directly re- the gastrointestinal tract. The Group suglated to justifying proposals for future gested that gastroenterologists be trained research. Work groups were urged to con- as oncologists, that investigative gastroensider such items as potential needs and terologists apply their expertise to gasdirections for clinical and basic research, trointestinal malignancy, and that gastroclinical trials, cooperative studies, research enterologists collaborate with oncologists resources, preventive aspects, and research to develop new approaches to neoplastic training requirements. The Work' Groups disease of the gastrointestinal tract. reviewed and criticized the individual papers, established priorities among the proD . Human Experimentation posed research efforts, and produced a In an effort parallel to the survey of single report. The ordering of research research needs, a group of scientists was priorities was based upon a consideration charged by NIAMDD/NIH with assemof two factors; namely, the socioeconomic bling information concerning the use of and humanitarian importance of the disease in which research was to be done, and human subjects in gastroenterological rethe promise of success in generating new, search and particularly the risks of procedures used. The report of this work group useful information . appears in this document as Report XII. B . Executive Group III. Comments An Executive Group was formed to suA . Recurrent Themes pervise the editing of the reports. This A number of recurrent themes appeared group consisted of two of the Work Group chairmen, with three other gastroentero- in the contributions of individual scientists logical scientists, who reviewed and ana- and of the Work Groups. One frequently appearing theme is the lyzed the reports of the Work Groups. The Executive Group was assisted in these ef- need for trained research personnel; not forts by Eugene D. Jacobson and Leonard only individuals who possess the skills of
November 1975
OVERVIEW OF SURVEY
1055
today's investigators, but also those who are trained in new areas and who will contribute new ideas to research. Bright, well trained, young scientists can supply the vigor, imagination, and interdisciplinary expertise for creative research. Every Work Group report strongly recommended continued support of comprehensive research training. Another recurring theme is the need for well organized, carefully conducted, and scientifically valid clinical trials. In all areas of digestive diseases research such improved trials would serve two purposes: (1) determination of the real value of standard procedures, and (2) testing of new procedures, drugs, and instruments to determine whether or not they should be introduced into medical practice. Although they may appear easy to conduct, clinical trials are in fact difficult to conduct well. Scientifically valid clinical trials require exacting design and analysis, ample and competent manpower and facilities. Expert decisions specific to each case are needed with regard to organizing and conducting any clinical trial. Similar generalizations may be made about epidemiology. Epidemiological studies were recognized as an essential research need by nearly every Work Group. The general qualifications made about clinical trials also apply to epidemiological studies. To ensure valid information, these studies are best performed with the assistance of a central body of experts to provide the required planning, guidance, and analyses of data. A third recurring theme is the requirement for general and specialized research resources: purified, standardized chemical and biological substances; animal models; new methods and instruments; central groups of experts for clinical trials and epidemiological studies; and central reference laboratories for difficult assays and evaluations.
ual investigator-initiated versus centrally directed research efforts, relative use of the major devices for research support (grants, contracts, centers, etc .), and "peer review" funding versus institutional support. Each issue generated a wide span of views and anxieties about the decision-making process involved in fund allocation. How should limited research funds be allocated between investigator- initiated and government-initiated research? It was acknowledged that many factors must be considered: the importance of a given problem in socioeconomic and humanistic terms, the perception of societal needs, the scientific feasibility of a proposed research approach, presently available knowledge and technical capabilities, and the probability of success. Ultimately the decision must be based on a judgment as to which funding mechanism will be most effective in a specific situation. It was agreed that the same standards of excellence should apply to programmatic research as now apply to investigator-initiated research. There is also the question of how investigators will be attracted to an area that has not been especially active and exciting but has been judged to be important. The consensus was that undeveloped areas of research will be activated by potentially important discoveries, mainly through investigator-initiated research. If flexibility is maintained by supporting agencies, it should be possible to respond with support for new areas of research as they evolve. Complementary directed research is appropriate when the likelihood of success becomes high in an area where societal needs are also high, and when progress toward a limited goal is not likely to be achieved by uncoordinated isolated efforts. When a research area has been identified as important by scientists, advisors, and consumers, the increased availability of resources for creative work should attract more investigators to the problem.
