Antipsychotic prescriptions in people with dementia in primary care: a cohort study investigating adherence of dose and duration to UK clinical guidelines.

Care of Women with Obesity in Pregnancy

Background and aims EOS is a major cause of neonatal morbidity and mortality that can progress rapidly with minimal clinical and laboratory signs. Early identification of at risk newborns and prompt antibiotic treatment is therefore crucial. In 2012, National Institute for Health and Care Excellence (NICE) guidelines for EOS were published. Our local guideline includes fetal distress (abnormal cardiotocography) and meconium stained liquor as risk factors. We compare the outcomes with NICE and local guidelines. Methods Retrospective analysis of infants ≥35 weeks gestation admitted to a level-3 NICU over 4 months with suspected sepsis classified to have presumed (PS) or confirmed sepsis (CS). Results Of 81 cases identified, 44(54.3%) had PS and 37(45.7%) CS. 23(28.4%) babies in poor condition at birth received antibiotics on clinical grounds. Of remaining 58 cases, 36(62.1%) had PS and 22(37.9%) CS. Using local guideline in PS, 9(25%) required antibiotics, 13(36.1%) observed and 14(38.9%) were low risk. With NICE guideline, 5(13.9%) received antibiotics, 8(22.2%) observed and 23(63.9%) low risk. Using local guideline in CS, 10(45.5%) required antibiotics, 4(18.2%) observed and 8(36.3%) low risk but with NICE guideline, 3(13.6%) received antibiotics, 8(36.3%) observed and 11(50%) low risk did not require antibiotics or observations. Meconium was more common in CS (12/37; 32.4%) versus PS (6/44; 13.6%). Abnormal cardiotocography was noted in 40.5% CS cases versus 25% in PS. Conclusions Local guidelines with fetal distress as a risk factor may enable earlier identification of EOS risk. Larger study may enable better evaluation of our antibiotic therapy and resource implications.

AimsThe aim of this audit was to review the prescriptions in one community Child and Adolescent Mental Health Service (CAMHS) and to see whether these prescriptions were licenced for the prescribed indication and if the prescription was supported by national guidelines.MethodsI reviewed the treatment of 77 patients who were assessed by the consultant psychiatrist in one CAMHS team between January 2020 and August 2022.For each prescription I gatheredThe name of the medicationThe IndicationChild or young person's comorbiditiesI then compared this with the licenced use on the Summary Product Characteristics (SPC), as well as the guidance available from (National Institute for Health and Care Excellence (NICE), British Association of Psychopharmacology (BAP) and British National Formulary for Children (BNFc)).ResultsIn total there were 177 prescriptions for a variety of medication including antidepressants, antipsychotics, sedatives, and medication to treat ADHD.It was found that 25% of all prescriptions were prescribed according to the medication's licensed use, with 42%, 62% and 67% compatible with NICE guidelines, BAP guidelines and BNFc respectively. However, 12% deviated entirely from these guidelines, including prescriptions for mirtazapine (1), melatonin (9), quetiapine (6), risperidone (1) and olanzapine (4). These prescriptions were also associated with increased comorbidity with each child having at least one comorbid mental health problem.There was an 81% agreement between NICE and BAP guidelines, a 75% agreement between NICE and BNFc and 66% agreement between BAP guidelines and BNFc.ConclusionThis audit demonstrated that only a quarter of prescriptions were prescribed according to a licenced use, with the vast majority falling outside the product licence. This is important because the Joint Standing Committee on Medicines preference “an appropriate licenced preparation” over unlicenced prescribing.Furthermore, the defensibility of unlicenced prescriptions is increased when they are supported by published clinical guidelines which was the case in 88% of prescriptions that were reviewed. This leaves 12% of prescriptions that were not supported by either licencing or BAP, NICE or BNFc guidelines. There may be multiple causes for this, but it is likely that the high number is aggravated by the lack of NICE guidelines for common conditions such as anxiety as well as high levels of comorbidity in this population group which is not always reflected in clinical trials and guidelines.

In December 2020, the National Institute for Health and Care Excellence (NICE) reviewed the evidence and updated their recommendations on intermittently scanned (commonly known as Flash) and Continuous Glucose Monitoring (CGM) during pregnancy for women with type 1 diabetes (1). The NICE guidelines now recommend offering CGM to all pregnant women with type 1 diabetes to help them meet their pregnancy glucose targets and improve neonatal outcomes. Their evidence review, based on the CONCEPTT randomised trial (2) and a Swedish observational study (3) found that, compared to capillary glucose monitoring, CGM resulted in more women achieving their blood glucose targets, fewer caesarean sections and fewer neonatal intensive care admissions.

