J Thorac Cardiovasc Surg 2001;122:1051-1052
© 2001 The American Association for Thoracic Surgery
Reply
Eugenio Neri, MD
Istituto di Chirurgia Toracica e Cardiovascolare
Universitá agli Studi di Siena
Via Bracci
53100 Siena, Italy
Reply to the Editor:
I appreciated the attention paid to our article,
1 and I was honored by the editorial comment 2 about our study, which, with constructive criticism, extends the perspectives of the discussion. Moreover, I was really pleased to discover Walker's admiration for the culture of our city. His tribute to and appreciation of our cuisine is a delightful departure from the numbers and data usually filling the columns of this Journal. Gastronomy is an important field of human creativity, which shares with medicine the objective to improve the quality of life, and I feel privileged that Walker recognizes our talent at least in this field.
The empirical method, which is mainly responsible for the large bulk of data and numbers that regularly fill the pages of this Journal, entered medical practice some centuries ago, replacing, not without difficulties, the principle of authority, ipse dixit, which characterized the history of medicine for millenniums and still characterizes the art of cuisine. Cookbooks do not contain data, and Walker's derisive tone is worthy of this kind of literature; I much prefer a discussion on the empirical data substantiating or confuting a hypothesis. In this perspective, I emphasize the absolute relativity of our conclusions, and the admirable results that accompany the gratifying comments by Christian Hagl and Randall B. Griepp confirm the humility of our arguments.
In our article, my colleagues and I presented our experience on a particular population that, in statistical terms, represents a sample of a general population, with its own idiopathic characteristics related to the pathologic condition, to the geographic provenance, and to the quality of care of our institution. Our conclusions are undoubtedly influenced by these general limitations, affecting every retrospective study involving human beings. Actually our commitment was to provide data, and these data clearly indicate that in very old patients surgical treatment of type A acute aortic dissection is unlikely to reverse a fatal outcome. Without repeating our published results and comments, I contend that the statistical models of mortality and morbidity presented in our study show that many of the perioperative factors and complications traditionally associated with a poor outcome, such as stroke, renal insufficiency, chronic obstructive pulmonary disease, and cardiac insufficiency, are not independent risk factors, thus indicating an adequate standard of care. On the other hand, we highlight that age represents the true limit for surgery, at least in our particular environment. Our objective was not to convince the international surgical community to adopt treatment guidelines but to induce a reflection, based on our data, on the ethical and human aspects of this condition.
Cultural and regional differences find a place in this process, and we fully agree with Martin F. McKneally that the solutions should be found primarily in the local environment. The importance of public participation is indisputable, since our profession is an integral component of the structure of our society. Nevertheless, the medical community is the first to be acquainted with the effectiveness of treatments that surgeons can offer. We as surgeons have a moral and ethical obligation to inform our colleagues of our results and to develop appropriate referral guidelines in cooperation with them.
Although guidelines can be viewed as intrusive "cookbook medicine," which tend to eliminate physician expertise, intuition, and autonomy, they are intended to be a tool for effective communication and coordination among all health care clinicians involved in delivering emergency services.
Finally, we thank Ikonomidis for his observations, which give us the opportunity to clarify, with an example, the magnitude of the odds ratio for the variable age as an independent risk factor of adverse outcome. In our study, the variable age is considered as a continuous variable, and the odds ratio is calculated for 1 year of age; therefore, it is only apparently lower than that of other clinical factors in the multivariable analysis. The odds ratio (OR) for a certain age can be calculated by the following formula: OR = exp (LnOR x Age). In our study, the odds ratio for age in the morbidity model is 1.07 and LN1.07 is 0.068. For an 80-year-old man, the result is: OR = exp(0.068 · 80) = 230; that is considerable.
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References
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Neri E, Toscano T, Masseti M, Capannini G, Carone E, Tucci E, et al. Operation for acute type A aortic dissection in octogenarians: Is it justified? J Thorac Cardiovasc Surg. 2001;121:259-67.
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McKneally MF. "We don't do that here": reflections on the Siena experience with dissecting aneurysms of the thoracic aorta in octogenarians. J Thorac Cardiovasc Surg. 2001;121:202-3.
