Saturday, October 16, 2010

Dr Kiran welcomes the readership to the Pediatric Cardiology blog of Narayana Hrudayalaya, Bangalore. This post will see the review of one of the bestsellers of current generation, followed by interesting learning scenarios and the pearls. First: the book review.

“Sir, can you review ‘The Secret’ in your blog?” asked one of my students.

“Well; thanks for the suggestion, but I am not reviewing fiction”, I told him.

He looked a bit sad. “Sir, I mean Rhonda Byrne” he said slowly.

I did feel sorry for myself. It was stupid on my side to respond without the complete data. I should have asked him for complete details before discounting something as fiction.

“I am really sorry for the mistake. I will definitely review the book “The Secret” by Rhonda Byrne sometime in my blog. Thank you a lot for the suggestion.”

He felt happy. I felt lost out!

It is very common to make movies based on novels. But, this is rare- A book based on a movie! Rhonda Byrne achieved it in her own signature style. Both hits; one more than the other!

Most of the TV buffs would not forget the series “World’s Greatest Commercials”. This series was from Australia and many hooked on to it for the nice insight it provided for the creative genius and out-of-the-box thinking it provided. The concept and execution of programme was credited to Rhonda Byrne, a stoic lady with lots of common sense.

Despite all her credentials, she did find herself all time low at a point. Her business had unexpected changes and was at the brink of collapse. At the same time her father- her pillar of moral courage for years- passed away. Rhonda had hit a devastating low. It was at this time her daughter gave her a copy of the best seller titled “The Science of Getting Rich” by Wallace Wattles. The book was an anti-thesis for her. It seemed to counter everything she believed. Yet, there was a charm in the work and explanation. She could not stop thinking about it. She decided- “Why not? Anyway nothing else can go wrong. Why not implement the principle of this book in my life? Let us see the result, for I have nothing else to follow either!” The result was magical- both personal and financial.

During the process of reading and implementation, Rhonda felt that she had found a secret. She wanted to spread it. But how? She decided to make use of her existing contacts in television. Her modus operandi was simple. She would go to US and interview every teacher, write, scholar, Guru or professional speaker who was likely to know about the Secret. The interviews were compiled with background narration and edited sleekly. It was never meant for cinema halls or television, but for private circulation of like-minded people who were interested in the knowledge of Secret. It would be available on internet download in its partial version and on DVD on complete version. It was a runaway hit. Word-of-mouth publicity worked the best and the sales virtually exploded. There was no looking back for Rhonda.

When it was decided to make a book out of the movie, it was not a strategy to capitalize the success of the movie. Rhonda decided that the book should have its own soul independent of the movie. Those who have not seen the movie should also experience the book. Thus, “The Secret” remains a long homage to the thinkers and authors who inspired Rhonda: these included Charles Haanel,
Robert Collier, Wallace Wattles, Genevieve Behrend, Denis Waitley, Jack Canfield, and Neale Donald Walsch to name just a few. There are lot of narrations from the own experiences of author herself.

So, what IS the SECRET?

Rhonda says it is the “law of attraction”. To elaborate: whatever one thinks about or put attention into, becomes reality in life. You attract things, people, and situations that are of a similar “vibration” to you. The universe is essentially energy, and all energy vibrates at a certain frequency. And each person is vibrating at a particular frequency, existing as an energy field within larger energy fields.

Sounds Greek; but Rhonda explains.

Going by the contemporary logic, it is useful to imagine oneself as a transmission tower. The baseline vibration of the tower is determined by the thoughts and feelings of the person. The only difference is, unlike the regular tower, the human towers can broadcast these vibrations into the universe beyond space and time. By changing the vibrations by appropriate thoughts and feelings, one can attract better people and circumstances in life.

Let us see an example: People who are wealthy think only thoughts of more wealth. “They only know wealth, and nothing else exists in their minds.” Even most people who have made a fortune then lost it become wealthy again before long. This is because they remain focused on abundance all the time, despite current circumstances. The law of attraction MUST deliver to them the equivalent of their dominant thoughts.

