• Allogeneic pancreatic islet cell transplantation for type 1 diabetes mellitus
• Intraoperative red blood cell salvage during radical prostatectomy or radical cystectomy
• Interstitial photodynamic therapy for malignant parotid tumours
• Perioperative hypothermia (inadvertent)
• Ulcerative colitis - infliximab
• Abatacept for the treatment of rheumatoid arthritis

• Antenatal care
• Diabetes in pregnancy
• Prophylaxis for Infective Endocarditis
• Maternal and child nutrition
• Mental wellbeing of children in primary education
• Sleep apnoea hypopnea syndrome (obstructive) - continuous positive airway pressure
• Asthma (in adults) - corticosteroids
• Intraoperative nerve monitoring during thyroid surgery
• Suburethral sling insertion for stress urinary incontinence in men

Safe Births: Everybody’s business: An independent inquiry into the safety of maternity services in England from the Kings’s Fund makes the following recommendations:

• Teams themselves should:
  • agree safety-focused objectives
  • identify clear roles and responsibilities
  • utilise clear communication standards and protocols
• Safety should be placed at the heart of shared objectives for maternity services in quality joint working The Royal College of Midwives (RCM) and Royal College of Obstetricians and
• Regular reviews of demand and staffing should be conducted with an emphasis on deliveringthe right skill mix todeliver safe services
• Trust boards and managers should regularly receive information employment levels, skill mix and deployment achieved across all shift.
• Simple and effective tools to help maternity managers to manage employment and deployment, to map demand, capacity and patient flow and to provide timely feedback on levels achieved across all shifts and locations should be developed using work used in other specialties.
• A designated maternity unit manager should keep information on all training completed and planned.  Managers and Boards should reveive regular reports on training.
• RCOG, the Nursing and Midwifery Council (NMC) and the Postgraduate Medical Education and Training Board (PMETB) should spread expertise on skills training and emergency drills to all maternity units by adapting elements of existing simulation based training models and turning them into high-quality training tools that can be
  used locally at minimal cost and disruption
• Safety awareness training must be mainstream professional education at all levels.
• A single set of evidence-based guidelines that are backed by professional organisations, National Institute for Health and Clinical Excellence (NICE) and other organisations shoulddeveloped.
• Guidelines must be supplemented by short one page summaries and usable, consistent protocols.
• All disciplines should be encouraged to familiarise themselves with using guidelines in a local setting and should be trained to use the relevant protocols.  Their use should be regularly audited.
• Annual evidence digests and a national briefing system, tools like Map of Medicine should reinforce use of guidelines.
• A small set of reliable, safety-critical information measures should be collected.
• Simple systems for capturing local information on safety should be designed, implemented and maintained locally.
• Boards must prioritise safety, communicate that to staff and patients and make data on safety publicly available.
• Board members should be trained to strengthen advocacy for maternity safety.
• Governance structures must be in place to assure safety, this should strengthen safety committees and systems for collecting and reporting safety information.
• Regular executive walk-rounds, analysis of claims data, incident reports and other safety indicators, and by reviewing safety incidents in detail should be undertaken.
• Safety must be recognised as a business imperative.
• Standards for the safety of maternity services should be set and monitored only by the Healthcare Commission (in future the Care Quality Commission), with approarpiate advice received by professional bodies.
• Existing standards hould be distilled into a smaller number that are critical to safety, and can beconnected to data that can be collected by teams.
• Strategic health authorities and others providing regional leadership for maternity services should be primed to offer specific support to trusts undergoing reconfiguration.
• DH shouldensure financial incentives are aligned to promote the safest care and to galvanise boards into prioritising safety commissioning and patient choice should act as drivers for improvement.

Latest guidance from NICE.

