The precariousness of living with, and caring for people with, dementia: Insights from the IDEAL programme.

This paper uses precarity as a framework to understand the vulnerabilities experienced by those living with or caring for someone living with dementia. Drawing on qualitative interview data from the Improving the Experience of Dementia and Enhancing Active Life (IDEAL) programme, we attend to our participants' reflections on how they manage the condition and the wider circumstances in which this occurs. To interrogate the utility of precarity, we focus on our participants' descriptions of needs and challenges and set these alongside both the wider contexts in which they seek or offer care (formal and informal) and the sets of values attributed to different ways of living with dementia. Building on the work of Portacolone, our analysis identified four interconnected themes: uncertainty; experiences of support and services; independence and personhood; and cumulative pressures and concerns. We develop this analysis by reviewing how our themes reflect, extend, or depart from previously identified markers of precarity and consider the specific ways in which these markers shape the lives of those living with dementia.

Pattern of upper limb amputation associated with lower limb amputation: the UK military experience from Iraq and Afghanistan.

INTRODUCTION: The conflicts in Iraq and Afghanistan resulted in large numbers of personnel sustaining extremity injuries. In the context of polytrauma, partial hand amputation is often unrecorded. The aim of this work was to quantify the burden of upper limb (UL) amputation at any level occurring concurrently with a major (ankle and proximal) lower limb (LL) amputation. Knowledge of this cohort could aid in prosthetic modification to further improve quality of life outcomes in a population with dexterity loss. METHOD: A trauma database search was undertaken for all UK military LL amputees from the conflicts in Iraq and Afghanistan. A manual search method was employed to identify from the major LL amputees those who had a concurrent UL amputation at any level (including isolated finger amputation). Demographics, level of amputation, and injury profile data were recorded. RESULTS: Sixty-eight individuals were identified; the most prevalent population was bilateral LL with a unilateral UL amputation (60%). Most UL amputations were partial hand (75%). The was no statistically significant difference between left or right side (p=0.13). On the left side, correlation was found between amputation of the thumb and third digit (rho=0.34; p=0.005) not seen on the right. CONCLUSION: We have determined the rate of UL amputation at any level, in combination with LL amputation as a result of blast injury. Knowledge of these combinations enables further research to support anecdotal evidence that there is a need for tailored prosthetics in the context of potential dexterity loss making donning and doffing problematic.

Military trauma and orthopaedics experience of the UK COVID-19 pandemic: a lesson in versatility and how it can influence our deployed role.

The COVID-19 pandemic necessitated unprecedented change within the NHS. Some medical staff have been deployed into unfamiliar roles, while others have been exposed to innovative ways of working. The embedded military Trauma and Orthopaedic (T&O) cadre have been integral to this change. Many of these new skills and ways of working learnt will be transferable to deployed environments. Feedback from the T&O military cadre highlighted key areas of learning as changes in T&O services, use of technology, personal protective equipment, redeployment and training. This paper aims to discuss how these changes were implement and how they could be used within future military roles. The T&O cadre played important roles within their NHS trusts and the skills they learnt will broaden their skills and knowledge for future deployments.

Local injection of a hexametaphosphate formulation reduces heterotopic ossification in vivo.

Heterotopic ossification (HO), the pathological formation of ectopic bone, is a debilitating condition which can cause chronic pain, limit joint movement, and prevent prosthetic limb fitting. The prevalence of this condition has risen in the military population, due to increased survivorship following blast injuries. Current prophylaxes, which aim to target the complex upstream biological pathways, are inconsistently effective â€‹and have a range of side-effects that make them unsuitable for combat-injured personnel. As such, many patients must undergo further surgery to remove the formed ectopic bone. In this study, a non-toxic, U.S. Food and Drug Administration (FDA) -approved calcium chelator, hexametaphosphate (HMP), is explored as a novel treatment paradigm for this condition, which targets the chemical, rather that biological, â€‹bone formation pathways. This approach allows not only prevention of pathological bone formation â€‹but also uniquely facilitates reversal, which current drugs cannot achieve. Targeted, minimally invasive delivery is achieved by loading HMP into an injectable colloidal alginate. These formulations significantly reduce â€‹the length of the ectopic bone formed in a rodent model of HO, with no effect on the adjacent skeletal bone. This study demonstrates the potential of localized dissolution as a new treatment â€‹and an alternative to surgery â€‹for pathological ossification and calcification conditions.

