|
|
|
|
|
|
|
One
of the functions of Eyes on Evidence is to sum=
marise
the latest medical knowledge, with informed commentary from peers to
help support decision making in health and social care. This work is
supported by 34 Specialist Collections which filter the vast quanti=
ty
of published research, identify relevant sources of information and
review new publications.
This
month the NHS Evidence Specialist Collections published evidence
updates on headache and diabetic retinopathy.
Headache
remains a major clinical problem with a high prevalence of analgesic
over-use. We look at new evidence for migraine treatments in both
primary care and the emergency room. The evidence update on diabetic
retinopathy presents an up-to-date comprehensive collection of
information, from which we've highlighted new evidence on surgery a=
nd
experimental treatments. Other updates include the suggested use of
internet based cognitive behavioural th=
erapy
for the treatment of tinnitus and a guest editorial on early resear=
ch
into bicarbonate supplementation for patients with chronic kidney d=
isease.
We
also bring you the latest updates on the NHS Evidence portal with
information on how you can get involved.
|
|
<=
/span>
|
|
![](3D"EyesonEvidence_files/image005.gif")
|
|
Diabetic retinop=
athy
– intravitreal injections=
|
|
|
|
|
|
Overview: Diabetic retinopathy affects about 45 per cen=
t of
those diagnosed with diabetes and is one the most common ca=
uses
of blindness in the UK. Retinopat=
hy
affects the blood vessels supplying the retina and usually
affects both eyes. Blood vessels in the retina can become
blocked, leaky or grow haphazardly. This damage gets in the=
way
of the light passing through to the retina and if left
untreated can damage vision.
![](3D"EyesonEvidence_files/image006.jpg") =
The
first effect of diabetes on the retina is to cause the blood
vessels to begin to leak, causing diabetic macular oedema (DMO) or retinal swelling.<=
o:p>
Current treatment:<=
/span> L=
aser
treatment, to seal the leaking retinal blood vessels, is the
oldest form of treatment and still the most common, with go=
od
evidence that it preserves vision in patients with diabetic
macular oedema (DMO) (Mohamed Q et=
al Jama 2007;298(8):902-1). In 80 per ce=
nt of
cases it can prevent any further loss of sight.
NICE technology appraisals recommend the VEGF inhibitors, <=
span
class=3DSpellE>ranibizumab and =
pegaptanib
to treat people with wet age-related macular degeneration (=
AMD)
under certain conditions. =
These
drugs, which are given by injection into the eye, work by
blocking vascular endothelial growth factor or VEGF that ca=
uses
new blood vessels to grow in the eye. This stops the bleedi=
ng
at the back of the eye which causes the wet form of AMD in
certain conditions.<=
br>
These drugs are currently in stage III clinical trials for =
the
treatment of DMO.
New evidence: A
systematic review by O'Doherty =
(O'=
Doherty
M et al. Br J Ophthalmol. 2008
Dec;92(12):1581-90), examining evidence from randomised controlled trials found la=
ser
treatment may be of greater benefit in combination with new=
er
forms of treatment such as intravitrea=
l
use of steroids (triamcinolone)=
or antiangiogenic agents (VEGF inhibitor=
s);
concluding: "Giving one or two in=
travitreal
injections to reduce central macular thickness followed by
focal or grid laser to give a sustained response may offer =
an
alternative to treatment in DMO."<=
o:p>
Potential side effects of triamcinolone
are: posterior subcapsular cata=
ract;
vitreous haemorrhage; transient=
rise
in intraocular pressure; early rapid increases in intraocul=
ar
pressure (IOP) requiring surgical intervention; severe sub =
conjunctival hae=
morrhage;
culture-negative sterile endophthalmit=
is
and infectious endophthalmitis.=
<=
o:p>
Another systematic review by Yilmaz
(Yi=
lmaz
T et al. Ophthalmology 2009;116(5):902-11) concluded that <=
span
class=3DSpellE>intravitreal tri=
amcinolone
acetonide injection is effectiv=
e in
improving visual acuity in patients with refractory DMO in =
the
short-term, but the benefits do not seem to persist in the
long-term.
