Post 16: 27 January 2006
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 Technology Assessments and Appraisals
FOOD: a multicentre randomised trial evaluating feeding policies in patients admitted to hospital with a recent stroke (Dennis) 136 pages, Volume 10, number 2
Study findings did not support routine supplementation of hospital diet for unselected stroke patients who are predominantly well nourished on admission nor did they support a policy of early initiation of percutaneous endoscopic gastrostomy (PEG) feeding in dysphagic stroke patients.
The clinical and cost-effectiveness of donepezil, rivastigmine, galantamine and memantine for Alzheimer’s disease (Loveman) 176 pages, Volume 10, number 1
To provide an update review of the best quality evidence for the clinical effectiveness and cost-effectiveness of donepezil, rivastigmine and galantamine for mild to moderately severe Alzheimer’s disease (AD) and of memantine for moderately severe to severe AD.
The clinical effectiveness and cost-effectiveness of computed tomography screening for lung cancer: systematic reviews (Black) 106 pages, Volume 10, number 3
Computed tomography (CT) screening for lung cancer does not currently meet the accepted National Screening Committee criteria, with no randomised controlled trials and no evidence to support its clinical effectiveness or cost-effectiveness.
Latest Guidelines
NICE (2006) Arrhythmia - implantable cardioverter defibrillators (ICDs) - guidance. London: NICE.
Updated NICE guidance on the use of implantable-cardioverter defibrillators (ICDs) for people at risk of sudden cardiac death (SCD) as a result of cardiac arrhythmias. The guidance, recommends the following categories of patients for an ICD:
An ICD is a small device, placed beneath the skin of the upper chest below the left shoulder. Leads from the device are passed into the heart to continually sense for a rapid heart rhythm that might cause SCD and deliver a small electric shock to return the rhythm back to normal if necessary.
Parkinson's disease - full guideline, second consultation
A clinical practice guideline on Parkinson’s Disease is being developed for use in the NHS in England and Wales. Registered stakeholders for the guideline are invited to comment on the provisional recommendations during the consultation period, which runs until the 21tst February 2005. Publication of the final guideline is expected in June 2006. Please see the links above to access the guideline.
Latest Reports
Office for National Statistics (2006) Focus on Health. Basingstoke: Palgrave Macmillan.
Describes the health of people living in the UK. The data is based on five key areas : health status, risk factors, ill-health, preventive, curative and long-term care services and mortality. Emphasis is placed on trends over time.
House of Commons Committee of Public Accounts (2006) The NHS Cancer Plan: a
progress report: Twentieth Report of Session 2005–06: Report, together with formal minutes,
oral and written evidence. London: TSO.
Department of Health (2005) Report of the Ad Hoc Advisory Group on the Operation of NHS Research Ethics Committees. London: DoH.
NHS Research Ethics Committees (RECs) are convened to provide independent advice on
the extent to which proposals for research studies to be carried out within the NHS comply
with recognised ethical standards.
The primary purpose of a REC when considering the proposed study is to protect the
rights, safety, dignity and wellbeing of all actual or potential participants. Ethics review is
one of a series of safeguards intended to protect individuals. They are described in the
Research Governance Framework for Health and Social Care. Research governance is
intended to enable relevant research of good quality, as well as to forestall inappropriate
research.
Ethical approval is therefore only one of the r equirements for initiation of a r esearch
proposal. The Advisory Group was asked to report on the operation of NHS R esearch
Ethics Committees and on the inter face with other research approval processes.
Central Office for Research Ethics Committees (2006) Implementing the recommendations of the Ad Hoc Advisory Group: consultation. London: National Patient Safety Agency.
Through its Central Office for Research Ethics Committees (COREC), the National Patient Safety Agency (NPSA) has published its consultation on implementing the recommendations of the Report of the ad hoc advisory group on the operation of NHS research ethics committees, an independent report commissioned by the Department of Health. One of the key proposals in the consultation is to reconfigure the research ethics committee system as a more agile research ethics service. This will include the establishment of a new independent group of National Research Ethics Advisers who will ensure that only appropriate proposals for studies are considered by full committees and who will also be able to take some straightforward decisions on their behalf. The consultation ends on the 21st April 2006.
