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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.

Objective In July 2018, NHS England, introduced a pause on vaginal mesh, including the mid-urethral sling (MUS) for treatment of stress urinary incontinence (SUI). NICE guidelines recommend MUS as one of the surgical options for SUI. The aim of our study was to investigate healthcare professionals choices for surgical treatment of SUI, if conservative measures failed. Study design The urogynaecology department at our tertiary level hospital devised a questionnaire using SurveyMonkey. This was distributed via email to 1058 healthcare professionals of different medical backgrounds. The surgical options were based on the NICE guideline and its patient decision making aid. We also used surgical information from the British society of Urogynaecology (BSUG) and British association of urological surgeons (BAUS). Results We received 214 responses of which 204 were complete. Twenty six percent of replies were from obstetricians and gynaecologists, 36 % had over 20 years experience and 79 % were female. Forty four percent had no previous knowledge of surgical options. Mid-urethral sling was the most popular choice based on description, success and specific complications. Urethral bulking agent was the only option that increased in popularity after describing complications. Twenty two percent would avoid surgery due to the risk of complications. Conclusion This is the first study evaluating healthcare professionals surgical choice for SUI. Despite negative media publicity and NHS pause on MUS, it was still the most popular choice before and after informing of specific complications. The urethral bulking agent was the only surgical treatment, which increased in popularity after considering complications.

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.

Objective: There are no existing validated search filters for the group of 37 Organisation for Economic Co-operation and Development (OECD) countries. This study describes how information specialists from the United Kingdom’s National Institute for Health and Care Excellence (NICE) developed and evaluated novel OECD countries’ geographic search filters for MEDLINE and Embase (Ovid) to improve literature search effectiveness for evidence about OECD countries. Methods : We created the draft filters using an alternative approach to standard filter construction. They are composed entirely of geographic subject headings and are designed to retain OECD country evidence by excluding non-OECD country evidence using the NOT Boolean operator. To evaluate the draft filters’ effectiveness, we used MEDLINE and Embase literature searches for three NICE guidelines that retrieved >5,000 search results. A 10% sample of the excluded references was screened to check that OECD country evidence was not inadvertently excluded. Results : The draft MEDLINE filter reduced results for each NICE guideline by 9.5% to 12.9%. In Embase, search results were reduced by 10.7% to 14%. Of the sample references, 7 of 910 (0.8%) were excluded inadvertently. These references were from a guideline about looked-after minors that concerns both OECD and non-OECD countries. Conclusion: The draft filters look promising—they reduced search result volumes while retaining most OECD country evidence from MEDLINE and Embase. However, we advise caution when using them in topics about both non-OECD and OECD countries. We have created final versions of the search filters and will validate them in a future study.

Objective: Chief aim of the current study was to draw attention in the prescribing pattern and utilization of PPIs in one year at a single private hospital of Saudi Arabia. Methods: This is a cross-sectional, retrospective drug utilization research on Proton pump inhibitors (PPIs). The PPI usage pattern of in- and out- patients of Al-Mana Group of Hospital (AGH) Al-Khobar between January 1, 2019 and December 31, 2019 were investigated, including incidence, prevalence, and duration. Results: We observed 27229 items of PPI were dispensed in the inpatient and outpatient pharmacy department of AGH-Al-khobar. Among all the PPI user more than the half {(52.98%, n = 14426), 95%CI (52.0-53.5)} were male. Nearly equal number of PPI users belongs between 18-40 years {(39.22%, n =10680), 95%CI (38.64-39.80)} and 41-60 years {(39.15%, n =10662), 95%CI (38.6-39.75)}. Among all the PPI users 61.46% (n=16736) were from community of Saudi Arabia while 38.53% (n=10493) from Non-Saudi. Among all the dispensed PPIs drugs Pantoprazole is dispensed to the highest number of patients {79% (95%CI, 78.53-79.50) (n=21515), p

