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Background\ud The NICE guideline for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) emphasises the need for an early diagnosis in primary care with management tailored to patient needs. However, GPs can be reluctant to make a diagnosis and are unsure how to manage people with the condition.\ud \ud Methods\ud A meta synthesis of published qualitative studies was conducted, producing a multi-perspective description of barriers to the diagnosis and management of CFS/ME, and the ways that some health professionals have been able to overcome them. Analysis provided second-order interpretation of the original findings and developed third-order constructs to provide recommendations for the medical curriculum.\ud \ud Results\ud Twenty one qualitative studies were identified. The literature shows that for over 20 years health professionals have reported a limited understanding of CFS/ME. Working within the framework of the biomedical model has also led some GPs to be sceptical about the existence of the condition. GPs who provide a diagnosis tend to have a broader, multifactorial, model of the condition and more positive attitudes towards CFS/ME. These GPs collaborate with patients to reach agreement on symptom management, and use their therapeutic skills to promote self care.\ud \ud Conclusions\ud In order to address barriers to the diagnosis and management of CFS/ME in primary care, the limitations of the biomedical model needs to be recognised. A more flexible bio-psychosocial approach is recommended where medical school training aims to equip practitioners with the skills needed to understand, support and manage patients and provide a pathway to refer for specialist input.

The long-awaited guideline from the National Institute for Health and Clinical Excellence (NICE) for the management of chest pain of recent onset has now been published. This provides detailed recommendations for the management of patients with chest pain of possible or likely cardiac origin. This clarity should be welcomed by Acute Physicians who have seen a significant increase in emergency referrals to hospital, of which up to 25% in our practice are patients with chest pain. The guidance aims to help and support healthcare professionals to direct their patients into the appropriate referral stream.

In response to the article by Wood et al 1 on the current state of knowledge among doctors on acute gut decontamination, we would point out that the National Institute for Health and Clinical Excellence (NICE) self-harm guideline published in 2004 addresses this issue in its guidance about the general management of patients who have self-poisoned.2 NICE’s role is to provide guidance …

The last decades of the 20th century saw rising rates of surgery for heavy menstrual bleeding with associated high costs and morbidity.1,2 GPs have been implicated as contributing to this as referral rates vary widely between practices and high referral rates are significantly associated with high operative rates.3 GPs have also been criticised for being dismissive of menstrual problems and not addressing patients' concerns.4 A NICE guideline has been published recently which could lead to better primary care management of heavy menstrual bleeding and improve patients' quality of life.5 In the past, heavy menstrual bleeding has been defined in terms of volume of menstrual blood loss.6 However, volume of loss is not routinely measured in clinical practice and there is a poor correlation between measured loss and women's perceptions of their blood loss.7 It was thought that psychological problems could explain the lack of correlation between measured and perceived blood loss, but we now know that the relationship between heavy menstrual bleeding and psychiatric illness is no different to the relationship between psychiatric illness and other physical symptoms.8 There are several alternative explanations. Firstly, for individual women a change in volume of loss may be more significant than absolute volume of loss, for instance in leading to concern that something might be wrong or in challenging menstrual concealment strategies.4,9 Secondly, women's ability to contain heavy loss depends on their social circumstances; for …

Dr Ismail summarises recent NICE guidance on how to provide consistent clinically and cost-effective practice for the diagnosis, treatment and long-term management of urinary tract infection in childhood. Copyright © 2008 Wiley Interface Ltd

Steve Chaplin summarises the recently updated NICE guideline on the management of hypertension in primary care. Copyright © 2006 Wiley Interface Ltd

