- Email: [email protected]
Re: The challenge for neurosurgery in the 21st century (Ausman J. Surg Neurol 2008;69:102)
110
Letters to the Editor / Surgical Neurology 70 (2008) 108–111
after aneurysmal subarachnoid hemorrhage. In their study, 12 (39%) of 31 patients in the MgSO4 treatment group discontinued because of hypotension. We had previously studied the relationship between the current MgSO4 dosage and blood pressure (unpublished data). Twelve patients with subarachnoid hemorrhage were prescribed MgSO4 therapy, in which they first received 20 mmol bolus MgSO4 over 30 minutes followed by an infusion of 80 mmol over 24 hours. Another 12 patients with subarachnoid hemorrhage received the same amount of normal saline infusion. Hourly blood pressure records 12 hours before and 12 hours after the start of magnesium sulfate were analyzed. Systolic blood pressure (mean ± SD) was 140.6 ± 3.3 mm Hg before the MgSO4 treatment and 136.0 ± 3.7 mm Hg after the MgSO4 treatment (P = .421). Diastolic blood pressure (mean ± SD) was 64.0 ± 9.8 mm Hg before the MgSO4 treatment and 60.6 ± 6.5 mm Hg after the magnesium sulfate treatment (P = .302). Pulse rate (mean ± SD) was 80.6 ± 6.1 per minute before the magnesium sulfate treatment and 83.2 ± 6.0 per minute after the magnesium sulfate treatment (P = .163). We conclude that the direct hypotensive effect of MgSO4 treatment, in the dosage of current clinical trials, is mild and other factors such as sedatives, natriuresis, or sepsis are the actual culprits of hypotensive episodes in patients with aneurysmal subarachnoid hemorrhage. However, it should be noted that, in conjunction with other anesthetic agents, MgSO4 infusion would reduce anesthetic dose requirement and might lead to a reduction in mean arterial blood pressure during surgery [1]. George K.C. Wong, FRCS (SN) W.S. Poon, FRCS Division of Neurosurgery Prince of Wales Hospital The Chinese University of Hong Kong Hong Kong, China E-mail address: [email protected] doi:10.1016/j.surneu.2007.12.029 Reference [1] Elsharnouby NM, Elsharnouby MM. Magnesium sulphate as a technique of hypotensive anaesthesia. Br J Anaesth 2006;96:727-31.
Response Wong and Poon present an interesting letter to the editor concerning our paper. They present (unpublished) data where they studied the effect of MgSO4 on the blood pressure up to 12 hours after application. Based on the results, they concluded that the direct hypotensive effect of MgSO4 is mild. They suggest other factors (ie, sedatives, natriuresis, or sepsis) might be responsible for hypotensive episodes in patients with aneurysmal subarachnoid hemorrhage. Interactive effect of
MgSO4 and sedatives/anesthetic agents is mentioned. Indeed, these factors were not analyzed in our paper. I present the following comments and concerns: (1) Is it not possible that a hypotensive effect of MgSO4 occurs later than 12 hours after its application? (2) Sedatives, natriuresis, and sepsis per se might lead to hypotensive episodes. But how about the interactive/additive effect of MgSO4 on natriuresis and sepsis? Much remains to be researched and discussed on this topic. We thank Wong and Poon for their comments.
