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Nicolaides KH, Syngelaki A, Poon LC, Rolnik DL, Tan MY, Wright A, Wright D. First-trimester prediction of preterm pre-eclampsia and prophylaxis by aspirin: Effect on spontaneous and iatrogenic preterm birth. BJOG 2024; 131:483-492. [PMID: 37749709 DOI: 10.1111/1471-0528.17673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/29/2023] [Accepted: 09/02/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVE To report the predictive performance for preterm birth (PTB) of the Fetal Medicine Foundation (FMF) triple test and National Institute for health and Care Excellence (NICE) guidelines used to screen for pre-eclampsia and examine the impact of aspirin in the prevention of PTB. DESIGN Secondary analysis of data from the SPREE study and the ASPRE trial. SETTING Multicentre studies. POPULATION In SPREE, women with singleton pregnancies had screening for preterm pre-eclampsia at 11-13 weeks of gestation by the FMF method and NICE guidelines. There were 16 451 pregnancies that resulted in delivery at ≥24 weeks of gestation and these data were used to derive the predictive performance for PTB of the two methods of screening. The results from the ASPRE trial were used to examine the effect of aspirin in the prevention of PTB in the population from SPREE. METHODS Comparison of performance of FMF method and NICE guidelines for pre-eclampsia in the prediction of PTB and use of aspirin in prevention of PTB. MAIN OUTCOME MEASURE Spontaneous PTB (sPTB), iatrogenic PTB for pre-eclampsia (iPTB-PE) and iatrogenic PTB for reasons other than pre-eclampsia (iPTB-noPE). RESULTS Estimated incidence rates of sPTB, iPTB-PE and iPTB-noPE were 3.4%, 0.8% and 1.6%, respectively. The corresponding detection rates were 17%, 82% and 25% for the triple test and 12%, 39% and 19% for NICE guidelines, using the same overall screen positive rate of 10.2%. The estimated proportions prevented by aspirin were 14%, 65% and 0%, respectively. CONCLUSION Prediction of sPTB and iPTB-noPE by the triple test was poor and poorer by the NICE guidelines. Neither sPTB nor iPTB-noPE was reduced substantially by aspirin.
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Affiliation(s)
| | - Argyro Syngelaki
- Fetal Medicine Research Institute, King's College Hospital, London, UK
- Institute of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London, UK
| | - Liona C Poon
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, China
| | - Daniel L Rolnik
- Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Victoria, Australia
| | - Min Yi Tan
- Department of Obstetrics and Gynaecology, St Mary's Hospital, London, UK
| | - Alan Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - David Wright
- Institute of Health Research, University of Exeter, Exeter, UK
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Jenkinson AC, Kaltsogianni O, Dassios T, Greenough A. Postnatal corticosteroid usage in United Kingdom and Ireland neonatal units. Acta Paediatr 2023; 112:2503-2506. [PMID: 37675620 DOI: 10.1111/apa.16968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/05/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023]
Abstract
AIM To perform a survey on postnatal corticosteroids usage in neonatal units in the United Kingdom and Ireland. METHODS An 18-item structured questionnaire was created asking for the level of neonatal care and corticosteroid prescribing practices. A consultant neonatologist or senor specialty training registrar/advanced neonatal nurse practitioner was contacted in every neonatal unit in the UK and Ireland between September and December 2022. RESULTS The response rate to the survey was 96% (203 of 211 units). Postnatal corticosteroids were prescribed in 48% of units: 5% of special care units, 43% of local neonatal units and 100% of neonatal intensive care units. Most units (90%) prescribed dexamethasone, which was prescribed to infants born at gestational ages less than 30 weeks in all those units prescribing postnatal corticosteroids, however, eight units also reported use in infants greater than 30 weeks of gestation. Dexamethasone regimens varied with starting doses from 50 to 500 μg/kg/day. Most tertiary units (97%) prescribed repeated courses of dexamethasone. In all levels of neonatal care, postnatal corticosteroids were prescribed to ventilated infants as well as those receiving non-invasive respiratory support. CONCLUSION There is use of postnatal corticosteroids in all levels of neonatal care and much of the practice is not evidence based.
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Affiliation(s)
- Allan C Jenkinson
- Department of Women and Children, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Ourania Kaltsogianni
- Department of Women and Children, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Theodore Dassios
- Department of Women and Children, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Department of Women and Children, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Lakshmi A, Shah R, Begaj A, Jayarajan R, Ramachandran S, Morgan B, Faust G, Patel N. NICE 2022 guidelines on the management of melanoma: Update and implications. J Plast Reconstr Aesthet Surg 2023; 85:401-413. [PMID: 37572388 DOI: 10.1016/j.bjps.2023.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 07/09/2023] [Accepted: 07/16/2023] [Indexed: 08/14/2023]
Abstract
AIMS In July 2022, NICE updated the guidelines on the management of melanoma by lowering the number of follow-up appointments and sentinel lymph node biopsy (SLNB) but increasing the number of scans. This study aims to evaluate the implications of executing the new guidelines in terms of cost-effectiveness and personnel. METHODS All patients newly diagnosed with melanoma in 2019 at a regional skin cancer specialist center were reviewed. Data were analyzed for their journey on an idealized pathway modeled over a 5-year follow-up period when adhering to both the previous and new guidelines. Differences in the management of melanoma were elucidated by comparing these changes. The cost was quantified on a perpatient basis and the financial implication on each department was considered. RESULTS One hundred and ten patients were diagnosed with melanoma in 2019, stages I-III. The changes ease the burden on plastic surgery and dermatology; however, increased pressure is faced by radiologists and histopathologists. An overall cost benefit of £141.85 perpatient was calculated, resulting in a decrease of 1.22 hospital visits on average and an increase in the time spent there (19.55 min). The additional expenses of implementing the new guidelines due to the added BRAF tests, CT, and ultrasound scans are outweighed by savings from the reduction in follow-up appointments and SLNB. CONCLUSION The focus has shifted to less invasive procedures for lower melanoma stages and fewer follow-up appointments, at the expense of more genetic testing and imaging. This paper serves as a useful baseline for other centers to plan their service provision and resource allocation to adhere to the updated guidelines.
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Affiliation(s)
- Aiswarya Lakshmi
- University of Cambridge, School of Clinical Medicine, United Kingdom.
| | - Rahul Shah
- University of Cambridge, School of Clinical Medicine, United Kingdom
| | - Ardit Begaj
- Plastic Surgery Department, University Hospitals of Leicester, United Kingdom
| | - Rajshree Jayarajan
- Plastic Surgery Department, University Hospitals of Leicester, United Kingdom
| | | | - Bruno Morgan
- Radiology Department, University Hospitals of Leicester, United Kingdom
| | - Guy Faust
- Oncology Department, University Hospitals of Leicester, United Kingdom
| | - Nakul Patel
- Plastic Surgery Department, University Hospitals of Leicester, United Kingdom
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Jess MA, Ryan C, Wellburn S, Atkinson G, Greenough C, Peat G, Coxon A, Roper H, Fatoye F, Ferguson D, Dickson A, Ridley H, Martin D. Does pain duration and other variables measured at baseline predict re-referral of low back pain patients managed on an evidence-based pathway? A cohort study. Physiotherapy 2023; 121:5-12. [PMID: 37591028 DOI: 10.1016/j.physio.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 04/02/2023] [Accepted: 07/26/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVE To explore the association between baseline pain duration and the likelihood of re-referral of patients with low back pain (LBP) managed on the evidence-based North East of England Regional Back Pain and Radicular Pain Pathway (NERBPP). STUDY DESIGN Longitudinal, observational cohort study. METHODS In all, 12,509 adults with LBP were identified as having been discharged from the pathway, between May 2015 and December 2019. To quantify any association between baseline pain duration and the likelihood of re-referral, two statistical modelling approaches, were used: logistic regression models for odds ratios and generalised linear models with a binomial link function in order to quantify risk differences. RESULTS Twenty-five percent of patients with LBP, who were discharged, re-referred for management over a 4.5-year period. A large difference in pain duration of 2 SD days was statistically associated with re-referral, with an odds ratio of 1.22 (95% CI: 1.03, 1.44) and a risk difference of 3.6% (95% CI: 0.6, 6.6). Nevertheless, the predictive value of an individual's pain duration was found to be weak for re-referral. Higher baseline disability [odds ratio of 1.40 (95% CI: 1.07, 1.83)] and a younger age at baseline [odds ratio of 0.73 (95% CI 0.61, 0.86)] were also associated with an increased risk of re-referral. CONCLUSIONS Baseline pain duration, disability and younger age are statistically associated with re-referral onto the NERBPP. However, the value of these variables for predicting an individual's risk of re-referral is weak. CONTRIBUTION OF PAPER.
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Affiliation(s)
- Mary-Anne Jess
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK.
| | - Cormac Ryan
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| | - Shaun Wellburn
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| | - Greg Atkinson
- School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | | | - Glynis Peat
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Andrew Coxon
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Helena Roper
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Francis Fatoye
- Department of Health Professions, Faculty of Health and Education, Manchester Metropolitan University, UK
| | - Diarmaid Ferguson
- Northumbria Healthcare NHS Trust, North Tyneside General Hospital, North Shields, UK; Primary Care Rheumatology & Musculoskeletal Medicine Society, York, UK
| | - Alastair Dickson
- Primary Care Rheumatology & Musculoskeletal Medicine Society, York, UK; The North of England Low Back Pain Pathway, NIHR Applied Research Collaboration (ARC) North East and North Cumbria, St Nicolas' Hospital, Newcastle Upon Tyne, UK; AD Outcomes Ltd, York, UK
| | - Helen Ridley
- Getting It Right First Time (GIRFT): Clinically led improvement programme delivered in partnership with the Royal National Orthopaedic Hospitals NHS Trust, NHS England and NHS Improvement, UK
| | - Denis Martin
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK; NIHR Applied Research Collaboration for the North East and North Cumbria, UK
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Pereira Carvalho N, Pierson K, Shaker-Naeeni H, Sabel E. Managing self-harm in young people presenting to the emergency department and challenges in navigating the national guidelines. BJPsych Bull 2023:1-4. [PMID: 37272611 PMCID: PMC10387412 DOI: 10.1192/bjb.2023.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
SUMMARY Suicide is the most common cause of death for young people in the UK and around 50% of completed suicides in young people have previous self-harm as a theme. Hence, robust management of young people presenting with self-harm to the emergency department is crucial. Guidelines published by the National Institute for Health and Care Excellence (NICE) and the Royal College of Psychiatrists advise an overnight admission for under-16s with self-harm, which is a challenge during winter pressures or bed shortages. In this editorial we discuss the difficulties faced when navigating NICE 2004 guidance documents with the realities of the coalface and consider the prospects for current practice and the future with the NICE 2022 guidance.
