Recent developments that caught the eye


Child ’flu vaccine pilot enters second year
 
More than 700,000 schoolchildren from across England will be offered a free winter ’flu vaccine as part of the continued rollout of Public Health England’s (PHE) vaccination strategy. 
 
In the first year of the programme, vaccinations were offered to primary school children in a mixture of rural, urban and inner city settings. Now, in the second phase of the pilot, children in Years 7 and 8 (aged 11-13) in selected secondary schools will be offered the vaccine. Most children will receive the vaccine as a nasal spray. 
 
All pre-school children aged 2-4 will also be offered a nasal spray vaccine to protect them against flu. This accompanies the existing ’flu programme, which provides flu vaccination to anyone in at risk groups, pregnant women and those aged 65 or over. 
 
Dr Paul Cosford, Director for Health Protection and Medical Director at PHE, said: “The pilots are an important addition to the national programme and are being carefully planned for the second year running. They are helping us to understand the best way to implement the programme nationally, ensuring that we can set up a successful and sustainable programme, vaccinating children and young people to protect them and the wider population. 
 
“It’s important that children take up the offer of a vaccination if offered to them later in the year. Every year, hundreds of thousands of people may see their GP and tens of thousands may be hospitalised because of ’flu each winter.” 
 
Dr Mary Ramsay, PHE’s Head of Immunisation said: “Last year there was an overall uptake of 52.5% in school- age children and early findings from the pilots suggest a likely impact of vaccinating on levels of ’flu circulating more widely. 
 
“The high uptake levels achieved in most pilot areas last year using school- based delivery demonstrate the feasibility of achieving high coverage levels and this is encouraging as we approach the second year of the pilots. However, it is important that we continue this on-going close monitoring of the programme.”
Non-adherence rife among arthritis patients, findings show
 
Large numbers of people with severe rheumatoid arthritis (RA) are failing to take expensive medication as prescribed, according to a new multi-centre study led by researchers at Manchester University. 
 
The Manchester team collected adherence data for 286 patients attending 60 rheumatology clinics across the UK between 2008 and 2012 who had rheumatoid arthritis treated with anti-TNF agents. Of these, 27% reported non-adherence to therapy, according to the defined criteria at least once over the first six-month period. 
 
Anti-TNF therapy, which block the tumour necrosis factor (TNF) pathway in the inflammatory process that causes rheumatoid arthritis, has revolutionised treatment of the condition over the past 10-15 years. But it is expensive, costing between £8,000 and £12,000 a year per patient.
 
Professor Alan Silman, medical director of Arthritis Research UK, said: “Anti-TNF drugs have transformed the lives of a substantial number of patients with rheumatoid arthritis and related disorders. This success has been at a considerable cost to the NHS but there was always the assumption that patients prescribed these drugs will have the necessary regular injections. The fact that a considerable proportion of patients are missing doses of these very expensive agents is worrying, as clearly their effectiveness would be reduced.” 
 
The study did not identify whether patients’ non-adherence was deliberate or accidental. Further research at the centre is ongoing to try and understand more about the reasons why patients with arthritis may not always take their medications as prescribed.
Concept of cancer overdiagnosis still poorly understood, survey finds
 
A third of women who are given information about the chance of “overdiagnosis” through the NHS breast screening programme may not fully understand the risks involved, according to research published in the British Journal of Cancer.
 
In a survey of around 2,200 women, Cancer Research UK (CRUK) scientists at University College London (UCL) found that only 64% felt they fully understood the information given about overdiagnosis by the national breast screening programme.  
 
Information about overdiagnosis has only been included in the NHS breast screening invitation leaflets since late 2013, meaning that overdiagnosis is likely to be a new concept for many people. 
 
But despite uncertainty over the information they were given, intentions to attend breast screening remained high. Only 7% of women said they would be less likely to attend screening after receiving the overdiagnosis warning, while 4% of women said they would in fact be more likely to attend screening after receiving the information. 
 
Study author, Dr Jo Waller, a researcher at the Health Behaviour Research Centre, UCL, said: “The study found that many women still struggle to understand the balance of benefits and harms linked to breast screening, so we need to find better ways to communicate the risks as well as the benefits.”  
 
Sara Hiom, CRUK’s director of early diagnosis, added: “The concept of overdiagnosis is still very new for a lot of women because it has only been included in the NHS leaflets for a year. We hope that over time, people’s understanding of this concept will increase as more and more women receive information explaining this risk of screening. 
 