Objectives & Background Minor head injuries account for a significant number of paediatric presentations to the Emergency Department. In 2007 NICE produced national guidelines to improve and standardise practice across the UK. One indication for CT head scanning is vomiting ≥3 times, even in the absence of any other risk factors. In this study we reviewed CT outcomes with specific focus on children with isolated vomiting. Methods All CT Heads performed by Chelsea and Westminster Hospital Paediatric ED for minor head injury in patients under 16 years of age between July 2007 and May 2013 were reviewed. We identified those in whom the sole indication for CT head was vomiting ≥3 times post head injury. Results 8096 children attended our department with head injury during the study period. Of these 516 (6.4%) underwent CT of the head. In 104 patients (20.2%) the indication for the CT was isolated vomiting, as the sole indication. Of this group, only one child had an abnormal CT (a minor finding requiring no intervention). The remaining 412 patients in the study had other NICE indications for a CT (sometimes multiple). Of these 67 (16.3%) had an abnormal scan. Conclusion This study looks at practice in our unit over a 6 year period, starting 6 months after the 2007 NICE guidelines were introduced. This clearly shows that a large percentage of CTs are being performed on children following minor head injury on the basis of vomiting alone (20.2%). The yield of this is however extremely low with only 0.96% of the patients scanned having an abnormality. There are other clinical decision making algorithms in use internationally which do not have isolated vomiting as an indicator. We believe the current NICE guideline is exposing children‘s9 heads to unnecessary ionising radiation.

Background Early onset neonatal infection (EONI) is serious but uncommon. In England c. 10% of babies are treated for suspected EONI but practice varies significantly. The National Institute for Health and Clinical Excellence has developed guidelines for England. Methods The guideline was developed according to the procedures in the NICE Guidelines Manual (2009). Results The principles underlying the recommendations were: a) start antibiotics as quickly as possible; b) minimize the extent of antibiotic exposure in babies without an infection; c) continuous assessment of blood culture status in automated systems provides reliable information about whether a significant isolate is present; antibiotics can be stopped safely if blood cultures are negative 24–36 hours after they are taken. The key recommendations relate to: 1. The early administration of antibiotics; 2. The timely cessation of antibiotics if blood cultures are negative, the baby is well and a CRP measurement c. 24 hours after the start of antibiotics is normal; 3. The value of investing in information technology to support timely reporting of blood culture results to clinical areas because improved systems are likely to pay for themselves through reductions in hospital stay. Conclusion The severity of EONI requires urgent action at the first suspicion of infection. Modern laboratory technology allows an early cessation of antibiotics in the majority of babies who are not infected.

Background To improve reliable diagnosing UTI in young, non-toilet trained children, a diagnostic strategy of the Nice guideline was nationally introduced in the Netherlands. This study aims to determine the impact of this new diagnostic strategy in clinical practice. We evaluated determinants of successful implementation. Methods We conducted a cross-sectional observational study, with observations before and after implementation. We prospectively collected data from healthy children aged 1 month- 2 years, presenting with fever at the emergency room at Sophia Children’s Hospital in 2008 and 2010–2011. Primary outcome measure: assessment of children suspected with UTI according to the guideline and determinants of implementation. Secondary outcomes: number of contaminated cultures, hospitalisation and antibiotic treatment. Outcome measures are assessed by mean (95%CI). Differences before and after implementation were tested using Chi-squared test. Effects of determinants were evaluated using regression analysis. Results The preintervention group consisted of 207 children (male 64.3%, median age 0.98 years (interquartile range IQR0.77), the postintervention group 194 children (male 55.2%, median age 1.06 year (IQR0.78). Correctly diagnosed UTI increased from 41 (19.8%; 95% CI:14.3–25.3) in the the preintervention group to 101 (52.1%; 95%CI:45.0–59.2) in the postintervention group(p-value Conclusion Implementation of the guideline has lead to a significant higher frequency of correct assessment of UTI in young children. We could not identify determinants at patient, process or professional level with significant influence on successful implementation.

