National Institute Of Health And Clinical Excellence Research Articles

579 Audit to Measure if >5% Reduction in Weight Occurred, as Recommended by the National Institute of Health and Clinical Excellence (NICE), for Patients Suffering from Osteoarthritis Before Their Scheduled Total Joint Replacements, at Darwen Health Link Surgery

Abstract Aim Osteoarthritis causes damage to synovial joints, manifesting as pain, loss of function, and disability. A high BMI is correlated with an increased incidence of osteoarthritis, for which NICE recommends a >5% (ideally >10%) decrease in baseline weight to improve pain and functionality. This audit aims to measure Darwen Health Link’s adherence to NICE guidelines 226 “Osteoarthritis in over 16s: diagnosis and management” for the management of osteoarthritis patients regarding weight-loss. Method This audit analysed 15 osteoarthritis patients with a BMI>30 who underwent total joint replacements from November 2021 to November 2022. Patient records were analysed for their weight management from 3-12 months prior to surgery, up till their surgery period to assess: if weight-loss advice was provided, and if >5% weight-loss took place. Standards were designated per clinician recommendations and NICE guidelines. Results All osteoarthritic patients (n = 15) were given weight-loss advice at presentations before surgery. However, only 20% (n = 3) of patients lost >5% of their baseline weight before their joint replacements, against the 50% standard. Therefore, interventions to improve weight-loss in patients and clinician guidance were implemented. These include a targeted poster, detailed weight-loss advice packs for patients, and clinician education about weight-loss programmes available locally. Conclusions The first part of the audit indicates suboptimal performance by Darwen Health Link. Their performance will be re-audited in 3 months post-interventional implementation. Reducing osteoarthritis’s burden on patients in primary care can significantly reduce pain and the need for surgery.

FTP4.9 An audit to measure if >5% reduction in weight occurred, as recommended by the National Institute of Health and Clinical Excellence (NICE), for patients suffering from osteoarthritis before their scheduled total joint replacement surgery, at Darwen Health Link Surgery

Abstract Aim Osteoarthritis causes damage to synovial joints, manifesting as pain, loss of function, and disability. A high BMI is correlated with an increased incidence of osteoarthritis, for which NICE recommends a >5% (ideally >10%) decrease in baseline weight to improve pain and functionality. This audit aims to measure Darwen Health Link’s adherence to NICE guidelines 226 “Osteoarthritis in over 16s: diagnosis and management” for the management of osteoarthritis patients regarding weight-loss. Method This audit analysed 15 osteoarthritis patients with a BMI>30 who underwent total joint replacements from November 2021 to November 2022. Patient records were analysed for their weight management from 3-12 months prior to surgery, up till their surgery period to assess: if weight-loss advice was provided and if >5% weight-loss took place. Standards were designated per clinician recommendations and NICE guidelines. Results All osteoarthritic patients (n=15) were given weight-loss advice at presentations before surgery. However, only 20% (n=3) of patients lost >5% of their baseline weight before their joint replacements, against the 50% standard. Therefore, interventions to improve weight-loss in patients and clinician guidance were implemented. These include a targeted poster, detailed weight-loss advice packs for patients, and clinician education about weight-loss programmes available locally. Conclusion The first part of the audit indicates suboptimal performance by Darwen Health Link. Their performance will be re-audited in 3 months post-interventional implementation. Reducing osteoarthritis’s burden on patients in primary care can significantly reduce pain and the need for surgery.

Functional constipation in preschool and school age children: ways to solve the problem

Functional constipation is a significant medical problem in pediatrics. Constipation often causes discomfort in children of any age and, in the absence of timely and effective treatment, can lead to chronic intoxication and the development of various complications, ultimately affecting the patient's quality of life. The article presents the definition of functional constipation in children over 4 years of age in accordance with the Rome IV Criteria (2016), etiology, pathophysiological mechanisms, clinic, diagnostic criteria and differential diagnosis of functional and organic constipation in preschool and school age children, possible complications. In accordance with the draft Consensus of the Society of Pediatric Gastroenterologists (2013), for a more objective assessment of the nature of the stool, the Bristol scale of stool forms is given. The physiology of the colon and the role of motor disorders in the occurrence of functional constipation are described. The physiology of the colon and the role of motor disorders in the occurrence of functional constipation are described. In accordance with the recommendations of the National School of Gastroenterology, the National Institute of Health and Clinical Excellence (NICE) in the UK, ESPGHAN and NASPGHAN, the basic principles of constipation therapy in preschool and school age children are given. The main groups of drugs that are used in the treatment of constipation in children of this age are described: stimulating and osmotic laxatives, prokinetics. Numerous foreign studies and clinical recommendations indicate that stimulants are effective and safe for the treatment of functional constipation, including in children's practice and are most in demand. The analysis of the use of one of the main drugs of the group of stimulating laxatives - sodium picosulfate in numerous international and Russian clinical studies is presented. The effectiveness and favorable safety profile of sodium picosulfate, the possibility of individual dose selection in connection with the liquid form of release are shown. A clinical example of the treatment of functional constipation in a 6-year-old child is given.

