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This week in BMJ Saturday 29 March 1997

Women with breast cysts of type I have increased risk of breast cancer

Several studies have shown that women with palpable cysts in their breasts are at increased risk of breast cancer. Two types of breast cyst can be identified - type I cysts, with low concentrations of sodium and high concentrations of potassium ions, and type II cysts, with opposite characteristics. Bruzzi et al (p 925) investigated the correlation between cyst type and risk of breast cancer in 802 women with aspirated breast cysts. After a median follow up of six years, the women had a relative risk of breast cancer of 1.69 compared with the local general population, and those with type I cysts had a risk four times higher than those with type II cysts. The authors conclude that the excess risk of breast cancer in women with breast cysts seems to be concentrated among women with type I cysts, but the size and duration of this risk are still to be assessed.

Financial incentives seem to influence retirement on grounds of ill health

Many doctors are asked by pension companies whether a patient of theirs should retire from work. Poole (p 929) has studied the processes and outcomes of ill health retirement in four public and two private organisations. Rates of retirement were found to vary greatly between organisations, and in two, rates varied geographically within the same organisation. In four, modes of age or length of service coincided with enhancements in benefits, suggesting that financial incentives were strongly influencing applications to retire. In two, women retired at a greater rate than men up to age 40 and over age 50. The author believes that pension schemes need to improve their processes for granting ill health benefits. Doctors should be wary of  conflicts of interest and work to guidelines when advising on the merits of a patient's application.

Echocardiography may not be essential in patients with acute dyspnoea

Echocardiography is an essential investigation in patients with suspected left ventricular systolic dysfunction, but its availability is currently limited in the NHS. On p 936 Gillespie et al show that echocardiography may not be essential in diagnosing left ventricular systolic dysfunction in patients with acute dyspnoea if they have abnormal results on electrocardiography or chest radiography. This finding could be used to streamline the selection of patients for echocardiography, with priority being given to those in whom there is most diagnostic doubt.

Free care for children in rural South Africa has increased clinic attendance for minor illnesses

Charging user fees for primary care services in developing countries is controversial. Large declines in attendance have often been reported when fees have been introduced. South Africa's new government abolished all charges applying to children under 6 years and to pregnant and lactating women. Wilkinson et al (p 940) report the impact of this policy change on the number of patients attending a rural mobile clinic service. Attendance by children for immunisation and growth monitoring did not increase; nor did attendance for antenatal care, though women did start antenatal care a little earlier. The largest change was in the number of children seeking treatment for apparently minor illnesses - a workload widely perceived by staff as largely unnecessary. When preventive services such as immunisation and antenatal care are functioning well, a blanket introduction of free care may not be the best policy.

Guidelines do not improve blood pressure control in primary care

The primary care white paper suggests that guideline development should be encouraged by the Royal College of General Practitioners. Previous studies have determined that guidelines have been ineffective because the implementation process failed to use a bottom up approach. In a study over two years Mashru and Lant (p 942) found that despite general practitioners having the ownership of criteria in standard setting, improvement in blood pressure control was not achieved. General practitioners did, however, improve their management of hypertensive patients by better recording of more routine measurements such as body mass index and selected laboratory investigations in patients' notes. The results suggest that research is needed into the educational methods best suited to bringing about complex behavioural changes affecting clinical management of patients.