Background and Aims Major congenital heart disease (CHD) is defined as CHD that needs operative or catheter based intervention in the first year of life. National institute of clinical excellence (NICE) in March 2008 recommended screening of outflow-tracts in addition to four-chamber view as part of the anomaly scan to improve CHD detection rates. We aimed to examine the clinical spectrum of antenatally and postnatally diagnosed major CHD in our institute pre- and post-introduction of NICE guideline. Methods This is a retrospective review over six years from Jan 2006 to Dec 2011. Data was obtained from antenatal records, patient’s clinical and electronic records. Results A total of 74 babies had major CHD diagnosed out of which 37 (50%) were diagnosed antenatally. Antenatal diagnosis pre- and post- NICE guidelines were 12/29 (41%)and 25/45 (55%) respectively as also termination of pregnancies with critical CHD doubled. Common postnatal presentations included cardiovascular collapse 4 (11%), cyanosis 8 (22%), murmurs 12 (32%), heart failure 5 (13.5%), faltering growth 5(13.5%). 4 babies were critically ill with severe acidosis and 3 needed intubation and ventilation prior to transfer to a tertiary unit. Median age at intervention for duct dependent lesions was 10 days and other major CHD was 5 months. Conclusions Although antenatal screening methods have improved, a large proportion of babies with CHD are still undetected. Routine Pulse-oximetry screening has proved to be an effective screening adjunct in four large studies and hence should be considered as part of early neonatal examination.

CG144 provides a comprehensive review of the literature and useful practical guidance, but two aspects puzzle me.1 2 Firstly, the Guideline Development Group (GDG) provides no empirical evidence for changing from the current practice of immediate treatment with low molecular weight heparin (LMWH) and scanning when feasible (often in usual working hours) to scanning …

Aims NICE guideline CG54 (August 2007) recommends DMSA scan in children under 3 years with recurrent and/or atypical UTI and for all children with recurrent UTI. Prior to this, most children under five years with a proven UTI underwent a DMSA scan (Royal College of Physicians guideline, 1991). We aimed to assess the impact of the introduction of NICE guideline 54 in terms of DMSA scan rate, indication and results following UTI in children. Methods All children (under 16 year) who had a DMSA scan following UTI in 2007 (Jan-July) prior to the introduction of the NICE guidelines were identified, and compared with those undergoing DMSA scanning in 2010 (Jan-Dec). Cases with no proven UTI, previously known anatomical urinary tract abnormalities or other indications were excluded. Results We compared cases from 2007 (n=39) and 2010 (n=26), with no significant difference in terms of sex (p=0.903) or age distribution (p=0.812). The monthly scan rate reduced significantly from an average of 6.5 scans in 2007 to 2.2 scans in 2010 (p Conclusion Our results suggest that prior to the introduction of the NICE guideline, children were being over investigated with DMSA scans, with the associated implications of radiation from isotope exposure, child/parental stress and financial implications. We have significantly reduced the number and rate of DMSA scans in our unit following UTI. Results demonstrate a tendency towards a higher positive scan rate. Importantly, all those scans which would no longer be indicated were normal suggesting that the reduction in DMSA scans is unlikely to lead to missing significant pathology.

Aims To find out the numbers of elective caesarean section carried out before 39 weeks gestations and the number of infant morbidity resulting from variation from the NICE guideline. Background Studies have shown that delivery by elective caesarean section (CS) is associated with the increase risk of transient tachypnea of the newborn (TTN) compared to vaginal delivery. Gestational age less than 39 weeks was found to be associated with increased risk of TTN in infants delivered by elective CS. NICE guideline recommend that elective CS should not routinely be carried out before 39 weeks. Methods Retrospective study was performed during 2 months period from beginning January – February 2011. Proforma was used to collect information which was then analysed. Results There were approximately 3184 deliveries carried out in Northumbria NHS foundation trust per year and during the 2 months study period, there were 60 elective Caesarean sections. 25% of the CS were done before 39 weeks gestations. 5 out of 15 had medical reasons, 2 out of 15 had social reasons, and the reasons for the remaining were unrecorded. No infants had TTN or admitted to SCBU in the women who had CS after 39 weeks. For those who had elective CS prior to 39 weeks gestation, 1 infant was admitted to SCBU due to TTN. Conclusions It is important to adhere to the NICE guideline to perform elective CS after 39 weeks to reduce TTN, unless the reason to perform elective CS earlier was justified and clear documentation followed.

