AW: AW: [HSF] Acute dissection - what now?- Robert Goetz-History of Cardiac Surgery

Thu Aug 16 11:25:48 EDT 2007

Pray tell in what field is uninamity of thought or action considered a sign of intellectual (or economic for that matter) health? Particularly in response to the needs of a population? Housing? Transportation? Aviation? 

As I will further argue much of this comtempt for variation is based (presumed) on a naive view of health. Specifically that there is or can be known at least, the right solution for health care across the whole population. This is not an argument for nilism either.

As to the last sentence there is no need to confuse "observation" with a single, temporal occurence. In fact, this is one major problem for both population studies and single practioner observations.  As in the education of youth most knowledge is inferred from results over very short time periods, eg 30 day mortality, 9 month school year, etc. The whole system is set to preclude the best possible insight and relevant measurements whether one is a doctor or a teacher.

tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Thursday, August 16, 2007 6:02:19 AM
Subject: RE: AW: AW: [HSF] Acute dissection - what now?- Robert Goetz-History of Cardiac Surgery

Tea

I agree with what you say regarding populations, however in reality population statistics and population based healthcare is the only way we can provide a good and consistent service to out patients. 

Health economists frown at the autonomy of doctors. The reason why the same patient with the same disease can end up with 20 different treatments in 20 different places is the application of 'individual' medicine and 'physician judgement'. If you took your car to be serviced, you would not expect it to be done in 20 different ways depending on where you took it. This is why overall healthcare in the United States remains poor even though it is amongst the most advanced in the world - because of huge health care variations some get excellent care, others get terrible care and rest vary in between, simply because doctors are treating individuals the way they (doctors) seem fit rather than treating disease populations. This applies for example to the continued widespread use of venous grafting and mitral valve replacement. Applying treatment to a population usually results in better health for all. We agree as we have talked about before that some
 treatments will be harmful to individual patients, but hopefully the number needed to harm (NNH) by far exceeds the number needed to treat (NNT) so the net is a health gain for the population.

Regarding the patient in discussion, reliable assessment of harm, or lack of, cannot be made within a day of surgery.