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Affiliation(s)
| | - Kim Pierson
- Hertfordshire Partnership University NHS Foundation Trust, Hatfield, UK
| | | | - Esther Sabel
- Hertfordshire Partnership University NHS Foundation Trust, Hatfield, UK
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Algera JP, Demir D, Törnblom H, Nybacka S, Simrén M, Störsrud S. Low FODMAP diet reduces gastrointestinal symptoms in irritable bowel syndrome and clinical response could be predicted by symptom severity: A randomized crossover trial. Clin Nutr 2022; 41:2792-2800. [PMID: 36384081 DOI: 10.1016/j.clnu.2022.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND & AIMS Fermentable oligo-, di-, monosaccharides and polyols (FODMAPs) can provoke symptoms in patients with irritable bowel syndrome (IBS). We aimed to compare the effects of diets with low vs. moderate FODMAP content on gastrointestinal (GI) symptoms and bowel habits, and to identify possible predictors of clinical response to a low FODMAP diet and FODMAP sensitivity in IBS. METHODS Adult participants with IBS (Rome IV criteria, n = 29) were included and adhered to two 7-day diet periods, with either low (4 g/day) or moderate (23 g/day) amounts of FODMAPs, in this randomized, double-blind, crossover study. The periods were separated by a wash-out period (≥14 days). IBS-Severity Scoring System (IBS-SSS) and a stool diary (Bristol Stool Form) were completed before and after the diet periods. At baseline, severity of GI symptoms and gut microbial fermentation were assessed (every 15 min, 4 h) during the Lactulose Nutrient Challenge Test (LNCT). Clinical response and FODMAP sensitivity were defined by reduction after low FODMAP period, and increase after moderate FODMAP period in IBS-SSS (≥50 points), respectively. RESULTS Severity of GI symptoms (P = 0.04), stool consistency (P = 0.01), and stool frequency (P = 0.01) differed between the interventions, with reduced overall GI symptom severity, abdominal pain intensity and frequency, bowel habits dissatisfaction, and daily life interference (P < 0.05 for all), as well as more firm (P = 0.03) and less frequent (P < 0.01) stools after low FODMAP intervention, but not after moderate FODMAP intervention. A third (34%) responded clinically to the low FODMAP diet, and the response could be predicted by higher IBS-SSS at baseline (P = 0.02). Although modest associations between FODMAP sensitivity (22%) and GI symptoms during LNCT were observed, no independent predictors could be identified. CONCLUSIONS A diet low in FODMAPs reduces GI symptoms and affects bowel habits in IBS, compared with a moderate FODMAP diet. Assessment of IBS severity before the intervention may be used to predict clinical response to a low FODMAP diet. Trial registry (http://www. CLINICALTRIALS gov): Registered under Clinical Trial number NCT05182593.
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Affiliation(s)
- Joost P Algera
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Dagsu Demir
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Törnblom
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sanna Nybacka
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simrén
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Center for Functional GI & Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stine Störsrud
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Gelder CL, Robinson S, Leitch F, McMahon AJ. Drowning in antibiotics. Ann R Coll Surg Engl 2022; 104:605-610. [PMID: 35639453 PMCID: PMC9433187 DOI: 10.1308/rcsann.2022.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 09/03/2023] Open
Abstract
INTRODUCTION The National Confidential Enquiry into Perioperative Deaths (NCEPOD) report recommended that 'fluid prescribing be given the same value as drug prescribing', yet fluid prescription is commonly delegated to junior doctors despite being a notoriously challenging topic. When antibiotics are given as an infusion they are diluted in 100ml of fluid, which is often unaccounted for when thinking about a patient's fluid requirements. This closed-loop audit aimed to assess first, intravenous (IV) fluid therapy and second, electrolyte prescribing compliance with National Institute for Health and Care Excellence (NICE) guidelines, with and without the additional fluid given with antibiotic administration. METHODS Two retrospective audits were performed. Total fluid and electrolyte volume received with and without antibiotic fluids was correlated with recommendations in the NICE guidelines. Between cycles 1 and 2, potassium chloride with sodium chloride and glucose (PSG) was introduced as an alternative to IV maintenance fluid, and bolusing of antibiotics was mandatory. RESULTS When analysing total fluid volume input per day, 10.4% and 7.45% of patients met their fluid requirement accurately in the first and second cycles, respectively. Within cycle 1, the mean total additional fluid that was given over 3 days with antibiotics was 1,572.73ml. In cycle 2, this decreased to 469.44ml when antibiotics were given as a bolus. CONCLUSIONS In this closed-loop audit we noted that patients receiving IV fluids and IV antibiotics received too much additional fluid when the antibiotic dilution fluid was taken into account. Additional fluid was reduced alongside the proportion of electrolyte complications when bolusing of antibiotics was introduced. We recommend that that all nurses are trained to give antibiotics as a bolus because it can help to reduce fluid-related complications.
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Affiliation(s)
| | | | - F Leitch
- NHS Greater Glasgow and Clyde, UK
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Fernandes M, Winckworth L, Lee L, Akram M, Struthers S. Screening for early-onset neonatal sepsis on the Kaiser Permanente sepsis risk calculator could reduce neonatal antibiotic usage by two-thirds. Pediatr Investig 2022; 6:171-178. [PMID: 36203516 PMCID: PMC9523803 DOI: 10.1002/ped4.12344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/27/2022] [Indexed: 12/03/2022] Open
Abstract
Importance Effective screening strategies for early-onset neonatal sepsis (EONS) have the potential to reduce high volume parenteral antibiotics (PAb) usage in neonates. Objective To compare management decisions for EONS, between CG149 National Institute for Health and Care Excellence (NICE) guidelines and those projected through the virtual application of the Kaiser Permanente sepsis risk calculator (SRC) in a level 2 neonatal unit at a district general hospital (DGH). Methods Hospital records were reviewed for maternal and neonatal risk factors for EONS, neonatal clinical examination findings, and microbial culture results for all neonates born at ≥34 weeks' gestation between February and July 2019, who were (1) managed according to CG149-NICE guidelines or (2) received PAb within 72 h following birth at a DGH in Winchester, UK. SRC projections were obtained using its virtual risk estimator. Results Sixty infants received PAb within the first 72 h of birth during the study period. Of these, 19 (31.7%) met SRC criteria for antibiotics; 20 (33.3%) met the criteria for enhanced observations and none had culture-proven sepsis. Based on SRC projections, neonates with '≥1 NICE clinical indicator and ≥1 risk factor' were most likely to have a sepsis risk score (SRS) >3. Birth below 37 weeks' gestation (risk ratio [RR] = 2.31, 95% confidence interval [CI]: 1.02-5.22) and prolonged rupture of membranes (RR = 3.14, 95% CI: 1.16-8.48) increased the risk of an SRS >3. Interpretation Screening for EONS on the SRC could potentially reduce PAb usage by 68% in term and near-term neonates in level 2 neonatal units.
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Affiliation(s)
- Michelle Fernandes
- The Department of Neonatal Medicine and the Neonatal Intensive Care Unit, Princess Anne HospitalUniversity Hospitals Southampton NHS Foundation TrustSouthamptonUK,The MRC Lifecourse Epidemiology Centre and Human Development and Health Academic Unit, Faculty of MedicineUniversity of SouthamptonSouthamptonUK,Nuffield Department of Women's and Reproductive Health, John Radcliffe HospitalUniversity of OxfordOxfordUK
| | | | - Lyrille Lee
- Department of PediatricsRoyal Hampshire County HospitalWinchesterUK
| | - Madiha Akram
- Department of PediatricsRoyal Hampshire County HospitalWinchesterUK
| | - Simon Struthers
- Department of PediatricsRoyal Hampshire County HospitalWinchesterUK
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Matharu GS, Blom AW, Board T, Whitehouse MR. Does the publication of NICE guidelines for venous thromboembolism chemical prophylaxis influence the prescribing patterns of UK hip and knee surgeons? Ann R Coll Surg Engl 2022; 104:195-201. [PMID: 34825570 PMCID: PMC9773855 DOI: 10.1308/rcsann.2021.0157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We assessed the practice of surgeons regarding venous thromboembolism (VTE) chemical prophylaxis for total hip replacement (THR) and total knee replacement (TKR), before and after issuing of updated National Institute for Health and Care Excellence (NICE) guidance in 2018. METHODS A survey, circulated through the British Hip Society and regional trainee networks/collaboratives, was completed by 306 UK surgeons at 187 units. VTE chemical prophylaxis prescribing patterns for surgeons carrying out primary THR (n=258) and TKR (n=253) in low-risk patients was assessed after publication of 2018 NICE recommendations. Prescribing patterns before and after the NICE publication were subsequently explored. RESULTS Following the new guidance, 34% (n=87) used low-molecular-weight heparin (LMWH) alone, 33% (n=85) aspirin (commonly preceded by LMWH) and 31% (n=81) direct oral anticoagulants (DOACs: with/without preceding LMWH) for THR. For TKR, 42% (n=105) used aspirin (usually monotherapy), 31% (n=78) LMWH alone and 27% (n=68) DOAC (with/without preceding LMWH). NICE guidance changed the practice of 34% of hip surgeons and 41% of knee surgeons, with significantly increased use of aspirin preceded by LMWH for THR (before=25% vs after=73%; p<0.001), and aspirin for TKR (before=18% vs after=84%; p<0.001). Significantly more regimens were NICE guidance compliant after the 2018 update for THR (before=85.7% vs after=92.6%; p=0.011) and TKR (before=87.0% vs after=98.8%; p<0.001). CONCLUSION Over one-third of surveyed surgeons changed their VTE chemical prophylaxis in response to 2018 NICE recommendations, with more THR and TKR surgeons now compliant with latest NICE guidance. The major change in practice was an increased use of aspirin for VTE chemical prophylaxis.
