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The NICE Guideline (NG23) 2015 Menopause: Diagnosis and Management states that ‘women who are likely to go through the menopause as a result of medical or surgical treatment should be offered support and information about the menopause and fertility before they have their treatment, and a referral to a Health Care Professional with expertise in the menopause’. To investigate whether discussion about the surgery causing the menopause, and advice on possible treatments had been documented, I conducted a retrospective study of women undergoing bilateral oophorectomy at a central London teaching hospital from 1st April 2018 to 30th September 2018. Only 30% of women (8 out of 27) in this study had documentary evidence of having received menopause advice around the time of bilateral oophorectomy.

The NICE guideline on managing pregnancy induced hypertension recommends a low dose aspirin as prophylaxis for pre-eclampsia. Eligibility for aspirin is assessed using risk factor-based evaluation using major and moderate risk factors. Understanding prevalence of risk factors as per guideline and the level of adherence of clinicians to guideline are important in managing pre-eclampsia. This study aimed to assess the prevalence of major and moderate risk factors for pre-eclampsia in this population as per NICE guidelines and to understand the clinician's level of adherence to the guideline. A cross-sectional study was carried out in the professorial unit, Teaching Hospital, Anuradhapura, Sri Lanka using a structured data collection sheet to collect data from pregnant women admitted for delivery within a period of one month. Out of 420 pregnant women, 20 (4.5%) had major or moderate risk factors and eligible for aspirin prophylaxis as per NICE guideline. But only seven (35%) of them were identified based on the guideline and given aspirin during antenatal care. There were 11 (2.6%) women with major risk factors but only five were identified and from nine women with moderate risk factors, only two were identified as eligible. Comparatively, identifying eligibility based on major risk factors was higher than moderate risk factors. Although the prevalence of risk factors of preeclampsia is low, there is a gap between NICE guideline recommendations and the actual practice among clinicians in antenatal care from this rural district. Clinicians should be provided with updated information on NICE guideline to improve recognizing risk factors and prescribing aspirin.

Aims While a centralized system for the care of patients with a sarcoma has been advocated for decades, regional variations in survival remain unclear. The aim of this study was to investigate regional variations in survival and the impact of national policies in patients with a soft-tissue sarcoma (STS) in the UK. Methods The study included 1,775 patients with a STS who were referred to a tertiary sarcoma centre. The geographical variations in survival were evaluated according to the periods before and after the issue of guidance by the National Institute for Health and Care Excellence (NICE) in 2006 and the relevant evolution of regional management. Results There had been a significant difference in survival between patients referred from the North East, North West, East Midlands, West Midlands, South West, and Wales in the pre-NICE era (five-year disease-specific survival (DSS); South West, 74% vs North East, 47% (p = 0.045) or West Midlands, 54% (p = 0.049)), which was most evident for patients with a high-grade STS. However, this variation disappeared in the post-NICE era, in which the overall DSS for high-grade STS improved from 47% to 68% at five years (p < 0.001). Variation in the size of the tumour closely correlated with the variation in DSS, and the overall size of the tumour and incidence of metastasis at the time of diagnosis also decreased after the national policies were issued. Conclusion The survival of patients with a STS improved and regional variation corrected after the introduction of national policies, as a result of a decreasing size of tumour and incidence of metastasis at the time of diagnosis, particularly in patients with a high-grade STS. This highlights the positive impact of national guidelines on regional variation in the presentation, management, and outcome in patients with a STS. Cite this article: Bone Joint J 2021;103-B(9):1541–1549.

The aim was to investigate the agreement between the ADI-R Deaf adaptation and ADOS-2 Deaf adaptation overall diagnostic categorisation for autism (AUT) and a wider threshold to include autism spectrum (ASD) in a cohort of deaf children with and without ASD. We compared results of the instruments used on their own and when combined and propose standard criteria for the combined use of the ADI-R Deaf adaptation and ADOS-2 Deaf adaptation for use with deaf children. In total, 116 deaf children had a Gold standard NICE guideline assessment; 58 diagnosed with ASD and 58 without ASD, and for both groups a blinded informant based ADI-R Deaf adaptation and direct assessment using the ADOS-2 Deaf adaptation were separately completed. There was moderate agreement between the ADI-R Deaf adaptation and ADOS-2 Deaf adaptation for the wider threshold of ASD (Kappa, 0.433). To achieve the lowest number of false negatives, the most successful assessment tool approach is using the wider threshold of ASD with either ADI-R Deaf adaptation or ADOS-2-Deaf adaptation (95% sensitivity). This compares with 88% for the ADI-R Deaf adaptation alone and 74% for the ADOS-2-Deaf adaptation alone (wider threshold of ASD). To achieve a low number of false positives, the most successful assessment tool approach is a combination of ADI-R Deaf adaptation and ADOS-2- Deaf adaptation (using the narrow threshold of autism for both) (95% specificity). This compares with 83% for the ADI-R Deaf adaptation alone and 81% for the ADOS-2-Deaf adaptation (narrow threshold) alone. This combination is therefore recommended in specialist clinics for diagnostic assessment in deaf children.

BACKGROUND: In 2018 NHS prescriptions in England cost £8.83 billion. Within ophthalmic prescribing, glaucoma is the most costly indication. The 2017 glaucoma NICE guideline shows there is little evidence for clinical preference of particular molecules within a therapeutic class, yet the cost of these products varies greatly. We aim to describe trends in glaucoma prescribing and its relation to recent NICE Guidance. METHODS: Prescription cost analyses for England from 2009 to 2018 were reviewed and data concerning items for the treatment of glaucoma were extracted. Costs and prescription frequencies were normalised for inflation and population. RESULTS: The 2018 cost of glaucoma prescribing was £114.2 million. This cost is 18.1% lower than in 2009 but the annual number of items prescribed per 10,000 people has increased from 1382 to 1668 (20.7%). This is despite an increased prescription of combination drops from 265 to 478 per 10,000 (80.4%). Preservative free item prescriptions rose from 1.7% of total spend in 2009, at £3.4 million in 2009, to 13.9%, in 2018, at £22.5 million. Generic items represented 11.7% of prescriptions in 2009 and 55.2% in 2018. Around half of glaucoma spending is accounted for by the use of preservative free or branded items in the place of the cheapest item in each therapeutic class. CONCLUSIONS: Glaucoma prescribing costs the NHS a great deal. There is a broad trend to generic prescribing as per recent NICE guidance, but significant further costs could be saved with no robustly evidenced clinical consequence.

