National Institute for Health and Clinical Excellence guidelines on preoperative tests: the use of routine preoperative tests for elective surgery
ABSTRACT Clinical Guideline CG3 from the National Institute for Health and Clinical Excellence (NICE) makes recommendations on appropriate clinical practice in preoperative testing for elective surgery. Unfortunately, there is minimal evidence on which the guidelines could be based and therefore they were constructed on the basis of professional opinion. This resulted in the construction of a decision matrix of Byzantine complexity built on foundations of sand: surgical risk is estimated using an unvalidated ad hoc risk estimation method; anaesthetic risk is estimated using the American Society of Anesthesiologists (ASA) risk method that has been demonstrated to be incapable of generating consistent risk assessments. The resultant matrix may be suitable for use as a template for future research, but is extremely complex and inadequately rigorous for routine use.
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ABSTRACT: Context: There is controversy as to whether papillary thyroid microcarcinoma (PTMC) represents more than one disease entity with different outcomes, requiring different treatment. Objectives: To compare characteristics, recurrence, and mortality of incidental and nonincidental PTMC and to identify factors associated with prognosis. Setting and Design: Two reviewers performed searches of online databases (1966-2012), reference lists, and conference abstract books. Longitudinal studies of subjects >16 years old receiving any treatments for papillary thyroid cancer ≤10 mm in size were included. Two reviewers independently screened abstracts and articles, abstracted data, and assessed quality of studies using National Institute of Clinical Excellence and PRISMA criteria. Results: Of 1102 abstracts identified, 262 studies were reviewed and 17 studies included, comprising 3523 subjects, with mean follow-up of 70 months and total follow-up of 21 329 person-years. This included 854 subjects with incidental PTMC (follow-up, 4800 person-years; mean tumor size, 4.6 mm [3.3-6.7 mm]) and 2669 nonincidental PTMC cases (follow-up, 16 529 person-years; mean tumor size, 6.9 mm [5.6-8.0 mm]). The recurrence rate in the incidental group (0.5%; 95% confidence interval [CI], 0, 1%, P< .001) was significantly lower than that in the nonincidental group PTMC (7.9%; 95% CI, 5, 11%), with an OR of recurrence of 14.7 (95% CI, 5.6-54.8, P< .001) for nonincidental PTMC, compared with incidental PTMC. Lymph nodes were involved in 80% (126/157) of recurrences. On meta-regression, age, sex, size, tumor multifocality, lymph node involvement, and treatment modality were not significantly associated with recurrence. Conclusions: Our meta-analysis strongly suggests the existence of at least two distinct entities of PTMC. Incidental PTMC has different clinical characteristics and a much lower recurrence rate than nonincidental PTMC, suggesting that management protocols should be re-considered. Additional studies with standardized data collection are required to explore potential differences between subgroups of nonincidental PTMC.The Journal of Clinical Endocrinology and Metabolism 05/2014; 99(8):jc20132118. DOI:10.1210/jc.2013-2118 · 6.31 Impact Factor
Annals of Clinical Biochemistry 06/2013; 50(4). DOI:10.1177/0004563213494149 · 2.08 Impact Factor
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ABSTRACT: Percutaneous lead extraction is considered a safe and effective procedure, although published results derive primarily from cohort studies. The authors performed a systematic review and meta-analysis of the last 15 years' experience in this field, to give an objective evaluation of the efficacy and safety of this procedure. Moreover, the subsequent metaregression analysis enabled the identification of the main factors influencing these results: patient age, presence of leads in situ for more than 1 year, presence of device infection and use of laser sheath. These findings are significant in order to improve our extraction approach, data reporting and future research.Expert Review of Medical Devices 07/2013; 10(4):551-73. DOI:10.1586/17434440.2013.811837 · 1.78 Impact Factor