Current NICE Guidance Research Articles

G568(P) Sedation for mri/cy: a service improvement project

Context The information for this project was collected from the children’s wards at UHCW. Patients attending for elective scans requiring sedation were included. Sedation was administered as per the trust protocol. This protocol is based on current NICE and BNFc guidance. Weight Weight >15 kg - Midazolam sedation Problem We found that sedation of children for elective MRI/CT scans was insufficient more often than not. This led to failed scans which in turn led to delays in diagnosis, stress for patients and families. In addition this incurred significant financial cost to the Trust due to failed scans and referrals to BCH for scans under GA. Assessment of problem and analysis of its causes 60 scans were reviewed over a 6 month period in 2013. 38 children underwent midazolam sedation and 22 were given chloral hydrate. Chloral hydrate sedation was successful in 90% of cases, whereas midazolam was only successful in 18% of cases. After discussion with the finance department we calculated that failed scans combined with referrals to BCH was costing the trust c. £70,000 per year. Intervention We have discontinued the use of midazolam sedation for MRI/CT scans The trust is in the process of developing a paediatric GA scan service at UHCW Strategy for change The initial results of the study were presented to the paediatric department at the monthly clinical audit meeting. After discussion, the decision to stop using midazolam for scan sedation was disseminated amongst community and hospital based paediatricians. A multi-disciplinary team comprising paediatricians, radiographers, radiologists and anaesthetists was formed. This team is in the process of designing and trialling a GA scan service at UHCW. This will enable us to provide scans to children who would beforehand have probably had 1–2 failed scans and then been referred to BCH. In addition this service may also provide the trust with increased revenue and savings. Measurement of improvement We now only have children weighing 15 kgs that require sedation are being referred directly to BCH for GA scans while we develop our own service. This ensures that they will not need to undergo a probably unsuccessful scan under sedation with us before being referred. Effects of changes Discontinuing the use of midazolam sedation has prevented children undergoing a stressful procedure that was unsuccesful in 82% of cases. This has improved patient care in the form of reducing delays in diagnosis and lowering parental anxiety. It has also saved the trust c. £70,000 per year in failed scans and referrals to BCH. Lessons learnt This project has shown me that using a structured approach when considering a problem makes it easier to change systems/processes. Our department knew that midazolam wasn’t particularly successful but when you present that as a 82% failure rate it makes things a lot clearer. Forming an MDT to try to find a solution was also of huge benefit as it very quickly became clear that the radiology department shared our frustrations regarding failure of sedation. This in turn has enabled us to move forward with development of our own GA scan service quite quickly. Message for others If you feel there is a problem/issue in your department analyse it in a structured way and try to form a solution to the issue rather just presenting a problem If an MDT needs to be involved ensuring that there are clear goals identified is very important so as to avoid being sidetracked.

EVALUATING CURRENT ASSESSMENT AND TREATMENT OF DELIRIUM BY UK PALLIATIVE CARE PHYSICIANS

BackgroundDelirium is a common condition seen in all areas of clinical medicine, particularly in patients with advanced disease. Its prevalence is expected to rise from the current level of 28-90%...

221 A phase II trial to assess the safety and immunological activity of TroVax plus pemetrexed/cisplatin in patients with malignant pleural mesothelioma. The SKOPOS trial

lowered and called ‘extra-NICE’; this recommends a CXR if one has not been obtained within the previous three months, the patient is aged 60+, a smoker or ex-smoker, with 10 or more pack-years of smoking, and with: • a new or altered cough of any duration reported to primary care • and/or increased breathlessness or wheezing (whether or not associated with purulent sputum). Controls receive usual care (current NICE guidance). Patients are being individually remotely randomised. To date, 34 general practices have been trained and are now open to recruitment (22 South East Wales, 6 in North Wales and 6 in South Yorkshire). 157 patients have been randomised to date. We are also undertaking a nested qualitative study to inform the feasibility of individually randomising patients to an urgent CXR or not.

