PSA screening: Information to give men

Information to give asymptomatic men who request a ‘screening’ PSA test

Based on  BMJ2014;348:g2559 and   BMJ 2013;346;f325

·         GPs have received expert guidance, from the UK and the US, that they can ‘improve the health of their patients by advising them AGAINST having the PSA test’. This is because, based on research involving hundreds of thousands of people over many years, we now know that:

o   The test is unlikely to prevent you dying from prostate cancer over the next 10 or 15 years or help you to live longer

o   Elevated PSA levels are common and lead to additional tests which can be harmful

o   PSA testing finds cancers which may never cause problems. But once these cancers are found it is hard not to treat it. These treatments can result in significant side effects such as impotence and urinary incontinence

o   By choosing not to have a PSA test you can have a similar length of life and avoid the potential harms associated with tests, procedures and treatments

·         For every 1,000 men who are screened with a PSA test

• 1 death from prostate cancer will be prevented
• 100 will receive a false positive and will need prostate biopsy
• 100 will be diagnosed with prostate cancer and most likely receive potentially harmful treatment, which they may never have needed
• Biopsies and treatment are associated with significant harms

This UK view agrees with US Screening Recommendations 2012 which does NOT recommend screening for prostate cancer at any age as the benefits of screening for prostate cancer by measuring PSA does not outweigh harms.

If despite this advice, you still want to have a PSA test then it is recommended that the test is restricted to men aged from 55 to 69. If your PSA test is found to be low (2 or less) no further PSA testing is recommended, as your lifetime risk of developing significant prostate cancer is very low and continued testing is more likely to cause you harm. If your PSA is found to be greater than 2, you may benefit from continued screening.

GP Tips: IBS and FODMAPS

GP Tips: FODMAPS and IBS

 By Simon Curtis and Yvonne McKenzie, Specialist Dietitian and co-author of the British Dietetic Association guidelines on IBS 

‘Doctor, I just feel so bloated!’

 Once we have excluded bowel pathology, coeliac disease and ovarian cancer we are left with the patient who still has the misery of abdominal bloating (‘I feel like I’m pregnant doctor’) and the other symptoms of IBS. It is so common, so hard to help and the response to drugs is often so disappointing. The good news is that whilst dietary change can be hard, and requires commitment, there is increasing evidence that it can have a dramatic benefit….

 We covered IBS on our blog over a year ago GP Tips on IBS but since then new evidence-based guidelines by the British Dietetic Association have been published, and in particular there is great interest in the role of fermentable carbohydrates or FODMAPS.

 What were the key points of the BDA guideline?

 BDA evidence-based guidelines for IBS 2012

 Key recommendations (ideally dietitian led) based on the evidence are:

·        First line dietary management

 

o   Check for food intolerance, especially lactose (and consider low lactose trial)

o   Provide general healthy eating advice, including on fluid, caffeine, alcohol and modifying dietary fibre intake

·        Second line, if symptoms continue despite the above

o   For IBS-C (constipation dominant) consider daily supplementation with linseeds

o   Try a 4 week trial of probiotics

o   For all IBS types, advise reducing fermentable carbohydrates (FODMAPs), guided by an appropriately trained dietitian

 So, what are FODMAPS?  FODMAPS review paper 2013

 FODMAP stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols. These are short-chain fermentable carbohydrates. They trigger symptoms in susceptible individuals such as bloating, pain, flatus and erratic bowel function due to poor small bowel absorption, high osmotic activity and rapid colonic bacterial fermentation producing gases. The low FODMAP diet was developed at Monash University in Melbourne.

 Four clinical trials have been published and up to 86% of patients have achieved relief of symptoms (when the advice was given by appropriately trained dietitians) compared to  traditional IBS advice, with benefits seen after only 4 weeks. The paper concludes that ‘the evidence is now sufficient to confirm the efficacy of this approach for IBS’.

 For a podcast discussing FODMAPS and this research click here

 So, what should we advise patients?

 Once we have excluded other pathology, as a first-line treatment refer patients with mild symptoms to the BDA Food Fact Sheet on IBS

 As a second-line approach, refer moderately to severely affected patients to specialist dietitians who are trained on the low FODMAP approach. Patients are best not to self-manage their condition because this can lead to nutritional inadequacy (e.g. calcium), and they need guidance on systematically re-introducing FODMAPS, to help verify causality and support long-term symptom control and food variety. However, if specialist help is not available the FODMAPS review paper 2013 has a useful table of high FODMAP foods and suitable alternatives, and the team at Monash have also developed an iphone and ipad app low FODMAP app, and recipe books (from Australia and the US) are available. For example, with fruit apples and pears are high in FODMAPS, whilst bananas, grapes and strawberries are suitable alternatives.