B. General Concerns
IV. Specific Recommendations of Priority Areas Each Work Group made specific recommendations of those areas of research that should be fostered because of importance and feasibility. A few of the major recom-
Some of the opinions and concerns that were voiced in the course of the survey and in the discussions of the second conference included basic versus applied research, the proper extent of targeted research, individ-
1056
OVERVIEW OF SURVEY
Vol . 69, No . 5
mendations of each Work Group are listed here .
crosis, analogous to the artificial kidney.
I. Diseases of the Esophagus • Controlled clinical trials of medical and surgical therapy for esophageal reflux and for lye injury. • Investigation of natural and synthetic substances that increase contraction of the lower esophageal sphincter and therefore may be useful in treating reflux esophagitis.
V. Metabolic Diseases of the Liver • Vigorous pursuit of recently developed animal models of alcoholic liver disease should greatly improve our understanding of how alcohol causes liver cell necrosis and why this sometimes goes on to fibrosis. • The liver is a major site for metabolism of most drugs and can be injured by many drugs. The mechanisms of metabolism of drugs and of perverted metabolism that leads to injury deserves extensive study. • Controlled clinical trials are needed to evaluate the treatment of jaundice in newborns by exposure of the infant to visible light or by giving the mothers phenobarbital during the last few days of pregnancy.
II. Peptic Diseases • Development of simple tests that will accurately identify those likely to get ulcers. • Development of teams to help conduct controlled clinical trials of conventional and new methods of medical and surgical treatments, including the very promising histamine blockers and prostaglandins. • Expansion of supplies of natural and synthetic forms of gastrointestinal hormones to elucidate their role in ulcer disease . Ill. Diseases of the Pancreas • Development of a multicenter program to evaluate therapy of acute pancreatitis. • Attraction of many disciplines to study the problem of why the defense mechanisms sometimes fail and allow the pancreas to digest itself. • Vigorous pursuit of the excellent leads that have been made in the study of the interaction of hormones and neural transmitters with their receptors on the walls of pancreatic cells. IV. Inflammatory Diseases of the Liver • Isolation of hepatitis viruses so that vaccines can be prepared. This goal now appears within reach . • Determination of why liver injury continues after the injurious agent is withdrawn. • Development of liver support systems for treatment of massive hepatic ne-
VI. Diseases of the Gallbladder and Biliary Passages • Continuation of studies on dissolution of cholesterol gallstones by feeding chenic acid. • Determination of the mechanism of formation of pigment stones. • Extensive study of the pathophysiology of biliary secretion in newborn infants so the wide variety of disorders in this function can be better categorized, and thereby better treated. VII. Diseases of Intestinal Absorption and Secretion • Development of drugs to block intestinal secretion in secretory diarrheal diseases such as cholera and tourist's diarrhea. • Intensification of research on the combination of malnutrition and diarrhea, since this combination is the number one killer of infants and children worldwide. A primary objective would be to develop vaccines for immunization. • Development of better and safer substances for intravenous feeding for use
November 1975
OVERVIEW OF SURVEY
in those conditions in which food cannot be taken by mouth.
