Instruction:
Discussion Topic: Read the case study on p. 299 of your textbook. Based on the information provided and your own research, which procedure would you recommend to me should I develop a blockage of the carotid artery? Make a persuasive case for your choice. [And, yes, you can ask me questions about my medical history in the discussion topic. But please read the Medical Q & A post to see if your question has already been answered.] Here is the instruction Q&A.
Do you or any family members have a history of stroke, heart disease, heart attack, seizures?
Yes. My father has angina, many cardio stents, and history of a double bypass. My mother has a-fib. Both grandmothers died of strokes. One grandfather had a ruptured aortic aneurysm.
Have you ever been diagnosed with any blood-thinning issues?
No
Any allergies to contrast dye that you are aware of?
Not that I’m aware of.
Do you know if the buildup in your carotid artery has narrowing of more 70%? Narrowing of 50-70%?
The narrowing is 65%.
History of irregular heart rhythm?
No . . . except when grading papers. [I’m kidding!]
Any bleeding in the brain in the past two months?
Gosh, I hope not!
History of kidney disease?
No
Any known allergies to medications?
I am allergic to most substances known to mankind, including 99.9% of all painkillers. I am not exaggerating. It is a very real problem. I have to carry a flash drive with all my allergies on my person at all times.
Do you exercise regularly?
I swim three times a week. I also torment the law school basketball league every chance I get.
Do you have risk factors of stroke such as hypertension or smoking?
I have never smoked. I do not have hypertension, but I have had high cholesterol in the past.
How old are you?
Proudly, I turned 50 years in May!
How much do you feel this condition currently interferes with your daily activities?
My condition is noticeable.
How do you feel about needing to take blood thinner medications daily?
I’m concerned about blood thinners because I bruise very easily without them. Plus I’m a natural-born klutz. I’m hobbling around on a broken leg right now.
If your lifestyle needed to change after the surgery, would it be easy for you to do?
It would be much easier for me than most people since I survived a near-fatal car crash and had to learn to walk and function all over again at the age of 25. Hence, why I am not playing in the WNBA.
Height and weight
I am 5′ 6″ and weigh ~140 lbs.
One thing no one asked but I will offer unsolicited: I am terrified of being incapacitated by a stroke (after watching what my grandmothers went through).
Also, I prefer sedation or general anesthesia to local anesthesia. If I can hear or see anything, I would probably have a panic attack.
Is your cholesterol being treated with medication or just diet and exercise?
I do take atorvastatin for high cholesterol, but it’s still well controlled by diet and exercise. The drug is merely a safeguard given my strong family history. [Even on medication and a strict diet, my father’s cholesterol level is well over 400.]
Do you have a pacemaker or anything of the sort that a magnet will pick up in a test, (i.e., MRI)?
My entire body is held together by metal and mesh.
Are you diabetic or pre-diabetic?
I was pre-diabetic a year ago. But I was able to control it with diet. Now my counts are normal. However, both my parents and my maternal aunts and uncle are diabetic.
Have you ever had neck surgery?
No, that’s one surgery I have not had to endure.
Do you ever experience slight to severe chest pain at all?
No
What is your medical procedure preference? Why?
Nice try, but this is your assignment, I have given you all the information to offer your recommendation to me. This is about the only question I won’t answer. I mean, come on, I gave you my age and weight!!! What more do you want? LOL
Now here is the student answer that need to respond back to them.
Student1:
Bailey, Hoyt and Yoshihasi (2012) state the two fundamental principles of evidence based medicine (EBM) include an ordinal ranking of evidence and evidence without patient preferences, values and circumstantial information is not sufficient when making a medical decision. Clinical practice guidelines (CPG) along with EMB help to standardize medical care. “Such standardization implies that clinical practice should be consistent with the best available evidence that would apply to the majority of the patients (Bailey et al, 2012).” In regards to your health question; based upon CPG, EBM and your Q&A, I would recommend an endarterectomy if you ever develop a carotid artery.
