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Veterans are not a demographically homogenous group, yet minority groups continue to be under-represented in research and report feeling less able to access clinical services to seek support. While veteran-specific healthcare has responded to the needs of the majority, the success of veteran mental health services is contingent on serving the whole veteran population. Key to the personalisation of healthcare is the question of access and a need to address specific inequalities and barriers to help-seeking behaviour. In this paper, we explore the issues of access to veteran healthcare at three levels: those barriers common to all veterans; those common to all minority groups of veterans; and those relevant to specific minority groups of veterans. Stigma, military attitudes and culture (eg, stoicism), and access to services and professionals with veteran-specific knowledge are universal barriers across veteran groups. Minority groups report a heightening of these barriers, alongside being 'othered' in veteran care settings, a lack of representation of them or their experiences in service descriptions and advertising, a lack of professional cultural competencies on specific issue, and the veteran environment potentially being retraumatising. Finally, barriers specific to individual groups are discussed. Attending to these is essential in developing holistic approaches to personalised healthcare that meets the needs of all veterans.
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Introduction: Moderate-to-high physical activity participation is associated with a reduced risk of infertility. Yet, exercise interventions that target cardiorespiratory fitness, independent of weight loss, are lacking in obesity and female fertility research. Purpose: The primary objective of the PRO-FIT-CARE (PROmoting FITness for CArdiometabolic & REproductive Health) study was to assess the feasibility of a moderate-to-high-intensity online exercise program for persons with obesity and female infertility. Methods: Feasibility, safety, acceptability, and efficacy were assessed by examining: (1) recruitment and consent rate, (2) study retention, (3) adverse events, (4) participant satisfaction, (5) adherence, and (6) cardiorespiratory fitness. Results: Eleven of thirty-two women contacted agreed to participate in the program (34.4% consent rate). Eight participants (72.7%) completed the study. One musculoskeletal injury was reported. There was a 30% adherence rate based on prescribed exercise intensity (60%-80% of heart rate maximum). One of eleven participants attended 80% of the exercise intervention. Based on a weekly satisfaction survey, the program had an overall high level of satisfaction. Compared to sex and age normative data, post-intervention, two of eight participants improved their cardiorespiratory fitness percentile rank. Conclusion: The study highlights challenges with adherence to an online exercise program. While the program was safe and participants reported high levels of program satisfaction, approaches to improve adherence must be incorporated.
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A mobile phone app was used by 59 veterinary practitioners to collect case histories and images of 191 cattle with congenital defects distributed nationally over a 3-year period. The majority of cases were recorded during the spring calving season (57.6%) in pluriparous dairy dams. The majority of calves were recorded at birth or within the first week (66.5%) in singletons born at full-term. On the majority of farms (75.9%), this was the only congenitally deformed bovine recorded up to that point in the year and on the majority of farms, there were no congenitally deformed cattle recorded in the previous 5 years. The majority of congenital defects (83.5%) were recorded in the musculoskeletal or digestive systems. The three most commonly recorded individual defects were intestinal atresia (24.1%), schistosomus reflexus (20.4%) and ankylosis (6.8%); multiple defects were recorded in 13.1% of cases. These findings highlight the relatively high prevalence of intestinal atresia and schistosomus reflexus in calves attended by veterinary practitioners, which warrants implementation of preventive measures. The project highlights the potential benefits of veterinary-practitioner apps to detect changing trends in endemic, or the emergence of novel, congenital or other conditions.
