Prospective medicine: the role for genomics in personalized health planning

A curriculum for the new dental practitioner: preparing dentists for a prospective oral health care environment

The emerging concept of prospective health care would shift the focus of health care from disease management to disease prevention and health management. Dentistry has a unique opportunity to embrace this model of prospective and collaborative care and focus on the management of oral health. Academic dentistry must better prepare future dentists to succeed in this new health care environment by providing them with the scientific and technical knowledge required to understand and assess risk and practice disease prevention. Dental schools must consider creating career pathways for enabling future graduates to assume important leadership roles that will advance a prospective oral health care system.

Bone marrow angiogenesis magnetic resonance imaging in patients with acute myeloid leukemia: peak enhancement ratio is an independent predictor for overall survival

Emerging evidence suggests that progression of hematologic malignancies is associated with angiogenesis. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) can provide global and functional imaging of tumor angiogenesis. In this study, we performed bone marrow DCE-MRI prospectively at diagnosis and after induction chemotherapy in 78 de novo acute myeloid leukemia (AML) patients and correlated it with treatment outcome. An algorithm to assess bone marrow angiogenesis by measuring the DCE-MRI time-intensity curve pixel by pixel was developed using 3 distinct parameters: peak enhancement ratio (Peak) to indicate tissue blood perfusion; amplitude (Amp) to reflect vascularity; and volume transfer constant (K trans) to indicate vascular permeability. The Peak and Amp decreased significantly at remission status after induction chemotherapy. Patients with higher Peak or Amp at diagnosis had shorter overall survival and disease-free survival than others. Cox multivariate analysis identified higher Peak value (hazard ratio, 9.181; 95% confidence interval, 1.740-48.437; P = .009) as an independent predictor for overall survival in addition to unfavorable karyotype and old age. Our findings provide evidence that increased bone marrow angiogenesis measured by DCE-MRI can predict adverse clinical outcome in AML patients. DCE-MRI may help to select high-risk phenotype AML patients for tailored antiangiogenic therapy and to monitor treatment response.

Proposal for a new health record to support personalized, predictive, preventative and participatory medicine

Today's approach to patient care and the medical record that directs and documents it is largely focused on identifying and treating the patient's disease. This has resulted in a sporadic, reactive healthcare system. Shifting medicine's focus to personalized strategic health planning will require a new approach to the patient 'work-up', a new relationship between the patient and the provider and a new medical record to support it. A prospective health record should be developed to enable personalized and preventative strategies, including assessment of health risks, evaluation of current health status, tracking of disease pathogenesis, prediction of disease events and long-term planning for maintaining wellness and limiting disease. The record should utilize emerging technologies to track predictive clinical risk factors, thereby enabling preventative responses and personalized medicine.

Prospective health care: the second transformation of medicine

Emerging scientific technologies provide rich sources of predictive biomarkers, which will enable the development of tools to quantify risk and anticipate disease, so health care can become rational, preventive and personalized.

Emerging scientific technologies provide rich sources of predictive biomarkers, which could transform health care. Identification of causal biomarkers will enable the development of tools to quantify risk and anticipate disease. Accurate health risk analysis is rapidly becoming feasible, so health care can become rational, preventive and personalized.

Ethics and research assessing the relative roles of genes and the environment

Research on the interaction of genes and the environment is revealing that many human diseases have both genetic and environmental components. Even traditional "environmental" diseases, such as infections, appear to interact with genetic components in the human host. Environmental genetics research will inevitably increase understanding of individual susceptibilities to toxic exposures in the environment and harmful side effects of medications; therefore, it has great promise for improving the prevention and treatment of human diseases. However, realizing the benefits of this research requires careful attention to ethical issues that are particularly relevant in this context. This article reviews some of the most pressing issues related to research design and methods, as well as from the application of research results (e.g., workplace genetic screening and legal toxic torts, personal medical responsibility, and the relationship between genetics and public health measures).

Breast cancer: integrating the patient with her genome

Increasingly, gene expression data are becoming the currency of the realm in assessing disease prognosis. This has been especially evident in cancer, particularly those malignancies for which tumor samples are fairly accessible and understanding prognostic factors has clear implications for treatment decisions. Recently, Pittman et al. demonstrated substantially increased accuracy of personalized disease outcome prediction in breast cancer by integrating gene-expression profile data with traditional clinical risk factors in a set of 158 breast cancer patients.

Chemopreventive drug treatment in subjects with genetic predisposition to cancer: prescriber liability and healthcare disparities

Advancements in pharmacogenomics and chemoprevention promise to reduce cancer incidence and mortality, but utilization will undoubtedly be accompanied with ethical and legal issues that largely remain unexplored or discussed. As pharmacogenomic information is assessed more comprehensively and inexpensively, it will influence decisions regarding when and to whom chemoprevention therapy will be initiated. Pharmacogenomics will change the manner in which the liability system will perceive and analyse risks. Management of the risks related to chemopreventive treatment will differ from traditional disease management. Knowledge about cancer susceptibility will need to consider environmental factors as they relate to healthcare disparities.

Personalized psychiatry: a realistic goal

It is becoming increasingly evident that the implementation of true personalized medicine will not come as rapidly and smoothly as initially hoped. In the aftermath of the drafting of the human genome in 2001, the popular and scientific media featured numerous commentaries heralding the approaching arrival of personalized medicine to the clinic, and describing its huge benefits for patients. Media coverage predicted a drastic transformation for the practice of medicine, second to the revolution brought about by the discovery of vaccines and antibiotics. From the perspective of another 3 years, during which substantial new insights were made into the enormous complexity of human genome variation, it seems that true personalized medicine may still be decades away for many aspects of medical treatment. Nonetheless, the prospects for implementation of at least certain elements of personalized medicine for one key discipline, psychiatry, might be relatively close and more realistic. With the correct focus, realization of some benefits of genetic patient profiling for psychiatric pharmacotherapy might be near, and in due course, lead the way for true personalized psychiatry.