Shima's r=
eview
of intravitreal injections of V=
EG F
inhibitors, (Sh=
ima
C et al. Acta Ophthalmol
2008;86(4):372-6.), retrospectively examined the systemic a=
nd
ocular complications that developed within two months of ea=
ch intravitreal injection of bevacizumab in 707 patients (1300
injections) with intraocular neovascul=
arization
or macular oedema. It reported =
nine
ocular and eight systemic complications, advising caution w=
hen
considering intravitreal inject=
ion of
this drug.
Commentary:<=
span
style=3D'font-size:10.0pt;font-family:Arial;color:black'>
"As intravitreal use of st=
eroids
(triamcinolone) and antiangiogenic agents (VEGF inhibitor=
s) are
not yet licensed for treating diabetic retinopathy, they sh=
ould
be restricted to a clinical trial setting so that we can de=
termine
their most appropriate use." - Dr Peter Scanlon is a consultant
ophthalmologist at Cheltenham
General Hospital and natio=
nal
director of the English Screening Prog=
ramme
for Diabetic Retinopathy.
|
<=
/span>
|
|
|
|
|
|
|
|
Diabetic macular=
oedema - vitrectomy
|
|
|
|
|
|
Overview: Vitrectomy is a
conventional surgical operation, commonly used for diabetic=
macular
oedema (DMO) which has benefits=
in
terms of improved acuity and reduced macular thickness.<=
o:p>
Current treatment:<=
/span>&n=
bsp;Vitrectomy is commonly used to reliev=
e vitreomacular traction and has also b=
een
used to aid transvitreal oxygen=
ation
and improved growth factor diffusion away from the premacular retina.<=
o:p>
![](3D"EyesonEvidence_files/image007.jpg") =
New evidence: A review of the
evidence, encompassing five randomised=
controlled trials, (Laidlaw DA, =
Eye.
2008 Oct;22(10):1337-41. Epub 2008 Apr 25) found a modest
improvement for patients selected for surgery on the basis =
of ocular
coherence tomography (OCT), partial vi=
treomacular
separation or clinical signs of traction such as an epiretinal membrane or taut thickened=
hyaloid. However, this has not been
subjected to controlled study. It concludes: "The evid=
ence
at present suggests that vitrectomy
for DMO should be restricted to those with clinical or ocul=
ar
coherence tomography (OCT) signs of traction."<=
span
style=3D'font-size:9.0pt;font-family:Arial;color:#0179C1'><=
o:p>
Commentary:<=
span
style=3D'font-size:10.0pt;font-family:Arial;color:black'> &=
quot;Vitrectomy, for people with DMO, ![](3D"EyesonEvidence_files/image008.jpg") =
ha=
s only
proved to be effective when there is traction on the
macular." - Dr=
Peter
Scanlon is a consultant ophthalmologist at Cheltenham General
Hospital
and national director of the English Screening Programme for Diabetic Retinopathy.<=
o:p>
|
<=
/span>
|
|
|
|
|
|
|
|
Migraine<=
/a>
- acupuncture
|
|
|
|
|
|
Overview: Migraine is a severe headache that often has
associated symptoms, such as nausea, increased sensitivity =
and
visual problems. The annual cost of migraine to the European
economy, in terms of medical care and absence from work, is
estimated at 27bn Euro. It is a common condition affecting =
one
in four women and one in 12 men in the UK.
Current treatment:<=
/span> <=
/span>![](3D"EyesonEvidence_files/image009.jpg") =
Th=
ere is
currently no cure for migraine. However, a number of treatm=
ents
can be used to relieve the symptoms of migraine, of which
painkillers are the most frequently used, with or without an
antiemetic. Most patients can be treated adequately for acu=
te
headache alone, but some need prophylactic interventions
because their attacks are too frequent.
New evidence: A
Cochrane systematic review (Li=
nde
K et al, Cochrane Database of Systematic Reviews 2009, Issu=
e 1)
of 22 randomised trials with 44=
19
participants, investigated whether acupuncture is effective=
in
the prophylactic treatment of migraine. Six trials (includi=
ng
two large trials with 401 and 1715 patients) compared
acupuncture to no prophylactic treatment or routine care on=
ly.
After three to four months patients receiving
acupuncture had higher response rates and fewer
headaches. A study with long-term follow up saw no evi=
dence
that effects dissipated up to nine months after cessat=
ion
of treatment. However, the review found no evidence fo=
r an
effect of 'true' acupuncture over sham interventions and
questioned the importance of the exact point location of the
acupuncture needles. It concludes: "available studies
suggest that acupuncture is at least as effective as, or
possibly more effective than, prophylactic drug treatment a=
nd
has fewer adverse effects."
