(Disability in young people and adults one year after head
injury: prospective cohort study)
http://bmj.com/cgi/content/full/320/7250/1631

Disability in patients admitted to hospital with a head injury is
far higher than expected because previous work has not
studied properly representative patient groups and because
classification on arrival at hospital underestimates later
problems. Support and rehabilitation after discharge are also
inadequate, according to a study in this week's BMJ.

Researchers in Scotland tracked the progress of over 2,500
young people and adults (aged 14 years or more) admitted to
hospital with a head injury. They found that the initial severity
of injury (classified as mild, moderate or severe) was not
closely related to the level of disability in survivors one year
later. Most survivors of severe head injury (78%) were
disabled, yet disability was also common and occurred with
similar frequency in survivors of mild (51%) and moderate
(54%) injuries. In addition, the authors found that, of the
disabled survivors, less than half were seen in hospital after
discharge, only 28% reported having received any form of
rehabilitation and only 15% had contact with social work
services.

The authors acknowledge that research into head injuries is
fraught with difficulties, yet such failure to achieve a good
recovery - even among young patients with no "adverse"
factors in this study - lead the authors to conclude "that it
may be inappropriate to class these injuries as 'mild'." They
also recognise the lack of support and rehabilitation for
disabled survivors and suggest that further investigations are
needed to evaluate services to promote recovery.

Contact:

Professor Graham Teasdale Department of Neurosurgery,
University of Glasgow, Southern General NHS Trust,
Glasgow G51 4TF
Email: y.mitchell{at}clinmed.gla.ac.uk
 

(2)  WOMEN ARE UNAWARE THAT MAMMOGRAPHY
CAN DETECT NON-PROGRESSIVE CANCERS

(US women's attitudes to false positive mammography
results and detection of ductal carcinoma in situ: cross
sectional survey)
http://bmj.com/cgi/content/full/320/7250/1635

Most women are unaware that detection of non-progressive
cancer by screening mammography can lead to unnecessary
invasive treatment, according to a study in this week's BMJ.

Researchers surveyed 479 women in the United States, aged
between 18 and 97 years, about their attitudes to and
knowledge of false positive results and detection of
non-progressive forms of cancer. Both are potential harms of
mammography - often leading to women undergoing invasive
treatment of unknown benefit including surgery,
chemotherapy and mastectomy.

Overall, only 8% of women thought that mammography could
harm a woman without breast cancer. Almost all (99%) knew
that false positive mammograms occur, but accepted them as
a consequence of screening and most would not take them
into account when deciding about screening. Even women
who had had a false positive result were highly tolerant. In
contrast, only 6% of women were aware that screening can
detect cancers that may never progress and many even
doubted their existence. Once informed however, most
women were concerned and wanted to take this into account
when deciding about screening.

In light of these results, the authors conclude that education
should focus less on false positives and more on the less
familiar breast abnormalities, and the ambiguity associated
with their detection and treatment.

Contact:

Steven Woloshin, Assistant Professor of Medicine, Veterans
Administration Medical Center, White River Junction, VT
05009, USA
Email: steven.woloshin{at}dartmouth.edu
 

(3)  ELDERLY PEOPLE WOULD WELCOME LIVING
WILLS

(Views of elderly people on living wills: interview study)
http://bmj.com/cgi/content/full/320/7250/1640

Over 70% of elderly people in the UK are interested in
making a living will and most have clear views on the issues
raised by them, reveals a study in this week's BMJ.

In the first study of its kind in the UK, researchers at Imperial
College School of Medicine, London interviewed 74 elderly
patients, aged between 66 and 97 years, at two British
hospitals. Despite little previous knowledge of written wills,
the researchers found that many older people were interested
in the concept of recording their healthcare wishes to make
their views known and to relieve the burden of decisions on
their family.

Overall, 92% of participants indicated when they would no
longer wish their lives to be prolonged by medical
interventions. Many disabilities were unacceptable to
participants - many stating that they would prefer "comfort
only" care to active treatment, even if they might die.
Interestingly, women were less likely than men to request
active treatment options in such circumstances. The most
feared condition was advanced dementia, the least was being
in a wheelchair. At the end stage of a terminal disease, 94%
said they would refuse surgery, 93% artificial feeding, 92%
ventilation and 90% cardiac resuscitation.

In conclusion, the authors suggest that a living will, specially
designed for elderly people, may be appropriate and is
currently being prepared.

Contact:

Rebekah Schiff, Clinical Research Fellow, Imperial College
School of Medicine, Hammersmith Hospital, London W12
0NN.
Email: rebekah{at}rspscomp.demon.co.uk
 

(4)  IS BRITISH PRIMARY CARE UNDER THREAT FROM
MODERNISATION?

(Editorial: Fix what's wrong, not what's right, with general
practice in Britain)
http://bmj.com/cgi/content/full/320/7250/1616

Several of the proposed changes to the NHS could damage
Britain's strong primary care infrastructure, according to
editorial this week's BMJ.

University professors from Belgium, Norway and the United
States look at the key features of a strong primary healthcare
system - continuity of care and a comprehensive financing
system - and warn that reform could destroy the backbone of
Britain's unique health care structure.

Evidence suggests that the UK system of continuity of care -
where every patient is registered with one general practitioner
- is cost-effective. Yet proposed reforms, such as dual
registration, "cut directly across this evidence," say the
authors. Furthermore, the provision of walk-in centres and
telephone lines staffed by nurses are likely to be expanded
"without evidence that they improve health or are
cost-effective" they add. In terms of a financing mechanism,
the current system of payment for general practitioners has,
say the authors, "served the health of Britain well" and they
warn that abandoning this system "could result in less health
improvement occurring at the same cost."

"Britain has clearly done something right with its National
Health Service" conclude the authors, and they call for the
government to consider the evidence before interfering with
these fundamental aspects of primary care.

Contact:

Professor Jan De Maeseneer, Department of General
Practice and Primary Health Care, Ghent University, De
Pintelaan 185, B-9000 Ghent, Belgium
Email:  jan.demaeseneer{at}rug.ac.be

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