Recent developments that caught the eye


Women fail to recognise cervical cancer symptoms

Many women under the age of 30 fail to recognise the symptoms of cervical cancer, new research led by scientists at King’s College London has revealed.

In many cases, women were not diagnosed for more than three months after the first symptoms displayed because the patient did not believe the symptoms were serious. 

Insights 2-6 Women

About one in 134 women will get cervical cancer at some point in their lives, with women in their 30s most at risk. In England, the NHS offers screening to prevent cervical cancer to women aged 25-64.

In the study, researchers interviewed 128 women under 30 years of age and with a recent diagnosis of cervical cancer – equating to approximately 37% of all women under 30 diagnosed in 2010 in England.

Of these, 40 had been diagnosed after going to the doctor because they had symptoms, 86 had been diagnosed as a result of routine NHS screening and two were diagnosed during management of an unrelated condition.

Among the 40 women diagnosed after going to the doctor with their symptoms, the majority had reported bleeding after sex or between periods. More than a quarter (28% – 11 women) had waited for more than three months to see a doctor; 10 of these said that they had not known what the symptoms of cervical cancer were. Women under 25 were more likely to delay compared with women aged 25-29.

Many women also reported that it had taken more than three months to be diagnosed after frst going to the doctor (60% – 24 women). There was some evidence that women did not reattend quickly after their frst consultation despite symptoms persisting.

Dr Lindsay Forbes, senior author of the study, from the Promoting Early Cancer Presentation Group at King’s College London, said: “Our study suggests that women, especially women under 25, are often not aware of the symptoms of cervical cancer and delay seeing their doctors. A better understanding of the importance of these symptoms could help promote earlier diagnosis and improve survival in this group. Cervical screening tests aim to prevent cancer from developing – the test looks for changes caused by long-standing HPV infection in women without symptoms. Women who have persistent symptoms need to be offered a proper examination, not simply a cervical screening test.”

The study was funded by the NHS Cancer Screening Programmes.
Fatty acid link to reduced CHD risk

A study by scientists at the University of Eastern Finland has found that dietary polyunsaturated fatty acids may reduce the risk of coronary heart disease (CHD).

Writing in Arteriosclerosis, Thrombosis & Vascular Biology, a journal of the American Heart Association, the scientists discovered that people with diets rich in polyunsaturated fatty acids – which are found in fsh, vegetable oils, and nuts – had a lower risk of developing coronary heart disease.

However, while recent studies have not found an association between the consumption of saturated fats and the risk of cardiovascular diseases, it was discovered that the risk of cardiovascular disease is reduced when saturated fats are replaced with polyunsaturated fats. This has not been observed when replacing saturated fats with carbohydrates.

The study was based on the dietary habits of 1,981 men aged 42-60. They were assessed at the baseline of the Kuopio Ischaemic Heart Disease Risk Factor Study (KIHD) at the University of Eastern Finland in 1984–1989. During a follow-up of 21.4 years, 565 men were diagnosed with a coronary heart disease. Out of these, 183 were cardiac events resulting in the death of the patient.

The study used computational replacement models to study how the replacement of fatty acids with other types of fatty acids or carbohydrates affects the risk of coronary heart disease. These models showed that the consumption of polyunsaturated fatty acids was especially linked to reduced risk of dying of heart disease, no matter whether they replaced saturated fats, trans fats or carbohydrates in the diet. However, replacing saturated fats with carbohydrates did not affect the risk of heart disease. Furthermore, the quality of carbohydrates, measured by the glycaemic index, was irrelevant in these replacement models. A surprising observation was that the consumption of monounsaturated fatty acids was linked to a higher risk.

NICE seeks access to clinical drug trial data
Insights 2-6 Pills
NICE will ask for access to clinical trial data from the European regulatory authorities if all of the relevant data is not supplied by pharmaceutical companies.

This follows calls for increasing transparency from pharmaceutical companies after Roche was criticised for its handling of data for the drug Tamifu.

