Community juries disagree with RACGP on PSA testing
THREE well informed community juries have disagreed with Royal Australian College of General Practitioners (RACGP) guidelines which advise GPs not to broach the subject of prostate-specific antigen (PSA) testing with patients. In research published in the MJA, 40 people from NSW representing diverse social and cultural backgrounds and with no experience of prostate cancer were recruited, and allocated to two juries of mixed sex and ages, and one all-male jury of PSA screening age. The juries, which were briefed on evidence and given time to deliberate PSA testing’s dilemmas, concluded that “GPs should initiate discussions about PSA testing with men over 50 years of age”. RACGP guidelines advise GPs to only provide patients with information about the benefits, risks and uncertainties of testing and treatment if they specifically ask for it. The three juries, convened in 2014, viewed pre-recorded expert testimony on the biology, diagnosis, treatment and prognosis of prostate cancer; qualitative empirical evidence on how GPs manage PSA testing; ethical and legal aspects of patient consent; and potential harms and benefits of screening asymptomatic men. “The mixed juries voted for GPs offering detailed information about all potential consequent benefits and harms before PSA testing, and favoured a cooling-off period before undertaking the test”, the researchers wrote. “The all-male jury recommended a staggered approach to providing information. They recommended that written information be available to those who wanted it, but eight of the 12 jurors thought that doctors should discuss the benefits and harms of biopsy and treatment only after a man had received an elevated PSA test result.”
High rate of preventable cancers in Indigenous peoples
NEW research published in The Lancet Oncology has found clear differences in the scale and profile of cancer in Indigenous and non-Indigenous populations in Australia, New Zealand, Canada and the US. Incidence data derived from population-based cancer registries in each country, including Queensland, WA, and the NT in Australia, compared age-standardised rates by registry, sex, cancer site and ethnicity for incident cancer cases, excluding non-melanoma skin cancers, diagnosed between 2002 and 2006. The study, which included 24 815 cases of cancer in Indigenous patients and more than 5.6 million in non-Indigenous patients, found the overall cancer burden in Indigenous populations compared with non-Indigenous populations was substantially lower in the US, similar or slightly lower in Australia and Canada, and higher in New Zealand. The most commonly occurring cancers among Indigenous men, irrespective of jurisdiction, were lung, prostate and colorectal cancer. Breast cancer was the most frequent cancer in Indigenous women, followed by lung and colorectal cancer. Indigenous men had higher rates of lung cancer, with observed rates between 44% (in WA) and 155% (New Zealand) higher than those observed in non-Indigenous men. Cervical cancer incidence was higher among Indigenous women in most jurisdictions. In Australia, the incidence of head and neck cancers rates was up to 91% higher in Indigenous men and substantially higher among Indigenous women in the NT. “The high incidence of several common and largely preventable neoplasms, including cervical and lung cancer, shows the need for better health surveillance and targeted prevention, early detection, and vaccination programmes in Australia, New Zealand, Canada, and the USA”, the researchers wrote. An accompanying commentary said that despite data shortcomings, the research highlighted striking findings on the higher incidence of potentially highly preventable cancers in Indigenous people. “These findings strengthen the argument for a strategic focus on the burden of cancer in indigenous people, the need for better monitoring, and the development of interventions that address the factors that drive cancer inequities”, the editorial said.
Work stress linked to stroke risk
HIGH strain jobs are associated with an increased risk of stroke, especially in women, according to a study published in Neurology. Acknowledging that previous studies had linked psychological work stress with an increased risk of cardiovascular disease, the researchers said “to our knowledge, this is the first meta-analysis to evaluate the association between job strain and the risk of stroke”. The meta-analysis included six prospective cohort studies of 138 782 individuals aged from 18 to 75 years, and relied on an occupational stress model which assesses jobs on the basis of psychological demand (time pressure, mental load and coordination responsibilities) and job control (an individual’s potential control over decision making). Jobs fell into four categories: low strain jobs (low demand, high control), passive jobs (low demand, low control), active jobs (high demand, high control), and high strain jobs (high demand, low control). It found high strain jobs were associated with increased risk of stroke (risk ratio [RR] 1.22) compared with low strain jobs, and was more pronounced for ischaemic stroke (RR 1.58). The risk of stroke was significant in women (RR 1.33) and non-significant in men (RR 1.26). The researchers wrote that cultural differences might have an important effect on perceived job strain, “For example, it was reported that German physicians perceived higher job stress than Australian physicians and coping behavior was significantly different between them”, they wrote. They suggested long-term work stress could lead to “neuroendocrine perturbations, such as enhanced activation of the hypothalamic pituitary adrenal axis and sympathetic nervous system, which may result in an elevated inflammatory response, destabilization of atherosclerotic plaques, accelerated cellular aging, enhanced cortisol secretion, and hemo-dynamic perturbations, as well as other risk factors for stroke”. Because exposure to high strain jobs was associated with an increased risk of stroke "it is of vital importance for individuals with high strain occupations to address lifestyle issues", the authors wrote. An accompanying editorial said that high job strain might be considered “an independent stroke risk factor in the future—and one that is potentially modifiable”.