ObjectiveInflammatory bowel disease (IBD) is increasingly managed with the use of biologic therapies. National guidelines (National Institute for Health and Care Excellence (NICE)) suggest considering cessation after 1 year of therapy but lack detailed criteria for this. We aimed to describe clinical outcomes from the introduction of a biologic review panel (BRP) to implement modified criteria for cessation of antitumour necrosis factor (anti-TNF) therapy and step down to single-agent immunomodulator.DesignRetrospective review of patient outcomes following BRP implementation.PatientsAll patients on biologic therapy discussed in the BRP within a 5-year period.SettingSingle IBD network covering three hospital sites.InterventionsModified criteria for biologic cessation were based on published evidence; they excluded individuals with no suitable maintenance immunomodulator, previous surgery or evidence of active disease, additional indications for anti-TNF therapy and previous relapse on biologic cessation. All patients with IBD on a biologic were discussed at the BRP.Main outcome measuresRelapse following IBD cessation and relative cost of BRP.Results136 patients with IBD were reviewed, with 45 patients meeting the NICE guideline criteria for cessation. The BRP and modified criteria affected decision to withdraw therapy in 38% of these. Therapy was withdrawn in 27 patients, with a 20% 24-month relapse rate. Younger age at cessation was significantly associated with relapse (p=0.01).ConclusionThe BRP approach has proved a safe and effective means of decision making in stopping biologic therapy. Future work to inform exclusion criteria is required.

Objectives: This study aims to investigate the impact of the national guideline on the prevalence and outcome in patients with soft-tissue sarcoma (STS) who had undergone inadvertent excisions. Methods: A total of 2336 patients were referred to a tertiary sarcoma centre from six regions (North East, North West, East Midlands, West Midlands, Wales, and South West) in the United Kingdom with a diagnosis of STS between 1996 and 2016, of whom 561 patients (24.0%) had undergone inadvertent excisions. Patients were categorised into two groups of 10-year periods pre and post the National Institute for Health and Clinical Excellence (NICE) guideline implementation in 2006. Results: The proportion of inadvertent excisions decreased after the NICE guideline implementation: 27.2% (pre-NICE) versus 19.8% (post-NICE) (p = 0.001). A substantial regional variation (17.4%–34.5%) in the proportion of inadvertent excisions in the pre-NICE era was reduced in the post-NICE era (14.3%–22.4%). The 5-year disease-specific survival was 77.7% (pre-NICE) versus 75.6% (post-NICE) (p = 0.961) and there was a trend toward lower incidence of local recurrence in the post-NICE era; 13.5% (pre-NICE) versus 10.5% (post-NICE) (p = 0.522). Multivariate analyses revealed that residual tumours in re-resection specimens were independently associated with an increased risk of disease-specific mortality (HR, 3.35; p < 0.001) and local recurrence (HR, 1.99; p = 0.017), which was significantly reduced after the NICE guideline implementation (53.2% versus 42.0%; p = 0.022). Conclusions: The NICE guideline implementation reduced the proportion of patients with STS who had undergone inadvertent excisions and residual tumour in re-resection specimens, indicating an improved pre-referral management of STSs.

Chronic pain is debilitating and depressing. ‘Chronic primary pain has no clear underlying condition or the pain (or its impact) appears to be out of proportion to any observable injury or disease. ’1 In July 2014, Sir Simon Wessely stated in an article in The Times entitled, Pain may be in the mind , that: ‘Many of them [chronic pain patients] have mental health disorders — anxiety, depression, etc’, and that, ‘patients felt dismissed and denigrated when they were referred to mental health services … ’. 2 As patient safety campaigners, we are hearing from many people who are developing ‘unexplained’ chronic pain conditions after taking antidepressants (ADs), as prescribed, and sometimes over many years — and this has often led to polypharmacy with other drugs added ‘for symptoms’ along the way, most likely including ADs, benzodiazepines, Z-drugs, opioids, …

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

Introduction/Background Chronic constipation has been shown to lead to poor school performance and consequently deficiencies in education, as well as poor health-related quality of life. In children who suffer from chronic constipation, colonic transit studies (CTS) are ordered by specialist services to provide information that aids clinical management decisions Aim The aim of this audit was to evaluate the impact of CTS outcomes on clinical management decisions involving patients with chronic constipation. It also looked at the radiology reports of included transit studies, specifically at whether they included the number and location of radio opaque markers. The NICE guideline ‘Constipation in children and young people: diagnosis and management’ and The Royal College of Radiologists audit template ‘Complete reporting of colonic transit marker studies’ were used to determine best practice. Subjects and Method A retrospective audit looking at the list of patients with chronic constipation who underwent CTS at Alder Hey Children’s Hospital. Working backwards from November 2019, the first 100 patients who met inclusion criteria were selected. Included patients had to best knowledge conducted CTS in full and also had a clinic letter following completion of the study. Management outcomes were grouped into 4 categories: decrease, no change to management, an increase of oral laxatives or an increase using management stronger than oral laxatives e.g. rectal medications or surgical interventions. Results The majority of included transit studies were requested by either paediatric surgery (n=71) or gastroenterology (n=20). Only 60% of CTS reports included both the number and location of markers and 13% included neither. There was a mean of 8 days from transit study to radiology report completion. The mean transit time was 72 hours, with a range of 0–144 hours. Management outcomes were varied for both normal and slow transit. Twice as many patients with slow transit were managed with therapies stronger than oral laxatives. Patients with normal transit time were over twice as likely to have no change to their management. A transit time of >100 hours resulted in almost 80% of patients being managed with treatment stronger than oral laxatives. Summary and Conclusion There appears to be a trend towards escalating management with intensive combination treatment regimes in patients whose CTS suggested slow transit and especially in patients with transit times greater than 100 hours. The range of the management choices used in patients with normal transit do however illustrate that clinicians within Alder Hey are making clinical decisions based upon the wider clinical picture of the patient, which fits with NICE guidance. This audit does illustrate that CTS radiology reports can be adapted to ensure each report contains the number and location of markers. Recommendations All CTS radiology reports should include the number and location of radio opaque markers. The location of markers should be reported into 3 regions (right colon, left colon and rectosigmoid colon) as suggested. A proforma has been distributed within the Alder Hey radiology department detailing results and recommendations. A re-audit to assess the application of these recommendations is currently underway.