Carl Muroi, MD Department of Neurosurgery University Hospital Zurich Zurich CH-8091, Switzerland E-mail address: [email protected] doi:10.1016/j.surneu.2008.01.019
Re: The challenge for neurosurgery in the 21st century (Ausman J. Surg Neurol 2008;69:102) Letter to the Editor, I read with considerable interest your recent editorial concerning the future of neurosurgery. I agree with your analysis and conclusions especially that “Neurosurgery as we know it today will be of historical interest” and that neurosurgeons must increase their efforts to work with others, adding medical oncology (and the gamma knife, for example) to those disciplines you mentioned where neurosurgeons are collaborating. In addressing change, you indicate that “Those [physicians] that change will win in the market place of the future, whereas those who do not will fail.” Left unexplored is the question of how does the physician change. How does he confront and assimilate the knowledge of change? I am concerned that if we do not come up with new approaches to further the education of practicing physicians facing the technological and intellectual advances about which you write, they simply will not be able to keep up and thus change. I do not think that current Continuing Medical Education processes—large annual meetings, local medical staff gatherings, regional 2-day conferences, the classic printed or online journals, etc—will be sufficient. There is just too much developing over too short a time for the practicing physician to assimilate under these opportunities. Each Continuing Medical Education process I previously mentioned will continue to have its favorable influence; but opportunities for more intense involvement with knowledgeable physicians, both scientists and clinicians, must be developed. I am thinking in terms of in-residence opportunities of education that do not interfere with standard residency
Letters to the Editor / Surgical Neurology 70 (2008) 108–111
programs but provide experience commensurate with the learning curve [2]. The education of neurosurgeons and other physicians in the complexities of the gamma knife required such an effort (Jack Wissinger, MD, personal communication). Some schools recognize the necessity of this by providing intense programs for practicing physicians who recognize the need to expand their knowledge base [1]. The military has remedial and development schools for soldiers advancing to the next level of responsibility, including trauma physicians [3], that last weeks. I do not believe what I have presented above is the final solution to the problem, or even an adequate statement of the problem; but I hope that it is a warning of a recognizable problem and an arguably coherent call for a debate on its solution. Clark Watts, MD, JD Austin, TX 78731, USA doi:10.1016/j.surneu.2008.01.027 References [1] Dean, Office of Continuing Education. Mini-fellowship program. The University of Texas Southwestern Medical Center of Dallas; 2007. [2] Hatlie MJ. Climbing the learning curve. JAMA 1993;270:1364-5. [3] Moore EE, Knudson MM, Schwab CW, Trunkey DD, Johannigman JA, Holcomb JB. Military-civilian collaboration in trauma care and the senior visiting surgeon program. N Eng J Med 2007;357:2723-7.
Response I totally agree with Dr Watts that the systems we now have in place to educate neurosurgeons about the rapidly changing future and how to deal with it are inadequate. Yet, this is also a problem of the individual who is not thinking of the future. There is little that can be done for those who are not interested in changing, and there are many in medicine and neurosurgery who have this basic problem. What Dr Watts is saying is how do we prepare our members for the 21st century. This is a key question because it is very hard for a practicing physician to do this once he or she is in an established practice. Yet, there are those who make the time to change and to learn. There has to be a fundamental understanding that one needs to change and grow rather than just “try to make it.”
111
Actually, the neurosurgical meetings do need to be broader in scope, including discussions of the major social, economic, and political issues of the day. Invited speakers on subjects outside of neurosurgery and in developing scientific areas would also be valuable if focused on how this information can be applied to neurosurgery and neurological diseases. A whole morning session should be devoted to these events, but it is hard for program chairpersons to initiate change in their societies because too many are interested in “doing things the way we always did.” There are 3 issues that are occurring simultaneously. One is the rapid advance in superspecialities in neurosurgey that makes each superspecialist less interested in other superspecialities. The constraints of personal time also add to this problem. Second is the need to keep up with general advances in neurosurgery and even medicine. Easy places to get summaries of the advances in neurosurgery in general and medicine are hard to find and not convenient. Third is an opportunity to learn new approaches to a superspecialty. This need seems to be answered by the special courses held before each meeting. During a national meeting, for example, a full day section could be devoted to having the invited speakers lecture in one room on advances in all specialties in neurosurgery. A similar session could be held for other areas of general medicine and surgery with very brief talks. This would be a “meeting within a meeting.” There are many advances in other areas of medicine that neurosurgeons do not know or are not published in the neurosurgical journals they read. Finally, Dr Watts' idea of short “learning experiences” in academic centers for those in practice appeals to me. Lastly, the fundamental answer to the issues Dr Watts raises is in Group Practice. Being a member of a larger group allows time for more specialization and advanced education. This approach is the only way to survive in the future under the huge wave of change that is happening everywhere in the world. Yet many neurosurgeons are resistant to this idea. They will lose as time progresses. These are issues that should be discussed at a national level with Strategic Planning Committees everywhere in the world. I agree with Dr Watts that we need more ideas here. Please write to us with your thoughts, and Surgical Neurology will publish them.