The AllTrials group was set up in the UK on the back of the Tamifu revelations to call for all past and present clinical trials to be registered and their full methods and summary results reported. To date, 79,855 people and 507 organisations have signed the AllTrials petition, including NICE and patients involved in NICE (PIN).

NICE has outlined its drive for greater access to trial data in an update to the process guide used for developing technology appraisal recommendations.

This follows a public consultation that received responses from more than 50 external organisations, including a number of pharmaceutical companies and the Association of the British Pharmaceutical Industry.

In the update, NICE has strengthened the chapter in the process guide on declarations to ensure that medical directors must sign a declaration when they make submissions to NICE declaring that they have identifed all clinical trial data.

NICE will only approach the European regulatory authorities if the pharmaceutical companies have not provided the necessary clinical data.

Elsewhere, NICE has outlined plans for earlier decision problem meetings so that companies can get advice early on and address any potential issues with the methodology or presentation of clinical trial data, to help speed up the appraisal process.
More out-of-hours support for GPs needed in end of life care
Insights 2-6 Hands
Charity Sue Ryder has called for more specialist support to be available for GPs to enable them to offer around the clock support for the dying and their loved ones.

The charity claims only 8% of CCGs in England currently commission comprehensive 24/7 support services for the dying, their carers and families – a situation described as “unacceptable”.

The charity claims that increasing the range of services commissioned for people at the end of life will ensure more people are able to die in their place of choice, surrounded by loved ones and in receipt of expert and co-ordinated care. It will also alleviate pressure on other parts of the health and care system such as GP surgeries and hospitals.

Dr John Hughes, former GP and Medical Director at Sue Ryder, said: “Sue Ryder frmly believes that people who are dying, their carers and their families should be able to access the care they want, when they want – no matter where they live.”

To draw attention to the situation, the charity has launched a new campaign, Dying Doesn’t Work 9 to 5, which highlights the needless suffering people at the end of life can experience. They are asking all GPs to support the campaign by raising awareness of the issue locally. GPs can check if their CCG is one of the 8% by visiting www. sueryder.org/not9to5.

Our cancer and palliative care feature.
Physicianpharmacist partnership best for people with hypertension

Patients diagnosed with high blood pressure receive better care from a physician-pharmacist partnership than from physician management alone, new research has found.

Pharmacists can play a key role in communicating with physicians to address suboptimal therapy, helping physicians to provide counselling on lifestyle change and performing patient follow-up.

The research was carried out to evaluate the individual care processes of the physician-pharmacist collaborative intervention in treating hypertension.

The study, which combined two randomised controlled clinical trials and was led by researchers at Brunel University London, found that each antihypertensive medication alone led to systolic blood pressure (SBP) reduction of 7.19mm Hg, and each session of counselling about lifestyle change alone resulted in a SBP reduction of 5.30mm Hg.

The data, which covered a six-month period, was taken from two US studies in 2008 and 2009. In total 496 patients were treated.

Puttarin Kulchaitanaroaj, Research Fellow at Brunel University London’s Health Economics Research Group and co-author of the study, said: “By combining data from two trials and using instrumental variable regression we wanted to address unmeasured confounders and isolate the individual actions from the intervention package that led to a successful outcome – in this case, a reduction in hypertension in patients. We hope that researchers can further and better investigate links between care processes and outcomes.”

For more information visit http:// www.sciencedirect.com/science/article/pii/S1551741114001132
New Guidelines on antibiotic resistance to be published

NICE is developing two new guidelines which will help to tackle the growing threat of antibiotic resistance.

The first is on safe and effective antimicrobial stewardship in relation to the use of antimicrobials in health and social care, and the second is a public health guideline that will focus on changing people’s knowledge, attitudes and behaviours in relation to the use of antimicrobials.

The announcement followed a report published by Public Health England (PHE) that said cases of resistant bacteria in England have continued to rise despite continued warnings about unnecessary antibiotic use.