Objectives To evaluate the different policies to recognize child maltreatment in emergency departments (EDs) in Europe in order to define areas of improvement. Methods A survey was conducted on the recognition of child maltreatment in EDs in European countries with a focus on screening methods, parental risk factors, training and hospital policies. The survey was distributed through different key members from the EUSEM, REPEM and the EuSEN. A summary score based on the NICE guideline (4 questions on child characteristics, 4 questions on parental characteristics and 5 questions on hospital policy) was calculated. Results We analysed 185 completed surveys, representing 148 hospitals from 29 European countries. Of the respondents, 28.6% used a screening tool, and 31.8% had guidelines on parental risk factors. A total of 42.2% did not follow training based on child characteristics, and 57.6% did not follow training on parental characteristics. A total of 71.9% indicated that there was a need for training. 50.8% of the respondents reported a standardized policy for the detection of child maltreatment. Translating the survey results to NICE summary scores of the EDs in Europe, we found that 25.6% (34/133) met most, 22.6% (30/133) met some and 51.9% (69/133) met few of the NICE guideline recommendations. More specifically, with respect to hospital policies, 33.8% (45/133) met most, 15.0% (20/133) met some and 51.1% (68/133) met few of the NICE guideline recommendations. Conclusion There is high variability regarding policies for child maltreatment detection and only a quarter of the EDs met most of the NICE guideline recommendations for child maltreatment. There is a need for the use of screening tools, training of ED staff and implementation of local hospital policies.

The National Institute for Health and Care Excellence (NICE) have now published new guidance on the management of diabetic ketoacidosis (DKA) in children, with slightly different recommendations to the British Society of Paediatric Endocrinology and Diabetes (BSPED) 2020 guideline.1 It is a specific update of the fluid therapy recommendations for children and young people with DKA, within the existing NICE guideline for diabetes (2015, NG18).2 This adds to the debate and confusion around the ideal …

Introduction In March 2019, NICE published a lung cancer update evidence review (NICE Guideline NG122) recommending brain imaging for those patients who have stage II or III non-small cell lung cancer prior to treatment with curative intent. We present a multi-centre retrospective review of real world data, looking at the prevalence of brain metastases in our lung cancer cohort. We review the impact on management and compare it with the assumptions made in the economic modelling from the NICE Guideline. Methods Consecutive patients with clinical stage II and stage III lung cancer in the calendar year 2018 (01/01/2018 – 31/12/2018) from 11 acute trusts across the UK were retrospectively reviewed. Patients who had brain imaging as part of their investigations pre-treatment were reviewed to see the impact on radical management. Data was collected on those who presented with brain metastases within 6 months of treatment, who had not previously undergone brain imaging. Patients who died within 6 months of treatment were excluded. Results Data from 579 patients was analysed. Overall the prevalence of brain metastases was 5.5% (10/182) in stage II disease (Pre-treatment cohort 2% (1/51), post-treatment cohort 6.9% (9/131)) versus NICE model prevalence 9.5% (14/161). The prevalence was 6.3% (25/397) in stage III disease (Pre-treatment cohort 4.8% (11/227), post-treatment cohort 8.2% (14/170)) versus NICE model prevalence 9.3% (11/123). Table 1 compares outcomes for the pre-imaged cohort to the data from NG122. Discussion Our large data set from 11 Trusts across the UK demonstrates the prevalence of brain metastases in stage II and III lung cancer is lower than that used in the economic modelling from NICE. We show that 30% of stage III patients who have brain metastases on pre-treatment imaging continue to undergo radical lung cancer treatment (NICE assumption 0%). A much higher percentage of stage III patients undergo brain specific treatments than was assumed in NICE economic model, even when treatment intent is changed to palliative. This data strengthens the argument to consider re-examining the economic analysis with real-world data.

Background The Knowsley Community Respiratory Service (KCRS) provides 24 hours per day, 7 days per week hospital at home support for patients with COPD. Current UK guidance1 recommends that patients with an arterial PaO2 of Aims To evaluate the outcome of patients with COPD exacerbations being managed at home with an arterial PaO2 of Methods Retrospective data were evaluated over a period of 10 months for 103 patients. Smokers (37), Male:42% Female:58%, Mean age: 73, Mean predicted FEV1%: 42.8%. Group A & B Mean NEWS2:3 Results 79 avoided admission (77%) & 24 admitted (23%). Number of patients kept at home but admitted within 30 days is 6 (7.6%). Group A (37) were safely managed at home, Group B (42). More intervention required such as repeat ABG for patients managed at home in group A. Overall 17 patients received 02 titration to prevent a hospital admission (Group A: 10, Group B:7). Conclusion The community respiratory team supports patients to be managed at home safely with a lower Pa02 to avoid unnecessary hospital admission and provide early supported discharge. Reference Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE guideline December 2018.

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

Aim Urine sampling is a common investigation in the paediatric emergency department, often requested at triage. We noticed frequent occasions of samples being incorrectly requested and sent for analysis. This often creates unnecessary inconvenience for patients and carers and can delay discharge. There is also potential for misdiagnosis of UTI and antibiotics being unnecessarily prescribed, as well as increased costs. Our aim was to evaluate staff awareness of the correct investigation for paediatric UTI based on the current NICE guideline (February 2019). This was done with the intention of developing clinical practice, in order to improve patient experience, reduce the number of diagnosis errors, and reduce department costs. Method Twenty-two staff members undertaking paediatric emergency triage were surveyed to check knowledge of the clinical indications for requesting a sample and sending for analysis. An online survey was also carried out to compare our practice with other Trusts. We used The Model for Improvement to test interventions according to errors noted. Results Only 45% (10/22) of staff were aware of the NICE guideline. 59% (13/22) would request a urine sample from all patients presenting with fever. Furthermore, 55% (12/22) would send all samples for patients under 3 years for urgent analysis, regardless of presenting complaint. This contrasted markedly from our online survey results, which showed 58% (7/12) would send samples in those under 1 year, 8% (1/12) in those less than 6 months, and 25% (3/12) in those less than 3 months (as per NICE guidance). In one Trust doctors did their own urine microscopy based on clinical grounds. Conclusion The results of our survey show an inadequate level of staff training regarding paediatric urine sampling and analysis, and awareness of the NICE guideline. This results in unnecessary samples being requested and sent for analysis. To increase staff awareness, posters with easy to follow flow-charts have been produced for the triage rooms and training is underway. We also aim to revise hospital guidelines in accordance with NICE guidance. The future intention is to re-survey triage staff following these changes, and evaluate the cost saving of reduced urine analysis.

