Clinical Effectiveness Bulletin

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					            Clinical Effectiveness Bulletin
                                                 June 2001

            Updating Health Professionals on Developments in Clinical Practice

                                   The summer months          ited and distances           Clinical Effectiveness
  Inside this issue:              are prone to specific       travelled. In the year       Bulletin focuses on
                                  diseases and to con-        ending April 2001 UK         some issues associ-
Hay fever                    1    ditions    associated       residents made over          ated with summer and
Treating hay fever in        2    with increased travel.      58 million visits over-      travel. We have also
                                    The number of trips       seas, 12.3 million of        taken this opportunity
“Economy class syndrome”     2    abroad by UK resi-          which were to destina-       to provide an update
                                  dents is increasing, as     tions outside Western        on the latest NICE
Combined hepatitis A and B   2
vaccines                          is the number of dif-       Europe.                      guidance.
Malaria prevention in        3    ferent countries vis-         This   issue   of   the
Nice referral practice       3    Hay fever
Nice guidance summaries      4
                                 • Avoiding    excessive       Ocular symptoms can         terfenadine         and
                                   exposure to pollen,         be treated with an          astemizole have been
                                   especially    during        ocular antihistamine        associated with po-
                                   peak times, will often      or an ocular cromo-         tentially fatal cardiac
                                   provide some relief of      glycate.                    arrhythmias at high
           Allergy to grass                                                                plasma concentra-
        pollen is the most
                                   symptoms to hay fe-       • Ideally, treatment with
                                   ver sufferers. These                                    tions. This situation is
                                                               a nasal steroid should
    common cause of hay            preventative meas-                                      avoidable in most pa-
                                                               begin at least a week
          fever in the UK.         ures should comple-                                     tients provided suit-
                                                               before the hay fever
                                   ment drug therapy.                                      able precautions are
        Allergy to tree and                                    season starts. For a
                                                                                           taken. Terfenadine is
     weed pollens, as well       • Choice of drug treat-       first-time sufferer, a
                                                                                           now only available on
                                   ment depends mainly         rapid onset oral anti-
     as mould spoes, also                                                                  prescription.
                                   upon predominant            histamine should be
                    occurs.        symptoms and pa-            used initially, in con-    • Many hay fever prod-
                                   tients’ preference for      junction with a nasal       ucts are available to
        Treatment that has
                                   topical or oral ther-       steroid.                    buy ‘over the counter’
     worked previously to                                                                  from      pharmacies.
          control hay fever
                                   apy. The mainstays of     • There is no difference
                                   treatment are intrana-                                  GPs should ensure
                                                               in efficacy between
      symptoms should be           sal corticosteroids                                     they are aware of
                                                               the individual nasal
    documented and used            and oral antihista-                                     which products pa-
                                                               steroids.    Choice
                                   mines.                                                  tients have tried be-
   as a basis fo treatment                                     should be based
                                                                                           fore a prescribing de-
                                                               upon patient prefer-
     for the “new season”        • Nasal corticosteroids                                   cision is made.
                                                               ence and cost.
           and modified if         are highly effective in
                 necessary.        treating hay fever.       • Although oral antihis-      Anon.
                                   Oral antihistamines         tamines do not differ       Treatment of seasonal al-
                                                                                           lergic rhinitis (hay fever).
                                   relieve rhinorrhoea         in efficacy, individual     MeReC Bulletin 1998; 9:
                                   and sneezing but not        patient response may        9-12.
                                   nasal    congestion.        vary. In addition,
Page 2                                                                                 Clinical Effectiveness Bulletin

    The safety of any        Treating hay fever in pregnancy
          individual           The best first line ap-     • Mast cell stabilisers       no safer alternatives
                             proach is avoidance of          (eg sodium chromo-          are available.
       medication in         allergens. If this is inef-     glycate) can be con-      • Allergen immunother-
    pregnancy can be         fective drug treatment          sidered as excellent         apy has a risk of ma-
   discussed with the        depends on symptom              first line therapy, es-      ternal anaphylactic
           National          severity and the bene-          pecially in place of         reactions and should
                             fits and risks of treat-        intranasal corticoster-
         Teratology                                                                       be used with caution.
                             ment to the mother and          oids.
        Information          foetus.                                                     Any recommendations
          Service on                                       • Phenothiazines   (eg      on treatment should be
                             • Intranasal corticoster-       promethazine) may         accompanied by in-
      0191 232 1525                                                                    formed consent.
                               oids are considered           be used without con-
                               superior to antihista-        cerns regarding its         NHS Centre for Reviews
                               mines and should be           teratogenicity.             and Dissemination.
                               considered first line                                     Treating allergic rhinitis in
                               therapy. Use of the         • Decongestants     may       pregnancy: safety consid-
                               lowest effective dose         be used for short term      University of York: DARE
                               is recommended.               symptom relief when         2000.