1057
V. Follow-up Efforts
The Work Group reports obviously show substantive overlap with each other, as well as overlap with research that would be • Isolation of the transmissable agent in construed by some to be in fields other Crohn's disease with a view toward than digestive diseases. Readers are likely to identify omissions of important research developing a vaccine for treatment. • Determination of how prolonged ul- areas. Also, the effort was originally decerative colitis causes cancer of the signed to identify digestive diseases recolon so this complication can be search needs from the point of view of the United States; as one looks at worldwide avoided without total colectomy. problems, other research areas and emIX. Cancer of Digestive Or{?ans phases would emerge (e.g., shistosomiasis). • A separate report on Cancer of Diges- The Executive Group vigorously solicits views of readers of these Work Group retive Organs was not written. ports. A follow-up mechanism is being X. Instruments for Dia{?nosis, established for completion of recommendaInvestigation, and Treatment of Digestive tions regarding future digestive diseases Diseases research needs, and for aiding implementa• Development of methods for treat- tion of the advice contained in these rement of gastrointestinal hemorrhage ports . Analysis of views submitted by the by endoscopic means such as laser readers regarding the research ideas, their beams, electrocoagulation, and importance, recommended emphases, etc., will aid in reaching the final recommendaothers. • Development of methods to move en- tion on priorities of research items within doscopic instruments to any part of and between the several Work Group rethe digestive tract quickly, safely, and ports. Comments should be addressed to Morton I. Grossman, M.D ., VA Wadsworth accurately. • Development of centers to evaluate Hospital Center, Building 115, Room 115, the clinical safety arid efficacy of the Los Angeles, California 90073. rapidly expanding endoscopic capabilities. REFERENCES VIII. Colonic and Inflammatory Bowel Diseases
XI. Psychosocial Forces • Studies on the usefulness of biofeedback techniques in digestive diseases. For example, control of gastric secretion in peptic ulcer and control of colonic motor activity in irritable colon.
1. Grossman MI, eta!: Digestive disease as a national problem . Gastroenterology 53:689-696, 1967 ; 53:821-833, 1967; 54:86-92, 1968; 54:246-252, 1968; 55 :102-104, 1968; 55:105-112, 1968; 55 :392-396, 1968 2. Second conference on digestive disease as a na · tiona! problem. Gastroenterology 68:1345-1416, 1975
Vol. 69, No. 5 Printed in U.S.A.
An Overview of the Survey
I. Why the survey was done . II. How the survey was done A. Work groups B. Executive group C. Cancer of digestive organs D. Human experimentation III. Comments A. Recurrent themes B. General concerns IV. Specific recommendations V. Follow-up efforts I. Why the Survey Was Done Digestive diseases account for a large fraction of all sickness, but only a small fraction of all the dollars for research and training are spent on them. That was and is the contention of a number of leaders in the gastroenterological community. About a decade ago these leaders embarked upon a campaign to document this contention and to use that documentation in an attempt to get redress. The fruits of this decade of effort have been summarized at the two Conferences on Digestive Disease as a National Problem. 1• 2 Material presented at the first conference, held in 1967, established unequivocally that digestive diseases did indeed account for a major fraction of all sickness. While the first conference called for greater research support in digestive diseases, no explicit, comprehensive description of research opportunities and needs was presented. Research support cannot be justified merely because a problem is important; it must also be shown that promising avenues are available for exploitation. In preparation for the second conference, held in 1973, the Digestive Disease Program of the National Institute of Arthritis, Metabolism and Digestive Diseases, National Institutes of Health (NIAMDD/ NIH), initiated a program to conduct a survey to identify future needs and opportunities in digestive disease research. The
reports presented here are the fruits of that survey. These reports show that there are abundant promising opportunities in digestive diseases research. They can serve both to justify increased support for research in digestive diseases and to indicate some of the priorities in the use of such additional funds. These reports should prove useful in the planning activities of the Administration, the Congress, scientific societies and individual scientists, and lay organizations. II. How the Survey Was Done This assessment of needs and opportunities in digestive diseases research was based upon a series of papers* prepared by scientists actively engaged in research in this field. These investigators were asked to identify areas in which too little research effort has been expended, as well as un* Copies of the individual papers submitted to each of the Work Groups can be obtained from the Digestive Diseases Program, National Institute of Arthritis, Metabolism and Digestive Diseases, Room 603, Westwood Building, National Institutes of Health, Bethesda, Maryland 20014. Copies will 'be available to the public at cost of duplication (ten cents per page, per fee schedules published as Notice of Proposed Amendments to the Department of Health, Education and Welfare Regulation on Availability of Records to the Public, pursuant to 5 U.S.C. 552 and 42 U.S.C. 1306, Federal Register, 40, p. 4439, January 30, 1975).
