Post 7: 18th November 2005
Links are given to online full text resources, all other materials can be obtained via the Fade Library, just mail your request to library.services@fade.nhs.uk
Latest Systematic Reviews
Gilbody S, et al. Screening and case finding instruments for depression. Cochrane Database Syst Rev 2005;(4):CD002792.
Latest Technology Assessments and Appraisals
Review: NICE Technology Appraisal Guidance No.60 Patient education models for diabetes (types 1 and 2): Proposal to incorporate the review into a current guideline
NICE has recommended that structured patient education is made available to all people with diabetes at the time of initial diagnosis and then as required on an ongoing basis, based on a formal, regular assessment of need. The guidance identifies a number of principles of good practice for effective education.
Acute coronary syndromes - clopidogrel (No. 80): Clarification of recommendation 1.3
NICE has issued guidance to the NHS in England and Wales on the use of Clopidogrel in the treatment of non-ST-segment-elevation acute coronary syndrome.
Hot Topics in Health Management
Healthcare Associated Infection (HCAI)
European Working Time Directive (EWTD)
Latest Reports
Life expectancy at birth by health and local authorities in the United Kingdom 1991-1993 to 2002-2004
Life expectancy at birth results for health and local authorities in the United Kingdom are now available for 2002-2004. These figures have been added to existing trend data from 1991-1993 to 2001-2003 which have not been revised.
Results are rolling averages, produced by aggregating deaths and population estimates for each three year period. Notes on the interpretation of life expectancy at birth and its calculation are contained within the report. Results for each area can be found via the links to Excel workbooks.
Sustainable Food and the NHS
NHS trusts spend about £500 million a year on food and catering. The government is committed to the economic, environmental, social and health benefits of sustainable food procurement, but this is difficult to translate into practice at a local level. In 2004 the Better Hospital Food Programme (BHFP) commissioned the King's Fund to identify opportunities for managing food procurement sustainably and promoting healthy eating in acute hospitals. Reporting on the project, this paper includes a framework to help organisations to assess their procurement and catering practices, and recommends policies, menu designs and contract specifications.
National Audit Office (2005) Reducing Brain Damage: Faster access to better stroke care. London: The Stationery Office.
Stroke costs about £7 billion a year. The direct cost to the NHS is about £2.8 billion a year – more than the cost of treating coronary heart disease – and annual costs to the wider economy associated with lost productivity, disability and informal care are around £4.2 billion. Stroke is one of the top three causes of death in England and a leading cause of adult disability. Approximately 110,000 strokes and a further 20,000 Transient Ischaemic Attacks (‘mini strokes’) occur in England every year. There are at least 300,000 people in England living with moderate to severe disabilities as a result of stroke.
The report’s conclusions and recommendations target areas needing attention and action:
- A fast response to stroke, including rapid access to brain scanning, reduces the risk of death and disability. However, Ambulance Trusts, Accident and Emergency departments, Radiology departments and stroke teams rarely provide an effective, integrated emergency response to stroke.
- The clinically optimal model of stroke care is care delivered in a specialised stroke unit, and 63 per cent of patients are accessing a stroke unit at some point in their hospital stay. However, what constitutes a stroke unit varies considerably between hospitals and stroke units are of insufficient size.
- Without a brain scan, treatment cannot commence safely. Research shows that scanning all stroke patients immediately is the most cost effective strategy. Although most hospitals have the capacity to provide CT scans within 24 hours of admission, in 2004 most patients waited more than two days.
- Thrombolytic (clot busting) drugs can improve patients’ chances of recovery after a stroke, but are rarely part of acute stroke care in England. Achieving rates of thrombolysis in England in line with those being achieved in leading Australian hospitals could generate net savings to the health service of over £16 million a year, with more than 1,500 patients fully recovering from their strokes each year who would not otherwise have done so.
- Early access to rehabilitation can restore movement, improve recovery and reduce delayed discharges. However, access to professionals such as psychologist, physiotherapists, occupational and speech therapists and social workers can be patchy.
- Hospitals said that around half of patients receive rehabilitation services that meet their needs in the first six months after discharge, and this falls to around a fifth of patients in the 6 12 months after discharge. There is also a serious impact on carers which is not being addressed adequately. The lack of clarity about how responsibilities are divided between health and social care services is a barrier to the delivery of patient-centred care.
- Many people still do not realise that strokes are largely preventable and cannot list the main risk factors, or how to manage them. Over three times as many women died of stroke than of breast cancer in England and Wales in 2002, but 40 per cent more women mentioned breast cancer than mentioned stroke when asked what the top causes of death were.
