National Institute For Health And Clinical Excellence Guidelines Research Articles

NICE guideline and current practice of antibiotic prophylaxis for high risk cardiac patients (HRCP) among dental trainers and trainees in the United Kingdom (UK)

The National Institute for Health and Clinical Excellence (NICE) introduced the antibiotic prophylaxis guideline in 2008 for cardiac patients in the UK, which has led to a decrease in national prescription levels for antibiotic prophylaxis. Despite the introduction of the guideline there is still a discrepancy in levels of compliance among the dental community. The aims of this study were to determine the understanding of the NICE clinical guideline on antimicrobial prophylaxis against infective endocarditis (IE) and the difference in antibiotic prescription for high risk cardiac patients (HRCP) between dental trainers and trainees. A proforma was designed and distributed among dental trainers and trainees attending a conference at the London deanery. The trainers were GDPs responsible for training dental trainees allocated to them over a 12 month period based in a general dental practice. Dental trainees were recent graduates about to commence their vocational dental training. Eighty-five vocational dental trainees and 70 trainers completed the proforma on a voluntary basis. The results of the study confirm that most trainers (95.7%) and trainees (94.1%) are aware of this guideline but only 62% of trainers and 69.7% of trainees have read the guideline. Compliancy with the guideline was low among trainers (55.7%) and trainees (77.6%). Compliance was high among those who had read the guideline. Trainers were more likely to prescribe prophylaxis antibiotics for HRCP. The majority (74-76%) would prescribe antibiotics on a specialist's request. Some trainers (54.9%) and trainees (48.2%) would want antibiotics themselves if they were HRCP. This study concludes that much needs to be done to improve the understanding and practice of NICE guideline among the dental trainers and trainees.

Venous thromboembolism prophylaxis: do trial results enable clinicians and patients to evaluate whether the benefits justify the risk? proceedings of an ad hoc working group meeting

Venous thromboembolism prophylaxis: do trial results enable clinicians and patients to evaluate whether the benefits justify the risk? proceedings of an ad hoc working group meeting

Summary of: NICE guideline and current practice of antibiotic prophylaxis for high risk cardiac patients (HRCP) among dental trainers and trainees in the United Kingdom (UK)

Objective The National Institute for Health and Clinical Excellence (NICE) introduced the antibiotic prophylaxis guideline in 2008 for cardiac patients in the UK, which has led to a decrease in national prescription levels for antibiotic prophylaxis. Despite the introduction of the guideline there is still a discrepancy in levels of compliance among the dental community. The aims of this study were to determine the understanding of the NICE clinical guideline on antimicrobial prophylaxis against infective endocarditis (IE) and the difference in antibiotic prescription for high risk cardiac patients (HRCP) between dental trainers and trainees. Methods A proforma was designed and distributed among dental trainers and trainees attending a conference at the London deanery. The trainers were GDPs responsible for training dental trainees allocated to them over a 12 month period based in a general dental practice. Dental trainees were recent graduates about to commence their vocational dental training. Eighty-five vocational dental trainees and 70 trainers completed the proforma on a voluntary basis. Results The results of the study confirm that most trainers (95.7%) and trainees (94.1%) are aware of this guideline but only 62% of trainers and 69.7% of trainees have read the guideline. Compliancy with the guideline was low among trainers (55.7%) and trainees (77.6%). Compliance was high among those who had read the guideline. Trainers were more likely to prescribe prophylaxis antibiotics for HRCP. The majority (74-76%) would prescribe antibiotics on a specialist's request. Some trainers (54.9%) and trainees (48.2%) would want antibiotics themselves if they were HRCP. Conclusion This study concludes that much needs to be done to improve the understanding and practice of NICE guideline among the dental trainers and trainees.