Treating newborn hypoglycaemia prevents neuronal injury
NEONATAL hypoglycaemia is not associated with an adverse neurologic outcome when treatment is provided to maintain a blood glucose concentration of at least 2.6 mmol/L (47 mg per decilitre), according to New Zealand research. The prospective cohort study, published in the New England Journal of Medicine, included 404 neonates with a gestational age of at least 35 weeks who were considered at risk for hypoglycaemia and treated to maintain a blood glucose concentration of at least 2.6 mmol/L, with blood glucose intermittently measured for up to 7 days. Neonatal hypoglycaemia was observed in 216 children (53%). At age 2 years, the children were assessed for development and visual and executive function. The researchers found the risk of neurosensory impairment or processing difficulty was not higher among children with neonatal hypoglycaemia when they were treated to maintain blood glucose concentration than among children without neonatal hypoglycaemia, even among those with multiple hypoglycaemic episodes, episodes on multiple days or severe episodes. Children with unrecognised and untreated low glucose concentrations (detected only on continuous interstitial glucose monitoring) also had no increased risk of abnormal neurodevelopment. The researchers wrote that their study suggested a protocol of regular blood glucose monitoring in the first 48 hours after birth and intervention aimed at maintaining a blood glucose concentration of at least 2.6 mmol/L was effective in preventing neuronal injury in at-risk term and late-preterm newborns. However, they wrote that a surprising finding was an association of neurosensory impairment, especially cognitive delay, with higher glucose concentrations and less glucose stability, indicated by a larger proportion of time outside the central range of 3‒4 mmol/L in the first 48 hours, saying this needed further investigation. An accompanying editorial described the study findings as “worrisome”, saying it added to the debate about how best to treat newborns with transient hypoglycaemia.
Contamination from removing gloves, gowns common
CONTAMINATION of skin and clothing occurs frequently when health care workers remove contaminated gloves or gowns, according to US research published in JAMA Internal Medicine. The research was based on a point-prevalence study and quasi-experimental intervention at four hospitals in Ohio. Simulations of contaminated personal protective equipment (PPE) removal were conducted using fluorescent lotion. A cohort of health care personnel at one hospital participated in the intervention that included education and practice in removing contaminated PPE. Of 435 glove and gown removal simulations using fluorescent lotion, contamination of skin or clothing occurred in 200 (46.0%), with similar contamination frequency at the four hospitals. Contamination occurred more frequently from removing gloves than gowns (52.9% v 37.8%) and during lapses in technique (70.3% during lapses v 30.0% with no lapses). The intervention resulted in a reduction in skin and clothing contamination (60.0% before the intervention v 18.9% after), which was sustained after 1 and 3 months. The researchers wrote that although contamination of skin and clothing was reduced by the intervention, it was not reduced to zero, highlighting the need for additional measures to reduce contamination during PPE removal. They said there was “a need for a redesign of PPE to provide products that are easy to remove while minimizing the risk for self-contamination”. An accompanying commentary said that due to limitations of current infection control methods and the spectre of multidrug-resistant pathogens, “the time for achievable solutions that health care workers will follow is now”.
Some benefit from physical therapy for low back pain
EARLY physical therapy resulted in statistically significant improvement in disability for adults with recent onset low back pain (LBP) compared with usual care, but the difference was modest, a study published in JAMA has found. The randomised clinical trial found physical therapy did not achieve the minimum difference considered clinically important at the individual patient level, and there was no difference between groups in disability scores at 1-year follow up. The trial included 220 adults aged 18‒60 years with recent onset LBP who were randomised following a primary care visit to four sessions of early physical therapy involving manipulation and exercise or usual care (no additional intervention beyond education) during the first 4 weeks. Early physical therapy showed significant improvement compared with usual care on disability scores at 3 months but not after 1 year. Some secondary outcomes showed statistically significant differences favouring greater improvement in the early physical therapy group particularly at 3 months, but not beyond. The researchers wrote that primary care physicians were typically the first-contact provider for patients with LBP, and that many guidelines did not advise referral to physical therapy in the first few weeks as most patients recovered rapidly regardless. However, they said as research showed that delaying treatment could increase the risk for invasive procedures in some patients, the potential benefits of early physical therapy “should be considered in light of the time and effort required to participate in physical therapy”.