Perception paradox between the doctors and patients in the industrial-bureaucratic age of medicine: Defensive versus offensive medicine in anticoagulation and atrial fibrillation ablation

Second victims in health care: current perspectives

Medical errors are a serious public health problem and the third-leading cause of death after heart disease and cancer. Every day, the health care professionals (HCPs) practice their skill and knowledge within excessively complex situations and meet unexpected patient outcomes. These unexpected complications and unintentional errors will always be a part of the medical system due to the universal nature of human fallibility and technology. While not all errors are life-threatening, they can significantly compromise a patient's quality of life. However, the victims of medical error reach far beyond the patient. The second victim (SV), which defined for the first time by Albert Wu in his description of the impact of errors on HCPs by both personally and professionally, is a medical emergency equivalent to post-traumatic stress disorder. When the errors occur, it causes a domino effect including the four groups: the patient and family (first victim), the HCP [SV], the hospital reputation (third victim), and patients who are harmed subsequently (fourth victims). The rights of our patients to safe, reliable, and patient-centered care are critical and most important as a primary and utmost aim of medicine. However, we also have to take care of our own (SVs), especially when we have good people who mean to do well and then find themselves in an emotionally complex situation. There is a need to articulate to the public, politicians, and media how system failure leads to medical error even in hand of well-educated and competent HCPs are given an increasing clinical workload. Furthermore, despite several leading institutions in western countries have developed formal support programs that allow HCPs to cope with their emotional distress by obtaining timely support in an emphatic, confidential, non-judgmental environment, we need to raise awareness of this phenomenon and appropriate institutional responses both to harmed patients and their families and HCPs.

Post-truth era and cardiology: After ORBITA, before CABANA

The evidence-based medicine is rooted in the scientific truth. Oxford Dictionaries has released its 2016 word of the year: "Post-truth," which they define as "relating to or denoting circumstances in which objective facts are less influential in shaping public opinion than appeals to emotion and personal belief". In everything from climate change denial to the anti-vaccine movement, we're seeing the consequences of a failure to engage with scientific evidence. Fake news and post-truth pronouncements are increasingly common in social media and political era and are unfortunately also progressively being applied to the medical science. We also see some evidence of post-truth signals in daily cardiology procedures and guidelines including both interventional cardiology and cardiac electrophysiology. Guideline recommendations made before the randomized-controlled trials (RCT) are published might result in a scenario that the interventions or procedures have been performed on millions of people, costing billions of dollars, leading to unnecessary use of health care resources and often, ending up being even accepted as routine procedures in certain clinical situations. "Justice delayed is justice denied" is a legal cliché meaning that if timely justice is not provided to the sufferer, it loses it importance and violates human rights. In medicine, "The RCT delayed is justice denied", as highlighted by ORBITA (Objective Randomised Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina) trial and as may happen with CABANA (Catheter Ablation versus Anti-arrhythmic Drug Therapy for Atrial Fibrillation Trial) in the post-truth era.

Palliative treatment of coronary "atherosclerotic cancer" by drug-eluting or bare-metal stents: From oculo-stenotic reflex period to age of precision medicine

Medications and treatments are said to have a palliative effect if they relieve symptoms without having a curative effect on the underlying disease such as atherosclerosis or cancer. Some authors speculated that atherosclerotic coronary artery disease (CAD) could be considered a "cancer of the coronary arterial wall". Although the percutaneous coronary intervention (PCI) has proven to be effective in decreasing mortality rates among patients with acute coronary syndromes, the previous meta-analyses of PCI versus optimal medical therapy for stable CAD have not been able to demonstrate a reduction in major adverse cardiac outcomes. However, few cardiologists discussed the evidence-based benefits of angiogram and PCI for stable CAD, and some implicitly or explicitly overstated the benefits. Recently, the precision medicine is defined as an evidence-based approach that uses innovative tools and biological and data science to customize disease prevention, detection, and treatment, and improve the effectiveness and quality of patient care. Providing patients with accurate and complete information appears to be an effective way to combat the reliance on the oculostenotic reflex. The foundation of precision medicine is the ability to tailor therapy based upon the expected risks and benefits of treatment for each individual patient. As said by Doctor William Osler, "The good physician treats the disease; the great physician treats the patient who has the disease."

The short-term impact of the catheter ablation on noninvasive autonomic nervous system parameters in patients with paroxysmal atrial fibrillation

BACKGROUND

The autonomic nervous system (ANS) is a potentially potent modulator of the initiation and perpetuation of atrial fibrillation (AF), whereas the presence of AF can activate and alter the ANS. The catheter ablation of AF (AFCA) may cause the cardiac ANS dysfunction, whereas restoration of sinus rhythm or sympathovagal imbalance by AFCA can reverse this process. Our principal goal was to investigate the short-term effect of AFCA on ANS functions evaluated by noninvasive chronotropic (CI), resting heart rate (RHR), and heart rate recovery (HRR) indices.

METHOD

A total of 45 patients were enrolled with symptomatic, drug refractory paroxysmal AF undergoing first cryoballoon (CB) pulmonary vein antrum isolation (PVAI) with one 28-mm CB using single 3-minute freeze techniques without bonus applications. All patients underwent symptom-limited exercise treadmill testing to evaluate noninvasive parameters of ANS before PVAI. For those patients who remained in sinus rhythm, an additional exercise test was repeated after 1 and 3 months after discharge.

RESULTS

The autonomic CI and RHR/HRR indices were impaired after PVAI and persisted post-PVAI 3 months. However, these parameters were not different in patients with and without recurrence.

CONCLUSION

This study demonstrated that the successful AFCA might concurrently impair the ANS parameters. The autonomic imbalance between the sympathetic and parasympathetic activity after AFCA could either become antiarrhythmic and/or proarrhythmic based on which of the two components was going to prevail after successful AFCA. The impaired ANS balance after PVAI might also be another hypothetical mechanism for AF recurrence particularly in the absence of PV reconnection.