Background: The Knowsley Community Respiratory Service (KCRS) provides 24 hours per day, 7 days per week hospital at home support for patients with COPD. Current UK guidance1 recommends that patients with an arterial PaO2 of Aims: To evaluate the outcome of patients with COPD exacerbations being managed at home with an arterial PaO2 of Methods: Retrospective data were evaluated over a period of 10 months for 103 patients. Smokers (37), Male:42% Female:58%, Mean age: 73, Mean predicted FEV1%: 42.8%. Group A & B Mean NEWS2:3 Results: 79 avoided admission (77%) & 24 admitted (23%). Number of patients kept at home but admitted within 30 days is 6 (7.6%). Group A (37) were safely managed at home, Group B (42) . More intervention required such as repeat ABG for patients managed at home in group A. Overall 17 patients received 02 titration to prevent a hospital admission (Group A: 10, Group B:7). Conclusion: The community respiratory team supports patients to be managed at home safely with a lower Pa02 to avoid unnecessary hospital admission and provide early supported discharge. 1. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE guideline December 2018

Globally, pneumonia is responsible for significant morbidity and mortality in children. The incidence of community-acquired pneumonia (CAP) in Europe is estimated to be approximately 33 per 10 000 in those under 5 years of age and 14.5 per 10 000 in those aged 0–16 years.1 In 2019, the National Institute for Health and Care Excellence (NICE) published a guideline on prescribing antibiotics for CAP in adults and children.2 The purpose of the guidance was to optimise antibiotic use and decrease antibiotic resistance. It does not address the management of hospital-acquired pneumonia. This review concentrates on the relevant paediatric advice. Other relevant guidelines include: ‘Fever in under 5s: assessment and initial management’ (NICE 2019, NG143), Self-limiting respiratory tract and ear infections—antibiotic prescribing overview (NICE January 2020) and Cough (acute): antimicrobial prescribing NICE guideline (NG120) (February 2019) (box 1). Box 1 ### Relevant guidelines 1. General prescribing strategies. 2. Which antibiotics to prescribe. 3. Dosing, course length and route of administration. ### General prescribing strategies #### Factors to consider

The new NICE guidelines on thyroid disease and its management do not recommend the routine use of liothyronine, but do not completely rule it out either. Guidelines from the British and European Thyroid Associations are open to a “trial of liothyronine” on an individual basis.Some patients do not feel well on L-thyroxine despite a serum TSH in the reference range. Key issues to consider in such patients include establishing whether the patient had established hypothyroidism initially, and whether the L-thyroxine has been titrated carefully enough, possibly using small increments, to achieve a careful balance between symptoms and serum TSH concentrations. Patients should also be considered for other causes of the symptoms which may be wide-ranging.Meta-analyses of several, but small, randomised control trials show no advantage, or disadvantage of liothyronine over L-thyroxine. However, detailed sub-analysis identifies some tantalising results eg on preferential weight loss, patient preference, and possibly genetic markers. Although linked with plausible theoretical explanations, these results may be over-interpreted. The key questions are whether a short-term trial treatment is worthwhile and safe, and whether in the future sub-groups of patients can be identified who may benefit from liothyronine. These questions remain divisive but require additional focussed research.It could be argued that inflated costs of liothyronine in some countries have either distracted from or helped focus on the science. Costs need to be addressed. However better biomarkers of tissue level thyroid action, and a better understanding of the impact of genetic polymorphisms will help to make progress when choosing if there is a place for liothyronine in the future.(words: 262)

Intra-uterine insemination (IUI) is a cheaper, less intensive treatment modality for achieving a pregnancy in couples with specific indications. The use of IUI seems to have declined after NICE guideline 2013 (CG 156) recommended IVF over IUI in couples with unexplained and mild male factor infertility. This review examines the current evidence and the applicability of IUI as a first-line option of treatment in couples with unexplained and mild male factor subfertility. The outcome of the review supports this argument. It is likely that IUI will re-emerge as an effective treatment option and thereby increase the choice to patients. However, there is a need for ongoing research and investment into funding of good quality trials to improve and strengthen the evidence base.

What you need to know Around 660 000 women give birth in England and Wales each year. Antenatal care provides women (and their partners) with support and information about pregnancy, birth, and the postnatal period, and assesses their risk of complications. Even in fit and healthy women, concerns and complications can still arise, and good quality antenatal care can enable women to identify and manage potential problems, to reduce the chance of poor outcomes for both the woman and the baby, and to enhance the woman’s (and her partner’s) experience of pregnancy and childbirth. This new guideline from the National Institute for Health and Care Excellence (NICE)1 replaces the previous version of the NICE guideline on antenatal care published in 2008. This article summarises recommendations from the guideline. We use the terms “woman” or “mother” throughout, but the guidance should be taken to include people who do not identify as women but who are pregnant. ### What is new in this guidance

Four members of the NICE guideline development committee for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) left the group just weeks before the final guideline was due to be published, The BMJ has learnt. The departures suggest divisions within the committee over the guideline’s final content, which is an update on 2007 guidance on diagnosing and managing ME/CFS. Three have resigned, and one has been removed by NICE. The draft guidance, published in November 2020,1 included significant changes to the 2007 recommendations2 and raised questions about how the evidence could have shifted so substantially. In 2007 NICE recommended interventions such as cognitive behavioural therapy and graded exercise therapy for people with mild or moderate ME/CFS, whereas the draft update cites a “lack of evidence for the effectiveness of these interventions.” …

Chest X-rays (CXR), antibiotics and inhaled/nebulized therapy are overused in bronchiolitis, despite evidence-based guidelines suggesting supportive management only. This study investigates the effect of the implementation of the NICE bronchiolitis guideline in a secondary paediatric unit in England. We present a quality improvement project with a completed audit cycle (winter 2014-2015 and 2015-2016) pre- and post-implementation of the NICE bronchiolitis guideline. The educational intervention included sessions for raising awareness of appropriate and inappropriate management of bronchiolitis for both clinicians and nursing staff. As a result, the number of chest radiographs reduced fivefold (from 20 to 4% of patients, absolute reduction 16%), antibiotics reduced more than threefold (from 22 to 6% of patients, absolute reduction 16%) and inhaled/nebulised treatment up to twofold (from 30 to 16%, absolute reduction 14%). Overall NICE guideline compliance rose from 28 to 63%.Implementation of the NICE bronchiolitis guideline supported by a simple educational intervention can effectively reduce the number of inappropriate chest radiographs and antibiotic prescribing in bronchiolitis, and enhance compliance with the NICE guideline. What is Known: • Bronchiolitis management in paediatric units in the UK is variable, with poor evidence for existing guidance. Best available evidence was compiled into the NICE guideline, aiming to standardize care. • Some evidence exists for the effectiveness of quality improvement approaches to improve the management of bronchiolitis. What is New: • NICE guidance can be effectively applied to a department using simple educational tools. • Effective NICE implementation reduces the rates of unnecessary chest radiograph and antibiotic administration for patients admitted with bronchiolitis in District General Hospitals.