So, there is a caveat. How about the negative things that often rule your thought process without your control? People who discover this law would worry more about the effects that their negative thoughts. So? But Rhonda is categorical: affirmative thoughts are many times more powerful than negative ones. “Just proclaim to the Universe that all your good thoughts are powerful, and that any negative thoughts are weak.” There is thankfully a time delay or buffer between your thoughts and their coming to fruition, which allows you some space to refine what you really want. It is only a matter of practice.

Rhonda advises the use of a 3-point creative process to get the best out of the Secret.

1. Ask the universe—you must be crystal clear about what you want.
2. Believe—act, speak, and think as though you have already received what you have asked for.
3. Receive—feel great that it is coming to you. Feeling good sets up the necessary vibration to manifest the desire.
Rhonda uses another simple example: It is as if placing an order in a restaurant. You place the order and wait for it to get delivered. There, you have the faith on humans. Can’t you develop a stronger faith on the “all-delivering” universe? Similarly, when you have placed an order in the restaurant, you would never go into the kitchen and find out how it is done. That takes away the entire purpose of “hassle-free” eating. You have to follow the same ideology here. Don’t worry how the universe provides it to you. Just have faith that it WILL provide it to you.

“The more time you invest in feeling good, the Secret works better for you”. How to do that? As Charles Haanel has put it in his masterpiece “The Master Key System”: Start living in a state of love and gratitude for everything around you. This is enough to create vibrations that that attract better things in life. It is vital to elevate how you feel in any moment, since when you have negative feelings you are blocking all the good that the universe wants to give you. The Secret should teach to make gratitude a way of your life. Affirming that you are surrounded by plenty ensures that plenty more comes your way. Give thanks for everything when you get up in the morning and before turning in at night, and watch your outlook on life and circumstances change. Instead of thinking that life is a struggle, start believing that things come easily to you

Is it all mystical rubbish? We would love to get cynical and discard the idea as pile of non-provable stuff. The Secret includes a quote attributed to Buddha: “All that we are is the result of what we have thought.” Again, this is a rational, rather than a mystical, concept. The circumstances you find yourself in today, if you are not happy with them, are not “you”! The only reason anyone is not living the life of their dreams is that they are thinking more thoughts about what they DON’T want than what it is they DO want.

The majority of people who buy The Secret probably do so with an improvement of their finances in mind. However, there are also chapters on health and relationships, and how using the law of attraction can change the world. The book and the film may be seen as works of marketing genius that have made their creator millions, but plenty of people testify to their powerful effect, attracting many intelligent people who are interested in the link between mind and physical manifestation.

Get your hands on the Book or the DVD. It will surely leave you with a “feel-good” sensation atleast!

With this review, I am winding up the book review part in the blog. I had a clear reason for the book reviews. I had gone back to some of these books when I was down with dejection for various reasons in the world. It is generally what most of us go through. Each of those reasons are like forced ‘bitter pills’ which depress you more than anything else. The list need not be produced!

In the early phase of the career, the concentration is on acquiring knowledge and skills with minimal concentration towards money. In the last phases, it is acquiring fame and power. It is the middle phase which is problematic. The financial needs do not match the earnings many times. Yet, despite all the personal issues, it is important to remain sane in medical profession. Letting the mind wander may come in the way of decision making. I have seen people who could beautifully isolate the work and personal/ professional problems. Somehow, I could never do it. I had to reach the books for the rescue. The books did a wonderful job for me. They gave me the solace that I badly wanted. I thought of generalising peace obtained. That was the whole reason why the reviews of these self-help books came up. However, I felt that the needs of the blog demand more scientific discussion. Hence, I am stopping the book reviews. Still, if someone has made any attempt to write a review on any book, please send it. I shall post those last ones for all. Thanks to my friends who did review a book for the blog and for the list of books that I have received. Sorry for letting few friends down! It is probably for the greater interest!!