Meningococcal B disease

The RCN Learning Zone is a FREE online service to help RCN members with their continuing professional development and professional portfolio management. The RCN Learning Zone is available at www.rcn.org.uk/members/learningzone.php This practice profile is based on NS632 Willcox A (2012) Meningococcal B disease: assessment and management. Nursing Standard. 26, 26, 50-55. As a nurse working with adults, I was sceptical about how reading this article would be relevant to my practice because meningococcal B disease is the leading cause of death in early childhood. Adults can, however, present with meningococcal B disease. Prevention and early detection of the disease are imperative to improve patient outcomes and prevent morbidity. Meningococcal B disease is difficult to diagnose and manage, therefore it is essential for nurses to recognise the symptoms and refer patients for immediate medical treatment. Bacterial meningitis is inflammation of the meninges, the membranes protecting the brain. Symptoms of meningitis may include fever, nausea or vomiting, lethargy, poor appetite, headache, myalgia and respiratory problems. It is also important to be aware of the specific signs of bacterial infection, including photophobia, stiff neck and a non-blanching rash. The article highlighted the difference between meningitis and septicaemia and improved my awareness of the signs of septic shock. The article also emphasised the need for nurses and doctors to follow appropriate management pathways for suspected bacterial meningitis, so I read the National Institute for Health and Clinical Excellence (NICE) (2010) guidelines. I am better informed about the less common and more specific symptoms of the disease. The NICE (2010) guidelines also highlight contraindications to performing a lumbar puncture, which are useful to know when relaying information to medical staff about the patient’s health on admission to hospital or on presentation at the GP surgery. I would like to study the pathways further so that I understand fully what action to take.

Compliance with NICE guidance on the use of anti-TNFα agents in ankylosing spondylitis: an East and West Midlands regional audit

Here we report on an audit performed to examine compliance with National Institute for Health and Clinical Excellence (NICE) guidelines for the use of anti-tumour necrosis factor alpha (anti-TNFalpha) in treating patients with ankylosing spondylitis (AS). Data from 17 rheumatology centres across the Midlands were collected prospectively from patients with AS attending outpatient clinics and retrospectively in patients receiving anti-TNFalpha but not attending outpatient clinics during the audit. In total, 80% of the 416 patients for whom data were collected were male. Of the 238 patients recruited prospectively, 41% were receiving anti-TNFalpha. Reviewing all patients on anti-TNFalpha (N=275), pre-treatment assessments 12 weeks apart were documented in 55% of patients. After anti-TNFalpha treatment had started, regular 12-weekly assessments occurred in 46% of patients. Therefore, compliance with NICE guidance was found to vary among centres. Based on our audit, clinical capacity, and clinical or patient choice might be influencing the suboptimal adherence seen in assessment timing suggested by NICE guidelines relating to the use of anti-TNFalpha in treating patients with AS.

Opioids in palliative care: is the new NICE guideline relevant to specialist palliative care providers?

The National Institute for Health and Clinical Excellence (NICE) issued guideline CG140 in May 2012, for professionals commencing strong opioids in adult palliative care patients.1 Although this guideline is for...

PP025. Urinary dipstick proteinuria testing – Does automated strip analysis offer an advantage over visual testing?