Department of Health (2006) Best Research for Best Health:A new national health research strategy: The NHS contribution to health research in England. London: DoH.
Best Research for Best Health outlines the direction that NHS research and development (R&D) will take over the next five years to ensure a vibrant, world-class environment for conducting and using NHS health research.
Academy of Medical Sciences (2006) Personal data for public good: using health information in medical research. London: Academy of Medical Sciences.
This report claims that research has been inhibited by confusing regulatory guidance, stifling bureaucracy and unnecessary constraints on researchers’ access to health data. The large numbers treated by the NHS and the use of electronic records should allow the UK to lead the field in analysing health data to allow better understanding and tackling of disease. Instead it has been hidebound by bureaucracy.
Department of Health (2006) Implementing local commissioning for primary care dentistry - understanding the transitional provisions order: factsheet no. 8. London: DoH.
The purpose of this factsheet is to explain how the following groups of dentists will transfer to the new contracts:
Care Services Improvement Partnership (2006) Women at Risk: The mental health of women in contact with the judicial system. London: DoH.
Sets out the key findings and recommendations of the work, and in particular the role of the NHS when responsibility for the health of those in custody is fully transferred to PCTs in April 2006. Two key messages underpinning all the recommendations is the need for partnership working within establishments, between government departments, and between statutory and voluntary organisations in the community, and the need to make interventions at an early stage of a woman’s contact with the criminal justice system. This publication has only just become available, although it was originally published on the 6th January 2006.
Evidence from Journals
Öngür D
About 30% of men with schizophrenia or schizoaffective disorders have obsessive-compulsive symptoms
Evid. Based Ment. Health, Vol.9, No.1, p.28
Grant BF
About 26% of people in the US have an anxiety, mood, impulse control, or substance disorder
Evid. Based Ment. Health, Vol.9, No.1, p.27
Harpaz-Rotem I
Young people admitted with self-injury had more severe psychiatric disorders in 2000 than in 1990
Evid. Based Ment. Health, Vol.9, No.1, p.26
Schmidt N
Suicide ideation and attempts are more prevalent in people aged 25–44 years in Australia but become less prevalent in older people
Evid. Based Ment. Health, Vol.9, No.1, p.25
Links PS
History of psychiatric hospital admission increases the risk of suicide less in the very old than in middle aged people
Evid. Based Ment. Health, Vol.9, No.1, p.24
Foong J
Epilepsy or a family history of epilepsy increases the risk of schizophrenia or schizophrenia-like psychosis
Evid. Based Ment. Health, Vol.9, No.1, p.23
Becker DR & Drake RE
Supported employment interventions are effective for people with severe mental illness
Evid. Based Ment. Health, Vol.9, No.1, p.22
Terman M
Review: light therapy is an effective treatment for seasonal affective disorder
Evid. Based Ment. Health, Vol.9, No.1, p.21
Blacker D
Neither vitamin E nor donepezil delays progression from amnestic mild cognitive impairment to Alzheimer’s disease in the long term
Evid. Based Ment. Health, Vol.9, No.1, p.20
Gilley DW
Review: cholinesterase inhibitors reduce burden and care time for informal carers of people with Alzheimer’s disease
Evid. Based Ment. Health, Vol.9, No.1, p.19
Burgio L
Training nursing home care staff to recognise psychopathology improves their ability to identify depressed residents
Evid. Based Ment. Health, Vol.9, No.1, p.18
Price DJR
A structured activity programme reduces depressive symptoms in moderately depressed older men with coronary heart disease, but not women
Evid. Based Ment. Health, Vol.9, No.1, p.17
Byrne MK
Pharmacotherapy and cognitive behavioural therapy: similarly cost effective compared with community referral for disadvantaged women with major depression
Evid. Based Ment. Health, Vol.9, No.1, p.16
Muzina DJ
Divalproex and lithium are similarly cost effective for adults with bipolar disorder
Evid. Based Ment. Health, Vol.9, No.1, p.15
Bowden CL
Cognitive therapy is more cost effective than standard care alone for bipolar disorder
Evid. Based Ment. Health, Vol.9, No.1, p.14
Overbeek T & Schruers K