The pattern of paediatric blast injury in Afghanistan.

INTRODUCTION: Between 2009 and 2015, 3746 children died, and 7904 were injured as a result of armed conflict within Afghanistan. Improvised explosive devices (IEDs) and explosive remnants of war accounted for 29% of child casualties in 2015. The aim of this study was to review the burden of paediatric blast injuries admitted to Camp Bastion, Afghanistan, and to investigate the hypothesis that children suffer proportionally more head injuries than adults. METHOD: A retrospective analysis was undertaken of prospectively collected data derived from the UK Joint Theatre Trauma Registry of ambulant paediatric (aged 2-15 years) admissions with blast injuries at the Role 3 Field Hospital, Camp Bastion from June 2006 to March 2013. The data set included demographic information, injury profile and severity (New Injury Severity Score) and operative findings. The pattern of injuries were investigated by looking at trends in the number and severity of injuries sustained by each body region. RESULTS: During this period, 295 admissions were identified, 76% of whom were male, with an overall mortality rate of 18.5%. The most common blast mechanism was an IED (68%) causing 80% of fatalities. The lower extremities were the most commonly injured body region, accounting for 31% of total injuries and occurring in 62% of cases. 24.3% of children between 2 and 7 years suffered severe head or neck injuries compared with 19.8% of children aged between 8 and 15 years. 34% of head injuries were rated unsurvivable and accounted for 88% of fatalities. 77% of cases required an operation with a mean operating time of 125 min. The most common first operations were debridement of soft tissues (50%), laparotomy (16%) and lower limb amputation (11%). CONCLUSION: Although paediatric blast casualties represented a small percentage of the overall workload at Camp Bastion Role 3 Medical Facility, the pattern of injuries seen suggests that children are more likely to sustain severe head, face and neck injuries than adults.

The burden of gunshot wounding of UK military personnel in Iraq and Afghanistan from 2003-14.

INTRODUCTION: Gunshot wounding (GSW) is the second most common mechanism of injury in warfare after explosive injury. The aim of this study was to define the clinical burden of GSW placed on UK forces throughout the recent Iraq and Afghanistan conflicts. METHODS: This study was a retrospective review of data from the UK Military Joint Theatre Trauma Registry (JTTR). A JTTR search identified records within the 12 year period of conflict between 19 Mar 2003 and 27 Oct 2014 of all UK military GSW casualties sustained during the complete timelines of both conflicts. Included cases had their clinical timelines and treatment further examined from time of injury up until discharge from hospital or death. RESULTS: There were 723 casualties identified (177 fatalities, 546 survivors). Median age at the time of injury was 24 years (range 18-46 years), with 99.6% of casualties being male. Most common anatomical locations for injury were the extremities, with 52% of all casualties sustaining extremity GSW, followed by 16% GSW to the head, 15% to the thorax, and 7% to the abdomen. In survivors, the rate of extremity injury was higher at 69%, with head, thorax and abdomen injuries relatively lower at 5%, 11% and 6% respectively. All GSW casualties had a total of 2827 separate injuries catalogued. A total of 545 casualties (523 survivors, 22 fatalities) underwent 2357 recorded surgical procedures, which were carried out over 1455 surgical episodes between admission to a deployed medical facility and subsequent transfer to the Royal Centre for Defence Medicine (RCDM) in the UK. This gave a median of 3 (IQR 2-5) surgical procedures within a median of 2 (IQR 2-3) surgical episodes per casualty. Casualties had a combined length of stay (LoS) of 25 years within a medical facility, with a mean LoS in a deployed facility of 1.9 days and 14 days in RCDM. CONCLUSION: These findings define the massive burden of injury associated with battlefield GSW and underscore the need for further research to both reduce wound incidence and severity of these complex injuries.

