AW: [HSF] Acute dissection - what now?

Mon Aug 13 21:12:04 EDT 2007

What do you think of this imaginary data? We randomize everyone in the world to group A or group B. Group A receives a drug A (imagine a betablocker or ASA) and group B doesn't. There is a decade followup that shows Group A had a raw mortality of 1.0001% while Group B had 1.001% per annum. Assume (somebody could calculate the actual p value for that) but let's assume p is .00001 for an absolute survival advantage of 3,600,000/ year for Group A. Would your position be that drug A was helpful for everyone that took it, and therefore everyone who does not take drug A is mistreated and thereby harmed, so everyone you meet should take drug A? Even if Dr. Dunce noticed that half of his patients in town Y died on drug A with the yellow fever every year?

Or would you argue that this is the most expensive, statistically valid, and powerful study ever done, but also perhaps the most stupid? What if you did the same for a statin, and Plavix and two or three drugs for every organ system and got similar results? Would that be excellent health care if we all took 30 drugs? What if we could imagine a hundred?  

Would it be better if we did one test first to sort out group A and B? How about two tests? Ten? All known tests? Would this help?

Should we all take drugs for malaria since this imaginary study might actually be true for chloroquinine? We can't get a broader population then the known world (with a test or two thrown in) can we?

If you don't think so, how is the AICD data different in kind from this imaginary study?

 How is the next study (or your latest study) that you are going to do be different in kind looking back at the end of your career?

Or would you argue that "doctors" must make some type of "judgement" first for a "good" study"?

 What about patients? Do patients have a role what so ever, theoretically speaking, in good medical care other than being a "population" or merely following "directions" for good medical care based on populations? That is, other than choosing or not choosing, or being able to afford or not afford to have "good" medical care, do patients matter? How are they to decide? Based on our opinion?  Is medicine a one way street? Be careful of your answer as it may redefine our analysis of "good medicine" absolutely at least on a theoretical basis. Or conversely, is good medical care actually unimaginable, theoretically speaking, without patient independent interaction? How does showing up at all change things for the potential patient or doctor?  Now that is an interesting direction to think about.

tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Monday, August 13, 2007 8:12:43 PM
Subject: RE: AW: [HSF] Acute dissection - what now?

Roberto

That is why we need data to answer these questions. 

That one case was successful does not mean it (the technique) was a success. As I said we lost a patient 3 weeks ago from non-surgical management of a Type A. I disagree with Tea's thesis that if the patient is alive it implies your strategy was a success. A strategy is not based on a single patient but on a population. Its success is not a binary one but a probabilistic one i.e what proportion of patients treated with a technique will have a particular outcome. If you chose to stab a patient in the chest and they survive without surgery it is neither implies that stabbing people in the chest is safe nor that not operating on them is life-saving. 