- The new GPs’ contract has improved stroke prevention. Nearly all the desired GP activities, such as measuring and controlling blood pressure and cholesterol in those people who have had a previous stroke or TIA will soon be achieved, except, however, the very low referral rate for scans for people who have had a stroke or TIA.
- Some scans and interventions are being carried out after the time when they would have been of benefit. Around £1.2 million a year is being inefficiently spent on scans for patients with TIA after the critical time-period has passed. Providing carotid surgery within two weeks to eligible patients could prevent around 250 strokes, and result in a net saving to the health service of around £4 million, each year.
- All patients with suspected TIA should be assessed and investigated within seven days. However, only a third of people with TIA are seen in a TIA clinic, and the median waiting time is 14 days.
Commissioning Obesity Services - PCTs' Services and Strategies (available from FADE)
Tackling obesity is a major public health challenge and, from next year, PCTs will have additional funds for this purpose. Commissioning obesity services: PCTs’ services and strategies is a new publication from the NHS Alliance that provides examples of best practice from primary care trusts across England. Building on a review of 26 PCTs carried out by the NHS Modernisation Agency, it incorporates more information gathered by the NHS Alliance public health network. The publication covers the whole spectrum from developing a local strategy to providing services for children and adults, and it ranges from schemes that promote physical activity to the provision of surgery. Organised into themes, examples include:
- The local action plan for tackling obesity in children and young people developed by Durham and Chester-le-Street PCT includes training staff in schools to encourage high quality physical activity at lunchtime.
- The three PCTs in West Surrey are disseminating good practice through care pathways. For adults, it sets an outcome of 10% sustained reduction in body weight over a year, and recommends that if this is achieved, all patients should be offered an annual follow-up by their GP and re-referral if weight gain is more than 3kg over a two-year period. There’s nothing quite so effective as starting good habits early in life.
- Brent PCT has set up breast feeding cafés where mothers have the chance to meet each other along with health visitors and midwives, and can share their experiences, problems and solutions. GP practices can be just as innovative.
- The Castlefields Surgery in Runcorn, Cheshire, has obtained funding to increase fruit and vegetable consumption among their patients. GPs and nurses can issues ‘prescriptions’ – vouchers offering £1 off fruit and vegetable purchases at the local ASDA and Hatton Food Co-operative stores. In the waiting room, trained community volunteers distribute fruit and smoothies and encourage discussion about healthy eating.
Practice Based Commissioning - Policy Into Practice : Feedback Report (available from FADE)
Practice based commissioning (PBC) has tremendous potential to redesign NHS services. But it will fail if the Department of Health, primary care trusts and strategic health authorities do not put more effort into engaging frontline clinicians – not least, by talking to them.
If GP practices do not get actively involved in PBC, then Payment by Results will suck more resources out of primary care by incentivising hospital activity – and general practice will be less able to compete with other providers of primary care services.
That is Professor David Hunter’s conclusion after studying the experience and views of nearly 900 participants at a series of five NHS Alliance regional workshops on PBC, organised with partners Astra Zeneca and Medical Management Services.
His report on the workshops, Practice based commissioning: policy into practice, highlights a series of issues:
- Although many are enthusiastic about PBC’s potential, a substantial proportion of GPs and practices feel uninformed, unconvinced and uninvolved.
- At the national level, there needs to be more recognition that there are few incentives for practices to engage in PBC. There should be financial recognition for the management and clinical time involved that is not contingent upon the financial health or otherwise of the PCT.
- PCTs need a clear strategy for communicating with all their practices about PBC and how best to develop it. Budget information and monitoring, along with activity date, are fundamental.
- Practices need to consider forming groups and networks, based on locality or like-minded-ness. They can form federations, consortia or companies, creating clusters that will provide economies of scale.
Professor Hunter said:
“Practice based commissioning is a high risk policy which needs to be implemented with care. Yet we are seeing a communications failure at all levels.
“Unless practices and GPs are given appropriate support there is a real risk of the NHS being destabilised. That would mean the government would fail to achieve its goal of strengthened healthcare outside hospitals.”