Cognitive behavioural therapy reduces nocturnal panic in people with panic disorder
Evid. Based Ment. Health, Vol.9, No.1, p.13
Grilo CM
Cognitive behavioural therapy does not improve outcome in obese women with binge eating disorder receiving a comprehensive very low calorie diet programme
Evid. Based Ment. Health, Vol.9, No.1, p.12
Isaac MT
Individual dietary education reduces olanzapine associated weight gain
Evid. Based Ment. Health, Vol.9, No.1, p.11
Edlinger M, Fleischhacker WW
Review: no evidence to support gradual over abrupt switching of antipsychotics
Evid. Based Ment. Health, Vol.9, No.1, p.10
Leucht DS, Davis JM
Intramuscular haloperidol and olanzapine begin to reduce psychosis within 24 hours
Evid. Based Ment. Health, Vol.9, No.1, p.9
Kazdin AE
Multisystemic therapy reduces long term rearrest compared with usual treatment
Evid. Based Ment. Health, Vol.9, No.1, p.8
Barton J
Atomoxetine improves teacher rated symptoms in children with ADHD more than placebo
Evid. Based Ment. Health, Vol.9, No.1, p.7
Fombonne E
Risperidone improves restricted, repetitive, and stereotyped behaviour in autistic children and adolescents
Evid. Based Ment. Health, Vol.9, No.1, p.6
Larsen TK
Poor social and interpersonal functioning prior to diagnosis predicts poor outcome for people with first episode psychosis
Evid. Based Ment. Health, Vol.9, No.1, p.5
Latest Questions to the Primary Care Question Answering Service
ASSESSMENT AND DIAGNOSIS
A Duke's score is quoted after an exercise ECG test - I know it relates to ST level changes but how is it worked out and what is a 'significant' score?
How should I interpret a 24 hour BP recording. Is the average reading reasonable to use even if the patient has had a number of high recordings during busy parts of the day ie commuting or getting up?
When should I investigate a patient in primary care for phaeochromocytoma?
In any patient with IHD and > 20% CVD risk started on full treatmnet with statins,aspirin,ACE and bblockers what is the new risk of CVD in the next 10yrs ie by how much is the risk lowered in total by all treatments ?
What are the long term complications on renal function of taking Lithium (for say over 20 years)? How, apart from measuring serum creatinine, should renal problems be monitored in such patients?
How often should CHD risk be assessed in patients with diabetes?
We have been asked to diagnose chronic renal failure as part of the new GP contract. Could you give us guidelines as to how to diagnose this and guidelines on how to manage it, given also that the creatinine level acceptable seems to differ with age.
Do women with previuosly normal smear test results who are no longer sexually active need to continue to have smears? and is there a time scale from last sexual activity where by we would consider stopping?
Are there guidelines on interpretation of 24 hr BP results?
CAUSES, RISKS AND PREVENTION
Do you know of any patient education DVD's (non commercial) that would be suitable for playing in the waiting room, eg brief scenarios about asthma, hypertension, diabetes, flu vacs, childcare etc?
What is the incidence of penicillin allergy?
Could you tell me what to suggest in women over 50 who are still taking pop ,how do we establish when it is time to stop contraception?
What is the antibiotic of choice to treat a case of chlamydia in a breast feeding mother? and what side effects could the baby develop?
CHILD HEALTH
What is the antibiotic of choice in a child who has suspected meningitis presenting to general practice, if they are allergic to penicillin? is it iv chloramphenicol?
Is there any evidence to suggest if infantile colic actually exists and if so, are there any effective remedies ?
What is the latest guidance for managing suspected epiglotittis in the community whilst waiting for an ambulance; is there a role for steroid or anitiobiotic use?
NEUROLOGICAL DISEASE
What interventions are appropriate for a patient with PCOS hoping to start a family in the near future?
HEALTH MANAGEMENT
Please define patient care pathways
MUSCOLOSKELETAL DISEASES
Should you automatically give calcium and Vit D to someone newly diagnosed as having osteoporosis that you commence on Alendronate?
GASTROENTEROLOGY
My patients mother has alpha tripsin1 deficiency and her consultant has asked her daughter to attend for advice & screening. What information do I need to give her?
Does increasing fibre have any benefit in people suffering from haemorrhoids?
TREATMENT AND DISEASE MANAGEMENT
Is there any guidance on the management of HRT withdrawal?
