Interpreting QCancer scores

QCancer and referral

 

Early diagnosis of cancer is a real Hot Topic, and there has been a huge ammount of interest on our Autumn courses in using the QCancer tools to aid patient assessment. These tools should  obviously only be used to aid (and not supplant) clinical assessment by a patient’s GP, but the most frequently asked question has been: is there a recommended referral threshold for the Qcancer risk tool?

So, we asked Prof. Julia Hippisley-Cox herself and this is her reply:

‘In terms of the threshold, there is no absolute threshold currently – my view is that the tool quantifies risk in a way that helps the GP and patient make an assessment of probabilities. For some people, I risk of 2% will seem high and they will want full investigation. For others they will concentrate on the 98% risk that they don’t have cancer X. The assessment also needs to take account of the risks associated with investigation  - for lung cancer, then the risk of an adverse event to a CXR is pretty low but for other tests [eg endoscopic ultrasound scan of the pancreas] then the discomfort of the procedure and risk of perforation might be higher.

That said, we have looked at risk thresholds in each of the papers and there is a table of sensitivity, specificity etc at different thresholds. I tend to think a threshold of 2% overall is reasonable rule of thumb (NB this is the referral threshold recommended by the National Cancer Action Team when using the RAT tool for colorectal and lung cancer, Simon). I suspect this is something the new NICE guidelines may address more fully. I am going to present to them in December.

We have got a new paper coming out [no publication date yet] which combines all the cancers into one tool and gives a global cancer risk and then apportions the risk of each cancer. I will let you know once this is available. In the meantime, there are some slides in the public section of the download page of www.qresearch.org which will give you an idea.’

 http://www.qcancer.org/

 

NB disclaimer: These tools are designed to assess the risk of a patient having an existing, but as yet undiagnosed, cancer. The calculators take account of the patient's age, sex, family history, medical history and symptoms. The tools are intended to be used by doctors in a health care setting.

 Thanks Julia! Simon

 

Olympics, Exercise and Ankle Injuries

Olympics, Exercise and Ankle Injuries

The excitement and success of the Olympics and Paralympics seems to have had a positive effect on the nation.  Cycling to and from the practice each day I’ve noticed a visible increase in the number of people out exercising.  This can only be a good thing for the health of the nation, but it does come with consequences: people seeing their GPs with musculoskeletal injuries.  

This week I’ve had a run of sprained ankles coming in from people with a variety of shapes, sizes and athletic ability.  I always feel my management of acute injuries is a little basic, despite (or possibly because of) spending almost a year doing T&O jobs as a junior doctor.  It turns out that the ability to consent 90 year old ladies for a hemi-arthroplasty while ignoring all co-morbidities has little relevance to the general practice MSK case mix.  

So, is there more to it than rest, ice, compression and elevation?

With fortuitous timing a leaflet included with this months BJGP from Arthritis Research UK on Sports and Exercise Medicine¹ contained an interesting piece on management of acute inversion ankle sprains.

These are the most common ankle injury, resulting in a lateral ligament sprain.  So what do they recommend? 

•  Initially use the Ottawa rules to decide whether XR is required

a.       The Ottawa rules recommended XR is only necessary if there is any pain in the malleolar zone and either tenderness at the posterior edge or tip of lateral or medial malleolus, base of the 5^th metatarsal or navicular or inability to bear weight both immediately on injury and at review.

b.      Anterior malleolus tenderness doesn’t count for the rules – presumably its more likely to be ligament-related pain

c.       The leaflet has a very good diagram of the rules – click here

2.        

• Advise “PRICED” – like RICE but elongating the acronym to include things you’ll tell the patient to do anyway

a.       Protect – clean any other wounds, splint if broken, etc.

b.      Rest

c.       Ice

d.      Elevation

e.      Drugs – simple analgesia +/- anti-inflammatory

• Review after 72 hours and re-examine – initially the ankle is usually too painful to manage a meaningful examination

a.       3 key tests here – the latter two assess portions of the lateral ligament

                                                               i.      Assess proprioception – can they stand on one foot? – this can be significantly compromised by an ankle injury and increases the risk of re-injury.

