Primary Care Clinical Effectiveness Bulletin

August2010

Welcome to the WPCT Primary Care Clinical Effectiveness Bulletin, which aims to promote best practice by giving GPs and primary care health professionals quick access to recently issued clinical guidance. The Bulletin provides brief summaries, and (where useful) includes tables or flow charts taken directly from the guidance document. Wherever possible, each section contains a hyperlink which enable you to access the complete set of guidance documents on-line (In the case of NICE, this includes Quick Reference Guides and patient information booklets). This edition appears after a gap of several months, but we intended to issue the Bulletin on a monthly basis in future. Your feedback would be much appreciated – please contact the Clinical Effectiveness Facilitator at Wandsworth PCT by e-mail or phone 020 8812 7827.

Contents

  1. NICE Clinical Guidelines
  2. Management of lower urinary tract symptoms (LUTS) in men (CG97, May 10)
  3. Recognition and treatment of neonatal jaundice (CG98, May 10)
  4. The Diagnosis and management of idiopathic childhood constipation in primary and secondary care (CG99, May 10)
  5. Alcohol-use disorders: diagnosis and clinical management of alcohol related physical complications (CG100, Jun 10)
  6. Management of chronic obstructive pulmonary disease in adults in primary and secondary care (CG101, Jun 10)
  7. Management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care (CG102, Jun 10)
  8. Delirium: diagnosis, prevention and management (CG103, Jul 10)
  9. Diagnosis and management of metastatic malignant disease of unknown primary origin (CG104, Jul 10)
  10. The use of non-invasive ventilation in the management of motor neurone disease (CG105, Jul 10)
  11. NICE Public Health Guidelines
  12. Alcohol-use disorders - preventing the development of hazardous and harmful drinking (PH25, Jun 10)
  13. Guidance on the prevention of cardiovascular disease at the population level (PH26, Jun 10)
  14. Quitting smoking in pregnancy and following childbirth (PH27, Jun 10)
  15. Weight management before, during and after pregnancy (PH28, Jul 10)
  16. NICE Technology Appraisals
  17. Infliximab (review) and adalimumab for the treatment of Crohn’s disease (TA187, May 10)
  18. Human growth hormone (somatropin) for the treatment of growth failure in children (TA188, May 10)
  19. Sorafenib for the treatment of advanced hepatocellular carcinoma (TA189, May 10)
  20. Lung cancer (non-small-cell) - pemetrexed (maintenance) (TA190, Jun 10)
  21. Gastric cancer (advanced) - capecitabine (TA191, Jul 10)
  22. Lung cancer (non-small-cell, first line) - gefitinib (TA192, Jul 10)
  23. Leukaemia (chronic lymphocytic, relapsed) - rituximab (TA193, Jul 10)
  24. Bone loss (therapy-induced) in non-metastatic prostate cancer - denosumab (terminated appraisal) (TA194, Jul 10)
  25. Table listing NICE Interventional Procedure Guidance
  26. Local clinical guidelines recently approved by CEMMaG
  27. Wandsworth Diabetes Guidelines (2nd Edition, August 2010)
  28. Local guidelines on COPD
  1. NICE Clinical Guidelines

1.1.Management of lower urinary tract symptoms (LUTS) in men (CG97, May 10)

This clinical guideline offers evidence-based advice on the effective management of lower urinary tract symptoms (LUTS) in men. The lower urinary tract consists of the bladder, prostate gland and urethra. The guideline makes recommendations covering:
- initial assessment
- referral for specialist assessment
- specialist assessment
- conservative management
- drug treatment
- managing retention
- surgery
- long term catheterisation and containment

The following tables are reprinted directly from the NICE quick reference guide:

….. cont/…..

