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O'Mahony R.,Guideline | Murthy L.,Uk Cochrane Center | Akunne A.,KSG Trans | Young J.,Royal Infirmary
Annals of Internal Medicine | Year: 2011

Description: Delirium is common, is often underrecognized, and is associated with poor outcomes and high costs. In July 2010, the National Institute for Health and Clinical Excellence released a guideline that addressed diagnosis, prevention, and management of delirium. This synopsis focuses on the main recommendations about prevention of delirium. Methods: The National Clinical Guideline Centre developed these guidelines by using standard methodology of the National Institute for Health and Clinical Excellence. A multidisciplinary guideline development group posed review questions, discussed evidence, and formulated the recommendations. To underpin the guideline, a technical team from the National Clinical Guideline Centre systematically reviewed and graded pertinent evidence identified from literature searches of studies published in English to August 2009 and performed health economic modeling. Stakeholder and public comment informed guideline development and modifications. Recommendations: Considering prevention a feasible and costeffective health strategy, the guideline development group made 13 specific recommendations that addressed the stability of the care environment (both the care team and location) and the provision of a multicomponent intervention package tailored for persons at risk for delirium. The multicomponent intervention package included assessment and modification of key clinical factors that may precipitate delirium, including cognitive impairment or disorientation, dehydration or constipation, hypoxia, infection, immobility or limited mobility, several medications, pain, poor nutrition, sensory impairment, and sleep disturbance. © 2011 American College of Physicians.


Dworzynski K.,Guideline | Ronald A.,Birkbeck, University of London | Bolton P.,King's College London | Happe F.,King's College London
Journal of the American Academy of Child and Adolescent Psychiatry | Year: 2012

Objective: This 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). Method: Data 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. Results: Girls, 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. Conclusions: These 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. © 2012 American Academy of Child and Adolescent Psychiatry.


Hill J.,Guideline | Bullock I.,Guideline | Alderson P.,Health Level
Annals of Internal Medicine | Year: 2011

The National Clinical Guideline Centre develops evidence-based clinical guidelines on behalf of the National Institute for Health and Clinical Excellence in the United Kingdom. These guidelines are developed for the National Health Service in England, Wales, and Northern Ireland and establish recommendations on best practice. The authors summarize the main methods used in development, how evidence from systematic reviews is interpreted to form recommendations, who is involved in the process, and the main outputs that are published. © 2011 American College of Physicians.


Mant J.,University of Cambridge | Al-Mohammad A.,Sheffield Teaching Hospitals NHS Foundation Trust | Swain S.,Guideline | Laramee P.,Guideline
Annals of Internal Medicine | Year: 2011

Description: The National Institute for Health and Clinical Excellence released its first clinical guideline on heart failure in 2003. This synopsis describes the update of that guideline, which was released in August 2010 and discusses the diagnosis, treatment, and monitoring of heart failure. Methods: Guideline developers considered clinical evidence, health economic analyses, clinical expert opinion, and patient views. Systematic literature searches were performed, and an original decision model assessed the cost-effectiveness of serial measurement of serum natriuretic peptide to monitor patients with chronic heart failure. Recommendations: First, this guideline update describes the role of serum natriuretic peptide measurement, echocardiography, and specialist assessment in the diagnosis of heart failure. Second, it presents a pathway for pharmacologic treatment, rehabilitation, and pacing therapy (including implantable cardioverter-defibrillator and cardiac resynchronization therapy) for patients with heart failure and left ventricular systolic dysfunction and patients with heart failure and preserved ejection fraction. Finally, it explains the recommendation to monitor patients with heart failure by using serial measurement of serum natriuretic peptide. © 2011 American College of Physicians.


O'Flynn N.,Guideline | Potter J.,Clinical Effectiveness and Evaluation Unit
Annals of Internal Medicine | Year: 2011

The general election in the United Kingdom in May 2010 resulted in the election of a new government, a coalition between Conservative and Liberal Democrat parties. Six weeks after the election, a white paper, "Equity and Excellence: Liberating the NHS," that proposed profound changes to the structure and organization of the health service was published. The change that generated the most discussion was the proposal that general practitioners be placed at the center of the system and given control of about 80% of the National Health Service's £100 billion budget. The proposals were greeted with considerable concern by many health care professionals, patient representatives, and the media. In response, the government organized an independent review, and proposals have been altered in response. This article outlines the current organization of the National Health Service, the rationale for change, and government proposals. © 2011 American College of Physicians.