Ani

> Date: Wed, 15 Aug 2007 20:30:02 -0700> From: tacuff at swbell.net> Subject: Re: AW: AW: [HSF] Acute dissection - what now?- Robert Goetz-History of Cardiac Surgery> To: OpenHeart-L at lists.hsforum.com> CC: > > Excuse my confusion or that which I create. It must be hard for someone to respond to my many questions. You and I are not dissimilar in that respect. Not to put words in your mouth, but I infer that what happens to the individual patient may not necessarily be (and thus is not) the basis for your judgment. This leaves among other choices an overall omniscient (naive?) view, the selected population's behavior (whose selection?), or the formal process itself of correct research hypotheses, which of course, never proves anything but just eliminates the unlikely and presumably therefore the untrue.> > I think that I have argued here and elsewhere, rightly or wrongly, that the observed behavior of specific patients or a series of them, is both a
 convenient and useful starting and ending point. I further have suggested that mathematical (statistical) manipulation of populations is not a suitable end in it self, but rather a clarification of our original observation(s). Our desired end result is, again, the actual observed (measured) well being of particular patients. Our theories of causality need to match that end, not visa versa. > > tea> > > ----- Original Message ----> From: Ani Anyanwu <anianyanwu at hotmail.com>> To: openheart-l at lists.hsforum.com> Sent: Wednesday, August 15, 2007 7:48:23 PM> Subject: RE: AW: AW: [HSF] Acute dissection - what now?- Robert Goetz-History of Cardiac Surgery> > > Tea> > See my previous post "the fallacy of surgical research" and also your response for insight into what I might consider a baseline to assess harm and, more importantly, what I might not.> > Ani> > > > > Date: Wed, 15 Aug 2007 12:15:16 -0700> From: tacuff at swbell.net> Subject: Re: AW: AW: [HSF] Acute
 dissection - what now?- Robert Goetz-History of Cardiac Surgery> To: OpenHeart-L at lists.hsforum.com> CC: > > We look at the awesome pictures of the galaxies and notice that only some swirl in spiral patterns. If we could look at the individual stars (must less planets) of those swirl glaxies, we would find most stars in the swirl. The swirl is perhaps best understood as a harmonic of the interaction of individuals of the system, but some stars are disappearing into the central black hole and others into a different fate accelerating away into space. Populations and individuals do not have the same behavior in any universe except the mind. I am still waiting on a response from Ani as to which is the proper baseline from which to assess harm.> > tea > > > ----- Original Message ----> From: David Harris <drdharris at yahoo.co.uk>> To:> OpenHeart-L at lists.hsforum.com> Sent: Wednesday, August 15, 2007 10:26:37 AM> Subject: Re: AW: AW: [HSF] Acute dissection -
 what now?- Robert Goetz-History of Cardiac Surgery> > > Another must to read is Vasilii I Kolesov. A surgeon> to remember. Igor E Konstantinov. Tex Heart Inst J> 2004; 31(4): 349-358.> > While we`re on the topic of the aortic dissection:> My patient woke up 2 days ago, I took him back today.> The aorta still looked strong. The brachiocephalic> interestingly gave origin to both carotids, and was a> nice big vessel to cannulate. I also cannulated> femoral, and could get a clamp between L subclavian,> and brachiocephalic, and clamped brachiocephalic> proximally. I never clamp aorta in dissections, but> the arch looked OK, and dissection was still localised> to ascending. The entry site was a 1cm tear just> above, and to left of right coronary. It had tracked> along greater curve, and re-entry was just before> brachiocephalic. The> repair was simple.> > I think we need to look at each case individually, and> taylor the needs accordingly. I think we would
 have> wiped him out if we had attempted formal repair> initially......first give the cat a chance to bounce> back!!> > Dave Harris> > --- "Dr. Roberto Battellini"> <battr at medizin.uni-leipzig.de> wrote:> > > For the residents reading HSF,> > > > Robert Goetz (Bob knows him as Goetz worked in Cape> > Town), performed the> > first successful clinical coronary artery bypass in> > 1960.> > Read Ann Thorac Surg 2000;69:1966-72, fascinating> > paper by Igor> > Konstantinov.> > Roberto> > > > -----Ursprüngliche Nachricht-----> > Von: openheart-l-bounces at lists.hsforum.com> > [mailto:openheart-l-bounces at lists.hsforum.com] Im> > Auftrag von> > Rwmfglycar at aol.com> > Gesendet: Dienstag, 14. August 2007 18:13> > An: OpenHeart-L at lists.hsforum.com> > Betreff: Re: AW: [HSF] Acute dissection - what now?> > > > > > In a message dated 8/14/2007> 9:54:45 A.M. Eastern> > Daylight Time, > > Jbflegejr at aol.com writes:> > > > Myron Wheat at the University of Florida 30 or 40> >
 years ago reported on the> > > > medical treatment of acute aortic dissection, I> > think in the Journal of > > Thoracic Surgery. He had a fairly large number of> > cases for the time and> > the > > early > > mortality was not very high. If I come across the> > reference, I will post> > it. > > John Flege> > > > > > > > > > Myron Wheat's paper was in the context of a very> > high mortality of surgery > > in acute dissection cases. In 1963 Michael Roman and> > Robert Goetz published> > I > > think 3 successful cases of urgent surgery done at> > Einstein in the Bronx. > > There was quite a flurry of attempts to repeat this> > success with dismal> > results > > (the initial success was in the nature of a "Black> > Swan"). Wheat then > > published his unloading therapy the results of which> > were better than> > surgery. A > >> year or two later it was pointed out that the> > natural history of ascending > > aortic dissection was worse than descending
 aortic> > dissection and that> > Wheat's > > treatment was failing for the ascending cases.The> > reason for this was> > obvious: > > acute aortic insufficiency, acute coronary> > obstruction and acute hemorrhage> > > > into the pericardial cavity were more likely to kill> > the patient than a > > hematoma contained by the pleura. At that time the> > idea took hold that> > ascending > > aortic dissections get emergency surgery and> > descending aortic dissections> > are > > started with unloading therapy and closely observed.> > The rule of thumb stated by Ben works. The > > missing factor in this > > debate is knowledge that would enable us to predict > > outcome, to declare> > with any > > certainty into which third of the three outcomes > > the patient will fall. > > Obviously the presence of one of the three> > potentially> lethal complications> > is > > likely to put the patient into one of the first two> > outcomes. Patient > > anatomical and
 biological variability is wide and> > difficult to measure. (I> > notice > > Roberto thinking of this when he mentions the> > thinness of the intimal> > layer). All > > of us have had the experience of inaccurate> > prediction. > > I had a case with acute dissection in a> > severely hypertensive> > little > > old lady. Although she did not yet have a> > potentially lethal complication, > > the dissection had tracked from mid ascending aorta> > back to just above the > > sinotubular junction. She was not making urine. I> > advised emergency> > surgery > > which she refused. I thought she could get worse at> > any moment and decided> > to > > sit with her through the night titrating her> > therapy.> > She started making urine and was quite stable by the> > morning. I offered her> > > > surgery again and once again was turned down> flat. I> > kept track of her for a> > > > year. She remained proud of having refused to let> > the doctors meddle with> >
 her.> > Bob> > > > > > > > ************************************** Get a sneak> > peek of the all-new AOL> > at > > http://discover.aol.com/memed/aolcom30tour> > _______________________________________________> > 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> -----------------------------------------> _______________________________________________> 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_______________________________________________> 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
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