AW: AW: [HSF] The fallacy of surgical research

Fri Aug 3 12:00:56 EDT 2007

More importantly though Kocher's example goes to confirm my rant about surgeons' biased observations of their own data and how you can never know the truth if you do not measure your own outcome. 

Remember at the time, and indeed till this date, Kocher was regarded as the greatest thyroid surgeon. The full story is that actually Kocher heard of this complication from a colleague and, like the rest of us, first denied it had occurred in his patients. He however decided to recall his patients though and what he found shocked him. He said while he thought he was helping patients he turned them into cretins living a life worth not living. I suspect it is the case with some of the patients we operate on today, many of whom we claim success because they are extubated the next day or even better leave hospital in a few weeks. If you don't do a systematic follow-up you will never know the truth.

ANi

> Date: Fri, 3 Aug 2007 08:54:30 +0200> Subject: Re: AW: AW: [HSF] The fallacy of surgical research> From: axel.m.laczkovics at ruhr-uni-bochum.de> To: OpenHeart-L at lists.hsforum.com> CC: > > concerning theodor kocher i recall an information which i guess is of > great importance:> > after total thyroidectomy he saw some of his patients phlegmatic and > simply looking stupid with all the now well-known symptoms of myxedema. > he then made a follow-up on as many pts as he could, which was extremly > progressive and analytical for the time 100 years ago. and he realized > a correlation between his operation and the outcome of his pts and > acknowledged this as a surgical mistake - his mistake! the > consequence was the partial thyroidectomy as performed today.> > this for me is a great consequence and also demonstrates a great > character.> > axel laczkovics> bochum> > > > Am Donnerstag, 02.08.07 um 19:23 Uhr schrieb psimha:> > > Emil Theodor Kocher> > Swiss surgeon, born August 25, 1841, Bern; died July 27, 1917, Bern.> > Nobel prize in 1909> >> > Associated eponyms:> > Kocher zonde> > Spoon-shaped probe for goitre operations.> >> > Kocher's arced incision> > Oblique incision for opening the knee joint.> >> > Kocher's incision I> > Oblique abdominal incision paralleling the thoracic cage on the right > > side of the abdomen for cholecystectomy.> >> > Kocher's incision II> > Tranverse incision over glandula thyreoidea in the neck for > > thyroidectomies.> >> > Kocher's method I> > A method for fixation of the uterus. Fundus uteri is fixated to the > > abdominal wall.> >> > Kocher's method II> > Invagination method for radical operation for hernia inguinalis.> >> > Kocher's method III> > Method for reducing dislocations of the shoulder.> >> > Kocher's reflex> > Contraction of abdominal muscles following moderate compression of the > > testicle.> >> > Kocher's sign> > Eyelid phenomenon in hyperthyreosis and Basedow's disease.> >> > Kocher's syndrome> > Splenomegaly with or without lymphocytosis and lymphadenopathy in > > thyrotoxicosis.> >> > Kocher's tweezers> > Vascular tweezers.> >> > Kocher-Debré-Semélaigne syndrome or disease> > A syndrome of hypothyroidism associated muscular enlargement to give > > the appearance of an infant Hercules.> >> > Kocherisation> > Operative technique in opening the duodenum to expose the ampulla of > > the common bile duct. Dr. Roberto Battellini wrote:> >> What did they investigate? You mean Kocher from the Kocher clamp?> >> Roberto> >>> >> -----Ursprüngliche Nachricht-----> >> Von: openheart-l-bounces at lists.hsforum.com> >> [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von psimha> >> Gesendet: Donnerstag, 2. August 2007 16:11> >> An: OpenHeart-L at lists.hsforum.com> >> Betreff: Re: AW: [HSF] The fallacy of surgical research> >>> >> Roberto , you forgot Theodore Kocher and Egaz Moniz .