Resistant Chronic Spontaneous Urticaria - A Case Series Narrative Review of Treatment Options.

Chronic spontaneous urticaria (CSU) can be extremely debilitating to the patient and challenging for the treating clinician. The National Institute of Health and Clinical Excellence (NICE) in the United Kingdom (UK) recommendation of omalizumab for patients who fail to respond to high-dose anti-histamines has improved treatment options and quality of life. However, there is still lack of clear guidelines for treatment of patients resistant to standard and anti-IgE therapies. We discuss the therapeutic strategies employed among nine extremely resistant CSU cases and the heterogeneity between guidelines from different societies. Patients with anti-histamine-resistant urticaria either remained on omalizumab or started on immunosuppressive drugs (dapsone or ciclosporin) when they stopped responding to omalizumab. We used clinical assessment, skin biopsies (when available) and previous published reports to consider dapsone (for predominantly neutrophilic infiltration), or ciclosporin at doses between 2 and 4 mg/kg/day. One patient with ciclosporin-resistant urticaria responded to mycophenolate mofetil. Two patients remain on long-term omalizumab due to its relative safety and efficacy including 1 patient with underlying antibody deficiency where omalizumab was preferred over risks of using immunosuppressive medications. These case studies bring to light the real-world difficulties in managing patients with resistant CSU and the need for generating the evidence base on alternative therapeutic options such as synergistic use of biologics and immunosuppressive drugs.

Final nail in the coffin.

Synthetic midurethral slings (MUS) for the management of stress urinary incontinence (SUI) have come under intense scrutiny of late. The NICE (National Institute of Health and Clinical Excellence) guidelines for the management of urinary incontinence over the past 15 years have continued to be cautious in their recommendations of the obturator MUS whilst being supportive of the retropubic (RP) MUS. In the 2006 NICE clinical guidance (CG 40), the advice was to make women aware of the "lack of long-term data" for obturator MUS. In 2013 (CG 171), when this guidance was updated, the advice remained unchanged.

The Cheshire & Merseyside Collaborative trainee-led on-call service: a review of safety and efficiency

To assess safety and efficiency of the Cheshire & Merseyside Collaborative, the largest trainee led on-call service in the UK, based on discrepancy rates and time taken to issue reports. All studies reported by the collaborative in a 4-week period were evaluated for discrepancy and the time taken to issue a report. These figures were compared against the Royal College of Radiologists (RCR) guidelines and a recent national audit of discrepancy rates. The time taken to report was measured against the National Institute of Health and Clinical Excellence (NICE) and Trauma Audit Research Network (TARN) guidelines. The overall discrepancy rates for the collaborative were 2.5% for minor discrepancies and 2% for major discrepancies, which is within the RCR standard. The median time taken to issue a report was 30 min, which is within the NICE and TARN 1-h targets. The Cheshire & Merseyside Collaborative can be deemed a safe and efficient way of delivering an out-of-hours radiology service.

SAT0409 BIOLOGIC TREATMENT IN PSORIATIC ARTHRITIS AND AXIAL SPONDYLOPATHY REDUCES SICKNOTES ISSUED BY GPS, DESPITE DELAYS IN DIAGNOSIS: A REAL-LIFE STUDY IN WALES.

