Objectives
Determine if patients prefer multi-vessel percutaneous coronary intervention (mv-PCI) over coronary artery bypass graft surgery (CABG) for treatment of symptomatic multi-vessel coronary artery disease (mv-CAD) despite high 1-year risk.
Background
Patient risk perception and preference for CABG or mv-PCI to treat medically refractory mv-CAD is poorly understood. We hypothesize that patients prefer mv-PCI instead of CABG even when quoted high mv-PCI risk.
Methods
585 patients and 31 physicians were presented standardized questionnaires with a hypothetical scenario describing chest pain and medically refractory mv-CAD. CABG or mv-PCI were presented as treatment options. Risk scenarios included variable 1-year risks of death, stroke and repeat procedures for mv-PCI and fixed risks for CABG. Participants indicated their preference of revascularization method based on the presented risks. We calculated the odds that patients or physicians would favor mv-PCI over CABG across a range of quoted risks of death, stroke and repeat procedures.
Results
For nearly all quoted risks, patients preferred mv-PCI over CABG, even when the risk of death was double the risk with CABG or the risk of repeat procedures was more than three times that for CABG (p<0.0001). Compared to patients, physicians chose mv-PCI less often than CABG as the risk of death and repeat procedures increased (p<0.001 and p=0.004, respectively).
Conclusion
Patients favor mv-PCI over CABG to treat mv-CAD, even if 1-year risks of death and repeat procedures far exceed risk with CABG. Physicians are more influenced by actual risk and prefer mv-PCI less than patients despite similarly quoted 1-year risks.
The cholinergic heat-labile neurotoxin produced by Clostridium species is primarily responsible for the clinical manifestations of botulism. The classic phenotypic presentation of botulism consists of subacute descending flaccid paralysis with intact sensory function. Traditionally, it is classified into 3 main forms (foodborne, wound-related, and infantile) on the basis of primary site of toxin entry into the human nervous system. Toxemia is the common pathophysiology in all forms of botulism. Adult intestinal toxemia botulism is an extremely rare form of the disease with pathogenesis similar to that of infant-type botulism. Symptomatic adults usually have an anatomic abnormality in the gastrointestinal tract leading to changes in normal gut flora. The current case is an addition to the growing literature on this unusual clinical variant of botulism.
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