> >> Prasanna> >> Dr. Roberto Battellini wrote:> >>> >>> Ani,> >>> Science in an art and science discipline (surgery) is very > >>> complicate,> >>>> >> near> >>> >>> the theory of caos. Tell the clinical academics to come to surgical> >>> services and do science. They are not going to make it better than we> >>> surgeons. Of course, we are not as good in biostatistics as they > >>> are. And the most> >>> important factor, the surgeon itself is never included in the > >>> studies!> >>>> >>> By the way, there are 2 Nobel Prize surgeons, Carrel and Forssmann> >>>> >> (together> >>> >>> with Cournand).> >>>> >>> Roberto> >>>> >>> -----Ursprüngliche Nachricht-----> >>> Von: openheart-l-bounces at lists.hsforum.com> >>> [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Ani > >>> Anyanwu> >>> Gesendet: Mittwoch, 1. August 2007 22:14> >>> An: openheart-l at lists.hsforum.com> >>> Betreff: RE: [HSF] The fallacy of surgical research> >>>> >>> The other issue the discussions on myocardial protection brings up > >>> is the> >>> fallacy of surgical research and the poor understanding of research > >>> method> >>> by surgeons. This is what prompted the Lancet editor many years ago > >>> to> >>> describe surgical research as 'comic opera'. The reality is that few > >>> in> >>> academics or research takes us surgeons seriously. Look at the> >>> representation of surgeons in key research bodies, funding of > >>> surgical> >>> research by NIH or similar bodies, surgical influence in research > >>> groups,> >>> surgical publications in key journals, guidelines committees, > >>> involvement> >>>> >> in> >>> >>> key epidemiological efforts etc. The only Nobel prize received by a> >>>> >> surgeon> >>> >>> in the recent era wasn't even for surgical research. The problem is > >>> we as> >>> surgeons believe too much in our individual selves and individual > >>> methods> >>> that we become blinkered as to the requirements of the scientific > >>> method.> >>> Examples include> >>> - there is evidence that such and such an additive to cardioplegia > >>> is of> >>> benefit (this evidence comes from isolated animal hearts, animal> >>>> >> experiments> >>> >>> and at best clinical measures of surrogate markers - these do not > >>> mean the> >>> additive is benefit in the human, indeed it could be worse)> >>> - it has worked well in my cases so it is okay (but as Dr Salerno > >>> and> >>> Prasanna say the heart has great reserve - that nothing goes wrong > >>> does> >>>> >> not> >>> >>> mean all is okay)> >>> - i have had no deaths (the patient came to you alive; why is it an> >>> achievement that he remains alive after surgery? (unless the aim of> >>>> >> surgery> >>> >>> was to save life))> >>> - Kirklin and Buckberg or Cleveland clinic demonstrated...(i.e. > >>> eminence> >>> based medicine; but how many have ever read work of Kirklin or > >>> Buckberg?> >>>> >> Do> >>> >>> they stand up to the requirements of scientific proof? Indeed did > >>> either> >>> really show clinical benefit of the things we attribute to them? For> >>>> >> example> >>> >>> the 'seminal' Cleveland clinic NEJM paper purpurtedly showing > >>> benefit of> >>>> >> IMA> >>> >>> over SVG barely constitutes evidence of such)> >>> - There was no enzyme rise (has anyone cared to show any > >>> relationship> >>> between enzyme rise and any outcome of interest after surgery? Does > >>> the> >>> patient really care what his CK, troponin or coronary sinus lactate > >>> are?> >>>> >> Why> >>> >>> do we look at outcomes of no relevance to the patient?)