A review of 10 years of scapula injuries sustained by UK military personnel on operations.

BACKGROUND: Scapula fractures are relatively uncommon injuries, mostly occurring due to the effects of high-energy trauma. Rates of scapula fractures are unknown in the military setting. The aim of this study is to analyse the incidence, aetiology, associated injuries, treatment and complications of these fractures occurring in deployed military personnel. METHODS: All UK military personnel returning with upper limb injuries from Afghanistan and Iraq were retrospectively reviewed using the Royal Centre for Defence Medicine database and case notes (2004-2014). RESULTS: Forty-four scapula fractures out of 572 upper limb fractures (7.7%) were sustained over 10 years. Blast and gunshot wounds (GSW) were leading causative factors in 85%. Over half were open fractures (54%), with open blast fractures often having significant bone and soft tissue loss requiring extensive reconstruction. Multiple injuries were noted including lung, head, vascular and nerve injuries. Injury Severity Scores (ISS) were significantly higher than the average upper limb injury without a scapula fracture (p<0.0001). Brachial plexus injuries occurred in 17%. While military personnel with GSW have a favourable chance of nerve recovery, 75% of brachial plexus injuries that are associated with blast have poorer outcomes. Fixation occurred with either glenoid fractures or floating shoulders (10%); these were as a result of high velocity GSW or mounted blast ejections. There were no cases of deep soft tissue infection or osteomyelitis and all scapula fractures united. CONCLUSION: Scapula fractures have a 20 times higher incidence in military personnel compared with the civilian population, occurring predominantly as a result of blast and GSW, and a higher than average ISS. These fractures are often associated with multiple injuries, including brachial plexus injuries, where those sustained from blast have less favourable outcome. High rates of union following fixation and low rates of infection are expected despite significant contamination and soft tissue loss.

Computational modelling of wounded tissue subject to negative pressure wound therapy following trans-femoral amputation.

Proof-of-concept computational models were developed and applied as tools to gain insights into biomechanical interactions and variations of oxygen gradients of wounded tissue subject to negative pressure wound therapy (NPWT), following trans-femoral amputation. A macro-scale finite-element model of a lower limb was first developed based on computed tomography data, and distributions of maximum and minimum principal stress values we calculated for a region of interest (ROI). Then, the obtained results were applied iteratively as new sets of boundary conditions for a specific spatial position in a capillary sub-model. Data from coupled capillary stress and mass- diffusion sub-models were transferred to the macro-scale model to map the spatial changes of tissue oxygen gradients in the ROI. The -70 mmHg NPWT resulted in a dramatic change of a wound surface area and the greatest relative contraction was observed at -150 mmHg. Tissue lateral to the depth of the wound cavity revealed homogenous patterns of decrease in oxygenation area and the extent of such decrease was dependent on the distance from the wound surface. However, tissue lateral to the width of the wound demonstrated heterogeneous patterns of change, as evidenced by both gradual increase and decrease in the oxygenation area. The multiscale models developed in the current study showed a significant influence of NPWT on both macro-deformations and changes of tissue oxygenation. The patterns of changes depended on the depth of the tissue, the geometry of the wound, and also the location of tissue plane.

Towards research combat readiness: prepared, prospective and preapproved.

Research drives the advancement of medical knowledge during war, but planning and execution are too slow to enable early data acquisition. Future conflicts are likely to be shorter and more dispersed, requiring innovation to avoid missing out on the crucial early stages. To seize the initiative, we suggest that a collection of preapproved research studies be designed, stored and maintained within the medical command structure so that they are ready for immediate implementation at the onset of future conflicts, even during the most kinetic early phases of deployment.