espanolLa rotura de un aneurisma aortico abdominal (AAA) es un evento altamente letal que continua asociada a una alta mortalidad, a pesar de su disminucion en las ultimas dos decadas, asociada a la adopcion de la cirugia endovascular como primera linea de tratamiento y a avances en el manejo anestesico y perioperatorio. La actuacion frente a un AAA roto (AAAr) puede dividirse en cuatro etapas: diagnostico, manejo perioperatorio, cirugia y posoperatorio. En el marco de las guias americana y europea sobre manejo de AAAr y de la Guia NICE, se expone una actualizacion de los puntos criticos en cada etapa: desde el papel diagnostico clave del angio-TAC hasta el manejo de complicaciones posoperatorias, como el sindrome compartimental abdominal. La creacion de protocolos y algoritmos basada en la evidencia ayuda en la toma de decisiones y disminuye el tiempo desde el diagnostico hasta el control hemorragico, esencial para la supervivencia EnglishA ruptured abdominal aortic aneurysm (rAAA) is a highly lethal event remaining associated with a high overall mortality, in spite of the reduction in the mortality from rAAA over the last two decades linked with the adoption of an endovascular aneurysm repair (EVAR) as the forefront strategy, as well as the advances in perioperative critical care practices. Management of a rAAA can be divided into four stages: diagnosis, perioperative management, surgical repair and postoperative period. Within the framework of American and European clinical practice guidelines on the management of abdominal aortic aneurysms and NICE guideline, all of them recently published, updated critical issues for each stage are shown. From the key role of CT angiogram for the diagnosis to the postoperative complications, such as abdominal compartment syndrome The creation of evidence-based protocols and algorithms for rapid diagnosis and treatment aids to make decisions and at the same time it will reduce the time since diagnosis to control of hemorrhage, which is essential for survival.

Background: Long term oxygen therapy provides survival benefit for hypoxic chronic obstructive pulmonary disease (COPD) patients. However concurrent smoking and home oxygen presents significant risk to patients, household and neighbours. NICE COPD guidelines 2018 state ‘Do not offer long-term oxygen therapy to people who continue to smoke despite being offered smoking cessation advice and treatment and referral to specialist stop smoking services’ Aim: Evaluate Respiratory professionals’ opinions on provision of home oxygen in current smokers following NICE guidelines Method: Survey monkey questionnaire was composed and sent via professional networks on email and Twitter Results: 358 individual responses,22% Consultants and 88% worked in respiratory care daily(Fig 1). 75% did at least 1 home oxygen order in last 12 months,41% doing more than 10. 27% would consider prescribing home oxygen to current smokers,46% prescribed home oxygen to current smokers in the past. After NICE guideline,35% reported change to their practice. 45% considered a patient an ex-smoker at 3 months,57% recommending CO monitoring to confirm. Conclusion: Despite NICE guidelines,1 in 4 respiratory professionals would prescribe home oxygen to current smokers, although 1 in 3 report change in their practice. Most consider patients to be ex-smokers after 3 months. Home oxygen provision in current smokers remains highly debated with different opinions in Respiratory community despite current guidelines

Background and aims Practice of prescribing IV fluids in hospitals is invariably left to most junior doctors. Only 16% of surgical consultants feel that junior doctors are appropriately educated in regard to IV fluid prescribing. NICE in December 2013 introduced a guideline for intravenous fluid therapy which was later updated. Methods We audited the practice of prescribing IV fluids in our hospital against the 10 standards of the NICE guideline. We randomly selected 40 adult in-patients (20 medical and 20 surgical) who were on intravenous fluid therapy for at least 24 hours. Medical and nursing notes and prescription charts were assessed as to their compliance with audit standards. Results The compliance of IV fluid therapy was found to be very poorly compliant with the NICE guideline. Only 29% of 10 standards were found to be >90%. Few recommendations were made based on the results. We decided to develop a new IV fluid policy for our hospital. We planned to put together teaching sessions for junior doctors and nursing staffs. We decided to develop more user friendly IV fluid chart integrated with current drug chart. All IV fluids need to be infused via pump. We developed a task team to implement all these recommendations. After a series of meeting including anaesthetists, medical team, nurses and pharmacy, we managed to accomplish an action plan. Conclusions Intravenous fluid therapy is very important part of treatment of patients in hospital. Auditing the practice of IV fluid therapy helps in improving the standards.

Objectives (1) To derive a simple risk score for preterm pre-eclampsia based on the model used in the ASPRE trial, and (2) to compare it (i) with the original ASPRE algorithm, (ii) with the NICE Guideline score, and (iii) with and without biochemical and ultrasonic predictors. Design Prospective cohort study. Setting Cambridge, UK. Population or sample 4184 nulliparous women from the Pregnancy Outcome Prediction study. Methods Maternal history model coefficients from the ASPRE algorithm were translated into a risk score, preserving the relative weight of each coefficient. Main outcome measures Preterm delivery with a diagnosis of pre-eclampsia. Results The area under the ROC curve (AUC) for preterm pre-eclampsia was 0.846 (95% CI 0.787-0.906) for the risk score and 0.854 (95% CI 0.795-0.914) for the original ASPRE algorithm (P = 0.14). In all, 9.1% of women had a risk score of ≥30 and their risk ratio for preterm pre-eclampsia was 13.3 (95% CI 6.3-27.8), sensitivity 57.1% (37.5-74.8%), false-positive rate (1-specificity) 8.8% (8.0-9.7%), and LR+ 6.5 (4.6-9.1). The score had higher specificity than the NICE Guideline criteria. First trimester levels of PAPP-A and PlGF were not predictive when included in a model with the risk score. In contrast, mean arterial pressure at booking and 20-week uterine artery Doppler were independently associated with preterm pre-eclampsia and the latter modestly increased the AUC (by ~0.02). Conclusions A simple risk score derived from the ASPRE screening study predictive model provided clinically useful prediction of the risk of preterm pre-eclampsia. Tweetable abstract A simple risk score derived from the ASPRE screening study provided clinically useful prediction of the risk of preterm pre-eclampsia.