Aims The National Institute for Health and Clinical Excellence (NICE) guidelines state that patients with Borderline Personality Disorder (BPD) should not be prescribed medication for the individual symptoms related to the illness and that psychological interventions should be considered as part of their management. We aimed to assess the use of medication and access to psychological therapies in an inpatient population, after the implementation of NICE guidance introduced in January 2009. Methods This was a retrospective study. Case notes of patients with a diagnosis of BPD (ICD-10 F60.3 and F60.31), discharged from four acute inpatient wards in Sheffield for a period of twelve months, were studied using a structured questionnaire based on BPD NICE guidance (2009). Results There were 68 discharges, involving 47 patients, with BPD accounting for 10.1% of the 670 total discharges. Of the 68 discharges, 78% were prescribed drug treatment specifically for BPD (including antipsychotics, antidepressants, mood stabilisers and anxiolytics), whilst 45% were prescribed medication without documented evidence a co-morbid diagnosis existed, and 41.2% received 3 or more medications. Of the 47 patients, only 17% received a structured psychological intervention which included cognitive analytical therapy (n = 4), cognitive behavioural therapy (n = 3) and dialectical behavioural therapy (n = 1). Conclusions Despite NICE recommendations, patients with BPD continue to receive a variety of psychotropic medications and to have limited interventions from psychological services with a high proportion receiving unstructured therapy. Reasons (including service costs and evidence of effectiveness of all treatments) need to be explored.

February 2002 saw the circulation of the National Institute for Clinical Excellence (NICE) Guideline for the Management of type 2 Diabetes: Renal Disease – Prevention and Early Management. Although commissioned by the Department of Health before the Institute was formed in 1999, and therefore not subjected to the full NICE guideline development process, it represents the guidance of NICE at least until the next proposed review date in March 2005.

Local teams of doctors, social workers, and teachers are needed to improve the diagnosis and treatment of autism, the National Institute for Health and Clinical Excellence (NICE) says in new guidance. Gillian Baird, a consultant paediatrician at Guy’s and St Thomas’ NHS Foundation Trust in London, who chaired the group that developed the guideline, said that although it was the job of the medical profession to diagnose autism, all services that support the wellbeing of children could help by recognising the possible signs and symptoms. “The NHS led multi agency strategy groups recommended in the NICE guideline will hopefully lead to more joined up working between these key services through …

Background The National Institute for Health and Clinical Excellence (NICE) recommendations in 2008 for antibiotic prophylaxis before dental treatment contradict previous practice. There is a potential difficulty in explaining the new guidance to patients who have long believed that they must receive antibiotics before their dental treatment. Aim This study investigated the patient-related barriers and facilitating factors in implementation of the NICE guidance. Methods In-depth interviews were conducted with nine patients concerning their views about barriers and factors that could influence the implementation of the NICE guidance on antibiotic prophylaxis before dental treatment. Data were analysed using framework analysis. Results For patients the rationale for the NICE guidance was unclear. They understood that at the population level the risk of infective endocarditis was less than the risk of adverse reaction to antibiotics. However, on an individual level they felt that the latter risk was negligible given their previous experience of antibiotics. They were aware that standards of care change over time but were concerned that this may be an example where a mistake had been made. Patients felt that the characteristics of the person advising them about the new guidance were important in whether or not they would accept them – they wished to be advised by a clinician that they knew and trusted, and who was perceived as having appropriate expertise. Conclusions Patients generally felt that they would be most reassured by information provided by a clinician who they felt they could trust and who was qualified to comment on the issue by respecting their autonomy. The implications of the findings for the development of patient information are discussed.