> >>> - Ventricular fibrillation means bad protection ( but has anyone > >>> shown so> >>> scientifically? maybe fibrillation is intrinsic to some techniques > >>> and> >>>> >> rare> >>> >>> with others and is a reflection of the technique rather than the > >>> degree of> >>> protection; certainly a fibrillating heart in Salerno's beating heart> >>> technique has different implications to an Arch done by Martin on > >>> DHCA)> >>> - The patient was extubated the next day (and so what? Several > >>> times you> >>>> >> go> >>> >>> back to ask what happened to the patient 2 months later and you hear > >>> a> >>> different story. This outcome is of no relevance at all unless aim of> >>> surgery was to allow extubation in patient previously ventilator> >>>> >> dependent)> >>> >>> - My method of cold myocardial preservation works (but how do you > >>> know> >>>> >> that> >>> >>> that is what is working? As Salerno says if you don't know the > >>> myocardial> >>> temperature how do you know it is the hypothermia, and not some other> >>> factor, that is in play?)> >>> - Since I changed I use less inotropes (but you decide what you > >>> use- could> >>> you not be just biased towards the success of your change? Maybe you> >>>> >> should> >>> >>> compare two methos objectively)> >>> - Multiple defibrillation harms the heart and leads to bad outcome > >>> (maybe> >>> but could it be the condition requiring defibrillation that is > >>> resulting> >>>> >> in> >>> >>> the bad outcome rather than the shock?)> >>> - I have done it this way for 10 years and never had problems (how > >>> do you> >>> know? Have you actually measured the outcomes on all your patients? > >>> Kocher> >>> said the same about his thyroidectomies and was shocked when he > >>> recalled> >>>> >> his> >>> >>> patients and found the majority had myxedema)> >>> etc> >>> The inability to critique within the scientific framework and a lack > >>> of> >>> understanding of, or refusal to apply the research method, is a major> >>> problem in surgery and is in part the reason why we are so diverse in> >>> opinion and yet so opinionated and firm in our belief that what we > >>> do is> >>> right (when yet examined there is often no evidence to support it). > >>> No> >>> internist or scientist or epidemiologist would approve a drug based > >>> on any> >>> of the criteria we list above yet we swear by what we do to the > >>> degree> >>>> >> that> >>> >>> we suggest alternative approaches are inferior. Until we start > >>> thinking in a scientific and epidemiological manner, we as> >>> surgeons will remain the laughing stock of academic medicine.> >>> Ani> >>>> >>>> >>>> Date: Thu, 2 Aug 2007 04:52:48 +1000> To: > >>>> OpenHeart-L at lists.hsforum.com>> >>>>> >>> From: benjamin.bidstrup at bigpond.com> Subject: Re: [HSF] Inotropes,> >>> ventricular fibrillation and myocardial protection> CC: > > What > >>> this does> >>> is once again ask the question, how do we measure > myocardial> >>> preservation?> > We can look at the highly sensitive markers such as> >>> Troponin which > indicate some element of damage to components of the> >>> myofibrils. and > so on. Echo - RWMA ECG and the list goes on.> We > >>> need to> >>> look at use of inotropes, IABP, survival. Khuri published > on his> >>> intramyocardiall pH device stating that poor preservation as > > >>> reflected> >>>> >> by> >>> >>> pH changes resulted in altered long term survival.> > Much of the> >>>> >> cocktails'> >>> >>> components have been determined by isolated > rat heart experiments. > >>> They> >>> have translated well to the human, but it > is very hard to measure > >>> total> >>> water content of an intact heart or > regional blood flow > >>> distribution in> >>>> >> a> >>> >>> human model.