1053
1054
OVERVIEW OF SURVEY
Vol. 69, No . 5
tapped areas which show promise of gener- R. Johnson, who provided initial scientific ating new, useful information. The papers editing of each report and coordinated subwere criticized and modified by other sci- sequent revisions by chairmen of the Work entists to ensure that the recommendations Groups and members of the Executive were a useful mix between the obvious Group. directions that require pursuit and genu C . Cancer of Dif{estive Organs inely new proposals. The Work Group on Cancer of Digestive A. Work Groups Organs found an extensive overlap of their The field of gastroenterology was arbi- efforts with the National Cancer Plan detrarily divided into areas (Work Groups), veloped by the National Cancer Institute. each chaired by an active scientist of Therefore, they did not issue a separate recognized accomplishment. The chairman report . The absence of a report on cancer selected the members of his Work Group, should not be construed to mean that who then divided their area into as many gastroenterologists feel that research on subareas as they thought appropriate. cancer of the digestive tract is unimportant Opinions about the needs and the promise or that gastroenterologists should not parof research in each subarea were solicited ticipate in such research. The Work Group from active scientists throughout the on Cancer of Digestive Organs strongly United States and abroad. More than 300 recommended that there be increased liaiscientists contributed data and ideas in son with the National Cancer Institute to this phase of the effort. An invitation to determine the role of the gastroenterologist participate in the effort was issued to the in cancer research. It is recognized that general scientific community via several although gastroenterologists diagnose and scientific journals. Summaries of past re- treat gastrointestinal malignancies, they search efforts or reviews of the "state of the do very little of the research on cancer of art" were limited to material directly re- the gastrointestinal tract. The Group suglated to justifying proposals for future gested that gastroenterologists be trained research. Work groups were urged to con- as oncologists, that investigative gastroensider such items as potential needs and terologists apply their expertise to gasdirections for clinical and basic research, trointestinal malignancy, and that gastroclinical trials, cooperative studies, research enterologists collaborate with oncologists resources, preventive aspects, and research to develop new approaches to neoplastic training requirements. The Work' Groups disease of the gastrointestinal tract. reviewed and criticized the individual papers, established priorities among the proD . Human Experimentation posed research efforts, and produced a In an effort parallel to the survey of single report. The ordering of research research needs, a group of scientists was priorities was based upon a consideration charged by NIAMDD/NIH with assemof two factors; namely, the socioeconomic bling information concerning the use of and humanitarian importance of the disease in which research was to be done, and human subjects in gastroenterological rethe promise of success in generating new, search and particularly the risks of procedures used. The report of this work group useful information . appears in this document as Report XII. B . Executive Group III. Comments An Executive Group was formed to suA . Recurrent Themes pervise the editing of the reports. This A number of recurrent themes appeared group consisted of two of the Work Group chairmen, with three other gastroentero- in the contributions of individual scientists logical scientists, who reviewed and ana- and of the Work Groups. One frequently appearing theme is the lyzed the reports of the Work Groups. The Executive Group was assisted in these ef- need for trained research personnel; not forts by Eugene D. Jacobson and Leonard only individuals who possess the skills of
November 1975
OVERVIEW OF SURVEY
1055
today's investigators, but also those who are trained in new areas and who will contribute new ideas to research. Bright, well trained, young scientists can supply the vigor, imagination, and interdisciplinary expertise for creative research. Every Work Group report strongly recommended continued support of comprehensive research training. Another recurring theme is the need for well organized, carefully conducted, and scientifically valid clinical trials. In all areas of digestive diseases research such improved trials would serve two purposes: (1) determination of the real value of standard procedures, and (2) testing of new procedures, drugs, and instruments to determine whether or not they should be introduced into medical practice. Although they may appear easy to conduct, clinical trials are in fact difficult to conduct well. Scientifically valid clinical trials require exacting design and analysis, ample and competent manpower and facilities. Expert decisions specific to each case are needed with regard to organizing and conducting any clinical trial. Similar generalizations may be made about epidemiology. Epidemiological studies were recognized as an essential research need by nearly every Work Group. The general qualifications made about clinical trials also apply to epidemiological studies. To ensure valid information, these studies are best performed with the assistance of a central body of experts to provide the required planning, guidance, and analyses of data. A third recurring theme is the requirement for general and specialized research resources: purified, standardized chemical and biological substances; animal models; new methods and instruments; central groups of experts for clinical trials and epidemiological studies; and central reference laboratories for difficult assays and evaluations.