Background The NICE guideline for antibiotic prophylaxis before dental treatment has made a substantive change and fundamental departure from previous practice that affects long-standing beliefs and practice patterns. There is potential difficulty for healthcare professionals explaining the new guidance to patients who have long believed that they must receive antibiotics before their dental treatment. Aim To explore clinicians' attitudes towards the NICE guidance on antibiotic prophylaxis, their use of the guideline in clinical practice, barriers to the implementation of the guideline, and how best to overcome any perceived barriers. Methods In-depth interviews were conducted with seven dental care professionals, two cardiologists and a cardiac care nurse. The data were analysed using the framework method to extract central themes and opinions. Results Clinicians generally perceived that initially patients would be reluctant to follow the NICE guidance. This was felt to be particularly true of the patient cohort that had previously been prescribed prophylactic antibiotics. They found it difficult to explain the new guidance to patients who have had infective endocarditis and have long believed that they must receive antibiotics before their dental treatment. Concerns were also raised about the legal position of a clinician who did not follow the guidance. Clinicians generally suggested that the provision of accurate information in the form of leaflets and valid websites would be the best way to advise patients about the new guidance. Conclusions Clinicians anticipated difficulties in explaining to patients the change in clinical practice necessitated by adherence to the NICE guidance, most notably for patients with a history of infective endocarditis or where the patient's cardiologist did not agree with the NICE guidance. They placed particular emphasis on the provision of accurate information in order to reassure patients.

Background The RACPC is a well-established “one-stop” service, with goal to identify patients with stable chest pain due to coronary artery disease (CAD) and quickly reassure those with non-cardiac pain. In March 2010, NICE published a new guideline, which advocates assessing likelihood of CAD based on age, gender, history and risk factors (RF). If estimated likelihood is >60%, invasive coronary angiography (ICA) is recommended as the first-line diagnostic investigation. If estimated likelihood is 30%–60%, functional imaging is recommended. If estimated likelihood is Methods 167 consecutive patients referred to RACPC between October 2009 and March 2010 were retrospectively assessed for likelihood of CAD according to the new NICE guideline. Choice of investigations and eventual outcome (confirmed CAD vs no evidence of CAD) were compared between subgroups defined by estimated likelihood of CAD. An economic analysis of cost of investigation per patient was undertaken using current Payment by Results national tariffs. Results Our patient population had a high prevalence of RF with 38.1% having a total of three or more RF. Consequently 23.2% of patients had an estimated likelihood of CAD of 60%. 7.2% of patients were lost to follow-up. 14.4% of patients were ultimately confirmed to have CAD on ICA, which correlated with pre-test estimated likelihood. 6% of patients with likelihood 60% were confirmed to have CAD. Average cost of investigation per patient was £528. A negative ETT resulted in average cost per patient of £347. An inconclusive ETT resulted in higher cost (£728) as did inability to exercise (£435) due to the need for further investigations. A positive ETT resulted in average cost of £1174 due to the high cost of ICA. Were the NICE guideline strictly applied to our patient population, average cost per patient would have been substantially higher at £838 (£362 per patient if likelihood 60%). Overall this corresponds to a 60% increase in cost. Conclusion The 2010 NICE guideline appears to significantly overestimate the true risk in our patient population. Were the guideline strictly applied, almost half of our patients would proceed to ICA as a first-line investigation, but many of them would be found to have unobstructed coronary arteries. As ICA is an expensive investigation, this would inevitably result in a significant increase in average cost per patient. Relatively few patients would be eligible for CTCA, which is an excellent non-invasive “rule-out” test for CAD and relatively inexpensive compared with other investigations.