Based upon evidence found in a random controlled trial (RCT) to determine the best surgical procedure for a carotid artery; the EBM and CPG relied on patient preferences and values as a contributing factor in making the best medical determination. The study conducted by Murad, Shahrour, Montori, Sha, and Ricotta (2011) highlighted that when compared to endarterectomy, stenting had a relative risk (RR) factor of 1.45 with a confidence interval (CI) of 1.06-1.99 which demonstrated an increase in risk of stroke and a RR of 0.43 and CI of 0.26-0.71 resulting in a decrease in the amount of heart attacks. The RR for stenting was > 1 which means the chances of having a stroke are increased. The RR for heart attacks was <1 which means the risk of heart attacks decrease. To break it down in layman’s terms, out of total of 7,848 patients for every 1,000 patients opting for stents nineteen more patients would have strokes ; while ten less patients would have heart attacks (Murad et al, 2011). The 95% CI means the numbers are pretty accurate. You do not present any current cardiovascular concerns besides your family history. You are petrified of strokes and stenting will increase the chances of a stroke over time. My recommendation is centered on expert recommendations; the relevancy of the recommendations to your specific case; and the appraisal and validity of the CPG overall.
I took into consideration your family history of cardiovascular diseases, your current medical state, and unsolicited information regarding strokes in making my recommendation. I would like to know your past medical exposure to radiation so I can discuss the amount of radiation involved in the procedure. I would presume your fatal car crash recovery required many x-rays. Having an endarterectomy and stents both have their pros and cons, but considering all of my research I am a proponent of my final recommendation. Please let me know if you have any further questions or concerns.
References
Hoyt, R. E., Bailey, N., and Yoshihasi, A. (Eds.). (2012). Health Informatics: A Practical Guide for Healthcare and Information Technology Professionals. (5th ed.).
Murad MH1, Montori VM, Ricotta JJ. Shah ND, Shahrour A, (2011). A systematic review and meta-analysis of randomized trials of carotid endarterectomy vs stenting. JVasc Surg. 2011 Sep;54(3): 832-6.
Student 2:
From my review of your medical Q&A, I observe that you have a high probability of developing heart disease, attributable to your family history, and carotid artery disease or the narrowing of the carotid artery. Should you develop a blockage of the carotid artery, I would recommend the surgical endarterectomy procedure for the following reasons:
1. According to the evidence of the case study, stenting was associated with an increased risk of stroke and decreased risk of myocardial infarction; the evidence proves that the surgery is better in reducing incidences of stroke.
2. According to Hoyt, et al (2012) “the second principle of evidence-based medicine (EBM) states that patients’ values and preferences are essential in the process of decision making” (p.290). In the Q&A, you mentioned that you are terrified of being incapacitated by a stroke another reason I recommend the surgical option is because of your aversion to stroke (not that anyone would want it anyway).
3. Again, Hoyt, et al (2012) stated that “patients vary in their surgical risk e.g. those with a history of heart disease may prefer less invasive procedure to avoid prolonged anesthesia (p.299).” On the flipside, you noted your preference to sedation or general anesthesia to local anesthesia in order to avoid a panic attack. This is also why I believe in surgery as your best option.
Evidence-Based medicine from my perspective is a pathway to achieve the highest level of quality in healthcare through unbiased and substantial medical evidence. Sackett, et al. (1996) defines EBM as “the integration of best research evidence with clinical expertise and patient values”. According to Hoyt, et al. (2012) “clinical practice guidelines (CPGs) obtain the best of evidence-based medical information and create a treatment strategy to treat a specific disease or ailment.” These strategies are meant to reduce costs and also improve the health of the patient. From experience, medical performance is based on quality and quality is based on evidence; to achieve quality care, Clinicians must have access to the best available medical care hence the need for Evidence-Based Medicine. Realistically, today, a lot of challenges arise from EBM practice such as situations where results may not be applicable to every patient population. I believe that in spite of these limitations, its benefits outweigh those limitations.
REFERENCES
Sackett D. L, Rosenberg W. M C, Gray J A M, Haynes R. B, Richardson W. S (1996). Evidence based medicine: what it is and what it isn't. BMJ 312:71
Hoyt, R. E., Bailey, N., and Yoshihasi, A. (Eds.). (2012). Health Informatics: A Practical Guide for Healthcare and Information Technology Professionals. (5th ed.). Raleigh, NC: lulu.ISBN: 978-1105437557
Health Informatics, Chapter 15: Evidence-Based Medicine and Clinical-Practice Guidelines
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