Daniel Jones

The diagnostic test accuracy of rectal examination for prostate cancer diagnosis in symptomatic patients: a systematic review

BackgroundProstate cancer is the most common cancer in men in the UK. NICE guidelines on recognition and referral of suspected cancer, recommend performing digital rectal examination (DRE) on patients with urinary symptoms and urgently referring if the prostate feels malignant. However, this is based on the results of one case control study, so it is not known if DRE performed in primary care is an accurate method of detecting prostate cancer.MethodsThe aim of this review is to ascertain the sensitivity, specificity, positive and negative predictive value of DRE for the detection of prostate cancer in symptomatic patients in primary care.CENTRAL, MEDLINE, EMBASE and CINAHL databases were searched in august 2015 for studies in which a DRE was performed in primary care on symptomatic patients and compared against a reference diagnostic procedure.ResultsFour studies were included with a total of 3225 patients. The sensitivity and specificity for DRE as a predictor of prostate cancer in symptomatic patients was 28.6 and 90.7%, respectively. The positive and negative predictive values were 42.3 and 84.2%, respectively.ConclusionThis review found that DRE performed in general practice is accurate, and supports the UK NICE guidelines that patients with a malignant prostate on examination are referred urgently for suspected prostate cancer. Abnormal DRE carried a 42.3% chance of malignancy, above the 3% risk threshold which NICE guidance suggests warrants an urgent referral. However this review questions the benefit of performing a DRE in primary care in the first instance, suggesting that a patient’s risk of prostate cancer based on symptoms alone would warrant urgent referral even if the DRE feels normal.

GP recruitment and retention

As a GP registrar, I was rather downhearted after reading the letter by Dr Glasspool in the March BJGP .1 Is it that bad? Are we really in crisis? Are all the GPs retiring, locuming, and emigrating? Dr Glasspool helpfully points us to social media for a true picture, and it seems he is right! A search on Twitter for ‘GP recruitment’, ‘GP workload’, and ‘GP …

Interventions to improve the uptake of cervical cancer screening among lower socioeconomic groups: A systematic review

Cervical cancer is the fourth most common cancer in women worldwide. Screening can reduce both the incidence and mortality of the disease but is often not utilized by lower socioeconomic groups. A systematic review, including studies of interventions to improve breast and cervical cancer screening uptake, up to 2006, found targeted interventions could be effective. A formal update has been conducted on the effectiveness of interventions to improve the uptake of cervical cancer screening among lower socioeconomic groups. A systematic computerized literature search was undertaken in June 2016 for relevant papers published since 2006. Data was extracted on study participants, setting, intervention and control using a predefined extraction tool and a full quality assessment was undertaken using the Cochrane risk of bias tool. This update yielded 16 studies of mixed quality, in addition to the 13 studies from the original review. The interventions were categorized into local interventions including HPV self-testing, lay health advisors, inreach, outreach and mixed, and strategies enhancing attendance within an organized program. This review has found two large, randomized controlled trials for the use of HPV self-testing to increase cervical screening uptake. Both reviews have found varying success using lay health advisors, with the majority of included papers reporting a statistically significant increase in screening uptake. HPV self-testing can improve uptake of cervical cancer screening among lower socioeconomic groups. This is a relatively new method of cervical screening that was not included in the earlier review. The findings of this updated review largely support that of the 2006 review for the use of lay health advisors.

Burnout in general practice

Workload pressures on GPs are increasing, due to an increasing number of patients requiring attention and the extended periods that they are now living with multiple, complex chronic conditions. In addition, the recruitment and retention of GPs in the UK is falling; at the time of writing this article, these factors have led the profession to be described as being in a state of crisis. In 2015, the RCGP estimated that there was a shortfall of over 3000 GPs. With this in mind, there is increasing concern about the mental and physical health of the workforce, and the sustainability of the speciality and its workload. This article will look at burnout, what it is, its prevalence in the medical profession and what help is available.

NICE Nuggets: NG23 Menopause: Diagnosis and management

In the UK, the average age of menopause is 51 and approximately 80% of women will experience some perimenopausal symptoms. However, evidence suggests that services available for menopausal women in the UK are variable. The RCGP curriculum states that women-specific health matters, including contraception, pregnancy, menopause and disorders of reproductive organs, accounts for 25% of general practitioner consultations. The curriculum goes on to say ‘as a GP you should know how the social and biological features of the perimenopause and menopause period interact and affect health, social wellbeing and relationships’. The NICE guideline Menopause: Diagnosis and management (NG23), covers the diagnosis and management of menopause, including women who have premature ovarian insufficiency. The guideline aims to improve the consistency of support and information provided to women in menopause.

NICE Nuggets: NG20 Coeliac disease: Recognition, assessment and management

Coeliac disease is an autoimmune condition that causes chronic inflammation of the small intestine as a result of an abnormal immune response to gluten. Coeliac disease is thought to affect 1 in 100 people in the UK but only 10%–20% will have a formal diagnosis. The RCGP curriculum states that digestive problems are common in general practice and GPs have a central role in the diagnosis and management of digestive problems in primary care. The NICE guideline: Coeliac disease: Recognition, assessment and management (NG20), provides an evidenced-based approach to the diagnosis and management of coeliac disease in children young people and adults.

Globus pharyngeus: an update for general practice

Globus pharyngeus or globus sensation is the painless sensation of a lump in the throat and may be described as a foreign body sensation, a tightening or choking feeling. It is often associated with persistent clearing of the throat, chronic cough, hoarseness, and catarrh.1 Globus pharyngeus makes up 4% of ear, nose, and throat (ENT) referrals and is reported to have been experienced by up to 45% of the population.1 The aetiology of globus pharyngeus remains uncertain. Causes suggested include cricopharyngeal spasm, lingual tonsil, cervical osteophytosis, hiatus hernia, gastro-oesophageal reflux, sinusitis, post-nasal drip, goitre, foreign body, anxiety, and, very rarely, hypopharyngeal cancer.2 It has been suggested that regurgitation of stomach acid and digestive enzymes induces chronic inflammation of the laryngopharynx resulting in symptoms. Studies have reported reflux in 23–68% of patients with globus sensation. However, some report a similar rate in asymptomatic control patients.1 It is thought that gastro-oesophageal reflux is likely to be the cause in a subgroup of patients but cannot explain all cases.2 Oesophageal motility disorders are another potential aetiological factor. Studies suggest an association between upper oesophageal sphincter function and globus sensation, with one showing elevated sphincter pressure in 28% of patients with globus pharyngeus compared with 3% of controls.1 Psychological …

Consultation Skills and the Work of Michael Balint

Many sources claim that Michael Balint revolutionized general practice just as it was beginning to establish itself as a speciality in its own right. Basing most of his concepts on theories of psychoanalysis, Balint set himself the task of finding a ‘space’ for general practice as a separate clinical discipline. Balint believed that it was the GPs ability to provide holistic continual care which stretched from cradle to grave that really separated general practice from hospital medicine. Balint developed many ideas and concepts around the doctor—patient relationship, all of which are still relevant to general practice today. Balints theories depend heavily on three aspects of general practice: the personal qualities of the GP, the GPs skills and the wider socio-economic and political context of general practice. It is hoped that having an understanding of Balints ideas and theories can improve the consultation for all GPs both new and experienced.