Commentary:<=
span
style=3D'font-size:10.0pt;font-family:Arial;color:black'>
"The evidence that ![](3D"EyesonEvidence_files/image010.jpg") =
ac=
upuncture
shows an effect that may be superior to pharmacological
therapies, but may not be superior to sham acupuncture, is
puzzling. One explanation might be a powerful placebo effec=
t in
some subjects, which is a common feature of many headache
trials where measurement of effects is problematic and psyc=
hological
factors may have considerable influence on responses and
outcomes." - Pr=
ofessor
David Chadwick is emeritus consultant neurologist at the Wa=
lton
Centre, Liverpool and cl=
inical
lead for NHS Evidence – neurological.
|
<=
/span>
|
|
|
|
|
|
|
|
Migraine<=
/a>
- dexamethasone
|
|
|
|
|
|
Overview: At least 14 percent of people who suffer with
migraine will visit an accident and emergency department as=
a
result of the condition.
Current treatment: see above.
New evidence: T=
here
is evidence to suggest that dexamethas=
one
is efficacious in preventing headache recurrence when added=
to
standard treatment for the management of acute migraine
headache in patients who visited emergency
departments as a result of their symptoms.
A systematic review (Singh A et a=
l.
(2008) Academic Emergency Medicine 15(12):1223-33.) pooled
analysis of seven trials involving 742 patients. Its results
suggest a modest but significant benefit when dexamethasone is added to standard
anti-migraine therapy to reduce the rate of patients with
moderate or severe headache on 24- to 72-hour follow-up
evaluation.
![](3D"EyesonEvidence_files/image011.jpg") =
In=
terms
of safety it reported: "adverse effects related to the
administration of a single dose of dex=
amethasone
were infrequent, mild, and transient."
Commentary: =
&q=
uot;Singh
et al (Singh=
A =
et al.
(2008) Academic Emergency Medicine 15(12):1223-33.) is a good quality systematic review,
indicating a modest treatment effect of adding dexamethasone to other migraine
treatment." Pr=
ofessor
David Chadwick is emeritus consultant neurologist at the Wa=
lton
Centre, Liverpool and cl=
inical
lead for NHS Evidence – neurological.
|
<=
/span>
|
|
|
|
|
|
|
|
Tinnitus<=
/a>
- cognitive behavioural therapy=
|
|
|
|
|
|
Overview: Tinnitus is the perception of noise in the ea=
r or
head, which is generated inside the body rather than coming
from outside. It is very common, affecting about a third of=
the
population at some time.
Most tinnitus is caused by a problem with the
inner ear, the auditory nerve or the parts of the brain
involved in deciphering sounds.
Current treatment:<=
/span> C=
hronic
tinnitus is a frequent symptom presented to GPs but no drug
treatment to date has shown itself to be effective. While i=
t is
not a psychological disorder, it can cause psychological
problems including anxiety, tension, concentration loss,
frustration, sleep disturbance and depression.<=
o:p>
One treatment option is cognitive behavioural therapy (CBT), a psycholo=
gical
treatment combining relaxation, remode=
lling
thoughts and use of challenging situations to improve the
patient's attitude towards tinnitus. It is commonly
administered in one-to-one sessions with a therapist or in a
group setting. However, evidence suggests that internet
provision of CBT could be as effective.<=
o:p>
New evidence: A
randomized controlled trial conducted by Ka=
ldo
V et al, (Behav ![](3D"EyesonEvidence_files/image012.jpg") =
Ther. 2008 Dec;39(4):348-59),
compared internet CBT with standard group-based CBT. After =
one
year, results showed improvements in both groups with few
differences between them, leading to the conclusion:
"Internet treatment for tinnitus distress merits furth=
er
investigation, as the outcomes achieved are promising. The
Internet treatment consumed less therapist time and was 1.7
times as cost-effective as the group treatment." Altho=
ugh
this was a small trial and further research is required.<=
o:p>
Commentary: =
&q=
uot;Cognitive
behavioural therapy continues t=
o hold
a prominent place in the treatment of tinnitus. With the
current shortage of cognitive behaviou=
ral
therapists in the tinnitus field, the use of internet-based=
CBT
is a model worth considering." - Dr Veronica Kennedy is a consultant audiovestibular physician at Halliwell Health and Children's Centr=
e, Bolton.
|
<=
/span>
|
|
|
|
|
|
|
|
Accreditation update
|
|
|
|
|
|
Public consultation on the draft accreditation decisions for
National Institute for Clinical Excellence's Centre for
Clinical Practice (NICE CCP), National Institute for Clinic=
al
Excellence's Centre for Health Technology Evaluation (NICE
CHTE) and Scottish Intercollegiate Guidelines Network (SIGN)
closed on 20 August.