Background:Seronegative inflammatory arthritis including psoriatic arthritis (PsA) and axial spondyloarthropathies (AxS) are chronic inflammatory diseases associated with significant morbidities. The National Institute of Health and Clinical Excellence (NICE) has produced several pieces of guidance on disease management including the use of biologic therapies which have been shown to improve patient outcomes and quality of life. However, there are limited real-life data on patient journey from symptom onset to diagnosis and treatment including with biologics in the UK.Objectives:The purpose of this study is to examine the real-life patient journey from symptom onset to diagnosis and treatment.Methods:Data from the Secure Anonymised Information Linkage (SAIL) databank in Wales, which holds over a billion anonymised records, were used to assess the treatment of patients with PsA or AxS, aged 18 years or over with at least one READ code present for PsA or AxS in their primary care records. We examined the drug use of patients across primary, secondary care and specialist rheumatology clinics to explore the use of NSAIDs, DMARDs and biologics in the real-life setting while exploring demographics, comorbidities and surgical procedures of 1829 PsA and 908 AxS patients.Results:The AxS patients were significantly younger at diagnosis and were predominantly male. Typical delays in diagnosis of 8-9 years from symptom onset were observed. The rate of stopping or switching a biologic medication was similar for AxS and PsA patients (Table 1). There was a significant reduction in sicknotes issued following biologic initiation for PsA (Difference: 14.6%, 95% CI: 8.7% to 20.4%) and AxS (Difference 16.9%, 95% CI: 10.5% to 23.3%)Table 1.Characteristics of treatment of PsA and AxS patientsPsA (n=1829)AxS (n=908)Difference (95% CI)Female (%, n)55.1% (1007)29.1% (264)26 (22.2 to 29.6)*Mean age at diagnosis (years, SD)46.9 (14)43.5 (14.4)3.4 (2.3 to 4.5)*BMI (Index, SD)30.3 (6.3)28 (5.8)2.3 (1.8 to 2.8)*Time from symptom to diagnosis (years, SD)8.9 (5.5)8.0 (5.6)0.9 (0.5 to 1.3)Hypertension at diagnosis (%, n)24.2% (442/1829)19.4% (176/908)4.8 (1.5 to 8.0)*Time from diagnosis to biologic (years, SD)6.3 (4.7)6.1 (5.0)0.2 (-0.9 to 0.5)Used a Biologic (%, n)23% (420/1829)36.8% (334/908)13.8 (10.2 to 17.5)*NSAIDs used pre-biologic (SD)11.3 (3.2)11.6 (3.2)0.3 (-0.2 to 0.8)Number of DMARDs used pre-biologic (SD)3.1 (1.5)2.5 (1.7)0.6 (0.4 to 0.8)*Biologic treatment change/failure (%, n)21.6% (92/425)22% (74/336)0.4 (-6.4 to 5.5)Sicknotes issued by GPᵻpre-biologic (SD)33.9% (144/425)33.6% (113/336)0.3 (-6.5 to 7.0)Sicknotes issued by GPᵻpost-biologic (SD)(%, n)19.3% (82/425)16.7% (56/336)2.6 (-2.9 to 8.0)Hospitalised for serious infection pre- diagnosis (%, n)7.2% (131/1829)6.3% (57/908)0.9 (-1.2 to 2.8)Hospitalised for serious infection post- diagnosis (%, n)10.4% (190/1829)11.6% (105/908)1.2 (-1.3 to 3.8)Hospitalised for serious infection post- biologic (%, n)5.6% (24/425)6.3% (21/336)0.7 (-2.8 to 4.2)* Significant at p<0.05ᵻ General practioner/Primary care physicianConclusion:Patients with PsA and AxS were treated with NSAIDs and DMARDs prior to receiving biologic medication in accordance with NICE guidelines. However, there was a long delay from symptom onset to diagnosis. Biologic treatment reduced sicknotes issued by GPs confirming the benefit of biologic treatment on work productivity observed in clinical trials.Acknowledgments:The work is funded by a Investigator-led grant from Novartis Pharmaceuticals UK LimitedDisclosure of Interests:Ernest Choy Grant/research support from: Amgen, Bio-Cancer, Chugai Pharma, Ferring Pharmaceuticals, Novimmune, Pfizer, Roche, UCB, Consultant of: AbbVie, Amgen, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Chelsea Therapeutics, Chugai Pharma, Daiichi Sankyo, Eli Lilly, Ferring Pharmaceuticals, GlaxoSmithKline, Hospita, Ionis, Janssen, Jazz Pharmaceuticals, MedImmune, Merck Sharp & Dohme, Merrimack Pharmaceutical, Napp, Novartis, Novimmune, ObsEva, Pfizer, R-Pharm, Regeneron Pharmaceuticals, Inc., Roche, SynAct Pharma, Sanofi Genzyme, Tonix, UCB, Speakers bureau: Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Chugai Pharma, Eli Lilly, Hospira, Merck Sharp & Dohme, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Roche, Sanofi-Aventis, UCB, Sinead Brophy: None declared, Roxanne Cooksey: None declared, Lindsey Hanson Employee of: Lindsey Hanson is a permanent employee of Novartis Pharmaceuticals UK Limited, Anna Halliday Shareholder of: Anna Halliday owns Novartis share, Employee of: Anna Halliday is a permanent employee of Novartis Pharmaceuticals UK Ltd.

