National Institute For Health And Care Excellence Research Articles

Depresion as a neurological manifestation in patients with post-COVID- 19 syndrome: A sysematic review

"An increase in the number of cases with persistence of symptoms following acute SARS-CoV-2 infection, known as post-COVID-19 syndrome has been acknowledge by the National Institute for Health and Care Excellence (NICE). This syndrome is associated with high rates of neuropsychiatric symptoms, suggesting an effect of COVID-19 on the central nervous system. However, a clear description of such an effect is currently lacking, and therefore there are no treatment guidelines for patients experiencing this syndrome or patients with neuropsychiatric manifestations in this context. Hence, the aim of this review is to analyze the available information regarding the association between the presence of depression in post-COVID-19 syndrome and describe the physio pathological process. For the completion of this review, a search was conducted in the PubMed database using the keywords COVID- 19, Depression, Post-COVID-19 syndrome, and SARS-CoV-2. The review was conducted according to the extended PRISMA guidelines for focused reviews. As significant findings, we identified that survivors of severe COVID-19 have higher rates of depression. Among the predictive factors for the development of post- COVID-19 depression are advanced age, longer hospital stays, symptom severity, and disease duration. While the pathogenesis of depression in post-COVID-19 syndrome is unknown, the main contributors to its development are recognized as cytokine-mediated inflammatory response and changes in neurotransmitters."

Recommendations for Upper Limb Motor Recovery: An Overview of the UK and European Rehabilitation after Stroke Guidelines (2023).

Upper limb impairment is common after stroke, with a significant impact on the stroke survivor's function, social participation and quality of life. Clinical guidelines are needed to inform clinical practise, tailor interventions to improve outcomes and address unresolved research questions. This review contributes to the evidence guiding clinical practise for upper limb motor recovery after stroke by summarising the recommendations from the UK rehabilitation guidelines (National Institute for Health and Care Excellence (NICE) and the Intercollegiate Stroke Working Party (ISWP)) and the European Stroke Organisation (ESO) guidelines, all published in 2023. All three guidelines target researchers, clinical practitioners, stroke survivors and their social networks. An important feature in all three guidelines was therapeutic intensity, with all guidelines recommending increased therapeutic intensity. Unlike the ESO, the NICE and ISWP additionally include specific research recommendations. While the NICE guidelines seem more holistic and target a wider audience, the three guidelines are complimentary. We recommend that a future consensus statement should be developed in partnership between all three organisations, agreeing on scope and using the same terminology, on recommendations to improve stroke rehabilitation in the UK and Europe.

Intravenous fluid therapy: an audit and discussion of improvements required for prescribers and administrators.

Foundation doctors and nurses are the clinicians most closely involved in fluid assessment, intravenous (IV) fluid prescription and administration. However, both groups report challenges regarding IV fluids. At a large NHS trust in England, adherence to the National Institute for Health and Care Excellence (NICE) guideline CG174, regarding IV fluids, was largely unknown. To assess the baseline adherence, within the hospitals, to CG174 and identify areas for improvement. A set of 12 audit standards were developed and used to collect data across 29 clinical areas between September 2022 and May 2023, with 255 patients receiving IV fluids at any time during their inpatient stay included. For two standards target adherence of 95% was achieved, with an adherence less than 50% in most. Areas of particularly poor adherence included assessing and meeting fluid and electrolyte requirements, patient reassessment and developing IV fluid management plans. Trust baseline adherence to NICE CG174 requires improvement, particularly regarding patient assessment and reassessment, and meeting electrolyte requirements.

A Multi-dimensional Framework of Valued Output for Primary Care in England.