The visual urinary test strip is widely accepted for screening for proteinuria in pregnancy, given the convenience of the method and its low cost. However, test strips are known to lack sensitivity and specificity. The 2010 NICE (National Institute for Health and Clinical Excellence) guidelines for management of pregnancy hypertension have recommended the use of an automated test strip reader to confirm proteinuria (http://nice.org.uk/CG107). Superior diagnostic test performance of an automated (vs. visual) method has been proposed based on reduced subjectivity. To compare the diagnostic test properties of automated vs. visual read urine dipstick testing for detection of a random protein:creatinine ratio (PrCr) of ⩾30mg/mmol. In this prospective cohort study, consecutive inpatients or outpatients (obstetric medicine and high-risk maternity clinics) were evaluated at a tertiary care facility. Random midstream urine samples (obtained as part of normal clinical care) were split into two aliquots. The first underwent a point-of-care testing for proteinuria using both visual (Multistix 10SG, Siemens Healthcare Diagnostics, Inc., Tarrytown NY) and automated (Chemstrip 10A, Roche Diagnostics, Laval QC) test strips, the latter read by an analyser (Urisys 1100®, Roche Diagnostics, Laval QC). The second aliquot was sent to the hospital laboratory for analysis of urinary protein using a pyrocatechol violet molybdate dye-binding method, and urinary creatinine using an enzymatic method, both on an automated analyser (Vitros® 5,1 FS or Vitros® 5600, Ortho-Clinical Diagnostics, Rochester NY); random PrCr ratios were calculated in the laboratory. Following exclusion of dilute samples with urinary creatinine concentration <3mM (given inflation of PrCr values in dilute urine by our method), diagnostic test properties were determined for visual and automated dipstick proteinuria testing (⩾1+) for detection of a random PrCr ⩾30mg/mmol. 160 women (81.9% outpatients) were screened at one/more antenatal visits, providing a total of 233 urine samples for analysis. Both visual and automated read urinary dipstick testing showed low sensitivity (56.0% and 53.9%, respectively). Positive likelihood ratios (LR+) and 95% CI were 15.0 [5.9,37.9] and 24.6 [7.6,79.6], respectively. Negative LR (LR-) were 0.46 [0.29,0.71] and 0.47 [0.31,0.72], respectively. Automated dipstick urinalysis is not more sensitive than visual read urinalysis for detection of proteinuria in a primarily outpatient setting in pregnancy. Both have excellent LR+ but only fair to poor LR- as previously recognised for visual dipstick testing. Performance of automated strip analysis testing may vary with the test strips and analyser used.

Antibiotic Prophylaxis for Dental Procedures

The possibility that bacteremia from the mouth could cause infective endocarditis (IE) was first suggested >100 years ago, and it was later reinforced by others who targeted the viridans group streptococci from poor oral hygiene and dental extractions.1–3 These observations, along with the advent of antibiotics, eventually led to the first guidelines from the American Heart Association (AHA) in 1955. Antibiotic prophylaxis (AP) became the primary focus for prevention of IE and a standard of care for countries around the world. Controversy concerning efficacy and safety issues has existed for >30 years, and there has been a progressive reduction in the patient populations and the procedures suggested for AP since that time. Of concern, and in spite of a decreasing emphasis on AP for cardiac patients, upwards of 25 noncardiac patient populations are recommended for AP by some clinicians out of concern for systemic infections that might originate from dental procedures (eg, prosthetic joints).4 Article see p 60 Significant differences in recommendations from experts in the United States, United Kingdom, and other countries over the years highlight the lack of convincing data to either support or reject this practice. The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom issued new recommendations in 2006, which took the bold step of eliminating AP altogether.5 Current (2007) AHA guidelines narrow the focus to only 4 cardiac groups at higher risk for a bad outcome from IE but who represent ≈10% of all people at risk for IE.6 The AHA-defined moderate-risk groups represent ≈90% of people at risk for IE, all of whom were recommended for AP before 2007. There are, therefore, no …

PWE-113 Coeliac serology at a large district general hospital, results in 6394 patients

IntroductionCoeliac disease has an estimated UK prevalence of 1% and is an important, common cause of many gastro-intestinal and non-gastro-intestinal symptoms. Coeliac serological blood tests are commonly performed in both...