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Enfermedades de los Bovinos , Atresia Intestinal , Animales , Bovinos , Atresia Intestinal/veterinaria , Enfermedades de los Bovinos/epidemiologíaRESUMEN
BACKGROUND: Sleep disturbance in UK Armed Forces personnel appears to be frequent due to factors such as hostile sleeping environments and can persist even once they have transitioned into civilian life. Despite this, there is currently very limited literature surrounding the prevalence and associated factors of insomnia disorder among UK veterans. AIMS: This study aimed to expand knowledge of the prevalence and associated demographic, military, health and functional outcomes with probable insomnia disorder within a clinical sample of veterans. METHODS: Treatment-seeking veterans from a national UK mental health charity were invited to complete a questionnaire including socio-demographic, military, health and well-being questions. RESULTS: Of the sample, 489 (43%) completed the questionnaire. Seventy per cent of the sample reported having probable insomnia disorder. Having probable insomnia disorder was significantly associated with being younger and having physical health problems. Moreover, unadjusted models found associations between probable insomnia disorder and common mental health difficulties, obsessive-compulsive disorder and complex post-traumatic stress disorder. CONCLUSIONS: The results suggest that many UK veterans with physical and mental health difficulties experience co-morbid insomnia disorder. Therefore, it is important that clinical services are aware of this prevalence and use targeted interventions to reduce the frequency of insomnia disorder in this population.
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Personal Militar , Trastornos del Inicio y del Mantenimiento del Sueño , Trastornos del Sueño-Vigilia , Trastornos por Estrés Postraumático , Veteranos , Humanos , Veteranos/psicología , Trastornos del Inicio y del Mantenimiento del Sueño/epidemiología , Personal Militar/psicología , Trastornos por Estrés Postraumático/complicaciones , Trastornos por Estrés Postraumático/epidemiología , Trastornos por Estrés Postraumático/psicología , Trastornos del Sueño-Vigilia/epidemiología , Resultado del TratamientoRESUMEN
AIM: To determine the proportion of computed tomography (CT) coronary angiography (CTCA) referrals with coronary artery calcification (CAC) evident on previous non-cardiac CT imaging and how this impacted the diagnostic yield for CTCA, the requirement for additional diagnostic testing, and the associated costs to confirm or refute obstructive coronary artery disease (CAD). MATERIALS AND METHODS: A retrospective review of CTCA examinations was undertaken between 01/05/2018 and 31/05/2020 in which the examinations were cross referenced for previous non-gated thoracic CT at Royal United Hospitals Bath. Major epicardial vessel CAC on baseline CT was re-evaluated by published semi-quantitative methods, giving a per-patient CAC score (mild = 1-3, moderate = 4-6, severe >6). Subsequent incomplete CTCA diagnostic yield, further testing, and cost implications were examined. RESULTS: Of the 2140 CTCA examinations identified, 13% (280/2140) had a preceding non-gated thoracic CT (53% female, age 63 ± 11 years). The incomplete diagnostic rate increased with CAC grade, mild 32%, (RR 12; 95% CI 4-40), moderate 64% (RR 25; 95% CI 8-80), severe 75%, (RR 29; 95% CI 9-94). Additional diagnostic testing occurred in 4% for the mild CAC category, and 14% and 42% for moderate and severe, respectively. When severe CAC was identified on a non-gated thoracic CT a cost saving of £171/patient (dobutamine stress echo [DSE]) and £61/patient (myocardial perfusion scintigraphy [MPS]) was established with a direct to functional testing pathway. CONCLUSIONS: In patients referred for CTCA where severe CAC was identified on a preceding non-gated thoracic CT a direct to functional testing altered management in 42% of cases and was cost-effective.
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Enfermedad de la Arteria Coronaria , Humanos , Femenino , Persona de Mediana Edad , Anciano , Masculino , Angiografía Coronaria/métodos , Valor Predictivo de las Pruebas , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Angiografía por Tomografía Computarizada/métodosRESUMEN
Carnitine palmitoyl transferase II (CPT II) deficiency is a rare disorder of fatty acid metabolism in cell mitochondria. There is limited information about the disease process and complications of anaesthesia, particularly in the obstetric population. Due to the increased risks of general anaesthesia in patients with CPT II deficiency, neuraxial anaesthesia is the preferred method of anaesthesia. We describe a patient with CPT II deficiency who had spinal anaesthesia for caesarean section. Subsequently, the patient had prolonged neuraxial blockade, a previously undescribed complication in a patient with CPT II deficiency.
