Bernard Higgins

British guideline on the management of asthma: A national clinical guideline

These guidelines have been replaced by British Guideline on the Management of Asthma. A national clinical guideline. Superseded By 2012 Revision Of 2008 Guideline: British Guideline on the Management of Asthma. Thorax 2008 May; 63(Suppl 4): 1–121.

Diagnosis and management of type 1 diabetes in adults: summary of updated NICE guidance.

#### The bottom line #### How patients were involved in the creation of this article Patients were involved at every stage of creating the guideline. Patient groups and individuals contributed to the scoping of the update and at the consultation stage. Lay members were active in the Guideline Development Group, contributing to the formulation of the recommendations summarised here, and were instrumental in setting the new treatment targets. Having type 1 diabetes reduces the life expectancy of adults in the United Kingdom by as much as 13 years.1 Despite incontrovertible evidence that good care reduces the risk of complications such as blindness, renal failure, and premature cardiovascular disease and death,2 as well as complications of treatment such as severe hypoglycaemia,3 fewer than 30% of UK adults with type 1 diabetes achieve current national treatment targets for glucose control.4 The challenges of managing type 1 diabetes do not lessen after the age of 18 years. Since the publication of the 2004 National Institute for Health and Care Excellence (NICE) guideline, new technologies to achieve diabetic control have become available—for example, insulin analogues, new glucose meters, and real time …

Diagnosis and management of lower limb peripheral arterial disease: summary of NICE guidance

Lower limb peripheral arterial disease (referred to as peripheral arterial disease in this summary) is common, affecting 3% to 7% of people in the general population and 20% of people over the age of 75.1 It is associated with an increased risk of cardiovascular morbidity and mortality and severely limits people’s functional capacity and quality of life. Peripheral arterial disease is often asymptomatic, but when it is symptomatic the most common presentation is intermittent claudication (pain in the legs, buttocks, or thighs brought on by walking and relieved by rest). Critical limb ischaemia is characterised by severely diminished circulation, ischaemic pain, ulceration, tissue loss, and/or gangrene. Owing to rapid changes in diagnostic methods, endovascular treatments, and vascular services, there is considerable uncertainty about the management of people with peripheral arterial disease, with management varying greatly across England and Wales.2 This article summarises some of the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the management of peripheral arterial disease.3 NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Secondary prevention of cardiovascular disease in people with peripheral arterial disease

Management of acute upper gastrointestinal bleeding: summary of NICE guidance

Acute upper gastrointestinal bleeding is the commonest medical emergency managed by gastroenterologists in the United Kingdom. The most frequently identified source of bleeding is peptic ulcer disease, but other important causes exist, particularly oesophageal or gastric varices, which are classically associated with more severe bleeding. A large audit in the UK in 20071 indicated that the rate of mortality from acute upper gastrointestinal bleeding (about 7%) has not changed much over the past 50 years, and that service provision varies considerably across the UK. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the management of acute upper gastrointestinal bleeding.2 NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Risk assessment At presentation with acute upper gastrointestinal bleeding, assess for risk of serious adverse events or need for intervention. To do this use the following formal risk assessment scoring systems for all patients with acute gastrointestinal bleeding: the Blatchford scoring system3 at first assessment and the full Rockall scoring system4 after endoscopy (tables 1⇓ and 2⇓). [ Based on low to very low quality evidence from prospective and retrospective case reviews ] View this table: Table 1  The Blatchford scoring system.3 For a patient with acute upper gastrointestinal bleeding, add up scores in the right hand column for each risk marker (if no value applies for a particular marker, score 0) to derive a total score* View this table: Table 2  The full (post-endoscopy) Rockall scoring system.4 For a patient with acute upper gastrointestinal bleeding, add up scores at the top of the …

Identifying and prioritizing uncertainties: patient and clinician engagement in the identification of research questions