Human factors in contingency operations.

The UK Defence Medical Services are currently supporting contingency operations following a period of intensive activity in relatively mature trauma systems in Iraq and Afghanistan. Among the key lessons identified, human factors or non-technical skills played an important role in the improvement of patient care. This article describes the importance of human factors on Role 2 Afloat, one of the Royal Navy's maritime contingency capabilities, and illustrates how they are vital to ensuring that correct decisions are made for patient care in a timely manner. Teamwork and communication are particularly important to ensure that limited resources such as blood products and other consumables are best used and that patients are evacuated promptly, allowing the facility to accept further casualties and therefore maintain operational capability. These ideas may be transferred to any small specialist team given a particular role to perform.

40 years of terrorist bombings - A meta-analysis of the casualty and injury profile.

INTRODUCTION: Terrorists have used the explosive device successfully globally, with their effects extending beyond the resulting injuries. Suicide bombings, in particular, are being increasingly deployed due to the devastating effect of a combination of high lethality and target accuracy. The aim of this study was to identify trends and analyse the demographics and casualty figures of terrorist bombings worldwide. METHODS: Analysis of the Global Terrorism Database (GTD) and a PubMed/Embase literature search (keywords "terrorist", and/or "suicide", and/or "bombing") from 1970 to 2014 was performed. RESULTS: 58,095 terrorist explosions worldwide were identified in the GTD. 5.08% were suicide bombings. Incidents per year are increasing (P<0.01). Mean casualty statistics per incidents was 1.14 deaths and 3.45 wounded from non-suicide incidents, and 10.16 and 24.16 from suicide bombings (p<0.05). The kill:wounded ratio was statistically higher in suicide attacks than non-suicide attacks, 1:1.3 and 1:1.24 respectively (p<0.05). The Middle East witnessed the most incidents (26.9%), with Europe (13.2%) ranked 4th. The literature search identified 41 publications reporting 167 incidents of which 3.9% detailed building collapse (BC), 60.8% confined space (CS), 23.5% open space (OS) and 11.8% semi-confined space (SC) attacks. 60.4% reported on suicide terrorist attacks. Overall 32 deaths and 180 injuries per incident were seen, however significantly more deaths occurred in explosions associated with a BC. Comparing OS and CS no difference in the deaths per incident was seen, 14.2(SD±17.828) and 15.63 (SD±10.071) respectively. However OS explosions resulted in significantly more injuries, 192.7 (SD±141.147), compared to CS, 79.20 (SD±59.8). Extremity related wounds were the commonest injuries seen (32%). DISCUSSION/CONCLUSION: Terrorist bombings continue to be a threat and are increasing particularly in the Middle East. Initial reports, generated immediately at the scene by experienced coordination, on the type of detonation (suicide versus non-suicide), the environment of detonation (confined, open, building collapse) and the number of fatalities, and utilising the Kill:Wounded ratios found in this meta-analysis, can be used to predict the number of casualties and their likely injury profile of survivors to guide the immediate response by the medical services and the workload in the coming days.

The Ship's Doctor in the Royal Navy--100 years of tradition and progress.

The changing role of the Senior Service over the past century through numerous militarily heterogeneous environments and operations has necessitated an evolution in the role of the deployed Medical Officer. However: versatility, specialist knowledge, caring for a wide and varied patient population of friendly and enemy forces, and the dual role of being an officer as well as a doctor, have remained consistent. Identifiable changes in military medical officer training, the shape of the Defence Medical Services, and modern advances in treatment and communication have evolved the Ship's Doctor role from the pre-Second World War setting of a contracted Naval Medical Service, through growth, to a shrinking cadre again in a return to the contingency operations of today. Still, the role today remains attractive to a subset of doctors looking for something more from their medical practice; as the nature of conflict changes, so too will the role of the Ship's Doctor. The ongoing requirement for flexibility and versatility will remain. Medical Officers will continue to meet the need to provide high quality care to their patients and, as has always been the case, will continue to be drawn to the Service's principal appeal of an exciting world-wide role with the potential for unique experiences.