James I. Ausman, MD, PhD Editor
Letters to the Editor / Surgical Neurology 70 (2008) 108–111
after aneurysmal subarachnoid hemorrhage. In their study, 12 (39%) of 31 patients in the MgSO4 treatment group discontinued because of hypotension. We had previously studied the relationship between the current MgSO4 dosage and blood pressure (unpublished data). Twelve patients with subarachnoid hemorrhage were prescribed MgSO4 therapy, in which they first received 20 mmol bolus MgSO4 over 30 minutes followed by an infusion of 80 mmol over 24 hours. Another 12 patients with subarachnoid hemorrhage received the same amount of normal saline infusion. Hourly blood pressure records 12 hours before and 12 hours after the start of magnesium sulfate were analyzed. Systolic blood pressure (mean ± SD) was 140.6 ± 3.3 mm Hg before the MgSO4 treatment and 136.0 ± 3.7 mm Hg after the MgSO4 treatment (P = .421). Diastolic blood pressure (mean ± SD) was 64.0 ± 9.8 mm Hg before the MgSO4 treatment and 60.6 ± 6.5 mm Hg after the magnesium sulfate treatment (P = .302). Pulse rate (mean ± SD) was 80.6 ± 6.1 per minute before the magnesium sulfate treatment and 83.2 ± 6.0 per minute after the magnesium sulfate treatment (P = .163). We conclude that the direct hypotensive effect of MgSO4 treatment, in the dosage of current clinical trials, is mild and other factors such as sedatives, natriuresis, or sepsis are the actual culprits of hypotensive episodes in patients with aneurysmal subarachnoid hemorrhage. However, it should be noted that, in conjunction with other anesthetic agents, MgSO4 infusion would reduce anesthetic dose requirement and might lead to a reduction in mean arterial blood pressure during surgery [1]. George K.C. Wong, FRCS (SN) W.S. Poon, FRCS Division of Neurosurgery Prince of Wales Hospital The Chinese University of Hong Kong Hong Kong, China E-mail address: [email protected] doi:10.1016/j.surneu.2007.12.029 Reference [1] Elsharnouby NM, Elsharnouby MM. Magnesium sulphate as a technique of hypotensive anaesthesia. Br J Anaesth 2006;96:727-31.
Response Wong and Poon present an interesting letter to the editor concerning our paper. They present (unpublished) data where they studied the effect of MgSO4 on the blood pressure up to 12 hours after application. Based on the results, they concluded that the direct hypotensive effect of MgSO4 is mild. They suggest other factors (ie, sedatives, natriuresis, or sepsis) might be responsible for hypotensive episodes in patients with aneurysmal subarachnoid hemorrhage. Interactive effect of
MgSO4 and sedatives/anesthetic agents is mentioned. Indeed, these factors were not analyzed in our paper. I present the following comments and concerns: (1) Is it not possible that a hypotensive effect of MgSO4 occurs later than 12 hours after its application? (2) Sedatives, natriuresis, and sepsis per se might lead to hypotensive episodes. But how about the interactive/additive effect of MgSO4 on natriuresis and sepsis? Much remains to be researched and discussed on this topic. We thank Wong and Poon for their comments.