With this, let us get back to the regular section: Interesting learning scenarios

PROSTINS AND ANTEGRADE FLOW

Is there a role of prostins when the antegrade flow into the pulmonary arteries is reasonable in cases of cyanotic hearts? We had a 2-month-old baby with Tetralogy. The antegrade flow PA was well documented. Despite this, the infant was desaturating. There were no pulmonary issues to explain the problem. On documentation of a restrictive PDA and no good reason for the desaturation, we considered a trial of Prostins; and it worked! The saturations did improve quite well, but desaturaion would ensue as soon as the supply of prostins tapered. That prompted us to go in for a BTT shunt. The question is: Is there a way to predict the need of additional blood flow into the lungs? As seen with this baby, the “visually sufficient” amount of antegrade flow was not enough to carry on with the saturations. Is there a thumb rule or a scientific way to predict the sufficiency of Qp in cyanotic hearts? Let us know your experiences.

ROSS WITH NO HOMOGRAFT?!

This one was an interesting. The question was brought up by our senior fellow, Dr Shweta. When a Ross procedure is done, we replace the pulmonary valve by an orthotopic homograft. How about leaving the RVOT without homograft and allowing free PR as in transannular patch repair of TOF? The annulus is still intact here unlike a severed annulus of TAP. So, the tolerance is likely to be better. This also ensures that the problems associated with homograft can be avoided. Why not extend the logic of TAP to this scenario and go on? I did not have the correct answer. The logic does not sound very good superficially, but not bad either! Is there any data or experience with this scenario? If anyone has thought of anything in similar lines, please let us know.

GOOD ONE OR BAD TWO?

Corrected Transpositions indeed create interesting discussions. As a convention, we have been using single ventricle repairs for cTGA with non-routable VSD with PS. Except for the issue of routability, the ventricles would have supported 2-pumps easily. Is the conventional repair of converting such anatomies to classical cTGA (VSD closure with LV to PA homograft) underutilised? One of our senior surgeons always quote that the best of single pump repair is inferior to any 2-pump repair. Is this analogy OK with cTGA also? It is said that the recent studies with insufficient numbers performed have reported minimal outcome differences between systemic LV and systemic RV. But, when the actual discussion comes to management plan, BD Glenn et al is decided! What is the experience in other centres? Please let us know.

RHEUMATIC CHAMBERS!?

We know the rheumatic involvement of heart valves for ages. Historically, development of the science of congenital heart passed through the route of rheumatic hearts. RHD still remains a major issue with developing countries. The pancarditis pathology of RHD is well understood. However, does it affect the overall geometry of chambers in a different way? For example, give the same quantity of mitral regurgitation, does the LV of RHD different from that of non-RHD etiology? When it comes to the management, we go by the LV volumes as a marker of progress. But the mitral valve of RHD has different operation technique and outcome compared to the non-RHD group. Are we extrapolating the volume analogy of MR for RHD cases also just for the lack of sufficient data? Are there any studies to understand the LV volume differences in RHD Vs non-RHD cases with same amount of regurgitation? If anyone has done any work on it, please enlighten us.

ENLARGING THE VSD

We had earlier discussed the issue of conal tissue resection as a part of VSD routing. Now, the question goes to the other side. The option of enlarging the VSD is considered by surgeons who tackle daring things like REV. It is definitely a risky business. We recently came across a 10-year-old who had undergone enlargement of VSD for routing issues. She was fine in the immediate post-operative period and was later lost for follow up. When she returned after 3 years, we were surprised to find a severe LVOT obstruction at the junction of IVS and its patch take-off. The VSD enlargement which was sufficient during the post-op period had outgrown somehow. Is this known? Can the enlarged VSD grow on its own? Is the natural history different for the native VSD against the enlarged VSD? Is this predictable? The amount of data we have is not adequate enough to draw conclusions. If anyone has seen these scenarios earlier, please let us know.

PEDIATRIC CARDIOLOGY PEARLS

91. Between the two papillary muscles of left ventricle, the medial papillary muscle is more vulnerable to ischemia. (Voci P, Bilotta F, Caretta Q, et al. Papillary muscle perfusion pattern. A hypothesis for ischemic papillary muscle dysfunction. Circulation journal in the year 1995 page 1714)

