The Doctor-Patient Relationship, Its Place in Modern Medicine -- A Dilemma

A medical student views the dilemmafaced in rendering modern, efficient medical services while striving to maintain the recognition and observance of the fact of each patient as individual

Durability of saphenous vein grafts: 44-year follow-up of a saphenous vein interposition graft in a pediatric patient

We report the 44-year follow-up of a 9-year-old girl who underwent a saphenous vein interposition graft in 1964 after suffering extensive pelvic trauma with complete disruption of the right common femoral artery. The patient recovered from this injury and experienced no disability or pain until 2008, when she suddenly developed numbness in the right leg. Evaluation at that time showed a new occlusion of the saphenous vein graft, and she underwent uneventful repeat revascularization with autogenous vein. To our knowledge, this 44-year patency is the longest reported for a saphenous vein graft

A systematic review and meta-analysis of randomized trials of carotid endarterectomy vs stenting

ObjectiveThe purpose of this systematic review and meta-analysis was to synthesize the available evidence derived from randomized controlled trials (RCTs) regarding the relative efficacy and safety of endarterectomy vs stenting in patients with carotid artery disease.MethodsWe searched MEDLINE, EMBASE, Current Contents, and Cochrane CENTRAL through July 2010 to update previous systematic reviews. Two reviewers determined trial eligibility and extracted descriptive, methodologic, and outcome data (death, nonfatal stroke, and nonfatal myocardial infarction). Random-effects meta-analysis was used to pool relative risks and the I2 statistic was used to assess heterogeneity.ResultsThirteen RCTs proved eligible enrolling 7484 patients, of which 80% had symptomatic disease. Methodological quality was moderate to high, with better quality among RCTs published after 2008. Compared with carotid endarterectomy, stenting was associated with increased risk of any stroke (relative risk [RR], 1.45; 95% confidence interval [CI], 1.06-1.99; I2 = 40%), decreased risk of periprocedural myocardial infarction (MI; RR, 0.43; 95% CI, 0.26- 0.71; I2 = 0%), and nonsignificant increase in mortality (RR, 1.40; 95% CI, 0.85-2.33; I2 = 5%). When analysis was restricted to the two most recent trials with the better methodology and more contemporary technique, we found stenting to be associated with a significant increase in the risk of any stroke (RR, 1.82; 95% CI, 1.35-2.45) and mortality (RR, 2.53; 95% CI, 1.27-5.08) and a nonsignificant reduction of the risk of MI (RR, 0.39; 95% CI, 0.12-1.23). For every 1000 patients opting for stenting rather than endarterectomy, 19 more patients would have strokes and 10 fewer would have MIs. Outcome data in asymptomatic patients were sparse and imprecise; hence, these conclusions apply primarily to symptomatic patients.ConclusionCompared with endarterectomy, carotid artery stenting (CAS) significantly increases the risk of any stroke and decreases the risk of MI

A unitary test of the Ratios Conjecture

The Ratios Conjecture of Conrey, Farmer and Zirnbauer predicts the answers to numerous questions in number theory, ranging from n-level densities and correlations to mollifiers to moments and vanishing at the central point. The conjecture gives a recipe to generate these answers, which are believed to be correct up to square-root cancelation. These predictions have been verified, for suitably restricted test functions, for the 1-level density of orthogonal and symplectic families of L-functions. In this paper we verify the conjecture's predictions for the unitary family of all Dirichlet $L$-functions with prime conductor; we show square-root agreement between prediction and number theory if the support of the Fourier transform of the test function is in (-1,1), and for support up to (-2,2) we show agreement up to a power savings in the family's cardinality.Comment: Version 2: 24 pages, provided additional details, fixed some small mistakes and expanded the exposition in place

Global wealth disparities drive adherence to COVID-safe pathways in head and neck cancer surgery

Peer reviewe

The National Early Warning Score and its subcomponents recorded within ±24 hours of emergency medical admission are poor predictors of hospital-acquired acute kidney injury

YesBackground: Hospital-acquired Acute Kidney Injury (H-AKI) is a common cause of avoidable morbidity and mortality. Aim: To determine if the patients’ vital signs data as defined by a National Early Warning Score (NEWS), can predict H-AKI following emergency admission to hospital. Methods: Analyses of emergency admissions to York hospital over 24-months with NEWS data. We report the area under the curve (AUC) for logistic regression models that used the index NEWS (model A0), plus age and sex (A1), plus subcomponents of NEWS (A2) and two-way interactions (A3). Likewise for maximum NEWS (models B0,B1,B2,B3). Results: 4.05% (1361/33608) of emergency admissions had H-AKI. Models using the index NEWS had the lower AUCs (0.59 to 0.68) than models using the maximum NEWS AUCs (0.75 to 0.77). The maximum NEWS model (B3) was more sensitivity than the index NEWS model (A0) (67.60% vs 19.84%) but identified twice as many cases as being at risk of H-AKI (9581 vs 4099) at a NEWS of 5. Conclusions: The index NEWS is a poor predictor of H-AKI. The maximum NEWS is a better predictor but seems unfeasible because it is only knowable in retrospect and is associated with a substantial increase in workload albeit with improved sensitivity.The Health Foundatio