The NICE guidelines on the assessment of chest pain

The National Institute for Health and Clinical Excellence (NICE) published guidelines on the investigation of patients with chest pain of recent onset. The most prominent change to current protocols is that calcium scoring is proposed as the first-line investigation in patients with an estimated likelihood of coronary artery disease (CAD) of 10–29%, proceeding to multidetector computed tomography coronary angiography (CTCA) if the calcium score is above zero.1 For patients with 30–60% likelihood of CAD, functional testing is recommended with stress echocardiography, single photon emission computed tomography (SPECT) or cardiac magnetic resonance (CMR). For patients with 61–90% likelihood of CAD or calcium score greater than 400, X-ray invasive coronary angiography is recommended. The rationale underpinning these recommendations is that cardiac CT is considered an accurate ‘rule out’ test in patients with low likelihood of CAD given the extensive data confirming excellent prognosis of a zero calcium score in asymptomatic populations, and the excellent negative predictive value of CTCA.2 Functional tests on the other hand have better diagnostic performance in patients with higher pretest likelihood of CAD than in patients with low likelihood (Bayes theorem). It is hoped that the guidelines will reduce the high rate of normal coronary arteries at X-ray invasive coronary angiography, which was 39% in a recent ACC National Cardiovascular Data Registry, and is likely to be similar in most NHS Trusts.3 As exercise tolerance testing is no longer recommended; the guidelines will lead to an increase in referrals for imaging functional tests. The choice of imaging modality has been deliberately left open in the guidelines. Although this choice will often be driven by local availability, there are some differences in the evidence base and diagnostic yield and with the increasing awareness of the risks of ionizing radiation from medical exposure, the cumulative radiation burden of patients in their diagnostic journey, warrants particular consideration. Until recently, the median radiation dose for CTCA has been as high as 22 mSv, which can equate to an estimated risk of future cancer of 1 in every 270 in 40-year-old women undergoing the test.4 However, it is now possible to significantly reduce the radiation dose from CTCA by reducing the scan length and the scanning field of view to cover just the heart, electrocardiographically controlled tube current modulation during the cardiac cycle and reduction of the output of computed tomography X-ray tube from 120 kVp to 100 kVp for non-obese patients. The most effective way to lower the radiation dose, suitable in patients with regular heart rates below 60 bpm, is prospective electrocardiogram-triggering, which limits the acquisition to 10% of the cardiac cycle reducing the dose to 2–4 mSv.5 This is lower than conventional X-ray invasive coronary angiography, but not the new dual axis rotational coronary angiography which reduces radiation dose and contrast load. Such low radiation doses will however not be achievable in many UK centres without some investment.

Sa1329 Celiac Serology at a Large District General Hospital, Results in 6394 Patients

Introduction Coeliac disease has an estimated UK prevalence of 1% and is an important, common cause of many gastro-intestinal and non-gastro-intestinal symptoms. Coeliac serological blood tests are commonly performed in both primary and secondary care. Positive coeliac serology occurs in patients with: (i) Coeliac disease, (ii) Latent Coeliac disease, (iii) Dermatitis herpetiformis. The UK national institute for health and clinical excellence (NICE), 1 British society of gastroenterology guidelines (BSG) and American Gastroenterology Association (AGA) 2 guidelines recommend that all patients with positive coeliac serology undergo duodenal biopsy since diagnosis of coeliac disease requires both positive serology and typical histological findings. Methods We reviewed the results of all coeliac serology tests performed at our hospital laboratory in the previous 12 months. The case notes for all patients with positive results were reviewed. Results 6394 endomysial antibody results were performed on adult patients between 1 October 2010 and 30 September 2011. 100 (1.6%) were positive. Of these 67 (67.0%) underwent biopsy. 50 (74.6%) had histological evidence of coeliac disease; 5 (7.5%) were inconclusive and 11 (16.4%) had no evidence of coeliac disease. Of those who did not undergo biopsy 11 (33.0%) were known to have CD or refused D2 biopsy. In 22 (21.6%) patients gastroenterological follow-up had not been arranged, of these 16 (72.7%) tests had been arranged in primary care. Conclusion In this study 1.6% of those tested had serology suggestive of coeliac disease, this is marginally larger than expected by chance and suggests that testing was not appropriately targeted. Surprisingly 21.6% of positive tests did not have appropriate follow-up arranged. We suspect these findings are not confined to our institution. Our findings suggest that engagement and education of non-gastroenterology colleagues, particularly those in primary care is important in order that patients receive appropriate treatment and conform to AGA, BSG and NICE guidelines. We plan in future that all positive coeliac serology test reports be issued with the advice that referral to a gastroenterologist is recommended. Competing interests None declared.