We thank the correspondents for these kind and helpful comments.1 In adopting the Global Initiative on Obstructive Lung Disease (GOLD) classification of severity of airflow obstruction, the National Institute for Health and Clinical Excellence (NICE) guideline update has introduced consistency with international guidelines including those of the American Thoracic Society and the European Respiratory Society. The NICE guidelines note that this classification relates specifically to degrees of airflow obstruction which are arbitrary and may not be closely related to degrees of clinical severity in chronic obstructive pulmonary disease (COPD).2 The current use of the term ‘severe’ for airflow obstruction with forced expiratory volume in 1 s (FEV1)

This talk will describe the methodology used for the development of the new NICE guideline on the treatment of schizophrenia for the UK, paying particular attention to meta-analytic and, where possible, economic methods or considerations used to develop recommendations on the use of Family therapy, CBT and the arts therapies. Some time will also be given to examining the evidence behind the first formal meta-analytic review of early intervention services for people with early schizophrenia, and a suggestion that these services may be beneficial as a result of them including evidence-based treatments rather than such services having a particular approach or service ideology. If time allows, we will also examine the evidence behind the choice of antipsychotic in the schizophrenia guideline, and speculate on the continuing usefulness, if any, of using terms such as ‘typical’, ‘atypical’, ‘first generation’ or ‘second generation’.

IntroductionThere were 16,482 administrations of Electro-convulsive Therapy (ECT) to 2835 individuals in England between January-March 1999. Controversy still surrounds the safety, ethics and necessity of ECT with some patients reporting severe adverse effects and feeling particularly strongly about it being administered without their consent. NICE guidelines along with the ECT accreditation service (ECTAS) sought to address these concerns and raise standards for ECT in UK.Aims and ObjectiveTo identify any barriers to compliance with NICE guidelines regarding consent for ECT.MethodsAll patients newly started on ECT during a 3 month period at Hellesdon Hospital were enrolled into this study. Case notes were analysed for 16 patients against the 21 standard ECTAS consent criteria.ResultsThe hospital rated good (70–89%) or excellent (90–100%) for all guidance except the one which requires patients to complete some sections of the consent form. Only 63% of the patients had completed these, however 100% went on to sign the consent form before every session. Guidance compliance was excellent for 15 (72%) of items examined.ConclusionsThere is good compliance with NICE guideline relating to consent for ECT. The only barrier to full compliance was inadequate documentation by patients in some sections. Steps to improve patient participation can now be implemented. This will provide assurance that ECT is used appropriately and that the process fully enables informed consent. Further research is required to discover the reasons for unsatisfactory patient participation in the consent process.

Background and aims: The National Institute for Health and Clinical Excellence (NICE) in UK has recently published a clinical guideline on the diagnosis, treatment and long-term management of urinary tract infection (UTI) in children. UTI in infants and young children is of peculiar importance because it can cause acute significant morbidity and long-term medical problems, including hypertension and impaired renal function. The full NICE guideline is a 178-page documentation designed to lead to more consistent clinical practice among different practitioners caring for children with suspected UTI. It offers guidance on diagnosis, effective investigations, treatment and follow-up. Methods: We have design an easy-to-use, userfriendly desktop windows application for the health practitioners based on the NICE guideline as a quick reference for the management of children with suspected UTI. The software is intuitively easy to use and requires no advanced computer skills. Results: The software provides an easy navigation system based on the main contents of the NICE guideline: history, urine sample collection and testing, treatment, investigations and information for patients/carers. It aids selection of appropriate radiological investigation depending on the clinical status and age category of the patient. It offers guidance on choice of antibiotics, duration of treatment, requirement for specialist follow-up and information to be given to patients and their carers. Fig 1 Conclusion: We have designed an easy-to use simple electronic assistant based on the current NICE guidelines (UK) on the diagnosis, treatment and long-term management of UTI in children.

[⇓][1] ![Figure][2] Having read the National Institute for Health and Clinical Excellence guidance on antisocial personality disorder and found it provided more questions than answers, I was unsure what this text would add to my understanding. The book, however, is surprisingly

