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BMJ 2011; 343 doi: (Published 14 September 2011) Cite this as: BMJ 2011;343:d5798

Stent looks unsafe for adults with intracranial arterial stenosis

In November 2008, researchers began a trial of angioplasty and stent placement for adults with a stroke or transient ischaemic attack caused by an intracranial arterial stenosis. The trial ended early, less than three years later, when a data monitoring committee decided it was futile and probably unsafe to continue. Rates of death or stroke in the first month were 14.7% (95% CI 10.7% to 20.1%) in 224 adults given the best medical management and a stent compared with 5.8% (3.4% to 9.7%) in 227 controls managed with drugs alone. Twenty five of the 33 strokes in the stent group occurred within one day of the procedure. Another eight occurred within a week.

The findings were unexpected, and follow-up will continue to try to find out why outcomes were so much worse, initially at least, for adults treated with a stent. Wingspan, a self expanding stent, was approved by the US Food and Drug Administration in 2005 for adults with symptomatic and severe intracranial stenoses. This is the first head to head trial of the stent against best medical management, say the researchers. Dual antiplatelet treatment with aspirin and clopidogrel combined with aggressive management of cardiovascular risk factors clearly worked better.

US trainees plagued by debt, distress, and a poor quality of life

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When researchers asked a national cohort of US residents in training to fill in questionnaires about quality of life, burnout, and debt, 15% (2402/16 187) reported a quality of life that was “as bad as it can be” or “somewhat bad.” All respondents were in the first three years of postgraduate training in internal medicine. The overall response rate was 74.1%.

High levels of emotional exhaustion (45.8%; 7394/16 154) and depersonalisation (28.9%; 4541/15 737)—cardinal symptoms of burnout—were also common.

Trainees on internal medicine …

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