Improving efficiency and productivity are key aspects to ensure that general practices in England can meet the needs of a growing population with increasingly demanding and costly healthcare needs. However, current evidence on the efficiency and productivity of general practices is weak, partly due to suboptimal approaches to measure their 'valued' output. To overcome this limitation, this paper presents a multi-dimensional framework and indicators of valued output from the healthcare decision-maker's perspective. We identified existing primary care performance frameworks through a targeted literature review. We reviewed the frameworks and selected the dimensions relating to the impact on patients' health outcomes, corresponding with the definition of 'valued' output from the healthcare decision-maker perspective. For each dimension, we reviewed the National Institute for Health and Care Excellence (NICE) evidence base and guidance on best practice to develop indicators of valued output. Clinical experts and representatives of the main primary care stakeholders reviewed and validated the framework's comprehensiveness and development process. Based on a review of three existing frameworks, we synthesised a multi-dimensional output framework comprising 13 dimensions for significant primary care-related conditions and services and 51 indicators of valued output. Each indicator of valued output measures a healthcare episode and the resulting impact on patient's health. The multi-dimensional framework and indicators provide a theoretical tool to improve the measurement of primary care output in economic efficiency and productivity studies. Future research should explore the measurability of the indicators through available datasets and the implementation of the framework through analytical approaches for efficiency measurement.

450 Outcomes of Groin Hernia Surgery in ELHT: A Comparative Retrospective Study with NICE, BHS, and EHS Statistics

Abstract Aim The aim of this study was to evaluate the results of groin hernia surgery, at East Lancashire Hospitals Trust (ELHT) by comparing the severity of pain and recurrence rates with established standards set by the National Institute for Health and Care Excellence (NICE) British Hernia Society (BHS) and European Hernia Society (EHS). Method This retrospective analysis involved patients who underwent groin hernia repair between 2019 and 2021 at ELHT trust hospitals. The selection criteria were based on guidelines provided by the BHSs Hernia Commission Guide. Data was collected from records during the specified time frame. Results Out of all cases chronic pain occurred in 2.90% which's notably lower compared to the 10 12% range reported by the European Hernia Society. Furthermore, the recurrence rate at ELHT was found to be 2.51% below the rate of 15% mentioned by the European Hernia Society. Conclusions Based on these findings it can be concluded that ELHT has achieved outcomes in groin hernia surgery when compared to benchmarks set by the European Hernia Society. Notably ELHT demonstrated rates of chronic pain and recurrence highlighting successful surgical interventions and providing valuable insights for best practices in hernia surgery. These results have implications for optimizing outcomes. May influence future guidelines and practices, in groin hernia surgery.

A study investigating the implementation of NICE recommended psychological interventions for people with psychosis following a psychiatric inpatient admission

The period of time following discharge from an inpatient setting presents a unique window of opportunity for people with psychosis to engage in psychological treatment. In England, The National Institute for Health and Care Excellence (NICE) guidelines outline that every person with a schizophrenia diagnosis should be offered individual Cognitive Behavioural Therapy for psychosis (CBTp) and Family Intervention (FI). This study aimed to explore rates of offer and receipt of NICE recommended therapies for adults with a schizophrenia spectrum disorder diagnosis in the year following discharge from an inpatient unit. We then investigated possible predictors of therapy offer and receipt. We used a large electronic healthcare records database to perform a secondary data analysis. A generalised linear regression model was used to explore possible predictors. Overall, our results showed low rates of offer and receipt of recommended therapies (Any recommended therapy (CBT only, FI only or CBT + FI) received = 39(8%), offered = 70(15%)). Predictor variable results were identified and discussed. The low level of offer and receipt of recommended therapies is concerning given the recommendations in the NICE guidelines for people with psychosis. Our study highlighted the need for more consistent and reliable procedures for recording this information. Further investigation into the reasons for low levels of implementation overall is important to aid the development of recommendations for how this can be improved.

Introducing the UK Antimicrobial Registry (UKAR) study: providing real world data on new antimicrobials to support antimicrobial stewardship and tackle antimicrobial resistance.