• Prostate cancer
• Osteoarthritis
• Ventilation tubes (grommets) in children with OME
• Irritable bowel syndrome
• Liposuction for chronic lymphoedema
• Laparoscopic mobilisation of the greater omentum for use in breast reconstruction
• Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal metastases
• Psychosis (first onset) - neuroimaging
• Follicular non-hodgkins lymphoma (recurrent or refractory stage III or IV) - rituximab
• Community engagement
• Smoking cessation

Updated from Prodigy to new CKS Format:

• Anaemia - iron deficiency
• Immunizations - childhood
• Leg ulcer - venous
• Opioid dependence
• Palliative cancer care - constipation

Clinical summaries of the Topic Reviews issued in February 2008 please follow the links below:

• Clinical summary: Iron deficiency anaemia – assessment
• Clinical summary: Iron deficiency anaemia - management
• Clinical summary: Immunizations childhood programme
• Clinical summary: Immunizations childhood – children up to 1 year of age
• Clinical summary: Immunizations childhood – children 1-2 years of age
• Clinical summary: Immunizations childhood – children 2-10 years of age
• Clinical summary: Immunizations childhood – children over 10 years of age
• Clinical summary: Immunizations childhood – additional immunizations
• Clinical summaries: Leg ulcer venous – uncomplicated venous leg ulcer
• Clinical summaries: Leg ulcer venous – infected venous leg ulcer
• Clinical summaries: Leg ulcer venous – healed venous leg ulcer
• Clinical summaries: Leg ulcer venous – persistent venous leg ulcer
• Clinical summaries: Opioid dependence – new presentation
• Clinical summaries: Opioid dependence – Considering substitution therapy
• Clinical summaries: Opioid dependence –Starting and stabilizing on maintenance therapy
• Clinical summaries: Opioid dependence – Continuing maintenance therapy
• Clinical summaries: Opioid dependence – Detoxification – from maintenance therapy
• Clinical summaries: Opioid dependence – Detoxification – not on maintenance therapy
• Clinical summary: Opioid dependence – Missed or vomited doses
• Clinical summary: Opioid dependence – Acute withdrawal syndrome
• Clinical summary: Opioid dependence – Collapse due to opioid overdose
• Clinical summary: Opioid dependence – Travelling abroad
• Clinical summary: Opioid dependence – Unknown patient
• Clinical summary: Palliative cancer care – constipation

Consultations from NICE seeking views on a clinical practice guideline developments for:

• Familial hypercholesterolaemia: consultation
• Lipid modification: Consultation on section 4.3 - Cardiovascular risk assessment

and requesting views on the use of erlotinib to treat small-cell cancer.

• Lung cancer (non-small cell) - erlotinib (appraisal consultation)

Guidance offering evidence-based recommendations on how to improve the physical environment to encourage physical activity. It demonstrates the importance of such improvements and the need to evaluate how they impact on the public’s health

• PH008 Physical activity and environment: Quick reference guide
• PH008 Physical activity and environment: Guidance
• 2008/004 New NICE public health guidance on creating environments to encourage physical activity
• PH008 Physical activity and environment: Costing report

• Interventions in medicines reconcilliation at the point of admission
• Physical activity and environment
• Psoriasis - infliximab
• Ultrasound guided catheterisation of the epidural space
• Arteriovenous extracorporeal membrane carbon dioxide removal
• Mesothelioma - Pemetrexed

The House of Commons Health Committee. National Institute for Health and Clinical Excellence: First Report of Session 2007–08, Volume I: Report, together with formal minutes

The report identifies the following problems

• Topic selection. Only a few selected medical technologies are chosen as suitable for assessment as technology appraisals. There is also far too little emphasis on disinvestment. Here we found NICE’s responses to our questions disingenuous. While few older treatments may do no good at all, many will not be cost-effective;

• The wider benefits of treatment to society, for example to carers, are not included in NICE’s economic evaluations;

• NICE often does not have all the information it needs to make a full assessment. It does not have access to all the information the Medicines and Healthcare products Regulatory Agency (MHRA) uses and clinical trials are usually designed without NICE’s work on cost-effectiveness in mind;

• Experts are not sufficiently well used; and

• Publication of guidance is slow; licensed medicines are often not prescribed while PCTs and clinicians wait for NICE to make a decision.