Submitted comments have been collated and will be considere=
d by
the NHS Evidence Accreditation Advisory Committee at its
meeting tomorrow (10 September), following which final
accreditation decisions will be made.
At the meeting the committee will also make draft accredita=
tion
decisions on applications from NICE Interventional Procedur=
es
(IP) programme; NICE Centre for
Public Health Excellence (CPHE), and the Sowerby
Centre for Health Informatics at Newcastle Ltd (SCHIN) for =
its
clinical knowledge summaries.
|
<=
/span>
|
|
|
|
|
|
|
|
Guest editorial: chronic
kidney disease
|
|
|
|
|
|
NHS Evidence invite experts in their field to
write an informed commentary on an aspect of their wor=
k.
Each month Eyes on Evidence presents a condensed versi=
on
of one of the latest reports, with links to the f=
ull
editorial for those who would like to read more.<=
o:p>
Metabolic acidosis is a common complication in=
patients
with advanced chronic kidney disease (CKD) particularly whe=
n glomerular filtration rate falls belo=
w 30
ml/min. This, in turn, may bring about a variety of <=
span
class=3DSpellE>sequelae such as stunted growth in
children, loss of bone and muscle mass, negative nitrogen
balance and possible acceleration of progression of chronic
kidney disease.
Results of a randomised
controlled trial (de Brito-Ashurst
I et al; J Am Soc Nephrol.
2009 Jul 16) suggests positive effects of bicarbonate
supplementation for patients with chronic kidney disease (C=
KD),
highlighting the importance of metabolic acidosis in the pr=
ogression
of the condition.
The trial followed 134 adult patients with CKD
over two years, of ![](3D"EyesonEvidence_files/image013.jpg") =
wh=
ich
half took oral sodium bicarbonate supplements and the other
half received standard care.
The group which received supplementation had
slowed progression to end-stage renal disease (ESRD) and
improved nutritional status, with a significant increment in
dietary protein intake. The positive renal effects were
observed in the absence of any effects on blood pressure or=
proteinuria.
The findings are consistent with Shah's study =
of
5422 individuals (Shah SN et a=
l Am J
Kidney Dis. 2009 Aug;54(2):270-7.), which showed that low s=
erum
bicarbonate levels are associated with kidney disease
progression independent of baseline estimated glomerular filtration rate and other
clinical, demographic, and socioeconomic factors. However, =
like
any other single centre study, this report will require fur=
ther
validation by a double blind placebo controlled multi-centre
trial.
Muhammad Yaqoob is professor of nephrology at
William Harvey Research Institute, Bar=
ts.
Ione de Brito-Ashurst is a cons=
ultant
at the Department of Renal Medicine and Transplantation,
William Harvey Research Institute, Bar=
ts.
For details read their full editorial.
|
<=
/span>
|
|
|
|
|
|
|
|
Your questions answered<=
/span>
|
|
|
|
|
|
Something to add?<=
o:p>
Question: Ca=
n I
suggest guidelines or other information to be included in N=
HS
Evidence?
Answer: Ye=
s. To
ensure comprehensive access to information, NHS Evidence
encourages the submission of suggestions and recommendation=
s by
users and content providers. This can be done by completing=
the
comments box on NHS Evidence under the 'feedback' li=
nk,
selecting 'source inclusion' as the feedback subject. <=
o:p>
Locating information=
<=
o:p>
Question: Ca=
n you
perform a search for me?