Background Intravenous fluids are one of the most frequently prescribed drugs in hospital, and yet the practice continues to fall short of National Institute for Health and Care Excellence (NICE) guidelines. Paediatric patients are particularly vulnerable to complications of intravenous fluid therapy. Aims, objectives and standards We aim to better prescribing practices of intravenous fluid prescription and fluid balance monitoring by staff in the paediatric wards, and to make recommendations and carry out interventions to improve areas where the adherence to NICE guideline ‘Intravenous fluid therapy in children and young people in hospital’, published in December 2015, is poor, as identified by the first cycle of the audit. Methodology Data was collected prospectively from the notes of patients aged 0 to 16 years admitted in the two general paediatric wards at Mater Dei Hospital over a four month period. Patients started on intravenous maintenance fluids were included. Data included which fluid was prescribed, the indication, prescription practices, input and output charting and monitoring of serum electrolytes and glucose. Children with diabetic ketoacidosis and renal or hepatic disease were excluded. Results A total of 65 patients were included. In only 5% of the treatment charts reviewed was the maintenance intravenous fluid prescribed, despite there being a specific section for fluid prescription. Actual weight was recorded on 89% of the drug charts. Estimated weight was documented in the remaining 11%. 81% of calculations of infusion rate on actual weight were performed correctly according to the Holliday-Segar formula. 100% of patients were administered 5% dextrose in 0.45% saline, as per local availabilities. On admission, U&Es were checked in 97%, and blood glucose in 79% of patients. However, U&Es were only checked in 31% and blood glucose in 14% of the patients still on maintenance fluids 24 hours later. Fluid input and output charting was documented in 94% of patients, but in only 19% of these patients were subtotals written every 24 hours. The standard charts used at Mater Dei Hospital do not have a section for 12 hourly documentation. Conclusion Staff within the department must be educated regarding the need for improved intravenous fluid prescription and the importance of conducting daily U&Es and blood glucose input and output monitoring. Documentation of input and output must also be improved. The input and output charting form needs to be reviewed to include 12 hourly subtotals.

Introduction The NICE Guideline on Epilepsies recommends that any child presenting with an unprovoked first afebrile seizure should be assessed by a paediatrician with specialist interest in epilepsy within 2 weeks. This has arisen from data that suggest that 30%–50% of these patients can develop recurring seizures and misdiagnosis can occur in up to 30% of these patients. The new NHS contract from April 2017 requires hospital staff to arrange internal referrals with a specialist if a patient presents acutely with that problem, rather than requesting the respective general practitioners (GP) to make a specialist referral. Aims To determine what percentage of patients had follow up arranged and where these follow–up arrangements were to, i.e. GP, Children’s Assessment Unit (CAU), Paediatric outpatient clinic To determine the time between the initial patient contact to the clinic appointment Methods Information on patients under the age of 16 who presented with a seizure to the emergency department(ED) between June and December 2017 was collated. A retrospective review of the electronic clinical notes of those who presented with a first afebrile seizure was undertaken. Results 242 entries of patients presenting with a possible seizure was noted during our study period. 53 of these patients presented with a first afebrile seizure in ED. 54% were males, the majority were between the ages of 1 and 5 and generalised tonic-clonic seizure was the commonest subtype seen. 39% were referred to a paediatric outpatient clinic, 28% to CAU and 15% were advised follow up with GP. 32/53 children did not get referred to Paediatric Epilepsy services. Only 1/53 patient was seen in a paediatric epilepsy clinic within the NICE recommended timeframe of 2 weeks. Conclusion Alarmingly, only 40% of patients presenting with a first afebrile seizure are currently being referred appropriately and under 2% of the patients are being seen within the recommended timeframe of less than 2 weeks. We have therefore created a local guideline for children presenting with a first afebrile seizure which includes a clear referral pathway to Paediatric Epilepsy services, with a plan to commence regular First seizure clinics within the trust.

Introduction NICE guideline ‘chest pain of recent onset: assessment and diagnosis’ (CG95) recommends CT Coronary Angiography (CTCA) as the first line investigation for stable chest pain if clinically indicated. The aim is to investigate the need for a coronary artery calcium (CAC) score before CTCA. Methods Retrospective data was collected on patients who underwent both CAC and CTCA from 2016 to 2018. Patients were excluded if they had any previous intervention. Population characteristics and outcomes by year were analysed with Chi-Squared test. Clinically relevant findings were defined as >50% coronary artery stenosis or malignant aberrant courses. Relationship between age and calcium score was analysed with Spearma’s Rank, regression analysis and receiver operating characteristics (ROC). Results 1665 patients were identified and 164 were excluded, leaving 1501 patients (F=735, M=766; Range=17-94; Median=58). The proportion of clinically relevant findings were not significantly changed over the period of study (p>0.2). The proportion of normal scans has decreased from 61% in 2016 to 46% in 2018, with a corresponding increase in mild artery stenosis (p 800 (AUCage:male=0.79; AUCage:female=0.88) Conclusion There was an increase in proportion of patients with mild disease but no significant change in those with clinically relevant findings. Performing a CAC prior to CTCA for patients under 42 years old provides poor value.

ObjectiveTo compare the management recommendations of the Kaiser Permanente neonatal early-onset sepsis risk calculator (SRC) with National Institute for Health and Care Excellence (NICE) guideline CG149 in infants ≥34 weeks’ gestation who developed early-onset sepsis (EOS).DesignRetrospective multicentre study.SettingFive maternity services in South West of England and Wales.Patients70 infants with EOS (MethodsRetrospective virtual application of NICE and SRC through review of maternal and neonatal notes.Main outcome measureThe number of infants recommended antibiotics by 4 hours of birth.ResultsThe incidence of EOS ≥34 weeks was 0.5/1000 live births. Within 4 hours of birth, antibiotics were recommended for 39 infants (55.7%) with NICE, compared with 27 (38.6%) with SRC. The 12 infants advised early treatment by NICE but not SRC remained well, only one showing transient mild symptoms after 4 hours. Another four babies received antibiotics by 4 hours outside NICE and SRC guidance. The remaining 27 infants (38.6%) received antibiotics when symptomatic after 4 hours. Only one infant who was unwell from birth, died. Eighty-one per cent of all EOS infants were treated for clinical reasons rather than for risk factors alone.ConclusionWhile both tools were poor in identifying EOS within 4 hours, NICE was superior to SRC in identifying asymptomatic cases. Currently, four out of five EOS have symptoms at first identification, the majority of whom present within 24 hours of birth. Antibiotic stewardship programmes using SRC should include enhanced observation for infants currently treated within NICE guidance.