Key recommendations are:

• The need for a system whereby all medicines are assessed at launch. A shorter, less in-depth evaluation should be made between the time of licensing authorisation and marketing, so that clinicians can prescribe useful and cost-effective drugs as soon as they are launched.  A lower cost-per-quality adjusted life year (QALY) threshold should be employed during this early assessment to ensure that only the products that are most cost- and clinically effective are available straightaway.

• NICE should have access to the same material used by the licensing body, clinical trials should be registered and there should be closer working between NICE and the pharmaceutical industry.

• Evaluation of older, possibly cost ineffective therapies should take place too

• Legislation shoul be changed to accommodate the need to ensure that assessments of products take account of the wider benefits to society

• The threshold used by NICE in its full assessments be reviewed; further research comparing thresholds used by PCTs and those used by NICE should be undertaken. An independent body should determine the threshold used when making judgements of the value of technologies to the NHS.

• Elements of clinical guidelines should be made mandatory. A suitable example would be risk assessment for all patients at risk of developing venous thromboembolism.

• Better mechanisms are needed to ensure that the NHS pays a fair and affordable price for medicines. We recommend that NICE should be involved in any new system and that any change to its remit should be adequately resourced.

• Risk-sharing schemes, such as the recently approved case of bortezomib (Velcade) and the older example of beta interferon and glatiramer acetate, should be used with caution. They hould not be used as a catch-all in cases of uncertainty over a drug’s benefit. Uncertainty could be better addressed by the careful design and performance of a publicly funded randomised controlled clinical trial. Better use should be made of NICE’s ‘only in research’ recommendation in this regard.

The rport identifies issues with uptake of guidance by PCTs to ensure this happens NICE should offer:

• More help for PCTs to implement guidance
• Better assessment of the level of uptake
• PCTs should play a larger role in the development of guidance
• Better use of experts in the development of guidance

The report though concludes that conclude that NICE does a vital job in difficult circumstances. The development of more and more health technologies and procedures, alongside rising patient expectations and the ageing population, is going to make it even more difficult in the future. Healthcare budgets in England, as in other countries, are limited. Patients cannot expect to receive  every possible treatment. Demand outstrips resources and priorities have to be determined.  Rationing is essential, and NICE has a key role to play.

Latest Nice Guidelines are:

• Interventions in medicines reconcilliation at the point of admission (PSP)
• Atopic eczema in children (CG)
• Thoracoscopic aortopexy for severe primary tracheomalacia (IP)
• Circumferential epithelial radiofrequency ablation for Barrett’s oesophagus (IP)
• Thoracoscopically-assisted mitral valve surgery (IP)
• Hybrid procedure for interim management of hypoplastic left heart syndrome in newborns (IP)
• Thoracoscopic excision of mediastinal parathyroid tumours (IP)
• Endoscopic saphenous vein harvest for coronary artery bypass graft (IP)

Apologies for the title which will only make sense if you are familiar with the work of the Jazz Butcher but a pun is always worthwhile.

The Stroke Specialist Library is being developed to provide high quality, evidence-based information on all of aspects of Stroke. This site is aimed at health professionals with an interest in Stroke.

Using the traditional NLH hub approach with information divided into Guidance & Pathways, Evidence, Reference, Education/CPD and Patient Information the Library offers information on the following topics.

Ischaemic Stroke

• General / Overviews
• Causes / Risk Factors
• Diagnosis
• Disease Management
• Prevention
• Patient Information
• Rehabilitation

Haemorrhagic Stroke

• General / Overviews
• Causes / Risk Factors
• Diagnosis
• Disease Management
• Rehabilitation
• Prevention
• Patient Information

Subarachnoid Haemorrhage

• General / Overviews
• Causes / Risk Factors
• Diagnosis
• Disease Management
• Rehabilitation
• Prevention
• Patient Information

Intracerebral Haemorrhage

• General / Overviews
• Causes / Risk Factors
• Diagnosis
• Disease Management
• Rehabilitation
• Prevention
• Patient Information

Transient Ischaemic Attack

• General / Overviews
• Causes / Risk Factors
• Diagnosis
• Disease Management
• Prevention
• Patient Information

Unusual / Complex cases of stroke

• Causes / Risk Factors
• Diagnosis
• Disease Management
• Rehabilitation
• Prevention
• Patient Information