                                                             ii.      Anterior draw test – assesses the anterior talofibular ligament (ATFL – see the pic below) – stabilise the leg, put a hand behind the heel and pull forwards – feel for laxity, no ‘end-feel’ implies a grade 3 sprain (complete tear); compare to the uninjured side

                                                            iii.      Talar tilt test – assesses the calcaneofibular ligament (CFL)– stabilise the leg, then invert the hind foot – again, feel for laxity, comparing to the uninjured side

1.       CFL injuries confer a worse outcome (the ATFL always goes first then the CFL so it’s a multiple injury) - the paper suggests that onward referral may be needed if the CFL is damaged.

2.       ATFL damage alone can be managed conservatively.

3.       But reading Clinical Sports Medicine² (the definitive sports medicine textbook), they cite a 2002 Cochrane review concluding that there was insufficient evidence to recommend surgery over conservative treatment for grade 3 ankle sprains – but conservative Rx here implies management by a sports medicine team.

4.       Early physio may be helpful in more severe injuries.

•  Rehabilitation – can start at this review – in fact all the stages are likely to overlap

a.       Explain the injury may take 6-12 weeks to heal

b.      Get the patient exercising the ankle

                                                               i.      Encourage range of movement – get them to write the alphabet with their toe

                                                             ii.      Improve eversion strength – using an elastic fitness band looped around a chair leg, evert against resistance – the aim is for low power, high reps – 3 sets of 10 bd

                                                            iii.      Improve proprioception – may be the most important part – initially practice balancing on the affected leg and building up the duration, then try on more unstable surfaces – ideally a wobble board, but a pillow will do

                                                           iv.      Arthritis Research UK has a great patient leaflet so all this – click here

• Return to sport

a.       Start when the pain has settled, full range of movement, eversion strength is good and proprioception is at least as good as the other leg.  Start easy and build up slowly.

b.      Clinical Sports Medicine highlights the benefits of strapping for any athlete with a significant injury for 6-12 months post-injury.  There are lots of common methods, but the simplest is stirrups – put anchor tape circumferentially around the lower leg then with the foot in a neutral position apply stirrups under the hind foot from medial to lateral until stable.

So, at the very least I have a better idea of what I’m testing, why I’m testing it and which patients are at risk of worse outcomes and may benefit from more intensive treatment.  The Hands On series from Arthritis Research UK is aimed at GPs and well worth a read – click here. 

My appraisal’s looming and I remember part of my PDP being improvement in MSK – I’ll keep looking for primary care management of acute injuries.  Anyone who’s interested in more Facebook or Tweet us and I blog it when I find it.  For all you MSK GPwSI’s out there send us your tips!

Enjoy the weekend, the Paralympics promises masses more of exciting sport and hopefully medals. 

Neal

References:

1.       P Wheeler, et al.  Sport and exercise medicine.  Hands On no. 12, series 6, Arthritis Research UK.

2.       P Brukner, K Khan.  Clinical Sports Medicine, 3^rd edition.  Lateral ligament injuries, pages 617-622

Clinical Biochem: GP Tips

Clinical Biochemistry: GP Tips

With thanks to Prof Jonathan Kay (Consultant Chemical Pathologist, Oxford Radcliffe Hospitals), and the GPs of the

19 Beaumont Street

Journal Club

When should I worry about a low sodium?

► hyponatraemia

·        Increasingly common with more elderly people on diuretics and SSRIs, and many seem to be stable and asymptomatic.  SSRIs are a common cause.

·        Monitor. If patient is stable no need to be too concerned even if sodium is as low as 125.

·        Be aware of rare causes such as Addisons and SIADH

o       Addison’s; suggested by low Na and high K. Ask the lab to do a short synacthen test if clinically suspected

o       SIADH:  if suspect, check urine osomolality; if high this suggests SIADH

And potassium?