The UK Antimicrobial Registry (UKAR) has been developed to capture data on real world usage of antimicrobial agents with an initial focus on those used to treat drug-resistant infections. Several industry partners have committed support for the study, which is included in the National Institute for Health and Care Research (NIHR) portfolio in England with similar arrangements in the three devolved UK nations. The two antimicrobials in the National Institute for Health and Care Excellence (NICE) subscription model pilot (cefiderocol and ceftazidime/avibactam) are included in the UKAR and future expansion of work in this area is planned. This model decouples payment from usage by using a fixed annual fee. The study will provide information on the characteristics of patients receiving study drugs, the infections being treated, treatment effectiveness and adverse events. UKAR potentially provides a novel resource of enduring value to support healthcare in the UK and more widely and contribute to AMR National Action Plan goals for optimal use of antimicrobials.

Summary of the best evidence for early exercise rehabilitation in patients with mechanically ventilated ICU-acquired weakness

To integrate the best evidence for early rehabilitation of mechanically ventilated ICU-acquired weakness (ICU-AW) patients using evidence-based methods, providing evidence-based basis for standardized evaluation and intervention of early exercise therapy for mechanically ventilated ICU-AW patients. A systematic search was conducted on the American Thoracic Society (ATS) Clinical Practice Guidelines, Registered Nurses' Association of Ontario (RNAO), Guidelines International Network (GIN), Canadian Medical Association Clinical Practice Guideline Library (CMACPGL), BMJ Clinical Evidence, UpToDate, Scottish Intercollegiate Guidelines Network (SIGN), PubMed, Cochrane Library, National Guideline Clearinghouse (NGC), Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), UM-library, Physiotherapy Evidence Database (PEDro), National Institute for Health and Care Excellence (NICE), New Zealand Guidelines Group (NZGG), Chinese Medical Pulse Guidelines Website, CNKI and Wanfang data and other Chinese and English databases, professional team websites, and guideline websites for expert consensus, guidelines, randomized collected trial (RCT), systematic reviews and other evidence on early exercise rehabilitation for mechanically ventilated ICU-AW patients. The search time limit was from the establishment of the database to December 31, 2023. Literature search, screening, evaluation, information extraction was independently conducted by two evaluators with cross checking, and quality evaluation of the included literature was conducted. A total of 21 literatures were enrolled, including 5 guidelines, 5 systematic reviews, 4 expert consensuses, and 7 RCT, all of which with high evidence level and all were enrolled. They were summarized into seven aspects with assessment screening, exercise safety standards, precautions, setting of exercise time, exercise intensity, exercise sequence, and recommended exercise content as the core, and 32 best evidences. The evidence summarized can provide evidence-based basis for standardized assessment and intervention of early exercise rehabilitation in mechanically ventilated ICU-AW patients. ICU medical practitioners need to combine the actual clinical environment, individual differences and rehabilitation goals of patients, to provide targeted health guidance and intervention for the prevention of ICU-AW in mechanically ventilated patients.

Best evidence summary of sleep protection in premature infants in the neonatal intensive care unit: a narrative review.

Sleep influences the interaction between infants and their environment, as well as the achievement of crucial milestones in motor and language development. This is particularly significant for preterm infants in vulnerable positions. However, prematurely born infants in the neonatal intensive care unit (NICU) are exposed to various stimuli such as noise and light, which disrupt their normal sleep patterns. This study assesses and consolidates the existing evidence on non-pharmacological strategies for protecting and promoting sleep in preterm infants. By providing an evidence-based data repository, it offers a valuable reference for clinical interventions. We conducted computer-based searches using various databases and resources, including UpToDate, BMJ Best Practice, Guidelines International Network (GIN), National Institute for Health and Clinical Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), National Guideline Clearinghouse (NGC), Registered Nurses Association of Ontario (RNAO), Joanna Briggs Institute (JBI), World Health Organization (WHO), Cochrane Library, Web of Science, PubMed, China National Knowledge Infrastructure (CNKI), Wanfang Data, and China Biology Medicine disc (CBM). The search period spanned from January 2014 to May 2024. We have included a total of 22 articles in our review, comprising two guidelines, 11 systematic reviews, 1 evidence summary, 1 technical report, 2 practice recommendations, and 5 randomized controlled trials. The evidence was synthesized from eight domains: sleep team construction, risk factor assessment, sleep assessment tools, positional management, noise control, light management, sensory stimulation, and hospital-home transition sleep management, resulting in 27 pieces of evidence. This study summarizes the optimal evidence for the management of sleep in premature infants, providing empirical support for standardizing the management of sleep in premature infants. It is recommended that healthcare professionals judiciously apply the best evidence while considering the clinical context, thus promoting safe sleep for premature infants.