Women worried about overdiagnosis can speak to CRUK’s specialist cancer nurses on freephone 0808 800 4040. http://www.cancerresearchuk.org. Waller J, et al. British Journal of Cancer advance online publication; doi:10.1038/ bjc.2014.482
Asthma drugs ‘may suppress growth’
 
Corticosteroid drugs in inhalers given to children with asthma may suppress their growth, evidence suggests. 
 
Two new systematic reviews published in The Cochrane Library focus on the effects of inhaled corticosteroid drugs (ICS) on growth rates. The authors of the reports found that children’s growth slowed in the first year of treatment, although the effects were minimised by using lower doses. 
 
Inhaled corticosteroids are prescribed as the first-line treatment for persistent asthma and have been hugely effective in controlling asthma and reducing asthma deaths and hospital visits. 
 
The first review focused on 25 trials involving 8,471 children up to 18 years old with mild to moderate persistent asthma. These trials tested all available inhaled corticosteroids except triamcinolone and showed that, as a group, they suppressed growth rates when compared to placebos or non-steroidal drugs. Fourteen of the trials, involving 5,717 children, reported growth over a year. The average growth rate, which was around 6-9 cm per year in control groups, was reduced by about 0.5 cm in treatment groups. 
 
The second review considered data from 22 trials in which children were treated with low or medium doses of inhaled corticosteroids. These trials tested different doses of all drugs except triamcinolone and flunisolide. Only three trials followed 728 children for a year or more, with one of these trials testing three different dosing regimens. In the three trials, using lower doses of the inhaled corticosteroids, by about one puff per day, improved growth by a quarter of a centimetre at one year. 
 
The researchers found that growth suppression varied across studies, and so they looked at the relationship between a variety of factors and their effects on growth. Some of the variation could be explained by the drugs used, although since this was an indirect comparison the authors say more evidence is needed. 
 
Lead author Linjie Zhang, of the Faculty of Medicine at the Federal University of Rio Grande in Brazil, said: “The evidence we reviewed suggests that children treated daily with inhaled corticosteroids may grow approximately half a centimetre less during the first year of treatment. 
 
“But this effect is less pronounced in subsequent years, is not cumulative, and seems minor compared to the known benefits of the drugs for controlling asthma and ensuring full lung growth.” “Conclusions about the superiority of one drug over another should be confirmed by further trials that directly compare the drugs.”
Seeing the same GP at every visit reduces A&E attendance
Insights 2-5 Seeing same GP
Visits to accident and emergency departments can be reduced if a patient sees the same GP every time they visit the doctor’s surgery, research by academics at the University of Bristol has revealed. 
 
The report, titled Primary care factors and unscheduled secondary care: a series of systematic reviews, found that patients who saw the same GP every time they attended their GP surgery were less likely to require emergency care. The findings were published in the open access journal BMJ Open.
 
A number of other factors contributed to keeping people out of the emergency wards. These included:  
  • How easy it is for patients to access GP surgeries and primary care providers 
  • The distance the patients live away from the emergency department  
  • The number of confusing options patients had for accessing emergency care. 
Recent figures from the King’s Fund suggest that admissions among people with long-term conditions that could have been managed in primary care cost the NHS £1.42 billion per year. This could be reduced by up to 18% through investment in primary and community- based services, the report authors say.  

The report recommends that, for patients in high-risk group, there should be a targeted increase in continuity of care with GPs. These include older patients, those from poorer backgrounds and those suffering from multiple conditions.  

The report is based on research funded by the National Institute for Health Research School for Primary Care Research.  

To see the report visit http://bmjopen.bmj.com/content/4/5/e004746

Cancer Fund to increase by 40 per cent
 
Thousands more cancer patients in England will be given access to restricted cancer treatments following the announcement by NHS England of a £160m boost, over a two-year period, to the Cancer Drugs Fund. 
 
Established four years ago to provide pioneering drugs, rejected or not yet approved by NICE, to patients adjudged to have the greatest need, the Fund will now be increased from £200m a year to £280m a year. 
 
To date, more than 55,000 cancer patients have benefited, according to NHS figures. But with the number of people diagnosed with cancer each year increasing by 9% since 2009, the rising costs of ever more sophisticated drugs and the burgeoning pipeline, the latest increase will help meet increasing demand. 
 
NHS England has also announced two additions to the extensive list of cancer agents included in the fund. These are:  
  • Enzalutamide (Xtandi) for prostate cancer  
  • Lenalidomide (Revlimid) for a new group of patients with myelodysplastic syndrome, a rare blood condition. 
Professor Peter Clark, an oncologist and Chair of the Cancer Drugs Fund (CDF), has recommended a review by the CDF panel of experts of a number of drugs currently on the list, making evidence- based decisions about what will deliver greatest benefit to patients.