ual investigator-initiated versus centrally directed research efforts, relative use of the major devices for research support (grants, contracts, centers, etc .), and "peer review" funding versus institutional support. Each issue generated a wide span of views and anxieties about the decision-making process involved in fund allocation. How should limited research funds be allocated between investigator- initiated and government-initiated research? It was acknowledged that many factors must be considered: the importance of a given problem in socioeconomic and humanistic terms, the perception of societal needs, the scientific feasibility of a proposed research approach, presently available knowledge and technical capabilities, and the probability of success. Ultimately the decision must be based on a judgment as to which funding mechanism will be most effective in a specific situation. It was agreed that the same standards of excellence should apply to programmatic research as now apply to investigator-initiated research. There is also the question of how investigators will be attracted to an area that has not been especially active and exciting but has been judged to be important. The consensus was that undeveloped areas of research will be activated by potentially important discoveries, mainly through investigator-initiated research. If flexibility is maintained by supporting agencies, it should be possible to respond with support for new areas of research as they evolve. Complementary directed research is appropriate when the likelihood of success becomes high in an area where societal needs are also high, and when progress toward a limited goal is not likely to be achieved by uncoordinated isolated efforts. When a research area has been identified as important by scientists, advisors, and consumers, the increased availability of resources for creative work should attract more investigators to the problem.
B. General Concerns
IV. Specific Recommendations of Priority Areas Each Work Group made specific recommendations of those areas of research that should be fostered because of importance and feasibility. A few of the major recom-
Some of the opinions and concerns that were voiced in the course of the survey and in the discussions of the second conference included basic versus applied research, the proper extent of targeted research, individ-
1056
OVERVIEW OF SURVEY
Vol . 69, No . 5
mendations of each Work Group are listed here .
crosis, analogous to the artificial kidney.
I. Diseases of the Esophagus • Controlled clinical trials of medical and surgical therapy for esophageal reflux and for lye injury. • Investigation of natural and synthetic substances that increase contraction of the lower esophageal sphincter and therefore may be useful in treating reflux esophagitis.
V. Metabolic Diseases of the Liver • Vigorous pursuit of recently developed animal models of alcoholic liver disease should greatly improve our understanding of how alcohol causes liver cell necrosis and why this sometimes goes on to fibrosis. • The liver is a major site for metabolism of most drugs and can be injured by many drugs. The mechanisms of metabolism of drugs and of perverted metabolism that leads to injury deserves extensive study. • Controlled clinical trials are needed to evaluate the treatment of jaundice in newborns by exposure of the infant to visible light or by giving the mothers phenobarbital during the last few days of pregnancy.