Introduction and aim NICE guideline surveillance determines whether previously published guidelines need updating. The surveillance process must balance time constraints with methodological rigor. It includes a rapid review to identify new evidence to contradict, reinforce or clarify guideline recommendations. Despite this approach, the screening burden can still be high. Applying additional search techniques may increase the precision of the database searches. Methods A retrospective analysis was conducted on five surveillance reviews with less than 2% of the studies included after screening. Modified searches were run in MEDLINE, Embase and PsycINFO (where appropriate) to test the impact of additional search techniques: focused subject headings, subheadings, frequency operators and title only searches. Modified searches were compared to original search results to determine: the retrieval of included studies, the precision of the search and the number needed to read. Studies not retrieved by the modified search were checked to determine if the surveillance decision would have been affected. Results The additional search techniques tested indicated that a combination of focused subject headings and frequency operators could improve the precision of surveillance searches. The modified search retrieved all the original studies included in the surveillance review for three of the reviews tested. Some of the original included studies were not retrieved for two reviews but the missing studies would not have affected the surveillance decision. Conclusions Combining focused subject headings and frequency operators is a viable option for improving the precision of surveillance searches without compromising recall and without impacting the surveillance decision.

We read with interest the excellent editorial ‘Postnatal care: new NICE guideline for the “Cinderella service”’.1 GPs’ involvement in the care of women in the perinatal period has never been so important as currently, during the COVID-19 pandemic. Pregnant women affected by COVID-19 are at higher risk of developing serious complications,2 especially women of Black, Asian, and minority ethnic backgrounds, and those with underlying medical conditions.3 MBRRACE-UK reported that the maternal mortality rate due to COVID-19 …

Objective: We previously developed draft MEDLINE and Embase (Ovid) geographic search filters for Organisation for Economic Co-operation and Development (OECD) countries to assess their feasibility for finding evidence about the countries. Here, we describe the validation of these search filters. Methods: We identified OECD country references from thirty National Institute for Health and Care Excellence (NICE) guidelines to generate gold standard sets for MEDLINE (n=2,065) and Embase (n=2,023). We validated the filters by calculating their recall against these sets. We then applied the filters to existing search strategies for three OECD-focused NICE guideline reviews (NG103 on flu vaccination, NG140 on abortion care, and NG146 on workplace health) to calculate the filters’ impact on the number needed to read (NNR) of the searches. Results: The filters both achieved 99.95% recall against the gold standard sets. Both filters achieved 100% recall for the three NICE guideline reviews. The MEDLINE filter reduced NNR from 256 to 232 for the NG103 review, from 38 to 27 for the NG140 review, and from 631 to 591 for the NG146 review. The Embase filter reduced NNR from 373 to 341 for the NG103 review, from 101 to 76 for the NG140 review, and from 989 to 925 for the NG146 review. Conclusion: The NICE OECD countries’ search filters are the first validated filters for the countries. They can save time for research topics about OECD countries by finding the majority of evidence about OECD countries while reducing search result volumes in comparison to no filter use.

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.

The UK’s National Institute for Health and Care Excellence (NICE) is in the process of writing guidelines for “Medicines Associated with Dependence or Withdrawal Symptoms: Safe Prescribing ...

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.

Editor’s Note The following is reproduced here, with permission of the UK Council for Psychotherapy and their collaborators, because it makes interesting and generally applicable points about research methodologies. The references are: UKCP (2019) https://www.psychotherapy.org.uk/wp-content/uploads/2019/07/NICE-Depression-coalition-position-statement.pdf accessed 16 October 2019 UKCP (2019) https://cdn.ymaws.com/www.psychotherapyresearch.org/resource/resmgr/docs/downloads/StakeholderPositionStatement.pdf accessed 16 October 2019

Pelvic organ prolapse (POP) is a common presenting complaint in gynaecology. In the UK, prolapse accounts for 20% of women on the waiting list for major gynaecological surgery. It is therefore important that clinicians understand how accurately to assess women with prolapse. The aim of this review is to provide a comprehensive description of the assessment required. Anatomical assessment should be made using the standardized Pelvic Organ Prolapse quantification system (POP-Q). The use of POP-Q in women with POP is recommended by the NICE guideline because allows effective communication between clinicians, reproducible evaluation of surgical outcomes, meaningful comparison of published series and comparison of different populations. The main focus of the review is a detailed and practical explanation of the POP-Q.

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.

