Transition from service to civvy street: the needs of armed forces veterans and their families in the UK.

AIMS:: Although many veterans make the transition from military to civilian life without difficulty, a small proportion struggle due to an impact on mental and physical wellbeing. Stigma and a reluctance to seek help further exacerbate this problem. The Armed Forces Covenant outlines the importance of ensuring that public services are aware of the specific needs of veterans; however, evidence suggests that knowledge among professional staff may be limited. METHODS:: This exploratory study included three phases. Phase 1 (questionnaires) explored the needs of veterans and their families in Warwickshire (UK) regarding information about their health and wellbeing and the barriers and facilitators to accessing local public health services. Also in Phase 1, health and public services staff knowledge of veterans' needs and the Covenant is explored. In Phase 2, both samples attended a related focus group for a more in-depth exploration of the issues identified in Phase 1; in order to inform a Phase 3 workshop to co-develop an intervention. RESULTS:: Veterans, their families and friends, wanted more information about what services do, how and when to access them and what to expect. Confusion over when to seek help for mental health 'symptoms' was highlighted. More support for families was identified, alongside a need for health and social care staff to have a better understanding of the unique experiences and needs of veterans. Only 35% of staff reported a good understanding of the Armed Forces Covenant and their responsibilities to uphold it. CONCLUSIONS:: Public health teams within UK local authorities are well placed to ensure veterans have more knowledge about and access to public services. Interventions to address stigma and veterans' reluctance to seek help were needed. To this end, interventions for local veterans, their loved ones and staff in public services, designed in co-creation with these groups, is discussed.

Audit of suspected meningitis in a district in 1996-1997 and in 1999.

The Public Health Laboratory Service has published guidance outlining appropriate investigations and public health action to control the spread of meningococcal disease. We investigated compliance with this guidance in audits of suspected meningitis cases in our district notified to the public health department between January 1996 and December 1997, and in 1999. The total number of suspected meningitis cases in 1996-7 and in 1999 were 58 and 34 respectively. Meningococcal disease was suspected in 49 and 28 patients respectively, and for 58 (75.3%) of these case notes were found. Rash was more often a presenting sign in 1999. The second audit also showed a non-significant reduction in the proportion of patients given penicillin before hospital admission (22.4% vs. 7.1%, p = 0.12), and in CSF microscopy requests (31% vs. 17.6%, p < 0.5). Requests for meningococcal investigation by blood culture (77.5% vs. 79.4%, p < 0.5) blood PCR (34.5% vs. 64.7%, p < 0.001) and throat swab (25.9% vs. 55.9%, p < 0.005) were increased. Notifications of cases to the public health department within 24 hours of admission were also increased slightly (42.8% vs. 52.9%; p < 0.5). Changes in clinical practice can be achieved through guidelines, audit and feedback. The importance of parenteral penicillin administration prior to hospital admission, appropriate investigations and prompt public health notification should be re-emphasised.

Developing a framework for primary palliative care services.

Practice and empirical data indicate concerns regarding the delivery of primary palliative care, particularly the provision of a multidisciplinary approach. A collaborative study was undertaken between an academic unit and primary care practice to evaluate current care provision and explore methods of developing services. A two-phase study was carried out over a period of 18 months using an action research approach, in order to facilitate concurrent service evaluation, change in practice, and the involvement of professionals in research and practice development. The first phase highlighted the need to enhance primary palliative care services; a number of practice changes were identified and implemented during the second phase and evaluated using quantitative and qualitative methods. Data demonstrated the enhancement of services, benefits to patient care and professional working and the viability of an innovative model of palliative care delivery - that of a surgery-based clinic for palliative care patients and carers. A framework for the provision of multidisciplinary palliative care in the community was developed.

Postnatal depression: use of health services and satisfaction with health-care providers.

The objective of this study was to compare health-care use and satisfaction with health-care providers between depressed and non-depressed women in the first 4 months after childbirth. Sixteen weeks after delivery a questionnaire, which included the Edinburgh Postnatal Depression Scale (EPDS) and items about health-care use and satisfaction, was mailed to women who attended the antenatal clinic, Royal Women's Hospital, Brisbane. Completed questionnaires were returned by 574 (86.4%) of the 664 women surveyed. During the study period most women (91%) visited a general practitioner at least once and 117 (12%) saw their doctor on five or more occasions. A total of 118 (20.7%) scored above 12 on the EPDS. Depressed women were more likely to visit a psychiatrist (OR, 9.2; 95% CI, 4.3-19.6), social worker (OR, 6.1; 95% CI, 3.3-11.1), postnatal depression group (OR, 4.0; 95% CI, 1.3-12.6), paediatrician (OR, 2.5; 95% CI, 1.6-3.9), or a general practitioner (OR, 2.1; 95% CI, 1.4-3.2) than non-depressed women. Twenty-two (18.5%) of the depressed women had contact with a psychiatrist. Compared with non-depressed women, those scoring above 12 on the EPDS were less satisfied with the services of general practitioners (P=< 0.000), paediatricians (P=0.002), Nursing Mothers' Associations of Australia (P=0.043) and obstetricians (P=0.045). Postpartum depression leads to an increase use of health-care services and has a negative effect on satisfaction with some services.

Improving antenatal recognition of women at risk for postnatal depression.