The guideline and supporting documentation including can be accessed via the NICE website by clicking on the following hyperlink: The management of lower urinary tract symptoms in men

1.2.Recognition and treatment of neonatal jaundice (CG98, May 10)

Approximately 60% of term and 80% of preterm babies develop jaundice in the first week of life, and about 10% of breastfed babies are still jaundiced at 1 month of age. In most babies early jaundice is harmless. However, a few babies will develop very high levels of bilirubin, which can be harmful if not treated. This guideline provides guidance on the recognition, assessment and treatment of neonatal jaundice in babies from birth to 28 days. The guideline makes recommendations and describes clinical pathways covering:

- information and support for parents and carers
- investigation pathway
- additional care for high risk babies
- how to measure the bilirubin level
- phototherapy pathway
- exchange transfusion pathway
- how to manage hyperbilirubinaemia
- care of babies with prolonged jaundice

This guidance can be accessed via this hyperlink to the NICE website: Neonatal jaundice

1.3The Diagnosis and management of idiopathic childhood constipation in primary and secondary care (CG99, May 10)

Constipation is common in childhood. It affects around 5–30% of the child population, depending on the criteria used for diagnosis. Symptoms become chronic in more than one third of patients, and constipation is a common reason for referral to secondary care.
The guideline describes and makes recommendations in relation to:

- the need for patient centred care.
- history taking and physical examination
- how to investigate possible underlying causes
- clinical management for disimpactation
- clinical management for maintenance therapy
- promoting appropriate diet and lifestyle changes
- providing information and support
- specialist investigations and interventions

The guideline specifies critria and supplies detailed information in relation to:

- Key components of history-taking to diagnose constipation
- Key components of history-taking to diagnose idiopathic constipation
- Key components of physical examination to diagnose idiopathic constipation
- Laxatives: recommended doses

The Quick Reference Guide contains a number of tables and flow charts to assist with the recognition of idiopathic constipation in primary care. This guidance can be accessed via this hyperlink to the NICE website:Constipation in children and young people

1.4Alcohol-use disorders: diagnosis and clinical management of alcohol related physical complications (CG100, Jun 10)

In the UK, it is estimated that 24% of adults drink in a hazardous or harmful way. Hazardous and harmful drinking are commonly encountered among people attending hospital for reasons unrelated to alcohol. Persistent drinking at hazardous and harmful levels can result in damage to almost every organ or system of the body. Alcohol-related complications include acute alcohol withdrawal, alcohol-related seizures and delirium tremens, Wernicke’s encephalopathy, liver disease, and acute and chronic pancreatitis. This guideline looks at key areas in the investigation and management of the alcohol-related conditions listed above in adults and young people.

…..cont/……

Amongst other things, the NICE Quick Reference Guide gives a referral pathway for acute alcohol withdrawal which may be useful in primary care settings:

The Quick Reference Guide contains a number of tables and flow charts. This guidance and all supporting documents can be accessed via this hyperlink to the NICE website: Alcohol-use disorders: diagnosis and clinical management of alcohol related physical complications

1.5Management of chronic obstructive pulmonary disease in adults in primary and secondary care (CG101, Jun 10).

This guideline partially updates and replaces NICE clinical guideline 12 (CG101).It is estimated that 3 million people have COPD in the UK. COPD is predominantly caused by smoking and is characterised by airflow obstruction that is not fully reversible. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry.


The guidance and all supporting documents can be accessed via this hyperlink to the NICE website: Chronic obstructive pulmonary disease (update)

1.6
Management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care (CG102, Jun 10)

This guideline offers best practice advice on the care of children and young people younger than 16 years with bacterial meningitis and meningococcal septicaemia. Bacterial meningitis is an infection of the surface of the brain (meninges) by bacteria that have usually travelled there from mucosal surfaces via the bloodstream. Meningococcal septicaemia – or blood poisoning – occurs when the bacteria in the blood multiply uncontrollably. Meningococcal disease can appear as meningococcal meningitis or meningococcal septicaemia, or a combination of both.