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Affiliation(s)
- GS Matharu
- Bristol Medical School, University of Bristol, UK
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10
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Colomier E, Van Oudenhove L, Tack J, Böhn L, Bennet S, Nybacka S, Störsrud S, Öhman L, Törnblom H, Simrén M. Predictors of Symptom-Specific Treatment Response to Dietary Interventions in Irritable Bowel Syndrome. Nutrients 2022; 14:397. [PMID: 35057578 DOI: 10.3390/nu14020397] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/14/2022] [Accepted: 01/15/2022] [Indexed: 02/07/2023] Open
Abstract
(1) Background: Predictors of dietary treatment response in irritable bowel syndrome (IBS) remain understudied. We aimed to investigate predictors of symptom improvement during the low FODMAP and the traditional IBS diet for four weeks. (2) Methods: Baseline measures included faecal Dysbiosis Index, food diaries with daily energy and FODMAP intake, non-gastrointestinal (GI) somatic symptoms, GI-specific anxiety, and psychological distress. Outcomes were bloating, constipation, diarrhea, and pain symptom scores treated as continuous variables in linear mixed models. (3) Results: We included 33 and 34 patients on the low FODMAP and traditional IBS diet, respectively. Less severe dysbiosis and higher energy intake predicted better pain response to both diets. Less severe dysbiosis also predicted better constipation response to both diets. More severe psychological distress predicted worse bloating response to both diets. For the different outcomes, several differential predictors were identified, indicating that baseline factors could predict better improvement in one treatment arm, but worse improvement in the other treatment arm. (4) Conclusions: Psychological, nutritional, and microbial factors predict symptom improvement when following the low FODMAP and traditional IBS diet. Findings may help individualize dietary treatment in IBS.
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Korwisi B, Barke A, Kharko A, Bruhin C, Locher C, Koechlin H. Not really nice: a commentary on the recent version of NICE guidelines [NG193: chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain] by the Pain Net. Pain Rep 2021; 6:e961. [PMID: 34712885 PMCID: PMC8547929 DOI: 10.1097/pr9.0000000000000961] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/08/2021] [Accepted: 08/11/2021] [Indexed: 11/25/2022] Open
Abstract
The National Institute for Health and Care Excellence provides evidence-based advice that guides clinical practice. We highlight major criticisms related to the new guideline for chronic primary pain. The National Institute for Health and Care Excellence should revise their recent guideline to take into account all the available evidence on the treatment of chronic primary pain.
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Affiliation(s)
- Beatrice Korwisi
- Division of Clinical Psychology and Psychotherapy, Department of Psychology, Philipps-University Marburg, Marburg, Germany
| | - Antonia Barke
- Clinical and Biological Psychology, Catholic University Eichstaett-Ingolstadt, Eichstaett, Germany
| | - Anna Kharko
- Faculty of Health, University of Plymouth, Plymouth, United Kingdom
| | - Clara Bruhin
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Cosima Locher
- Faculty of Health, University of Plymouth, Plymouth, United Kingdom.,Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland.,Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Helen Koechlin
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland.,Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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12
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Stallard J, Varma P, Bonner R, Jivan S. National audit to assess standards of care for deliberate self-harm patients presenting to trauma centres with penetrating wounds and recommendations for action. J Plast Reconstr Aesthet Surg 2021; 75:881-888. [PMID: 34824024 DOI: 10.1016/j.bjps.2021.09.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 04/23/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The authors assessed the standard of care for patients presenting with deliberate self-harm (DSH) injuries to major trauma centres (MTCs) in England as well as hospitals within the major trauma network in Scotland. This was to generate an understanding of current practice, identify any shortfall and develop recommendations to improve safety and patient care. METHODS We contacted all MTCs in England and hospitals in the major trauma network in Scotland, asking their permission to be included in this study. Emergency department (ED) consultants at each unit were then invited to complete a telephone questionnaire clarifying their current management policies of DSH patients against NICE guidance. The telephone questionnaire was carried out by the same author to ensure interpretation was consistent. RESULTS Twenty-seven MTCs within England as well as the four hospitals in the major trauma network within Scotland were contacted. There was a total of 15 responses - 14 responses from MTCs within England and 1 response from a hospital in the trauma network in Scotland. The clear deficit in practice was identified and recommendations were generated. CONCLUSION Our study has shown that patients are transferred following DSH without a clear review of their physical, psychological and social needs. We hope to share our recommendations for the implementation of a local protocol to improve standards and safety.
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Affiliation(s)
- Joseph Stallard
- Department of Plastic Surgery, Pinderfields General Hospital, Wakefield WF14DG, UK.
| | - Parvathi Varma
- Department of Plastic Surgery, Pinderfields General Hospital, Wakefield WF14DG, UK.
| | - Rory Bonner
- Department of Plastic Surgery, Pinderfields General Hospital, Wakefield WF14DG, UK.
| | - Sharmila Jivan
- Department of Plastic Surgery, Pinderfields General Hospital, Wakefield WF14DG, UK.
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13
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Witheford M, Brandsma A, Lane R, Prent A, Mastracci TM. Survival and durability after endovascular aneurysm repair reflect era-related surgical judgement. J Vasc Surg 2021; 75:552-560.e2. [PMID: 34555479 DOI: 10.1016/j.jvs.2021.08.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 08/16/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Abdominal aortic aneurysm management guidelines from the National Institute for Clinical Excellence in 2020, based heavily on randomized controlled trials in an early era of infrarenal endovascular aneurysm repair (EVAR), suggested that the long-term outcomes after EVAR jeopardize its use in elective abdominal aortic aneurysm repair. We hypothesized that, in a rapidly evolving surgical field, the era of aneurysm repair may have a significant influence on long-term patient outcomes. METHODS Using a single-center retrospective cohort design, we identified two EVAR cohorts, the early cohort (n = 166) who underwent EVAR from 2008 to 2010, and a contemporary late cohort (n = 129) from 2015 to 2017. We assessed patient preoperative demographics and era of repair against the primary outcomes of reinterventions, reintervention-free survival, and mortality, addressing their relationships to anatomic selection criteria, graft durability, endoleak, and aneurysm diameter to 5 years after the procedure. RESULTS Early cohort patients had decreased reintervention-free survival (early 80.1% vs late 93.3%) and decreased overall survival (early 71.3% vs late 81%) at 3 years and throughout follow-up. The preoperative anatomy judged suitable for EVAR in early cohort patients was more variable than for late cohort patients, including 104% larger proximal and 106% larger distal landing zone diameters, with a mean 11.6-mm shorter length infrarenal aortic and 13.3-mm shorter length iliac sealing zones in the early group. Early cohort patients had more complications during follow-up, including graft kinking and endoleaks, and 24.4% of early vs 8.5% of late patients underwent one or more reinterventions. CONCLUSIONS Although technical skill in EVAR implantation may not evolve significantly after a threshold of cases, surgical judgement, relating to anatomic selection and device sizing, requires feedback from long-term sequalae and significantly impacted EVAR outcomes by era. EVAR patients from an early repair era had significantly worse outcomes, with more complications, reinterventions, and a decrease in survival.
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Affiliation(s)
- Miranda Witheford
- Division of Vascular Surgery, Complex Aortic Team, Royal Free NHS Foundation Trust, London, UK; Division of Vascular Surgery, University Health Network, Toronto, Ontario, Canada
| | - Amarins Brandsma
- Division of Vascular Surgery, Complex Aortic Team, Royal Free NHS Foundation Trust, London, UK
| | - Rene Lane
- Division of Vascular Surgery, Complex Aortic Team, Royal Free NHS Foundation Trust, London, UK
| | - Anna Prent
- Division of Vascular Surgery, Complex Aortic Team, Royal Free NHS Foundation Trust, London, UK
| | - Tara M Mastracci
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK; Department of Surgery and Interventional Sciences, University College London, London, UK.
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14
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Keohane D, Downey C, Sheridan GA, O'Kelly P, Quinlan JF. Hip fracture surgery within 36 hours reduces both 30-day and 1-year mortality rates. Surgeon 2021; 20:262-267. [PMID: 34229977 DOI: 10.1016/j.surge.2021.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/15/2021] [Accepted: 05/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Currently the Irish Hip Fracture Standards [IHFS] recommend a Time-to-Surgery [TTS] of within 48 h of admission. The aim of our research is to determine if there was a statistically significant relationship between TTS and 30-day or one-year mortality and to assess whether a 48 h window for surgery is still the most appropriate recommendation. METHODS USED This was a single-hospital retrospective review of all of the fragility hip fractures between 1st January 2013 and 31st December 2017. Patient demographics were described using descriptive statistics. Dependent variables of interest were 30-day mortality and one-year mortality. Independent predictor variables analysed included age, ASA grade, fracture type, surgery performed, anaesthesia administered, length of stay and TTS (hours as an interval variable), TTS in less than 36 h (binary variable) and TTS in less than 48 h (binary variable). When the significant predictor variables were identified, in order to control for confounder variables, a multivariate regression analysis was performed to identify which predictors were still significantly associated with the outcome variables even after controlling for all other known confounder variables. RESULTS In total, 806 patients were identified. TTS within 36 h was predictive of a significantly lower 30-day mortality when compared to those undergoing surgery after 36 h (p = 0.031). In contrast, TTS within 48 h did not demonstrate a significantly lower 30-day mortality when compared to those undergoing surgery after 48 h (p = 0.104). On multivariate regression analysis, TTS <36 h (p = 0.011) and age (p < 0.0001) were all independently predictive of 30-day mortality. On multivariate regression analysis, both age (p < 0.0001) and TTS < 36 h (p = 0.002) were significantly predictive of one-year mortality. CONCLUSION Performing hip fracture surgery within 36 h confers a significant reduction in both 30-day and one-year mortality rates when compared to patients undergoing surgery outside of this time frame. A 36-h window also appears to be superior to a 48-h window because performing surgery within 48 h has no significant impact on the reduction of 30-day mortality rates. We recommend that national guidelines reflect these important findings.
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Affiliation(s)
- David Keohane
- Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin 24, Ireland.
| | - Colum Downey
- Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin 24, Ireland.
| | - Gerard A Sheridan
- Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin 24, Ireland.
| | - Patrick O'Kelly
- Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin 24, Ireland.
| | - John F Quinlan
- Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin 24, Ireland.
