NICE guideline “Ectopic pregnancy and miscarriage”: new changes and importance for the clinicist

The purpose of this publication is to summarize the current data on the effectiveness of progestogens in patients with threatened miscarriage (vaginal bleeding in the first trimester of pregnancy) and to review the updated UK National Institute for Health and Care Excel (NICE) clinical guidelines on ectopic pregnancy and miscarriage.In accordance with the opinion of the Cochrane Society experts and the updated NICE clinical guidelines for 2021, vaginal progesterone at a dose of 800 mg/day is the only intervention that has been shown to be effective in increasing live births compared to placebo for women with one or more previous miscarriages and early vaginal bleeding (relative risk 1.08, 95% confidence interval 1.02–1.15, high certainty evidence). Upon confirmation of fetal heartbeat, this treatment should be extended until 16 weeks of gestation.There is still uncertainty over the effectiveness and safety of alternative progestogen treatments (as dydrogesterone) for threatened and recurrent miscarriage. There is also no evidence of benefit of any other preparations or doses of progesterone in patients at risk of miscarriage.

P-BN18 Cholecystectomy following ERCP: A retrospective audit from a single centre

Background 15% of the adult population are estimated to have gallstones (GS) and managing GS related disease can represent a significant challenge to surgical and endoscopic services alike. One particular challenge is the management of bile duct calculi (BDC), and treatment can vary according to the unit/institution. NICE has published guidelines (CG188) on the management of GS disease with the recommendation that bile duct clearance and cholecystectomy be offered for symptomatic and asymptomatic BDC. This retrospective audit was performed to determine compliance of a single centre with respect to offering cholecystectomy following ERCP for BDC. Methods A retrospective audit was performed for the year 2018 at a single centre utilising the trust ERCP database. The audit was analysed against NICE guideline CG188 and specifically whether patients treated with ERCP for BDC were then treated with cholecystectomy or had a documented justification as to why cholecystectomy was declined. 2018 was chosen so that at least a 2-year period of follow-up could be analysed. As well as the trust ERCP database, the trust electronic documentation record and paper notes were consulted to determine compliance with the guideline. Results 149 ERCPs were performed on 121 patients at this centre in 2018. Of these, 82 patients were included as 39 had an ERCP for malignant disease or had already had a cholecystectomy. Of those 82, 51 (62%) had an ERCP as an emergency while 31 (38%) had an elective procedure. The median age was 65, 54% being male and 46% female. 45 (55%) had a cholecystectomy following ERCP, 29 as an emergency, and 16 electively. Of those 37 who did not have a cholecystectomy, 20 (54%) had no recorded documentation to justify a decision not to proceed to cholecystectomy. Conclusions GS disease has the potential to cause significant morbidity. If an ERCP has been performed for BDC, NICE recommends that cholecystectomy should be offered to mitigate further GS related complications. Patients may of course decline an operation, or a joint decision made not to pursue operative management due to identified surgical risks. This audit demonstrated that 54% of patients at this institution who did not have a cholecystectomy following ERCP had no documented reason why cholecystectomy was declined. Robust follow-up and documentation measures have since been put in place and a follow-up audit is being performed to monitor improvement.

Die S3-Leitlinie zur vaginalen Geburt am Termin – Zusammenfassung

Die Deutsche Gesellschaft für Hebammenwissenschaft (DGHWi) und die Deutsche Gesellschaft für Gynäkologie und Geburtshilfe (DGGG) haben zusammen mit weiteren Akteur*innen die S3-Leitlinie „Die vaginale Geburt am Termin“ entwickelt 3. Im Mittelpunkt der aktuellen S3-Leitlinie steht die evidenzbasierte Betreuung der vaginalen Geburt am Termin. Insbesondere werden Interventionen kritisch reflektiert. Zu diesen zählen die CTG-Kontrolle, die Fetalblutanalyse, der Ultraschall im Kreißsaal, das Schmerzmanagement, der Betreuungsprozess in der Eröffnungsphase, Austrittsphase und Nachgeburtsphase. Die inhaltlichen Empfehlungen sind zum größten Teil an die Empfehlungen der NICE-Guideline CG190 „Intrapartum Care for healthy women and babies“ 1 adaptiert.

Review of menopause advice given to patients undergoing bilateral oophorectomy

The NICE Guideline (NG23) 2015 Menopause: Diagnosis and Management states that ‘women who are likely to go through the menopause as a result of medical or surgical treatment should be offered support and information about the menopause and fertility before they have their treatment, and a referral to a Health Care Professional with expertise in the menopause’. To investigate whether discussion about the surgery causing the menopause, and advice on possible treatments had been documented, I conducted a retrospective study of women undergoing bilateral oophorectomy at a central London teaching hospital from 1st April 2018 to 30th September 2018. Only 30% of women (8 out of 27) in this study had documentary evidence of having received menopause advice around the time of bilateral oophorectomy.