Management in the pre-hospital setting - Primary care healthcare professionals should transfer children and young people with suspected bacterial meningitis or suspected meningococcal septicaemia to secondary care as an emergency by telephoning 999. The following table shows signs and symptoms:

The guidance and all supporting documents can be accessed via this hyperlink to the NICE website: Bacterial meningitis and meningococcal septicaemia

1.7Delirium: diagnosis, prevention and management (CG103, Jul 10)

The guideline is of interest to doctors, nurses and other staff working in critical, acute and electivecare in hospitals, and GPs and care assistants working in long-term care.The guideline identifies key priorities for implementation covering these areas:
1. Risk factor assessment
2. Indicators of delirium: at presentation
3. Interventions to prevent delirium
4. Give a tailored multicomponent intervention package:
5. Diagnosis (specialist clinical assessment)
6. Initial management

The guidance and all supporting documents can be accessed via this hyperlink to the NICE website: Delirium

1.8Diagnosis and management of metastatic malignant disease of unknown primary origin (CG104, Jul 10)

This guideline is for healthcare professionals and other staff who care for patients withmetastatic malignant disease of unknown primary origin. This applies principally to health professionals working in the secondary care setting. The guidance and all supporting documents can be accessed via this hyperlink to the NICE website: Metastatic malignant disease of unknown primary origin

1.9Use of non-invasive ventilation in the management of motor neurone disease (CG105, Jul 10)

Motor neurone disease (MND) is a fatal neurodegenerative disease. It is characterised by the onset ofsymptoms and signs of degeneration of primarily the upper and lower motor neurones. Respiratorymuscle weakness resulting in respiratory impairment is a major feature of MND, and is a strongpredictor of quality of life and survival. Non-invasive ventilation can improve the symptoms and signsrelated to respiratory impairment and hence survival.This guidance covers the identification and assessment of respiratory impairment in patients withMND, as well as provision of non-invasive ventilation. Differences in the pathway of care for patientswith severe bulbar impairment or severe cognitive problems that may be related to respiratoryimpairment are included.The guidance and all supporting documents can be accessed via this hyperlink to the NICE website: Motor neurone disease - non-invasive ventilation

2NICE Public Health Guidance

2.1Alcohol-use disorders - preventing the development of hazardous and harmful drinking (PH24, Jun 10)

  • This is one of three pieces of NICE guidance addressing alcohol-related problems. (See also: CG100 Alcohol-use disorders in adults and young people; and (forthcoming) Alcohol dependence and harmful use: diagnosis and management in young people and adults.)
  • Alcohol-related harm is a major health problem. The guidance identifies how government policies on alcohol pricing, its availability and how it is marketed could be used to combat such harm (see recommendation 1 to 3). Changes in policy in these areas is likely to be more effective in reducing alcohol-related harm among the population as a whole than actions undertaken by local health professionals.
  • The recommendations for practice support, complement – and are reinforced by – these policy options. They cover:
  • Licensing. Resources for identifying and helping people with alcohol-related problems.
  • Children and young people aged 10 to 15 years – assessing their ability to consent, judging their alcohol use, discussion and referral to specialist services.
  • Young people aged 16 and 17 years – identification, offering motivational support or referral to specialist services.
  • Adults – screening, brief advice, motivational support or referral.

The guidance and all supporting documents can be accessed via this hyperlink to the NICE website: Alcohol-use disorders - preventing the development of hazardous and harmful drinking

2.2Guidance on the prevention of cardiovascular disease at the population level (PH25, Jun 10)

The guidance comprises two sets of recommendations aimed at national policy makers and local practitioners respectively.
Recommendations 1 to 12 outline a national framework for action. They break new ground for NICE by focusing on legislative, regulatory and voluntary changes – including further development of existing policies. Topics covered include:

  • How to reduce the nation’s consumption of salt, saturated fats and trans fats
  • How to ensure food marketing and promotions aimed at children and young people do not encourage them to consume high levels of salt, saturated fats and trans fats
  • Commercial interests
  • Food product labelling
  • The European Union’s common agricultural policy
  • Public sector catering guidelines
  • Advice on take-aways and other food outlets.

The recommendations for practice mainly focus on how to plan, develop and run effective regional CVD prevention programmes (recommendations 13–18). Other topics covered include:

  • Children and young people
  • Public sector food provision
  • Physical activity
  • Health impact assessments of regional and local plans and policies
  • Take-aways and other food outlets
  • Nutrition training for catering managers.