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15
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Dayasiri K, Hull J, Rao S. NICE guidance on diagnosis and management of cystic fibrosis. Arch Dis Child Educ Pract Ed 2021; 106:31-34. [PMID: 32447278 DOI: 10.1136/archdischild-2019-316882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 04/17/2020] [Accepted: 04/26/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Kavinda Dayasiri
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Jeremy Hull
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Sahana Rao
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
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16
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Almohtadi A, Subramaniam M, Mattson A, Malhotra B, Eriksson FM. The effect of the transition to Electronic Patient Records on adherence to venous thromboembolism prophylaxis guidelines in general surgical patients. J Healthc Qual Res 2021; 36:168-175. [PMID: 33487584 DOI: 10.1016/j.jhqr.2020.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/21/2020] [Accepted: 10/30/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND OBJECTIVES Surgical patients are at risk of hospital-acquired venous thromboembolisms (VTEs), and preventative measures such as thromboembolism deterrent stockings (TEDs) and low molecular weight heparin (LMWH) are proven to be beneficial. The National Quality Requirement in the NHS Standard Contract 2017/19 in England mandates that 95% of inpatients undergo VTE risk assessments. As hospitals transition to Electronic Patient Records (EPR), it is important to observe the impact on vital safety indicators such as VTE risk. The aim of this study is to observe the effect of implementing EPR in a tertiary centre on adherence to national guidelines, including VTE assessment rates and prophylaxis administration in surgical patients. MATERIALS AND METHODS Using consecutive sampling, all acute surgical admissions at the hospital from 26/02/2018 to 18/03/2018 (n=154) pre-EPR and 31/10/2018 to 25/11/2018 (n=151) post-EPR were observed for VTE risk assessment, 24-h re-assessment, prophylaxis prescriptions, administration, and patient compliance. Data was compared using a two-tailed Z-test. RESULTS Pre-EPR, 96% of patients had completed VTE assessments, which increased after EPR implementation to 97% (p=0.39). LWMH prescription rates decreased from 82% to 77% following EPR (p=0.14). Moreover, TED prescriptions decreased from 84% to 64% post-EPR (p<0.01). Administration rates of prophylaxis generally improved post-EPR. The 24-h re-assessment rate decreased from 62% to 54% of patients (p=0.08). CONCLUSION The study demonstrated that EPR is non-inferior to paper records. Transitioning to an EPR system did not interfere with the completion of VTE risk assessments, hence did not negatively impact the ability to achieve national targets.
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Affiliation(s)
- A Almohtadi
- Medical School, St. George's University of London, Cranmer Terrace, Tooting, London SW17 0RE, United Kingdom.
| | - M Subramaniam
- Medical School, St. George's University of London, Cranmer Terrace, Tooting, London SW17 0RE, United Kingdom
| | - A Mattson
- Medical School, St. George's University of London, Cranmer Terrace, Tooting, London SW17 0RE, United Kingdom
| | - B Malhotra
- Medical School, St. George's University of London, Cranmer Terrace, Tooting, London SW17 0RE, United Kingdom
| | - F M Eriksson
- Medical School, St. George's University of London, Cranmer Terrace, Tooting, London SW17 0RE, United Kingdom
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17
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Bowie-DaBreo D, Sünram-Lea SI, Sas C, Iles-Smith H. Evaluation of Treatment Descriptions and Alignment With Clinical Guidance of Apps for Depression on App Stores: Systematic Search and Content Analysis. JMIR Form Res 2020; 4:e14988. [PMID: 33185566 PMCID: PMC7695532 DOI: 10.2196/14988] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 05/19/2020] [Accepted: 06/02/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The use of apps for the treatment of depression shows great promise. However, there is uncertainty regarding the alignment of publicly available apps for depression with clinical guidance, their treatment fidelity and evidence base, and their overall safety. OBJECTIVE Built on previous analyses and reviews, this study aims to explore the treatment and safety issues of publicly available apps for depression. METHODS We conducted a content analysis of apps for depression in the 2 main UK app stores (Google Play and Apple App Store). App store listings were analyzed for intervention content, treatment fidelity, and fit with the National Institute for Health and Care Excellence (NICE) guidelines for the treatment of depression in adults. RESULTS A total of 353 apps for depression were included in the review. App descriptions reported the use of 20 treatment approaches and 37 treatment strategies. Many apps used transdiagnostic (155/353, 43.9%) and multitheoretical interventions to treat multiple disorders including depression. Although many interventions appeared to be evidence-informed, there were issues with treatment fidelity, research evidence, and fit with clinical guidelines. None of the apps fully aligned with the NICE guidelines for depression. CONCLUSIONS App developers have adopted many evidence-informed treatments in their interventions; however, more work is needed to improve clinical validity, treatment fidelity, and the safety of apps. We urge developers to consult relevant guidelines and standards, and to engage in reflective questioning on treatment and safety to address these issues and to improve treatment content and intervention design.
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Affiliation(s)
- Dionne Bowie-DaBreo
- Research and Innovation Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Department of Psychology, Lancaster University, Lancaster, United Kingdom
| | | | - Corina Sas
- School of Computing and Communications, Lancaster University, Lancaster, United Kingdom
| | - Heather Iles-Smith
- Research and Innovation, Northern Care Alliance NHS Group, Salford, United Kingdom
- University of Salford, Salford, United Kingdom
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Walkup JT, Strawn JR. High-quality antidepressant prescribing: please consider whether "perfection is the enemy of progress". BMC Med 2020; 18:150. [PMID: 32438910 PMCID: PMC7243321 DOI: 10.1186/s12916-020-01621-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/07/2020] [Indexed: 12/30/2022] Open
Affiliation(s)
- John T Walkup
- Pritzker Department of Psychiatry and Behavioral Health, Anne and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Box 10, Chicago, IL, 60611, USA.
| | - Jeffrey R Strawn
- Department of Psychiatry, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Child & Adolescent Psychiatry and Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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19
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Papachristidis A, Vaughan GF, Denny SJ, Akbari T, Avornyo E, Griffiths T, Saunders E, Byrne J, Monaghan MJ, Al Fakih K. Comparison of NICE and ESC proposed strategies on new onset chest pain and the contemporary clinical utility of pretest probability risk score. Open Heart 2020; 7:e001081. [PMID: 32467136 PMCID: PMC7259870 DOI: 10.1136/openhrt-2019-001081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 12/02/2019] [Accepted: 02/17/2020] [Indexed: 02/06/2023] Open
Abstract
AIMS Patients with de novo chest pain are usually investigated non-invasively. The new UK-National Institute for Health and Care Excellence (NICE) guidelines recommend CT coronary angiography (CTCA) for all patients, while European Society of Cardiology (ESC) recommends functional tests. We sought to compare the clinical utility and perform a cost analysis of these recommendations in two UK centres with different primary investigative strategies. METHODSRESULTS We compared two groups of patients, group A (n=667) and group B (n=654), with new onset chest pain in two neighbouring National Health Service hospitals, each primarily following either ESC (group A) or NICE (group B) guidance. We assessed the clinical utility of each strategy, including progression to invasive coronary angiography (ICA) and revascularisation. We present a retrospective cost analysis in the context of UK tariff for stress echo (£176), CTCA (£220) and ICA (£1001). Finally, we sought to identify predictors of revascularisation in the whole population.Baseline characteristics in both groups were similar. The progression to ICA was comparable (9.9% vs 12.0%, p=0.377), with similar requirement for revascularisation (4.0% vs 5.0%.; p=0.532). The average cost of investigations per investigated patient was lower in group A (£279.66 vs £325.77), saving £46.11 per patient. The ESC recommended risk score (RS) was found to be the only predictor of revascularisation (OR 1.05, 95% CI 1.04 to 1.06; p<0.001). CONCLUSION Both NICE and ESC-proposed strategies led to similar rates of ICA and need for revascularisation in discrete, but similar groups of patients. The SE-first approach had a lower overall cost by £46.11 per patient, and the ESC RS was the only variable correlated to revascularisation.
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Affiliation(s)
- Alexandros Papachristidis
- Cardiology, King's College Hospital NHS Foundation Trust, London, UK
- Cardiovascular Division, King's College London, London, United Kingdom
| | | | - Sarah J Denny
- Cardiology, Lewisham and Greenwich NHS Trust, London, UK
| | - Tamim Akbari
- Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Edith Avornyo
- Cardiology, Lewisham and Greenwich NHS Trust, London, UK
| | - Tracey Griffiths
- Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Emma Saunders
- Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Jonathan Byrne
- Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Mark J Monaghan
- Cardiology, King's College Hospital NHS Foundation Trust, London, UK
- Cardiovascular Division, King's College London, London, United Kingdom
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20
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Clevers E, Tran M, Van Oudenhove L, Störsrud S, Böhn L, Törnblom H, Simrén M. Adherence to diet low in fermentable carbohydrates and traditional diet for irritable bowel syndrome. Nutrition 2020; 73:110719. [PMID: 32086111 DOI: 10.1016/j.nut.2020.110719] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 12/03/2019] [Accepted: 12/12/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Dietary interventions in irritable bowel syndrome (IBS) include a traditional IBS diet following the guidelines from the National Institute for Health and Clinical Excellence and a diet low in fermentable oligo-, di-, monosaccharides and polyols (FODMAPs). The aim of this study was to evaluate the adherence to these diets, food groups difficult to replace, and dietary determinants of symptom improvement. METHODS Sixty-six patients with IBS were randomized to a 4-wk low FODMAP or traditional IBS diet. Participants completed 4-d diet diaries before and during the intervention and reported symptoms on the IBS severity scoring system. We described adherence to the diets on the food group and product level and investigated the association between adherence and symptom improvement. RESULTS Adherence to the low FODMAP diet was good and consistent: All participants had a comparable shift in the diet's principal components compatible with the guidelines. Most high FODMAP products were well replaced with low FODMAP equivalents. However, total energy intake fell by 25%, mainly owing to a 69% decreased intake of snacks (P < 0.001). The traditional IBS diet did not shift the diet's principal components, and despite the guidelines, consumption of coffee and alcoholic beverages remained rather high (>50% of baseline). Total energy intake fell by 11% (P = 0.15). For both diets, there was a trend toward an association between adherence and symptom improvement (P < 0.10). CONCLUSION In both the low FODMAP and traditional IBS diet, certain food groups were difficult to replace. Because adherence may predict symptom improvement, close dietary guidance might enhance the efficacy of both diets.
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Affiliation(s)
- Egbert Clevers
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Belgium
| | - Milly Tran
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lukas Van Oudenhove
- Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Belgium
| | - Stine Störsrud
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lena Böhn
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Törnblom
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simrén
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
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Arhi CS, Ziprin P, Bottle A, Burns EM, Aylin P, Darzi A. Colorectal cancer patients under the age of 50 experience delays in primary care leading to emergency diagnoses: a population-based study. Colorectal Dis 2019; 21:1270-1278. [PMID: 31389141 DOI: 10.1111/codi.14734] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 05/10/2019] [Indexed: 12/27/2022]
Abstract
AIM The incidence of colorectal cancer in the under 50s is increasing. In this national population-based study we aim to show that missed opportunities for diagnosis in primary care are leading to referral delays and emergency diagnoses in young patients. METHOD We compared the interval before diagnosis, presenting symptom(s) and the odds ratio (OR) of an emergency diagnosis for those under the age of 50 with older patients sourced from the cancer registry with linkage to a national database of primary-care records. RESULTS The study included 7315 patients, of whom 508 (6.9%) were aged under 50 years, 1168 (16.0%) were aged 50-59, 2294 (31.4%) were aged 60-69 and 3345 (45.7%) were aged 70-79 years. Young patients were more likely to present with abdominal pain and via an emergency, and had the lowest percentage of early stage cancer. They experienced a longer interval between referral and diagnosis (12.5 days) than those aged 60-69, reflecting the higher proportion of referrals via the nonurgent pathway (33.3%). The OR of an emergency diagnosis did not differ with age if a red-flag symptom was noted at presentation, but increased significantly for young patients if the symptom was nonspecific. CONCLUSION Young patients present to primary care with symptoms outside the national referral guidelines, increasing the likelihood of an emergency diagnosis.