The quality of guidelines on the pancreatic perioperative enhanced recovery after surgery: a systematic quality appraisal using AGREE II instrument.

To evaluate the quality of guidelines on the pancreatic perioperative enhanced recovery after surgery both domestically and internationally, providing reference and reference for clinical practice. Systemically retrieved in the guideline websites, professional association websites and databases, such as up to date, BMJ Best Practice, PubMed, Embase, The Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Wan Fang Data, China Science and Technology Journal Database(VIP), China Biology Medicine disc (CBMdisc), Medlive, Guidelines International Network(GIN), National Guideline Clearinghouse(NGC), National Institute for Health and Care Excellence(NICE), Registered Nurses Association of Ontario(RNAO), Scottish Intercollegiate Guidelines Network(SIGN), Joanna Briggs Institute Library(JBI), including guidelines and expert consensus on enhanced postsurgical recovery in pancreatic surgery published as of December 20, 2023. The Appraisal of Guidelines for Research and Evaluation II(AGREE II) tool was applied to evaluate the quality of the guidelines by four assessors. This study included seven guidelines, all of which were rated as Grade B in terms of quality, with ICC coefficients ranging from 0.752 to 0.884, indicating a high level of consistency. When formulating guidelines in the future, it is recommended to use AGREE II as a reference, emphasizing the standardization of the guideline development process and methods, fully considering patients' values and preferences, focusing on the applicability of the guidelines, and striving to create high-quality evidence-based recommendations.

Unlocking the Potential of Underutilized Technology: A New Paradigm for Resident Doctor Efficiency.

Background The precision of clinical documentation in trauma and orthopaedic surgery is pivotal, given its profound implications on patient care and medicolegal risks. This study assessed the impact of an autotext template intervention on the adherence of clinical documentation to the neurovascular assessment standards set by the National Institute for Health and Care Excellence (NICE) and the British Orthopaedic Association Standards for Trauma (BOAST). Methods Conducted at a single hospital, this observational study comprised two phases: a retrospective analysis of clinical documentation for 56 fracture patients (n=56) followed by the implementation of an autotext template and subsequent analysis of a new cohort of 57 patients (n=57). The intervention aimed to enhance documentation quality in line with NICE and BOAST guidelines. Results Initial findings revealed a prevalent use of the nonspecific term "NVI" (neurovascularly intact), with only 8.5% (n=5) of pre-intervention documents adhering to detailed motor function assessments and a mere 6.8% (n=4) recording limb colour. Post-intervention analysis showed a significant improvement, with 91.23% (n=52) of documents listing nerves (P < 0.001) and 96.49% (n=55) adhering to motor function documentation using the Medical Research Council (MRC) grading scale (P < 0.001). Despite these advancements, the study acknowledges potential limitations such as the Hawthorne effect and the ongoing challenge of staff rotations. Conclusion The autotext template intervention markedly enhanced the adherence to neurovascular assessment documentation standards, as evidenced by the substantial increases in detailed parameter reporting and supported by statistically significant P-values. This advancement highlights the necessity of equipping clinicians with practical tools to uphold high documentation standards amidst challenging clinical conditions. Future investigations should focus on the long-term sustainability of these improvements across varying medical staff cohorts.