Evidence from Journals
Quality of life in bipolar disorder: A review of the literature. Erin E Michalak, Lakshmi N Yatham and Raymond W Lam. Health and Quality of Life Outcomes 2005, 3:72
A sizable body of research has now examined the complex relationship between quality of life (QoL) and depressive disorder. Uptake of QoL research in relation to bipolar disorder (BD) has been comparatively slow, although increasing numbers of QoL studies are now being conducted in bipolar populations. We aimed to perform a review of studies addressing the assessment of generic and health-related QoL in patients with bipolar disorder. A literature search was conducted in a comprehensive selection of databases including MEDLINE up to November 2004. Key words included: bipolar disorder or manic-depression, mania, bipolar depression, bipolar spectrum and variants AND quality of life, health-related QoL, functional status, well-being and variants. Articles were included if they were published in English and reported on an assessment of generic or health-related QoL in patients with BD. Articles were not included if they had assessed fewer than 10 patients with BD, were only published in abstract form or only assessed single dimensions of functioning. The literature search initially yielded 790 articles or abstracts. Of these, 762 did not meet our inclusion criteria, leaving a final total of 28 articles. These were sub-divided into four categories (assessment of QoL in patients with BD at different stages of the disorder, comparisons of QoL in Patients with BD with that of other patient populations, QoL instrument evaluation in patients with BD and treatment studies using QoL instruments to assess outcome in Patients with BD) and described in detail. The review indicated that there is growing interest in QoL research in bipolar populations. Although the scientific quality of the research identified was variable, increasing numbers of studies of good design are being conducted. The majority of the studies we identified indicated that QoL is markedly impaired in patients with BD, even when they are considered to be clinically euthymic. We identified several important avenues for future research, including a need for more assessment of QoL in hypo/manic patients, more longitudinal research and the development of a disease-specific measure of QoL for patients with BD.
Herbert B. Peterson, M.D., and Kathryn M. Curtis, Ph.D. (2005) Long-Acting Methods of Contraception. NEJM Volume 353:2169-2175.
Wen MC, et al. Efficacy and tolerability of anti-asthma herbal medicine intervention in adult patients with moderate-severe allergic asthma. J Allergy Clin Immunol 2005 Sep;116(3):517-24.
Wilt TJ, et al. Use of spirometry for case finding, diagnosis, and management of chronic obstructive pulmonary disease (COPD). Evid Rep Technol Assess (Summ) 2005 Aug;(121):1-7.
Lister MS, et al. Randomized, double-blind, placebo-controlled trial of vaginal misoprostol for management of early pregnancy failures. Am J Obstet Gynecol 2005 Oct;193(4):1338-43.
Galvin JE, et al. The AD8: a brief informant interview to detect dementia. Neurology 2005 Aug 23;65(4):559-64.
Latest Questions to the Primary Care Question Answering Service
Is there any method currently available to test for human papilloma virus in patients other than clinical examination or cervical smears
Can HIV be transmitted via mosquitoes and if not why not?
Is Gingko Biloba contraindicated in type 2 IDDM.
In a young 22year old patient is on dianette for hirtuism who now requires o/c pill what should be prescribed as dianette is no longer licensed as a contraceptive?
If a child is born with one undescended testis, at what age should he be have an orchidopexy?
What treatments or recommedations for pre-menopausal woman with lack of libido
Can antidepressants or lithium cause IBS?
Should a person with neutropaenia have a flu jab?
What is the evidence for the use of steroids in the treatment of croup? Can they be used in a primary care setting?
1) In patients with previous TIA, is there any evidence of using an antiplatelet (i.e. aspirin or clopidogrel) plus warfarin versus warfarin alone in preventing stroke? 2) Are there any harms associated with using clopidogrel and warfarin versus warfarin alone in preventing strokes in patients with prior TIA?
I have been informed that an alpha blocker should not be prescribed concomitantly with sildenafil or similar medication - it is almost a contraindication and if given then one should wait at least 6 hours in between each dose - what is the evidence for this?
In patients with linear IgA disease, what is the evidence for the use of dapsone & what would be a suitable alternative if patient developed side effects (macrocytic anaemia and psychosis).
In an anxious patient 58 years old, with a family history of glaucoma, which antidepressant is least likely to induce glaucoma? Patient is worried about possibly raising the IOP if put on antidepressants
Is there any evidence that pyridoxine hydrochloride 0.2% cream applied to the hands, arms and toes of patients with chemically induced peripheral neuropathy is effective?
Is it safe to use chloramphenicol eye ointment around a circumcision wound in an infant?
Is there any evidence for adverse effects of long-term (years) SSRI use in a man aged 35years?
What is the relavance of poor R-wave progression with an otherwise normal ecg.
What guidelines are there for assessment, investigation & treatment of probable CFS?
Could you please comment on strengths and weaknesses of ASCOT study about hypertension?