►Hypokalaemia

·        K levels go down in warm weather, harmless psueudohopkalaemia; no action needed

·        Worry if K level is < 3

o       Consider referral to exclude Conn’s syndrome if K<3 and no other cause (e.g. diuretics) and hypertensive. Conn’s syndrome is underdiagnosed.

o       In patients on diuretics, if hypokalaemic but K level is >3 there is no evidence this is harmful. If K level is < 3, switch to a k sparing diuretic. This is a better strategy than trying to treat with K supplements

►Hyperkalaemia

·        Usually an artefact due to delay in transportation

·        The rate of change is more important in renal failure, so monitor closely especially if k>5.5 and discuss with renal team if going up or >6

Is there a place for testing magnesium levels?

►Magnesium

o       Relatively cheap test, probably under requested

o       Magnesium deficiency causes symptoms similar to hypocalcaemia e.g. tingling, parasthesia, muscle weakness, leg cramps and tetany

o       Often seen with hypokalaemia and occurs with diuretics, chronic PPI use, GI loss, renal disease, chronic alcoholism and poorly controlled diabetes

o       If <0.7 is associated with QT prolongation

o       Consider testing therefore in, for example, an older person on diuretics with muscle weakness, leg cramps or parasthesia

What about statins and raised CK levels?

►Creatinine Kinase

·        Levels are higher in males and black people of African or Caribbean origin

·        If CK levels are >5 times normal on a statin, you should stop the statin. If less than this and asymptomatic, then no need to worry.

And slightly ‘dodgy’ LFTs?

►LFTS

·        Minor abnormalities very common with fatty liver disease

·        If transaminases < twice the upper limit of normal then further investigation probably not necessary for most patients (especially if clinical picture fits for steatosis)

·        Bilirubin

o       If <1.5 times upper limit of normal, no need to be concerned

o       If largely conjugated (>70%) and <3 times upper limit of normal, then it is likely to be Gilbert’s

o       Consider genetic testing for Gilbert’s. Can request on an EDTA sample requesting ‘genotype for Gilbert’s’ to get definitive diagnosis

Lipid testing: fasting or not, and how often?

►Lipids

·        For risk prediction use total cholesterol/HDL ratio which can be non-fasting (total cholesterol is not affected by eating)

·        With total cholesterol there is a within day variation of up to 25% and also the level tends to rise throughout the day as cholesterol is protein bound

·        Fasting test is required for TGs and LDL.

·        For monitoring, annual tests are enough

Useful sites for further information:

·        www.bettertesting.org.uk  excellent site to have as a ‘favourite’ with good tips on minor abnormalities

·        www.labtestsonline.org.uk     patient info site but very useful

Simon 

Eating Disorders: GP Tips

Eating Disorders: GP Tips

With thanks to Prof Chris Fairburn (Professor of Psychiatry at the University of Oxford, and author of CBT and Eating Disorders and Overcoming Binge Eating) and Dr Debbie Waller (GP, co-editor Oxford Book of Women’s Health and part of the NICE Eating Disorders Guidelines Development Group).

How common are eating disorders, and how are they defined?

Anorexia Nervosa (1 or 2 patients per 2,000 people)

• Extreme concern about shape and weight (with denial of thinness)
• Marked under eating and maintenance of an unduly low body weight (BMI<17.5)

Bulimia nervosa (18 per 2,000)

• Extreme concern about shape and weight (marked fear of fatness)
• Strict dieting punctuated by frequent episodes of loss of control (binges)
• Extreme behaviour to try to avoid weight gain e.g. self-induced vomiting, strict dieting, mis-use of laxatives etc

 ENDOS ‘eating disorder not otherwise specified’ (>20 per 2,000)

• Resembles AN or BN but do not meet their diagnostic criteria

How should I pick them up?

By thinking and asking! Often hidden due to denial (AN) or shame about binge eating (BN), and often somatic or psychiatric presentations before diagnosis. Keep antennae alert, and consider if

• Low weight in a young woman
• Inappropriate requests for help with dieting
• Fatigue, dizziness, syncope, GI symptoms
• Oligomenorrhea
• Depression (or Anxiety)

And ask the questions:

• Do you think you have an eating problem? 
• Do you have a problem controlling your eating?
• Do you worry unduly about your weight?  Do other people think you do?