Is adjunctive Cannabidiol effective in controlling seizures for adult patients with Lennox-Gastaut Syndrome? – A single centre long term follow up study

Epileptic encephalopathies are a disabling and life-limiting cause of childhood-onset epilepsy. Lennox Gastaut syndrome (LGS) is a characteristic example. In spite of the development of multiple medical and surgical therapies, many patients with these conditions remain treatment refractory Cannabidiol was licenced by The National Institute for Health and Care Excellence (NICE) in December 2019 for the adjunctive treatment of seizures associated with Lennox Gastaut syndrome [TA 615].As the largest complex epilepsy centre in the Midlands, we describe our findings from a single centre retrospective study in 50 adults (aged 16 and over) with LGS- associated epilepsy. Our outcome measure was the efficacy of Cannabidiol on seizures of differing types over a 6–24-month period.Patients were treated with adjunctive Cannabidiol (with Clobazam, as per NICE recommendations). Each patient’s usual anti-seizure medications (ASMs) were continued. Patients with a Vagal Nerve Stimulator (VNS) in situ remained on this treatment.Gradual titration of Cannabidiol from 1 mg/kg/day up to 10 mg/ kg/ day reduced the frequency of both focal and generalised seizures with ≥ 50 % seizure reduction in 76 % of the cohort. No patients became seizure free. Cannabidiol was well tolerated; 94 % of the cohort remained on the drug at last follow up.

Experience of CBT in adults with ADHD: a mixed methods study.

The National Institute for Health and Care Excellence (NICE) recommends Cognitive-Behavioural therapy (CBT) as the psychotherapeutic treatment of choice for adults with Attention Deficit Hyperactivity Disorder (ADHD) in the UK. However, the literature often refers to adapted CBT programs tailored for ADHD and provides limited insight into how adults with ADHD experience and perceive this form of treatment in routine clinical practice. This mixed-methods study aims to explore ADHD individuals' experience and perception of CBT delivered in routine clinical practice, to gain a better understanding of this treatment's helpfulness and perceived effectiveness. A survey (n=46) and semi-structured in-depth interviews (n=10) were conducted to explore the experience of CBT and its perceived effectiveness in managing ADHD. The interviews were analysed using thematic analysis and the survey was synthesised using descriptive narratives. The thematic analysis highlighted three key themes: difficulties with the CBT framework, difficulties with CBT therapists, and consequences of CBT. The survey highlighted similar findings. Participants described the CBT framework as, generic, rigid, and too short, and described the CBT therapist as unspecialised, unempathetic, and not sufficiently adapting CBT to ADHD-related difficulties. Overall, participants found non-adapted, generic CBT in the UK to be unhelpful, overwhelming, and at times harmful to their mental well-being. Therefore, it is necessary for clinical bodies in the UK, while following the indicated NICE guidelines, to be mindful of adapting CBT delivery of CBT, to be most effective for people with ADHD and to mitigate potential harm.

Are Sleep Quality, Daytime Sleepiness and Depression Associated with Knee Pain? A Cross-Sectional Study in Older Adults

Abstract Introduction Osteoarthritis (OA) is common among older adults, and studies have suggested that it is commonly associated with sleep problems and depression. However, the results are inconsistent concerning overall sleep quality, daytime sleepiness, and depression in studies that consider OA knee pain specifically. Objectives To examine the relationship between sleep quality, daytime sleepiness and depression, and OA knee pain in older adults. Methods This was a cross-sectional study. Adults aged 60 and above with OA knee pain according to the National Institute for Health and Care Excellence (NICE) guidelines, and who had preserved cognitive function were recruited. Sleep quality, daytime sleepiness, and depression symptoms were assessed using the Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale (ESS), and the Center for Epidemiologic Studies Depression Scale (CESD), respectively. The generalized linear model (GzLM) approach was used in the statistical analysis. A logistic regression model was performed to evaluate whether ESS, PSQI, and CESD symptoms were associated with knee pain. Results The sample comprised 451 older adults. Sleep quality (OR = 1.22, 95% confidence interval [CI]: 1.07 to 1.40) and depressive symptoms (OR = 1.09, 95%CI: 1.01 to 1.17) were associated with knee pain, but there was no association with excessive daytime sleepiness (OR= 1.09, 95%CI: 0.90 to 1.20). Conclusions Sleep quality and depression symptoms are associated with knee pain.