The purpose of this study was to assess the effectiveness of a practical antenatal screen used at the Royal Women's Hospital, Brisbane, to identify women at risk for postnatal depression. It was a prospective, hospital-based, cohort study of 901 women (600 with and 301 without prenatal risk factors for postnatal depression). Depression was measured 16 weeks after the birth using the Edinburgh Postnatal Depression Scale. More of the women with a prenatal risk factor for depression (25.9%) scored above 12 on the Edinburgh Postnatal Depression Scale than those without any risk (10.9%) (p < or = 0.001). Low social support (p < or = 0.001), a personal history of mood disorder (p < or = 0.001) and a past history of postnatal depression ( p = 0.002) were all strongly associated with postnatal depression in this sample. Results indicate that an objective, psychosocial assessment during pregnancy improves recognition of women at risk for postnatal depression.

Measuring social support in pregnancy: can it be simple and meaningful?

BACKGROUND: It is important to determine the level of a woman's social support at the booking-in interview for prenatal care, but measurement tends to be ad hoc and nonquantifiable. The purpose of this study was to describe the Maternity Social Support Scale and the relationship between support scale ratings and the Edinburgh Postnatal Depression Scale and other health and service use outcomes. METHODS: Women (n = 901) who attended the antenatal clinic at the Royal Women's Hospital in Brisbane, Australia, were asked to complete a support scale as part of their booking-in interview. Participants were contacted at 16 weeks postpartum and invited to complete a follow-up questionnaire. Relationships between the scale and study outcomes were explored using analysis of variance and chi-square tests. RESULTS: Women with low social support in pregnancy were more likely than well-supported women to report poorer health during pregnancy (p = 0.006) and postnatally (p < 0.001), to book later for prenatal care (p = 0.000), to seek medical help more frequently (p = 0.004), and to be more depressed postnatally (p = 0.0001). CONCLUSION: Social support during pregnancy can be measured in a meaningful and simple way through the use of a short questionnaire administered at the prenatal booking-in visit.

The status of prenatal care among Medicaid Managed Care patients in Connecticut.

Providing quality prenatal care to high-risk, pregnant adolescents represents an important challenge to health care providers and health plans. Using national prenatal care guidelines, this study sought to evaluate the quality of important processes and outcomes of prenatal care delivered to women age 21 years and younger enrolled in three health plans serving the Connecticut Medicaid population. Some important findings include 93% compliance with recommended processes of prenatal care, an 11% C-section rate, an average length of hospital stay of 4.0 days for women having a C-section, and a 10% premature delivery rate. Opportunities for improvement include 40% failing to begin prenatal care in the first trimester, 31% not receiving the recommended number of prenatal care visits, and 8% delivering a low-birth-weight infant. This study provides important descriptive information on processes and outcomes of care for pregnant adolescents within Medicaid Managed Care and also identifies opportunities for improvement.

The impact of screening for risk factors associated with postnatal depression at the first prenatal visit.

Although 10-15% of Australian women suffer from postnatal depression (PND), few efforts have been made, prenatally, to predict which women may develop the condition. The objective of this study was to evaluate the impact on patients, staff and services of an intervention designed to identify women at risk for PND. Women were screened at their first prenatal visit for factors associated with PND, and were asked to complete a questionnaire at their next clinic visit to assess the impact of the screening questions and the usefulness of a PND information kit. To assess the impact of the intervention on the prenatal clinic routine, all staff associated with the intervention were interviewed individually and their responses were tape recorded and analysed for themes. Patients reported a high level of satisfaction with the intervention. Staff responded well to the new procedure and offered constructive comments to improve the process.

Neuroleptic malignant syndrome and compulsive drinking of water.

In spite of multiple authoritative reviews in recent years on the subject of neuroleptic malignant syndrome, the association of neuroleptic malignant syndrome with excessive fluid consumption has received little attention. This association is described and comments are made as to its possible origins. Further investigations are required to determine the strength and nature of the association. Such findings may have implications not only for clinical management but also for the poorly-understood neurochemistry of the neuroleptic malignant syndrome.

Effects of DNA-repair processes on the induction of genetic duplications in bacteria by ultraviolet light.

A straightforward positive selection for genetic duplication is possible in strains of Salmonella typhimurium that carry the aroC321 allele. Strains with a single copy of this allele require phenylalanine, tyrosine and tryptophan for growth. Such strains give rise to tryptophan prototrophs, which still require phenylalanine and tyrosine, through the formation of a duplication that includes about 30% of the chromosome. We have constructed strains that permit the simultaneous study of duplications and mutations and have used these strains to explore the effects of DNA repair processes on the induction of duplications by ultraviolet light (UV). UV causes dose-dependent increases in the frequency of duplications in bacteria. The exposure required to induce duplications is much less in a delta uvrB strain than in repair-proficient strains, suggesting that duplications result from DNA lesions that are subject to excision repair. The photoreversibility of UV-induced preduplication lesions implicates pyrimidine dimers in the induction of duplications. Unlike its effect on the induction of mutations, the error-prone repair process associated with plasmid pKM101 does not enhance the induction of duplications. The prevention of duplication-formation by a recA mutation suggests that the formation of duplications involves recombinational events. Taken together, the data indicate that the same DNA lesions can be mutagenic and recombinagenic in bacteria, but that the two effects involve different pathways of processing DNA damage.

Urate deposits in the renal medulla. Prevalence and associations.

Urate deposits within microtophi were found in 8% of unselected autopsies in Brisbane, Australia. Significant association were demonstrated with (a) a history of gouty arthritis and (b) the existence of nitrogen retention and renal disease of apparently primary, but not gouty, origin. However, in 26% of the patients, a retrospective survey of their medical records did not reveal any causative factor. The possible aetiological importance of the urine flow rate is stressed. The presence of medullary urate deposits at autopsy was most frequently associated with a history of gout or the presence of pre-existing and non-gouty renal disease, although no aetiological factor could be determined in a quarter of the cases.