The NICE OECD countries’ geographic search filters: Part 2—validation of the MEDLINE and Embase (Ovid) filters

Objective: We previously developed draft MEDLINE and Embase (Ovid) geographic search filters for Organisation for Economic Co-operation and Development (OECD) countries to assess their feasibility for finding evidence about the countries. Here, we describe the validation of these search filters.Methods: We identified OECD country references from thirty National Institute for Health and Care Excellence (NICE) guidelines to generate gold standard sets for MEDLINE (n=2,065) and Embase (n=2,023). We validated the filters by calculating their recall against these sets. We then applied the filters to existing search strategies for three OECD-focused NICE guideline reviews (NG103 on flu vaccination, NG140 on abortion care, and NG146 on workplace health) to calculate the filters’ impact on the number needed to read (NNR) of the searches.Results: The filters both achieved 99.95% recall against the gold standard sets. Both filters achieved 100% recall for the three NICE guideline reviews. The MEDLINE filter reduced NNR from 256 to 232 for the NG103 review, from 38 to 27 for the NG140 review, and from 631 to 591 for the NG146 review. The Embase filter reduced NNR from 373 to 341 for the NG103 review, from 101 to 76 for the NG140 review, and from 989 to 925 for the NG146 review.Conclusion: The NICE OECD countries’ search filters are the first validated filters for the countries. They can save time for research topics about OECD countries by finding the majority of evidence about OECD countries while reducing search result volumes in comparison to no filter use.

EP.WE.690PPI Prescribing in Vascular Discharges

Aims Aspirin and clopidogrel are ubiquitously seen in prescriptions of most attendees to hospitals, especially those being admitted to a vascular unit. Most, if not all, are on at least one anti-platelet agent, and some are on dual antiplatelets (DAPA) or an anticoagulant. These increase the risk for upper gastrointestinal (UGI) bleeds, which lead to significant morbidity and mortality. In order to prevent this, proton pump inhibitors (PPIs) are recommended to be prescribed for patients with increased risk of UGI bleeds. Our aim for this audit was to evaluate the prescription of PPIs in vascular patients discharged from a major vascular hub. Methods Data was collected from a prospectively maintained database of consecutive primary vascular discharges between 01/09/2020 and 31/09/2020. Results 87 patients discharged in this period (71% Male, Median age 72 (22-92) yrs). 26% of admissions accounted for Diabetic foot infection management, 25% for Critical Limb Ischaemia management and 20% for Thoracic or Aortic Aneurysm management. 70% of patients were discharged with either a single or DAPA. 94% of patients met the NICE guideline for requirement for a PPI. 49% of those patients were not discharged with a PPI. Of the patients who should have been prescribed a PPI on discharge, 5% suffered UGI bleeds in the follow up period (2/42). Conclusions PPIs are often not prescribed when discharging vascular patients, most of whom are high risk for having UGI bleeds. We will re-audit this after education and protocols have been implemented.

EP.TU.201Evaluating and Improving the Management of Tonsilitis in an A+E Department: An Educational Intervention

Aims Tonsilitis is one of the most common presentations to the A+E department. We aimed to assess whether patients presenting with tonsilitis are being managed in-line with current guidance. We then set out to educate A+E staff about tonsilitis management and then assessed for improvement in management. Methods All patients presenting to A+E in one fortnight with a documented diagnosis of tonsilitis were included. We reviewed the notes to assess the choice of treatment in each case and whether a clinical score was used to guide choice of treatment (in accordance with NICE guideline [NG84]). We designed and delivered an educational intervention for A+E staff covering tonsilitis guidelines. The audit was repeated two weeks later. Results Over the study period, 49 patients were included; only 35% (n = 17) had either a clinical score documented or had all components of a score recorded. In total, 39% (n = 19) were treated with antibiotics. Of these, 63% (n = 12) should not have been prescribed an antibiotic and 37% (n = 7) were prescribed an inappropriate antibiotic. At re-audit, (n = 50 cases), 58% (n = 29) had a clinical score documented and 28% (n = 14) were treated with antibiotics. Of these, 29% (n = 4) should not have been prescribed antibiotics and 21% (n = 3) were prescribed an inappropriate antibiotic. Thus, after this teaching session, there was a significant improvement in antibiotic prescribing practices (63% vs 29%, p = 0.026). Conclusions A+E assessment and management of tonsilitis frequently deviated from guidelines, but a single teaching session vastly improved clinical scoring and antibiotic prescribing practices.