- Email: [email protected]
Complexity: the science for medicine and the human story
Correspondence
However, the COMPARE trial studied a real-life population and in real-life practice, the stent thrombosis rates at 1 year with the paclitaxel-eluting stent are consistent, and numerically worse, than our results. In COMPARE, the rate of stent thrombosis at 30 days was 2·0% and at 1 year 3·0%. The SYNTAX trial,2 with Dawkins as a coauthor, reported a stent thrombosis rate with the paclitaxel-eluting stent of 2·1% at 30 days and 3·1% at 1 year. The Horizons trial3 reported a stent thrombosis rate with the paclitaxeleluting stent of 3·2% at 1 year. Dawkins seems to suggest that “lowfrequency adverse event rates”—by implication stent thrombosis—should not influence clinical practice. We strongly disagree. Stent thrombosis carries high morbidity and mortality. Therefore any drug-eluting stent that significantly reduces early stent thrombosis has an important advantage in terms of safety endpoints at the outset, which is unlikely to be lost in the late and very late phase. In all-comer studies, paclitaxel-eluting stents are associated with a constant risk of very late stent thrombosis. In the COMPARE trial, safety and efficacy were significantly in favour of the everolimus-eluting stent. Finally, the multicentre SPIRIT IV trial, which compared a paclitaxeleluting stent with an everolimuseluting stent showed similar safety and efficacy outcomes as our COMPARE trial, supporting our conclusion (unpublished data). The hypothesis set out by Nicholas Kounis and John Goudevenos is interesting and Kounis’s publications on the subject are thoughtprovoking. Unfortunately, we cannot confirm or rule out a role for metal allergy as a partial explanation for our results. We declare that we have no conflicts of interest.
Elvin Kedhi, Eugene McFadden, *Pieter C Smits, for the COMPARE trial investigators [email protected]
1162
Department of Cardiology, Maasstad Ziekenhuis, 3062 ZJ Rotterdam, Netherlands 1
2
3
Daemen J, Wenaweser P, Tsuchida K, et al. Early and late coronary stent thrombosis of sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice: data from a large two-institutional cohort study. Lancet 2007; 369: 667–78. Serruys PW, Morice MC, Kappetein PA, et al, for the SYNTAX Investigators. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009; 360: 961–72. Stone GW, Lansky AJ, Pocock SJ, et al, for the HORIZONS-AMtI Trial Investigators. Paclitaxeleluting stents versus bare-metal stents in acute myocardial infarction. N Engl J Med 2009; 360: 1946–59.
Complexity: the science for medicine and the human story Athar Yawar (Feb 13, p 546) affirms that medicine is better served by science than art, albeit with a new, human science that is less objective, certain, and isolationist. Such a discipline describes the new post-normal science of chaos and complexity, which Stephen Hawking says he thinks will be the science for the 21st century.2 Science keeps changing, as does medicine—the science of humanity. Hippocratic medicine replaced divine intervention and the supernatural with the science of natural observations, guiding medicine to the 18th century.3 A post-Hippocratic medicine emerged with influences from classical science of structure and predictability, probabilistic and reductionist modern science, and then post-modern science of deconstruction.2 These coalesced to a normal science, before 2000, of a puzzle-solving approach with uncertainty managed and values unspoken. René Dubos called for a neoHippocratic medicine to bring together art and science, with a holistic approach different from this normal scientific approach, to reflect the complexities of the patient and 1
differing realities.3 Complexity science is the 21st century neo-Hippocratic science that brings these together, defining a post-normal, more holistic science, with features of uncertainty, irregularity, and subjectivity, which serves medicine better.4 Medicine and its underlying science not only change, but lie in the eye of the beholder.2 To some they mean absolute truth and validity, to others uncertainty and the contextual nature of reality. This makes medicine a human story, with an ever-changing complex, dynamic, intertwined art and science—and chaos and complexity its science for the 21st century.4 We declare that we have no conflicts of interest.
*Vivian S Rambihar, Vanessa S Rambihar [email protected] Department of Medicine, University of Toronto and Scarborough Hospital, Toronto, ON M1P 2V5, Canada 1 2 3 4
Yawar A. Medicine and the human story. Lancet 2010; 375: 546–47. Rambihar VS. Science, evidence, and the use of the word scientific. Lancet 2000; 355: 1730. Dubos R. Hippocrates in modern dress. Persp Biol Med 1966; 9: 275–88. Rambihar VS. CHAOS from Cos to Cosmos: a new art, science and philosophy of medicine, health…and everything else. Toronto: Vashna. 1996.