BACKGROUND To arrive at an agreed, prioritized ranking of treatment uncertainties in asthma that need further research, by developing a collaboration of patients, carers and clinicians, facilitated by the James Lind Alliance Working Partnership between Asthma UK and the British Thoracic Society. METHODS A four-step procedure: (1) establish a collaborative Working Partnership; (2) identify and collect treatment uncertainties by using a patient survey and analysing existing systematic reviews, clinical guidelines and query-answering services; (3) categorize uncertainties; and (4) convene a workshop using a nominal group process to establish a ranked prioritization of treatment uncertainties in asthma. FINDINGS Agreement and rankings were reached for 10 treatment uncertainties. The highest was given to the uncertainty surrounding the adverse effects of inhaled and oral steroids. The top three priorities dealt with clinical management issues, where uncertainties still exist, namely concerns about the side effects of inhaled and oral steroids, how to manage asthma when other illnesses exist or how to rely on personal decisions in an ever-changing illness (self-management). INTERPRETATION The key outcome is the generation of a prioritized list of treatment uncertainties in asthma, agreed by a collaboration of patients and health professionals, to inform the commissioning of new research. Such a large number of patient-identified treatment uncertainties had not previously been identified in the literature, an indication perhaps that asthma self-management is a neglected research area. Whether the results have an influence of research funding decisions is not yet known.

Azithromycin for Acute Exacerbations of Asthma : The AZALEA Randomized Clinical Trial

Importance Guidelines recommend against antibiotic use to treat asthma attacks. A study with telithromycin reported benefit, but adverse reactions limit its use. Objective To determine whether azithromycin added to standard care for asthma attacks in adults results in clinical benefit. Design, Setting, and Participants The Azithromycin Against Placebo in Exacerbations of Asthma (AZALEA) randomized, double-blind, placebo-controlled clinical trial, a United Kingdom-based multicenter study in adults requesting emergency care for acute asthma exacerbations, ran from September 2011 to April 2014. Adults with a history of asthma for more than 6 months were recruited within 48 hours of presentation to medical care with an acute deterioration in asthma control requiring a course of oral and/or systemic corticosteroids. Interventions Azithromycin 500 mg daily or matched placebo for 3 days. Main Outcomes and Measures The primary outcome was diary card symptom score 10 days after randomization, with a hypothesized treatment effect size of -0.3. Secondary outcomes were diary card symptom score, quality-of-life questionnaires, and lung function changes, all between exacerbation and day 10, and time to a 50% reduction in symptom score. Results Of 4582 patients screened at 31 centers, 199 of a planned 380 were randomized within 48 hours of presentation. The major reason for nonrecruitment was receipt of antibiotics (2044 [44.6%] screened patients). Median time from presentation to drug administration was 22 hours (interquartile range, 14-28 hours). Exacerbation characteristics were well balanced across treatment arms and centers. The primary outcome asthma symptom scores were mean (SD), 4.14 (1.38) at exacerbation and 2.09 (1.71) at 10 days for the azithromycin group and 4.18 (1.48) and 2.20 (1.51) for the placebo group, respectively. Using multilevel modeling, there was no significant difference in symptom scores between azithromycin and placebo at day 10 (difference, -0.166; 95% CI, -0.670 to 0.337), nor on any day between exacerbation and day 10. No significant between-group differences were observed in quality-of-life questionnaires or lung function between exacerbation and day 10, or in time to 50% reduction in symptom score. Conclusions and Relevance In this randomized population, azithromycin treatment resulted in no statistically or clinically significant benefit. For each patient randomized, more than 10 were excluded because they had already received antibiotics. Trial Registration clinicaltrials.gov Identifier: NCT01444469.

Diagnosis and management of community and hospital acquired pneumonia in adults: summary of NICE guidance.

Community acquired pneumonia is a common condition that causes considerable morbidity and has a mortality rate of approximately 20% for patients admitted to hospital in the United Kingdom.1 It is diagnosed in 5-12% of adults who present to general practitioners with symptoms of lower respiratory tract infection,2 3 and 22-42% are subsequently admitted to hospital.3 4 Adherence to previous guidelines has been poor, and this variation in practice can lead to suboptimal outcomes such as increased mortality and longer stay in hospital.5 6 7 Hospital acquired pneumonia (excluding ventilator associated pneumonia) has a point prevalence of approximately 1% of hospital inpatients, is estimated to lengthen hospital admission by an average of eight days, and has a high mortality rate.8 9 This article summarises the most recent recommendations for the management of both types of pneumonia from the National Institute for Health and Care Excellence (NICE).10 NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Presentation with lower respiratory tract infection Of people who present to general practitioners with symptoms of lower respiratory tract infection, only a small proportion have community acquired pneumonia. In those who do not have a clinical diagnosis of pneumonia, the decision whether to prescribe antibiotics can be difficult, with a tendency towards over-prescription. Performing a point of care C reactive protein test can help to identify patients with lower respiratory tract infections who will, and will not, benefit from antibiotics.

