Down the cascade

BMJ 2004; 329 doi: (Published 16 September 2004) Cite this as: BMJ 2004;329:678
  1. Ami Schattner, head of department of medicine (
  1. Kaplan Medical Centre, Rehovot and Hebrew University Hadassah Medical School, Jerusalem, Israel

    When Dan's wife called on Monday morning—my busiest day—and asked if I could see Dan urgently, I mentally said no but found myself telling her to come. She was impossible to refuse; Dan was one of those favourite patients who remind you how successful (and lucky) you both were.

    Eight years ago, at the age of 70, he came to me complaining of weight loss and anorexia, certain that he has incurable cancer. When coeliac disease was diagnosed and responded completely to a gluten-free diet, his relief was touching. Later, he needed cardiac surgery and came again to get my blessing. Examination revealed high grade carotid artery stenosis, and a search of the evidence led me to recommend carotid endarterectomy preceding cardiac surgery by two teams on the same operation. This was something of a novelty …

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