Working on healthy choices

Working on healthy choices

Prevalence and pregnancy outcomes of gestational diabetes mellitus by different international diagnostic criteria: a prospective cohort study in Vietnam

Background: Several diagnostic criteria for gestational diabetes mellitus (GDM) have been developed and used internationally. This study estimated the prevalence of GDM and pregnancy outcomes among Vietnamese women.Methods: A prospective cohort study of 2030 women was undertaken in Vietnam between 2015 and 2016. Baseline interview and a single-step 75-g oral glucose tolerance test (OGTT) were conducted at 24–28 weeks of gestation. GDM was defined by five international diagnostic criteria: America Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), International Association of the Diabetes and Pregnancy study groups (IADPSG), National Institute of Health and Clinical Excellence (NICE), and World Health Organization (WHO). Maternal and neonatal outcomes were assessed using medical records. Besides descriptive statistics and univariate analyses, logistic regressions were performed to ascertain the associations between GDM and maternal and neonatal outcomes.Results: The prevalence of GDM varied considerably by the diagnostic criteria: 6.4% (ADA), 7.9% (EASD), 22.8% (IADPSG/WHO), and 24.2% (NICE). Women with GDM according to EASD were more likely to have macrosomic infants (adjusted odds ratio (OR) 4.35, 95% confidence interval [CI]: 1.49–12.72), despite no apparent increase in risk under other criteria. Babies born to mothers with GDM appeared to be large-for-gestational age (LGA) by ADA criteria (adjusted OR 2.10, 95% CI: 1.10–4.02) or EASD criteria (adjusted OR 2.15, 95% CI: 1.16–3.98), when compared to their counterparts in the normal group. No significant differences in maternal and other neonatal outcomes were found between the normal and GDM groups.Conclusions: A global guideline is needed for the diagnosis, prevention and management of GDM.

Weight Status at Postpartum: Being Normal Weight Yet Centrally Obese!

Background: Obesity among women of child-bearing age has been a public health concern in the recent past. Central obesity has been found to be rising in different countries. Objectives: This study determined prevalence and correlates of central obesity and normal weight central obesity among postpartum women. Study Design: Randomly selected 460 postpartum women attending health facilities for vaccination/growth monitoring of their infants in Kasarani sub-county, Nairobi County, Kenya took part in the study. BMI was used to measure overall obesity. Central obesity was assessed by waist circumference (WC), waist to hips ratio (WHR) and waist to height ratio (WHTR). National Institute of Health and Clinical Excellence (NICE) BMI-WC index was used to assess health risk. Bivariate analysis was used to determine correlates of central obesity. Results: The prevalence of CO as defined by WC, WHR and WHTR were 66.3%, 62.1% and 50.6% respectively. Prevalence of normal weight central obesity was 39.2%, 36.5%, and 34.4% by WC, WHR, and WHTR respectively. One in every three participants, 38.6%, had high or very high health risk while 15% had increased risk and 44.1% had no increased health risk. Parity and age showed significant positive association with central obesity (Age: WC r = 0.156, p ≤ 0.001; WHTR r = 0.190, p ≤ 0.001; Parity: WC r = 0.0126, p = 0.009; WHTR r = 0.149, p = 0.002). Conclusion: Central obesity prevalence was high regardless of the measure used. About a third of the postpartum women with normal weight BMI was centrally obese and was either at high or very high health risk. Health care workers should therefore use a central obesity measure alongside BMI when assessing nutrition status in the study setting.

Management of Metastatic Spinal Cord Compression in Ireland: Are Surgeons Overlooked?