Carl Muroi, MD Department of Neurosurgery University Hospital Zurich Zurich CH-8091, Switzerland E-mail address: [email protected] doi:10.1016/j.surneu.2008.01.019
Re: The challenge for neurosurgery in the 21st century (Ausman J. Surg Neurol 2008;69:102) Letter to the Editor, I read with considerable interest your recent editorial concerning the future of neurosurgery. I agree with your analysis and conclusions especially that “Neurosurgery as we know it today will be of historical interest” and that neurosurgeons must increase their efforts to work with others, adding medical oncology (and the gamma knife, for example) to those disciplines you mentioned where neurosurgeons are collaborating. In addressing change, you indicate that “Those [physicians] that change will win in the market place of the future, whereas those who do not will fail.” Left unexplored is the question of how does the physician change. How does he confront and assimilate the knowledge of change? I am concerned that if we do not come up with new approaches to further the education of practicing physicians facing the technological and intellectual advances about which you write, they simply will not be able to keep up and thus change. I do not think that current Continuing Medical Education processes—large annual meetings, local medical staff gatherings, regional 2-day conferences, the classic printed or online journals, etc—will be sufficient. There is just too much developing over too short a time for the practicing physician to assimilate under these opportunities. Each Continuing Medical Education process I previously mentioned will continue to have its favorable influence; but opportunities for more intense involvement with knowledgeable physicians, both scientists and clinicians, must be developed. I am thinking in terms of in-residence opportunities of education that do not interfere with standard residency
Letters to the Editor / Surgical Neurology 70 (2008) 108–111
programs but provide experience commensurate with the learning curve [2]. The education of neurosurgeons and other physicians in the complexities of the gamma knife required such an effort (Jack Wissinger, MD, personal communication). Some schools recognize the necessity of this by providing intense programs for practicing physicians who recognize the need to expand their knowledge base [1]. The military has remedial and development schools for soldiers advancing to the next level of responsibility, including trauma physicians [3], that last weeks. I do not believe what I have presented above is the final solution to the problem, or even an adequate statement of the problem; but I hope that it is a warning of a recognizable problem and an arguably coherent call for a debate on its solution. Clark Watts, MD, JD Austin, TX 78731, USA doi:10.1016/j.surneu.2008.01.027 References [1] Dean, Office of Continuing Education. Mini-fellowship program. The University of Texas Southwestern Medical Center of Dallas; 2007. [2] Hatlie MJ. Climbing the learning curve. JAMA 1993;270:1364-5. [3] Moore EE, Knudson MM, Schwab CW, Trunkey DD, Johannigman JA, Holcomb JB. Military-civilian collaboration in trauma care and the senior visiting surgeon program. N Eng J Med 2007;357:2723-7.
Response I totally agree with Dr Watts that the systems we now have in place to educate neurosurgeons about the rapidly changing future and how to deal with it are inadequate. Yet, this is also a problem of the individual who is not thinking of the future. There is little that can be done for those who are not interested in changing, and there are many in medicine and neurosurgery who have this basic problem. What Dr Watts is saying is how do we prepare our members for the 21st century. This is a key question because it is very hard for a practicing physician to do this once he or she is in an established practice. Yet, there are those who make the time to change and to learn. There has to be a fundamental understanding that one needs to change and grow rather than just “try to make it.”
111
Actually, the neurosurgical meetings do need to be broader in scope, including discussions of the major social, economic, and political issues of the day. Invited speakers on subjects outside of neurosurgery and in developing scientific areas would also be valuable if focused on how this information can be applied to neurosurgery and neurological diseases. A whole morning session should be devoted to these events, but it is hard for program chairpersons to initiate change in their societies because too many are interested in “doing things the way we always did.” There are 3 issues that are occurring simultaneously. One is the rapid advance in superspecialities in neurosurgey that makes each superspecialist less interested in other superspecialities. The constraints of personal time also add to this problem. Second is the need to keep up with general advances in neurosurgery and even medicine. Easy places to get summaries of the advances in neurosurgery in general and medicine are hard to find and not convenient. Third is an opportunity to learn new approaches to a superspecialty. This need seems to be answered by the special courses held before each meeting. During a national meeting, for example, a full day section could be devoted to having the invited speakers lecture in one room on advances in all specialties in neurosurgery. A similar session could be held for other areas of general medicine and surgery with very brief talks. This would be a “meeting within a meeting.” There are many advances in other areas of medicine that neurosurgeons do not know or are not published in the neurosurgical journals they read. Finally, Dr Watts' idea of short “learning experiences” in academic centers for those in practice appeals to me. Lastly, the fundamental answer to the issues Dr Watts raises is in Group Practice. Being a member of a larger group allows time for more specialization and advanced education. This approach is the only way to survive in the future under the huge wave of change that is happening everywhere in the world. Yet many neurosurgeons are resistant to this idea. They will lose as time progresses. These are issues that should be discussed at a national level with Strategic Planning Committees everywhere in the world. I agree with Dr Watts that we need more ideas here. Please write to us with your thoughts, and Surgical Neurology will publish them.
James I. Ausman, MD, PhD Editor