Katharina Dworzynski

How Different Are Girls and Boys Above and Below the Diagnostic Threshold for Autism Spectrum Disorders

OBJECTIVEnThis study aimed to explore sex differences in autistic traits in relation to diagnosis, to elucidate factors that might differentially impact whether girls versus boys meet diagnostic criteria for autism or a related autism spectrum disorder (ASD).nnnMETHODnData from a large population-based sample of children were examined. Girls and boys (aged 10-12 years) meeting diagnostic criteria for an ASD were compared with those failing to meet diagnostic criteria despite very high scores on a trait measure of ASD, the Childhood Autism Spectrum Test (CAST). Information about behavioral difficulties as reported by teachers, and early estimates of intellectual functioning, were compared.nnnRESULTSnGirls, but not boys, meeting diagnostic criteria for ASD showed significantly more additional problems (low intellectual level, behavioral difficulties) than peers with similarly high CAST scores who did not meet diagnostic criteria.nnnCONCLUSIONSnThese data suggest that, in the absence of additional intellectual or behavioral problems, girls are less likely than boys to meet diagnostic criteria for ASD at equivalently high levels of autistic-like traits. This might reflect gender bias in diagnosis or genuinely better adaptation/compensation in girls.

The diagnostic accuracy of the natriuretic peptides in heart failure: systematic review and diagnostic meta-analysis in the acute care setting

Objectives To determine and compare the diagnostic accuracy of serum natriuretic peptide levels (B type natriuretic peptide, N terminal probrain natriuretic peptide (NTproBNP), and mid-regional proatrial natriuretic peptide (MRproANP)) in people presenting with acute heart failure to acute care settings using thresholds recommended in the 2012 European Society of Cardiology guidelines for heart failure. Design Systematic review and diagnostic meta-analysis. Data sources Medline, Embase, Cochrane central register of controlled trials, Cochrane database of systematic reviews, database of abstracts of reviews of effects, NHS economic evaluation database, and Health Technology Assessment up to 28 January 2014, using combinations of subject headings and terms relating to heart failure and natriuretic peptides. Eligibility criteria for selecting studies Eligible studies evaluated one or more natriuretic peptides (B type natriuretic peptide, NTproBNP, or MRproANP) in the diagnosis of acute heart failure against an acceptable reference standard in consecutive or randomly selected adults in an acute care setting. Studies were excluded if they did not present sufficient data to extract or calculate true positives, false positives, false negatives, and true negatives, or report age independent natriuretic peptide thresholds. Studies not available in English were also excluded. Results 37 unique study cohorts described in 42 study reports were included, with a total of 48 test evaluations reporting 15u2009263 test results. At the lower recommended thresholds of 100 ng/L for B type natriuretic peptide and 300 ng/L for NTproBNP, the natriuretic peptides have sensitivities of 0.95 (95% confidence interval 0.93 to 0.96) and 0.99 (0.97 to 1.00) and negative predictive values of 0.94 (0.90 to 0.96) and 0.98 (0.89 to 1.0), respectively, for a diagnosis of acute heart failure. At the lower recommended threshold of 120 pmol/L, MRproANP has a sensitivity ranging from 0.95 (range 0.90-0.98) to 0.97 (0.95-0.98) and a negative predictive value ranging from 0.90 (0.80-0.96) to 0.97 (0.96-0.98). At higher thresholds the sensitivity declined progressively and specificity remained variable across the range of values. There was no statistically significant difference in diagnostic accuracy between plasma B type natriuretic peptide and NTproBNP. Conclusions At the rule-out thresholds recommended in the 2012 European Society of Cardiology guidelines for heart failure, plasma B type natriuretic peptide, NTproBNP, and MRproANP have excellent ability to exclude acute heart failure. Specificity is variable, and so imaging to confirm a diagnosis of heart failure is required. There is no statistical difference between the diagnostic accuracy of plasma B type natriuretic peptide and NTproBNP. Introduction of natriuretic peptide measurement in the investigation of patients with suspected acute heart failure has the potential to allow rapid and accurate exclusion of the diagnosis.

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.2nnNICE 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.nn### Risk assessmentnnAt 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 ]nnView this table:nnTable 1 nu2002The 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* nnnnView this table:nnTable 2 nu2002The full (post-endoscopy) Rockall scoring system.4 For a patient with acute upper gastrointestinal bleeding, add up scores at the top of the …

Rehabilitation after stroke: summary of NICE guidance

Each year, about 150u2009000 people in the UK have a first or recurrent stroke.1 Despite UK health policies that place a great emphasis on reducing stroke (such as the National Stroke Strategy2) and improvements in mortality and morbidity, guidance is needed on access to and provision of effective rehabilitation services to maximise quality of life after stroke. This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) on long term rehabilitation after stroke.3nnNICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations can be 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.nn### Organising rehabilitation and care for people with strokennRehabilitation may take place in a variety of settings—in hospital, in outpatient clinics, in the community, and in individuals’ own homes.nn### Planning and delivering stroke rehabilitationnnTo ensure the safety of the person with stroke while maintaining a patient centred approach, key processes need to be in place. These processes include assessment on admission …

Impairment in non-word repetition: a marker for language impairment or reading impairment?

Aimu2002 A deficit in non‐word repetition (NWR), a measure of short‐term phonological memory proposed as a marker for language impairment, is found not only in language impairment but also in reading impairment. We evaluated the strength of association between language impairment and reading impairment in children with current, past, and no language impairment and assessed any differential impairment of NWR, compared with two other tests of verbal memory in children with language impairment with and without reading impairment.

