This week in the BMJ
Volume 327, Number 7417, Issue of 27 Sep 2003Individualised risk communication increases screening but not informed choice
Individualised risk communication increases screening but not informed choice
Interventions communicating individualised risk to patients lead to an increase in the numbers undergoing screening, but this may not be based on informed choice. In this week's special issue on communicating risks Edwards and colleagues (p 703) present a systematic review on communicating individualised risk and screening choices. Individualised risk interventions included using specific risk estimates based on the individual's own risk factors for a condition (such as age or family history). They found that such interventions lead to increased participation in screening programmes overall but argue that the increased uptake cannot be attributed to informed decision making by people invited to screening.
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Public perceptions do not equate to risks, but reflect controversies
Public reactions do not necessarily relate to real risks to health, and these are fed by mass communication. On p 725 Bellaby uses three examples to contrast the varied public perceptions of risks to children's health: autism caused by MMR vaccination, variant Creutzfeldt-Jakob disease (vCJD) from food containing the agent that causes bovine spongiform encephalopathy (BSE), and injuries and death from road crashes. Perceived risks are filtered through mass media and the medical and scientific communities, which often miscommunicate true risk. As a result, Bellaby argues, parents tend to ignore the most obvious risks to their children (road crashes), reject experts' assessment (over BSE), and amplify a virtually non-existent risk (autism after vaccination). The author says that parents' concerns are reasonable if they are understood in light of the controversies that perceived risks can cause.
Do you ever mix up sensitivity and specificity?
Sensitivity and specificity are common and seemingly simple conventions—so why are they so hard to grasp? Loong (p 716) tackles this conundrum by offering a visual approach to understanding the sensitivity, specificity, and positive and negative predictive values of tests. Emphasising the importance of applying the right side of the brain, he uses a real clinical example to illustrate the distinctions and relationships between these concepts. Contrary to usual belief, Loong says that high sensitivity, which implies a test is effective at correctly identifying people who have the disease, is not necessarily a good thing. In addition, the positive and negative predictive values of tests are not fixed, but change if the prevalence of disease changes.
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Falls in elderly women are more often due to chronic disease than to drug use
Having a chronic disease or comorbidity is a better predictor than polypharmacy of falls in elderly women. Using cross sectional data from 4050 British women aged 60-79, Lawlor and colleagues (p 712) show that the risk of falling increases with the number of simultaneous chronic diseases and the number of drugs taken. However, the association with multiple diseases was stronger than that with polypharmacy and was independent of drug use and other confounders. Circulatory disease, chronic obstructive pulmonary disease, arthritis, and depression were associated with an increased risk of falling, as were two classes of drugs: antidepressants, and anxiolytics and hypnotics. Falling is common among elderly people and is associated with greater morbidity, disability, social isolation, and reduced quality of life.
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Midazolam calms agitation faster than haloperidolpromethazine
Midazolam works faster than haloperidol-promethazine in calming agitated patients. In a pragmatic randomised clinical trial in Brazil (p 708), 301 agitated or aggressive patients were randomised to intramuscular midazolam or intramuscular haloperidol plus promethazine. Almost 90% of patients given midazolam were tranquil or asleep after 20 minutes, compared with two thirds of those given haloperidol-promethazine. One potentially severe adverse event occurred with each treatment.
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