CARDIOVASCULAR DISEASE
1) In a patient with AF and previous TIAs on warfarin presenting with suspected angina is aspirin use contraindicated or more beneficial? 2) what is the percentage of haemorrhagic complications with aspirin and warfarin together do the risks outweigh the benefits?
GENITOURINARY - MALE
Can you please advise at which hospitals radical prostatectomies are carried out on the NHS.
RESPIRATORY
Aerochaber or volumatic in asthma patients, any evidence for or against?
Hitting the Headlines - Evidence Behind the Press Stories
Antiviral treatment for avian flu
Antiviral drugs for influenza may not be effective against avian flu, reported three newspapers (19 January 2006). These articles were based on a systematic review, which found that antiviral drugs eased symptoms of influenza but did not prevent infection. There was no evidence for their use or effectiveness in avian flu.
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Three newspapers (1-4) reported that there is no evidence that the antiviral drugs Tamiflu and Relenza are effective against avian flu. One of the articles (4) reported that both Tamiflu and Relenza, as well as two additional antiviral drugs, eased the symptoms of influenza but did not prevent infection.
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The newspaper articles are based on a report of two systematic reviews (5) of randomised controlled trials comparing the efficacy and safety of antivirals with placebo against influenza and asymptomatic influenza. The review found that both the older (amantadine and rimantidine) and newer antiviral drugs (Tamiflu and Relenza) prevented or eased symptoms of influenza but did not prevent infection. None of the investigated drugs was effective against influenza-like illnesses. The two older drugs, amantadine and rimantidine, also caused side effects such as hallucinations and agitation. The review was unable to provide any evidence specific to avian-derived influenza.
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The main message from the research study that none of the available drugs is likely to be sufficiently effective in the event of an avian-flu pandemic was correctly reflected in all the newspapers. However, three of the newspaper articles were brief and perhaps gave the impression that the research was more specific to avian-derived influenza than it actually was.
Evaluation of the evidence base for the efficacy of antiviral drugs for avian flu.
Where does the evidence come from?
The evidence comes from research led by Dr Thomas Jefferson, based at the Cochrane Vaccines Field, Italy. The study was supported by the UK Department of Health, the Cochrane Review Incentive Scheme 2005, and two ASL grants (ASL19 and ASL20).
What were the authors' objectives?
The objective was to assess the efficacy, effectiveness, and safety of registered antivirals against naturally occurring influenza in healthy adults.
What was the nature of the evidence?
This is based on two systematic reviews of randomised controlled trials of antiviral drugs for the prevention and treatment of influenza. Fifty-two trials comparing the effects of four antiviral agents with control (placebo, no intervention, or symptomatic medication) were included in the review. A comprehensive literature search of several electronic databases, reference lists and contact with the manufacturers and authors of identified studies was used to identify relevant trials. The review studied effects on cases of properly diagnosed influenza (symptomatic or asymptomatic); cases of influenza-like illness, pneumonia, and human influenza caused by avian-derived influenza viruses. It also investigated the effects of the drugs on how infectious people were and for how long (duration and concentration of nasal shedding of viruses or persistence in upper airways). Studies from any part of the world were reviewed.
What interventions were examined in the research?
The review included studies that assessed the effects of M2 ion channel blocking drugs (amantadine and rimantadine) and the neuraminidase inhibitors Tamiflu (oseltamivir) and Relenza (zanamivir), used at any dose, preparation or time schedule against influenza and influenza-like illness.
What were the findings?
Amantadine and Rimantadine:
When used to prevent influenza, amantadine was shown to prevent 61% of influenza A cases and 25% of influenza-like illness but it had no effect in preventing asymptomatic cases of influenza. Also, compared with placebo, amantadine was found to increase the odds of side effects (nausea, insomnia and hallucinations) by two-fold. Rimantadine was found to have similar effects.
When used to treat influenza, compared to placebo, amantadine and rimantadine significantly shortened duration of fever by around a day, but did not stop infected patients being infectious. No data were found for the effect of amantadine or rimantadine specifically on avian-derived influenza.
Tamiflu and Relenza (Neuraminidase inhibitors):
When used for the prevention of influenza, compared to placebo, neither Tamiflu (oral) nor Relenza (inhaled) had an effect against asymptomatic influenza or influenza like illness, even at higher doses. The efficacy of Tamiflu 75mg daily against symptomatic influenza was 61% and 73% at 150mg daily. Relenza (10mg daily) was 62% effective.
