Press releases Monday 20 April to Friday 24 April 2009

Please remember to credit the BMJ as source when publicising an article and to tell your readers that they can read its full text on the journal's website (http://www.bmj.com).

(1) Changing the way organ donation requests are made could prevent relatives denying consent
(2) Should cervical screening stop at age 50?
(2) Study calls for better provision for disabled children

(1) Study reveals substantial under-treatment of older people after stroke
(Research: Modifiable factors influencing relatives' decision to offer organ donation: systematic review)
http://www.bmj.com/cgi/doi/10.1136/bmj.b991
(Editorial: Improving relatives' consent to organ donation)
http://www.bmj.com/cgi/doi/10.1136/bmj.b701

Timing and whether a transplant coordinator makes the request are key factors in whether relatives consent to organ donation, according to a study published on bmj.com today.

Demand for organs far exceeds supply and in the UK this results in one patient on the transplant waiting list dying every day. One of the biggest barriers to increased donor rates is the refusal of consent by relatives.

A recent audit of 341 deaths in intensive care units in the UK revealed that 41% of relatives of potential donors denied consent. In an interview study a third of relatives who had refused donation said that they would not refuse again, whereas only a few of people who had given consent regretted their decision.

Lead author Dr Duncan Young, from John Radcliffe Hospital in Oxford, believes that given the refusal from relatives blocks so many transplants from going ahead, it is important to find out what factors would help them uphold the wishes of their next of kin.

The authors carried out a review of 20 studies on organ donation to investigate what factors either encouraged or discouraged relatives to consent. Two issues had the strongest effect on relatives: timing and the person making request. It is essential that a request for organ donation does not take place when notification of death is communicated to relatives or when brain stem death testing takes place - it is very important that there is a gap between ‘bad news' and a request for donation, say the authors.

The person making the request is also key and the study concludes that in an ideal situation a donor transplant coordinator together with hospital staff would make the request.

The following issues were also significantly linked to relatives denying or allowing donation to go ahead: the level of information they were given, how they perceived the quality of care given to their loved one, understanding what brain stem death actually means, the setting for the request (a private location is best), the approach and expertise of the individual and giving families enough time to consider the request.

The authors conclude that although their findings may be "unsurprising," implementing them may increase donation rates and ultimately save lives. They argue that "organ donation may be of sufficient benefit to society generally, and to organ recipients specifically, to justify the study and modification of organ donation requests to maximize consent."

In an accompanying editorial, Teresa Shafer from the LifeGift Organ Donation Center in Texas, says that requesting consent for donation is not simply "popping the question" but rather "a dynamic process consisting of observation, collaboration, planning, and action that is based on family and hospital dynamics."

She argues that hospitals and organ procurement organisations need to work together to increase the number of organs available and that "the donation request is too important to delegate to those who are not expert, prepared and focused on a successful outcome."

Contacts:
Research: Dr Duncan Young, Consultant in Critical Care, John Radcliffe Hospital, Oxford, UK
Email: duncan.young@nda.ox.ac.uk

REditorial: Teresa Shafer, Executive Vice President and Chief Operating Officer, LifeGift Organ Donation Center, Fort Worth, Texas, USA
Email: tsahfer@lifegift.org

It is not consistent to stop screening women after age 50 because the risk of cervical cancer - even after several negative smear results - is similar to that at younger ages, concludes a study published on bmj.com today.

Ever since the first organised cervical screening programmes started in Europe more than 40 years ago, discussion about the upper age limit for effective screening has been ongoing.

Evidence suggests that repeating smear tests in women aged 60-65 whose previous tests have been normal has little, if any, benefit, and some researchers have proposed that the age limit should be lowered to 50.

So researchers at the Erasmus Medical Center in The Netherlands and the University of Copenhagen in Denmark compared levels of cervical cancer after several negative smears at different ages.

Using data from a national cervical cancer register in The Netherlands (PALGA), they identified 219,000 women aged 45-54 years and 445,000 women aged 30-44 years after their third consecutive negative smear test. The women were then tracked for 10 years, during which time cases of cervical cancer were recorded.

