Showing papers by "David Cohen published in 2002"

Anaesthesia for fetal surgery.

Abstract: *Department of Anesthesia, Children’s Hospital, Harvard Medical School, Boston, MA,**Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia,University of Pennsylvania School of Medicine, Philadelphia and †Department of Anesthesia andCritical Care, The Hospital of the University of Pennsylvania, University of Pennsylvania Schoolof Medicine, Philadelphia, PA, USA

Seeking Justice on the Cheap: Is the East Timor Tribunal Really a Model for the Future?

Abstract: In response to the spectacle of ethnic cleansing, mass executions, concentration camps, systematic torture, mass rape and sexual enslavement in Bosnia and Rwanda, the Security Council created the first ad hoc international criminal tribunals since Nuremberg and Tokyo. While during the Cold War the political stalemate on the UN Security Council had inhibited such responses to grave humanitarian crises, the new political constellations of the early 1990s ushered in a new era of cooperation to achieve international justice. The International Criminal Tribunal for the Former Yugoslavia (ICTY) and the International Criminal Tribunal for Rwanda (ICTR) have now been trying cases for eight years-cases that have contributed enormously to the development of international humanitarian law.' Trials are also underway before a UN-sponsored tribunal in East Timor but there the results to date, as well as the prospects for the future, are far more questionable.It was inevitable that the establishment of the ICTY and ICTR would lead to demands for further attempts to call to account those responsible for other serious, large-scale violations of international humanitarian law. While the Security Council has lacked the political will to respond in all such cases (e.g., Sudan or Congo), they did move to establish tribunals for Cambodia, Sierra Leone, and East Timor. Because of the expense and duration of the trials before the ICTR and ICTY, however, the Security Council has become increasingly reluctant to fund new international tribunals of this scale." The new model seems to have become smaller scale operations with far fewer personnel, involving international "hybrid" tribunals, negotiated by treaty between the United Nations and a national government.'" East Timor is the first place where such trials have actually taken place.For the past five years the United Nations has been negotiating with the Cambodian government to create a joint UN/Cambodian hybrid tribunal to finally try some of those leaders responsible for the genocide of the Pol Pot regime in 1975-79, in which more than 1.5 million Cambodians perished. A new international/national hybrid tribunal has also been created by the United Nations for Sierra Leone. Despite delays due to funding problems, it will begin operations in late fall 2002, prosecuting cases involving the systematic murder, mutilation, rape, torture, and enslavement of civilians by the rebels during the civil war. In other instances governments have sought to forestall the United Nations from creating a tribunals by acting preemptively at the national level. Thus, the Indonesian government itself, since March 2002, has been conducting trials before Ad Hoc Human Rights Tribunals of military and political figures implicated in the murders, widespread destruction, and massive forced deportations in East Timor in 1999 (see box on page 4).While there is no question that the trials conducted by the ICTR and ICTY constitute a major watershed, it is also true that significant challenges remain- challenges that are best assessed from a regional perspective by considering the work of the UN hybrid tribunal in East Timor.East TimorFollowing the UN's announcement of election results in East Timor in September 1999, Timorese militias, armed and supported by Indonesian army and security forces, perpetrated widespread violence resulting in the deaths of substantial numbers of civilians, widespread rape, destruction and looting of property, and forced mass displacement of civilian populations. On January 31, 2000, the United Nations made public the report of the UN International Commission of Inquiry on East Timor. The report documented the systematic and widespread nature of the terror and violence in East Timor (requirements for establishing that the violence constituted crimes against humanity) and recommended the establishment of an international tribunal under UN auspices.The conclusions of this report were supported by the account of Indonesia's own investigation, conducted under the auspices of the Indonesian Human Rights Commission. …

Differences in length of stay between coronary bypass and valve procedures.

Abstract: OBJECTIVE Emphasis on cost reduction, national standardization of medical care, and quality improvement initiatives have led to reduced postoperative hospital stays after cardiac surgery. The present study was designed to verify the observation that valve patients have longer lengths of stay than bypass patients and to identify possible reasons. METHODS The inpatient records of 26 consecutive patients who underwent valve procedures at our institution were reviewed and compared with the records of 25 consecutive coronary bypass patients. Patients whose postoperative stays were longer than 2 weeks were considered outliers and were excluded from further review. RESULTS A total of 51 records were reviewed. There were no in-hospital deaths. Five patients in the valve group and two in the bypass group were excluded because of lengths of stay exceeding 14 days. The mean length of stay for the valve procedure group was 7.7 +/- 2.1 days, vs. 5.7 +/- 1.5 days for the coronary bypass group (p = 0.001). There were no reoperative procedures in either group, and the number of emergency procedures was higher in the bypass group. Both groups were similar with respect to age and sex. The frequencies of associated pulmonary disease and malnutrition were similar. Bypass patients had a higher incidence of vascular disease and/or renal disease. Sixty percent of valve procedures were complex operations. Valve patients had a higher incidence of cardiopulmonary bypass times exceeding 3 hours and more postoperative bleeding complications. Although not statistically significant, valve procedure patients were more likely to require prolonged mechanical ventilatory and circulatory support postoperatively. The frequencies of thrombotic complications, neurological complications, and nosocomial infections were similar for both groups. Postoperatively, more valve patients had atrial fibrillation, and all of them received anticoagulation. Multivariate analysis revealed only two factors to be significant with regard to length of stay: valvular surgery and the duration of postoperative ventilatory support. CONCLUSIONS Cardiac valve procedures are associated with prolonged lengths of stay compared with isolated coronary bypass procedures. Despite recent trends toward earlier operation, valve patients tended to present with advanced disease. More than half of the valve patients required complex surgical procedures. This is reflected in longer bypass times, increased bleeding complications, and more postoperative support. The proportion of valvular surgery patients should be considered when analyzing lengths of stay for cardiac surgery cohorts.

Paradoxical Clinical Value of Another Smoker's Paradox Response

Abstract: To the Editor: Dr Cohen and coworkers, based on data derived from 9 multicenter trials, have recently reported in the Circulation that the rate of target lesion revascularization (TLR) in patients undergoing contemporary percutaneous coronary intervention (PCI) was significantly lower in smokers despite the lack of differences regarding angiographic restenosis.1 The subtitle of the article questions the possible existence of “another smoker’s paradox.” Indeed, the dissociation between clinical and angiographic restenosis could have been related to “reduced sensitivity” to restenosis by smokers as the authors hypothesized, but this phenomenon may be also mediated by uncontrolled factors, such as the imbalances in access to advanced medical care because of socioeconomic differences related to smoking status. But, whatever the underlying mechanisms, the existence of paradoxical effects related to smoking status is still questionable. Furthermore, although the authors do briefly discuss the clinical value of the …