The principles of managing open fractures.

Any fracture of a bone which communicates with the outside environment via a wound in the skin is classified as an open fracture. This may be from penetration by sharp objects from the exterior, laceration caused by the fracture fragments, or shearing forces that tear or de-glove soft tissue from a limb. These injuries vary in mechanism and severity, ranging from a broken finger caught in a bulkhead door to a catastrophic lower limb fracture suffered from an improvised explosive device (IED). We address the management principles that can be applied to all open fractures regardless of cause.

'Did not attends' in children 0-10: a scoping review.

Patients who do not attend ('DNA') health appointments have been identified as a service problem incurring significant costs to the NHS. In order to explore the causes, effects and costs of child DNAs, we carried out a scoping study to map the literature and identify gaps in the research. Given the breadth of issues underpinning DNAs, a scoping study, including research studies, audits, policy documents and conference abstracts, was the most useful way to map the field. To foster public and patient participation, we sought advice from parents participating in the National Children's Bureau's Family Research Advisory Group. From a pool of 1997 items, we found few UK studies with non-attendance of 0-10 year olds as a primary focus, though many more incidentally reported DNA rates. Overall, four topics predominated: the conceptualization of DNAs; the correlates of non-attendance; initiatives to reduce non-attendance; and the relationship between non-attendance and safeguarding. The Family Research Advisory Group identified broadly similar issues, but with a stronger emphasis on communication and practical matters. While there may be circumstances where failing to attend appointments makes little or no difference to a child (or even benefits them) it is likely that there are children whose health or well-being are compromised as a result of failing to attend appointments. Both 'over' and 'under'-attendance can be a source of anxiety to health professionals. Areas where further work is needed include robust evaluation of the effectiveness, cost-effectiveness and maintenance of measures to reduce DNAs and a better understanding of the relationship of safeguarding to non-attendance.

Comparison of cancer diagnostic intervals before and after implementation of NICE guidelines: analysis of data from the UK General Practice Research Database.

BACKGROUND: The primary aim was to use routine data to compare cancer diagnostic intervals before and after implementation of the 2005 NICE Referral Guidelines for Suspected Cancer. The secondary aim was to compare change in diagnostic intervals across different categories of presenting symptoms. METHODS: Using data from the General Practice Research Database, we analysed patients with one of 15 cancers diagnosed in either 2001-2002 or 2007-2008. Putative symptom lists for each cancer were classified into whether or not they qualified for urgent referral under NICE guidelines. Diagnostic interval (duration from first presented symptom to date of diagnosis in primary care records) was compared between the two cohorts. RESULTS: In total, 37,588 patients had a new diagnosis of cancer and of these 20,535 (54.6%) had a recorded symptom in the year prior to diagnosis and were included in the analysis. The overall mean diagnostic interval fell by 5.4 days (95% CI: 2.4-8.5; P<0.001) between 2001-2002 and 2007-2008. There was evidence of significant reductions for the following cancers: (mean, 95% confidence interval) kidney (20.4 days, -0.5 to 41.5; P=0.05), head and neck (21.2 days, 0.2-41.6; P=0.04), bladder (16.4 days, 6.6-26.5; P≤0.001), colorectal (9.0 days, 3.2-14.8; P=0.002), oesophageal (13.1 days, 3.0-24.1; P=0.006) and pancreatic (12.6 days, 0.2-24.6; P=0.04). Patients who presented with NICE-qualifying symptoms had shorter diagnostic intervals than those who did not (all cancers in both cohorts). For the 2007-2008 cohort, the cancers with the shortest median diagnostic intervals were breast (26 days) and testicular (44 days); the highest were myeloma (156 days) and lung (112 days). The values for the 90th centiles of the distributions remain very high for some cancers. Tests of interaction provided little evidence of differences in change in mean diagnostic intervals between those who did and did not present with symptoms specifically cited in the NICE Guideline as requiring urgent referral. CONCLUSION: We suggest that the implementation of the 2005 NICE Guidelines may have contributed to this reduction in diagnostic intervals between 2001-2002 and 2007-2008. There remains considerable scope to achieve more timely cancer diagnosis, with the ultimate aim of improving cancer outcomes.