To reassess if our hospital has improved its assessment of delirium diagnosis, prevention and management after raising awareness of delirium through education, training and dissemination of delirium care bundle throughout the trust. A prospective sample of patients admitted to a district general hospital between 1 April 2017 to 8 April 2017 with confusion or developed confusion during their hospital stay. A total of 28 patients were identified and their notes were reviewed. The National …

NICE produced a guideline for the diagnosis and management of CF (NG78) in October 2017. This paper describes the process of producing the guideline and highlights some of the areas covered by it, including ideas for further research and tools that can be used by purchasers to help improve CF care.

Feverish illness is one of the leading causes for a child to be seen by healthcare professionals, and is a major cause for hospital admissions. In 2007, the National Institute for Health and Care Excellence (NICE) published the original guidance on feverish illness in children (CG47). This was developed to aid healthcare professionals in their decision-making process while managing children aged

Key points about how this guidance applies to primary care professionals are highlighted by David Morris

Duplex scanning is utilised by many departments in the investigation of suspected Deep Vein Thrombosis (DVT). NICE Guideline CG144 recommended repeat scanning for patients in whom the initial Wells score was ‘likely’ in the presence of a raised D-Dimer, following a normal first scan. Following implementation of this recommendation in our department there was a dramatic rise in the number of repeat scans being undertaken, all of which were negative for DVT. Introduction of an electronic message to the report, placing the onus back on the referring clinician to arrange repeat scan if deemed appropriate resulted in a fall in the number of scans being undertaken without impacting on patient outcome.

Background Antipsychotic medications are used among 19%-58% of adults with intellectual disabilities to manage challenging behaviour against the NICE guideline recommendations. Studies show that it is possible to completely withdraw antipsychotics in about one third of adults with intellectual disabilities and a dose reduction of 50% or more in another third. Method In Cornwall, over three years the present authors developed a structured pathway to withdraw antipsychotics among adults with intellectual disabilities which involved people with intellectual disabilities and their carers, GPs, community learning disability team members and pharmacists. Results The present authors managed to withdraw antipsychotics totally among 46.5% (33/71) and reduced over 50% of dosage in another 11.3% (8/71) of adults with intellectual disabilities. At three months follow-up no one required hospital admission or change in placement. Conclusion It is possible to withdraw/reduce antipsychotics in a high proportion of adults with intellectual disabilities if a concerted effort is made involving all stakeholders from the outset.

Introduction and Objective: Tuberculosis is a global disease and detection of acid fast bacilli in sputum smears remains the most widely used rapid diagnostic test.NICE guideline recommended collection of multiple respiratory samples(3 deep cough sputa)for laboratory diagnosis of respiratory TB. We explored compliance against the guideline locally regarding submission of specimen for diagnosis. Method: A retrospective review of all sputum specimens for culture received by microbiology laboratory over 6 months(1/4/2016 to 30/09/2016) was done and broncho-alveolar lavage samples submitted in the same period were excluded as single BAL will suffice as per the guidance. Results: Receiving samples(n=526) from 245patients, overall compliance with guideline is only 43% with further 10% submitting 2 specimens. Each area of high demand, respiratory department and GP, achieved only 58.4% and 38.6% and the worst outcome is revealed in acute clinical care and non-respiratory specialities. Percentage of positive results increased from 0.88%(1 out of 113)with one sample to 6.6%(7 out of 106)in three samples. Compliance with guideline for sample request by departments Conclusion: The project addressed the requirement to submit optimal number of sample request for good quality of diagnosis and it has led hospital IT system to automatically include 3 sputum sample requests for investigation of respiratory TB including access from GP.

Background: Measurement of the biomarker FeNO (fractionated exhaled nitric oxide) provides information on the degree of lung inflammation and can be used to support asthma diagnosis. The latest UK NICE asthma guideline (2017) recommends a diagnostic algorithm including FeNO, based on a cost-effectiveness analysis. In Germany FeNO testing is not yet reimbursed by the statutory health insurance (SHI) but endorsed in the national asthma guideline. Methods: To evaluate FeNO in primary care from SHI perspective, two diagnostic approaches were compared by modelling diagnostic accuracy and expected costs. The strategy according to the German guideline and the NICE diagnostic algorithm were transferred into decision trees. The probabilities used in the NICE cost-effectiveness analysis were inserted and supplemented by expert opinions on the underlying assumptions for Germany. Results: A base case was assumed for calculation of costs, in which 80% of the patients consult a general practitioner initially and 20% refer to a specialist. Further the case assumed a more frequent use of bronchial provocation instead of peak flow variability and a reimbursement of FeNO at 21.17 Euro per test. The resulting total sensitivity according to the German guideline is 78%, the total specificity 54% (PPV 53%, NPV 78%) and results in expected costs of 117.27 Euro. The UK NICE diagnosis algorithm transferred to Germany shows an overall sensitivity of 87%, specificity of 78% (PPV 73%, NPV 89%) and expected costs of 107.15 Euro. Conclusion: For the diagnosis of asthma, the strategy of the UK NICE guideline transferred to Germany is superior in terms of diagnostic accuracy and expected costs, up to a maximum price of 30 Euro per FeNO test.

Objectives of review. To identify advances in the treatment of bulimia nervosa (BN). Summary of recent findings. The NICE systematic review provides the best appraisal of what has been learned from the research on the treatment of BN, and the accompanying NICE guideline provides impartial evidence-derived recommendations regarding patient management. It is clear that a specific form of cognitive-behavior therapy (CBT) is the leading treatment for BN although its effectiveness needs to be enhanced. Early behavior change in treatment is a potent and reliable predictor of outcome. Managing these patients in primary care is difficult and the results are modest. It appears that self-help is of limited value. Future directions. There is a need to develop more effective treatments for BN. Research on adolescents is required since it cannot be assumed that findings obtained with adults will apply to younger patients. There is also a need for ‘effectiveness’ research in which treatments are evaluated under conditions that approximate those existing in routine clinical practice.