The National Institute of Health and Clinical Excellence (NICE) provide a framework of evidence-based guidelines for the management of metastatic spinal cord compression (MSCC). We aimed to compare our center's provision of service to these best practice guidelines and discuss key shortcomings with their implications for the spinal surgeon. Patients with radiologic evidence of MSCC over a 30-month period were identified using the hospital electronic radiological database. A chart review was performed analyzing MSCC management. Forty-one patients were identified. Pain was the most common presenting complaint, occurring in 76% of patients. Radiotherapy alone was the most common therapy employed (93% of patients). A surgical opinion was sought for 51% of patients. Histological diagnosis of the causative lesion occurred in 5 patients from surgical specimens. Incongruities between NICE guidelines and our practice exist. Early involvement of the spinal surgical services needs to be encouraged. Establishing a histological diagnosis of the spinal lesion should be seen as of therapeutic importance.

P07-11 - Management of Atrial Fibrillation post cardiac surgery

Atrial Fibrillation post cardiac surgery is associated with morbidity and long term sequalae. It is common post Cardiac surgery especially following valvular surgery. There is clear guidance from the National Institute of Health and Clinical Excellence (NICE) about management of patients to prevent and manage postoperative Atrial Fibrillation. "Unless contraindicated, offer a rhythm-control strategy as the initial management option for the treatment of postoperative atrial fibrillation following cardiothoracic surgery".

PTH-021 Reassessing The Value of Gastroscopy for The Investigation of Dyspepsia

Introduction The National Institute of Health and Clinical Excellence (NICE) first recommended a policy of H. pylori test and treat or empirical full dose proton pump inhibitor therapy for uninvestigated dyspepsia in 2004. 1 Following an initial fall in demand for gastroscopy (OGD), there has been a 30% increase in the last five years. 2 Whilst regarded as the gold standard, it is uncomfortable, costly, may require sedation and carries the risks of intubation. In an era when non-invasive tests are emerging, the role of OGD requires re-evaluation. Methods Data from consecutive OGDs performed between September 2015 and January 2016 to investigate dyspepsia was analysed. We determined the percentage of patients in whom OGD ± biopsy changed management as defined by an approach other than the non-invasive NICE recommendations. 1 Results 500 patients (39.8% male; mean age 58±16.1) underwent OGD for dyspepsia, some of whom also had dysphagia (6%), anaemia (4%), vomiting (4.2%) or suspected gastrointestinal (GI) bleeding (0.6%). 145 (29%) were sedated (midazolam (mean±SEM) 2.0 mg±1.0; fentanyl (when used) 50 mcg±23). 381 patients (76.2%) had abnormal endoscopy; 417 (83.4%) had biopsies taken (15.8% for histological assessment, 27.4% for rapid urease tests, 40.2% for both). Findings of uncertain relevance, or which could have been managed with empirical therapies, were seen in 299 patients (59.8%; including oesophagitis (n = 122), hiatus hernias (n = 178), gastric polyps (n = 34), gastritis (n = 236), gastric ulcers (n = 9), gastric erosions (n = 32), duodenitis (n = 40), duodenal ulcer (n = 1), duodenal erosions (n = 15) and a duodenal polyp (n = 1)). Diagnoses which would not have been appropriately managed by empirical therapies numbered 82 (16.4%). These included 71 (14.2%) patients with Barrett’s oesophagus (n = 39), oesophageal stricture (n = 2), oesophageal cancer (n = 1) and gastric cancer (n = 4) diagnosed at the time of endoscopy. An additional 11 (2.2%) diagnoses were made solely by histology, which included eosinophilic oesophagitis (n = 1), eosinophilic gastritis (n = 1), intestinal metaplasia (n = 3) and coeliac disease (n = 6). Conclusion Diagnoses which alter management are made by endoscopy in only 14.2% of patients with dyspepsia. Although the majority of patients have biopsies taken, the added value increases the yield to only 16.4%. Non-invasive, cost-effective diagnostic strategies are needed to better guide patient management and select the minority of patients who need endoscopic biopsy or therapy. References 1 www.nice.org.uk/guidance/CG184 (2014 update) 2 https://www.england.nhs.uk/statistics Disclosure of Interest None Declared

Preparing for Completely Smoke-Free Mental Health Settings: Findings on Patient Smoking, Resources Spent Facilitating Smoking Breaks, and the Role of Smoking in Reported Incidents from a Large Mental Health Trust in England.