Safety first: how should I assess patients’ level of risk?

Measure and record:

• BMI, BP and pulse
• Muscle strength (’the squat test’)
• Co-existent psychopathology
• Depression, anxiety, self-harm and suicide risk
• Lab tests
• Routine blood tests sufficient (FBC, electrolytes, glucose)
• Monitor electrolytes if repeated vomiting/laxative abuse
• Check ECG if BMI<15.5
• Check bone density scanning if amenorrhoeic

What are the broad principles of management?

• Recognition by the patient that they have a problem is the critical first step
• This process may take many weeks and requires a good therapeutic relationship, sensitive handling and family involvement
• Reliable education from reliable sources are key
• Teenagers: either family therapy or CBT.
• Adults: outpatient CBT is key, especially for BN and associated eating disorders. CBT is now also the leading treatment for AN, if the patient can be managed on an outpatient basis. Treatment of severe AN may require a more intensive, approach
• Regular monitoring of physical health by GP if needed.
• Weight only needs regular monitoring if BMI is very low, or dropping
• Osteoporosis may develop quickly in AN, and is partially reversible. Restoration of weight and normal menstruation is key. There is no evidence to support drug treatment (e.g. COCP or HRT) although supplementation with calcium and vitamin D is generally recommended.
• Encourage dental review in patients with frequent vomiting
• Comorbid depression responds to antidepressant medication (fluoxetine well tolerated) but higher than usual doses are often required.

When should I refer to specialist services?

• Refer early to specialist services all cases of AN
• Urgent referral if BMI <13.5, accelerated/rapid weight loss (>1kg per week) and/or significant medical/psychiatric complications
• BN
• GP-guided self-help is first step.  
• Recommend ‘Overcoming Binge Eating’, and offer to see every 2-4 weeks for support/encouragement
• Fluoxetine 60mg mane is not routinely recommended, as the therapeutic effect is so transitory in reducing binges. However, have low threshold for treating co-morbid depression.
• If fail to respond, refer for individualized CBT

What about University students and fitness to study?

Oxford University Guidelines for intermission from college:

• Significantly compromised physical (e.g. BMI<15  women <16 for men, electrolyte disturbance) or mental state
• Rapid weight loss e.g. >0.5 kg per week
• Fit to return when stable physical and mental state and BMI >16

Useful reading

·        Fairburn, CG.  Overcoming Binge Eating. Guilford Press, New York.

·        Treasure, J.  Anorexia nervosa: a survival guide for families, friends and sufferers. Psychology Press, Hove.

·        Abraham, S and LLewellyn-Jones, D. Eating Disorders: the Facts. OUP.

Recommended website: Eating Disorders Association: http://www.edauk.com/

Simon

With many thanks to Prof Chris Fairburn for his expert advice

http://www.psychiatry.ox.ac.uk/research/researchunits/credo/professor-christopher-fairburn

Phenomenology as resource for patients

Discussion of a paper by Dr Havi Carel – Phenomenology as a Resource for Patients, published in the Journal of Medicine and Philosophy (37;96-113, 2012).

There is a long history of thinking and theorising about what goes on in general practice, and this has contributed I think, to more effective and meaningful communication, to greater empathy, understanding, trust, and ultimately a better outcome for patients, however you choose to define it. Two notable examples are the biopsychosocial model and narrative-based medicine. The narrative-based approach in many ways “turned the conventional biomedical approach and even patient-centred one on its head”, as wrote Dr John Launer in an editorial in the BJGP back in February 2003. He continued:

“…Instead of listening to ‘the patient’s history’ to determine what to do, it judges our actions by whether they contribute to an improvement in the patient’s narrative”.

The huge increase in projects, groups and websites which focus on patient’s stories and on personal experience of illness is increasingly valuable in providing a source of support and information of a sort that is so important but unfortunately just not possible, it seems, to provide in the conventional GP setting..DiPEX website and the Oxford Health Experiences Research Group being an obvious example.  

