Michael Rudolf

Management of rheumatoid arthritis: summary of NICE guidance

Rheumatoid arthritis is a chronic, progressive autoimmune disease associated with inflammation principally in synovial joints and affecting over 400u2009000 people in the United Kingdom.1 In recent years it has become clear that pain and disability can be avoided if the disease is recognised early and treated promptly and appropriately. It is therefore crucial that all health professionals have knowledge of the recognition, management, and appropriate referral of patients with rheumatoid arthritis. This article summarises the recommendations in the guideline from the National Institute for Health and Clinical Excellence (NICE) on the management of rheumatoid arthritis, from early identification to managing chronic and severe disease.2nnNICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the opinion of the Guideline Development Group (GDG) of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.nn### Referral, diagnosis, and investigationsnn[ Based on high and moderate quality observational studies of early prognosis and identification or diagnosis ]nn[ Based on data from case series ]

What's nice about the new NICE guideline?

A new national guideline for the management of chronic obstructive pulmonary disease (COPD) was published by the National Institute for Health and Clinical Excellence (NICE) in June.1 Although technically only applicable to England and Wales (and even then only if adopted by the Welsh Assembly), it will be perceived by many international authorities as ‘the British guideline’ (with apologies to our Scottish colleagues), and it therefore seems appropriate to comment on whats new and relevant. It is over 6u2005years since the last NICE COPD guideline was published,2 and it is important to note that this 2010 version is only a partial update, concentrating on various aspects of diagnosis and severity classification and the management of stable disease. The management of acute exacerbations was specifically excluded from the scope of the guideline revision. This has had the consequence of producing a lengthy document (the full web-based version is over 600 pages!), much of which will be regarded by many readers as out of date. The Guideline Development Group (GDG) and the publishers have gone to great lengths to make as obvious as possible which parts of the guideline are new and which are not, but many will feel that this was a lost opportunity in not revising other sections as well.nnOne of the major strengths of a NICE guideline is that its recommendations are based on systematic reviews of the best available evidence (using extremely strict criteria for assessing the evidence), and also giving explicit consideration to cost effectiveness.3 In addition, the GDG is truly multidisciplinary, comprising healthcare professionals (doctors, nurses, physiotherapists) from primary and secondary care and patient representation.nnIt is good to see that the …

Patient care pathway, implementation and audit criteria for patients with atrial fibrillation

The patient care pathway maps the sequence of decisions that will be required to identify, assess, manage and monitor patients with atrial fibrillation (fig 1). The pathway also provides a “guide to the guideline” in that the decisions taken will be informed by the evidence base and recommendations of the full guideline document.nnnn Figure 1 nu2003Care pathway for diagnosing and treating atrial fibrillation. AF, atrial fibrillation; ECG, electrocardiogram.*Further management to include rate or rhythm control treatment strategy and appropriate antithrombotic therapy based on stroke risk stratification model.†Further follow-up for co-existing conditions and assessment for ongoing anticoagulation.nnnn### DiagnosisnnThe guideline recommends that in patients presenting with breathlessness, palpitations, syncope, chest discomfort or stroke, pulse palpation should be carried out to determine the presence of an irregular pulse that may indicate underlying atrial fibrillation. Thus, the detection of patients with atrial fibrillation, especially those asymptomatic, will be enhanced by opportunistically checking the pulse in “high-risk” patients attending for review. Confirmation of the arrhythmia through an electrocardiogram (ECG) is essential.nn### Further investigation and clinical assessmentnnFurther assessment and investigation focuses on identifying the cause of atrial fibrillation, on judging whether electrical or pharmacological intervention is required to control the arrhythmia and, finally, on establishing the risk of stroke and thromboembolism. Much of clinical assessment, basic blood tests (including thyroid function tests) and a chest x ray can be initiated in primary care. More specialised investigations, such as echocardiography or electrophysiological studies, may require referral to secondary care. Some general practitioners have access to open-access echocardiography, which may facilitate patient assessment for structural and functional heart disease. While most cardiologists would perform echocardiography, the guideline offers some pragmatic recommendations on when transthoracic (and transoesophageal) echocardiography should be done.nn### Treatment strategynnIn all cases of atrial fibrillation, consideration should be given to whether the arrhythmia should be treated and how. A rhythm control …

COPD and death: what exactly is the relationship?

It’s time to take stock of what we do and do not know about what patients with COPD actually die fromnnThe categorisation of different causes of death in patients with chronic obstructive pulmonary disease (COPD) has not usually been regarded as an important topic, but with all-cause mortality and cause-specific mortality now being used as outcome measures in large multicentre clinical trials,1,2 it is perhaps time to take stock of what we do and do not know about what patients with COPD actually die from. A number of studies that have addressed this issue over the years have, not surprisingly, found varying proportions of deaths ascribed to respiratory causes, lung cancer and cardiovascular disease (the three principal categories), with the results of any one study being highly dependent on both the source (and accuracy) of patient information and on the severity of underlying disease.3–7nnThe past year has witnessed a flurry of papers and editorials covering a number of widely different aspects of mortality in COPD, with topics ranging from the confidence we can have in interpreting mortality data,8 the possible …

For and against. Should steroids be the first line treatment for asthma

_nD Evidence for the inflammatory basis of rutt asthma comes from bronchial biopsies, which show inflammation of the mucosa even in patients with mild intermittent asthma.1 Mucosal oedema and excess mucus production cause reduction in the lumen and obstruction to airflow. Bronchospasm occurs as the natural foreign body response to irrita tion caused by inflammation, the bronchi become hyperactive and the airflow is further reduced. Persistent inflammation may lead to structural changes in the airways, with reduction in lung function and irreversible airways obstruction.2

Should steroids be the first line treatment for asthma?ForAgainst

_nD Evidence for the inflammatory basis of rutt asthma comes from bronchial biopsies, which show inflammation of the mucosa even in patients with mild intermittent asthma.1 Mucosal oedema and excess mucus production cause reduction in the lumen and obstruction to airflow. Bronchospasm occurs as the natural foreign body response to irrita tion caused by inflammation, the bronchi become hyperactive and the airflow is further reduced. Persistent inflammation may lead to structural changes in the airways, with reduction in lung function and irreversible airways obstruction.2

Author's response: ‘What's nice about the new NICE guideline?’

We thank the correspondents for these kind and helpful comments.1 In adopting the Global Initiative on Obstructive Lung Disease (GOLD) classification of severity of airflow obstruction, the National Institute for Health and Clinical Excellence (NICE) guideline update has introduced consistency with international guidelines including those of the American Thoracic Society and the European Respiratory Society. The NICE guidelines note that this classification relates specifically to degrees of airflow obstruction which are arbitrary and may not be closely related to degrees of clinical severity in chronic obstructive pulmonary disease (COPD).2 The current use of the term ‘severe’ for airflow obstruction with forced expiratory volume in 1 s (FEV1)<50% in place of ‘moderate’ (NICE 2004) may also help to underline the potentially serious nature of …