92. In 1916, in World War I England, Sir James Mackenzie presented a paper on Soldier’s heart- a form of heart trouble to which young soldiers were particularly susceptible, manifested in spare, thin young men with great vasomotor instability, easy fatigue, breathlessness, and pain over the region of the heart. Systolic murmurs were frequent, and heart size was normal. Exertion produced undue rapidity of the heart. During the latter part of World War I, the soldier's heart terminology was changed, and Thomas Lewis introduced the term effort syndrome into the British literature. In the US of A, they renamed the condition neurocirculatory asthenia, which became the official terminology in the U.S. Army and also was incorporated into the early nomenclature lists of the New York Heart Association. (Wooley CF. Where are the diseases of yesteryear? Da Costa's syndrome, soldier's heart, the effort syndrome, neurocirculatory asthenia, and the mitral valve prolapse syndrome. Circulation journal in year 1976 page 749)

93. When the degree of valvular pulmonary stenosis is severe enough to cause a decrease in fetal right ventricular output, a larger-than-normal atrial right-to-left shunt is established in utero. This condition has been termed critical pulmonary stenosis. (Freed MD, Rosenthal AR, Bernhard WF, et al. Critical pulmonary stenosis with diminutive right ventricle in neonates. Circulation Journal in year 1973 page 875)

94. In children with Pulmonary atresia with intact Interventricular septum, the tricuspid valve is invariably abnormal- may represent a continuation of the abnormality of distal structures, ranging from extreme stenosis to regurgitation. (Choi YH, Seo JW, Choi JY, et al. Morphology of tricuspid valve in pulmonary atresia with intact ventricular septum. Pediatric Cardiology journal in year 1998, page 38)

95. Infants of diabetic women have tenfold increased risk of developing Pulmonary Atresia with VSD. The infant of a mother with insulin-dependent diabetes had nearly a 20-fold increased risk of developing PA-VSD. (Ferencz C, Loffredo CA, Correa-Villasenor A, et al., eds. Malformations of the cardiac outflow tract in genetic and environmental risk factors of major cardiovascular malformations. The Baltimore-Washington Infant Study 1981 to 1989. Armonk, NY: Futura Publishing, 1997 page 102)
This brings us to the end of another post. Please let me know your comments and criticisms. I am planning to take up some of the controversies in pediatric cardiology and review of available literature about them with the current recommendations. There is another idea of reviewing one paper or anomaly with every post with the data as current as possible. One of these would replace the existing book-review section. Any fresh idea is welcome and would be duly acknowledged. Please use the comments link. Click on ‘comments’ to open a comments box and post your writing in it. Or you can also use my email id drkiranvs@gmail.com to put up your comments- both colourful and caustic are welcome!

Regards

Kiran

Friday, October 1, 2010

Dr Kiran welcomes all of you back to the present post of blog. One of my friends has taken a special interest in the “Book review” section. He is a management person, very familiar with the books described prior. Many times in the past I have heard him talking about the need for excellence and tragedy of incidental leadership in our country. He often spoke of his motto in life: “A school for teaching leadership.” Although ridiculed by many, he stuck to his views. Over years as my understanding is getting a bit mature, I feel the desperate need of my friend’s school!

I received an email from the same person asking me to introduce a book for our readership. He holds this book in a very high regard, which is interestingly titled “On Becoming a Leader”.

This post, we shall see the same book suggested by my friend. The book whose contents are described as “groundbreaking”! The author of the book is Dr. Warren Bennis PhD, founder and Distinguished Professor of the Leadership Institute, Marshall School of Business, at the University of Southern California in Los Angeles. At young age, Dr Bennis was influenced by teachings of Abraham Maslow. He found a mentor in Douglas McGregor, the common interest being Maslow. The term “Bureaucracies” was taken very seriously by him and critically analysed. Dr Bennis coined an antonym for the term. He used “Adhocracies” to imply the constructive angle. For his work on Group dynamics and new organizational forms, he obtained a PhD from MIT. Along with Harvard, Cincinnati he also served as faculty for IIM Kolkota. His most famous work till date remains “On becoming a Leader” published in 1989 and since then has been translated to 13 different languages across globe.

On Becoming a Leader is written in a personal style. It keeps asking the reader how one can make leadership a habit of existence while the world around the individual becomes a blur of change. In provides some of the extraordinary insights into the concept of leadership. The theme of the book can be summarised as “True leaders are not interested in proving themselves, they want above all to be able to express themselves fully.” The latter component becomes pertinent because only by continually seeking their fullest expression, leaders will be able to engage in periodic reinvention. Proving oneself is likely of a limited or static selfish value. Dr Bennis emphasises that life is not a competition but a flowering.