When used to prevent influenza in people living in households where someone has already been infected Tamiflu was shown to demonstrate a protective efficacy of 58.5% for households and from 68% to 89% in contacts of index cases. When used for the treatment of patients infected with influenza Tamiflu and Relenza were both associated with shorter times for the alleviation of symptoms and patients were less infectious (viral nasal titres were shown to be significantly reduced). However neither drug stopped patients being infectious irrespective of the dose of the drug.
No credible data assessing the effect of Tamiflu on avian-derived influenza were found. Data from previous studies relating to Tamiflu were briefly reported on in the discussion. High dose Tamiflu was shown to be effective in preventing lower respiratory tract complications (bronchitis and pneumonia) in influenza cases but not influenza-like illness.
What were the authors' conclusions?
The evidence does not support the use of amantadine and rimantadine for influenza. It is also suggested that neuraminidase inhibitors should not routinely be used in the control of seasonal influenza, and should only be used in a serious epidemic or pandemic alongside other public health measures.
How reliable are the conclusions?
This was a well conducted review and the authors' conclusions are likely to be reliable. An effort was made to obtain all the relevant information, and when conducting the review appropriate measures were taken to minimise error and bias. The authors were correct to point out that their conclusions are limited by the quality and quantity of the evidence base.
The review was looking at the effects of antiviral drugs against naturally occurring influenza in healthy adults and the results of the review are applicable to such an illness. The review was unable to provide any evidence specific to avian-derived influenza. Therefore it is unknown if the more effective drugs (Tamiflu or Relenza) would be less or equally effective against avian-derived influenza.
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 were no related systematic reviews identified on the Cochrane Database of Systematic Reviews (CDSR) or on the Database of Abstracts of Reviews of Effects (DARE).
References and resources
1. No evidence flu drugs work-study. The Guardian, 19 January 2006, p1.
2. Flu fight 'waste' . Daily Mirror, 19 January 2006, p8.
3. Flu drug warning. The Times, 19 January 2006, p2.
4. Flu drugs 'will not work' if pandemic strikes. The Guardian, 19 January 2006, p4.
Consumer information
Health Protection Agency - Influenza
Science & development network - Bird flu: the facts
Previous Hitting the Headlines summaries on this topic
New drug promises to hit flu where it hurts. Hitting the Headlines archive, 23 January 2003.
Drug stops flu's spread through families. Hitting the Headlines archive, 14 February 2001.
Document of the Week from the National Library for Health
Tramer, M.R., Reynolds, D.J.M., Moore, R.A., McQuay H.J. (1997) Impact of covert duplicate publication on meta-analysis: a case study. BMJ 315:635-64.
Objective: To quantify the impact of duplicate data on estimates of efficacy.
Design: Systematic search for published full reports of randomised controlled trials investigating ondansetron's effect on postoperative emesis. Abstracts were not considered.
Data sources: Eighty four trials (11 980 patients receiving ondansetron) published between 1991 and September 1996.
Main outcome measures: Percentage of duplicated trials and patient data. Estimation of antiemetic efficacy (prevention of emesis) of the most duplicated ondansetron regimen. Comparison between the efficacy of non-duplicated and duplicated data.
Results: Data from nine trials had been published in 14 further reports, duplicating data from 3335 patients receiving ondansetron; none used a clear cross reference. Intravenous ondansetron 4 mg versus placebo was investigated in 16 reports not subject to duplicate publication, three reports subject to duplicate publication, and six duplicates of those three reports. The number needed to treat to prevent vomiting within 24 hours was 9.5 (95% confidence interval 6.9 to 15) in the 16 non-duplicated reports and 3.9 (3.3 to 4.8) in the three reports which were duplicated (P<0.00001). n="25)" style="font-weight: bold;">
Conclusions: By searching systematically we found 17% of published full reports of randomised trials and 28% of the patient data were duplicated. Trials reporting greater treatment effect were significantly more likely to be duplicated. Inclusion of duplicated data in meta-analysis led to a 23% overestimation of ondansetron's antiemetic efficacy.
posted by skif at 11:17 am
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