Samarasekera E.J.,Guideline | Neilson J.M.,Guideline | Warren R.B.,University of Manchester | Parnham J.,Guideline | Smith C.H.,Guys Hospital
Journal of Investigative Dermatology | Year: 2013

The relationship between psoriasis and increased risk of cardiovascular disease (CVD) is controversial. We critically evaluate 14 cohorts and meta-analyze the magnitude of CVD risk for the primary outcomes of CVD mortality, stroke, and myocardial infarction (MI), and establish subgroup risk for different psoriasis severities and age groups. Increased CVD risk was identified only in individuals with severe psoriasis (defined as requiring systemic therapy or hospital admission): the risk ratio relative to the general population was 1.37 (95% confidence interval (CI) 1.17-1.60) for CVD mortality, 3.04 (95% CI 0.65-14.35) for MI, and 1.59 (95% CI 1.34-1.89) for stroke. The relative risks of CVD were highest in the younger, severe psoriasis population (e.g., 3.10 (95% CI 1.98-4.86) for MI at 30 years), and absolute risks were greatest in older individuals with severe psoriasis (e.g., 23.2 excess MIs per 10,000 person-years at 60 years). Uncertainty remains about whether CVD risk is directly attributable to psoriasis, as the majority of studies failed to adequately adjust for key traditional risk factors. © 2013 The Society for Investigative Dermatology.


Formoso G.,Guideline
Cochrane database of systematic reviews (Online) | Year: 2012

Tibolone is an option available for the treatment of menopausal symptoms, based on short-term data on its efficacy. However, there is a need to consider the balance between the benefits and risks of tibolone as there are concerns about breast and endometrial cancer as well as stroke. To evaluate the effectiveness and safety of tibolone in treating postmenopausal women. We searched the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Specialised Register (19 April 2011), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, 2nd Quarter), MEDLINE (from inception to 19 April 2011), EMBASE (1980 to week 3 April 2011), PsycINFO (1806 to week 3 April 2011), Clinical Trials.gov (30 April 2011). Individual researchers and the current manufacturer of tibolone were contacted to identify unpublished and ongoing trials. Randomised controlled trials (RCTs) that compared tibolone versus placebo, estrogens or combined hormone replacement therapy (HT) by assessing the percentage of women with menopausal symptoms, the severity of those symptoms and the occurrence of safety outcomes in postmenopausal women. Four review authors independently extracted information from the articles, resolving discrepancies by consensus. All outcomes studied were dichotomous. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using the random-effects model. Heterogeneity of studies was taken into account before deciding to combine the data. When compared to placebo, tibolone was more effective in relieving the frequency of vasomotor symptoms (two RCTs, n = 847; OR 0.42, 95% CI 0.25 to 0.69), although only the 2.5 mg/day dose of tibolone was significantly better than placebo; but with increased vaginal bleeding (seven RCTs, n = 7462; OR 2.75, 95% CI 1.99 to 3.80). When compared to equipotent doses of combined HT, tibolone reduced vaginal bleeding (15 RCTs, n = 6342; OR 0.32, 95% CI 0.24 to 0.42) but was less effective in relieving the frequency of vasomotor symptoms (two RCTs, n = 545; OR 4.16, 95% CI 1.50 to 11.58).As for long term safety, two major RCTs of tibolone versus placebo provided the most relevant data. An RCT of 3098 women with breast cancer and menopausal symptoms was halted after 3.1 years because of increased tumour recurrence (OR 1.50; 95% CI 1.21 to 1.85). However, in another RCT that selected osteoporotic women with negative mammograms (n = 4506) tibolone was associated with a reduction in breast cancer compared to placebo after 2.8 years (OR 0.32, 95% CI 0.13 to 0.79) although the trial was not specifically designed to assess that outcome and the number of overall events was low. In the same RCT, an excess risk of stroke was observed (OR 2.18, 95% CI 1.12 to 4.21). There was no clear evidence of a tibolone effect on endometrial cancer compared with placebo given the low number of events (seven RCTs, n = 8152; OR 1.98, 95% CI 0.73 to 5.32).There was no evidence of a difference in long term safety between tibolone and combined HT. Tibolone, used at the daily dose of 2.5 mg, may be less effective than combined HT in alleviating menopausal symptoms although it reduced the incidence of vaginal bleeding. There was evidence that treatment with combined HT was more effective in managing menopausal symptoms than was tibolone. Available data on the long term safety of tibolone is concerning given the increase in the risk of breast cancer in women who had already suffered from breast cancer in the past and in a separate trial the increase in the risk of stroke in women whose mean age was over 60 years. Similar concerns may exist for estroprogestins but their overall benefit-risk profile is better known and is more directly related to women with menopausal symptoms.