Introduction Due to a higher prevalence of intravenous drug use among offenders, prisons may have a higher prevalence of HCV than community, managing HCV and ensuring successful therapy may be more challenging in such settings.1 Durham has one of the largest prison populations in the UK. NICE endorsed therapy with pegylated interferon and ribavarin is recommended with reported rates of sustained viral response (SVR) of 75–85% with 6 months and 40–50% with 12 months therapy for genotypes 2/3 and 1, respectively.2 A new service was set up at University Hospital of North Durham in January 2008 to improve provision of HCV care within the NHS and the local prisons with a nurse led inreach service in prisons. Methods The aim of the study was to audit treatment outcomes of referrals to the HCV service in County Durham with current NICE guideline. Data were collected prospectively from January 08 using a computerised database. Results There were 120 referrals from January 3008 to September 2009; at time of abstract submission, follow-up data on SVR were available for those commenced on treatment between Jan to Dec 2008, data on these 59 HCV PCR positive patients including 47 prisoners are presented. 15 prisoners were unable to complete therapy as they were lost to follow-up following transfer/release from prisons in Durham. Reasons for not treating included patient refusal in 3 and DNAs of GP referrals and prisoners transferred elsewhere prior to start of therapy in 14 (Abstract 054). Conclusion Approximately three quarters of all HCV referrals were suitable for therapy; SVR of 100% and 86% were observed in those with genotype 2/3 and 1, respectively, who completed treatment, these outcomes are superior to those reported in NICE and were similar in prisoners and community referrals. There data suggest that while treatment outcomes for prisoners with HCV are similar to those treated in the community, the main obstacle in treating prisoners is ensuring therapy is completed as prisoners are lost to follow-up, in up to a quarter of cases due to transfers/ release. These findings indicate a need to improve the pathway for ensuring complete follow-up of this patient group.

Anyone who might be having a heart attack or has unstable angina should undergo 12 lead electrocardiography as soon as possible, say new guidelines from the UK National Institute for Health and Clinical Excellence (NICE). If patients need to be referred to hospital the result of the ECG should be sent ahead so it is there when they arrive, although recording and sending the result should not delay transfer to hospital, they say. The guideline on chest pain of recent onset has been jointly developed with the National Clinical Guidelines Centre for Acute and Chronic Conditions. Unlike many guidelines from NICE, the latest advice does not cover treatment for chest pain but focuses only on diagnosis, with the aim of reducing premature deaths by differentiating between people with acute coronary syndrome and those with stable angina. Chest pain accounts for up to 1% of visits …

Clinicians should check for depression in people with chronic physical health problems and ensure that any drugs they prescribe have a low risk of side effects and interactions, says the clinical watchdog for England and Wales. Clinical guidance published this week by the National Institute for Health and Clinical Excellence (NICE) recognises the fact that depression can be three times more common in patients with long term physical health problems than in patients without and affects as many as one in five people. Awareness of this, however, is sometimes lacking, …

Julius Wagner-Jauregg won the Nobel prize in 1927 for developing an effective treatment for syphilis which entailed deliberately infecting patients with malaria. This research suggests that fever may be a beneficial response to infection. The 2007 guideline from …

Aims and objectives To investigate attitudes of Irish dental practitioners, cardiologists and patients with cardiac lesions to the new NICE guideline for antibiotic prophylaxis against infective endocarditis and to determine the implications of this guideline for dental practice in Ireland. Methods Individually tailored anonymous postal questionnaires were sent to 500 dental practitioners, 54 cardiologists and 50 patients with a history of antibiotic prophylaxis usage before dental treatment. Results Two hundred and ninety questionnaires were returned from dental practitioners (a response rate of 58%), 20 questionnaires were returned from cardiologists (a response rate of 37%) and 34 questionnaires were returned from patients (a response rate of 68%). Two thirds of patients surveyed would be concerned about the possible cessation of antibiotic prophylaxis before dental treatment and would require either verbal or written confirmation from a cardiologist. Among the dental practitioners surveyed a significant majority were not willing to implement the NICE guideline without further information from the patient general medical practitioner, cardiologist or an official Irish body. Conclusion To enable patient re-education regarding antibiotic prophylaxis, dental practitioners must keep abreast of changes to current guidelines and understand the rationale driving these changes. Difficulties arise for dental practitioners when there is no national statutory body endorsing such guidelines, particularly now that the guidelines in relation to antibiotic prophylaxis in dentistry are so different.