ANi

> From: battr at medizin.uni-leipzig.de> To: OpenHeart-L at lists.hsforum.com> Subject: AW: [HSF] Acute dissection - what now?> Date: Tue, 14 Aug 2007 02:54:53 +0200> CC: > > Ani,> How many died without you knowing it??> > You know, I remember from the old old first Gibbon book ( I was general> surgery resident) a chapter about medical treatment in Type A as surgical> treatment was extremely risky. As I moved home many time, each one I cleared> my library and that book went to a Hospital library, but Bob must remember> the first Gibbons.> Roberto> > -----Ursprüngliche Nachricht-----> Von: openheart-l-bounces at lists.hsforum.com> [mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Tea Acuff> Gesendet: Montag, 13. August 2007 04:30> An: OpenHeart-L at lists.hsforum.com> Betreff: Re: [HSF] Acute dissection - what now?> > The main impediment to new understanding is believing our old> understanding...> > tea> > > ----- Original Message ----> From: Ani Anyanwu
 <anianyanwu at hotmail.com>> To: openheart-l at lists.hsforum.com> Sent: Sunday, August 12, 2007 6:34:48 PM> Subject: RE: [HSF] Acute dissection - what now?> > > Odd how our rules change and how we become more accepting and non-critical> of deviations from accepted standards of care, when the deviation comes from> another surgeon. > > I bet that if a similar patient with an MI complicating a type A had> undergone a PCI to RCA and percutaneous drainage of the pericardial space> and then was sent to the CCU for 4 days with the dissection left untreated,> we would all be screaming murder.> > I have actually seen 3 type A's managed by colleagues in the last year where> surgery was not undertaken immediately - one also had a staged procedure,> one was not operated for six weeks - and all did well. Maybe it is time for> us to revisit the UAB paradigm.> > Ani> > > > > To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Acute dissection -> what now?> Date: Sun, 12
 Aug 2007 13:26:34 -0400> From: hgrmd at aol.com> CC: >> > > Dave,> > ? I've never seen or heard of staging an acute dissection, but> your strategy seems to be working so far.? I suspect if you had tried to fix> the whole thing acutely, the patient would have died from RV failure.?> Still, I would think it's a small minority of acute Type A dissections that> can be staged.? If I'm not mistaken, the mean survival of untreated Type A's> is only a couple of days.> > > > Hal> > > -----Original Message-----> From:> David Harris <drdharris at yahoo.co.uk>> To: OpenHeart-L at lists.hsforum.com>> Sent: Sun, 12 Aug 2007 12:45 pm> Subject: Re: [HSF] Acute dissection - what> now?> > > > > Hi Prasannah,> > There was no definite site on the aorta, and> the aorta> was not thinned out and ready to rupture like I have> usually> seen. The adventitia was slightly thickened /> inflamed. There> was a small amount of liquid blood,> and clots, which were around the whole> ventricle.>
 Posterior clots were removed only once we were on> pump.> > I> took him back on 9 Aug for formal closure of the> chest so we could wean and> extubate (I had left the> sternum open to prevent any compression of the> RV,> which looked horrid at that stage). By this stage the> RV looked> normal, the aorta did not look worse (45mm)> externally, and echo showed no> extension of> dissection. He was extubated yesterday, and is still>> delirious / confused. Kidneys are working, creat now> 330mmol/l. I guess I> should plan for later this week?> > Dave> --- psimha> <prasannasimha at gmail.com> wrote:> > > Dave,> > How did he Tamponade ?> >> Prasanna> > David Harris wrote:> > > 60 yr old male presents with `acute> coronary> > syndrome`> > > to physician, inferior infarct pattern.> > >> > >> Cardiac cath done next day. L side normal, RCA> > > blocked. Aortic valve> intact. Aortic dissection> >> then> > > diagnosed. CT confirms that it extends from RCA to> > > below>
 brachiocephalic.> > >> > > Patient then referred to me: dehydrated,> obtunded,> > > creatinine 570mmol/l, anuric. > > >> > > Arrests soon after,> resuscitated. BP 50 - 60> > systolic> > > for 30 mins. Taken to OR for> salvage. Put on pump> > > (cannulated innominate) to keep him alive.> >> Tamponade> > > relieved, vein graft on beating heart to prox RCA.> > > Aorta> looks stable (not thinned out - yet)> > > Weaned with difficulty with IABP.>> > >> > > Now on 40%, ventilated, GCS 10, passing good> > urine,> > >> creatinine 500. Timing for full repair? Attempt> > cross> > > clamp during> repair?> > >> > >> > >> > > Dr. David G. Harris, FCS, MMED,> > >> Cardiothoracic Surgeon > > > Suite 207 > > > Kuils River Private Hospital, >> > > PO Box 1200, Kuils River, 7579, Cape Town, South> > Africa. > > > Tel> +27-21-9006411 > > > Fax +27-21-9006412 Mobile +27-83-3309587> > >> _______________________________________________> > > 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> >> -----------------------------------------> > > > > Dr.> David G. Harris, FCS, MMED,> Cardiothoracic Surgeon > Suite 207 > Kuils>
 River Private Hospital, > PO Box 1200, Kuils River, 7579, Cape Town, South> Africa. > Tel +27-21-9006411 > Fax +27-21-9006412 Mobile +27-83-3309587>> _______________________________________________> 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>> -----------------------------------------> > >> ________________________________________________________________________>> 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:>>
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