Chronic diarrhoea is a common problem seen in both primary and secondary care, affecting up to 5% of the general population at any given time.1 Evaluation of chronic diarrhoea poses myriad challenges to the clinician, not in the least because ‘diarrhoea’ means different things to different people (patients and clinicians) but also because it has a diverse aetiology and can be multifactorial in any given individual. Patients relate to loose stool consistency, increased frequency of defaecation, urgency or incontinence (or in combination with one or some of these symptoms) as ‘diarrhoea’ while physicians have traditionally used an increased frequency of defaecation or increased stool weight to define diarrhoea.1 The recent publication of updated British Society of Gastroenterology (BSG) guidelines by Arasaradnam and colleagues addresses this inconsistency, providing a pragmatic definition and approach to the diagnosis and investigation of patients with chronic diarrhoea (figure 1).2 The guidelines define chronic diarrhoea as ‘the persistent alteration from the norm with stool consistency between types 5 and 7 on the Bristol stool chart and increased frequency greater than 4 weeks’ duration’. Figure 1 Algorithm for the investigation of chronic diarrhoea based on clinical differential diagnosis. (from Arasaradnam et al , 2018, p. 1381). DG, diagnostics guidance; NG, NICE guideline; NICE, National Institute for Health and Care Excellence. The challenges presented by the diagnostic workup of chronic diarrhoea are arguably more pronounced in the elderly, wherein diverse aetiologies in the face of multiple potential clinical comorbidities and polypharmacy for these conditions, and additional limitations posed by frailty and resultant inability to undergo recommended investigations need careful consideration. This article aims to offer a pragmatic approach to the assessment of chronic diarrhoea in the elderly (figure 2). Figure 2 A proposed adapted algorithm for an approach to the assessment of chronic diarrhoea in the elderly. …

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.

Objective: To critically appraise the methodological rigour of the clinical practice guidelines (CPGs) vis-à-vis BPH surgery as used by specialist research associations in the US, Europe and UK, and to compare whether the guidelines cover all or only some of the available treatments. Methods: The current guidelines issued by the EUA, AUA and NICE associations have been analyzed by 4 appraisers using the AGREE-II instrument. We also compared the recommendations given in the guidelines for surgical and minimally invasive treatment to find out which of these CPGs include most of the available treatment options. Results: According to the AGREE II tool, the median scores of domains were: domain 1 scope and purpose 66.7%, domain 2 stakeholder involvement 50.0%, domain 3 rigor of development 65.1%, domain 4 clarity of presentation 80.6%, domain 5 applicability 33.3%, domain 6 editorial independence 72.9%. The overall assessment according to AGREE II is 83.3%. The NICE guideline scored highest on 5 out of 6 domains and the highest overall assessment score (91.6%). The EAU guideline scored lowest on 4 out of 6 domains and has the lowest overall assessment score (79.1%). Conclusions: The analyzed CPGs comprehensively highlight the minimally invasive and surgical treatment options for BPH. According to the AGREE II tool, the domains for clarity of presentation and editorial independence received the highest scores. The stakeholder involvement and applicability domains were ranked as the lowest. Improving the CPG in these domains may help to improve the clinical utility and applicability of CPGs.

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.

Aims Transition from paediatric to adult services is difficult and stressful to both clinicians and families. The authors investigated the impact of inappropriate attendances (patients 16 years or older and no longer under paediatric care) to the emergency department in order to determine the effectiveness of the transition process. The audit was conducted in a hospital providing primary, secondary and tertiary care over 8 months. Methods All attendances of patients 16 years or older to the paediatric emergency department between 1/04/2018–30/11/2018 were reviewed. A randomised sample was taken after exclusion of staff members, duplicates and direct admissions. A judgement was made as to whether the attendance was appropriate and subsequently correctly managed based on the Trust transition policy and the NICE Guideline (NG43) ‘Transition from children’s to adults’ services table 1.’ Data collected included lead clinical team, last attendance to Trust, future appointments, undergoing transition, limited life expectancy, whether undergoing treatment for malignancy or on clinical trials. Results From a total of 343 attendances, a randomized sample of 95 were selected. The average age was 16.8 years, with a maximum of 22 years. It was noted that only 19 (20%) patients had been involved with the transition process and only 11 (20%) of the appropriate attendances were on the Transition Exception Register. The financial burden of inappropriate attendances was estimated at over £19,000 per annum. Neurology, respiratory and orthopaedic specialities were identified as the lead team in most cases. Conclusion The audit highlighted issues surrounding the transition process including the need for early consideration and commencement and its subsequent impact on attendances to the paediatric emergency department. The importance of early, effective transition is highlighted by the financial burden associated with inappropriate attendances. Areas for service development could include more involvement of the transition team within the emergency department and discussion with specialities to improve transition clinic services.

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