Grammati Sarri

Diagnosis and management of chronic hepatitis B in children, young people, and adults: summary of NICE guidance

Chronic hepatitis B describes a spectrum of disease resulting from chronic hepatitis B virus (HBV) infection. About a third of the world’s population has serological evidence of past or present HBV infection, and 350-400 million people have chronic HBV infection.1 In the UK about 326 000 people are thought to have chronic hepatitis B.2 In some people, chronic hepatitis B may cause liver fibrosis, cirrhosis, and hepatocellular carcinoma; in others it is inactive and does not lead to important health problems.3 Antiviral therapy suppresses HBV replication and decreases the risk of progressive liver disease.4 This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) on the diagnosis and management of chronic hepatitis B in children, young people, and adults.5 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. ### Assessment and referral in primary care #### Children, young people, and adults who are seropositive for HBV surface antigen (HBsAg)

Diagnosis and management of menopause: summary of NICE guidance.

#### What you need to know The average age of menopause in the United Kingdom is 51 years, although 1% of women experience premature ovarian insufficiency (menopause before the age of 40 years). Eight out of 10 women experience perimenopausal symptoms, most commonly hot flushes and night sweats (figure⇓), which typically last about four years.1 Quality of life may be severely affected.2 Perimenopausal symptoms. FSH=follicle stimulating hormone; GNRH=gonadotrophin releasing hormone; LH=luteinising hormone Services and information available for menopausal women in the UK are variable.3 The use of hormone replacement therapy has been highly controversial.4 5 #### What’s new in this guidance This article summarises the most recent recommendations on the diagnosis and management of menopause from …

Diagnosis and Management of Menopause: The National Institute of Health and Care Excellence (NICE) Guideline

The Issue Menopause is a natural process that occurs in all women who live long enough. Many women experience no menopausal symptoms or only mild ones that do not require active medical management. However, a substantial proportion of women (about 20%) experience bothersome symptoms, such as hot flushes, night sweats, and trouble sleeping.1 The National Institute of Health and Care Excellence (NICE), based in the United Kingdom, has recently published guidelines for diagnosis and management of menopause. These guidelines provide clear and evidence-based advice to support both primary care physicians and those specializing in the care of women in midlife.

Vasomotor symptoms resulting from natural menopause: a systematic review and network meta-analysis of treatment effects from the National Institute for Health and Care Excellence guideline on menopause

Vasomotor symptoms (VMSs) are the hallmarks of menopause, occurring in approximately 75% of postmenopausal women in the UK, and are severe in 25%.

Preterm labour: summary of NICE guidance

#### What you need to know Preterm birth is the single biggest cause of neonatal mortality and morbidity in the UK, affecting over 52 000 babies (around 7.3% of live births) in England and Wales in 2012.1 About 75% of women delivering preterm do so after preterm labour,2 which is sometimes preceded by preterm prelabour membrane rupture.2 A “cause” for preterm labour is not always found, but it may be associated with infection. In other cases, preterm birth may result from elective delivery. Babies born preterm have high rates of mortality, with the risk of mortality being inversely proportional to gestational age at birth.3 Babies who survive have increased rates of disability.3 This article summarises the most recent recommendations on the prevention, diagnosis, and management of preterm labour from the National Institute for Health and Care Excellence (NICE).4 #### What’s new in this guidance

Data extraction for complex meta-analysis (DECiMAL) guide

As more complex meta-analytical techniques such as network and multivariate meta-analyses become increasingly common, further pressures are placed on reviewers to extract data in a systematic and consistent manner. Failing to do this appropriately wastes time, resources and jeopardises accuracy. This guide (data extraction for complex meta-analysis (DECiMAL)) suggests a number of points to consider when collecting data, primarily aimed at systematic reviewers preparing data for meta-analysis. Network meta-analysis (NMA), multiple outcomes analysis and analysis combining different types of data are considered in a manner that can be useful across a range of data collection programmes. The guide has been shown to be both easy to learn and useful in a small pilot study.

Vasomotor symptoms due to natural menopause; systematic review and network meta‐analysis (NMA) of treatment effects from the NICE Menopause Guideline

Vasomotor symptoms (VMSs) are the hallmarks of menopause, occurring in approximately 75% of postmenopausal women in the UK, and are severe in 25%.

Vasomotor symptoms resulting from natural menopause

Vasomotor symptoms (VMSs) are the hallmarks of menopause, occurring in approximately 75% of postmenopausal women in the UK, and are severe in 25%.

Diagnosis of the menopause: NICE guidance and quality standards:

New NICE Quality Standards on Menopause were published in February 2017, based on NICE guidance on ‘Menopause: diagnosis and management’; this editorial summarizes the aspects of relevance to clinical biochemistry laboratories. Women in the UK typically experience menopause at the age of 51, though there is wide variation. ‘Menopause’ refers specifically to the last menstrual period, which can only be confirmed in retrospect, and the ‘perimenopause’ (also termed the menopausal transition or climacteric) refers to the time in which many women have irregular menstrual cycles before menopause through to a year after the last period. Most women (8 out of 10) experience vasomotor symptoms (hot flushes and night sweats) but symptoms may include mood changes, lack of concentration and memory loss, joint and muscle stiffness, headaches, vaginal dryness and loss of libido. Symptomatic women frequently consult their GPs for advice and treatment. Menopause is usually a clinical diagnosis. This is emphasized by the first NICE Quality Statement: ‘Women over 45 years presenting with menopausal symptoms are diagnosed with perimenopause or menopause based on their symptoms alone, without confirmatory laboratory tests’. In developing the NICE guideline, a systematic review was carried out to assess the diagnostic accuracy of clinical indicators (age and menopausal symptoms), ultrasound parameters (ovarian volume, total antral follicle count) and biochemical tests (specifically follicle-stimulating hormone [FSH], antiMuüllerian hormone [AMH], oestrogen, inhibin A, inhibin B). These indices were considered either individually or in combination. Twenty-one studies were identified as meeting the protocol, of which four looked at the diagnostic accuracy of biochemical measurements. No single parameter, even hot flushes, was found to be useful in isolation, although algorithms combining menstrual history, surgical history, age, FSH and oestradiol concentrations did achieve correct classification of women with/without diagnosis of menopause. The reviewed evidence did not give the guideline development group confidence to recommend biochemical tests or ultrasound in diagnosis of menopause, as the results did not provide robust evidence for their routine use. In conclusion, the NICE guideline recommends that diagnosis is made without laboratory tests in otherwise healthy women aged over 45 years with menopausal symptoms:

NICE guideline committee's comments on editorial about menopause guideline.

We read with interest editorial on the National Institute for Health and Care Excellence (NICE) menopause guideline,1 and their comments on the presentation of evidence underpinning the guideline’s recommendations.2 We dispute their allegation that “methodological deficiencies undermine its conclusions.” The development of this guideline was based on a rigorous methodological approach involving a complex meta-analysis, known as a network meta-analysis. This method was used to assess the relative effectiveness of different treatments (pharmacological and non-pharmacological) to reduce the occurrence of vasomotor symptoms. This complex meta-analysis is methodologically superior to conventional meta-analyses because it allows the simultaneous comparison of different treatments to achieve an outcome for the population of interest (in this case, women in menopause). All the relevant peer reviewed publications …