Background: Rapid tranquillisation is used when control of agitation, aggression or excitement is required. Throughout the UK there is no consensus over the choice of drugs to be used as first line treatment. The NICE guideline on the management of violent behaviour involving psychiatric inpatients conducted a systematic examination of the literature relating to the effectiveness and safety of rapid tranquillisation (NICE, 2005). This paper presents the key findings from that review and key guideline recommendations generated, and discusses the implications for practice of more recent research and information.\ud \ud Aims: To examine the evidence on the efficacy and safety of medications used for rapid tranquillisation in inpatient psychiatric settings.\ud \ud Method: Systematic review of current guidelines and phase III randomised, controlled trials of medication used for rapid tranquillisation. Formal consensus methods were used to generate clinically relevant recommendations to support safe and effective prescribing of rapid tranquillisation in the development of a NICE guideline.\ud \ud Findings: There is a lack of high quality clinical trial evidence in the UK and therefore a ‘gold standard’ medication regime for rapid tranquillisation has not been established.\ud \ud Rapid tranquillisation and clinical practice: The NICE guideline produced 35 recommendations on rapid tranquillisation practice for the UK, with the primary aim of calming the service user to enable the use of psychosocial techniques.\ud \ud Conclusions and implications for clinical practice: Further UK specific research is urgently needed that provides the clinician with a hierarchy of options for the clinical practice of rapid tranquillisation.

The guideline from the National Institute for Health and Clinical Excellence (NICE) on urinary tract infections (UTI) in childhood1 was welcomed by the BMJ .2 3 Most readers will assume it was based on evidence correctly analysed by medical statisticians, robustly peer reviewed, and openly debated. As this is a controversial subject, dependent more on small studies than randomised controlled trials, many will imagine that it represented consensus following wide consultation, as stated.1 Sadly, all these assumptions are wrong. The NICE guideline committee …

As the developers of the recent NICE guideline on antenatal and postnatal mental health1 we found some aspects of the article by O'Keane and Marsh on depression during pregnancy of concern.2 Firstly, by focusing only on depression it perpetuates the myth that depression is the only important mental disorder of pregnancy and the postpartum period, when other disorders are also important, notably, anxiety disorders. Secondly, it is written from a secondary care perspective when the burden of care …

As well as seeming to discourage the detection of postpartum depression,1 the National Institute for Health and Clinical Excellence (NICE) is also encouraging the artificial intervention of immediate cord clamping.2 The NICE guideline for caesarean section includes a section on cord clamping. It states a number of “suggested” benefits and a number of “possible” harms. The reference is a review paper in a midwifery journal. …

Every time a new NICE guideline is produced, the impression I get is that invariably they are based on expediency and vested commercial interests, and although they assure us that they are based on good research evidence, the evidence is not apparent from the documents. My heart sank into my boots when I read the latest antenatal care guideline.

Objective: To audit the performance of the paediatric epilepsy services in a district general hospital based on NICE guidelines and parent satisfaction.Design: Retrospective audit.Setting: Paediatric epilepsy clinic in a district general hospital.Patients: Consecutive children (n = 54) with epilepsy attending the paediatric epilepsy clinic over a 4-month period.Methodology: Data from hospital notes was recorded in standardized study forms, which was subsequently entered into database and analysed independently. A parent/patient satisfaction survey was also conducted over the same period involving the same study population by sending out a postal questionnaire.Outcome measure: NICE epilepsy audit criteria and patient/carer satisfaction measured using the standards published by Webb et al.Results: The results show that the service achieved almost all the key targets set out in the NICE guidelines but performed less well in the parent satisfaction survey.Conclusion: This audit suggests that in addition to NICE guidelines, an evaluation of parent/patient satisfaction should form part of assessment of the quality of paediatric epilepsy service. (C) 2008 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

When implemented into clinical practice guidelines can have a positive effect on the quality of care provided to mothers and babies. This article highlights some of the key points for implementation of a national guideline into clinical practice.