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.

Flame figures in linear IgA bullous dermatosis: a novel histopathologic finding

BACKGROUND

Linear IgA bullous dermatosis (LABD) is an autoimmune subepidermal blistering disease usually with a neutrophil rich inflammatory infiltrate, and characterized by linear IgA deposition at the basement membrane zone (BMZ), and neutrophil predominant dermal inflammation. We report a case of LABD with numerous eosinophils and flame figure formation, a unique histopathologic finding not previously reported. A 69-year-old woman presented with a rapidly progressive, intensely pruritic rash over forearms, breasts, axillae, hips, and thighs. Thelesions were comprised of annular vesicles and bullae with hemorrhagic crusts and erosions. The clinical differential diagnosis included bullous pemphigoid(BP), LABD, and epidermolysis bullosa aquisita (EBA).

RESULTS

A biopsy from a bullous plaque on the wrist revealed a subepidermal blister with neutrophils and numerous eosinophils with flame figure formation.Direct immunofluorescent (DIF) microscopy revealed linear deposition of IgA at the BMZ.

CONCLUSIONS

Although unusual, the combined findings supported a diagnosis of LABD. Increased eosinophils may be associated with drug-induced LABD and may explain the numerous eosinophils in our case. It is important to be aware of this finding as the pathology may easily be misdiagnosed as BP, or possibly bullousWells syndrome. This case emphasizes that combined clinical, pathologic, and DIF findings are essential in the diagnosis of bullous dermatoses.

CLL/SLL with initial presentation as a longstanding cutaneous plaque: a rare case

While chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is the most common leukemia in the western world, it uncommonly initially presents as a cutaneous lesion. When it does, it is often found incidentally in the context of another distinct lesion. We present a case of CLL/SLL that initially presented as a solitary nodular erythematous plaque on the left flank of a healthy 60-year-old man without lymphadenopathy or constitutional symptoms. The lesion had been present for many years, but had recently begun to grow and become pruritic and painful. Excisional biopsy revealed a large nodular aggregate of variably sized CD20(dim), CD5(+), CD23(+), BCL-2(+) atypical lymphocytes in the dermis without epidermotropism. The lymphocytes were negative for BCL-1/cyclinD1, BCL-6, and CD10, and no other background lesion was identified. This constellation of biopsy findings was consistent with CLL/SLL. This case emphasizes the potential for involvement by CLL/SLL in the cutaneous biopsies of otherwise asymptomatic patients.

Role of Pathogens in Ossicular Prosthesis Problems

Objective: Microbial biofilms are commonly found on ossicular chain reconstruction prostheses (ORPs). They have been implicated as a cause of suboptimal hearing outcomes. The purpose of this study was to determine which middle ear pathogens might be involved with ORP biofilms and ORP problems, such as scarring or extrusion.

Method: ORPs were explanted at the time of revision surgery and analyzed for microbial colonization using quantitative polymerase chain reaction (qPCR) with pathogen-specific primers for Pseudomonas aeruginosa, Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae, Candida albicans, Candida parapsilosis, and Aspergillus niger. Results were correlated with the otologic status.

Results: The majority of ORPs (19 of 21) tested positive for at least one pathogen. On average, each ORP tested positive for the presence of 2 pathogens. Twelve tested positive for S aureus, 10 for H influenzae, 9 for P aeruginosa, and 1 for S pneumoniae. No samples revealed C albicans, C parapsilosis, or A niger. Hearing, cholesteatoma, presence of effusion, extent of middle ear scarring, and extrusion did not appear to correlate with the presence of specific pathogens.

Conclusion: ORPs commonly harbor polymicrobic bacterial colonies or biofilms. Fungal pathogens are not commonly found on ORPs. While the presence of these biofilm-forming organisms is evident, it is unclear whether these pathogens play a role in unfavorable outcomes with middle ear reconstruction.

Tympanostomy Tube Sequelae Related to Pathogens

Objective: Posttympanostomy tube (TT) sequelae have been associated with a wide range of middle ear pathogens. Though microbes commonly bind to TTs, it is unclear what leads to clinical pathology. The goal of our study was to investigate the role of middle ear pathogens in post-TT sequelae.

Method: TTs were explanted for a range of indications and analyzed for biofilm formation using electron microscopy (EM) and quantitative polymerase chain reaction (qPCR) with specific primers for otopathogens. Results were correlated with the otologic status.

Results: None of the 18 TTs demonstrated Aspergillus niger, Candida parapsilosis, or Candida albicans. Streptococcus pneumonia was found in one TT with recurrent otorrhea. Pseudomonas aeruginosa was found in 44.4% of TTs, 2 out of 2 TTs with active otorrhea, and 87.5% with recent or current otorrhea. Staphylococcus aureus was found in 78% of TTs and 6 out of 6 TTs with granulation tissue. Haemophilus influenza was found in 72% of TTs, irrespective of clinical status. EM revealed that TTs commonly have complex topographical features, which may serve as reservoirs for microbial growth and biofilm formation.

Conclusion: Post-TT sequelae, such as otorrhea and granulation tissue, are more common with P aeruginosa and S aureus colonization and/or biofilm development. H influenza is also prevalent, but less clearly related to clinical pathology. These findings may have implications related to the pathogenesis and treatment of post-TT sequelae.