Hitting the Headlines - Evidence Behind the Press Stories
Dietary supplements for knee osteoarthritis
The dietary supplements glucosamine and chondroitin are better at fighting osteoarthritis pain than prescription drugs, reported the Daily Mail (15 November 2005). It is not possible to comment on the reliability of the research findings as the presentation abstract and press release provide insufficient detail.
- The Daily Mail (15 November 2005) reported that research has revealed that dietary supplements are better at fighting osteoarthritis pain than prescription drugs (1).
The newspaper article is based on initial results from the GAIT (The Glucosamine/Chondroitin Arthritis Intervention Trial), presented at the American College of Rheumatology Annual Scientific Meeting (2). In the trial, 1,583 participants with painful knee osteoarthritis were randomly assigned to receive glucosamine hydrochloride, sodium chondroitin sulfate, both supplements, celecoxib, or a placebo. Lead author Daniel Clegg stated: "As expected, celecoxib improved knee pain in patients with osteoarthritis. For the study as a whole, the supplements were not shown to be effective; however, an exploratory analysis suggested that the combination of glucosamine and chondroitin sulfate might be effective in osteoarthritis patients who had moderate to severe knee pain." - It is not possible to comment on the reliability of the research findings as the presentation abstract and press release provide insufficient detail. In addition, the funders of the study, the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (NIH) have issued the following statement (3): "While we appreciate the desire of the media and the community to share the results of the GAIT study, NCCAM and our NIH study co-sponsor, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, are refraining from comment on the study until the full results are published in the peer-reviewed literature."
Systematic reviews - Information staff at CRD searched for systematic reviews relevant to this topic. Systematic reviews are valuable sources of evidence as they locate, appraise and synthesize all available evidence on a particular topic.
There was one related systematic review identified on the Cochrane Database of Systematic Reviews (CDSR) (4) and six on the Database of Abstracts of Reviews of Effects (DARE) (5-10).
References and resources
1. Sports pill 'fights joint pain better than drugs'. Daily Mail, 15 November 2005, p17.
2. American College of Rheumatology. Glucosamine and chondroitin sulfate may be useful for patients with moderate to severe pain from knee osteoarthritis. Press Release, 13 November 2005.
3. National Institutes of Health (NIH). NCCAM statement on presentation of GAIT results at ACR meeting. Press Release, 14 November 2005.
4. Towheed TE, Maxwell L, Anastassiades TP, Shea B, Houpt J, Robinson V, Hochberg MC, Wells G. Glucosamine therapy for treating osteoarthritis (Cochrane Review). In: The Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD002946. DOI: 10.1002/14651858.CD002946.pub2.
5. Ruane R, Griffiths P. Glucosamine therapy compared to ibuprofen for joint pain. British Journal of Community Nursing 2002;7(3):148-152. [DARE Abstract]
6. McAlindon T E, LaValley M P, Gulin J P, Felson D T. Glucosamine and chondroitin for treatment of osteoarthritis: a systematic quality assessment and meta-analysis. JAMA 2000;283(11):1469-1475.[DARE Abstract]
7. Leeb B F, Schweitzer H, Montag K, Smolen J S. A metaanalysis of chondroitin sulfate in the treatment of osteoarthritis. Journal of Rheumatology 2000;27(1):205-211. [DARE Abstract]
8. Barclay T S, Tsourounis C, McCart G M. Glucosamine. Annals of Pharmacotherapy 1998;32(5):574-579. [DARE Abstract]
9. Glucosamine and arthritis. Bandolier 1997;46:1-3. [DARE Abstract]
10. Towheed T E, Hochberg M C. A systematic review of randomized controlled trials of pharmacological therapy in osteoarthritis of the knee, with an emphasis on trial methodology. Seminars in Arthritis and Rheumatism 1997;26(5):755-770. [DARE Abstract]
Consumer information
NHS Direct: Osteoarthritis
Arthritis Research Campaign
Arthritis Foundation: Alternative therapies, glucosamine and chondroitin sulfate
Previous Hitting the Headlines summaries on this topic
New pill for arthritis. Hitting the Headlines archive, 20 August 2004.
National Library for Health - Focus On
Compensation Status and Surgical Outcome
Document of the Week from the National Library for Health
Ghost writers and guest authors threaten the credibility of published research.
Annals of Internal Medicine publishes a report by two editors who are concerned about the frequency of submissions from ghost writers and guest authors who have not been responsible for the original research or the writing of the paper.
For example, a drug company may have carried out the research and written the report, but then ask an academic to add their name to authorship. This would hide the issue of bias, influencing the credibility of the research. NHS Athens passwords are required, and can be obtained from http://www.nelh.nhs.uk/home_use.asp
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