International journal of clinical practice
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Int. J. Clin. Pract. · Dec 2010
ReviewEndobronchial ultrasound-guided transbronchial needle aspiration.
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive mediastinal staging tool for lung cancer but also a diagnostic tool for mediastinal lesions near the airway. After a brief historic rationale, this article reviews the indications for EBUS-TBNA, provides an overview of practical, training and financial issues; reviews the evidence comparing the mediastinal staging tools and briefly discusses potential future applications. ⋯ EBUS-TBNA may be used in the future for staging when the mediastinal nodes are normal according to radiological staging and also in re-staging. EBUS-TBNA can be learned with appropriate training and mentorship; it offers numerous advantages over mediastinoscopy; and it is less invasive and can reduce costs by avoiding unnecessary mediastinoscopies in many cases.
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Int. J. Clin. Pract. · Dec 2010
Prevalence and outcome of litigation claims in England after laparoscopic cholecystectomy.
Approximately, 50,000 cholecystectomies are performed annually in the United Kingdom resulting in a number of negligence claims referred to the NHS Litigation Authority (NHSLA). The aim of this study was to assess the prevalence and outcomes of claims reported to the NHSLA after laparoscopic cholecystectomy performed in England between 1995 and 2008. ⋯ Common bile duct injury is the most common claim to the NHSLA after laparoscopic cholecystectomy and results in the highest proportion of successful claims and the largest sums paid to the claimant.
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Int. J. Clin. Pract. · Nov 2010
A two-millimetre free margin from invasive tumour minimises residual disease in breast-conserving surgery.
In breast-conserving surgery, the width of free margin around a tumour to ensure adequate excision is controversial. The aim of this study was first to evaluate the frequency of residual disease in wider excision specimens in patients who undergo further surgery because of close margins of < 5 mm. Secondly, the ability of demographic and tumour-related factors to predict the close margins was appraised. ⋯ We suggest that a free margin of 2 mm from invasive tumour is adequate to minimise residual disease, whereas the equivalent free margin for DCIS remains unclear. Patients with large tumours and lobular cancer type should be counselled at the time of first surgery concerning the higher risk of further excision and mastectomy.
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Int. J. Clin. Pract. · Nov 2010
Comparative StudyA comparison of intermediate and long-acting insulins in people with type 2 diabetes starting insulin: an observational database study.
Insulin is normally added to oral glucose-lowering drugs in people with type 2 diabetes when glycaemic control becomes suboptimal. We evaluated outcomes in people starting insulin therapy with neutral protamine Hagedorn (NPH), detemir, glargine or premixed insulins. ⋯ In routine clinical practice, people with type 2 diabetes commenced on NPH experienced a modest disadvantage in glycaemic control after 12 months compared with other insulins. When comparing the insulins, glargine achieved best HbA(1c) reduction, while premix showed greatest weight gain and the highest dose requirement, but had the best persistence of therapy.
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Int. J. Clin. Pract. · Nov 2010
ReviewThe glucose triad and its role in comprehensive glycaemic control: current status, future management.
The prevalence of type 2 diabetes across the world has been described as a global pandemic. Despite significant efforts to limit both the increase in the number of cases and the long-term impact on morbidity and mortality, the total number of people with diabetes is projected to continue to rise and most patients still fail to achieve adequate glycaemic control. Optimal management of type 2 diabetes requires an understanding of the relationships between glycosylated haemoglobin (HbA(1c)), fasting plasma glucose and postprandial glucose (the glucose triad), and how these change during development and progression of the disease. ⋯ However, many patients do not reach HbA(1C) targets set according to published guidelines. As recent data suggest, if driving HbA(1C) down to lower target levels is not the answer, what other factors involved in glucose homeostasis can or should be targeted? Has the time come to change the treatment paradigm to include awareness of the components of the glucose triad, the existence of glucose variability and their potential influence on the choice of pharmacological treatment? It is becomingly increasingly clear that physicians are likely to have to consider plasma glucose levels both after the overnight fast and after meals as well as the variability of glucose levels, in order to achieve optimal glycaemic control for each patient. When antidiabetic therapy is initiated, physicians may need to consider selection of agents that target both fasting and postprandial hyperglycaemia.