Chest physiotherapy during an acute exacerbation of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a slowly progressive, irreversible constriction of the airways causing breathlessness, cough and respiratory distress. The primary cause is repeated exposure to cigarette smoke, although occupational exposures may contribute towards its development. The prevalence of COPD is estimated between 2% and 4%, representing approximately one to two million people in England. Acute exacerbations occur when there is rapid and prolonged worsening of symptoms, which may include increased secretions and cough, and one in eight unplanned hospital stays concern COPD, making it the second largest cause of emergency admissions in the United Kingdom. Across Europe, admission rates vary in Nordic countries; rates have been estimated to be between 360 and 460 per 100,000 per year, and in 1994, COPD admissions are numbered 125,508 in Germany, 45,624 in Spain and 40,190 in Italy. This places a considerable financial burden on health care services, representing a condition for which economic evaluation of therapeutic interventions is particularly relevant. The National Institute for Health and Clinical Excellence (NICE) estimates the direct cost of COPD to the National Health Services (NHS), which exceeds £491m per year (expenditure based on 2001–2002 activity). More than half of this relates to hospital care with more than one million inpatient ‘bed days’ per year attributable to the disease. The estimates of cost are US$88 to US$7757 per exacerbation in the United States, and across Europe, inpatient costs account for approximately Eur2.9b annually. COPD is a heterogeneous condition. Individuals commonly experience dyspnoea, but a smaller proportion may experience excessive secretions, particularly during an exacerbation. Removing these secretions may or may not be beneficial to these individuals, and this may be an individual preference. Manual chest physiotherapy (MCP) involves external manipulation of the thorax using the techniques of percussion and vibration, and recent systematic reviews have identified a limited role for MCP during an acute exacerbation of COPD. NICE guidelines recommend that all the patients are taught to use positive expiratory pressure and instructed in active cycle of breathing technique. These guidelines are based on the best evidence that is currently available. However, physiotherapy research is a growing discipline and much of the earlier evidence regarding chest physiotherapy is fundamentally flawed by small sample sizes and a lack of homogeneity within the sample studied. These studies measure short-term outcomes and in essence, consider efficacy, that is to say the effects, both positive and negative, of these techniques. In 2001, a comprehensive review of the literature regarding manual physiotherapy techniques was undertaken. This focused on patients with compromised respiratory function and impaired mucociliary clearance, who were not being mechanically ventilated. It aimed to identify studies of acceptable quality, designed to evaluate the use and the mode of manual techniques, so as to compile clear and concise clinical practice guidelines. This proved impossible to achieve, owing to the lack of suitable evidence. Whilst eight articles report designs that evaluate a specific manual technique, using secretion clearance

Infective endocarditis of presumed dental origin and the new NICE guidelines: a case report

AbstractIntroduction: Antimicrobial prophylaxis against infective endocarditis (IE) in patients undergoing interventional procedures is no longer recommended. We present a case of IE following dental treatment for which NICE guidelines were followed.Case report: A 59‐year‐old gentleman presented with a 1 week history of general malaise, nausea, loss of appetite and lethargy after minimal exertion. Known mitral valve prolapse was reported, and an initial differential diagnosis included subacute bacterial endocarditis. An echocardiogram and Streptococcus mitis growth in the blood cultures supported the likely diagnosis. He was referred to the Oral and Maxillofacial Surgery Department where his previous dental history revealed dental treatment 1 month before admission. In line with the current National Institute for Health and Clinical Excellence (NICE) guidelines, the patient did not receive antibiotics preoperatively.Discussion: Dental professionals should be able to recognise the signs and symptoms of IE. It is important to remain informed about such a pathological entity and be aware of its diagnosis and management. Patients with certain cardiac conditions who are at increased risk of developing IE still remain at risk, despite the recent change in the NICE guidelines. The promotion of preventive dentistry and medicine is crucial to reduce the overall risk of IE.