137 DIAGNOSIS AND MANAGEMENT OF FAMILIAL HYPERCHOLESTEROLAEMIA IN A TERTIARY CARDIAC CENTRE

<h3>Introduction</h3> Familial hypercholesterolaemia (FH) is a treatable risk factor for premature myocardial infarction (MI), yet it remains poorly diagnosed in the UK. Current NICE guidance (2008) recommends use of Simon Broome (S-B) criteria for diagnosis of ‘definite’ or ‘possible’ FH with referral to a specialist for confirmation of diagnosis and initiation of cascade testing. Cardiac centres have valuable opportunities to identify such patients and implement these recommendations. We examined diagnosis and referral patterns for FH in light of NICE guidance at our tertiary centre. <h3>Methods</h3> Using hospital electronic records we identified all patients with a total cholesterol (TC) ≥7.5 mmol/l, who presented to our cardiac services from January to December 2011. For the visit relating to the high TC measurement, we examined patient records to determine if they were assessed by a physician and if there was sufficient documentation to apply S-B criteria, namely (1) family history of premature MI or FH, (2) physical examination for FH stigmata or (3) consideration of a diagnosis of FH with referral to a lipid clinic. <h3>Results</h3> We examined records for 126 patients and excluded 45 who had not directly seen a physician relating to the index TC measurement. Among the 81 patients included in this study (mean age 57.8, 56% male), approximately half were seen as in-patients. A total of 4% (n=3) were classified as ‘definite’ FH (2 had a prior diagnosis and 1 was not referred), 16% (n=13) as ‘possible’ (none referred), and 7% (n=6) as ‘other known lipid disorders’. Over 2/3 (n=59) could not be classified due to insufficient information available to apply the S-B criteria, although 4 of these patients were referred for a specialist opinion and 3 were known to the lipid clinic. Documentation of examination for FH stigmata was absent in almost all cases (98%, n=79). Family history of coronary heart disease (CHD) was documented in 67% (n=54) of cases, of whom 54% (n=29) had a positive history. Of the latter, the type of CHD and age of onset were adequately documented in only 69% and 66% respectively. Documentation of family history of high cholesterol was absent in 89% of cases. In 43% (n=35) of all cases there was no documentation that the cholesterol result had been noted. Finally we estimated that approximately 4–6% of acute coronary syndrome patients had TC levels &gt;7.5, thus representing a potentially enriched population for FH. <h3>Conclusions</h3> While a significant opportunity exists in tertiary cardiac units to identify and refer potential FH cases, S-B criteria are not being routinely documented to consider such patients for onward referral. Universal focus on high dose statin therapy after ACS may in part have contributed to diminished consideration of the wider implications of FH and familial risk. Raising awareness of FH in cardiac units across the country could have significant population health benefits through cascade screening.

PP.55 Screening Women for Asymptomatic Bacteriuria in Early Pregnancy May Reduce the Risk of Low Birth Weight

IntroductionAnatomical changes in pregnancy predispose women to asymptomatic bacteriuria (ASB). Current NICE guidance in the UK advises that a mid-stream urine (MSU) sample should be offered in early pregnancy to...

P13 New HIV diagnoses in a busy inner-city cohort: How far have we come?

BackgroundOur service is located in a high HIV prevalence area (6.2/1000), and a large proportion of late presentations. We have widened the availability of HIV testing as a major strategy to reduce HIV related morbidity and mortality in our population.Aims/ObjectivesTo assess the evolving trends in demographics, clinical and laboratory findings of newly diagnosed HIV patients in our busy inner city clinic. To develop HIV testing strategies further with the implementation of current NICE guidance that recommends testing all medical admissions, and assess the potential future impact of this on presentation patterns in our cohort.MethodsRetrospective case note review of 92 consecutive new HIV diagnoses between 2009 and 2011. Data were collected on demographics, clinical stage, CD4 count, source of referrals, and drug resistance. Findings were compared to previous data sets in the same clinic over three audit periods between 2003 and 2011.ResultsThe proportion of males newly diagnosed has increased from 33% (2003) to 51% (2011), and the median age of all diagnoses has crept up to 39.5 years from 36.7 years. The proportion of referrals from primary care is now the largest (51%). Very late presenters (CD4 &lt;200), remain high in our population at 53%, and this is well above the national average of 30%. Primary drug resistance is 16%, currently double the national average.Discussion/ConclusionsThere continues to be a high rate of very late presenters in our cohort. Strengthening current interventions and implementation of NICE guidance will be essential in an effort to reduce late diagnoses.

Should rigors be included as an amber sign in the nice guidelines for feverish illness in children?