PHE found that between 2010 and 2013 there was a 6% increase in the combined antibiotic prescribing of GPs and hospitals. Over the same four-year period, antibiotic prescribing to hospital inpatients rose by 12% and other community prescriptions, such as by dentists, rose by 32%.

There was also a 12% increase in the number of bloodstream infections caused by E.coli, with varying levels of resistance to key antibiotics for this infection of between 10-19%.

The findings are taken from the first annual report of PHE’s English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR).

The first guideline to be published by NICE, on antimicrobial stewardship, will focus on specific questions relating to safe and effective antimicrobial stewardship in relation to the use of antimicrobials in health and social care. It will look at systems, interventions and processes that can positively influence health and social care practitioners’ decision making.

The second guideline will be a public health guide focusing on changing the public’s knowledge, attitudes and behaviours in relation to the use of antimicrobials, and to educate health and social care practitioners about practices that can reduce the spread of antimicrobial resistance.

NICE will also develop a quality standard on antibiotic prescribing as part of a suite of new public health quality standards.
Accurate and rapid diagnosis for MS needed says NICE

People with multiple sclerosis (MS) should get a rapid and accurate diagnosis of their condition, and access to specialist advice and proven therapies, NICE has said.

MS is the most common neurological condition in young adults in the UK, affecting about 100,000 people.

Diagnosis is currently done in an ad hoc way, with many people often misdiagnosed. Additionally, people with MS can go for more than a year without having their condition and medication monitored.

An audit carried out by the Royal College of Physicians and the MS Trust in 2011 found that although some MS patients received excellent care from the NHS, this was not universal and there were variations in the quality and the quantity of care provided in England and Wales.

Now, NICE has updated guidelines frst published in 2003 to set out how people with MS can receive better care. Dr Paul Cooper, Consultant Neurologist at the Greater Manchester Neuroscience Centre, who chaired the NICE guideline group, said: “The care someone receives should not depend on where they live. One of the central areas that we have tried to address in the guidance is identifying and recognising inequalities in services and in care throughout the NHS.”

NICE now recommends that people with suspected MS should be referred to a consultant neurologist. MS should not be diagnosed on the basis of MRI fndings alone and only a consultant neurologist should make the diagnosis of MS.

Additionally, every person with MS should have a comprehensive review of their care at least once a year and multidisciplinary teams, comprised of MS nurses, GPs, psychologists, and therapists, should oversee the care they receive.

However, the guidance does not recommend the use of the cannabinoid drug Sativex or fampridine, saying they only provide modest beneft, despite signifcant cost to the NHS. Sativex costs £50,000 per quality-adjusted life year (QALY), while fampridine costs in the region of £160,000 per QALY – signifcantly above NICE’s threshold of £30,000.

Other recommendations made in the guidance include offering people with MS an appropriate single point of contact to speak about their care, concerns and different treatment options, and encouraging people with MS to exercise.
Patients taking Warfarin should have the option of a self-monitoring device

NICE experts have recommended the use of self-monitoring for patients on warfarin, saying it would help get more patients onto anticoagulants, improve patients’ International Normalised Ratio (INR) control and lead to fewer clinic visits and better outcomes.

Adults with atrial fibrillation or heart valve disease who are on long- term anticoagulation therapy and who are at higher risk of developing blood clots can use self-monitoring coagulometers such as the Coaguchek XS system (Roche Diagnostics) and the InRatio2 PT/INR Monitor, according to NICE guidance.

The devices monitor clotting time using the INR measure. The INR enables the dose of anticoagulant to be adjusted if required. This in turn can help prevent major bleeding, heart attack or stroke resulting from an over- or under-dose of anticoagulant.

Self-monitoring can involve:
  • Self-testing – where the user performs the INR test themselves and then contacts their health professional for advice on any change to the dosage of anticoagulant that may be required 
  • Self-managing – where the user performs the INR test themselves and then adjusts the dosage of their anticoagulant medication by following an agreed care protocol.