Upadhyay A.,Guideline | Earley A.,Guideline | Haynes S.M.,Guideline | Uhlig K.,Guideline
Annals of Internal Medicine | Year: 2011

Background: The optimal blood pressure target in patients with chronic kidney disease (CKD) is unclear. Purpose: To summarize trials comparing lower versus higher blood pressure targets in adult patients with CKD and focus on protein-uria as an effect modifier. Data Sources: MEDLINE and the Cochrane Central Register of Controlled Trials (July 2001 through January 2011) were searched for reports from randomized, controlled trials with no language restriction. Study Selection: Authors screened abstracts to identify reports from trials comparing blood pressure targets in adults with CKD that had more than 50 participants per group; at least 1-year follow-up; and outcomes of death, kidney failure, cardiovascular events, change in kidney function, number of antihypertensive agents, and adverse events. Data Extraction: Reviewers extracted data on study design, methods, sample characteristics, interventions, comparators, outcomes, number of medications, and adverse events and rated study quality and quality of analyses for proteinuria subgroups. Data Synthesis: Three trials with a total of 2272 participants were included. Overall, trials did not show that a blood pressure target of less than 125/75 to 130/80 mm Hg is more beneficial than a target of less than 140/90 mm Hg. Lower-quality evidence suggests that a low target may be beneficial in subgroups with proteinuria greater than 300 to 1000 mg/d. Participants in the low target groups needed more antihypertensive medications and had a slightly higher rate of adverse events. Limitations: No study included patients with diabetes. Trial duration may have been too short to detect differences in clinically important outcomes, such as death and kidney failure. Ascertainment and reporting of adverse events was not uniform. Conclusion: Available evidence is inconclusive but does not prove that a blood pressure target of less than 130/80 mm Hg improves clinical outcomes more than a target of less than 140/90 mm Hg in adults with CKD. Whether a lower target benefits patients with proteinuria greater than 300 to 1000 mg/d requires further study. Primary Funding Source: Kidney Disease: Improving Global Outcomes (KDIGO). © 2011 American College of Physicians.


Bermingham S.L.,Guideline | Ashe J.F.,Guideline
BJU International | Year: 2012

The aim of this review was to identify studies that have evaluated the impact of symptomatic urinary tract infection (UTI) and UTI-associated bacteraemia on quality of life, and to summarize these data in a way that is useful for a health researcher seeking to populate a cost-utility model, design a clinical study or assess the effect of UTIs on quality of life relative to other conditions. We conducted a systematic search of the literature using MEDLINE, EMBASE, the NHS Economic Evaluations database, Health Technology Assessment database, Health Economics Evaluations database, Cost-Effectiveness Analysis Registry and EuroQol website. Studies that reported utility values for symptomatic UTI or UTI-associated bacteraemia derived from a generic QoL measurement tool or expert opinion were included. Studies using disease-specific instruments were excluded. Twelve studies were identified that included a generic measure of health-related quality of life for patients with UTIs. These measures included: the short-form (SF)-36 and SF-12 questionnaires; the Health Utilities Index Mark 2; Quality of Well Being; the Index of Well Being, standard gamble; the Health and Activity Limitation Index; and expert opinion. The authors of studies using either of the SF questionnaires were contacted for additional data. One research group provided previously unpublished data from a large cohort study; these scores were mapped to EuroQol 5-Dimension (EQ-5D) values using published algorithms and probabilistic simulations. The present review provides health researchers with several sources from which to select utility values to populate cost-utility models. It also shows that very few studies have measured quality of life in patients with UTI using generic preference-based measures of health and none have evaluated the impact of this health state on quality of life in children. Future studies ought to consider the inclusion of commonly used preference-based measures of health, such as the EQ-5D, in all patient populations experiencing symptomatic UTI or UTI-related complications. © 2012 THE AUTHORS.


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