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Anestesia Raquidea , Humanos , Femenino , Embarazo , Anestesia Raquidea/efectos adversos , Anestesia Raquidea/métodos , Carnitina O-Palmitoiltransferasa , Cesárea/métodos , CarnitinaRESUMEN
INTRODUCTION: Moral injury (MI) significantly impacts the lives of many UK military veterans however, there is a lack of manualised treatment to address the needs of this population. To develop future treatments that are acceptable and well tolerated, veterans should be consulted on their experiences of existing psychological treatments and suggestions for future treatments. METHODS: 10 UK military veterans were interviewed about their experiences of receiving treatment for psychological difficulties after MI, and beliefs about core components of future treatments. Thematic analysis of these interviews were conducted. RESULTS: 2 superordinate themes were identified: experiences of previous mental health treatment and perceptions of the proposed treatments. Reflections on cognitive behavioural therapy were mixed, with some describing that it did not ameliorate their guilt or shame. In future treatments, focusing on values, using written letters and including therapy sessions with close companions were considered beneficial. Veterans reported that a strong rapport with therapist was key for MI treatment. CONCLUSION: Findings provide a useful account of how current post-trauma treatments may be experienced by patients with MI. Although limited by sample size, the results highlight therapeutic approaches that may be helpful in future and provide important considerations for therapists treating MI.
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BACKGROUND: We hypothesized that avelumab plus axitinib could improve clinical outcomes in patients with advanced non-small-cell lung cancer (NSCLC) or urothelial carcinoma (UC). PATIENTS AND METHODS: We enrolled previously treated patients with advanced or metastatic NSCLC, or untreated, cisplatin-ineligible patients with advanced or metastatic UC. Patients received avelumab 800 mg every 2 weeks (Q2W) and axitinib 5 mg orally two times daily. The primary endpoint was objective response rate (ORR). Immunohistochemistry was used to assess programmed death-ligand 1 (PD-L1) expression (SP263 assay) and the presence of CD8+ T cells (clone C8/144B). Tumor mutational burden (TMB) was assessed by whole-exome sequencing. RESULTS: A total of 61 patients were enrolled and treated (NSCLC, n = 41; UC, n = 20); 5 remained on treatment at data cut-off (26 February 2021). The confirmed ORR was 31.7% in the NSCLC cohort and 10.0% in the UC cohort (all partial responses). Antitumor activity was observed irrespective of PD-L1 expression. In exploratory subgroups, ORRs were higher in patients with higher (≥median) CD8+ T cells in the tumor. ORRs were higher in patients with lower TMB (Asunto(s)
Carcinoma de Pulmón de Células no Pequeñas
, Carcinoma de Células Transicionales
, Neoplasias Pulmonares
, Neoplasias de la Vejiga Urinaria
, Humanos
, Carcinoma de Pulmón de Células no Pequeñas/tratamiento farmacológico
, Carcinoma de Pulmón de Células no Pequeñas/patología
, Axitinib/farmacología
, Axitinib/uso terapéutico
, Cisplatino/farmacología
, Cisplatino/uso terapéutico
, Neoplasias Pulmonares/tratamiento farmacológico
, Neoplasias Pulmonares/patología
, Anticuerpos Monoclonales/efectos adversos
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Remarkable perturbations in the stratospheric abundances of chlorine species and ozone were observed over Southern Hemisphere mid-latitudes following the 2020 Australian wildfires1,2. These changes in atmospheric chemical composition suggest that wildfire aerosols affect stratospheric chlorine and ozone depletion chemistry. Here we propose that wildfire aerosol containing a mixture of oxidized organics and sulfate3-7 increases hydrochloric acid solubility8-11 and associated heterogeneous reaction rates, activating reactive chlorine species and enhancing ozone loss rates at relatively warm stratospheric temperatures. We test our hypothesis by comparing atmospheric observations to model simulations that include the proposed mechanism. Modelled changes in 2020 hydrochloric acid, chlorine nitrate and hypochlorous acid abundances are in good agreement with observations1,2. Our results indicate that wildfire aerosol chemistry, although not accounting for the record duration of the 2020 Antarctic ozone hole, does yield an increase in its area and a 3-5% depletion of southern mid-latitude total column ozone. These findings increase concern2,12,13 that more frequent and intense wildfires could delay ozone recovery in a warming world.