 A community dietetic led IBS clinic would be a great thing for your CCG or organisation to commission. GPs are able to safely exclude significant pathology in the vast majority of patients, thereafter dietitian led management (which can be in groups and not necessarily 1 to 1) has the potential not only to be highly effective but also to reduce specialist REFERRAL costs and save patients from further unnecessary investigation. Such a clinic has already been set up in Somerset and is reporting excellent results.

 

Simon Curtis and Yvonne McKenzie, Oxford July 2013

 

 

 

 

 

Learning Disability

A new report, the CIPOLD report (Confidential Inquiry into premature deaths of people with LD) has recently published, and been discussed in a BMJ editorial

 The results are truly shocking:

·         People with LD in the UK die 16 years younger than the general population. Women with LD die 20 years earlier than would be expected, and men 13 years prematurely

·         There are biological and genetic reasons for some of this excess mortality, but 42% of these deaths are estimated to be premature and avoidable. They are attributable to delays in diagnosis and treatment, and failure to provide  adequate care.

·         Over a thousand adults and children with LD are dying each year in the UK through failure to provide adequate care.

 Depressingly, as the BMJ editorial points out, the results are ‘alarming but not surprising’ and seem to agree with multiple previous reports, inquiries and research studies over the years. The report argues for changes at a national level (e.g. establishing a LD mortality review body, better cohesion with health and social care, commissioning priorities etc) but in the meantime what should be doing now in primary care?

 

·         Make sure that we have an up to date register of all adults with a LD

o   And refer adults you suspect may have a LD but have not been assessed

·         We need to provide a system of organised and systematic detailed health checks for people with LD. The evidence for this approach is very strong, and yet only 53% of adults in England with a LD receive an annual check  click here

o   To help us introduce and deliver this, there is an excellent RCGP guide to health checks in people with LD which is freely available

o   The health checks should focus on the general (sensory impairment, constipation, dental, sexual health, cardiometabolic risk etc) and also the specific (e.g. in Down’s syndrome checking TSH and coeliac serology, and over 40 for dementia and Atlanto-axial instability and cervical myelopathy)

·         We need to be very aware of the concept of ‘diagnostic overshadowing’. This means mistakenly attributing symptoms of ill-health as being due to a behavioural problem, or an inherent part of their LD, rather than a sign that something is wrong. This leads to under investigation as symptoms are rationalised and interpreted as being part of the LD, and means that common and helpable problems are missed e.g. a change in behaviour may be caused by hearing loss due to ear wax, faecal soiling by overflow from constipation, cries and ‘hand-mouthing’ by gastro-oesophogeal reflux etc

 What about the extra time needed to perform these health checks?

In the UK there is a DES (direct enhanced service), which is specifically to encourage practices to identify patients with LD and offer them an annual check. Importantly, your patients on the register have to match those on your local authority register so you need to liaise with your local LD team. The practice will be paid c. £100 per health check. For more information on the DES click here

The CIPOLD report is truly shocking. We all have a responsibility to try to improve outcomes for adults with LD, but with our generalist and holistic skills no one is better placed than the GP to make a difference.

NB: Top Tips on helping people with LD by Matt Hoghton, RCGP Lead for LD ·         In order to deliver dignified, respectful and compassionate care you need to make extra time ·         Communicate with the person with the LD first, rather than their helper, and involve them as much as possible ·         Use language that they understand at a simple level, enhanced by pictures or symbols if necessary and demonstrate any examination or procedure before you perform it

 

Resources:

 Mencap have an excellent web-site full of useful health information for people with LD www.easyhealth.org.uk

RCGP guide to health checks in people with LD

CIPOLD report

DES guidance 2013/2014

 

 

 

Joint Hypermobility Syndrome

I mentioned on our recent Spring courses how I never used to know about hypermobility syndrome, despite many years as a GP, until we covered it on Hot Topics a couple of years ago and now I diagnose it regularly. We’ve had lots of emails from people wanting to know what we covered, so here it is with associated links. You will definitely pick up cases and, as ever, just knowing what the matter is with you is incredibly helpful – your patients will be very grateful! Let us know your experiences.