The National Institute for Health and Care Excellence (NICE) has changed the treatment goal for adult patients with active rheumatoid arthritis (RA) to remission or low disease activity with monthly monitoring until this is achieved.1 The NICE guideline committee said that the new guidance “aims to improve quality of life by ensuring that people with RA have the right treatment to slow the progression of their condition and control their symptoms.” After reviewing the latest evidence, the committee advised that adults diagnosed with RA should start treatment with a single conventional disease modifying anti-rheumatic …

Background Viral bronchiolitis is one of the most common causes of hospitalisation in young infants. It has previously been shown that many United Kingdom (UK) hospital Trusts were not compliant with many aspects of the National Institute for Health and Care Excellence (NICE) bronchiolitis guideline prior to its publication. Objectives This study aimed to investigate changes in the management of bronchiolitis by hospital Trusts between 2015 (before NICE guideline publication) and 2017, after publication. Study design We prospectively surveyed paediatricians at UK hospital Trusts on the management of bronchiolitis before (March to May 2015) and after (January to May 2017) the NICE bronchiolitis guideline publication in June 2015, using an electronic, structured questionnaire. Results In 2015 111 Trusts were represented and in 2017 100 Trusts. Significant improvements were seen in the use of nebulised bronchodilators and hypertonic saline and provision of parental written guidance. However, full compliance with the guideline did not change with 18% of Trusts compliant before publication of the guideline in 2015 and 19% fully compliant with the guideline in 2017. Conclusions Overall there were modest but important improvements in the reported management of bronchiolitis after the publication of the NICE guideline.

Children and young people with possible cancer usually present to their primary care physician first. NICE has published and updated guideline for suspected paediatric cancer referral. The aim of this study is to find out improvement in diagnosis of cancer among those group of patient via 2 weeks wait (WW) referral. Method This is retrospective review of 2 WW referral forms and outcome from Electronic medical notes. Our POSCU (Paediatric oncology share care unit) 2 WW cancer referral audit was carried out between November 2014 to January 2017. Results Total of 56 referrals was received during the 27 months. Only 2 children (3.6%) had cancer. Most of the referrals (98%) were seen within 2 weeks. The most common reason for referral is lymphadenopathy (39%) which is similar to other studies. Other reasons for referral include: fatigue, malaise and weight loss, headache/CNS signs, bony, abdominal and soft tissue mass, bruising, and non-specific symptoms. Conclusion This study confirmed that updated 2015 NICE guideline for cancer referral has not improved in pick-up rate of cancer. The finding from this study is similar to other studies; Abomeli et al. (Dec12 to 14) 83 referrals, had cancer Mant et al. (2007–2010) 35 referrals, 1 had cancer Ling et al. (2009–1012) 118 referrals, 2 had cancer Galloway et al. (2012 to 2015) 81 referrals, 2 had cancer. Roskin et al. (2004–2014) 93 referrals, 2 had cancer From the above 5 studies, 6 children (1.9%) were diagnosed with cancer in 317 referrals during 2004 to 2015. In our study, it was 3.6% (2/56). The pick-up rate of cancer hasn’t changed much. According to the NICE guideline, some of the presentations should be referred very urgently (within 48 hours) for specialist assessment. However, all of the referrals from our study were received for 2 weeks. Regular teaching sessions and development of referral pathway for the local GPs should help in improving the knowledge on early referral and diagnosis. GPs should be able to contact urgently if concerned instead of using referral pathway as a way of jumping the queue.

Background Variations between neonatal units in implementation of the Early Onset Neonatal Sepsis (EONS) National Institute for Health and Care Excellence (NICE) guideline CG149 were observed by trainees moving between units. Aim To explore variations in implementation of the NICE EONS guideline within the region, and identify quality improvement steps to improve implementation within shared network guidelines. Method Multicentre audit of compliance with the EONS NICE guideline was undertaken involving eight neonatal units within the two neonatal networks in the region. All neonates (≥34 weeks gestation), suspected of having EONS were prospectively audited over a consecutive four-week period between October 2016 – January 2017. Anonymised patient data was recorded on a standardised proforma. Results 320 neonates had suspected EONS. 53% were male with a mean ±SD gestation of 38.4±2.1 weeks. 93 (29%) did not fulfil criteria for initiation of antibiotics. 313 (98%) received Benzylpenicillin and 310 (97%) Gentamicin. 305 (95%) had a second C-reactive protein (CRP) level, but only 203 (67%) taken at 18–24 hours. 203/303 (67%) received first antibiotic dose within 1 hour from decision to treat, this varied between units from 25.8% to 91.7%. Blood culture result was unavailable in 98 (30%) by the NICE 36 hour target, this varied from 0% to 96.8% being available at 36 hours. There was one significant positive blood culture for Group B Streptococcus. Conclusions NICE EONS guideline is variably implemented. The units which performed better, have various toolkits, these include; use of an EONS proforma or electronic form within Badger.net, use of a drug chart with specific boxes for time of decision to treat, first dose of antibiotics administered and if greater than one hour then why, improved collaboration with microbiology laboratories to facilitate timely reporting of blood culture results and additional training on EONS. By implementing these changes then re-auditing we hope to see enhanced adherence to the EONS NICE guideline.

Two years ago, Clinical Medicine reported on the publication of NICE guideline NG31 Care of dying adults in the last days of life. [1,2][1] This document remains invaluable as an evidence-based resource for non-specialists caring for patients in their last hours to days of life. It describes how to

Objectives This quality improvement project sought to streamline diagnosis and management of women with a pregnancy of unknown location (PUL) by applying the National Institute for Health and Care Excellence (NICE) guidelines (2012) for the management of PUL. Methods A retrospective review of 30 charts with the diagnosis of PUL was conducted at the early pregnancy assessment clinic at Mount Sinai Hospital, Toronto, Canada. Outcomes including services provided, ER visits, number of ultrasounds, beta-hCG measurements, methotrexate use and surgical intervention were compared to the NICE guidelines. Process measures included adherence to the NICE PUL protocol. Balancing measures included measurement of increased risk of ruptured ectopic or surgical procedures with expectant management. An additional 30 charts were reviewed following the implementation of the NICE guidelines for the same outcome variables listed above. Results Prior to NICE guideline implementation, a 37% compliance rate with respect to ultrasound follow up, beta-hCG measurements and instructions for follow up was determined. It was found that 80% of patients were discharged from the clinic with a positive beta-hCG and 10% of women received methotrexate without a definitive diagnosis of ectopic pregnancy. Following NICE guideline implementation, compliance increased to 100% with respect to protocol and discharge criteria and there was no inappropriate methotrexate use or surgical procedures prior to diagnosis. Utilization of blood work and ultrasound resources remained unchanged. Conclusions Implementation of a standardized management algorithm for patients with a PUL can decrease unsafe management strategies, including inappropriate methotrexate use and premature follow up discharge.

The new NICE guideline on the menopause published in November provides information on diagnosis and the risks and benefits of HRT to enable shared decision making between women and healthcare professionals. Steve Chaplin provides an overview of the guidance.