A Retrospective Review of Men Referred to a Dedicated Erectile Dysfunction Clinic in Secondary Care.

Background and objectives Erectile dysfunction (ED) is a multifactorial disease associated with many medical co-morbidities and risk factors commonly encountered in primary care. Initial management includes lifestyle changes and the treatment of any identifiable conditions. Guidelines exist recommending the assessment and management of sufferers with clear indications for referral to secondary care. With the outbreak of COVID-19, non-urgent medical services, including ED, were suspended, creating a significant waiting list for these patients. The aim of this study was to review the management of men in both primary and secondary care who had been referred to a dedicated ED service. Materials and methods A retrospective review of men referred to secondary care between June 2018 and April 2021 with ED was undertaken, reviewing whether the guidelines published by the National Institute for Health and Care Excellence (NICE) and GP Notebook for the assessment, initial treatment, and referral were followed by the primary care clinician. A secondary aim was to recordthe outcome of those men after review in a secondary carededicated ED clinic. Results One hundred and forty-eight men were reviewed in the ED clinic, with 55 men (37.2%) requiring an intervention that was appropriate to have been delivered in primary care. The majority of those (76.3%) were successfully managed with a phosphodiesterase inhibitor. Of those treated in secondary care, almost 60% required a second-line therapy, such as a vacuum device or the administration of alprostadil, with 14 men (15%) necessitating the surgical implantation of a penile prosthesis. Conclusion With a rise in both the prevalence and incidence of ED, primary care physicians have a pivotal role in the screening and initial assessment of patients with ED, with evidence suggesting that a significant proportion can be successfully managed in this setting.

Prevalence, predictive factors, and outcomes of refeeding syndrome among medically critically ill patients: A retrospective cohort study.

Refeeding syndrome (RFS) is a life-threatening metabolic derangement occurring when nutrition is reintroduced after prolonged starvation. Limited data exist regarding RFS prevalence, risk factors, and outcome, particularly in critically ill patients. A retrospective cohort study was conducted in a medical intensive care unit from June 2018 to August 2020. RFS diagnostic criteria from the National Institute for Health and Care Excellence (NICE) and the American Society for Parenteral and Enteral Nutrition (ASPEN) were used. The primary outcome was 30-day mortality. Among 216 patients, RFS was diagnosed in 22.7% and 27.3% of patients per the NICE and ASPEN criteria, respectively. There was no significant difference in 30-day mortality between patients with and without RFS (22/59 [37.3%] vs 53/157 [33.8%]; P = 0.627). Independent predictors of RFS were malignancy (odds ratio [OR] = 2.09; 95% CI = 1.06-4.15; P = 0.035), septic shock (OR = 2.26; 95% CI = 1.17-4.39; P = 0.016), and high NICE RFS risk classification (OR = 2.52; 95% CI = 1.20-5.31; P = 0.015). Factors associated with reduced RFS risk were Sequential Organ Failure Assessment (SOFA) scores >12 (OR = 0.45; 95% CI = 0.23-0.88; P = 0.020) and high-dose vasopressor treatment (OR = 0.34; 95% CI = 0.14-0.79; P = 0.012). RFS affected one-fourth of the critically ill patients but did not significantly impact 30-day mortality. Malignancy, septic shock, and high NICE RFS risk classification were positively associated with RFS, whereas high SOFA scores and extensive vasopressor use were linked to decreased risk.

Scottish Intercollegiate Guidelines Network Guidance on Dementia: The Investigation of Suspected Dementia (SIGN 168) with Focus on Biomarkers-Executive Summary.