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Affiliation(s)
- C S Arhi
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - P Ziprin
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - A Bottle
- School of Public Health, Imperial College London, London, UK
| | - E M Burns
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - P Aylin
- School of Public Health, Imperial College London, London, UK
| | - A Darzi
- Department of Surgery and Cancer, Imperial College London, London, UK
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22
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Arjunan A, Jeelani MS, Docherty S, Taylor J. Chronic kidney disease referrals from general practitioners pre- and post National Institute for Health and Care Excellence guidance 2014. Clin Med (Lond) 2019; 19:490-493. [PMID: 31641066 DOI: 10.7861/clinmed.2019-0105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Mortality from chronic kidney disease (CKD) is increasing. Most patients die from cardiovascular disease and management of cardiovascular risks is key to prevent both mortality and progression to end-stage renal disease. In 2014, the National Institute of Health and Care Excellence (NICE) introduced guidance to help general practitioners (GPs) manage CKD patients. AIM We aimed to determine the impact of the updated CKD guidance on CKD/cardiovascular risks optimisation and the timeliness of referral from the primary care. METHODS All new GP referrals to the Regional Renal Service in 2012 and 2016 were analysed. Data were collected on patient age, estimated glomerular filtration rate (eGFR) at referral, blood pressure (BP), smoking, body mass index, glycated haemoglobin (HbA1c; in diabetic patients) and lipid assessment. RESULTS A total of 486 new GP referrals were received in 2012, and 574 in 2016 (18% increase post NICE CKD guideline). Post NICE, fewer stage 4 and 5 CKD patients were being referred. But late referrals (eGFR <20 mL/min/1.73 m2) were not improved. BP control had improved. More patients had cholesterol-levels checked. The number of smokers and obese patients had not improved. CONCLUSION Post NICE guidelines, GPs are better in optimising BP. Diabetes management and lifestyle modifications need further improvement.
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Affiliation(s)
| | | | | | - Jo Taylor
- Dorset County Hospital, Dorchester, UK
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23
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Coetzee O, Swartz L, Capri C, Adnams C. Where there is no evidence: implementing family interventions from recommendations in the NICE guideline 11 on challenging behaviour in a South African health service for adults with intellectual disability. BMC Health Serv Res 2019; 19:162. [PMID: 30866932 PMCID: PMC6417279 DOI: 10.1186/s12913-019-3999-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 03/07/2019] [Indexed: 02/01/2023] Open
Abstract
Background Low- and middle-income countries often lack the fiscal, infrastructural and human resources to conduct evidence-based research; similar constraints may also hinder the application of good clinical practice guidelines based on research findings from high-income countries. While the context of health organizations is increasingly recognized as an important consideration when such guidelines are implemented, there is a paucity of studies that have considered local contexts of resource-scarcity against recommended clinical guidelines. Methods This paper sets out to explore the implementation of the NICE Guideline 11 on family interventions when working with persons with intellectual disability and challenging behavior by a group of psychologists employed in a government health facility in Cape Town, South Africa. Results In the absence of evidence-based South African research, we argue that aspects of the guidelines, in particular those that informed our ethos and conceptual thinking, could be applied by clinical psychologists in a meaningful manner notwithstanding the relative scarcity of resources. Conclusion We have argued that where guidelines such as the NICE Guidelines do not apply contextually throughout, it remains important to retain the principles behind these guidelines in local contexts. Limitations of this study exist in that the data were drawn only from the clinical experience of authors. Some of the implications for future research in resource-constrained contexts such as ours are discussed. Smaller descriptive, qualitative studies are necessary to explore the contextual limitations and resource strengths that exist in low- and middle-income settings, and these studies should be more systematic than drawing only on the clinical experience of authors, as has been done in this study.
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Affiliation(s)
- Ockert Coetzee
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town, 7925, South Africa
| | - Leslie Swartz
- Alan J Flisher Centre for Public Mental Health, Department of Psychology, Stellenbosch University, Private Bag X1, Matieland, 7602, South Africa.
| | - Charlotte Capri
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town, 7925, South Africa
| | - Colleen Adnams
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town, 7925, South Africa
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Wong GJY, Lew CCH. Letter to editor re: Refeeding syndrome in adults receiving total parenteral nutrition: An audit of practice at a tertiary UK centre. Clin Nutr 2018; 37:2288. [PMID: 30219607 DOI: 10.1016/j.clnu.2018.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 08/15/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Gabriel Jun Yung Wong
- Dietetics and Nutrition Department, Ng Teng Fong General Hospital, 1 Jurong East Street 21, 609606, Singapore.
| | - Charles Chin Han Lew
- Dietetics and Nutrition Department, Ng Teng Fong General Hospital, 1 Jurong East Street 21, 609606, Singapore; Nutrition and Dietetics, College of Nursing and Health Sciences, Flinders University, Australia.
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25
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Healey EL, Afolabi EK, Lewis M, Edwards JJ, Jordan KP, Finney A, Jinks C, Hay EM, Dziedzic KS. Uptake of the NICE osteoarthritis guidelines in primary care: a survey of older adults with joint pain. BMC Musculoskelet Disord 2018; 19:295. [PMID: 30115048 PMCID: PMC6097435 DOI: 10.1186/s12891-018-2196-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 07/17/2018] [Indexed: 11/21/2022] Open
Abstract
Background Osteoarthritis (OA) is a leading cause of pain and disability. NICE OA guidelines (2008) recommend that patients with OA should be offered core treatments in primary care. Assessments of OA management have identified a need to improve primary care of people with OA, as recorded use of interventions concordant with the NICE guidelines is suboptimal in primary care. The aim of this study was to i) describe the patient-reported uptake of non-pharmacological and pharmacological treatments recommended in the NICE OA guidelines in older adults with a self-reported consultation for joint pain and ii) determine whether patient characteristics or OA diagnosis impact uptake. Methods A cross-sectional survey mailed to adults aged ≥45 years (n = 28,443) from eight general practices in the UK as part of the MOSAICS study. Respondents who reported the presence of joint pain, a consultation in the previous 12 months for joint pain, and gave consent to medical record review formed the sample for this study. Results Four thousand fifty-nine respondents were included in the analysis (mean age 65.6 years (SD 11.2), 2300 (56.7%) females). 502 (12.4%) received an OA diagnosis in the previous 12 months. More participants reported using pharmacological treatments (e.g. paracetamol (31.3%), opioids (40.4%)) than non-pharmacological treatments (e.g. exercise (3.8%)). Those with an OA diagnosis were more likely to use written information (OR 1.57; 95% CI 1.26,1.96), paracetamol (OR 1.30; 95% CI 1.05,1.62) and topical NSAIDs (OR 1.30; 95% CI 1.04,1.62) than those with a joint pain code. People aged ≥75 years were less likely to use written information (OR 0.56; 95% CI 0.40,0.79) and exercise (OR 0.37; 95% CI 0.25,0.55) and more likely to use paracetamol (OR 1.91; 95% CI 1.38,2.65) than those aged < 75 years. Conclusion The cross-sectional population survey was conducted to examine the uptake of the treatments that are recommended in the NICE OA guidelines in older adults with a self-reported consultation for joint pain and to determine whether patient characteristics or OA diagnosis impact uptake. Non-pharmacological treatment was suboptimal compared to pharmacological treatment. Implementation of NICE guidelines needs to examine why non-pharmacological treatments, such as exercise, remain under-used especially among older people.
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Affiliation(s)
- Emma Louise Healey
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK.