Renal Disaster Relief Task Force in Haiti earthquake After major earthquakes, crush syndrome, which results in acute kidney injury (AKI), is the second most frequent cause of mortality after direct trauma.1–3 With the hope of preventing crush syndrome and its complications, the Renal Disaster Relief Task Force (RDRTF) of the International Society of Nephrology intervened after the earthquake in Haiti on Jan 12, 2010. Médecins Sans Frontières provided logistic support. Conditions were austere, with laboratory, diagnostic imaging, and www.thelancet.com Vol 375 April 3, 2010
However, the COMPARE trial studied a real-life population and in real-life practice, the stent thrombosis rates at 1 year with the paclitaxel-eluting stent are consistent, and numerically worse, than our results. In COMPARE, the rate of stent thrombosis at 30 days was 2·0% and at 1 year 3·0%. The SYNTAX trial,2 with Dawkins as a coauthor, reported a stent thrombosis rate with the paclitaxel-eluting stent of 2·1% at 30 days and 3·1% at 1 year. The Horizons trial3 reported a stent thrombosis rate with the paclitaxeleluting stent of 3·2% at 1 year. Dawkins seems to suggest that “lowfrequency adverse event rates”—by implication stent thrombosis—should not influence clinical practice. We strongly disagree. Stent thrombosis carries high morbidity and mortality. Therefore any drug-eluting stent that significantly reduces early stent thrombosis has an important advantage in terms of safety endpoints at the outset, which is unlikely to be lost in the late and very late phase. In all-comer studies, paclitaxel-eluting stents are associated with a constant risk of very late stent thrombosis. In the COMPARE trial, safety and efficacy were significantly in favour of the everolimus-eluting stent. Finally, the multicentre SPIRIT IV trial, which compared a paclitaxeleluting stent with an everolimuseluting stent showed similar safety and efficacy outcomes as our COMPARE trial, supporting our conclusion (unpublished data). The hypothesis set out by Nicholas Kounis and John Goudevenos is interesting and Kounis’s publications on the subject are thoughtprovoking. Unfortunately, we cannot confirm or rule out a role for metal allergy as a partial explanation for our results. We declare that we have no conflicts of interest.
Elvin Kedhi, Eugene McFadden, *Pieter C Smits, for the COMPARE trial investigators [email protected]
1162
Department of Cardiology, Maasstad Ziekenhuis, 3062 ZJ Rotterdam, Netherlands 1
2
3
Daemen J, Wenaweser P, Tsuchida K, et al. Early and late coronary stent thrombosis of sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice: data from a large two-institutional cohort study. Lancet 2007; 369: 667–78. Serruys PW, Morice MC, Kappetein PA, et al, for the SYNTAX Investigators. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009; 360: 961–72. Stone GW, Lansky AJ, Pocock SJ, et al, for the HORIZONS-AMtI Trial Investigators. Paclitaxeleluting stents versus bare-metal stents in acute myocardial infarction. N Engl J Med 2009; 360: 1946–59.
Complexity: the science for medicine and the human story Athar Yawar (Feb 13, p 546) affirms that medicine is better served by science than art, albeit with a new, human science that is less objective, certain, and isolationist. Such a discipline describes the new post-normal science of chaos and complexity, which Stephen Hawking says he thinks will be the science for the 21st century.2 Science keeps changing, as does medicine—the science of humanity. Hippocratic medicine replaced divine intervention and the supernatural with the science of natural observations, guiding medicine to the 18th century.3 A post-Hippocratic medicine emerged with influences from classical science of structure and predictability, probabilistic and reductionist modern science, and then post-modern science of deconstruction.2 These coalesced to a normal science, before 2000, of a puzzle-solving approach with uncertainty managed and values unspoken. René Dubos called for a neoHippocratic medicine to bring together art and science, with a holistic approach different from this normal scientific approach, to reflect the complexities of the patient and 1
differing realities.3 Complexity science is the 21st century neo-Hippocratic science that brings these together, defining a post-normal, more holistic science, with features of uncertainty, irregularity, and subjectivity, which serves medicine better.4 Medicine and its underlying science not only change, but lie in the eye of the beholder.2 To some they mean absolute truth and validity, to others uncertainty and the contextual nature of reality. This makes medicine a human story, with an ever-changing complex, dynamic, intertwined art and science—and chaos and complexity its science for the 21st century.4 We declare that we have no conflicts of interest.
*Vivian S Rambihar, Vanessa S Rambihar [email protected] Department of Medicine, University of Toronto and Scarborough Hospital, Toronto, ON M1P 2V5, Canada 1 2 3 4
Yawar A. Medicine and the human story. Lancet 2010; 375: 546–47. Rambihar VS. Science, evidence, and the use of the word scientific. Lancet 2000; 355: 1730. Dubos R. Hippocrates in modern dress. Persp Biol Med 1966; 9: 275–88. Rambihar VS. CHAOS from Cos to Cosmos: a new art, science and philosophy of medicine, health…and everything else. Toronto: Vashna. 1996.
Renal Disaster Relief Task Force in Haiti earthquake After major earthquakes, crush syndrome, which results in acute kidney injury (AKI), is the second most frequent cause of mortality after direct trauma.1–3 With the hope of preventing crush syndrome and its complications, the Renal Disaster Relief Task Force (RDRTF) of the International Society of Nephrology intervened after the earthquake in Haiti on Jan 12, 2010. Médecins Sans Frontières provided logistic support. Conditions were austere, with laboratory, diagnostic imaging, and www.thelancet.com Vol 375 April 3, 2010