Another path-breaking concept is “Structured education and society often get in the way of leadership”. The statement may look clich├ęd, but Dr Bennis explains. “What we need to know gets lost in what we are told we should know.” Real learning is the process of remembering what is important to you, and becoming a leader is therefore the act of becoming more and more your true self. Leadership demands THAT unique vision of yours be accomplished. When people protest that they can’t lead, or don’t want to lead, they are usually thinking of management and giving speeches. But leadership is actually a challenge to escape mediocrity which in reality enables to lead oneself with the team. Thereby, the concept of leadership undergoes a paradigm shift.

As per Dr Bennis, the real leadership involves some of the hardcore ethics and needs. Just to list a few:

• Continuous learning and never-dying curiosity.
• A compelling vision: leaders first define their reality (what they believe is possible), then set about “managing their dream.”
• Developing the ability to communicate that vision and inspire others to follow it.
• Tolerating uncertainty and taking on risk: a degree of daring.
• Personal integrity: self-knowledge, candor, maturity, welcoming criticism.
• Being a one-off, an original: “Leaders learn from others, but are not made by others.”
• Reinvention: to create new things sometimes involves recreating yourself. You may be influenced by your genes and environment, but leaders take all their influences and create something unique.
• Taking time off to think and reflect, which brings answers and produces resolutions.
• Passion for the promises of life: a belief in the best, for yourself and others.
• Seeing success in small, everyday increments and joys, not waiting years for the Big Success to arrive.
• Using the context of your life, rather than surrendering to it.

The last point is interesting. Dr Bennis highlighted the link between self-knowledge and business success. Although it took some time to seep in, it is now a Globally recognised entity. At present, most of the successful leaders are not just satisfied with doing a job or running a company, but are trying to find an outlet for their personal vision of the world. Many companies attract best of brains by offering them good money and feeling of prestige. However, those companies which retain these best brains offer them more than that: the chance to make history. That goes very well with the motto of Amazon.com: “Work hard, play hard, change the world.”

Dr Bennis was probably one of the pioneers in the western world to break the myth of “Leaders are born”. He showed the west that Leaders can be MADE. He consistently argued against leadership thrust upon someone. These people have no guarantee of making good. If they do, their genetics or genius is lauded. If they don’t, they doom all their followers into deep well! Hence, leadership is more of a choice involving the leader himself first!

We often see the leaders on whom the responsibility is thrust upon, getting their vision narrowed. They try their best to enjoy the power and preferences to acquire what they lust the most. They cannot lead simply because they have no vision to empower everyone to achieve their best. When someone points to their fallacies, they always have the escape words ready: “I never asked for this; you gave it to me!” One of the tragedies of modern democracy is the choice people are given to choose. The paradigm shift that Dr Bennis provided in his masterpiece should work for the new age leaders. It may be ideal to end the summary with the own words of author, “What is true for leaders is, for better or worse, true for each of us. Only when we know what we’re made of and what we want to make of it can we begin our lives—and we must do it despite an unwitting conspiracy of people and events against us.”

Please let me know your comments on the above review. If you also have any book of interest in your collection, please write a similar review on the book. I shall post your review on your name. Otherwise, please inform me about the book. I shall try to review the book in the future posts with acknowledgements to the informer!

With this, let us get back to our regular feature: Interesting learning scenarios

ARTERIO-ARTERIAL

We have often seen collaterals to the ipsilateral arm in cases of classical BTT shunt. But, is it possible to have collaterals to subclavian artery from descending aorta in cases of modified BTT shunt? We came across on such situation in an 8-year-old with a blocked right BTT shunt. Angio demonstrated a collateral arising from descending thoracic aorta, scaling upto the right subclavian and opacifying its proximal course. Why should there be collateral to a vessel with good flow and same pressure? Is it because of partial block in earlier BTT shunt? Can such an event be an impetus for development of collateral? If anyone has seen this scenario earlier, please let me know.

