Development of a composite drought indicator for operational drought monitoring in the MENA region

This paper presents the composite drought indicator (CDI) that Jordanian, Lebanese, Moroccan, and Tunisian government agencies now produce monthly to support operational drought management decision making, and it describes their iterative co-development processes. The CDI is primarily intended to monitor agricultural and ecological drought on a seasonal time scale. It uses remote sensing and modelled data inputs, and it reflects anomalies in precipitation, vegetation, soil moisture, and evapotranspiration. Following quantitative and qualitative validation assessments, engagements with policymakers, and consideration of agencies' technical and institutional capabilities and constraints, we made changes to CDI input data, modelling procedures, and integration to tailor the system for each national context. We summarize validation results, drought modelling challenges and how we overcame them through CDI improvements, and we describe the monthly CDI production process and outputs. Finally, we synthesize procedural and technical aspects of CDI development and reflect on the constraints we faced as well as trade-offs made to optimize the CDI for operational monitoring to support policy decision-making-including aspects of salience, credibility, and legitimacy-within each national context.

An Audit of Neural Tube Defects in the Republic Of Ireland for 2012-2015

Neural tube defects (NTD) are potentially preventable in two-thirds of cases by periconceptional maternal Folic Acid (FA) supplementation. A national audit for the years 2009-11 showed no decline in NTD rates over twenty years. The aim of this national audit was to determine trends/rates and inform revision of national FA supplementation and food fortification strategies. Of 274,732 live and stillbirths there were 121(42.0%) cases of anencephaly, 136(47.2%) cases of spina bifida and 31(10.8%) cases of encephalocoele giving a total of 288 and overall rate of 1.05/1000 compared with 1.04/1000 in 2009-11(NS). In the 184 women where the information was available, only 29.9%(n=55) reported starting FA before pregnancy. The number of cases diagnosed antenatally was 91%(n=262) and 53%(n=154) were live-born. This audit confirms that over a generation, healthcare interventions have not succeeded in decreasing the number of pregnancies in Ireland complicated by NTD, and that revised strategies need to be developed and implemented.

Epidemiology of chromosomal trisomies in the East of Ireland

Background

Chromosomal trisomies are associated with advancing maternal age. In Ireland, information on the total prevalence and outcome of trisomy affected pregnancies is unavailable. This study aimed to ascertain more precise data on Trisomies 21, 18 and 13 in a large Irish region during the period 2011-2013.

Methods

Multiple information sources were used in case finding, including a regional congenital anomaly register, all maternity and paediatric hospitals in the region and the regional Department of Clinical Genetics.

Results

There were 394 trisomy cases from 80 894 total births, of which 289 were Trisomy 21, 75 were Trisomy 18 and 30 were Trisomy 13. The total prevalence rate was 48.9/10 000 births, 35.7, 9.3 and 3.7 for Trisomies 21, 18 and 13, respectively. Over 90% of Trisomies 18/13 and 47% of Trisomy 21 were diagnosed prenatally; 61% of Trisomy 21 cases and nearly 30% of Trisomies 18/13 were live births; 38% all trisomy affected pregnancies ended in a termination.

Conclusions

This study provides precise data on the total prevalence and outcome of trisomy affected pregnancies in the East of Ireland. Total prevalence rates were higher than previously reported. Prenatal diagnosis had a significant impact on outcome. These data provide a better basis for planning of services for live-born children affected by trisomy.

Development and implementation of a 'Mental Health Finder' software tool within an electronic medical record system

BACKGROUND

In Ireland, as in many other healthcare systems, mental health service provision is being reconfigured with a move toward more care in the community, and particularly primary care. Recording and surveillance systems for mental health information and activities in primary care are needed for service planning and quality improvement.

AIMS

We describe the development and initial implementation of a software tool ('mental health finder') within a widely used primary care electronic medical record system (EMR) in Ireland to enable large-scale data collection on the epidemiology and management of mental health and substance use problems among patients attending general practice.

METHODS

In collaboration with the Irish Primary Care Research Network (IPCRN), we developed the 'Mental Health Finder' as a software plug-in to a commonly used primary care EMR system to facilitate data collection on mental health diagnoses and pharmacological treatments among patients. The finder searches for and identifies patients based on diagnostic coding and/or prescribed medicines. It was initially implemented among a convenience sample of six GP practices.

RESULTS

Prevalence of mental health and substance use problems across the six practices, as identified by the finder, was 9.4% (range 6.9-12.7%). 61.9% of identified patients were female; 25.8% were private patients. One-third (33.4%) of identified patients were prescribed more than one class of psychotropic medication. Of the patients identified by the finder, 89.9% were identifiable via prescribing data, 23.7% via diagnostic coding.

CONCLUSIONS

The finder is a feasible and promising methodology for large-scale data collection on mental health problems in primary care.

Prevalence and risk of Down syndrome in monozygotic and dizygotic multiple pregnancies in Europe: implications for prenatal screening

OBJECTIVE

To determine risk of Down syndrome (DS) in multiple relative to singleton pregnancies, and compare prenatal diagnosis rates and pregnancy outcome.

DESIGN

Population-based prevalence study based on EUROCAT congenital anomaly registries.

SETTING

Eight European countries.

POPULATION

14.8 million births 1990-2009; 2.89% multiple births.

