Clinical Effectiveness Bulletin
NHS WALSALL HEALTH AUTHORITY
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-
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.
• 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
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-
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
not be considered a for Clinical Excellence,
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: RamaiahS@ha.walsall-ha.wmids.nhs.uk
Lichfield House Website: http://www.walsall.wmids.nhs.uk/ha/publications.htm
27-31 Lichfield Street
Walsall WS1 1TE
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
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-
Laparoscopic surgery should be consid-
Laparoscopic surgery for
January 2001 ered for the repair of hernias that reoccur or
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-
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
and prevention NICE website (www.nice.org.uk).
Prophylaxis for patients who
Detailed guidelines can be found via the
April 2001 have experienced a myocardial
NICE website (www.nice.org.uk).
Gemcitabine may be considered as first
Gemcitabine for pancreatic line chemotherapy to patients with ad-
cancer vanced pancreatic cancer and a Karnosky
score of 50 or more.