                The true      “Economy class syndrome”
    frequency of DVT           There has recently          • Drink plenty of water.      heparin.
       during long haul      been increased publicity
   flights is unknown.       on the risk of venous         • Perform leg stretching      Similar advice should
                                                             exercises.                be provided for those
      One study found        thromboembolism after                                     undertaking      long-
                             long haul aeroplane             For patients with risk    distance bus or train
      that 10% of over
                             flights. Although there       factors for thrombosis,     travel.
          50s developed      is currently little evi-      additional measures
   symptomless DVT           dence on which to base        may be considered, in-        Geroulakos G.
         in the calf after   recommendations the           cluding:                      The risk of venous throm-
        journeys lasting     following preventative        • Graded compression
                                                                                         boembolism from air
                             measures have been                                          travel. The evidence is
           over 8 hours.                                     stockings.                  only circumstantial.
                             suggested:                                                  BMJ 2001; 322: 188.
                                                           • Aspirin.
                             • Stand up occasion-
                               ally.                       • Low molecular weight

      It is important to      Combined hepatitis A and B vaccines
          identify those       Travellers to areas           planning to stay in en-     Short-stay or business
      patients at risk of    where hepatitis A and B         demic areas for over      travellers are usually at
                             are endemic may be at           3 months.                 low risk. However, they
             exposure to
                             risk of infection of hepa-                                may increase their risk
           hepatitis B to    titis A from drinking wa-     • Patients who require      by:
                prevent      ter and hepatitis B from        regular blood transfu-
                                                             sions or blood prod-      • Their sexual behav-
            unnecessary      medical or dental proce-
                                                             ucts who travel to or       iour.
       treatment. For        dures.      A combined
                             vaccine should be of-           plan to reside in an      • Lack of personal hy-
        many travelers       fered to:                       endemic area. Such          giene.
     simple hepatitis A                                      patients should have
                             • Adults and children           their antibody levels
          vaccination is       travelling frequently to
                                                             checked as they may         Combined hepatitis A and
               adequate.       endemic areas.                already have ac-            B vaccines.
                             • Adults and children           quired immunity.            DTB 1997; 35: 84-6.
Clinical Effectiveness Bulletin                                                                              Page 3

   Malaria prevention in travellers
    Non-drug preventive            • Insecticide     treated     • Observational studies           It is important to
  interventions                      clothing, electric fans,      have      associated            confirm the latest
  • Nets treated with in-            mosquito coils, vapor-        DEET and doxycy-
                                                                                                   information on
    secticide reduce the             ising mats, smoke,            cline with severe ad-
                                     insect repellent soap,        verse effects in chil-          endemic areas for
    number of mild epi-
    sodes of malaria and             and topical DEET re-          dren.                           malaria prophylaxis.
    reduce child mortality.          duce the risk of being       Vaccines                         Advice is available
                                     bitten.                                                       from any of the
  • There is limited evi-                                        • There is insufficient
                                    Drug prophylaxis                                               following numbers:
    dence that wraps and                                           evidence on the ef-
    top sheets treated             • There is limited evi-         fects of antimalarial
                                                                                                   0121 766 6611
    with insecticide re-             dence that doxycy-            vaccines in travellers.
    duce the number of               cline and mefloquine                                          020 7636 3924
    episodes of malaria.             are effective.                Croft A.
                                                                   Malaria: prevention in trav-    020 8200 6868
  • Air conditioning and           • There is little good          ellers.
    wearing trousers and             evidence on the ad-           Clinical Evidence 2001; 4:      ext 3421
    long sleeved shirts              verse effects of anti-        390-402.
                                                                                                   0151 708 9393
    may reduce the inci-             malarial drugs, par-
    dence of malaria.                ticularly mefloquine.