The new BTS/SIGN asthma guidelines: where evidence leads the way.

Announcing the publication of the new BTS/SIGN asthma guidelines as a supplement to this issue of Thorax . It is 12 years since the first British guidelines on asthma management in adults were published as two papers in the BMJ .1,2 The British Thoracic Society (BTS) guidelines were rewritten in 19933 with additional advice on childhood asthma, and further updated in 1995.4 Elsewhere, the Scottish Intercollegiate Guidelines Network (SIGN) published their guideline on the hospital management of asthma in 19965 based on the BTS work, and subsequently published on the primary care management of asthma in 19986 and the management of acute asthma in 1999.7 While the BTS versions have been among the most widely implemented of all clinical guidelines, there has been an increasing need to update them using evidence-based methodology and covering all aspects of asthma care. With this issue of Thorax the new British guidelines on the management of asthma8 produced jointly by the BTS and SIGN are published in a separate supplement. The development process has involved individuals from all relevant professional groups involved in asthma care in the UK. Initial literature searches based on key questions produced over 15 000 abstracts and all relevant published papers up to the end of September 2001 were considered. What changes has this evidence-based review brought? For those familiar with the previous guideline, the striking features will be the change in style and the increased size of the new version. The design will be more familiar to those working in Scotland since it follows the basic pattern of all SIGN publications. It is important—and hopefully interesting—for readers to be able to link the recommendations in the guideline to the supporting evidence, and the format of the guidelines follows naturally from this. …

The cost effectiveness of Nucleic Acid Amplification Techniques for the diagnosis of tuberculosis

BACKGROUND There is wide variation in the techniques deployed to diagnose tuberculosis in the UK, with little agreement on which tools or strategies are cost effective. This analysis therefore comprehensively evaluated the cost effectiveness of currently available diagnostic strategies for routine diagnosis of TB in the NHS. METHODS The analysis compared strategies consisting of Nucleic Acid Amplification Techniques, culture and microscopy. A decision tree was used to estimate costs and Quality-Adjusted Life Years (QALYs) from a UK health service perspective. The sensitivity and specificity of each test determined the true and false positive and negative results in patients suspected of having active tuberculosis. These results led to either early, correct diagnosis or delayed diagnosis and the associated costs and QALYs. The presence of active tuberculosis combined with the side effects of treatment was associated with reduction in quality of life. Costs included were test costs, drug costs and the management of tuberculosis. Drug costs were based on generic UK list prices. Uncertainty in the model was explored through probabilistic and deterministic sensitivity analyses. RESULTS/CONCLUSIONS The cost effective strategy at threshold of £20,000 per QALY was a strategy using only sputum microscopy and culture routinely, meaning Nucleic Acid Amplification Techniques are not cost effective at baseline. When the prevalence of tuberculosis was increased, however, nucleic acid amplification became cost effective at the same threshold. Aside from the prevalence, the results were shown to be robust. At low tuberculosis prevalence, Nucleic Acid Amplification Techniques may not be cost effective but their potential in higher prevalence situations is considerable.

An unusual cause of granulomatous disease

BackgroundChronic granulomatous disease (CGD) is an inherited disorder of phagocytic cells caused by an inability to generate active microbicidal oxygen species required kill certain types of fungi and bacteria. This leads to recurrent life-threatening bacterial and fungal infections with tissue granuloma formation.Case presentationWe describe a case of X-linked Chronic granulomatous disease (CGD) diagnosed in an 18-year-old male. He initially presented with granulomatous disease mimicking sarcoidosis and was treated with corticosteroids. He subsequently developed Burkholderia cepacia complex pneumonia and further investigation confirmed a diagnosis of CGD.ConclusionMilder phenotypes of CGD are now being recognised. CGD should be considered in patients of any age with granulomatous diseases, especially if there is a history of recurrent or atypical infection.