Ticagrelor Versus Clopidogrel in Patients With Acute Coronary Syndrome and on Dialysis: A Meta-Analysis.

This study aims to compare the safety and efficacy of clopidogrel and ticagrelor in patients with acute coronary syndrome (ACS) and undergoing dialysis. This study was conducted per the guidelines of the Preferred Reporting of Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive search was performed using electronic databases, including PubMed, EMBASE, and Web of Science, to identify relevant studies comparing clopidogrel and ticagrelor in patients undergoing dialysis. To ensure the inclusion of all relevant articles, a combination of the following keywords, along with medical subject heading (MeSH) terms, was used: "clopidogrel," "ticagrelor," "acute coronary syndrome," and "dialysis." The primary endpoint of this meta-analysis was the incidence of major adverse cardiovascular events (MACE), which consisted of cardiovascular death, myocardial infarction, stroke, and revascularization. The secondary endpoint was all-cause mortality. The occurrence of any bleeding events (including major and nonmajor bleeding events) and major bleeding events was chosen as the safety endpoints. A total of four studies were included in the pooled analysis. The pooled sample size was 5,417 patients, including 892 in the ticagrelor group and 4525 in the clopidogrel group. The findings indicate that ticagrelor, compared to clopidogrel, is associated with a significantly higher risk of MACEs, all-cause death, and major bleeding events. The findings suggest that clopidogrel may be a better choice for individuals with ACS undergoing dialysis due to its lower risk of MACE, all-cause death, and major bleeding events compared to ticagrelor.

Unusual nasopharyngeal foreign body in a four-year-old child.

Foreign bodies are amongst the commonest emergencies presenting to the otorhinolaryngologists. They can be remarkably difficult to see and remove. However, nasopharyngeal foreign bodies are exceedingly rare. Foreign bodies can have disastrous complications, such as rhinolith formation, septal perforation, erosion into the surrounding structures, and infections including sinusitis, otitis media, periorbital cellulitis, diphtheria, meningitis, and tetanus. Imaging investigations, such as X-ray, CT scan and MRI, can be of great help in diagnosing and planning treatment in clinically equivocal cases, although they are rarely needed. Complete removal of the foreign body is of paramount importance in treating this entity. This unique case demonstrates the importance of a thorough clinical examination and history in patients presenting with vague complaints, especially in the paediatric population due to their usually non-specific symptoms and insufficient history.

Consent, capacity and compliance in concussion management: cave ergo medicus (let the doctor beware).

While the acute effects of concussion and mild traumatic brain injury (TBI) are well understood, the certainty in the medical literature regarding the long-term outcomes of sports-related concussion is limited. Long-term deficits that may result from single, repeated concussions, and possibly subconcussive impacts, include cognitive dysfunction, depression and executive dysfunction. Perhaps most troublingly, repetitive head impacts have been linked to neurodegenerative diseases, including chronic traumatic encephalopathy (CTE), although the precise risk of long-term consequences remains unknown. CTE represents a distinct tauopathy with an unknown incidence in athletic populations; however, a cause and effect relationship has not yet been demonstrated between CTE and concussions or between CTE and exposure to contact sports, as no prospective longitudinal studies have been performed to address that question. Studies of high-school sports exposure and long-term outcomes have not demonstrated consistent findings.Medical advice regarding return to play and the risk of acute and/or long-term consequences is therefore problematic. It is important that the individual's right to make their own choices regarding their health is respected. Team, coach, parental, peer or financial pressures should not influence this decision. The choice to return to play after a concussion or mild TBI injury is the athlete's decision once they have (1) recovered from their injury and have the legal capacity to make an informed decision; (2) been medically assessed and (3) been informed of any possible long-term risks in a language that they can understand.Given the current lack of certainty in relation to long-term outcomes from concussion, is it possible to provide a framework to inform players of current evidence, as part of a consent process, even if the information upon which the decision to return to sport is based remains uncertain and evolving?

Wrongful birth: clinical settings and legal implications.

'Wrongful birth' is a term used in the English legal system when describing negligence claims for compensation brought against hospitals where it is argued on behalf of parents bringing the claim that with appropriate treatment their child should not have been born. This paper considers the basis for such claims and the difference between claims brought where there is a healthy child compared to one where the child is born with a disability. Claims arising from failed sterilisations are reviewed as well as those due to an alleged failure to detect fetal anomalies on routine ultrasound scanning. In regard to the latter we review the findings of a major report looking at such claims in England, and we consider practical learning and risk management points that can help to reduce the chances of litigation.

Informed consent and the law--an English legal perspective.

'Informed consent' is a widely used term, but its application in a legal perspective can be varied. American and Commonwealth jurisdictions have developed a 'patient-based' true informed consent approach, whereas in the English legal system a 'doctor-based' approach has traditionally been applied in relation to disclosure of risk. This article will seek to compare these approaches and give a brief overview of some of the key legal rulings which have shaped the requirement of consent. The decision in the English case of Chester vs. Afshar is considered as showing the significance the court attached to the principle of autonomy and using ethical and policy considerations to depart from established principles of English law relating to consent to treatment and disclosure of risk. This review is intended as general information and not as legal advice which should be sought from defence organisation and specialist health care lawyers.

Complications of ERCP: ethical obligations and legal consequences.

Endoscopic retrograde cholangiopancreatography (ERCP) is a skill and technique demanding high-risk procedure with an overall complication rate of about 5-10%. Pancreatitis remains the most common complication of ERCP, however, bleeding after sphincterotomies, infections and cardiopulmonary complications as well as perforations may also occur. Patient- and procedure-related risk factors of ERCP complications are mainly predictable so that ERCP often can be avoided and substituted for alternative imaging techniques, especially in high-risk patients. Written consent should be obtained for any ERCP to provide documentary evidence that explanation of the proposed procedure and endoscopic treatment was given and that consent was sought and obtained. The investigating doctor remains responsible for ensuring sufficient time for the patient's questions and to make informed decision before the start of any procedure. The most common legal consequence of an ERCP complication is a civil negligence claim for compensation, however, a clinician may in rare cases be faced with criminal proceedings where there is evidence of gross negligence. Analysis of claims against gastroenterologists suggests the conclusion that ERCP should be done for good indications, by trained endoscopists with standard techniques, with good, documented, patient-informed consent and communication before and after the procedure.

Ethical and legal implications in seeking and providing a second medical opinion.

Ethical and legal implications arise both when seeking a second medical opinion and when providing one. There has been debate as to whether a second opinion for a patient is a right or a concession and whilst today most would consider it to be a patient's right, there are nevertheless some disadvantages associated with seeking a second opinion. This article addresses the reasons why patients seek second opinions, it considers when physicians themselves should refer patients and it covers the issues involved in providing a second opinion particularly in cases where there is the potential for an allegation of malpractice. Finally, the arguments for and against treating patients who are referred for a second opinion are addressed. This paper has been prepared following a round table discussion on this subject, which was addressed during a symposium on Ethics in Gastroenterology and Digestive Endoscopy held in Kos in 2006.