| | - Ebenezer K Afolabi
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Martyn Lewis
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK.,Keele Clinical Trials Unit, David Weatherall Building, Keele University, Staffordshire, UK
| | - John J Edwards
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Kelvin P Jordan
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK.,Keele Clinical Trials Unit, David Weatherall Building, Keele University, Staffordshire, UK
| | - Andrew Finney
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK.,School of Nursing and Midwifery, Keele University, Staffordshire, UK
| | - Clare Jinks
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Elaine M Hay
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Krysia S Dziedzic
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
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26
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Poon LC, Rolnik DL, Tan MY, Delgado JL, Tsokaki T, Akolekar R, Singh M, Andrade W, Efeturk T, Jani JC, Plasencia W, Papaioannou G, Blazquez AR, Carbone IF, Wright D, Nicolaides KH. ASPRE trial: incidence of preterm pre-eclampsia in patients fulfilling ACOG and NICE criteria according to risk by FMF algorithm. Ultrasound Obstet Gynecol 2018; 51:738-742. [PMID: 29380918 DOI: 10.1002/uog.19019] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/23/2018] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To report the incidence of preterm pre-eclampsia (PE) in women who are screen positive according to the criteria of the National Institute for Health and Care Excellence (NICE) and the American College of Obstetricians and Gynecologists (ACOG), and compare the incidence with that in those who are screen positive or screen negative by The Fetal Medicine Foundation (FMF) algorithm. METHODS This was a secondary analysis of data from the ASPRE study. The study population consisted of women with singleton pregnancy who underwent prospective screening for preterm PE by means of the FMF algorithm, which combines maternal factors and biomarkers at 11-13 weeks' gestation. The incidence of preterm PE in women fulfilling the NICE and ACOG criteria was estimated; in these patients the incidence of preterm PE was then calculated in those who were screen negative relative to those who were screen positive by the FMF algorithm. RESULTS A total of 34 573 women with singleton pregnancy delivering at ≥ 24 weeks' gestation underwent prospective screening for preterm PE, of which 239 (0.7%) cases developed preterm PE. At least one of the ACOG criteria was fulfilled in 22 287 (64.5%) pregnancies and the incidence of preterm PE was 0.97% (95% CI, 0.85-1.11%); in the subgroup that was screen positive by the FMF algorithm the incidence of preterm PE was 4.80% (95% CI, 4.14-5.55%), and in those that were screen negative it was 0.25% (95% CI, 0.18-0.33%), with a relative incidence in FMF screen negative to FMF screen positive of 0.051 (95% CI, 0.037-0.071). In 1392 (4.0%) pregnancies, at least one of the NICE high-risk criteria was fulfilled, and in this group the incidence of preterm PE was 5.17% (95% CI, 4.13-6.46%); in the subgroups of screen positive and screen negative by the FMF algorithm, the incidence of preterm PE was 8.71% (95% CI, 6.93-10.89%) and 0.65% (95% CI, 0.25-1.67%), respectively, and the relative incidence was 0.075 (95% CI, 0.028-0.205). In 2360 (6.8%) pregnancies fulfilling at least two of the NICE moderate-risk criteria, the incidence of preterm PE was 1.74% (95% CI, 1.28-2.35%); in the subgroups of screen positive and screen negative by the FMF algorithm the incidence was 4.91% (95% CI, 3.54-6.79%) and 0.42% (95% CI, 0.20-0.86%), respectively, and the relative incidence was 0.085 (95% CI, 0.038-0.192). CONCLUSION In women who are screen positive for preterm PE by the ACOG or NICE criteria but screen negative by the FMF algorithm, the risk of preterm PE is reduced to within or below background levels. The results provide further evidence to support the personalized risk-based screening method that combines maternal factors and biomarkers. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- L C Poon
- King's College London, London, UK
- Chinese University of Hong Kong, Hong Kong SAR
| | | | - M Y Tan
- King's College Hospital, London, UK
- Lewisham University Hospital, London, UK
| | - J L Delgado
- Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - T Tsokaki
- King's College Hospital, London, UK
- North Middlesex University Hospital, London, UK
| | - R Akolekar
- King's College Hospital, London, UK
- Medway Maritime Hospital, Gillingham, UK
| | - M Singh
- King's College Hospital, London, UK
- Southend University Hospital, Essex, UK
| | | | - T Efeturk
- King's College Hospital, London, UK
- Homerton University Hospital, London, UK
| | - J C Jani
- University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - W Plasencia
- Hospiten Group, Tenerife, Canary Islands, Spain
| | | | - A R Blazquez
- Hospital Universitario San Cecilio, Granada, Spain
| | | | - D Wright
- University of Exeter, Exeter, UK
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Kerwat D, Zargaran A, Bharamgoudar R, Arif N, Bello G, Sharma B, Kerwat R. Early laparoscopic cholecystectomy is more cost-effective than delayed laparoscopic cholecystectomy in the treatment of acute cholecystitis. Clinicoecon Outcomes Res 2018; 10:119-125. [PMID: 29497322 PMCID: PMC5822851 DOI: 10.2147/ceor.s149924] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background This economic evaluation quantifies the cost-effectiveness of early laparoscopic cholecystectomy (ELC) versus delayed laparoscopic cholecystectomy (DLC) in the management of acute cholecystitis. The two interventions were assessed in terms of outcome measures, including utilities, to derive quality-adjusted life years (QALYs) as a unit of effectiveness. This study hypothesizes that ELC is more cost-effective than DLC. Materials and methods In this economic evaluation, existing literature was compiled and analyzed to estimate the incremental cost-effectiveness of ELC versus DLC. Six randomized controlled trials were used to schematically represent the probabilities of each decision tree branch. To calculate health outcomes, quality of life scores were sourced from three articles and multiplied by the expected length of life postintervention to give QALYs. From an National Health Service (NHS) perspective, one QALY may be sacrificed if the incremental cost-effectiveness ratio is above £20,000–£30,0000 in cost savings. Results This economic evaluation calculated the average net present values of ELC to be £3920 and DLC to be £4565, demonstrating that ELC is the less-expensive intervention, with potential cost savings of £645 per operation. When scaling these savings up to a population approximately comparable to the size of the UK, full-scale implementation of ELC rather than DLC will potentially save the NHS £30,000,000 per annum. Conclusion ELCs are cost-effective from the perspective of the NHS. As such, policy should review existing guidelines and consider the merits of ELC versus DLC, improving resource allocation. The findings of this article advocate that ELC should become a standard practice.
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Affiliation(s)
| | | | | | - Nadia Arif
- Department of Medicine, Brighton and Sussex Medical School, Brighton
| | - Grace Bello
- Department of Medicine, St George's University of London, London
| | | | - Rajab Kerwat
- Department of Medicine, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, London, UK
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28
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Dziedzic KS, Healey EL, Porcheret M, Afolabi EK, Lewis M, Morden A, Jinks C, McHugh GA, Ryan S, Finney A, Main C, Edwards JJ, Paskins Z, Pushpa-Rajah A, Hay EM. Implementing core NICE guidelines for osteoarthritis in primary care with a model consultation (MOSAICS): a cluster randomised controlled trial. Osteoarthritis Cartilage 2018; 26:43-53. [PMID: 29037845 DOI: 10.1016/j.joca.2017.09.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/20/2017] [Accepted: 09/26/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the effectiveness of a model osteoarthritis consultation, compared with usual care, on physical function and uptake of National Institute for Health and Care Excellence (NICE) osteoarthritis recommendations, in adults ≥45 years consulting with peripheral joint pain in UK general practice. METHOD Two-arm cluster-randomised controlled trial with baseline health survey. Eight general practices in England. PARTICIPANTS 525 adults ≥45 years consulting for peripheral joint pain, amongst 28,443 population survey recipients. Four intervention practices delivered the model osteoarthritis consultation to patients consulting with peripheral joint pain; four control practices continued usual care. The primary clinical outcome of the trial was the SF-12 physical component score (PCS) at 6 months; the main secondary outcome was uptake of NICE core recommendations by 6 months, measured by osteoarthritis quality indicators. A Linear Mixed Model was used to analyse clinical outcome data (SF-12 PCS). Differences in quality indicator outcomes were assessed using logistic regression. RESULTS 525 eligible participants were enrolled (mean age 67.3 years, SD 10.5; 59.6% female): 288 from intervention and 237 from control practices. There were no statistically significant differences in SF-12 PCS: mean difference at the 6-month primary endpoint was -0.37 (95% CI -2.32, 1.57). Uptake of core NICE recommendations by 6 months was statistically significantly higher in the intervention arm compared with control: e.g., increased written exercise information, 20.5% (7.9, 28.3). CONCLUSION Whilst uptake of core NICE recommendations was increased, there was no evidence of benefit of this intervention, as delivered in this pragmatic randomised trial, on the primary outcome of physical functioning at 6 months. TRIAL REGISTRATION ISRCTN06984617.
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29
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Paul SP, Caplan EM, Morgan HA, Turner PC. Barriers to implementing the NICE guidelines for early-onset neonatal infection: cross-sectional survey of neonatal blood culture reporting by laboratories in the UK. J Hosp Infect 2017; 98:425-428. [PMID: 29258918 DOI: 10.1016/j.jhin.2017.12.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 12/11/2017] [Indexed: 10/18/2022]
Abstract
The National Institute for Health and Care Excellence published guidelines for managing early-onset neonatal infections in 2012. It recommended provision for reporting blood cultures (BCs) with growth detected or not detected at 36 h. To determine if this was followed, a telephone survey was conducted amongst lead biomedical scientists based at microbiology laboratories (N = 209) in the UK. Overall, 202/209 responded and 139/202 had on-site facilities for BCs. BC results with growth detected or not detected at 36 h were available out-of-hours in 36/139 (26.6%) and 66/139 (47.5%) neonatal units, respectively. Early discontinuation of antibiotics should lead to improved antibiotic stewardship.
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Affiliation(s)
- S P Paul
- Department of Paediatrics, Torbay Hospital, Torquay, UK.
| | - E M Caplan
- Medical School, University of Bristol, Bristol, UK
| | - H A Morgan
- Medical School, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter, UK; Medical School, Peninsula College of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - P C Turner
- Department of Medical Microbiology, Torbay Hospital, Torquay, UK
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30
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Geekie J, Read J, Renton J, Harrop C. Do English mental health services know whether they followed N.I.C.E. guidelines with patients who killed themselves? Psychol Psychother 2017; 90:797-800. [PMID: 28719140 DOI: 10.1111/papt.12141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 06/23/2017] [Indexed: 12/18/2022]
Abstract
UNLABELLED Freedom of Information Act requests sent to 51 NHS mental health providers in England showed an average of 20.5 suicides per organization. Only one provider, however, could report how many people that had killed themselves had been offered N.I.C.E. recommended psychological therapy. Information that might prevent suicides is being ignored. PRACTITIONER POINTS Mental health services need, urgently, to develop data systems that can inform clinical team leaders about gaps in their services to suicidal people in their care Clinical psychologists have a particular responsibility to pressure managers to effectively monitor the provision of evidence-based treatments to suicidal people Trusts and commissioners must be aware of, and rectify, any failings of their services in relation to the prevention of suicide.
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Affiliation(s)
- Jim Geekie
- NHS Education for Scotland, Edinburgh, UK
| | - John Read
- School of Psychology, University of East London, UK
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31
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Barkham M, Moller NP, Pybis J. How should we evaluate research on counselling and the treatment of depression? A case study on how the National Institute for Health and Care Excellence's draft 2018 guideline for depression considered what counts as best evidence. Couns Psychother Res 2017; 17:253-268. [PMID: 29151815 PMCID: PMC5678230 DOI: 10.1002/capr.12141] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background Health guidelines are developed to improve patient care by ensuring the most recent and ‘best available evidence’ is used to guide treatment recommendations. The National Institute for Health and Care Excellence's (NICE's ) guideline development methodology acknowledges that evidence needed to answer one question (treatment efficacy) may be different from evidence needed to answer another (cost‐effectiveness, treatment acceptability to patients). This review uses counselling in the treatment of depression as a case study, and interrogates the constructs of ‘best’ evidence and ‘best’ guideline methodologies. Method The review comprises six sections: (i) implications of diverse definitions of counselling in research; (ii) research findings from meta‐analyses and randomised controlled trials (RCTs); (iii) limitations to trials‐based evidence; (iv) findings from large routine outcome datasets; (v) the inclusion of qualitative research that emphasises service‐user voices; and (vi) conclusions and recommendations. Results Research from meta‐analyses and RCTs contained in the draft 2018 NICE Guideline is limited but positive in relation to the effectiveness of counselling in the treatment for depression. The weight of evidence suggests little, if any, advantage to cognitive behaviour therapy (CBT) over counselling once risk of bias and researcher allegiance are taken into account. A growing body of evidence from large NHS data sets also evidences that, for depression, counselling is as effective as CBT and cost‐effective when delivered in NHS settings. Conclusion Specifications in NICE's updated guideline procedures allow for data other than RCTs and meta‐analyses to be included. Accordingly, there is a need to include large standardised collected data sets from routine practice as well as the voice of patients via high‐quality qualitative research.