The risk of oesophago-gastric cancer in symptomatic patients in primary care: a large case-control study using electronic records.

BACKGROUND: Over 15 000 new oesophago-gastric cancers are diagnosed annually in the United Kingdom, with most being advanced disease. We identified and quantified features of this cancer in primary care. METHODS: Case-control study using electronic primary-care records of the UK patients aged ≥40 years was performed. Cases with primary oesophago-gastric cancer were matched to controls on age, sex and practice. Putative features of cancer were identified in the year before diagnosis. Odds ratios (ORs) were calculated for these features using conditional logistic regression, and positive predictive values (PPVs) were calculated. RESULTS: A total of 7471 cases and 32 877 controls were studied. Sixteen features were independently associated with oesophago-gastric cancer (all P<0.001): dysphagia, OR 139 (95% confidence interval 112-173); reflux, 5.7 (4.8-6.8); abdominal pain, 2.6 (2.3-3.0); epigastric pain, 8.8 (7.0-11.0); dyspepsia, 6 (5.1-7.1); nausea and/or vomiting, 4.9 (4.0-6.0); constipation, 1.5 (1.2-1.7); chest pain, 1.6 (1.4-1.9); weight loss, 8.9 (7.1-11.2); thrombocytosis, 2.4 (2.0-2.9); low haemoglobin, 2.4 (2.1-2.7); low MCV, 5.2 (4.2-6.4); high inflammatory markers, 1.7 (1.4-2.0); raised hepatic enzymes, 1.3 (1.2-1.5); high white cell count, 1.4 (1.2-1.7); and high cholesterol, 0.8 (0.7-0.8). The only PPV >5% in patients ≥55 years was for dysphagia. In patients <55 years, all PPVs were <1%. CONCLUSION: Symptoms of oesophago-gastric cancer reported in secondary care were also important in primary care. The results should inform guidance and commissioning policy for upper GI endoscopy.

The risk of pancreatic cancer in symptomatic patients in primary care: a large case-control study using electronic records.

BACKGROUND: Over 8000 new pancreatic cancers are diagnosed annually in the UK; most at an advanced stage, with only 3% 5-year survival. We aimed to identify and quantify the risk of pancreatic cancer for features in primary care. METHODS: A case-control study using electronic primary care records identified and quantified the features of pancreatic cancer. Cases, aged ≥40 in the General Practice Research Database, UK, with primary pancreatic cancer were matched with controls on age, sex and practice. Putative features of pancreatic cancer were identified in the year before diagnosis. Odds ratios (OR) were calculated for features of cancer using conditional logistic regression. Positive predictive values (PPV) were calculated for consulting patients. RESULTS: In all, 3635 cases and 16,459 controls were studied. Nine features were associated with pancreatic cancer (all P<0.001 except for back pain, P=0.004); jaundice, OR 1000 (95% confidence interval (CI) 4,302,500); abdominal pain, 5 (4.4, 5.6); nausea/vomiting, 4.5 (3.5, 5.7); back pain, 1.4 (1.1, 1.7); constipation, 2.2 (1.7, 2.8); diarrhoea, 1.9 (1.5, 2.5); weight loss, 15 (11, 22); malaise, 2.4 (1.6, 3.5); new-onset diabetes 2.1 (1.7, 2.5). Positive predictive values for patients aged ≥60 were <1%, apart from jaundice at 22% (95% CI 14, 52), though several pairs of symptoms had PPVs >1%. CONCLUSION: Most previously reported symptoms of pancreatic cancer were also relevant in primary care. Although predictive values were small - apart from jaundice - they provide a basis for selection of patients for investigation, especially with multiple symptoms.

