Movember, Health Screening and Resistant Hypertension

Movember - Truth behind the 'Tache'

Men in the UK and around the world are raising money this month to promote men's health as part of Movember. The campaign takes place once a year in November and encourages men to grow a moustache to raise money for men's health. Initially this was focused on prostate cancer however since 2010 funds have also been used for testicular cancer research. The slogan is "knowledge is power, moustache is king". But an article in the BMJ this week written by a GP questions whether Movember is actually misleading men on some of its advice. 

The charity has obviously built a huge profile and the amounts of money raised is laudable, however some of the advice on the charity's website contradicts NHS advice, particularly with regards to screening tests. For example the website at one point suggested that all men aged 50 or above should seek a baseline PSA test. This has been recently updated but it recommends that men over age 50 should ask their doctor for a bowel cancer screening test annually (in contrast to NHS bowel screening programme recommendation of screening every two years) and that all men age 45 should undergo an HbA1c test. Aortic aneurysm screening is only relevant for men age 65-75 who have smoked and from age 20 men should have their BP checked every 2 years (or annually if high or low). The advice can be found here: http://uk.movember.com/mens-health/health-checklist/. It is unclear where Movember have sought this information. This frequency of screening tests is not based on evidence and may result in patients having conflict with their doctor. Also some of the more pressing issues on men's health receive very little if not no information, such as mental health, substance misuse, smoking, alcohol and obesity.

Periodic health checks

A recent Cochrane review looked at the benefits and harms of general health checks in terms of outcomes relevant to patients. Health checks such as these are generally assumed to be effective in reducing morbidity and mortality but these effects have not been effectively demonstrated. In fact these checks may result in overdiagnosis and overtreatment. 

While this study has looked at routine health checks in patients who are not known to have any medical condition, annual health checks are more likely to be of benefit in patients with chronic conditions. For example, in 2006 the Disability Rights Commission recommended the introduction of annual health checks for people with intellectual disabilities in an attempt to reduce health inequalities in this population. Mortality from preventable causes is three times higher in people with moderate to severe intellectual disabilities than it is in the general population, and the number of emergency admission to hospital is substantially increased. It is not yet known whether these checks will lead to fever hospital admissions but clearly it is important that attempts are made to reduce the health inequality between this group of patients and the general population and health checks may be a potential solution.

Resistant hypertension

Resistant hypertension is defined as high blood pressure which remains uncontrolled despite treatment with at least three anti-hypertensive agents at best tolerated doses. These patients are at greater risk of experiencing an adverse cardiovascular event. 5-10% of cases of resistant hypertension have a secondary underlying cause. Drug related causes include NSAIDS, oral contraceptives, adrenal steroid hormones, erythropoeitin, ciclosporin and tacrolimus. Target organ damage may occur eg. LVH, hypertensive retinopathy and renal disease - these patients should be referred to secondary care.

Examples of secondary causes of resistant hypertension (+symptoms):

• Primary hyperaldosteronism (Conn's syndrome) - hypokalaemia, fatigue, low renin, raised aldosterone levels (check plasma renin or aldosterone levels)
• Renal artery stenosis - carotid,, abdominal or femoral bruits, atherosclerotic disease, pulmonary oedema
• Renal parenchymal disease - albuminuria, micro-haematuria, nocturia and oedema (urinalysis)
• Obstructive sleep apnoea - obestiy, short neck, daytime somnolence, snoring, apnoea.
• Phaeochromocytoma - episodic palpitations, headaches and sweating (check 24hr urnary metanephrines or normetanephrines)
• Thyroid disease - hyperthyroidism increases systolic BP, hypothyroidism increases diastolic BP
• Cushing's syndrome - centripedal obesity, moon facies, abdominal striae, interscapular fat pad
• Coarctation of the aorta - radio-femoral delay, diminished femoral pulses, rib notching on CXR
• Intracranial tumours - early morning headache, positive family history