 NICE referral practice
  NICE have published             • Atopic eczema in chil-      • Urinary tract (outflow)
a pilot version of a                dren.                         symptoms.                        The full guide to
guide to appropriate re-                                                                           appropriate referral
ferral from general to            • Glue ear in children.       • Varicose veins.
                                                                                                   from general to
specialist services. The          • Menorrhagia.
document gives a range                                            Referral Practice. A guide       specialist services
of options that should            • Osteoarthritis of the         appropriate referral from
                                                                                                   can be downloaded
                                                                  general to specialist ser-
have been tried prior to            hip.                          vices. Version under pilot.      from the NICE
referral, but they should         • Osteoarthritis of the         London: National Institute
                                                                                                   website :
not be considered a                                               for Clinical Excellence,
                                                                  2000.                                         g
                                                                                                   www.nice.or .uk
                                  • Psoriasis.
  The topics piloted are:
• Acne.                           • Recurrent episodes of
                                    acute sore throat in
• Acute low back pain.              children.

The Clinical Effectiveness Bulletin is produced by Walsall Health Authority Public Health Directorate.
The editorial team comprises: Nigel Barnes, Alison Teale, Nick Pugh, John Linnane, Shalini
Pooransingh, Bolanle Akinosi, Ian Mather, Sushma Manthri and Sam Ramaiah with external
consultancy from Wayne Harrison.
Comments and suggestions regarding this bulletin are welcome and should be addressed to:
   Dr Sam Ramaiah                      Tel:        01922 720255
   Director of Public Health           Fax:        01922 722051
   Walsall Health Authority            Email:
   Lichfield House                     Website:
   27-31 Lichfield Street
   Walsall WS1 1TE
                              Title                                  Summary

 December      Autologous cartilage transplanta-    ACT should only be performed as part of a
   2000        tion for defects in knee joints     properly structured clinical trial.

                                                    Laparoscopic surgery for colorectal cancer
 December      Laparoscopic surgery for
                                                   should only be carried out as part of a clini-
   2000        colorectal cancer
                                                   cal trial.

 December      Riluzole for motor neurone           Riluzole should be used to treat the
   2000        disease                             amyotrophic lateral sclerosis form of MND.

                                                     Donepezil, rivastigmine and galantamine
                                                   should be made available to patients with
January 2001   Drugs for Alzheimer's disease
                                                   mild to moderate Alzheimer's disease in de-
                                                   fined circumstances.
                                                     Laparoscopic surgery should be consid-
               Laparoscopic surgery for
January 2001                                       ered for the repair of hernias that reoccur or
               inguinal hernias
                                                   that are on both sides.
                                                     Orlistat should be available for adults who
                                                   have lost at least 2.5 kg by diet and in-
                                                   creased activity in the month prior to their
               Use of orlistat for obesity in      first prescription and have either:
 March 2001                                        • A BMI of 28 or more and a persistent se-
                                                       rious illness despite standard treatment.
                                                   • A BMI of 30 or more with no associated
                                                     Pioglitazine combination therapy may be
                                                   offered if patients are unable to take
               Use of pioglitazone for type 2      metformin and sulphonyl urea as a combi-
 March 2001
               diabetes                            nation therapy or their blood glucose re-
                                                   mains high despite adequate trial of this
                                                     Temozolamide may be considered as sec-
                                                   ond line chemotherapy for recurrent malig-
 April 2001    Temozolamide for brain cancer       nant glioma in defined circumstances.
                                                     It is only recommended as initial chemo-
                                                   therapy in clinical trials.
                                                    The use of debriding agent should be
                                                   based on impact on comfort, odour control,
 April 2001    Guidance on wound care
                                                   patient acceptability, type and location of
                                                   wound and total cost.

               Pressure ulcer risk assessment       Detailed guidelines can be found via the
 April 2001
               and prevention                      NICE website (

               Prophylaxis for patients who
                                                    Detailed guidelines can be found via the
 April 2001    have experienced a myocardial
                                                   NICE website (
                                                     Gemcitabine may be considered as first
               Gemcitabine for pancreatic          line chemotherapy to patients with ad-
  May 2001
               cancer                              vanced pancreatic cancer and a Karnosky
                                                   score of 50 or more.