> > Why is it that there is no universal cocktail. Put > >>> 100> >>> cardiac teams > in a room and you will have 120 different ways of> >>>> >> preserving> >>> >>> the > myocardium.> I review papers that look at different methods of> >>> preservation and > they use markers such as inotrope use to determine> >>> improvement. How > variable that is is a whole new debate.> > > > >> >>> Tomas,>> >>>> >>>>>> A fibrillating heart is a dying heart? Is this an edict of some >> >>>>>>> >>>> sort? I've seen plenty of hearts that fibrillated during some part > >>>> > >of> >>>>> >>> their open heart operation only to have a completely, and I mean >> >>>> >>>> completely, normal EF on remote echo. Speaking in absolutes serves > >>>> > >no> >>>>> >>> purpose.> >> >> >> >Hal> >> >> >-----Original Message-----> >From:> >>>> >> Salerno,> >>> >>> Tomas <TSalerno at med.miami.edu>> >To: OpenHeart-L at lists.hsforum.com> > >>> >Sent:> >>> Wed, 1 Aug 2007 11:19 am> >Subject: Re: [HSF] Inotropes, ventricular> >>> fibrillation and > >myocardial protection> >> >> >> >> >A > >>> fibrillating> >>>> >> heart> >>> >>> is. "Dying" heart.> >The brain does not have seizure during CPB; > >>> neither> >>> should the heart > >fibrillate.> >Tomas> >> >----- Original Message > >>> ----->> >>>> >>>> rom: openheart-l-bounces at lists.hsforum.com >> >>>> <openheart-l-bounces at lists.hsforum.com>> >o:> >>>>> >> OpenHeart-L at lists.hsforum.com> >>> >>>>> >>> <OpenHeart-L at lists.hsforum.com>> >ent: Wed Aug 01 10:45:53 2007> > >>> >ubject:> >>> Re: [HSF] Inotropes,ventricular fibrillation and myocardial > > >>> >rotection>> >>>> >>>> Ani,> >aving graduated from voodoo homemade cocktails to blood and > >>>> its>> >>>> ariants, you would easily be able to see that the bad > >>>> cardioplegia's> >id> >>>>> >>> have a higher (more accurately uniform) incidence of fibrillation> > >>> >hich> >>> came down with better modifications of cardioplegia's. That does> > >>> >ake us> >>> wary and anyway fibrillation is not something by any stretch>> >>>> >>>> ormal.Transient defibrillation may appear innocuous but then it > >>>> has> >een> >>>>> >>> shown that such hearts have indeed been improperly preserved (from> > >>> >orks> >>>> >> of> >>> >>> Buckberg and Kirklin).Remember that sometimes speed etc etc may>> >>> ompensate> >>> but this may become an issue in longer case.> >rasanna> >ni Anyanwu> >>>> >> wrote:>> >>> >>>> >>>> I still do not understand why we are alarmed about transient > >>>> ventricular>> >>>> ibrillation on reperfusion and why using drugs to suppress it will > >>>> have> >>>>> >>> any> >mpact on outcome.> >> > Ani> >> >> >> > > >> Date: Wed, 1 Aug > >>> 2007> >>> 11:51:47 +0530> From: prasannasimha at gmail.com> To:>> >>>> >>>> penHeart-L at lists.hsforum.com> Subject: Re: [HSF] Inotropes, > >>>> ventricular>> >>>> ibrillation and myocardial protection> CC: > > I am not saying that > >>>> the>> >>>> rocaine or lignocaine is still acting. What I> meant is that since > >>>> the>> >>>> ibrillation is occurring with the hotshot delivery> with high local> >>>>> >>> lignocaine> >hanging the drug class may be beneficial.> Prasanna> > > >>> On> >>> 8/1/07, Ben Bidstrup> >benjamin.bidstrup at bigpond.com> wrote:> >> > I > >>> beg> >>> respectfully to differ. The> >idocaine (a fast Na channel> > > >>> blocker) is> >>>> >> all> >>> >>> but gone after a short while in> >he cardioplegia> > scenario. > >>> Getting a> >>> suitable level back into the > >circulation> >nd thus> > the heart at> >>> release of the clamp is what is > >needed.> >> > Perhaps a> > >>> >andomised> >>>> >> study> >>> >>> is in the offing.