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Affiliation(s)
- Michael Barkham
- Centre for Psychological Services Research University of Sheffield Sheffield UK
| | - Naomi P Moller
- Open University Milton Keynes UK.,British Association for Counselling and Psychotherapy Lutterworth UK
| | - Joanne Pybis
- British Association for Counselling and Psychotherapy Lutterworth UK
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32
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Ombelet W. The revival of intrauterine insemination: evidence-based data have changed the picture. Facts Views Vis Obgyn 2017; 9:131-132. [PMID: 29479397 PMCID: PMC5819320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
According to a number of high quality studies intrauterine insemination (IUI) with homologous semen should be the first choice treatment in case of unexplained and moderate male factor subfertility. IVF and ICSI are clearly over-used in this selected group of infertile couples. The limited value of IUI in infertility treatment as mentioned in the 2013 NICE guidelines was surely a premature statement and should be adapted to the actual literature. More evidence-based data are becoming available on different variables influencing the success rates after IUI. It can be expected that these findings may lead to a better understanding and use of IUI in the near future.
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Affiliation(s)
- Willem Ombelet
- Editor-in-Chief,Genk Institute for Fertility Technology, ZOL Hospitals, Schiepse Bos 6, 3600 Genk, Belgium,Hasselt University, Department of Physiology, Martelarenlaan 42, 3500 Hasselt, Belgium
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Atkins L, Kelly MP, Littleford C, Leng G, Michie S. Reversing the pipeline? Implementing public health evidence-based guidance in english local government. Implement Sci 2017; 12:63. [PMID: 28499393 PMCID: PMC5429536 DOI: 10.1186/s13012-017-0589-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 04/28/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the UK, responsibility for many public health functions was transferred in 2013 from the National Health Service (NHS) to local government; a very different political context and one without the NHS history of policy and practice being informed by evidence-based guidelines. A problem this move presented was whether evidence-based guidelines would be seen as relevant, useful and implementable within local government. This study investigates three aspects of implementing national evidence-based recommendations for public health within a local government context: influences on implementation, how useful guidelines are perceived to be and whether the linear evidence-guidelines-practice model is considered relevant. METHODS Thirty-one councillors, public health directors and deputy directors and officers and other local government employees were interviewed about their experiences implementing evidence-based guidelines. Interviews were informed and analysed using a theoretical model of behaviour (COM-B; Capability, Opportunity, Motivation-Behaviour). RESULTS Contextual issues such as budget, capacity and political influence were important influences on implementation. Guidelines were perceived to be of limited use, with concerns expressed about recommendations being presented in the abstract, lacking specificity and not addressing the complexity of situations or local variations. Local evidence was seen as the best starting point, rather than evidence-based guidance produced by the traditional linear 'evidence-guidelines-practice' model. Local evidence was used to not only provide context for recommendations but also replace recommendations when they conflicted with local evidence. CONCLUSIONS Local government users do not necessarily consider national guidelines to be fit for purpose at local level, with the consequence that local evidence tends to trump evidence-based guidelines. There is thus a tension between the traditional model of guideline development and the needs of public health decision-makers and practitioners working in local government. This tension needs to be addressed to facilitate implementation. One way this might be achieved, and participants supported this approach, would be to reverse or re-engineer the traditional pipeline of guideline development by starting with local need and examples of effective local practice rather than starting with evidence of effectiveness synthesised from the international scientific literature. Alternatively, and perhaps in addition, training about the relevance of research evidence should become a routine for local government staff and councillors.
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Affiliation(s)
- Lou Atkins
- Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB UK
| | - Michael P. Kelly
- Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, CB2 0SR UK
| | - Clare Littleford
- Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB UK
| | - Gillian Leng
- National Institute for Health and Care Excellence, 10 Spring Gardens, London, SW1A 2BU UK
| | - Susan Michie
- Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, WC1E 7HB UK
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Gray DG, Franklin JL, Nicholls MK, Eaton KA, Barrett AW. Compliance of referral and hospital documentation with National Institute of Health and Care Excellence guidelines for the extraction of third molars: a comparative analysis of two NHS Trusts. Br J Oral Maxillofac Surg 2017; 55:575-579. [PMID: 28372881 DOI: 10.1016/j.bjoms.2017.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 02/28/2017] [Indexed: 10/19/2022]
Abstract
To find out whether documentation for the extraction of wisdom teeth complies with National Institute of Health and Care Excellence (NICE) guidelines, we reviewed the referral letters and hospital notes of patients treated at the maxillofacial unit of two NHS Trusts (A: 314 records and B: 280) over 12 months (1 September 2012 to 31 August 2013). Compliance was assessed as unsatisfactory ("indication for extraction not mentioned", "incorrect indication", "indication unclear") or satisfactory ("correct indication implied", "correct indication explicit"). The grade of the clinician who examined the patient was also recorded. A total of 194/314 (62%) referral letters in Trust A and 126/280 (45%) in Trust B were unsatisfactory (p<0.001). Hospital notes were unsatisfactory in 168/323 (52%) and 87/297 (29%) of cases, respectively (p<0.001). In Trust A, middle grades saw 23% (75/323) of the patients, as compared with 53% (157/297) in Trust B. In both, junior staff produced the highest percentage of satisfactory documentation, but in Trust A they were also responsible for most of the unsatisfactory examples. However, senior house officers saw 60% (195/323) of the patients in Trust A, and only 28% (83/297) in Trust B. Consultants were responsible for significantly more unsatisfactory documentation (p<0.001). One referral letter (0.2%) and seven hospital records (1%) explicitly and accurately complied with the guidelines. We conclude that compliance of documentation with the current NICE guidelines is poor and inconsistent.
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Affiliation(s)
- D G Gray
- Department of Oral & Maxillofacial Surgery, Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE; Health Education England, Kent, Surrey, Sussex Deanery, and University of Kent, Centre for Professional Practice, Compass Centre South, Chatham Maritime, Kent ME4 4YG
| | - J L Franklin
- Maxillofacial Unit, Queen Victoria Hospital, Holtye Road, East Grinstead, RH19 3DZ; Health Education England, Kent, Surrey, Sussex Deanery, and University of Kent, Centre for Professional Practice, Compass Centre South, Chatham Maritime, Kent ME4 4YG
| | - M K Nicholls
- Health Education England, Kent, Surrey, Sussex Deanery, and University of Kent, Centre for Professional Practice, Compass Centre South, Chatham Maritime, Kent ME4 4YG
| | - K A Eaton
- Health Education England, Kent, Surrey, Sussex Deanery, and University of Kent, Centre for Professional Practice, Compass Centre South, Chatham Maritime, Kent ME4 4YG
| | - A W Barrett
- Department of Histopathology, Queen Victoria Hospital, Holtye Road, East Grinstead, RH19 3DZ.
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35
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Conn MK, Shafer S, Cline T. Anxiety Management in Primary Care: Implementing the National Institute of Clinical Excellence Guidelines. Arch Psychiatr Nurs 2017; 31:205-210. [PMID: 28359434 DOI: 10.1016/j.apnu.2016.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 09/23/2016] [Accepted: 09/27/2016] [Indexed: 11/16/2022]
Abstract
More than 40 million Americans suffer from anxiety disorders, ranking them as one of the most common mental health disorders in America. The purpose of this pilot study was to educate providers on the National Institute Clinical Excellence (NICE) anxiety guidelines and monitor providers' perceived competence in managing anxiety. Results showed perceived competence increased significantly pre-intervention to immediately post-intervention (p=0.001), and data revealed the scores did not change significantly immediately post-to six-weeks post (p=0.170). Providers who implemented the guidelines into practice had significantly higher scores (p=0.026) than those who did not implement the guidelines.
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Affiliation(s)
- Monica K Conn
- Robert Morris University, Hale Center 305, 6001 University Blvd, Moon Township, PA 15108, United States.
| | - Sheree Shafer
- Robert Morris University, Hale Center 305, 6001 University Blvd, Moon Township, PA 15108, United States.
| | - Thomas Cline
- St. Vincent College, Aurelius Hall, Room 219, 300 Fraser Purchase Rd, Latrobe, PA 15650, United States.
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36
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Abstract
Severe to profoundly deaf adults who score 50% or over on the Bamford-Kowal-Bench (BKB) sentence test currently cannot obtain NHS funding for a cochlear implant according to the NICE guidelines (NICE Technical Appraisal Guidance (TAG166), 2009. Cochlear implants for children and adults with severe to profound deafness. NICE technology appraisal guidance [TAG166]. http://www.nice.org.uk/ta166 accessed 08/02/2016). There is no cut-off restriction from the BKB score for children. This study challenges this restrictive criteria for adults, by presenting the outcomes of cochlear implantation in older children who scored over 50% on BKB sentence testing pre-implantation and therefore would not have been implanted under the adult NICE guidelines. Outcomes are presented using the Speech, Spatial and Qualities of Hearing Scale Version C (SSQ-C) (Gatehouse, S., Noble, W. 2004. The Speech, Spatial and Qualities of Hearing Scale (SSQ). International Journal of Audiology, 43: 85-99.). This study suggests a greater proportion of adults who are currently being restricted from having a cochlear implant would benefit from implantation.
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Affiliation(s)
- Fiona Vickers
- a Cochlear Implant Department , The Royal National Throat Nose and Ear Hospital , 330 Grays Inn Road, London , WC1X 8DA , UK
| | - Jane Bradley
- a Cochlear Implant Department , The Royal National Throat Nose and Ear Hospital , 330 Grays Inn Road, London , WC1X 8DA , UK
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Abstract
Multiple sclerosis (MS) is an inflammatory-demyelinating disease of the central nervous system that may entail severe levels of disability in the long term. However, independently of the level of disability, MS patients frequently experience severe fatigue that can be as disabling as objective neurological deficits. For that reason, it is mandatory to perform an early diagnosis of MS-related fatigue and start a suitable treatment as soon as possible. In clinical practice, MS-related fatigue should be assessed and managed by a multidisciplinary team involving neurologists, MS nurses, occupational therapists, and physiotherapists. When assessing a person with MS-related fatigue, the first step is to rule out potential triggers or causes of fatigue, which may be related to MS, such as urinary dysfunction, pain, or muscular spasms leading to a sleep disorder, or unrelated to it. Once these causes have been ruled out and appropriately tackled, a careful therapeutic intervention needs to be decided. Therapeutic interventions for MS-related fatigue can be pharmacological or non-pharmacological. Regarding the pharmacological treatments, although many drugs have been tested in clinical trials, only amantadine is currently recommended for this indication. Regarding the non-pharmacological approaches, they can be broadly divided into physical, psychological, and mixed physical/psychological interventions. Several studies, many of them randomised clinical trials, support the use of all these types of non-pharmacological interventions to treat MS-related fatigue. Recent publications suggest that the implementation of mixed approaches, which have a naturally comprehensive nature, may have excellent results in clinical practice, in relation not only to fatigue levels but also to more general aspects of MS.