<h3>Aims</h3> To evaluate what proportion of children with rigors seen in a busy Paediatric Unit had severe bacterial illness. <h3>Methods</h3> A prospective audit was done in a hospital where local protocol includes rigors as a red sign in addition to the signs suggested by NICE guidelines for feverish illness in children. 43 children with rigors seen during the 10 week audit period were included. <h3>Results</h3> 51 patients were identified of which 43 notes were found and included. Age range was between 5 months to 15 years. 60% had a temperature of &gt;39C. 65% had just one episode of rigor and &lt;10% had more than 2 episodes of rigor. Blood cultures were negative in all cases apart from one contaminant in a well patient who grew a Streptococcus viridians. Of the 43 patients, 18 (41%) children were treated as having a bacterial illness. 9 had culture positive UTIs, one had clear signs of pyelonephritis although cultures were negative, 1 had dysentery and 7 had chest signs and chest X ray changes consistent with chest infection with one of these being PCR positive for Pneumococcus. Only 5 (11%) of those found to have a focus had another red or amber NICE guidelines sign. <h3>Conclusion</h3> In our audit, of the 18 (41%) of children with feverish illness and rigors were treated as having a bacterial focus, of which, only 5 (11%) had a red or amber signs suggested by current NICE guidance. Including Rigor as an amber sign in the NICE guidance would prompt health practitioners to observe and investigate these children who have a high likelihood of having a bacterial illness.

Micrometastases - is it time to stop clearing and how will it affect axillary clearance numbers?

Background: Controversy surrounds the management of micro-metastases within sentinel lymph node biopsy (SNB). Current NICE guidance is to offer axillary lymph node clearance (ANC) following micrometastases on SNB based on evidence from two systematic reviews. This is likely to be debated following publication of ACOSOG Z0011 and the imminent publication of IBCSG 23-01. Both studies showed no benefit in overall, disease free survival or axillary recurrence rates of ANC over SNB alone.

S5 Prevalence of latent tuberculosis infection in immigrants to the UK: findings from a multi-centre study

<h3>Background</h3> Notifications for tuberculosis (TB) in the United Kingdom (UK) increased by 30% between 1992 and 2007 with overseas-born migrants accounting for 72% of cases in 2007. Much of this increase is due to the synergy of migration from high-TB burden countries and the reactivation of pre-existing latent TB infection (LTBI). Since 2006, NICE guidance advocates screening for LTBI in all children from countries with a TB incidence &gt;40/100 000 and adults from Sub-Saharan Africa and countries with a TB incidence &gt;500/100 000. The rationale underpinning these guidelines remains unclear particularly as there are little data on the prevalence of LTBI in immigrants to the UK from regions with different TB incidence rates. <h3>Aims</h3> To quantify the prevalence of LTBI in immigrants, assess factors associated with IGRA positivity and to determine LTBI yield from current screening thresholds recommended by NICE. <h3>Methods</h3> Analysis of data prospectively obtained through IGRA testing (QuantiFERON-Gold/QuantiFERON-Gold-in-tube) of immigrants in three different centres in the UK during 2008–2010. Descriptive analyses were undertaken. Yields at different screening thresholds were calculated. Subsequent univariate and multivariate analyses were undertaken to assess independent factors associated with IGRA positivity; p&lt;0.05 considered significant. <h3>Results</h3> In total 915 immigrants were screened during the study period. Median age was 26.8 years (interquartile range 22–33), 50.6% were female and 72.5% had previously been BCG vaccinated. 48.9% and 28.5% of migrants screened originated from the Indian Subcontinent and Sub-Saharan Africa, respectively. Overall 911/915 individuals had determinate IGRA results—199 (21.7%) tested positive and 712 (77.8%) tested negative; 4 (0.4%) individuals had indeterminate results. Multivariate analysis revealed that increasing age (p&lt;0.0001) and increasing TB incidence of country of origin (p=0.0014) were independently associated with IGRA positivity. Applying current NICE guidance resulted in a yield of 76/311 (24.4%) but would miss 61.8% of the immigrant population with LTBI (Abstract S5 Table 1). <h3>Conclusions</h3> Immigrants have a high prevalence of LTBI but current NICE guidance detects only 38.2% of new entrants with LTBI. Given the high rates of reactivation of LTBI in new entrants, our findings suggest that consideration should be given to reducing the screening threshold to include those from the Indian Subcontinent (incidence 170/100 000) which would result in 67.8% of all LTBI cases being identified.

Computerised cognitive behavioural therapy and its uses

AbstractThe use of computer software programmes to deliver cognitive behavioural therapy to people with mental health disorders is becoming increasingly popular. Here the authors describe what conditions computerised cognitive behavioural therapy may be useful for, discuss its advantages and disadvantages and outline the current NICE guidance on its use. Copyright © 2010 Wiley Interface Ltd