This is an executive summary of the recent guidance produced by the Scottish Intercollegiate Guidelines Network (SIGN) dementia guideline group with regards to the investigation of suspected dementia. This is a sub-section of the broader SIGN 168 guideline released in November 2023. The guideline group included clinicians with expertise in Old Age Psychiatry, Neurology, Radiology, and Nuclear Medicine supported by colleagues from the SIGN and Healthcare Improvement Scotland teams. There was representation from carers and support organizations with experience of dementia, to ensure the recommendations were appropriate from the perspective of the people being assessed for possible dementia and their carers. As the 2018 National Institute for Health and Clinical Excellence (NICE) dementia review included a review of the evidenced investigation of dementia, the SIGN guideline development group decided to focus on a review on the up-to-date evidence regarding the role of imaging and fluid biomarkers in the diagnosis of dementia. To give context to the consideration of more advanced diagnostic biomarker investigations, the guideline and this summary include the NICE guidance on the use of standard investigations as well as more specialist investigations. The evidence review supports consideration of the use of structural imaging, nuclear medicine imaging, and established Alzheimer's cerebrospinal fluid biomarkers (amyloid and tau) in the diagnosis of dementia. Although routine use of amyloid positron emission tomography imaging was not recommended, its potential use, under specialist direction, in patients with atypical or young-onset presentations of suspected Alzheimer's dementia was included as a clinical good practice point.

Safety of methotrexate administration in women with pregnancy of unknown location at high risk of ectopic pregnancy.

To evaluate the safety of current guidelines on methotrexate (MTX) administration in women with pregnancy of unknown location (PUL) who are considered to have a high risk of underlying ectopic pregnancy (EP), and to investigate whether implementation of these guidelines would result in inadvertent exposure to MTX of viable intrauterine pregnancies (IUPs). This was a retrospective observational study of consecutive clinically stable women who were classified with PUL at the early pregnancy unit of Nepean Hospital, Sydney, Australia, between 2007 and 2021. PUL was defined as a positive pregnancy test in the absence of signs of IUP or EP on transvaginal ultrasound. Patients with a PUL that behaved biochemically like an EP, but for which the location of pregnancy was not confirmed on ultrasound, were eligible for MTX to minimize the risk of subsequent tubal rupture. Criteria discussed in the guidelines of the American College of Obstetricians and Gynecologists (ACOG), American Society for Reproductive Medicine (ASRM), Royal College of Obstetricians and Gynaecologists (RCOG) and National Institute for Health and Care Excellence (NICE) were applied to the PUL database. The number of patients eligible to receive MTX and the number with an underlying viable IUP who would be inadvertently prescribed MTX were calculated. A total of 816 women with PUL were reviewed, of whom 724 had complete data and were included in the final analysis. Six patients had persistent PUL and the remaining 718 had a diagnosis of viable IUP, non-viable IUP, EP or failed PUL. According to the ACOG, ASRM, RCOG and NICE guidelines, the rate of MTX administration among patients with PUL would have been 2.76%, 4.56%, 0.41% and 35.36%, respectively. However, no persistent PUL would have received MTX according to the ACOG, ASRM and RCOG protocols (the NICE protocol identified patients with persistent PUL with a sensitivity of 100%), and the majority of MTX treatments were unnecessary because those patients were later classified as having non-viable IUP or failed PUL. Application of ACOG and ASRM guidance could result theoretically in inadvertent MTX administration to women with an underlying viable IUP at a rate of 4.1/1000 (3/724). Current guidelines used to predict high risk of EP in the PUL population lead to inadvertent MTX administration to women with an underlying viable IUP. These guidelines should be used wisely to ensure that no wanted pregnancy is exposed to MTX. Women with PUL should be monitored carefully, and MTX should be used judiciously when the location of pregnancy is yet to be confirmed. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Comparison of different methods of first-trimester screening for preterm pre-eclampsia: cohort study.