> >> > >> >>>> >>>> http://circ.ahajournals.org/cgi/content/abstract/79/5/1106>> >> > > >>>> This> >>>>> >>> reference relates to defib energy levels but i think you will> > see>> >>> here> >>> I am coming from.> >> > At James Cook, I was involved in the > >>> development>> >>> f> >>> a non> > depolarising cardioplegia solution, which is slowly > > >>> >working> >>>> >> its> >>> >>> way>> > up the development path. The main components are lidocaine > >>> and> >> >>> adenosine.>> >> >> >> >> > >Ben,> > >I use Amiadorone in the pump > >>> for all> >>> emazes > >>(and postop)> >nd> > >Amiadorone in the pump for all > >>> aortic> >>> valves. Since the St Thomas> >> >Cardioplegia (which we mix in blood)> >>> already has procaine > >adding> > >Lignocaine> >ould be> >>> redundant.(Incidentally Amiadorone is very cheap> > >in India !!)> >>> >>>> >>>> Prasanna> > >Ben Bidstrup wrote:> > >>Why the amiodarone. Surely > >>>> with> >>>>> >> some>> >>> >>>> erfusion, the electrolyte> > >>imbalances within the myocardium > >>>> would> >>>>> >>> correct> >nd SR ensue. If> > >>anything use lidocaine. Less toxic and> >>> cheaper, not a> >egative> > >>inotrope. It is what Yacoub taught me > >>> many> >>> years ago, and I have>> > >>used it to good effect (infrequently I > >>> might >> >>>> >>>> add).> > >>> > >>>Tohru,> > >>>> > did an AVR on an 87 yo man as a > >>>> 2nd> >>>>> >> case> >>> >>>>> >>> just a couple of> > >>>hours ago.> >gain, no LV vent, only a sump. > >>> While> >>> closing the> > >>>aortotomy, I began the>> > >>>continuous warm > >>> retrograde> >>> blood. The heart began fibrillating> > >>>after> > couple of> >> >>>> >>>>> minutes.> >>>>>> >>> I gave amio and then cardioverted. The > >heart had a> >> >>>slow> >>> junctional> > >>>rhythm until the clamp was released. A sinus rhythm>> >>>> >>>> eveloped shortly> > >>>afterwards. He came off with no inotropes. > >>>> It's> >>>>> >>> much> >asier on> > >>>the heart and> > >>>your nerves to cardiovert > >>> a >> >>>> >>>> clamped, flaccid> >eart rather than> > >>>trying to do it> > > >>>> >>>after the> >>>>> >>> clamp has been> >eleased.> > >>> I look forward to your visit at the > >>> STS.> >>>> >> As> >>> >>> I said before,> >'ll> > try to> > >>>have a couple of interesting > >>> cases> >>>> >> for> >>> >>> you and other> >nterested> > >>>members of HSF> > >>>to watch and> >>>> >> criticize> >>> >>> to your heart's> >ontent.> > >>>> > >>>Hal> > >>>> > >>>> > >>>> >> >>>> >>>>>> **************************************> >et a sneak peek of the> >> >>>>>> all-new AOL > >at> > > >>>>>> >>>http://discover.aol.com/memed/aolcom30tour>> >> >>>>>> _______________________________________________> > >>>OpenHeart-L> >>>>>>> >>> mailing> >ist> > >>>> > >>>Send postings to:> > >>> >> >>>> >>>> OpenHeart-L at lists.hsforum.com> > >>>>> > >>>To UNSUBSCRIBE, to > >>>> CHANGE> >>>>> >> email> >>> >>>>> >>> address, or to view archives:> >>> >>>> >>>>>> http://mmp.cjp.com/mailman/listinfo/openheart-l> > >>>> > >>>All> >>>>>>> >>> messages> >ransmitted by the OpenHeart-L are subject to the > >>> policies> >> >>>> >> and>> >>> >>>> >>>>>>>> disclaimers posted at:> > > >>>>>>>> >>>http://www.hsforum.com/listdisclaim> >>> >>>>>>>>> >>>>>> -----------------------------------------> > >>> > >>> > >> >>> >>>>>>> >>>> _______________________________________________> > >OpenHeart-L >> >>>>> >>> mailing> >>>> >>>>> >>> list> >> >> > >Send postings to:> > >OpenHeart-L at lists.hsforum.com> > >>> > >> >> >>>> >>>> To> >NSUBSCRIBE, to CHANGE email address, or to view archives:> >>> >>>> http://mmp.cjp.com/mailman/listinfo/openheart-l> > >> > >All > >>>> messages>> >>>> ransmitted by the OpenHeart-L are subject to the> > >policies and> >>>>> >>> disclaimers> >osted > >at:> > >http://www.hsforum.com/listdisclaim> >> >>>> >>>> ----------------------------------------->> >> >> > --> >> >> > Two> >>>>> >> things> >>> >>>>> >>> are infinite; the universe and human stupidity;> >nd I am> > not sure> >>>> >> about> >>> >>> the universe.