Answer: Un=
fortunately
we are not resourced to perform searches for individuals. We
have an introductory guide to sea=
rching
NHS Evidence, which can help you to make the best use of the
facilities available. You can also ask your local librarian=
for
assistance.
|
<=
/span>
|
|
|
|
|
|
|
|
Eyes
on Evidence, helps contextualise new
evidence, highlighting that which could signal a change in clin=
ical
practice as well as providing a platform for debate. It does not
constitute NICE guidance.
|
|
|
|
|
|
|
|
=
|
|
|
|
|
|
If you
would like to contribute to Eyes on Evidence or have a comment<=
o:p>
|
<=
span
style=3D'color:black'>
|
|
<=
span
style=3D'font-size:8.5pt;font-family:Arial;color:#333333'>about=
an
article please contact us at
|
![3D"email](3D"EyesonEvidence_files/= "3D\"http://system.newzapp.co.uk/GLink.asp?LID=3DMjU1MzMxOC=")
|
<=
span
style=3D'color:black'>
|
|
|
All artic=
les
are subject to editorial changes and no article is guaranteed
publication.
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Visit our website:
|
|
|
|
|
|
|
|
|
|
|
|
Contact Us:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
![](3D"EyesonEvidence_files/image016.gif") Diabetic
retinopathy – intravitreal inje=
ctions <=
/o:p>
Diabetic
macular oedema - vitrectomy
Migraine -
acupuncture
Migraine =
- dexamethasone
Tinnitus -
cognitive behavioural therapy<=
span
style=3D'font-size:8.5pt;font-family:Arial;color:#0179C1'>
Accredita=
tion
update
Guest
editorial: chronic kidney disease
Your ques=
tions
answered
|
|
|
|
|
|
|
|
|
|
|
|
|
Surgery update
NHS
Evidence - surgery, anaesthesia, perioperative and critical care,
has published a mini topic review for evidenc=
e on
anticoagulants and antiplatelet agent=
s with
regional anaesthesia.
|
|
|
|
|
|
|
![3D"Forward](3D"EyesonEvidence_files/imag= "3D\"http://system.newzapp.co.uk/GLink.asp?LID=3DMjU1MzMyNCwxMT=")
|
|
|
|
|
|
Raising standards
More
than 40 applications have been received in response to our
request for external advisers for the NHS Evidence accreditation =
programme.
We
will contact applicants shortly with more information about the r=
ole,
an application form and conflict of interest declaration to compl=
ete.
As
a reminder, we are looking for external advisers with expertise a=
nd
experience in guidance development or implementation to provide an
independent and reliable assessment of the NHS Evidence accredita=
tion
process.
For
details on how to get involved email: a=
dviserapply@evidence.nhs.uk
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Structured feedback
The
future development of NHS Evidence depends on your feedback. To h=
elp
with this we are creating advisory panels for sources of content,=
to
provide structured comment on how the search is working in every =
day
practice.
We
are looking for health and social care professionals who are
interested in evidence based practice and who use the internet to
access information for work.
Membership
is voluntary and feedback will be coordinated online.
For details email c=
ontactus@evidence.nhs.uk
|
|
|
|
|
|
|
|
|
|
|
|
|
Quick stats
Top ten searches on
NHS Evidence in August:<=
span
style=3D'font-size:8.5pt;font-family:Arial;color:#0179C1'>
1.
Diabetes
2.
Asthma
3.
Hypertension
4.
Depression
5.
Osteoporosis
6. Swine flu=
7. Obesity <=
/span>
8.
Stroke
9.
Epilepsy
10. COPD=
|
|
|
|
|
|
|
|
|
|
|
|
|
Find out more
NHS
Evidence will be at the following events:
9 September 2009=
The British Pharmaceutical Confere=
nce
& Exhibition - Manchester
9 September 2009
World Class Commissioning Analytic=
al
Fair - Leeds
17 - 18 September
35th UKMI Conference - Edinburgh
19 - 23 September
Liberal Democrats Party Conference=
- Bournemouth
22-23 Sep 2009
Nursing in Practice Event – =
London<=
/span>
27 September - 1 October=
Labour Party Conference - Brighton<=
/st1:place>
30 September - 1 October=
Primary Care Live – London<=
/span>
5 - 8 October
Conservative Party Conference R=
11; Manchester
20 - 21 October 2009<=
span
style=3D'font-size:10.0pt;font-family:Arial;color:blue'>
NHS Alliance 2009 - Manchester
|
|
|
|
|
|
|
|
|
![3D"NHS](3D"EyesonEvidence_files/image001.gif")
![](3D"EyesonEvidence_files/image015.gif")