Introduction: Despite high smoking prevalence and excessive smoking-related morbidity and mortality among people with mental disorder compared to the general population, smoking treatment is often neglected in mental health settings. The UK National Institute of Health and Clinical Excellence (NICE) recently issued public health guidance stipulating completely smoke-free mental health settings. This project evaluated existing smoking-related practices in preparation for guidance implementation. The objectives were to: audit the recording of smoking-related information and treatment provision; explore current arrangements relating to the facilitation of patient smoking; measure staff time spent and identify costs of facilitating smoking; and explore the role of smoking in smoking-related incidents. Methods: A mixed-methods study was conducted across four acute adult mental health wards, accommodating 16 patients each, over six months. It included a case-note audit, on-site observations, and a qualitative content analysis of incident reports. Results: Smoking status was recorded for less than half of the 290 patients admitted (138, 48%). Of those, 98 (71%) were recorded as current smokers, of whom 72 (74%) had received brief smoking cessation advice. Staff spent 6028 h facilitating smoking, representing an annual cost of £131,040 across four wards. Incident reports demonstrated that smoking facilitation was often central to the cause of incidences, triggered frustration in patients, and strained staff resources. Conclusion: The findings highlight the importance and potential of implementing completely smoke-free policies using comprehensive pathways.

Limits on costs and values of anticancer drugs in metastatic colorectal cancer: Policies and proposal.

607 Background: Guidelines from the National Institute of Health and Clinical Excellence (NICE) in the United Kingdom (UK) set limits on cost-effectiveness ratios (ACER) of 20,000-30,000 pound per quality of life-year gained (QALY). Bevacizumab (Bev) is not approved in UK in 1st-line metastatic colorectal cancer (mCRC). The objectives were twofold:1- Propose limits of 5,000 in Unites Sates dollars (US$) on 4-week drug costs and values 2- Weigh and compare drugs in various lines of mCRC. Methods: The 4-week costs (4wC) were calculated. Values were expressed as 4wC x hazard ratio of death (HR). Relative values (RV) were computed as 5,000/values. Results: In 1st-line, 4wC of Bev (5.0mg/Kg) was $4,620, values 3,049 and RV 1.64. Panitumumab (Pan) were $8,223, values 6,833 and RV 0.73 Cetuximab (Cet) were $9,775, values 7,820 and RV 0.64. In 2nd- line, 4wC of Aflibercept (Afl) was $5,000, RV 1.22, Bev (10 mg/KG) $9,240, RV 0.72 and Ramucirumab (Ram) $11,200 with RV 0.53. Regorafenib (Reg) in refractory disease had 4wC of $9,400, value 7,238 and RV 0.69. Trifluridine/tipiracil (TAS 102) at projected costs of $5,000 to $9,000, values were estimated at 3,400 to 6,120 with RV of 1.47 to 0.82. Conclusions: In 1st-line Bev had lower 4wC with higher values and RV than Pan, Cet and the $5,000 proposed limits. In 2nd-line, Afl was at the borderline of limits. Costs of Pan, Cet, Ram and Bev in 2ndand Reg in refractory disease were excessive and inflated for their values. Preliminary cost evaluation of TAS 102 seemed promising.

Glue, steam and Clarivein--Best practice techniques and evidence.

In July 2013, the National Institute of Health and Clinical Excellence (NICE) recommended "endothermal" ablation (meaning endovenous thermal ablation) is the first line treatment for truncal venous reflux in varicose veins. The initial endovenous thermoablation devices were radiofrequency ablation and endovenous laser ablation. More recently, Glue (cyanoacrylate), endovenous steam and Clarivein (mechanochemical ablation or MOCA) have entered the market as new endovenous techniques for the treatment of varicose veins. Glue and Clarivein do not require tumescent anaesthesia and do not use heat and therefore termed non-tumescent non-thermal (NTNT). Steam both requires tumescence and is also a thermal technique (TT). This article reviews the current position of these 3 new technologies in the treatment of varicose veins.

The changing landscape of infective endocarditis in the Netherlands.