Guidelines Round-Up
consensus Document puts NOACS in the Limelight


A new European joint consensus document on the use of antithrombotic drugs in patients with atrial fibrillation (AF) presenting with an acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention (PCI) has been published in the European Heart Journal. The recommendations take account of the increasing importance of non-vitamin K antagonist oral anticoagulants (NOACs) in this setting. 
 
This latest consensus, written by a task force representing a number of working groups and associations allied to the European Society of Cardiology (ESC), reflects the new evidence and various advances in thromboprophylaxis for AF that have emerged since 2010, when the last consensus document on this topic was published. Since then, NOACs have been introduced, with subsequent changes in the approach to stroke prevention for AF patients. 
 
The paper also reflects the diminished role of aspirin in AF stroke prevention guidelines, various improvements in angioplasty/stent technology, and the results of new randomised trials. Areas for further research are also highlighted. 
 
No published trial so far has directly evaluated the use of NOACs in patients with ACS and AF, although ongoing trials will address this. The consensus document states that “there is no strong evidence to suggest that NOACs behave differently to vitamin K antagonists [VKAs] in the setting of ACS or stenting”. It recommends that ACS patients who develop new-onset AF while on dual antiplatelet therapy should also be started with a VKA or NOACs. 
 
Drug-eluting stents are also recommended over bare metal stents in patients with AF. 
 
Professor Kurt Huber, the task force’s co-chairperson, said: “In the last four years, since the previous document, there have been many developments including the introduction of NOACs on the market. An update was needed to provide clinicians with guidance on how to manage these patients. 
 
“The recommendations will especially help patients with ACS who in addition need anticoagulation because they have AF and a CHA2DS2-VASc [stroke risk] score greater than one...This is a relatively large number of patients and clinicians need up-to-date advice.”
New breast cancer treatment recommended

NICE has published draft guidance on a new type of radiotherapy for breast cancer for use on NHS patients in England under carefully controlled circumstances. 
 
The guidance for the use of intrabeam radiotherapy was recommended by NICE as a treatment option for people with early breast cancer. The recommendation says that patients should be properly informed about the radiotherapy’s pros and cons and that further data should be collected. 
 
The draft guidance, published for consultation, says that intrabeam radiotherapy should be offered to NHS patients provided doctors:  
  • explain the full range of treatments available, highlighting their associated risks and benefits. This is to allow patients to make an informed decision about whether to choose Intrabeam or conventional radiotherapy  
  • enter details about all of their breast cancer patients having treatment with the intrabeam radiotherapy system onto a national register  
  • audit, review and document clinical outcomes locally and consider the relationship between outcomes and patients’ characteristics. 
Professor Carole Longson, director of health technology evaluation at NICE, said the treatment has the potential to be a much more efficient form of radiotherapy. “Unlike regular radiotherapy, with the intrabeam radiotherapy system only one dose is required,” she explained. 
 
“This single dose is given at the same time as surgery, eliminating the need for numerous hospital visits. Regular radiotherapy typically requires numerous doses over a 3-week period – although some people may receive it for longer – and is performed weeks or months after surgery or chemotherapy.” 
 
The Appraisal Committee concluded that while current evidence was not extensive, this type of radiotherapy could improve patients’ quality of life. 
 
More than 41,500 women in England are diagnosed with breast cancer every year. Of these, about 86% (35,970) will potentially have early breast cancer. 
 
Final guidance is expected in November 2014. Until then, local NHS bodies are expected to make their own funding decisions for new treatments.
Hepatitis C drug finally gets green light

In draft guidance for the treatment of chronic hepatitis C, NICE has recommended the use of the drug sofosbuvir (Sovaldi) following assurances of the drug’s cost effectiveness from the manufacturer. 
 
Around 160,000 people are chronically infected with the hepatitis C virus in England. Many people infected will remain asymptomatic and undiagnosed, and around one in three will eventually develop liver cirrhosis, with a small number of cases leading to liver cancer. 
 
Treatments for hepatitis C aim not only to halt progression of liver disease, but also to prevent transmission of the virus to other people. Sofosbuvir is an oral antiviral drug which inhibits replication of hepatitis C viral in infected cells. 
 
Professor Carole Longson, Director of the NICE Centre for Health Technology Evaluation, highlighted the potential side-effects of current treatments, such as interferon, which often needs to be given for a long period of time, often leading to non-adherence. 
 
“New treatments like sofosbuvir can shorten the duration of interferon-based therapy and in some cases don’t need to be taken with interferon at all. This could potentially encourage more people to seek treatment,” he said. Previous draft NICE guidance had concluded that there were some uncertainties in the evidence base for some subgroups of patients with chronic hepatitis C.