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Aerosoles , Cloro , Pérdida de Ozono , Ozono , Incendios Forestales , Aerosoles/efectos adversos , Aerosoles/análisis , Aerosoles/química , Australia , Cloro/análisis , Cloro/química , Ácido Clorhídrico/química , Ozono/análisis , Ozono/química , Calentamiento GlobalRESUMEN
AIMS: Guidelines have recommended reporting coronary artery calcification (CAC) if present on chest CT imaging regardless of indication. This study assessed CAC prevalence, prognosis and the potential clinical impact of its reporting. METHODS: We performed a single-centre retrospective analysis (January-December 2015) of 1400 chest CTs (200 consecutive within each age group: <40, 40-49, 50-59, 60-69, 70-79, 80-89, ≥90). CTs were re-reviewed for CAC presence and severity and excluded if prior coronary intervention. Comorbidities, statin prescription and clinical outcomes (myocardial infarction [MI], stroke, all-cause mortality) were recorded. The impact of reporting CAC was assessed against pre-existing statin prescriptions. RESULTS: 1343 patients were included (mean age 63±20 years, 56% female). Inter- and intra-observer variability for CAC presence at re-review was almost perfect (κ 0.89, p < 0.001; κ 0.90, p < 0.001) and for CAC grading was substantial and almost perfect (κ 0.68, p < 0.001; κ 0.91, p < 0.001). CAC was observed in 729/1343 (54%), more frequently in males (p < 0.001) and rising age (p < 0.001). A high proportion of patients with CAC in all age groups had no prior statin prescription (range: 42% [80-89] to 100% [<40]). The 'number needed to report' CAC presence to potentially impact management across all ages was 2. 689 (51%) patients died (median follow-up 74-months). CAC presence was associated with risk of MI, stroke and all-cause mortality (p < 0.001). After adjusting for confounders, severe calcification predicted risk of all-cause mortality (HR 1.8 [1.2-2.5], p = 0.002). CONCLUSION: Grading of CAC was reproducible, and although prevalence rose with age, prognostic and treatment implications were maintained in all ages.
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Enfermedad de la Arteria Coronaria , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Infarto del Miocardio , Accidente Cerebrovascular , Calcificación Vascular , Masculino , Humanos , Femenino , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Pronóstico , Estudios Retrospectivos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Vasos Coronarios , Factores de Riesgo , Medición de Riesgo/métodos , Calcificación Vascular/complicaciones , Enfermedad de la Arteria Coronaria/complicaciones , Tomografía Computarizada por Rayos X/métodos , Accidente Cerebrovascular/complicacionesRESUMEN
Pyrocumulonimbus (pyroCb) are wildfire-generated convective clouds that can inject smoke directly into the stratosphere. PyroCb have been tracked for years, yet their apparent rarity and episodic nature lead to highly uncertain climate impacts. In situ measurements of pyroCb smoke reveal its distinctive and exceptionally stable aerosol properties and define the long-term influence of pyroCb activity on the stratospheric aerosol budget. Analysis of 13 years of airborne observations shows that pyroCb are responsible for 10 to 25% of the black carbon and organic aerosols in the "present-day" lower stratosphere, with similar impacts in both the North and South Hemispheres. These results suggest that, should pyroCb increase in frequency and/or magnitude in future climates, they could generate dominant trends in stratospheric aerosol.
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Gold standard treatments for military personnel seeking support for mental health difficulties are often standardised and manualised to ensure high levels of treatment fidelity. While manualised treatments are preferable to less evidence-based idiosyncratic approaches, they may not fully account for the differences in symptom profiles present in patients with the same psychological diagnosis. Indeed, recent findings have highlighted that a significant proportion of individuals do not benefit from the 'gold standard' treatments. This brief report discusses the utility of statistical techniques, specifically latent profile analysis and network analysis, to support the transition to more evidence-based idiosyncratic, personalised care for clinical military, and general, populations. Further incorporation of such analysis methods may support arriving at a framework to support the personalisation of care in terms of the selection and adaption of evidence-based approach treatments based on individual clinical need.