Despite advances in the diagnosis and treatment of infective endocarditis (IE), the in-hospital mortality of IE has remained unchanged at about 20 %. Subgroups of patients such as those with prosthetic valve IE, IE associated with congenital heart disease or caused by certain microorganisms such as Staphylococcus aureus are at a much higher risk for complications, and may have one-year mortality rates of up to 60 % [1]. These high mortality rates, in combination with the advent of antibiotics, have led to the recommendation of antibiotic prophylaxis in guidelines since the early 1950s. Lately, increasing debate concerning microbacterial resistance due to possible overuse of antibiotics and lack of evidence supporting the use of antibiotic prophylaxis, has led to a change in policy in favour of restriction of antibiotic prophylaxis. The 2008 National Institute of Health and Clinical Excellence (NICE) guideline for IE has been cause for debate, advocating complete cessation of the use of antibiotic prophylaxis altogether. However, up to 20 % of UK physicians admit to prescribing antibiotic prophylaxis in very high-risk groups [2]. The situation in the UK may therefore be rather similar to the Netherlands, where 2008 European Society of Cardiology (ESC) and national guidelines recommend antibiotic prophylaxis use in high-risk patients, during high-risk procedures. In the current issue of the Journal, Krul et al. [3] have shown a gradual increase in the incidence of IE in a large non-academic hospital in the Netherlands. They have started the registry of cases in parallel with the introduction of the new guidelines for the prevention of endocarditis in the Netherlands. The design of the study may have caused under-registration of the occurrence of IE, as only the diagnosis treatment code (DBC) was screened for IE. Patients suffering from multiple disorders in intensive care environments may thus have been missed. Interestingly, the authors show that the increase of IE is mainly due to increase in prosthetic valve endocarditis, thus a population that received antibiotic prophylaxis to prevent IE according to ESC and Dutch guidelines. One could conclude from these figures that the increase in IE incidence is due to a higher prevalence of predisposing factors for IE rather than more restrictive prescription of antibiotic prophylaxis. This is in line with several recent studies. Finally, improving on larger studies with a similar design [4], the authors were able to retrieve the causal microorganism in all IE cases. They show that microorganisms typically found in mucosal infections caused the majority of IE cases. The notion that IE may be caused by bacteria from the mouth was suggested over 100 years ago [5]. Dental procedures have been pointed out as a source for bacteraemia causing IE. However, several large studies compared dental extraction with daily activities such as tooth brushing, and found that brushing teeth can cause bacteraemia in up to 32 % of cases [6]. Their data suggest that bacteraemia due to simple daily activities (including chewing food) may occur hundreds of times more often than bacteraemia due to dental procedures, or other medical procedures. This again calls the use of antibiotic prophylaxis for IE prevention into question. Rather, prevention of longstanding low-grade infection seems prudent. Krul et al. [3] suggest a large-scale registry to further elucidate mechanisms underlying IE increase in the Netherlands. Such efforts have been undertaken in international consortia such as the International Collaboration for Endocarditis. Other successful approaches have employed population-wide entry of all medical records in research databases such as the Rochester Epidemiology Project in Olmsted County, USA. With the recent introduction of mandatory International Classification of Disease (ICD-10) registration of all patients within the Netherlands, a Dutch national registry is possible. While registry of disease will improve disease understanding, prevention of IE could be most effective by education of our patients at risk for IE. Dental hygiene and prevention of caries and parodontitis are an integral part of the Dutch guidelines, and should be discussed with any patients at risk. In addition, patients suffering from alarm symptoms such as ongoing fever despite antibiotic treatment, or symptoms indicative of heart failure or thrombotic events, should seek medical attention. Patient education, and thereby patient empowerment, could be one of the most important tools to improve patient survival in IE.

Vitamin D supplementation should be routine in pregnancy: AGAINST: Proven benefits of vitamin D supplementation remain elusive.