In August 2020, the National Institute for Health and Care Excellence (NICE) published the draft guidance on chronic pain, which perhaps controversially advises against the use of all drugs except antidepressants.1 The committee cite an absence of evidence on effectiveness, their experience, information in product summaries, and the established or possible risk of harm as justification for their negative recommendations. Public reaction perhaps reflects the assumption the guidelines apply to all chronic pain conditions. This is not the case. The guideline explicitly does not cover pain conditions that have existing NICE guidelines including headache, low back pain (LBP) and irritable bowel syndrome (IBS).1–6 This creates an interesting tension, since some recommendations are discordant (Box 1). | Drug class | Draft NICE guideline: chronic pain in over 16s, August 20201 | NICE guideline: low back pain and sciatica in over 16s, updated September 20205 | NICE guideline: headache in over 12s, updated November 20154,a | NICE guideline: irritable bowel syndrome in adults, updated April 20176 | NICE guideline: osteoarthritis, updated February 20148 | |:--------------------------- | --------------------------------------------------------------------------------------------------------------- | ---------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------- | -------------------------------------------------------------------------------------------- | | Opioids | Do not offer | Do not offer | Be alert to the possibility of medication overuse headache in people whose headache developed or worsened while they were taking the following drugs for ≥3 months: | No specific recommendation | If paracetamol or topical NSAIDs are insufficient consider the addition of opioid analgesics | | NSAIDs | Do not offer | Consider oral NSAIDs (conditions apply) | No specific recommendation | Where paracetamol or topical NSAIDs are ineffective consider substitution with (or addition of) an oral NSAID/COX-2 inhibitor | | Paracetamol (acetaminophen) | Do not offer | Do not offer paracetamol alone | No specific recommendation | Consider offering paracetamol in addition to core treatments. | | Antidepressants | Consider an antidepressant, either duloxetine, fluoxetine, paroxetine, citalopram, sertraline, or amitriptyline | Do not offer SSRIs, serotonin–norepinephrine reuptake inhibitors, or tricyclic antidepressants | Consider amitriptyline for the prophylactic treatment of migraine | Consider TCAs as second line treatment for people with IBS. Consider SSRIs for people with IBS only if TCAs are ineffective | No specific recommendation | | Anticonvulsants | Do not offer | Do not offer | Do not offer gabapentin for prophylactic management of migraine | No specific recommendation | No specific recommendation | Box 1. Concordance between drug recommendations in draft NICE chronic pain guideline and NICE guidelines for low back pain, headache, irritable bowel syndrome, and osteoarthritis The guideline committee used the International Classification …

Fighting antimicrobial resistance on all fronts.

The aim was to understand why two recently published guidelines for the diagnosis and management of patients with abdominal aortic aneurysm, the National Institute for Health and Care Excellence (NICE) 2020 guidelines and the European Society for Vascular Surgery (ESVS) 2019 guidelines, have discordant recommendations in several important areas. A review of the approach, methodology, and evidence used by the two guideline committees was carried out to understand potential reasons for their differing recommendations in their two final published guidelines. NICE guidelines use a multidisciplinary committee to address a limited number of prospectively identified questions, using rigorous methods heavily reliant on evidence from randomised controlled trials (RCTs) supported by in house economic modelling, with the purpose of providing the best, cost-effective health care in the UK in 46 main recommendations. The ESVS guidelines use an expert committee to encourage clinical effectiveness across a range of European health economies. ESVS guideline topics, but not questions, are prospectively identified, assessment of evidence was less rigorous, and 125 recommendations were made. More up to date evidence searches by the ESVS committee partially underscore the differences in recommendations for screening women. The NICE committee did not consider sex specific analysis or evidence for thresholds for intervention but relied on sex specific modelling to support their advice to use endovascular repair (EVAR) for ruptures in women. Their recommendation to use open repair for ruptured abdominal aortic aneurysms (AAAs) in men aged<71 years was based on in house economic modelling. NICE recommends an open first strategy for non-ruptured AAA mainly based on earlier RCTs and UK specific economic modelling, while the ESVS guidelines recommend an EVAR first strategy after consideration of modern, but lower quality, evidence from observational studies. Similar reasons explain differences in the recommended treatments of juxtarenal aneurysms. Differences between the NICE and ESVS guidelines can be explained, at least in part, by their differing perspectives, methodologies, and quality assurance. Future ESVS guidelines may benefit from more multidisciplinary input and prospectively identified questions.