Limb salvage of severely injured extremities after military wounds.

Severely wounded extremities following battlefield injuries present a surgical dilemma to military surgeons of whether to attempt salvage or amputate the limb. There are many considerations to be made, including local and systemic patient factors, other wounded personnel and logistical constraints. Attempts have been made previously to form objective scoring criteria so as to remove possible subjectivity in this decision-making process. Furthermore, paediatric patients present their own particular dilemmas. This paper examines these various matters and, with contemporaneous evidence, presents recommendations for management.

Pathways to the diagnosis of ovarian cancer in the UK: a cohort study in primary care.

OBJECTIVE: To identify the routes patients with ovarian cancer take between first symptom presentation and diagnosis. DESIGN: Cohort study. SETTING: The study took place in 39 general practices in Devon, UK. POPULATION: All ovarian cancer patients identified in the practices, with a diagnosis between 2000 and 2007 inclusive. METHODS: All patients had their cancer symptoms, referrals, and diagnoses identified and dated using their doctors' records. MAIN OUTCOME MEASURES: Numbers of patients taking specific routes to diagnosis, together with the time taken to diagnosis. RESULTS: Three main routes to diagnosis emerged. The first was the expected route of outpatient referral: 195 (92% of the total) had at least one of the seven ovarian cancer symptoms or an abdominal mass. A total of 123 (58%) were referred to a specialist, although only 65 (31%) were referred to a gynaecologist. Thirty-five (17%) were initially investigated within primary care by ultrasound scanning, and a further 35 (17%) were admitted as emergencies. The interval from first symptom to referral was similar across the different pathways, with a median (interquartile range) time between the first symptom presenting to primary care and first investigation or referral being 2.5 (0, 27.5) days. The median interval from first symptom reported in primary care to diagnosis was 74.5 (32, 159) days. CONCLUSIONS: Only a minority of ovarian cancer patients follow the expected route to diagnosis, of urgent referral to a gynaecologist. In most women, GPs rapidly identified the need to investigate. Avoidable delays generally occurred after the decision to investigate was made.

What happens to new-onset headache in children that present to primary care? A case-cohort study using electronic primary care records.

The aim was to describe the consulting behaviour and clinical outcomes of children presenting with headache in primary care. This was a historical cohort study using data from the UK General Practitioner Research Database. Cases were children aged 5-17 years who presented to primary care with primary headache (migraine, tension-type headache, cluster headache) or undifferentiated headache (no further descriptor). Controls were age, sex and practice matched. Their records were examined for consultations, referrals, relevant treatments and specific diseases in the subsequent year. Children with headache (n = 48 575) were identified and matched to controls. At presentation, 9321 (19.2%) of headaches were labelled primary, 549 (1.1%) secondary and 38 705 (79.7%) received no formal diagnosis. Of the latter group, 2084 (5.4%) received a primary headache diagnosis in the subsequent year. Following a diagnosis of migraine, 258 (3.5%) had received a triptan and 1598 (21%) were using propranolol or pizotifen. Total consultations were higher in cases than in controls in the year before the headache: cases ages 5-8 years, mean (s.d.) 5.0 (4.0) consultations; controls 4.0 (3.5) consultations. In 1 year controls had 43 430 consultations, of which 256 (0.6%) were for headache, of whom 64 (25%) were referred to secondary care. Headache was a risk factor for benign and malignant tumours, cerebrovascular disease, primary disorders of raised intracranial pressure and depression. This risk was reduced if a diagnosis of a primary headache disorder could be made. Although there is an increased likelihood of a serious pathology with headache presentations, the risk is small particularly if a diagnosis of a primary headache is made. General practitioners are likely to be underdiagnosing migraine. This study can inform management guidelines for new presentations of headache in primary care, particularly when a secondary pathology is suspected.