> > Albert Einstein> >> > The greatest> >bstacle to > >>> discovery> >>> is not ignorance --- it is the> > illusion of knowledge.>> > Daniel J> >>> Boorstin> >> > Ben Bidstrup FRACS FRCSEd FEBCTS> > Consultant>> >>>> >>>> ardiothoracic Surgeon> > > >>>> _______________________________________________>> >>>>> >>>>>> penHeart-L mailing list> >> > Send postings to:> > >> >>>>>>> >>>> OpenHeart-L at lists.hsforum.com>> >> > To UNSUBSCRIBE, to CHANGE email> >>>>> >>> address, or to view archives:> >>> >>>> >>>> ttp://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages> >>>>> >>> transmitted> >y the OpenHeart-L are subject to the policies> > and> >> >>> disclaimers > >posted at:>> > http://www.hsforum.com/listdisclaim> > > >>> >> >>>> >>>> ----------------------------------------->> >> > > > -- > Prasanna > >>>> Simha> >>>>> >> M>> >>> >>>>> >>>>>> _______________________________________________>> >penHeart-L > >>>>>> mailing> >>>>>>> >>> list> > Send postings to:> OpenHeart-L at lists.hsforum.com> >> >o> >>>> >> UNSUBSCRIBE,> >>> >>> to CHANGE email address, or to view archives:>>> >>>> >>>> ttp://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages> >>>>> >> transmitted> >>> >>>>> >>> by> >he OpenHeart-L are subject to the policies and > disclaimers > >>> posted> >>> at:>> >ttp://www.hsforum.com/listdisclaim>> >>> -----------------------------------------> >> > >> >>> _________________________________________________________________> > > >>> 100's> >>> of Music vouchers to be won with MSN Music> > >> >>>> >> https://www.musicmashup.co.uk/ > >> index.html___________________________________> >>> >>>>> >>> ____________> > OpenHeart-L mailing list> >> > Send postings to:> >> >>> OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email> >>>> >> address,> >>> >>> or to view archives:> > > >>> http://mmp.cjp.com/mailman/listinfo/openheart-l>> >>>> >>>> All messages transmitted by the OpenHeart-L are subject to the > >>>> policies> >>>>> >>> and> > disclaimers posted at:> > > >>> http://www.hsforum.com/listdisclaim> >> >>> -----------------------------------------> >> >> > >> >>>> >>>> _______________________________________________> >penHeart-L mailing> >>>>> >> list>> >>> >>>> Send postings to:> >OpenHeart-L at lists.hsforum.com> >To UNSUBSCRIBE, > >>>> to> >>>>> >>> CHANGE email address, or to view archives:>> >>>> >>>> ttp://mmp.cjp.com/mailman/listinfo/openheart-l> >All messages > >>>> transmitted> >>>>> >>> by the OpenHeart-L are subject to the policies and> >isclaimers > >>> posted> >>>> >> at:>> >>> >>>> >>>> ttp://www.hsforum.com/listdisclaim>> >>>> ----------------------------------------> >> >> >>> >>>> _______________________________________________> >penHeart-L mailing> >>>>> >> list>> >>> >>>> Send postings to:> >OpenHeart-L at lists.hsforum.com> >To UNSUBSCRIBE, > >>>> to> >>>>> >>> CHANGE email address, or to view archives:>> >>>> >>>> ttp://mmp.cjp.com/mailman/listinfo/openheart-l> >All messages > >>>> transmitted> >>>>> >>> by the OpenHeart-L are subject to the policies and> >isclaimers > >>> posted> >>>> >> at:>> >>> >>>> >>>> ttp://www.hsforum.com/listdisclaim>> >>>> ----------------------------------------> >> >>> >>>> ____________________________________________________________________ > >>>> ____>> >>>> AOL now offers free email to everyone. Find out more about what's > > >>>> >free> >>>>> >>> from AOL at AOL.com.