The video version of this podcast can be found here: ·      https://youtu.be/hN5JRXItBJ4This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in October 2024 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.  I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.   Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through  There is a podcast version of this and other videos that you can access here: Primary Care guidelines podcast:  ·      Redcircle: https://redcircle.com/shows/primary-care-guidelines·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148 There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The Full NICE News bulletin for October 2024 can be found here:·      https://www.nice.org.uk/guidance/published?from=2024-10-01&to=2024-10-31&ndt=Guidance&ndt=Quality+standardThe links to the guidance covered in this episode can be found here: Digital technologies for assessing attention deficit hyperactivity disorder (ADHD):·      https://www.nice.org.uk/guidance/dg60Acute kidney injury: prevention, detection and management:·      https://www.nice.org.uk/guidance/ng148The 1-page visual summary on assessing the risk of acute kidney injury in adults having iodine-based contrast media: outpatient, non-urgent inpatient and community settings:·      https://www.nice.org.uk/guidance/ng148/resources/visual-summary-pdf-13551376429TranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in October 2024, focusing on what is relevant in Primary Care only.  Although most of the updates do not really relate to Primary Care, there were two areas that I found particularly interesting and relevant to us, ADHD and acute kidney injury.Right, let’s get started. We will start with digital technologies for assessing ADHD.  Let’s remember that attention deficit hyperactivity disorder (or ADHD) is a neurodevelopmental condition characterised by a persistent pattern of hyperactivity, impulsivity, and inattention that interferes with daily and occupational functioning.As a result, people with ADHD may make important decisions hastily without considering the long-term consequences.Treatment may be non-pharmacological, including psychoeducation, ADHD coaching, or environmental changes. Pharmacological treatment may include stimulant or non-stimulant medication. There is a perception that recently there has been a huge increase in the demand for ADHD services because of an increased awareness of this condition. The global prevalence of ADHD in children is estimated to be around 5% and, in the UK, the prevalence of ADHD in adults is estimated to be between 3% and 4%, being more commonly diagnosed in males than females.Following the current care pathway, people with suspected ADHD are referred to secondary care for assessment, which is based on clinical judgement, relying on information obtained from a range of sources. However, information from these sources may often be incomplete or contradictory, and the diagnosis may be further complicated due to an overlap with other disorders and mental health conditions, which usually causes an extended delay in reaching a diagnostic decision. This is why, many digital technologies have been developed to assist in the diagnosis, which could reduce patient waiting lists and free up NHS resources. And it is precisely these digital technologies that have been assessed by NICE.And one of these technologies is called the QbTest.What is the QbTest?Well, the QbTest has certain elements comparable to a computer game which measures the core symptoms of ADHD, that is, attention, impulsivity, and hyperactivity. Results from the test are compared with people without ADHD and the results are available within minutes. Trial evidence suggests that QbTest could reduce the time that it takes to make the diagnosis.So, NICE has concluded that using QbTest alongside a standard clinical assessment was a cost-effective use of NHS resources for assessing ADHD in children and young people. However, because of lack of evidence, it is not recommended for the diagnosis in adults, or to evaluate response to treatment for those already with an ADHD diagnosis. For them, further research has been recommended.  Right, let’s move to our next area, acute kidney injury.  The actual update in the acute kidney injury guideline refers to the recommendations for people having iodine-based contrast scans. I will go through this section today, but given that acute kidney injury is such an important issue, I will dedicate the next episode to it, so stay tuned.We need to be aware that there is a small but increased risk of acute kidney injury associated with an eGFR less than 30 when having iodine-based contrast media. Iodine contrast media is commonly used in a variety of investigations such as, for example, CT scans, angiography, and intravenous urography.So, how do we assess the risk of AKI in these patients?Well, before requesting a non-urgent iodine-based contrast media CT scan, we should assess whether the person has pre-existing kidney disease. If available, we will use an eGFR measurement from the past 6 months. However, if the person has been acutely unwell or clinically unstable since their last eGFR test, we should request a more recent eGFR. If no eGFR is available from the past 6 months, we will ask the following screening questions:do they have kidney disease or a kidney transplant?have they seen or are waiting to see a nephrologist or a urologist?do they have symptoms of acute illness likely to cause acute kidney injury such as diarrhoea, vomiting, fever, hypovolaemia, infection or difficulty passing urine? If the answer to any of the screening questions is yes, then we should request an eGFR. However, if the screening questions do not indicate a problem and the person is clinically stable, NICE says that we could consider proceeding without the need for further blood tests before the scan. However, in practice, and as a safety measure, it is likely that we will request the eGFR anyway, just in case. In order to prevent and reduce the risk of AKI, we will encourage oral hydration before and after procedures using this type of contrast, especially if they are at increased risk of contrast-associated acute kidney injury. In addition, we will consider temporarily stopping ACE inhibitors and ARBs in people having iodine-based contrast media if they have CKD with an eGFR less than 30. NICE has produced a 1-page visual summary on assessing the risk of acute kidney injury in adults having non-urgent iodine-based contrast media. I have put a link to it in the episode description but let’s quickly have a look at it.Firstly, a reminder that this is for non-urgent cases, where a delay in the investigation is unlikely to be clinically significant. Then, we will assess whether the patient has pre-existing kidney disease, and discuss the pros and cons, being aware that there is a small risk of AKI when eGFR is less than 30.Then we will check if we have an eGFR value within 6 monthsAnd if so, We will use this value for our decisionBut bearing in mind that if the person has been unwell or unstable, we should consider repeating the test.However, if we don’t have an eGFR value within 6 monthsWe will ask our screening questions about kidney disease, renal transplant, referral to urology or nephrology and any symptoms of acute illnessAnd if there are any risk factors for AKIWe will consider checking eGFR before proceeding.But if there are no risk factors for AKIWe will be able to proceed without needing to request further blood tests, although in practice we will probably request a new eGFR anyway. So that is it, a review of the NICE updates relevant to primary care.We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for listening and goodbye.

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