These developments have arisen from an unmet need or from dissatisfaction with conventional western medicine, and are underpinned by work in anthropology, sociology, philosophy and social sciences.

As a GP and someone with a lay interest in philosophy, I was interested to read a paper in the Journal of Medicine and Philosophy which described some work being carried out in Bristol between philosophers and medics, who are working towards using phenomenology as a resource for patients…. Does this seem ridiculous? Philosophy is after all often considered a very non-practical ‘head in the clouds’ discipline. On the contrary I think this work is thought-provoking and innovative, should complement the way in which we conceptualise illness, and importantly just may provide a new way for us to support patients in developing their own understanding and coping strategies in times of ill-health.

A useful route into describing this work is to mention the author of this paper and one of the leading academics involved in the project. Havi Carel is a philosopher who was diagnosed with a rare lung condition (LAM) in her thirties. She turned to her area of interest -phenomenology- to help her come to terms with this, and subsequently developed a project exploring how phenomenology could be used to enhance the “constricted concepts and dry medical language” which are generally used to describe illness. Phenomenology is a broad philosophical movement developed from work by Edmund Husserl at the start of the last century, but can be simply defined as the study of the structure of experience. Carel’s work involves discussions with health professionals and is now included in the medical curriculum at Bristol Medical School. You can read more about Havi Carel and her work here:  http://medicalhumanities.wordpress.com/2011/03/09/standing-on-the-shoulders-of-giants/

Literature and the arts have long been used to express the experience of illness, and Carel’s work is taking this concept forward in developing potential benefits from philosophy for patients and health provision more broadly, in a structured way. Developing a workshop for patients using this approach is especially interesting for doctors because the concepts used are in contrast to those we are familiar with from the bulk of our medical training. But the concepts do perhaps tap into our personal experiences of illness, or of those of our loved ones.

The toolkit proposed takes the form of a process that brings about redefinition of illness, with 3 phenomenological steps:

1.      Phenomenological reduction

This could be seen as something already engrained in us as GPs, namely seeing the person behind the diagnosis, but is expressed in the paper more as a shift away from the disease and towards the experience. It is suggested that illness forces a kind of phenomenal reduction on us when we are ill because it causes us to suspend our normal approach to the world. “Once the belief in the objective disease entity is bracketed and we are distanced from our usual way of experiencing, we can begin to explore how illness appears to the ill person, its structure and its essential features”.

2.      Thematizing illness

This part is about focusing on different aspects of the person’s experience of illness and also allows the many perspectives eg. of family members, friends, doctors etc. to be brought out and explored. This can help patients move to a more descriptive way of understanding their experience, bringing out a more adaptable and multidimensional view of illness, and away from seeing it as something objective and strictly defined. Different aspects can be explored depending on the individual.

3.      Review of one’s being in the world

This heading in laden with weighty philosophical discourse, and Heidegger’s broad understanding of ‘one’s being in the world’ is brought out in the article. But in summary this part of the workshop follows on from thematizing illness and involves exploring the overall effects of illness on one’s sense of place, interactions with surroundings and other people, on meanings and norms and on each aspect of that person’s individual world.  “By moving away from the narrow understanding of illness as a biological process a thick account of illness as a new way of being in the world can be developed by patients”.

This may all seem far removed from the consulting room, but I encourage you to consider the ideas brought out in this paper with an open mind. Carel and many philosophers not to mention practitioners before her have agreed that illness is ‘phenomenology in action’, but the work described in this paper is exciting in that it transforms the theory into a structured one-day workshop that is being planned by Carel and her collegues in Bristol. This has the potential to bring real benefits for patients although some details on how this will be run remain unclear. Another question is whether type of project can ever be made accessible to a broad variety of patients or will benefit a self-selecting minority.

Unfortunately the full text of the above article requires a subscription, but the abstract can be accessed for free: http://jmp.oxfordjournals.org/content/37/2/96.abstract

Zoe