Risk-Based Triage for Nephrology Referrals: The Time is Now

Aims: Sex and gender are critical determinants in the diagnosis, progression, and management of psychiatric conditions, influencing disease epidemiology, symptom presentation, treatment responses, and access to care. However, the extent to which these factors are systematically incorporated into UK psychiatric clinical guidelines has been unclear. To date, no review has assessed how sex and gender considerations are addressed in guidelines produced by the National Institute for Health and Care Excellence (NICE) or the Scottish Intercollegiate Guidelines Network (SIGN).This study aimed to evaluate the extent of sex and gender integration within psychiatric guidelines. It is the first to systematically assess these dimensions across NICE’s “Mental health, behavioural, and neurodevelopmental conditions” category and SIGN’s “Mental health and behavioural conditions” category, which encompass psychiatric and related conditions.Methods: A systematic review of all NICE and SIGN psychiatry guidelines was conducted to assess how sex and gender considerations were incorporated across key areas: epidemiology, clinical presentation, investigations, and management. The gender composition of guideline committee chairs was also evaluated. Psychiatry guidelines were ranked relative to other medical specialties to determine their comparative performance.Results: This review identified significant gaps in the integration of sex and gender considerations across NICE and SIGN psychiatry guidelines. Across NICE psychiatry guidelines, only 72% referenced sex and/or gender, and just 28% addressed these factors beyond reproductive contexts. While differential disease management (52%) and epidemiology (28%) were the most frequently considered aspects, investigations (17%) and clinical presentation (7%) were rarely discussed.Psychiatry ranked second among NICE specialty categories for integrating sex and gender considerations, and scored second-best for women committee chair representation. This is significant because guidelines chaired by women tended to incorporate sex and gender considerations more comprehensively than those chaired by men. Results from SIGN psychiatry guidelines demonstrated similar trends.Thematic analysis revealed that NICE and SIGN psychiatry guidelines were more likely than other specialties to acknowledge gendered challenges in accessing care, caregiving roles, social support networks, and current evidence gaps.Conclusion: As a specialty in which both biological and social determinants are central to diagnosis and treatment, psychiatry is well-positioned to lead improvements in sex and gender-sensitive clinical guidance. Despite psychiatry’s relatively strong performance compared with other specialties, significant gaps remain, particularly in differentiated clinical presentations. NICE and SIGN must establish robust mechanisms to embed sex and gender disaggregated evidence into guidelines. Psychiatrists have a critical opportunity to drive improvements to enhance equity and patient outcomes.

AimsTo assess the safety and efficacy of the Kaiser Permanente sepsis risk calculator (SRC) for babies at risk of early onset neonatal sepsis (EONS), compared with the National Institute for...

To test the hypothesis that the performance of first-trimester screening for pre-eclampsia (PE) by a method that uses Bayes' theorem to combine maternal factors with biomarkers is superior to that defined by current National Institute for Health and Care Excellence (NICE) guidelines. This was a prospective multicenter study (screening program for pre-eclampsia (SPREE)) in seven National Health Service maternity hospitals in England, of women recruited between April and December 2016. Singleton pregnancies at 11-13 weeks' gestation had recording of maternal characteristics and medical history and measurements of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), serum placental growth factor (PlGF) and serum pregnancy-associated plasma protein-A (PAPP-A). The performance of screening for PE by the Bayes' theorem-based method was compared with that of the NICE method. Primary comparison was detection rate (DR) using NICE method vs mini-combined test (maternal factors, MAP and PAPP-A) in the prediction of PE at any gestational age (all-PE) for the same screen-positive rate determined by the NICE method. Key secondary comparisons were DR of screening recommended by the NICE guidelines vs three Bayes' theorem-based methods (maternal factors, MAP and PAPP-A; maternal factors, MAP and PlGF; and maternal factors, MAP, UtA-PI and PlGF) in the prediction of preterm PE, defined as that requiring delivery < 37 weeks. All-PE developed in 473 (2.8%) of the 16 747 pregnancies and preterm PE developed in 142 (0.8%). The screen-positive rate by the NICE method was 10.3% and the DR for all-PE was 30.4% and for preterm PE it was 40.8%. Compliance with the NICE recommendation that women at high risk for PE should be treated with aspirin from the first trimester to the end of pregnancy was only 23%. The DR of the mini-combined test for all-PE was 42.5%, which was superior to that of the NICE method by 12.1% (95% CI, 7.9-16.2%). In screening for preterm PE by a combination of maternal factors, MAP and PlGF, the DR was 69.0%, which was superior to that of the NICE method by 28.2% (95% CI, 19.4-37.0%) and with the addition of UtA-PI the DR was 82.4%, which was higher than that of the NICE method by 41.6% (95% CI, 33.2-49.9%). The performance of screening for PE as currently recommended by NICE guidelines is poor and compliance with these guidelines is low. The performance of screening is substantially improved by a method combining maternal factors with biomarkers. © 2018 Crown copyright. Ultrasound in Obstetrics & Gynecology © 2018 ISUOG.

Radiological assessment of paediatric cervical spine injury in blunt trauma: the potential impact of new NICE guidelines on the use of CT

Bronchiolitis is a lower respiratory tract infection commonly seen in children less than 1 year of age.1 ,2 Predominantly occurring in winter months, bronchiolitis is in the majority managed in...

ObjectivesConstipation affects 1–3% of the child population worldwide with a prevalence of 10–20% in the UK.1 National Institute for Health and Care Excellence (NICE) and our local hospital guidelines recommend...

A recent editorial claimed that the 2014 National Institute for Health and Care Excellence (NICE) guideline on psychosis and schizophrenia, unlike its equivalent 2013 Scottish Intercollegiate Guidelines Network (SIGN) guideline, is biased towards psychosocial treatments and against drug treatments. In this paper we underline that the NICE and SIGN guidelines recommend similar interventions, but that the NICE guideline has more rigorous methodology. Our analysis suggests that the authors of the editorial appear to have succumbed to bias themselves.