Harold V. Liddle

The Rehabilitation of Coronary Surgical Patients

Coronary revascularization has been reported to have failed to effectively rehabilitate working-age patients. This study of 565 patients demonstrates that motivation to return to work is strongly influences by age and educational level. Patients under age 55 are more likely to return to work than are patients over that age, but preoperative job classification does not influence rehabilitation. Although preoperative disability was associated with a slightly lower return-to-work rate (90%) than was the case with patients working preoperatively (97%) preoperative retirement was a strongly negative influence on rehabilitation. In this study, 80% of the patients worked to or beyond retirement age, and duration of work was not influenced by preoperative disability. The salary produced by those patients who were rehabilitated by surgery was four and a half times greater than the total cost of care and disability payments for the entire patient population. The factors which seemed to be the most important in effective rehabilitation were the psychological preparation of patients and their families and the attitude toward rehabilitation expressed by physicians and employers.

Results of Direct Coronary Artery Graft Reconstruction:A Five-Year Clinical and Arteriographic Appraisal

Three hundred thirty-six patients with severe coronary artery disease were operated upon between June, 1969, and December, 1974. All were followed from 1 to 66 months (average, 37 months) with respect to survival and late myocardial infarction. The patients operated upon were compared statistically with a group of unoperated patients, and this evaluation demonstrated significantly better late survival in the surgically treated patients who had double- and triple-vessel disease. Two hundred thirty-six consecutive patients had clinical and late arteriographic reevaluation more than 6 months postoperatively; 78% were asymptomatic. Factors affecting graft patency are reviewed in detail. Late graft patency is determined by preoperative selection of vessels for grafting. Patency is not an index of success for this procedure. Surgical therapy appears to be the treatment of choice for patients with two- three-vessel coronary occlusive disease.

Late Results of Myocardial Revascularization

ince surgical myocardial revascularization for coronary artery disease was described by Vineberg [S, 91 in 1946, it has generated S enormous interest and equal skepticism among surgeons and internists alike. Clinical improvement in the symptoms of coronary artery disease has been ascribed to this surgical procedure by several authors [Z-41, and reduction in the incidence of late myocardial infarction with this procedure has been shown by Gorlin and Taylor [5 ] . However, no convincing evidence has been presented that late survival is significantly influenced by myocardial revascularization. This paper presents a retrospective nonrandom comparison of the incidence of myocardial infarction and mortality in a group of surgically treated patients with that in a group of medically treated patients in whom arteriographic evidence of disease was comparable.

Training, Examination, and Certification of a Thoracic Surgeon: A Position Paper: The American Board of Thoracic Surgery

The training of a thoracic surgeon is a complex process, requiring a minimum of six to seven years. Reliable examination of the trainee is similarly complex, requiring evaluation by various methods at different periods of time. Great care has been taken to keep the methods of examination free from bias and impartial by making the Residency Review Committee for Thoracic Surgery and the American Board of Thoracic Surgery completely independent organizations, unrelated to any other national professional organization. Use of a national professional testing service as a consultant has been a valuable addition to the examination process, which assures that the questions used are reliable and effective and that the results of the examination are objectively assessed. The process of training, examination, and certification of a thoracic surgeon has evolved based on the experience obtained over the past three decades and has repeatedly proved to provide a satisfactory measure of competency in thoracic surgery. It is an achievement of which all thoracic surgeons can feel justly proud. Modifications in the structure and function of the certification process will continue to be made as changes in our medical knowledge occur.

Assessment of Ventricular Function in Coronary Artery Disease Using Nitroglycerin and Computerized Analysis of Left Ventriculograms

The ability to predict if abnormalities in regional wall motion are reversible would assist in selecting patients for aortocoronary bypass operation. This study shows that asynergic areas of the ventricle may be reversed by nitroglycerin. Thirty-four asynergic areas in 30 patients with coronary artery disease were studied before and after administration of nitroglycerin. Nineteen patients with previous infarction, diagnostic Q waves in their electrocardiogram, and akinetic areas in the left ventricle had no change in their akinetic areas after nitroglycerin administration. Nine of these patients did show increased motion in other hypokinetic areas of the myocardium. Five of 11 patients with no evidence of previous infarction showed a dramatic improvement in akinetic areas after nitroglycerin, while of the remaining 6, 5 showed mild improvement. This illustrates that recoverable asynergic areas may be recognized by nitroglycerin.

HELP-based decision analysis applied to coronary artery disease☆

Abstract Decision analysis is an explicit, quantitative approach to making choices under uncertainty. A problem is broken into component modules and structured into a decision tree which attempts to account for all possible outcomes. Outcomes are assigned probabilities of occurring and utilities (measure of relative worth). The alternative which leads to the highest expected utility becomes the preferred choice for a decision maker. Application of decision theory to the decisions a physician must make in treating patients with suspected coronary artery disease appears fruitful because this approach identifies which factors are important. Decision analysis can be conveniently implemented using the HELP system for medical decision making.

Impasse at the Crossroads: Evolution or Regulation

Today, the free enterprise system of health care delivery is being challenged in the United States, where availability and consumption of health services and their cost are epochal. Review of the health care delivery systems of other nations reveals failure of the system when the national medical community has been divided, when government has monopolized the system, and when fee for service has been abandoned. Government intervention in American health care has been increasingly regulatory and promises to extend regulation in the immediate future. The American medical community can respond by unifying, by reducing its contribution to health care costs, and by changing physician behavior. Consumers have the responsibility to eliminate unnecessary utilization and to become more informed buyers of health care and insurance. The fiscal intermediary has the responsibility to provide tailored insurance options that are cost-effective. As informed and unified medical community can be a formidable force in shaping the future of health care in the United States.