Treatment needs and diagnosis awareness in primary care patients with chronic kidney disease

GPs in England are required to keep a register of patients with chronic kidney disease (CKD). National Institute for Health and Clinical Excellence (NICE) guidelines recommend regular follow-up, but patients are perceived to be low risk and not requiring active management. To assess treatment needs of CKD stage 3 patients in primary care, as well as their awareness of CKD. A cross-sectional analysis from a longitudinal prospective study in 32 general practices. A total of 1741 participants underwent clinical assessment including urine and blood tests. Participants were asked about awareness of their CKD. Results were reviewed and a letter recommending treatment in line with NICE guidelines was sent to their GP. The mean age of participants was 73 ± 9 years; 60% (n = 1052) were female and diabetes was present in 17%; 67% of participants required further intervention. Most required improved control of hypertension (n = 1576; 33.1% of cohort). Other recommendations included advice to investigate anaemia (n = 1142; 8.2%) or stop nephrotoxic drugs (n = 1120; 7.5%). Less than 6% of participants met NICE criteria for referral to nephrology services and 41% were unaware of their CKD diagnosis. Multivariable analysis identified subjects with formal educational qualifications, age <75 years, estimated glomerular filtration rate (eGFR) 30-44 ml/min/1.73 m(2), and significant albuminuria as more likely to be aware of their diagnosis. The study data show that the majority of patients required at least one intervention to improve the management of their CKD. Most interventions could be delivered in primary care and only a minority required nephrology referral. Many patients were unaware of their CKD diagnosis, and efforts should be made to improve this to facilitate involvement in their care.

And Now for Something Completely Different… Self-Management

Ten years ago, Kate Lorig et al1 published studies showing the benefits of self-management for various physical conditions in terms of lower costs to the care system and patient satisfaction. The concept is now getting attention in the mental field. In 2009, when the Mental Health Commission of Canada (MHCC) published Toward Recovery and Weil-Being,2 it noted that out of 3 Canadians living with mental illness do get the help they need. Goal 1 of the strategy proposes that people living with mental problems and illnesses are actively engaged and supported in their journey of recovery and well-being, and that people are able to choose programs and treatments to help them achieve the best possible quality of life, health, and social functioning. The MHCC further proposes an active partnership between mental providers, service users, and family members. Goal 5 of the strategy proposes timely access to appropriate and effective treatments which are based on the principle of the least intrusive and least restrictive alternatives. This In Review on self-management aligns with the system goals of the MHCC and offers perspectives on how improved access to self-management for people experiencing mild to moderate depression can be achieved in partnership with patients, families, primary care physicians, and psychiatrists. In their In Review article, Dr Dan Bilsker and colleagues3 point out that annual prevalence rates for depression had increased to 9.5% by 2001 , and it can be assumed that rates may be higher now given the mental effects of the recession. They cite an Alberta study reporting that 3-year prevalence rates are 21.8%. Dr Bilsker et al3 note that most people diagnosed with depression receive treatment in primary care, but primary care is not well equipped to provide optimal care for depressionp m as most people with depression received only a single session of treatment per year and no follow-up. The article reviews supported self-management (SSM), which is a low-intensity behavioural intervention that employs a self-management guide based on cognitivebehavioural therapy principles along with coaching by a care provider, family member, or supporter. has been included in treatment guidelines published by the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom and hence can be seen as highly relevant to the provision of treatment for depression in various settings, especially primary care. Paradoxically, Dr Bilsker et al3 find that the treatment of mild to moderate depression with antidepressants contravenes the NICE guidelines and suggest that the use of SSM has the potential to enhance patient safety while substantially reducing intervention costs.p206 is reviewed using quality assessment criteria, and studies are cited that show the efficacy of the approach. Dr Bilsker et al3 provide a case study that aptly illustrates the clinical utility of SSM. While the approach has potential to improve care in primary care, it also can be applied in other settings. It is presented as a low-cost intervention that can be effectively integrated into collaborative care. In his In Review article, Professor David A Richards,4 from the University of Exeter in the United Kingdom, outlines how stepped care and self-management have been implemented in the United Kingdom. While collaborative care provides an integral platform to build interventions, such as stepped care and SSM, Professor Richards notes that health care delivery systems may be well suited to the implementation of low-burden [on the provider] mental treatments, such as SSM.4. p 2 Mental systems may need to be restructured to support these types of interventions and Professor Richards notes the importance of competency-based training and robust data-outcome measurement systems to drive change. He also notes that telephony-based applications were shown to effectively treat more patients in one study. …