NO INFLOW CAVITY

Is it possible to have a ventricular cavity when there is absolutely no inflow to it? In other words, can there be LV cavity if there is mitral atresia intact IVS? Similarly, can there be a RV cavity in cases of Tricuspid atresia intact IVS? One of our senior surgeons ruled out such a scenario until we showed this! We had this 5-year-old with Tri Atresia with intact IVS and confluent branch PAs fed by a non-restrictive PDA. The PDA flow not only fed the branch PAs, but also trickled back into MPA and into the RV cavity via pulmonary valve in a retrograde fashion! Is this pattern seen by anyone? We could not recall having seen such combination anytime in the past. Should we call this Tri Atresia A (no inflow) or B (Normal PA pressure on cath) or C (PDA non-restrictive). I am planning to send the echo and cath images to someone like Dr PSS Rao, who has done great deal of work on Tri Atresia. Meanwhile, please let me know if you have any data on this scenario.

ANATOMY Vs STREAMING

How can one be sure that the disproportionate desaturation often found in some of the children is secondary to mixing or streaming? We had a 5-year-old with complete AV Canal defect, TAPVC and multiple VSDs. His great arteries were transposed with severe PS, but reasonably good sized branch PAs. He saturated about 78% in room air. Since the VSDs were too large to create a single piece of IVS and 2 proper pumps, it was decided for single pump repair. Now the questions would be: How to explain the desaturation when the branch PAs are good sized. Since it was also a TAPVC, would streaming matter? Also, how to establish the suitability for single ventricle if the PA entry is not possible? In the presence of so many odds, is it better just to open midline and go with the idea of on-table measurements of pressures and decide between BDG Vs BTT shunt? When we talk of streaming as one of the causes of disproportionate desaturation, do we consider the fluid dynamics with the available anatomy or is it just an extension of some hypothesis? Are there any studies to establish the streaming? Please let m e know your ideas on these issues.

DOUBLE ARCH PDA

How to distinguish between a diverticulum of Kommarel and double aortic arch when a PDA is found with the latter? We had a 5-year-old with the combination of double arch and PDA. Both dorsal and ventral arches gave rise to 2 neck vessels each. The PDA arose from the dorsal arch. The child surprisingly had no symptoms. Now, how to establish the dominant arch? Is the establishment of dominant arch a prerequisite for surgery? What is the least complicated way out? If you had any experience of having handled such a scenario, please let us know.

PEDIATRIC CARDIOLOGY PEARLS

86. The cause of supravalvular aortic stenosis is reduced or abnormal expression of the elastin gene on chromosome 7q11.23. Large arteries such as the aorta and proximal pulmonary arteries have high elastin content in the media and therefore are more commonly affected than smaller arteries. (Stamm C, Friehs I, Ho SY, et al. Congenital supravalvar aortic stenosis: A simple lesion? In European Journal of Cardiothoracic Surgeons. In year 2001 page 195)

87. Atleast one out of 4 children with congenitally correctedTGA will have dextrocardia or mesocardia (In Anderson’s textbook of Paediatric Cardiology. Edinburgh: Churchill Livingstone, 1987 page 867)

88. The incidence of co-existing anomalies increase multiple-folds in TGA with VSD than TGA with intact ventricular septum (In Kirklin’s textbook of cardiac surgery, New York: Churchill Livingston, 1993 page 1383)

89. The highest number of neonatal deaths in the first week of life due to a cardiac cause is by Hypoplastic Left Heart Syndrome. (Samanek M, Slavik Z, Zborilova B, et al. Prevalence, treatment, and outcome of heart disease in live-born children: A prospective analysis of 91,823 live-born children. In the journal Pediatric Cardiolohy in year 1989 page 205)

90. The individual leaflet sizes of mitral valve are a matter of debate in many cardiology centres. However, it is understood that the posterior leaflet is longer at its base and shorter in its basal-to-apical length than the anterior leaflet; both have approximately the same area (Ranganathan M, Lam JHC, Wigle ED, et al. Morphology of the human mitral valve. II: The valve leaflets. Circulation journal in year 1970 page 459)

This would bring us to the end of another post. Please let me know your comments and criticisms. Any fresh idea is welcome and would be duly acknowledged. Please use the comments box or my email id drkiranvs@gmail.com

Regards

Kiran