Issue 33.
NICE and beta interferon
NICE put out a press release on
21 June about the use of beta interferon for multiple sclerosis. This helps to
show readers the way that NICE works. The press statement said ‘The Institute
is extremely disappointed that the confidentiality of its appraisal
documentation has not been respected. It is clear … that one of the
organisations which were sent the provisional determination of the Appraisal
Committee has allowed information to leak to the media.
The institute's Chairman,
Professor Sir Michael Rawlins said:
"In order to avoid any
further uncertainty in the minds of patients and those who care for them, I have
no option other than to confirm that the provisional opinion of the Institute's
Appraisal Committee's is that other than for those patients who are already
receiving these medicines, they should not be made available in the NHS at the
present time. This is because, on the basis of a very careful consideration of
the evidence, their modest clinical benefit appears to be outweighed by their
very high cost."
The Appraisal Process allows for
consultation with patient and professional groups and with the manufacturers,
and for an appeal, before any guidance is issued. The appraisal of beta
interferon and glatiramer is at the consultation stage, which ends on 17 July.
Professor Rawlins continued:
"The Appraisal Committee
will listen carefully to the comments it receives from those it has consulted
before reaching a final conclusion, at the end of July. Until then, the
Institute will make no further comment.
It can be seen that NICE works in
two ways, collecting the scientific evidence, then approaching people involved
in care to get their views. It is not clear whether those views would alter the
NICE verdict.
Ref
(web)
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Cost-effectiveness of
counselling
Cross-sectional surveys have suggested no association between
the presence of a practice counsellor and psychotropic drug prescribing costs.
Another such survey found that general practices with counsellors made more
referrals to secondary mental health services. These data are very difficult to
interpret, not least because practices that employ counsellors may be more “psychologically
minded” and so more likely to identify and treat patients with anxiety or
depression.
Two randomised controlled trials found no clear differences
in the cost-effectiveness of counselling and usual GP care. Data from one
randomised controlled trial suggests that anti-depressant prescribing rates may
fall, at least briefly, with the use of counselling, a finding not supported by
two other studies. Two trials suggested that, with counselling, mental health
referrals were reduced, and one that GP consultation time was reduced.
A systematic review has collated 22 controlled trials that
have investigated the effect of a variety of on-site mental health professionals
(such as counsellors in primary care) on GP consultation rates, prescribing a
psychotropic
drugs and referrals to secondary care mental health services.
It indicates that the presence of such professionals has no consistent effect on
consultation rates. The review also suggests that patients referred to one of
these professionals are less likely to be given a prescription for psychotropic
drugs or to be referred to secondary care. However, these effects were not
quantified in the review
There is limited evidence suggesting that, in the short term,
brief counselling (generally fewer than 8 sessions) delivered by practice
counsellors results in better psychological symptom levels than does usual GP
care in the management of a wide range of mental health problems seen in primary
care. However, the clinical significance of these findings is uncertain. There
is also limited evidence to suggest counselling may result in greater patient
satisfaction, fewer mental health referrals and reduced prescribing of
antidepressant drugs. However, more data are needed to confirm these findings
and to establish the cost-effectiveness of counselling.
Ref:web
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The Health Hazards of Mobile Phones
Despite repeated horror stories about mobile phones in the
media, nearly half of the British public now owns one. Some 500 million people
worldwide use mobile phones. Clearly, they have decided that the benefits
outweigh any risks to their health. The publication of the Report of the
Independent Expert Group on Mobile Phones, a group organised by the
Department of Health is therefore welcome.
Mobile phones are low power radio devices that transmit and
receive radio frequency radiation through an antenna used close to the user’s
head. Symptoms said to be associated with their use include sleep disturbance,
memory problems, headaches, nausea, and dizziness. Changes in the permeability
of the blood-brain barrier, electroencephalographic activity, and blood pressure
have also been reported. The validity of these findings is uncertain, as are the
mechanisms for such actions.
UK guidelines are set by the National Radiological Protection
Board and are based on the assumption that the only risk from microwave
radiation arises from thermal effects – that is, from the heating of tissue
that it can induce. Today’s mobile phones, with a total power output of about
1 W, are estimated to produce insignificant local heating (equivalent to about a
0.1°C rise in temperature in the brain), which is unlikely to produce any
deleterious effects.
Recent research suggests, however, that there are “non-thermal”
effects on living tissue, ranging from immediate early gene expression and
micronucleus formation to changes in the excitability of nerve cells,
permeability of the blood-brain barrier, and the ability of rats to learn mazes.
Limits on exposure for workers have been suggested by the
International Commission on Non-Ionizing Radiation The recommendation of the
independent group that these guidelines for public exposure should be adopted is
prudent. So too are the report’s recommendations to minimise power output and
label phones with power ratings.
This is a controversial field of science. In vitro
experiments on cell proliferation, membrane properties, and ion channels are
difficult to extrapolate to humans. Moreover, it is also difficult to
extrapolate effects on brain function and behaviour from rodents to humans
because the entire brain of a rat or mouse is exposed but for a person using a
mobile phone only the small region of the head that is close to the phone would
be exposed.
The greatest mystery about non-thermal effects is their lack
of a theoretical basis. Biological systems might interact resonantly with
microwave fields but there is as yet no robust evidence.
Ref
(web)
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