The guidance and all supporting documents can be accessed via this hyperlink to the NICE website: Guidance on the prevention of cardiovascular disease at the population level

2.3Quitting smoking in pregnancy and following childbirth (PG26, Jun 10)

This guidance is for NHS and other commissioners, managers and practitioners who have a direct or indirect role in, and responsibility for, helping women to stop smoking when pregnant and following childbirth. This includes those working in: local authorities,education and the wider public, private, voluntary and community sectors.
It may also be of interest to women who:

  • are planning a pregnancy
  • are pregnant
  • have an infant aged up to 12 months (as well as their partners and families and other members of the public).

NICE says all pregnant women who smoke – and all those who are planning a pregnancy or who have an infant aged under 12 months – should be referred for help to quit smoking.
The eight recommendations include advice on:

  • How NHS professionals and others working in the public, community and voluntary sectors can identify women (including teenagers) who smoke when they attend an appointment or meeting.
  • How to refer them to NHS Stop Smoking Services (or the equivalent).
  • How NHS Stop Smoking Services staff (and staff from equivalent, non-NHS services) should contact and support all women who have been referred for help.
  • How to help their partners or ‘significant others’ who smoke.
  • When and how nicotine replacement therapy and other pharmacological support should be offered.
  • Training for professionals

The guidance and all supporting documents can be accessed via this hyperlink to the NICE website: Quitting smoking in pregnancy and following childbirth

2.4Weight management before, during and after pregnancy (PG27, Jul 10)

This guidance is for NHS and other commissioners, managers and professionals who have a direct or indirect role in, and responsibility for: women who are pregnant or who are planning a pregnancy, and mothers who have had a baby in the last 2 years. It is particularly aimed at: GPs, obstetricians, midwives, health visitors, dietitians, community pharmacists and all those working in antenatal and postnatal services and children’s centres. It may also be of interest to women before, during and after pregnancy, their partners and families, and other members of the public.
In this guidance the term ‘weight management’ involves:assessing and monitoring body weight, preventing someone from becoming overweight or obese, helping someone to achieve and maintain a healthy weight by eating healthily and being physically active.

The six recommendations include advice on: How to help women with a BMI of 30 or more to lose weight before and after pregnancy – and how to help them eat healthily and keep physically active during pregnancy. How to help all pregnant women eat healthily and keep physically active. The role of community-based services. The professional skills needed to achieve the above.

The guidance and all supporting documents can be accessed via this hyperlink to the NICE website: Weight management before, during and after pregnancy

3NICE Technology Appraisals

3.1Infliximab (review) and adalimumab for the treatment of Crohn’s disease (TA187, May 10)

This guidance replaces TA 40 issued in April 2002. The review and re-appraisal of infliximab for the treatment of severe active or active fistulising Crohn’s disease has resulted in a change in the guidance. Specifically, infliximab should now be given as a planned course of treatment until treatment failure (including the need for surgery) or for 12 months, whichever is shorter. Treatment should then only be continued if there is clear evidence of ongoing active disease. Adalimumab is now also recommended as another treatment option for people with severe active Crohn’s disease.

The guidance and all supporting documents can be accessed via this hyperlink to the NICE website: Infliximab (review) and adalimumab for the treatment of Crohn’s disease

3.2Human growth hormone (somatropin) for the treatment of growth failure in children (TA188, May 10)

The review and re-appraisal of human growth hormone (somatropin) for the treatment of growth failure in children has resulted in a change in the guidance. Human growth hormone (somatropin) is still recommended for the treatment of growth failure in children with growth hormone deficiency, Turner syndrome, Prader–Willi syndrome and chronic renal insufficiency, but there has been an extension of the guidance to include growth failure associated with either of the two following conditions:

  • born small for gestational age (SGA) with subsequent growth failure at 4 years of age or later
  • short stature homeobox-containing gene (SHOX) deficiency.

Criteria for discontinuation of treatment are described. However, the decision to stop treatment should be made in consultation with the patient and/or carers.