During follow-up, both age groups had similar levels of screening. After 10 years, the incidence of cervical cancer was similar in both groups (41 per 100,000 in the younger group and 36 per 100,000 in the older group), suggesting that among well-screened women without previous abnormalities the risk of developing cervical cancer is independent of age.

Based on these results, it is reasonable to assume that after several consecutive negative results the screening efficiency in terms of detection and prevention of cervical cancer is at the same level around age 50 as it is at younger ages, say the authors.

Whether the observed incidence rates warrant continued screening should be determined by subsequent analysis, but the study suggests that it would not be consistent to stop screening these women while not also relaxing the screening policy for younger women with similar screening histories.

In this respect, our study lends support to the current cervical cancer screening guidelines in England and other developed countries, which do not discriminate women by age up to 65 years, they conclude.

In an accompanying editorial, Björn Strander, Director of cervical screening at Sahlgren's University Hospital in Sweden, suggests we have to pay close attention to developments in invasive cancer in age groups above the cut-off point for screening and be prepared to adjust the screening ages as we learn more.

With modern computer technology we could tailor screening invitations to the individual, he says. Resources could then be allocated away from women who would not benefit from additional smears within a certain number of years to those who would, and the question of whether to screen above the age of 60 could then be answered - yes, for those who benefit the most from it.

Contacts:
Research: Matejka Rebolj, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
Email: m.rebolj@pubhealth.ku.dk

(2) Study calls for better provision for disabled children
(Research: Participation in life situations of 8-12 year old children with cerebral palsy: cross sectional European study)
http://www.bmj.com/cgi/doi/10.1136/bmj.b1458
(Editorial: Childhood disability and social policies)
http://www.bmj.com/cgi/doi/10.1136/bmj.b1020

Some European countries could make better provision for disabled children to allow them to participate in life on an equal basis with others, concludes a large study published on bmj.com today.

Participation, defined as involvement in life situations, is important for all children, but little is known about it in disabled children.

So a team of researchers set out to assess variations in the nature and rates of participation of 818 children with cerebral palsy aged 8-12 years in several European countries.

The children were randomly selected from population registers covering eight regions of six European countries (southeast France, southwest France, southwest Ireland, west Sweden, north England, Northern Ireland, east Denmark and central Italy).

Parents and children were interviewed about their participation in 10 main areas (domains) of daily life, such as mealtimes, communication, relationships, school and recreation.

Parents provided demographic information, such as type of employment, level of educational qualifications and whether the family lived in an urban or rural area. Frequency and severity of pain were assessed, and background information about each child's impairments including movement (motor function), intellectual ability, vision, hearing and communication was also collated.

Children with pain and those with more severely impaired walking, fine motor skills, communication and intellectual abilities had significantly lower participation on most domains. Even after controlling for severity of impairment, pain was strongly associated with lower levels of participation.

Participation on all domains also varied substantially between regions, with children in Denmark having much higher participation than children in other regions, after adjusting for impairment and pain.

These findings show how important it is to assess children's pain status and manage it effectively, say the authors. National policies and legislation in different countries can also have a powerful influence on the day to day lives of people with disabilities and their families, they add.

They suggest that both pain and participation of disabled children should be assessed in clinical practice to help guide intervention. They also recommend that national regulation and legislation should be directed to ensuring all countries adapt environments to optimise the participation of disabled children, building on the experience of those countries that make best provision.

This study reflects modern thinking about health and function, writes Peter Rosenbaum, Professor of Paediatrics at McMaster University in Canada, in an accompanying editorial.

He suggests that our efforts in childhood disability should be to promote the acquisition and enhancement of life skills in all dimensions, to enable young disabled people to participate in both the instrumental and discretionary opportunities of their lives, as the current study has explored.

"If we can broaden our clinical thinking beyond the biomedical dimensions of diseases to include participation ... we may help improve the quality of life and long term wellbeing of disabled children and young people along with their families," he concludes.

Contacts:
Research: Allan Colver, Professor of Community Child Health, Newcastle University, Royal Victoria Infirmary, Newcastle upon Tyne, UK
Email: allan.colver@ncl.ac.uk

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