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This paper discusses the introduction, development and utility of post-mortem imaging relating specifically to conflict-related and terrorist-related deaths and considers the use of computed tomography (CT) in the investigations. We demonstrate how a multi-disciplinary approach involving direct communication between forensic pathologist and radiologist can maximise evidential yield, reduce the need for unnecessary dissection and further our understanding of such injuries. This summarises our shared experience of hundreds of cases, each having been individually discussed and reviewed, and has helped shape our understanding of conflict injury as well as contributing to the development of mitigation strategies and adaptations to protective equipment. A series of clinical cases are presented to demonstrate some of the strengths and weaknesses of the process.
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The COVID-19 pandemic has resulted in a digital technology revolution which included widespread use in remote healthcare settings, remote working and use of technology to support friends and family to stay in touch. The armed forces have also increased its use of digital technology, but not at the same rate, and it is important that they do not fall behind in the revolution. One area where digital technology could be helpful is the treatment and management of mental health conditions. In a civilian setting, digital technology adoption has been found to be acceptable and feasible yet there is little use in the armed forces. In this personal view, we explore the potential use of personalised digital technology for mental health, the hype surrounding it and the dangers.This paper forms part of the special issue of BMJ Military Health dedicated to personalised digital technology for mental health in the armed forces.
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COVID-19 , Personal Militar , Humanos , Salud Mental , Tecnología Digital , Pandemias , Personal Militar/psicologíaRESUMEN
INTRODUCTION: Despite making up about 11% of the UK military, there remains limited investigation on the impact of adversity women experience during their service in the UK military. Military adversity can result in a range of well-being difficulties that may persist following transition out of military. The present study therefore examined the prevalence and correlates of different types of military adversity (defined as sexual harassment, sexual assault, emotional bullying and physical assault) within a community sample of UK women veterans. METHODS: Participants were recruited from a UK charity supporting women veterans. 750 women veterans completed an online survey collecting information on sociodemographic and military factors, military adversity, as well as mental health and well-being difficulties. Associations between variables were explored using multivariate logistic regressions. RESULTS: The findings indicate a high prevalence of military adversity (22.5% sexual harassment, 5.1% sexual assault, 22.7% emotional bullying and 3.3% physical assault). Younger women, those who held an officer rank during service and those who reported having a combat or combat support role during service were most at risk of military adversity. All types of adversity were significantly associated with probable post-traumatic stress disorder. Sexual harassment was additionally significantly associated with physical somatisation; sexual assault with alcohol difficulties; and emotional bullying with common mental health difficulties, low social support and loneliness. CONCLUSIONS: This study indicates that UK women veterans are at risk of a range of adverse experiences during military service and provides evidence of the impact of such adversities on mental health and well-being. Further research is required to better understand these relationships.
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Acoso Escolar , Personal Militar , Veteranos , Humanos , Femenino , Veteranos/psicología , Salud Mental , Trauma Sexual MilitarRESUMEN
INTRODUCTION: The rights, roles and responsibilities of servicewomen in the UK Armed Forces has changed dramatically over time. Previously, service personnel were automatically discharged from the military if they became pregnant. As the percentage of servicewomen in the UK Armed Forces increases, having children during service is becoming more common and maternity policies are now in place. Having children during military service can impact on the health and well-being of servicewomen, including a greater risk of illness when returning to work. METHODS: A cross-sectional, self-report survey was used for data collection. The response rate was approximately 45%. Female Army veterans were recruited via a female military association. The survey collected data on parental status, the timing of their first child (during or after service), and several current mental and physical health and well-being outcomes. RESULTS: Of the 750 female Army veterans who completed the survey, 406 reported having children. Of those with children, 14.5% had their first child during service compared with 85.5% after service. The most frequently endorsed health outcomes were low social support, loneliness and common mental health difficulties. Participants who had their first child during military service were more likely to have left the service non-voluntarily. CONCLUSIONS: This study provided insight into the impacts of having a first child during military service on servicewomen. Overall, female Army veterans who had their first child during service had poorer outcomes, including leaving service non-voluntarily. However, none of the health or well-being outcomes remained significant after adjusting the results. This study explored a widely under researched population and field of research. Future research should seek to expand on our findings and continue to explore the impacts of having a first child during military service for military mothers.