NICE guidance on CardioQ™

Our recent editorial has generated widespread debate about the National Institute for Health and Clinical Excellence (NICE) Technology Guidance on the CardioQ™ Doppler, and in particular the evidence on which this guidance was based [1]. Our greatest concern was that this guidance, which was intended to make the case for adoption of the product, seemed to be based on a small number of randomised trials each containing only a small number of patients, a point reiterated by Minto et al. [2]. Nesbitt et al. have asked ‘how much evidence is enough’ and this is indeed a fair question [3], but it is our view that the evidence regarding the CardioQ is not yet sufficient, amounting to eight trials and about 700 patients spread over more than a ten-year period, to warrant the robust commendation given to it by NICE. Analysis of data pooled from a small number of patients over a period of a decade or more will always be questionable because of changes in standards of care and practice over time, and thus we would answer the question ‘how much evidence is enough?’ by saying it depends on how old the evidence is. This is particularly pertinent when considering time to discharge from hospital, which has changed radically for nearly all forms of surgery over the past fifteen years. It is interesting to note that the most recent randomised trial of the CardioQ in major colorectal surgery has failed to demonstrate any benefit from use of the device [4]. As the authors of that trial point out, this may be simply because their standard fluid regimen resulted in higher cardiac outputs in their control group than in previous studies that did demonstrate benefit. We noted in our editorial that the difference between controls and study groups in the trials considered by NICE amounted to a small bag of fluid per patient [1], and this latest trial bears out the fact that a less conservative approach to fluid management during major surgery may yield the same beneficial results with or without the CardioQ. The process by which NICE develops such guidance has been well described by Campbell et al. [5], however they fail to make the point that every NICE guidance is given a great deal of weight by hospital managers, to the extent that pressure is placed on clinicians to justify why they choose not to adopt such guidance. Adoption or failure to adopt is audited within trusts, and clinicians thus fear claims of negligence if they fail to act within the guidelines. In addition, financial pressure may also be applied, as the NICE guidelines have been adopted into the Commissioning for Quality and Innovation (CQUIN) payment framework [6]. This places the onus on NICE to restrict issuing guidance on technologies to those for which the evidence is deemed to be of high quality, as well as with sufficient depth and breadth of supporting opinion. Our contention is that this is not the case for the CardioQ, especially as use of the device and the subsequent intravascular volume loading it may trigger is contentious in itself, as has also been pointed out by Woodcock [7]. In addition, we agree with Ghuman et al. [8], that advocating a single device for measuring haemodynamic data over other devices, which is inherent in the publishing of such technology guidance, is not merited when there isn’t conclusive evidence of superior benefit. In this final point, we agree with Singer, who also points out that the evidence base for comparing technologies is ‘scanty and inconsistent’ [9]. We hope that NICE will take these views into account, and consider issuing guidance on technology only when a strong body of independent evidence is available.