> > >>> >_______________________________________________>> >>>> >>>> OpenHeart-L mailing list> >> >Send postings to:> >> >>>>> >>> OpenHeart-L at lists.hsforum.com> >> >To UNSUBSCRIBE, to CHANGE email> >>>> >> address,> >>> >>> or to view archives:> > >>> >http://mmp.cjp.com/mailman/listinfo/openheart-l> >>> >>>> >>>> All messages transmitted by the OpenHeart-L are subject to the > >>>> policies> >>>>> >>> and> >disclaimers posted at:> >http://www.hsforum.com/listdisclaim>> >>>> >>>> -----------------------------------------> > > -- > Ben Bidstrup > >>>> FRACS> >>>>> >>> FRCSEd FEBCTS> Consultant Cardiothoracic Surgeon> > Two things are> >>>> >> infinite;> >>> >>> the universe and human stupidity; and I am > not sure about the > >>> universe.>> >>> Albert Einstein> > The greatest obstacle to discovery is not > >>> ignorance ---> >>> it is the > illusion of knowledge.> Daniel J Boorstin> > >> >>> _______________________________________________> OpenHeart-L mailing > >>> list>> >>>> >>> Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, > >>> to> >>> CHANGE email address, or to view archives:>> >>> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages> >>>> >> transmitted> >>> >>> by the OpenHeart-L are subject to the policies and > disclaimers > >>> posted> >>>> >> at:>> >>> >>> http://www.hsforum.com/listdisclaim>> >>> -----------------------------------------> >>> _________________________________________________________________> >>> The next generation of MSN Hotmail has arrived - Windows Live Hotmail> >>> http:// > >>> www.newhotmail.co.uk_______________________________________________> >>> OpenHeart-L mailing list> >>>> >>> Send postings to:> >>> OpenHeart-L at lists.hsforum.com> >>>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:> >>> http://mmp.cjp.com/mailman/listinfo/openheart-l> >>>> >>> All messages transmitted by the OpenHeart-L are subject to the > >>> policies> >>>> >> and> >>> disclaimers posted at:> >>> http://www.hsforum.com/listdisclaim> >>> -----------------------------------------> >>>> >>> _______________________________________________> >>> OpenHeart-L mailing list> >>>> >>> Send postings to:> >>> OpenHeart-L at lists.hsforum.com> >>>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:> >>> http://mmp.cjp.com/mailman/listinfo/openheart-l> >>>> >>> All messages transmitted by the OpenHeart-L are subject to the > >>> policies> >>>> >> and> >>> disclaimers posted at:> >>> http://www.hsforum.com/listdisclaim> >>> -----------------------------------------> >>>> >>>> >>>> >>> >> _______________________________________________> >> OpenHeart-L mailing list> >>> >> Send postings to:> >> OpenHeart-L at lists.hsforum.com> >>> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives:> >> http://mmp.cjp.com/mailman/listinfo/openheart-l> >>> >> All messages transmitted by the OpenHeart-L are subject to the > >> policies and disclaimers posted at:> >> http://www.hsforum.com/listdisclaim> >> -----------------------------------------> >>> >> _______________________________________________> >> OpenHeart-L mailing list> >>> >> Send postings to:> >> OpenHeart-L at lists.hsforum.com> >>> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives:> >> http://mmp.cjp.com/mailman/listinfo/openheart-l> >>> >> All messages transmitted by the OpenHeart-L are subject to the > >> policies and disclaimers posted at:> >> http://www.hsforum.com/listdisclaim> >> -----------------------------------------> >>> >>> >>> >> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the > > policies and disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
_________________________________________________________________
Celeb spotting – Play CelebMashup and win cool prizes
https://www.celebmashup.com/index2.html