Common sequelae of stroke

• Aphasia
• Apraxia
• Emotional sequelae

Causes / Risk Factors

• General
• Arteriosclerosis
• Alcohol Drinking
• Cardiac Causes
• Diabetes Mellitus
• Diet
• Genetics
• Hypertension
• Hyperlipidemia
• Smoking
• Vessel dissection
• Thrombosis

Diagnosis

• General
• Angiography
• Blood Tests
• CT Scan

• MRI Scan
  • MRA
• Ultrasound Scan
• Electrocardiogram
• Physical examination

Disease Management

• Emergency Care
  • Pre-hospital
  • Tools to identify stroke
  • Emergency Brain Imaging
  • Thrombolysis
  • Acute Stroke Care
    • Oxygen Therapy
    • Management of early dysphagia
    • Early therapy interventions
    • Cerebral monitoring
    • Early carotid endarterecomy

• Anti-platelet Drugs
  • Aspirin
  • Dipyridamole
  • Clopidogrel
  • Glycoprotein llb/lla inhibitors
• Thrombolytics
• Neuroprotective Agents
• Secondary Prevention
  • Anti-platelet Drugs
    • Aspirin
    • Dipyridamole
    • Clopidogrel
  • Anti-hypertensive drugs
    • ACE Inhibitors
    • Beta-blockers
    • Calcium Channel blockers
  • Lipid Regulating drugs
    • Statins
  • Anticoagulants
    • Warfarin
    • Phenindione
    • Acenocoumarol
• Surgical Interventions

Rehabilitation

• Assistive Technologies
• Carers
• Community Care
• Dysphagia Management
• Nursing Home Care
• Occupational Therapy
• Physiotherapy
• Psychotherapy
• Orthoptics and Visual Therapy
• Speech Therapy
• General/Other

• Prevention
  • Diet
  • Primary Prevention
  • Lipids Management
  • Physical Activity
  • Smoking Cessation
  • Overweight and Obesity
  • Hypertension management
  • General / Other
• Key Policies and related publications

• Management Issues
  • Clinical Governance
  • Economic Evaluations
  • Networks
  • Performance Indicators
  • Service Models
  • Specialist Stroke Units
  • Statistics
• Professional Bodies
• Support Groups

• Alcohol and schools intervention
• Asthma (in children) - corticosteroids
• Hypercholesterolemia - ezetimibe
• Asthma (for severe persistant allergic) - omalizumab
• Grenz rays therapy for inflammatory skin conditions
• Percutaneous Pulmonary valve implantation for right ventricular outflow tract dysfunction
• Mini/Micro screw implantation for orthodontic anchora ge
• Laparoscopic techniques for hysterectomy
• Soft palate implants for simple snoring
• Soft palate implants for obstructive sleep apnoea
• Transcranial magnetic stimulation for severe depression

Clinical guidelines intravenous immunoglobulin provide guidance on appropriate use of immunoglobulin products and a framework for the promotion of evidence based clinical practice to help improve consistency in patient care.

The guidelines support the Demand management plan for immunoglobulin use use makes recommendations on appropriate indications for immunoglobulin and the processes to be implemented by Trusts or SHAs to ensure that immunoglobulin is used appropriately by means of local Immunoglobulin Assessment Panels.

The Commissioner 2(11) (link to this months contents) has just been published. You can sign up for the e-mail alert on its blog, contact Katherine Bell its editor to get a mail of the pdf version or just subscribe to its RSS feed using the icon below.

.

This month’s contents are:

• Diabetes in the NHS: Commissioning and providing specialist services
• NHS Stop Smoking Services
• Commissioning for Patient Pathways
• Commissioning specialist adult learning disability health services
• Care Outside Hospital
• Delivering the 18 week patient pathway
• Eye care
• Commissioning Roadmap
• Facing the Future
• Report of the High Level Group (HLG) on Clinical Effectiveness
• Other documents

NLH 3.1 went live yesterday. ‘Big wows!’ I hear you cry. OK so what does it mean?