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Affiliation(s)
- Carmen Tur
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK. .,Queen Square MS Centre, UCL Institute of Neurology, University College London, London, UK.
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Lamb B. Expert opinion: Can different assessments be used to overcome current candidacy issues? Cochlear Implants Int 2016; 17 Suppl 1:3-7. [PMID: 27078520 DOI: 10.1080/14670100.2016.1161382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Since the National Institute of Health and Care Excellence (NICE) review of cochlear implantation in 2009, (NICE, 2009) there have been a number of significant changes to our understanding of the impact of severe-to-profound hearing loss on quality of life and comorbidity with life limiting illness. There have been questions about the validity of current methods of assessing candidacy for cochlear implants. There have also been significant improvements in the effectiveness of implants, the age of successful implantation and a reduction in costs. Additionally, the costs to the health and welfare system of not addressing severe-to-profound hearing loss are often not considered when assessing costs and benefits of this technology and when assessing candidacy criteria. Consideration of these changes since the NICE review suggests the need for an urgent review of the current guidance.
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Affiliation(s)
- Brian Lamb
- a University of Derby , Kedleston Road, DE22 1GB Derby , UK
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Yue J, Tabloski P, Dowal SL, Puelle MR, Nandan R, Inouye SK. NICE to HELP: operationalizing National Institute for Health and Clinical Excellence guidelines to improve clinical practice. J Am Geriatr Soc 2014; 62:754-61. [PMID: 24697606 DOI: 10.1111/jgs.12768] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom developed guidelines for the diagnosis, prevention, and management of delirium in July 2010 that included 10 recommendations for delirium prevention. The Hospital Elder Life Program (HELP) is a targeted multicomponent strategy that has proven effective and cost-effective at preventing functional and cognitive decline in hospitalized older persons. HELP provided much of the basis for seven of the NICE recommendations. Given interest by new HELP sites to meet NICE guidelines, three new protocols addressing hypoxia, infection, and pain that were not previously included in the HELP program were developed. In addition, the NICE dehydration guideline included constipation, which was not specifically addressed in the HELP protocols. This project describes the systematic development of three new protocols (hypoxia, infection, pain) and the expansion of an existing HELP protocol (constipation and dehydration) to achieve alignment between the HELP protocols and NICE guidelines. Following the Institute of Medicine recommendations for developing trustworthy guidelines, an interdisciplinary group of experts conducted a systematic review of current literature, rated the quality of the evidence, developed intervention protocols based on the highest-quality evidence, and submitted the protocols first to internal review and then to external review by an interdisciplinary panel of experts. The protocols were revised based on the review process and incorporated into the HELP materials. Inclusion of these protocols enhances the scope of the HELP program and allows fulfillment of NICE guideline recommendations for delirium prevention. The rigorous process applied may provide a useful example for updating existing guidelines or protocols that may be applicable to a broad range of clinical applications.
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Affiliation(s)
- Jirong Yue
- Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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Haddock G, Eisner E, Boone C, Davies G, Coogan C, Barrowclough C. An investigation of the implementation of NICE-recommended CBT interventions for people with schizophrenia. J Ment Health 2014; 23:162-5. [PMID: 24433132 DOI: 10.3109/09638237.2013.869571] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The National Institute for Clinical Excellence (NICE) guidelines recommend that individual cognitive-behaviour therapy (CBT) is offered to all people with a diagnosis of schizophrenia. In addition, the guidelines recommend that family intervention (FI) should be offered to all families of people with schizophrenia who are in close contact with the service user. However, implementation into routine services is poor. AIMS To survey mental health services to investigate how many people with a diagnosis of schizophrenia and their families are offered and receive CBT or FI. METHODS A comprehensive audit of a random sample of 187 service users receiving care from one, large mental health care trust in North West England was conducted over a 12-month period. RESULTS The audit recorded that only 13 (6.9%) of services users were offered and 10 (5.3%) received individual CBT, while 3 (1.6%) services users were offered and 2 (1.1%) received FIs within the 12-month audit period. CONCLUSIONS Implementation of CBT and FI is poor, particularly for FI. Reasons for poor implementation and service implications are discussed.
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Abstract
OBJECTIVE AND IMPORTANCE The candidacy for cochlear implant has changed over time and includes people with lesser degrees of hearing loss. Candidacy is based on the pure-tone audiometry thresholds and aided speech testing. The audiogram does not reflect the actual problems faced by an individual with and without hearing aids. The variability in the actual functional hearing and the pure-tone thresholds makes it difficult for the patients whose audiogram is borderline for cochlear implantation and they are not deriving enough benefit from hearing aids. CASE PRESENTATION Retrospective report of the audiological findings of two patients whose cochlear implant funding was refused based on their audiogram. In both instances, they were not deriving benefit from hearing aids and the pure-tone audiometry results were just outside the National Institute for Health and Care Excellence guidelines at 4 kHz. CONCLUSIONS Cochlear implant candidacy should be individually based and needs to take into account other factors such as work, quality of life, and social impact rather than just adhering to the pure-tone audiometry guidelines. These guidelines should not be considered as strict criteria nor used to deny the benefit of a cochlear implant at the earliest possible opportunity.
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Abstract
The range of opportunist pathogens in cancer and transplant patients continues to increase. New treatment modalities and forms of immunosuppression following transplantation have improved survival from the underlying disease but can lead to prolonged immunosuppression and increased risk of infection. NICE guidelines for the management of neutropenic sepsis are now available but have aroused some controversy, particularly over the recommendation for quinolone prophylaxis in high-risk patient groups. In addition to neutropenia, long-term defects in cell-mediated immunity are exposing patients to risk of chronic, viral, protozoal and fungal infection. Advances in diagnostic techniques have the potential to improve management and limit unnecessary empirical treatment, allowing a move towards a diagnosis-driven strategy. However, interpreting the clinical validity and utility of some of these assays can be difficult, particularly for low-prevalence infection where the positive predictive value of any diagnostic test is likely to be low and prompt empirical antibacterial therapy is still indicated in neutropenic patients.
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Affiliation(s)
- Rosemary A Barnes
- is Professor/Honorary Consultant, Department of Medical Microbiology and Infectious Diseases, Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK. Competing interests: RAB has served on advisory boards, received sponsorship and travel expenses to attend meetings and received honoraria for lectures/symposia from Merck, Sharp and Dohme, Astellas, Gilead Sciences and Pfizer. In addition, she has received educational grants, scientific fellowship awards and independent researcher grants from Gilead Sciences and Pfizer. She is a member of the European Aspergillus PCR Initiative Working Group of the International Society for Human and Animal Mycology and a board member of the foundation European Aspergillus PCR initiative. She is a member of the Steering Group of the NISCHR funded Microbiology and Translational Infection Research Group. She served on the clinical guideline development group for the NICE Neutropenic sepsis guideline
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Shah N, Musters C, Selwood A, Ellis D. The rise and fall of a psychiatric antenatal clinic: development of a perinatal psychiatric service linked directly to the provision of antenatal care. Obstet Med 2010; 3:69-72. [PMID: 27582846 DOI: 10.1258/om.2010.090034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2010] [Indexed: 11/18/2022] Open
Abstract
Usual referral pathways to psychiatric services can miss opportunities for timely intervention in maternal perinatal psychiatric ill health. Psychiatric illness leading to suicide is a significant factor in at least 10% of maternal deaths. Despite Royal College of Psychiatry and National Institute for Health and Clinical Excellence recommendations for specialist provision of perinatal mental health services, this remains sporadic and insufficient. We set out to develop a new integrated antenatal-psychiatric direct referral pathway and present a year of experience using this service model. The psychiatric service was delivered from within the antenatal clinic setting with a direct health-care professional (HCP) led referral pathway between 2003 and 2004. The service comprised one session per week of a senior psychiatric specialist registrar and provided three new patients and two follow-up appointments per week. During this period, a total of 75 referrals to the service were made with 57 individuals attending for an appointment. There was a range of diagnoses among the women who attended, with only 24% meeting eligibility criteria for referral to secondary psychiatric services. The majority diagnosis was depression. More severely ill women were not referred to this clinic by obstetric HCPs. In conclusion, this model for developing and delivering a specialist perinatal psychiatric service using direct links to antenatal medical care was not successful despite requiring minimal funding. Nevertheless, it has been used to inform development of a new perinatal service in keeping with the Royal College of Psychiatrists' recommendations and incorporating enhanced training of HCPs responsible for the referral pathway.
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Affiliation(s)
- N Shah
- Highgate Mental Health Centre - Camden and Islington NHS Foundation Trust
| | | | - A Selwood
- Department of Mental Health Sciences, UCL , London , UK
| | - D Ellis
- Highgate Mental Health Centre - Camden and Islington NHS Foundation Trust
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Perera A, Gupta P, Samuel R, Berg B. A Survey of Anti-Depressant Prescribing Practice and the Provision of Psychological Therapies in a South London CAMHS from 2003-2006. Child Adolesc Ment Health 2007; 12:70-72. [PMID: 32811125 DOI: 10.1111/j.1475-3588.2007.00445.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A survey was conducted in a South London CAMHS before and after the publication and implementation of NICE guidelines of 2005 for the treatment of depression in children and adolescents. The results for 2006 indicate that 28% of cases were receiving medication without psychological therapy. Of those prescribed medication, 96% were receiving a prescription for fluoxetine. Of those receiving psychological therapy most received cognitive behaviour therapy whilst none received interpersonal therapy. Although 72% of cases were receiving medication with psychological therapy this falls short of the 100% expectation of the NICE guidelines. Other services are encouraged to survey young people receiving ant-depressant medication against the NICE guidelines.
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Affiliation(s)
- Alfred Perera
- South West London and St George's Mental Health NHS Trust, London. E-mail:
| | - Priya Gupta
- South West London and St George's Mental Health NHS Trust, London. E-mail:
| | - Rani Samuel
- South West London and St George's Mental Health NHS Trust, London. E-mail:
| | - Birgit Berg
- South West London and St George's Mental Health NHS Trust, London. E-mail:
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