 Simon

JOINT HYPERMOBILITY SYNDROME

 Awareness amongst patients is rising around joint hypermobility syndrome (JHS) and it was very usefully reviewed in two papers in the BMJ.

 What is JHS?

 Not a boy band, but a heritable disorder of connective tissue leading to symptomatic joint hypermobility which predisposes to arthralgia, joint instability and soft tissue injury. The symptomatic word is crucial – many people have simple hypermobile joints that cause no problems. They make great dancers and gymnasts!

 It can be a multi-system disorder and non-articular complications include:

• Autonomic dysfunction (e.g. postural hypotension, urinary problems)
• Intestinal dysmotility (IBS is common)
• Laxity in other tissues causing skin problems, hernias or prolapses
• Obstetric complications, including premature rupture of membranes, precipitate delivery and perineal injury

Symptoms are often mild or minimal, but up to a quarter may develop a chronic pain syndrome. It is hereditary, and JHS is indistinguishable from the hypermobility type of Ehlers Danlos syndrome.

 Awareness of the condition is low, as hypermobility is often erroneously considered a variant of normality rather than an inherited connective tissue disorder. The diagnosis is commonly missed as patients tend to present with common, non-inflammatory musculoskeletal pains.

How common is JHS?

Joint hypermobility is very common, occurring in 10-20% of Western populations and higher in Indian, Chinese and Middle Eastern groups. However many of these are hypermobile without symptoms, JHS is diagnosed if the patient is hypermobile and symptomatic.

 

How is it diagnosed?

 Joint hypermobility is defined by the Beighton score.

1.	Can you put your hands flat on the floor with your knees straight?		1
		LEFT	RIGHT
2.	Can you bend your elbow backwards?	1	1
3.	Can you bend your knee backwards?	1	1
4.	Can you bend your thumb back on to the front of your forearm?	1	1
5.	Can you bend your little finger up at right angles to the back of your hand?	1	1
	TOTAL SCORE (maximum = 9, ≥ 4 is suggestive)

 

However, JHS is a symptomatic syndrome. It is an entirely clinical diagnosis, and can be diagnosed on the basis of the Brighton criteria.

Brighton Criteria for JHS JHS diagnosed if: ·         2 major criteria, OR ·         1 major and 2 minor, OR ·         4 minor criteria   Major criteria: ·         Beighton score of ≥ 4 ·         Arthralgia for > 3 months in ≥ 4 joints   Minor criteria ·         Beighton score of 1-3 ·         Arthralgia in 1-3 joints, or back pain, or spondylosis or spondylolisthesis ·         Joint dislocation, more than once ·         ≥ 3 soft tissue lesions e.g. epicondylitis, bursitis, tenosynovitis ·         Marfanoid habitus: Tall, slim, arachnodactyly ·         Skin: striae, hyper-extensibility, thin ·         Eyes: drooping eyelids, myopia ·         Varicose veins, hernias, uterine or rectal prolapse

But, to make the diagnosis we need to ‘think outside the box’.

 Common clues suggesting the diagnosis of JHS include:

• Late walking, poor ball-catching and hand-writing skills
• Recurrent ankle sprains and joint dislocations
• Non inflammatory joint and spinal pain. Chronic pain, unresponsive to analgesics
• Laxity in other tissues e.g. easy bruising, hernias, varicose veins, prolapse
• Functional gastrointestinal disorder e.g. ‘sluggish bowel’ with bloating
• Autonomic dysfunction e.g. orthostatic hypotension, postural tachycardia syndrome

 Management: ‘The key players are the GP and a suitably trained physiotherapist’.  We are expert at the holistic management of chronic, multisystem conditions such as JHS but diagnosis and understanding is key.

 

Physiotherapy is adapted, and includes more work on core strengthening, joint proprioception and fitness training.  Patients may also benefit from classes which help core stability and balance, such as Pilates and Tai Chi

NB Practice points: ·      Quickly look for hypermobility in patients chronic joint and MSK pain, and assess the Beighton score ·       Non-articular complications include autonomic dysfunction such as ‘IBS’ due to gut dysmotitility, and  laxity leading to hernias, prolapse etc. ·       Obstetric complications such as PROM, precipitate delivery and perineal injury – refer antenatally ·         Over-vigorous physiotherapy will make it worse; core strengthening is key

   

 

References and resources:

 BMJ2010;341:c3044 click here

 BMJ2011;342:c7167 click here

 NHS information click here

 Beighton score with images click here