International Guidelines Finder

This adds US National Guidelines Clearing House, the New Zealand Guidelines Group - Guidelines Library and the Australian National Health and Medical Research Council: Clinical Practice Guidelines to the guidelines database on the National Library for Health,

When you find results they will be presented in their own hub as shown below.

Bandolier is Now Searchable on the Evidence Based Reviews Hub

Bandolier has been added to the Evidence Based Reviews Hub. Clicking on the blue title link will take you to the article.

• Behaviour change
• Endovascular stent insertion for Intracranial Atherosclerotic Disease
• Laparoscopic uterine nerve ablation (LUNA) for chronic pelvic pain
• Intravesical microwave hyperthermia with intravesical chemotherapy for superficial bladder cancer
• Bortezomib monotherapy for relapsed multilple myeloma
• Adalimumab, etanercept and infliximab for the treatment of rheumatoid arthritis

ABC of breast diseases
Dixon M
London : BMJ, 2000
Link to Amazon Review

Breast cancer for dummies
Elk R and Morrow M
New York : Wiley, 2003
Link to Amazon Review

All woman life after breast cancer
Yelland F.R
Essex : Omnia, 2000
Link to Amazon Review

Before I say goodbye
Picardie
London : Penguin Books, 1998
Link to Amazon Review

E-Book

Introduction to breast care
Bird C
Chichester : Wiley, 2006
Link to Amazon Review

To use this resource you will need your NHS Athens password. If you haven’t got one and you work in the North West you can apply for one here.

E-Grey Literature (also available in hard copy)

Guidance on the use of capecitabine for the treatment of locally advanced or metastatic breast cancer
National Institute for Clinical Excellence
London : NICE, 2003
Link to E-Guideline

Guidance on the use of trastuzumab for the treatment of advanced breast cancer
National Institute for Clinical Excellence
London : NICE, 2002
Link to E-Guideline

Guidance on the use of vinorelbine for the treatment of advanced breast cancer
National Institute for Clinical excellence
London : NICE, 2002
Link to E-Guideline

Clinical effectiveness of trastuzumab for breast cancer: a systematic review
Lewis R
Health Technology Assessment NHS R&D HTA Programme
Southampton : HTA, 2002
Link to E-Report

Clinical effectiveness of vinorelbine for breast cancer: a systematic review and economic evaluation
Lewis R
Health Technology Assessment NHS R&D HTA Programme
Southampton : HTA, 2002
Link to E-Report

Guidance on the use of Taxanes for the treatment of breast cancer
National Institute of Clinical Excellence
London : NICE, 2000
Link to E-Guidline

Rapid and systematic review of the effectiveness and cost effectiveness of the Taxanes used in the treatment of advanced breast and ovarian cancer
Lister-Sharp D
Health Technology Assessment NHS R&D HTA Programme
HTA, 2000
Link to E-Report

The Royal College of Anaesthetists (RCOA), Midwives (RCM), Obstetricians and Gynaecologists (RCOG), and Paediatrics and Child Health (RCPCH) have published

Safer Childbirth - Minimum Standards for the Organisation and Delivery of Care in Labour

It looks at the staffing requirements, skill mix and teamwork required to provide effective and safe services in this area following concerns from Concerns from the Confidential Enquiry into Maternal and Child Health (CEMACH) and its predecessor organisations the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) and the Confidential Enquiry into Maternal Deaths (CEMD).

If you just want to read a briefing look at the Executive Summary. You can see what the mass media have to say about it direct from yesterdays post from Fade the Blog (which you can susbscribe to as RSS or as a daily email alert).

Into practice is an electronic bulletin aimed at those responsible for implementing NICE guidance. It is published on the second Wednesday of the month and includes details of the latest implementation tools and other news from the Implementation Directorate.

Register for the Newsletter here.

• Clinical Governance Support Team
• The Healthcare Commission
• NHS Litigation Authority - News
• Eastern Postgraduate General Education - GP Appraisal Resources
• NHS Networks
• Primary Care Contracting
• Commission for Social Care Inspection
• National Primary Care Research and Development Centre
• National Patient Safety Agency