Psychosocial assessment by phone for high-scoring patients taking the Edinburgh Postnatal Depression Scale: communication pathways and strategies.

The well-documented risks associated with perinatal depression provide a strong argument for universal screening. However, uncertainty about what to do with findings is a significant barrier to implementing screenings where obstetric care is provided. Based on experience with a comprehensive screening program, we describe a protocol for those critical communication pathways that encourage a dynamic phone exchange between a mental health caller and the patient who has scored in the high range on the Edinburgh Postnatal Depression Scale. In addition, we present guidelines for developing an action plan for addressing intervention needs and closing the feedback loop to the original administrators of the scale.

The sternoclavicular syndrome: experience from a district general hospital and results of a national postal survey.

OBJECTIVE: To report our local experience of the sternoclavicular syndrome and sample the experience of other rheumatologists in the UK. METHODS: We studied case records of 23 patients referred to the Southend rheumatology clinic and data obtained from a postal questionnaire survey of British rheumatologists. RESULTS: We describe 58 cases (20 males and 38 females, mean age 47.2 yr). The disease was unilateral in 40 patients. Shoulder and/or arm pain (38 cases) with limitation of shoulder movements was an important presenting feature; other presenting features were anterior chest wall pain (14 cases) and neck pain (15 cases). Peripheral joint involvement was seen in 12 cases. Skin rash was reported in 12 cases (psoriasis, 6; acne, 2; none had pustulosis). No patients had symptoms or signs of sacroiliitis, and HLA-B27 was negative in 22 out of 23 patients. 99Technetium scintiscanning showed increased uptake in the sternoclavicular region in 31/34 patients (91.1%), but not in the sacroiliac areas. Plain radiographs were abnormal in 18 cases (sclerosis, 9; erosions, 2; soft tissue swelling, 2; bony expansion, 5). CT and/or MRI scans (available in 27 cases) showed erosions in 12 and osteitis in 18. Available histology showed a variable picture, including inflammation, bone erosion, sterile osteomyelitis and fibrosis. The majority of patients (45) were treated with non-steroidal anti-inflammatory drugs: 12 received steroids and 10 received disease-modifying anti-rheumatic drugs (methotrexate, 4; sulphasalazine, 6). Follow-up information was available for 38 patients, of whom 14 became asymptomatic and 24 had chronic disease with intermittent flares. CONCLUSION: Sternoclavicular disease is not uncommon in the UK. It can present with pain in the shoulder, neck or anterior chest wall, and may be underdiagnosed. Our results do not show a link with acne or pustulosis. Features of spondyloarthropathies, such as sacroiliitis and HLA-B27 positivity, were rare in this survey.

Sacral insufficiency fractures: an unsuspected cause of low back pain.

We describe 10 cases of sacral fractures diagnosed within the rheumatology department at Southend Hospital over the last 5 yr. All presented with sudden-onset low back pain. The majority were elderly, frail, with chronic inflammatory disease (six with rheumatoid arthritis, one with polymyalgia rheumatica, one with vasculitis) and had received steroids. Diagnosis was delayed by the inability of plain radiographs to show these fractures and was ultimately demonstrated by technetium scintigraphy/computed tomography scan. We feel that this diagnosis should be considered in elderly patients with rheumatoid arthritis or other risk factors for osteoporosis who present with low back pain and sacral tenderness. Further clues may be parasymphyseal tenderness (suggesting associated pubic ramus fracture), elevated alkaline phosphatase and plain radiograph showing pubic ramus fractures or parasymphyseal sclerosis. Patients with this complication generally have a poor prognosis and two of our patients have died. Seven required in-patient stay (mean 20 days; range 14-41). The mortality, morbidity and costs incurred in management may be comparable to those of femoral neck fractures.

Consent for adolescent vaccination: issues and current practices.

To identify and describe implementation of state-level informed consent requirements for adolescent immunizations, current state regulations on informed consent and immunization services for children and adolescents were identified through the LEXIS-NEXIS legal data base. Regulations were coded for informed consent characteristics, consent exemptions, and current immunization requirements. State immunization program directors, project managers, and state hepatitis coordinators were surveyed to catalogue how regulations were implemented and document new policies or regulations under consideration. Parental consent for immunizations is standard practice in 43 states. Most states (n = 34) require separate consent for each injection when more than one injection is required to complete a vaccination, but only for a limited number of medical procedures. Nine states allow adolescents to self-consent for hepatitis B vaccination in sexually transmitted disease clinics and family planning clinics as part of the exemption for minors' receipt of sexual health services. Most states require consent for vaccination services provided to adolescents. Parental consent requirements are a potential barrier to vaccinating adolescents in some settings.

Survey of exposure to violence among the children of migrant and seasonal farm workers.

Numerous children of migrant and seasonal farm workers live in rural areas of our country. The lifestyles and living conditions of farm workers place the children of these families at high risk for many health problems. However, few studies have focused on the emotional and behavioral well-being of these children. This study extends past research by examining the emotional and behavioral health of the children of farm workers in relation to a potentially risky environmental exposure, namely, exposure to violence. In this descriptive study, the extent of violence exposure, including being a witness to and a victim of violence, is examined among 8-11-year-old children of migrant and seasonal farm workers. Potential relationships between sociodemographic factors and violence exposure are examined, and associations between violence exposure and children's emotional and behavioral problems, and weapon carrying behavior are investigated. The results show that more than half of the study children had been exposed to violence, with 46 percent having witnessed violence among others and 19 percent having been the direct victims of violence. There was a fair degree of overlap between having witnessed violence and having been a victim of violence; 13 percent of all study children both witnessed and had been victims of violence, 33 percent only had witnessed violence, and 6 percent only had been victims of violence. Violence exposure was positively related to children's emotional problems, behavioral problems, and weapon carrying behavior. Compared to non exposed children, violence exposed children were eight times more likely to evidence internalizing problems, were six times more likely to evidence externalizing problems, and were four times more likely to carry weapons (specifically, knives or guns).These findings suggest that there is a need for further research on this high-risk population, as well as the need to develop and implement innovative public health interventions for rural children.

Fluid and electrolyte disorders. Magnesium.

Magnesium is the second most abundant intracellular cation but it is still not measured often enough. It is closely linked with other electrolytes such as calcium, potassium, and phosphate so that the correct clinical interpretation of abnormal results can be complex.