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Summary of guidance relevant to general practice in August 2012

Lower limb peripheral arterial disease

GPs should make an early diagnosis of peripheral arterial disease (PAD) by performing an ankle brachial pressure index measurement, as NICE sets out new guidelines on the diagnosis and management of lower limb PAD.

Peripheral arterial disease is a common condition, affecting 3- 7 per cent of people in the general population and 20 per cent of people over the age of 60, in which the arteries carrying blood to the legs and feet become narrowed or blocked.

Despite the relatively high incidence of PAD, recognition and treatment of the disease varies across England.

The latest recommendations aim to resolve the considerable uncertainty and variations in practice and improve outcomes for patients.

NICE recommends assessing people with suspected PAD by asking about the presence and severity of possible symptoms of intermittent claudication and critical limb ischaemia, examining the legs and feet for evidence of critical limb ischaemia, for example ulceration, examining the femoral, popliteal and foot pulses, and measuring the ankle brachial pressure index.

All patients with PAD should be given information, advice, support and treatment regarding the secondary prevention of cardiovascular disease, in line with published NICE guidance.

Other recommendations include offering supervised exercise programme to all patients with intermittent claudication, and ensuring that all people with critical limb ischaemia are assessed by a vascular multi-disciplinary team before treatment decisions are made.

Support tools to help you put this guidance into practice

A suite of support tools are available for this guidance including a costing reportand template, clinical audit tools, and a baseline assessment tool.

There are also shared learning examples available on a redesigned, GP-commissioned service model for the earlydetection, referral and management of peripheral arterial disease, and a supervised exercise programme for patients with intermittent claudication.

Osteoporosis - risk assessment

GPs should use either the FRAX or QFracture tools to estimate fracture risk in at-risk patients, NICE says.

More than 300,000 people in the UK have fragility fractures each year. They occur most commonly in the spinal vertebrae, hip and wrist.

Fractures can lead to reduced life expectancy, with one in ten people with a hip fracture dying within 1 month, though most deaths are due to associated conditions and not the fracture itself.

While there are a number of therapies and treatments currently available for the prevention of fragility fractures for those at risk, identification can be imprecise.

This latest guidance recommends taking an assessment of fracture risk in all women aged 65 years and over and all men aged 75 years and over, and in women aged under 65 years and men aged under 75 years in the presence of risk factors.

These risk factors include; previous fragility fracture, current use or frequent recent use of oral or systemic glucocorticoids, a history of falls, family history of hip fracture and low BMI.

GPs should use either FRAX (without a bone mineral density BMD measurement) or QFracture, within their allowed age ranges, to estimate 10-year predicted absolute fracture risk when assessing risk of fracture.

NICE says to interpret the estimated absolute risk of fracture in people aged over 80 years with caution, because predicted 10-year fracture risk may underestimate their short-term fracture risk.

GPs are advised not to routinely measure BMD to assess fracture risk without prior assessment using FRAX (without a BMD value) or QFracture.

NICE also recommends measuring BMD to assess fracture risk in people aged under 40 years who have a major risk factor, such as history of multiple fragility fractures, major osteoporotic fracture, or current or recent use of high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer).

Support tools to help you put this guidance into practice

A suite of support tools have been published to help implement this guideline, which includes an electronic audit tool, a costing template and a baseline assessment tool.

Antibiotics for neonatal infection

The NHS should prioritise the treatment of babies with suspected early-onset neonatal infection and use antibiotics sensibly to avoid developing resistance to the drugs, according to latest NICE guidance.

Early-onset neonatal bacterial infection, infection that occurs within 72 hours of birth, is the cause of death for 1 in 4 babies who develop it, even when they are given antibiotics.

These infections are usually caused by organisms from the mother's genital tract, including group B Streptococcus (GBS), E.coli, Pseudomonas and Klebsiella.

Such infections may develop suddenly and rapidly, with mortality particularly high in premature babies and those with a low birth weight. They may also lead to the development of cortical lesions in the brain, and so subsequently cause neuro-developmental delay.

Currently, there are unnecessary delays in recognising and treating sick babies and wide variation in how the risk of early-onset neonatal infection is managed in healthy babies.

The latest advice from NICE aims to address this by setting out a framework based on risk factors and clinical indicators should be used to identify and treat babies with an increased likelihood of having an early-onset neonatal infection.

NICE recommends that intrapartum antibiotic prophylaxis should be offered in a timely manner to women whose babies are at higher risk of infection. This includes women who have had a previous baby with an invasive group B streptococcal infection, or a group B streptococcal colonisation, bacteriuria or infection in the current pregnancy.

Babies with suspected early-onset neonatal infection should receive antibiotics as quickly as possible, within 1 hour of the decision to treat.

Benzylpenicillin and gentamicin should be used in combination as the first-choice antibiotic regimen for treating suspected early onset neonatal infection.

Antibiotic use should be minimised in babies who are suspected of having an early-onset neonatal infection, but subsequently do not.

Support tools to help you put this guidance into practice

NICE has produced a podcast, a parent information leaflets, and a shared learning example: Supporting a 36 hour Neonatal Blood Culture status check by developing the availability of blood culture status in real time.

22 August 2012

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Selected, reliable information for health and social care in one place

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.