Home blood pressure monitoring may make office measurements obsolete

he conventional measurement of blood pressure(BP) in the office or clinic has been the cornerstonefor hypertension management for decades. How-ever, because of the white-coat and the masked hyper-tension phenomena, out-of-office BP monitoring withambulatory or home measurements is often required [1].ExtensiveresearchonambulatoryBPmonitoringhasestab-lished its role as the most accurate tool for hypertensiondiagnosis [1–3].Onthecontrary,despitetheincreasinguseof home BP monitoring by hypertensive patients in thedaily management of their high BP condition, research inthisfield,inparticularwhenconsideringoutcometrials,hasbeen delayed as compared to ambulatory BP monitoring[4,5].

Management of hypertension in adults in primary care: NICE guideline

Hypertension is common and is one of the leading causes of cardiovascular events such as stroke and ischaemic heart disease. It is responsible for approximately 12% of consultations in primary care. This is a summary of the key points in the 2011 National Institute for Health and Clinical Excellence (NICE) hypertension guideline.1 This is an update of NICE clinical guideline 18, which was first published in 2004 and was partially updated in 2006 (clinical guideline 34). The 2006 and 2011 updates were developed in collaboration with the British Hypertension Society (BHS). The areas included for updating were selected because of new evidence that might change existing recommendations. These included the use of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) in diagnosis; the place of new thresholds and targets for treatment; and a re-examination of the position of angiotensin-converting inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), calcium-channel blockers (CCBs), and diuretics in the treatment algorithm. Consideration of differences in management for people of various ages and ethnicity, as well as how to treat resistant hypertension, were also included. The management of blood pressure in people with diabetes was not included in this guideline. ### Diagnosis The diagnosis of hypertension uses both clinic blood pressure monitoring (CBPM) and ABPM readings (Box 1). If blood pressure measured in the clinic is 140/90 mmHg or higher, a second measurement should be taken during the consultation. If the second measurement is substantially different from the first, take a third measurement. The lower of the last two measurements should be recorded as …

Carcinoma of unknown primary: key radiological issues from the recent National Institute for Health and Clinical Excellence guidelines.

Carcinoma of unknown primary origin (CUP) accounts for 3-5% of cancer cases and is the fourth most common cause of cancer death in the UK. CUP management is challenging, partly owing to the heterogeneity of the condition and its presentation, but also owing to the lack of dedicated clinical services for these patients. The recent National Institute for Health and Clinical Excellence (NICE) guidelines on metastatic malignancy of unknown primary origin were developed to improve the co-ordination of diagnostic and clinical services at hospitals treating cancer patients in England and Wales, in particular by the setting up of CUP teams to manage these patients. Radiologists have a vital role in the diagnosis of these patients and should work closely with the CUP team to streamline the diagnostic pathway. This article summarises areas of the NICE guidelines relevant to radiology and discusses the radiological management of patients with CUP, including initial investigation, the importance of biopsy, the management of specific presentations, special investigations and organisational issues.

Access to the next wave of biologic therapies (Abatacept and Tocilizumab) for the treatment of rheumatoid arthritis in England and Wales: addressing treatment outside the current NICE guidance.

Patients in England and Wales with rheumatoid arthritis (RA) receive treatment from the National Health Service (NHS) with therapies approved by the European Medicines Agency (EMA), under guidance from the National Institute for Health and Clinical Excellence (NICE). This document overviews the current NICE guidelines for the treatment of RA and identifies scenarios when such guidance may not represent the optimum management strategy for individual patients. Specifically, we consider the use of tocilizumab or abatacept as the most appropriate treatments for some patients. In such scenarios, it may be possible for the clinician to secure access to the required therapy through an application procedure known as an ‘individual funding request’, the process of which is described in detail here. At present, it is unclear the extent to which the proposed reform of the NHS will affect the role of NICE in providing guidance and setting standards of care. Until the full impact of the proposed changes are realized, individual funding requests will remain a valuable way of securing the optimal treatment for all patients suffering from RA.Electronic supplementary materialThe online version of this article (doi:10.1007/s10067-011-1936-6) contains supplementary material, which is available to authorized users.