Obstetricians have an unfortunate track record of implementing interventions before they are properly evaluated—examples include thalidomide for pregnancy nausea, tocolytics to suppress preterm labour, and vitamins C and E for the prevention of pre-eclampsia. In 2012 the Chief Medical Officers of the UK (Vitamin D—advice on supplements for at risk groups) recommended that, ‘All pregnant and breastfeeding women should take a daily supplement containing 10 μg of vitamin D’. However, as recently as 2003 the National Collaborating Centre for Women's and Children's Health antenatal care guideline (p.42) had recommended that ‘There is insufficient evidence to evaluate the effectiveness of vitamin D in pregnancy. In the absence of evidence of benefit, vitamin D supplementation should not be offered routinely to pregnant women’. This was updated in 2008 (p.12) to ‘women may choose to take 10 μg of vitamin D per day’ and supplementation was only ‘advised’ in women in high-risk groups (essentially, those with pigmented skin, or who usually remain covered when outdoors, or who have a poor diet, or are obese). There have been claims for the benefits of vitamin D in almost every pathological condition, and yet proven benefits remain elusive (Harvey BMJ 2012;345:e4695). The US Institute of Medicine in 2010 (Dietary Reference Intakes for Calcium and Vitamin D) concluded that, ‘More targeted research should continue. Higher levels have not been shown to confer greater benefits, and in fact, they have been linked to other health problems, challenging the concept that “more is better”. There is emerging evidence that too much of these nutrients may be harmful’. The Committee on Obstetric Practice of the American College of Obstetricians and Gynecologists (Vitamin D: Screening and Supplementation During Pregnancy) stated in July 2011 that, ‘At this time there is insufficient evidence to support a recommendation for screening all pregnant women for vitamin D deficiency’ and suggested that ‘vitamin D supplementation during pregnancy beyond that contained in a prenatal vitamin should await the completion of ongoing randomized clinical trials’. A 2013 comment in the Lancet suggested that the safest approach was to recommend supplementation only in high risk women as defined by the National Institute of Health and Clinical Excellence (NICE) (Steer Lancet 2013;381:2143–5). The latest Health Technology Assessment review of vitamin D supplementation in pregnancy (Health Technol Assess 2014;18:1–190) has concluded that ‘It is not possible to make rigorously evidence-based recommendations regarding maternal vitamin D supplementation during pregnancy’ and added ‘Although modest doses of vitamin D in pregnancy might well be relatively safe, at least in the short term, there are no long-term data to inform their potential long-term effects on offspring health. As with most interventions, it is probably optimistic to expect that there will be no risk of adverse events’. Surely it is time that we learned to do the proper studies before making potentially harmful recommendations. Philip Steer is Emeritus Editor, BJOG. For a full disclosure of interests, please go to www.BJOG.org.

Guideline references and academic citations as evidence of the clinical value of health research

This article introduces a new source of evidence of the value of medical‐related research: citations from clinical guidelines. These give evidence that research findings have been used to inform the day‐to‐day practice of medical staff. To identify whether citations from guidelines can give different information from that of traditional citation counts, this article assesses the extent to which references in clinical guidelines tend to be highly cited in the academic literature and highly read in Mendeley. Using evidence from the United Kingdom, references associated with the UK's National Institute of Health and Clinical Excellence (NICE) guidelines tended to be substantially more cited than comparable articles, unless they had been published in the most recent 3 years. Citation counts also seemed to be stronger indicators than Mendeley readership altmetrics. Hence, although presence in guidelines may be particularly useful to highlight the contributions of recently published articles, for older articles citation counts may already be sufficient to recognize their contributions to health in society.

Implementing NICE obesity guidance for staff: an NHS trust audit.

The UK National Institute of Health and Clinical Excellence (NICE) has produced guidelines (CG43) on preventing and managing overweight and obesity, which apply to the National Health Service (NHS) as an employer. To record in an NHS trust baseline assessment and management of obesity by its occupational health (OH) service staff, with reference to the standards in CG43, enabling deficiencies to be identified and improvements to be recommended as a benchmark for future measurement. Criteria relevant to OH in CG43 were identified and data were collected from trust policies, interviews with managers, questionnaires to OH staff, examination of OH resources and case notes of staff attending OH. Results were checked for compliance with CG43 standards. Although the trust met NICE standards as an employer, significant lack of compliance was found in its OH service. Only 53% of staff attending medical examinations had weight recorded, OH resources were inadequate and 75% of its staff had received no training. Problems identified included lack of written guidance, time and care pathways. The resulting action plan included a consultant-led working party liaising with the trust's health and well-being committee, training, enhanced OH resources, an obesity protocol, a database and weight management clinics. We found not only a lack of OH policy guidance but apparent inertia in dealing with obesity. The action plan demonstrated how OH clinical practice can draw upon CG43 to combat obesity in an NHS workforce.