Diagnosis and management of drug allergy in adults, children and young people: summary of NICE guidance

All drugs have the potential to cause side effects or “adverse drug reactions,” but not all of these are allergic in nature. The diagnosis of drug allergy can be challenging, and there is considerable variation both in how drug allergy is managed and in geographical access to specialist drug allergy services.1 On the basis of a National Institute for Health and Care Excellence (NICE) analysis of hospital episode statistics, about half a million people admitted to NHS hospitals each year in England and Wales have a diagnostic label of “drug allergy,” with the most common being penicillin allergy.2 Fewer than 10% of people who think they are allergic to penicillin are truly allergic.3 Inadequate clinical documentation of allergic drug reactions and a lack of patient information (provided to and by patients) may lead to an inappropriate label of allergy to penicillin or other drugs remaining on a medical record. This can prevent future prescription even when clinically indicated. This article summarises the most recent recommendations from NICE on drug allergy.4nnNICE 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.nn### AssessmentnnWhen a course of treatment with a drug is started a patient may experience adverse symptoms for a variety of reasons. Not all reactions are caused by the drug itself and careful assessment is needed to establish the correct cause.nnnnSigns and allergic patterns of suspected drug allergy

Diagnosing and managing acute heart failure in adults: summary of NICE guidance.

Acute heart failure may present de novo in people without known cardiac dysfunction, or as an acute decompensation of known chronic heart failure. Acute heart failure is a common cause of admission to hospital (more than 67u2009000 admissions in England and Wales each year) and is the leading cause of hospital admission in people aged 65 years or more in the United Kingdom.1 European registry data show that nearly 50% of people admitted to hospital with acute heart failure are re-admitted within 12 months,2 and a third of people with acute heart failure die within a year of their first hospital admission.1 The diagnosis of heart failure can be challenging because of non-specific symptoms and clinical signs, and there is evidence of wide variation in the way people with acute heart failure are managed.1 This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) on acute heart failure.3 nnNICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations can be 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.nn### Organisation of care

End of life care for infants, children and young people with life limiting conditions: summary of NICE guidance

#### What you need to knownnChildren and young people can have a wide range of life limiting conditions and may sometimes live with such conditions for many years. This guideline recommends that end of life care be managed as a long term process that begins at the time of diagnosis of a life limiting condition and entails planning for the future. Sometimes it may begin before the child’s birth. It is part of the overall care of the child or young person and runs in parallel with other active treatments for the underlying condition itself.1 Finally, it includes those aspects related to the care of the dying.nnThis guideline was commissioned with the aim to standardise end of life care for infants, children, and young people living with a life limiting condition, and thus promote equity and consistency. Important themes are to involve children and young people and their parents or carers in decisions about their care, facilitate their care in their preferred location (most likely home), and plan for day and night care.nnThis article summarises the most recent guidance from the recent National Institute for Health and Care Excellence (NICE) on the planning and management of end of life care in infants, children, and young people.2 For a visual summary, please …

Cost-effectiveness analysis of natriuretic peptide testing and specialist management in patients with suspected acute heart failure

OBJECTIVESnTo determine the cost-effectiveness of natriuretic peptide (NP) testing and specialist outreach in patients with acute heart failure (AHF) residing off the cardiology ward.nnnMETHODSnWe used a Markov model to estimate costs and quality-adjusted life-years (QALYs) for patients presenting to hospital with suspected AHF. We examined diagnostic workup with and without the NP test in suspected new cases, and we examined the impact of specialist heart failure outreach in all suspected cases. Inputs for the model were derived from systematic reviews, the UK national heart failure audit, randomized controlled trials, expert consensus from a National Institute for Health and Care Excellence guideline development group, and a national online survey. The main benefit from specialist care (cardiology ward and specialist outreach) was the increased likelihood of discharge on disease-modifying drugs for people with left ventricular systolic dysfunction, which improve mortality and reduce re-admissions due to worsened heart failure (associated with lower utility). Costs included diagnostic investigations, admissions, pharmacological therapy, and follow-up heart failure care.nnnRESULTSnNP testing and specialist outreach are both higher cost, higher QALY, cost-effective strategies (incremental cost-effectiveness ratios of £11,656 and £2,883 per QALY gained, respectively). Combining NP and specialist outreach is the most cost-effective strategy. This result was robust to both univariate deterministic and probabilistic sensitivity analyses.nnnCONCLUSIONSnNP testing for the diagnostic workup of new suspected AHF is cost-effective. The use of specialist heart failure outreach for inpatients with AHF residing off the cardiology ward is cost-effective. Both interventions will help improve outcomes for this high-risk group.

Faltering growth in children: summary of NICE guidance

#### What you need to knownnGrowth in infants and preschool children is a common cause for parental and professional concern. Some weight loss is common in the early days of life, while establishing feeding, and is usually a physiological phenomenon associated with fluid shifts.1 The term “faltering growth” is used to describe a pattern of slower weight gain than expected for age and sex in infants and preschool children after these early days and is most often due to inadequate nutritional intake. nnConcerns about faltering growth arise in up to 5% of infants and preschool children, depending on the definition used.23 Concerns are usually raised in primary care, by parents, health visitors, or general practitioners (GPs). Current practice in assessment and management varies across the UK.4 This article summarises the recent National Institute for Health and Care Excellence (NICE) guidance on the recognition and management of infants and preschool children with faltering growth,5 focusing …