II. Peptic Diseases • Development of simple tests that will accurately identify those likely to get ulcers. • Development of teams to help conduct controlled clinical trials of conventional and new methods of medical and surgical treatments, including the very promising histamine blockers and prostaglandins. • Expansion of supplies of natural and synthetic forms of gastrointestinal hormones to elucidate their role in ulcer disease . Ill. Diseases of the Pancreas • Development of a multicenter program to evaluate therapy of acute pancreatitis. • Attraction of many disciplines to study the problem of why the defense mechanisms sometimes fail and allow the pancreas to digest itself. • Vigorous pursuit of the excellent leads that have been made in the study of the interaction of hormones and neural transmitters with their receptors on the walls of pancreatic cells. IV. Inflammatory Diseases of the Liver • Isolation of hepatitis viruses so that vaccines can be prepared. This goal now appears within reach . • Determination of why liver injury continues after the injurious agent is withdrawn. • Development of liver support systems for treatment of massive hepatic ne-
VI. Diseases of the Gallbladder and Biliary Passages • Continuation of studies on dissolution of cholesterol gallstones by feeding chenic acid. • Determination of the mechanism of formation of pigment stones. • Extensive study of the pathophysiology of biliary secretion in newborn infants so the wide variety of disorders in this function can be better categorized, and thereby better treated. VII. Diseases of Intestinal Absorption and Secretion • Development of drugs to block intestinal secretion in secretory diarrheal diseases such as cholera and tourist's diarrhea. • Intensification of research on the combination of malnutrition and diarrhea, since this combination is the number one killer of infants and children worldwide. A primary objective would be to develop vaccines for immunization. • Development of better and safer substances for intravenous feeding for use
November 1975
OVERVIEW OF SURVEY
in those conditions in which food cannot be taken by mouth.
1057
V. Follow-up Efforts
The Work Group reports obviously show substantive overlap with each other, as well as overlap with research that would be • Isolation of the transmissable agent in construed by some to be in fields other Crohn's disease with a view toward than digestive diseases. Readers are likely to identify omissions of important research developing a vaccine for treatment. • Determination of how prolonged ul- areas. Also, the effort was originally decerative colitis causes cancer of the signed to identify digestive diseases recolon so this complication can be search needs from the point of view of the United States; as one looks at worldwide avoided without total colectomy. problems, other research areas and emIX. Cancer of Digestive Or{?ans phases would emerge (e.g., shistosomiasis). • A separate report on Cancer of Diges- The Executive Group vigorously solicits views of readers of these Work Group retive Organs was not written. ports. A follow-up mechanism is being X. Instruments for Dia{?nosis, established for completion of recommendaInvestigation, and Treatment of Digestive tions regarding future digestive diseases Diseases research needs, and for aiding implementa• Development of methods for treat- tion of the advice contained in these rement of gastrointestinal hemorrhage ports . Analysis of views submitted by the by endoscopic means such as laser readers regarding the research ideas, their beams, electrocoagulation, and importance, recommended emphases, etc., will aid in reaching the final recommendaothers. • Development of methods to move en- tion on priorities of research items within doscopic instruments to any part of and between the several Work Group rethe digestive tract quickly, safely, and ports. Comments should be addressed to Morton I. Grossman, M.D ., VA Wadsworth accurately. • Development of centers to evaluate Hospital Center, Building 115, Room 115, the clinical safety arid efficacy of the Los Angeles, California 90073. rapidly expanding endoscopic capabilities. REFERENCES VIII. Colonic and Inflammatory Bowel Diseases
XI. Psychosocial Forces • Studies on the usefulness of biofeedback techniques in digestive diseases. For example, control of gastric secretion in peptic ulcer and control of colonic motor activity in irritable colon.
1. Grossman MI, eta!: Digestive disease as a national problem . Gastroenterology 53:689-696, 1967 ; 53:821-833, 1967; 54:86-92, 1968; 54:246-252, 1968; 55 :102-104, 1968; 55:105-112, 1968; 55 :392-396, 1968 2. Second conference on digestive disease as a na · tiona! problem. Gastroenterology 68:1345-1416, 1975