To compare the predictive performance of three different mathematical models for first-trimester screening of pre-eclampsia (PE), which combine maternal risk factors with mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI) and serum placental growth factor (PlGF), and two risk-scoring systems. This was a prospective cohort study performed in eight fetal medicine units in five different regions of Spain between September 2017 and December 2019. All pregnant women with singleton pregnancy and a non-malformed live fetus attending their routine ultrasound examination at 11 + 0 to 13 + 6 weeks' gestation were invited to participate in the study. Maternal characteristics and medical history were recorded and measurements of MAP, UtA-PI, serum PlGF and pregnancy-associated plasma protein-A (PAPP-A) were converted into multiples of the median (MoM). Risks for term PE, preterm PE (< 37 weeks' gestation) and early PE (< 34 weeks' gestation) were calculated according to the FMF competing-risks model, the Crovetto et al. logistic regression model and the Serra et al. Gaussian model. PE classification was also performed based on the recommendations of the National Institute for Health and Care Excellence (NICE) and the American College of Obstetricians and Gynecologists (ACOG). We estimated detection rates (DR) with their 95% CIs at a fixed 10% screen-positive rate (SPR), as well as the area under the receiver-operating-characteristics curve (AUC) for preterm PE, early PE and all PE for the three mathematical models. For the scoring systems, we calculated DR and SPR. Risk calibration was also assessed. The study population comprised 10 110 singleton pregnancies, including 32 (0.3%) that developed early PE, 72 (0.7%) that developed preterm PE and 230 (2.3%) with any PE. At a fixed 10% SPR, the FMF, Crovetto et al. and Serra et al. models detected 82.7% (95% CI, 69.6-95.8%), 73.8% (95% CI, 58.7-88.9%) and 79.8% (95% CI, 66.1-93.5%) of early PE; 72.7% (95% CI, 62.9-82.6%), 69.2% (95% CI, 58.8-79.6%) and 74.1% (95% CI, 64.2-83.9%) of preterm PE; and 55.1% (95% CI, 48.8-61.4%), 47.1% (95% CI, 40.6-53.5%) and 53.9% (95% CI, 47.4-60.4%) of all PE, respectively. The best correlation between predicted and observed cases was achieved by the FMF model, with an AUC of 0.911 (95% CI, 0.879-0.943), a slope of 0.983 (95% CI, 0.846-1.120) and an intercept of 0.154 (95% CI, -0.091 to 0.397). The NICE criteria identified 46.7% (95% CI, 35.3-58.0%) of preterm PE at 11% SPR and ACOG criteria identified 65.9% (95% CI, 55.4-76.4%) of preterm PE at 33.8% SPR. The best performance of screening for preterm PE is achieved by mathematical models that combine maternal factors with MAP, UtA-PI and PlGF, as compared to risk-scoring systems such as those of NICE and ACOG. While all three algorithms show similar results in terms of overall prediction, the FMF model showed the best performance at an individual level. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

National myeloma patient survey shows continuing inappropriate imaging and geographical inequalities.

To evaluate the provision of imaging at diagnosis of myeloma from the service user perspective with a specific focus on how the experiences of patients align with the National Institute for Health and Care Excellence (NICE) guidelines (NG35, 2016) on first-line imaging practice for myeloma in the United Kingdom. A national survey was performed to evaluate access to imaging from the patient's perspective. Patients with myeloma who received their diagnosis between 2017 and March 2022 were invited to participate. Data were collected using an online survey from 895 patients and carers between 4 and 14 March 2022. Most patients had more than one imaging test. First-line MRI was used in 69.2% of respondents. First-line skeletal survey (SS, whole body X-rays) remained common (48.7% of respondents). 18F-fluorodexyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) was used least often (23.1% of respondents). SS was used more often in East England (57.9%) and Scotland (61.2%) than in South East England (36.3%). Despite NICE recommendations, first-line MRI was not used in a third of patients surveyed, with geographical variation in imaging practice. Patients are still undergoing multiple imaging tests at diagnosis. Healthcare professionals should continue to emphasize the superiority of MRI compared to SS to drive for improvements in care. Current recommendations on first-line imaging for myeloma are not provided consistently across the United Kingdom. There is a need to drive change and support healthcare professionals to deliver guidance-based recommendations to improve experience and outcomes for patients.