METHODS

DS cases included livebirths, fetal deaths from 20 weeks, and terminations of pregnancy for fetal anomaly (TOPFA). Zygosity is inferred from like/unlike sex for birth denominators, and from concordance for DS cases.

MAIN OUTCOME MEASURES

Relative risk (RR) of DS per fetus/baby from multiple versus singleton pregnancies and per pregnancy in monozygotic/dizygotic versus singleton pregnancies. Proportion of prenatally diagnosed and pregnancy outcome.

STATISTICAL ANALYSIS

Poisson and logistic regression stratified for maternal age, country and time.

RESULTS

Overall, the adjusted (adj) RR of DS for fetus/babies from multiple versus singleton pregnancies was 0.58 (95% CI 0.53-0.62), similar for all maternal ages except for mothers over 44, for whom it was considerably lower. In 8.7% of twin pairs affected by DS, both co-twins were diagnosed with the condition. The adjRR of DS for monozygotic versus singleton pregnancies was 0.34 (95% CI 0.25-0.44) and for dizygotic versus singleton pregnancies 1.34 (95% CI 1.23-1.46). DS fetuses from multiple births were less likely to be prenatally diagnosed than singletons (adjOR 0.62 [95% CI 0.50-0.78]) and following diagnosis less likely to be TOPFA (adjOR 0.40 [95% CI 0.27-0.59]).

CONCLUSIONS

The risk of DS per fetus/baby is lower in multiple than singleton pregnancies. These estimates can be used for genetic counselling and prenatal screening.

Anorectal malformations and pregnancy-related disorders: a registry-based case-control study in 17 European regions

OBJECTIVE

To identify pregnancy-related risk factors for different manifestations of congenital anorectal malformations (ARMs).

DESIGN

A population-based case-control study.

SETTING

Seventeen EUROCAT (European Surveillance of Congenital Anomalies) registries, 1980-2008.

POPULATION

The study population consisted of 1417 cases with ARM, including 648 cases of isolated ARM, 601 cases of ARM with additional congenital anomalies, and 168 cases of ARM-VACTERL (vertebral, anal, cardiac, tracheo-esophageal, renal, and limb defects), along with 13 371 controls with recognised syndromes or chromosomal abnormalities.

METHODS

Multiple logistic regression analyses were used to calculate adjusted odds ratios (ORs) for potential risk factors for ARM, such as fertility treatment, multiple pregnancy, primiparity, maternal illnesses during pregnancy, and pregnancy-related complications.

MAIN OUTCOME MEASURES

Adjusted ORs for pregnancy-related risk factors for ARM.

RESULTS

The ARM cases were more likely to be firstborn than the controls (OR 1.6, 95% CI 1.4-1.8). Fertility treatment and being one of twins or triplets seemed to increase the risk of ARM in cases with additional congenital anomalies or VACTERL (ORs ranging from 1.6 to 2.5). Maternal fever during pregnancy and pre-eclampsia were only associated with ARM when additional congenital anomalies were present (OR 3.9, 95% CI 1.3-11.6; OR 3.4, 95% CI 1.6-7.1, respectively), whereas maternal epilepsy during pregnancy resulted in a five-fold elevated risk of all manifestations of ARM (OR 5.1, 95% CI 1.7-15.6).

CONCLUSIONS

This large European study identified maternal epilepsy, fertility treatment, multiple pregnancy, primiparity, pre-eclampsia, and maternal fever during pregnancy as potential risk factors primarily for complex manifestations of ARM with additional congenital anomalies and VACTERL.

Trends in the prevalence, risk and pregnancy outcome of multiple births with congenital anomaly: a registry-based study in 14 European countries 1984-2007

OBJECTIVE

To assess the public health consequences of the rise in multiple births with respect to congenital anomalies.

DESIGN

Descriptive epidemiological analysis of data from population-based congenital anomaly registries.

SETTING

Fourteen European countries.

POPULATION

A total of 5.4 million births 1984-2007, of which 3% were multiple births.

METHODS

Cases of congenital anomaly included live births, fetal deaths from 20 weeks of gestation and terminations of pregnancy for fetal anomaly.

MAIN OUTCOME MEASURES

Prevalence rates per 10,000 births and relative risk of congenital anomaly in multiple versus singleton births (1984-2007); proportion prenatally diagnosed, proportion by pregnancy outcome (2000-07). Proportion of pairs where both co-twins were cases.

RESULTS

Prevalence of congenital anomalies from multiple births increased from 5.9 (1984-87) to 10.7 per 10,000 births (2004-07). Relative risk of nonchromosomal anomaly in multiple births was 1.35 (95% CI 1.31-1.39), increasing over time, and of chromosomal anomalies was 0.72 (95% CI 0.65-0.80), decreasing over time. In 11.4% of affected twin pairs both babies had congenital anomalies (2000-07). The prenatal diagnosis rate was similar for multiple and singleton pregnancies. Cases from multiple pregnancies were less likely to be terminations of pregnancy for fetal anomaly, odds ratio 0.41 (95% CI 0.35-0.48) and more likely to be stillbirths and neonatal deaths.

CONCLUSIONS

The increase in babies who are both from a multiple pregnancy and affected by a congenital anomaly has implications for prenatal and postnatal service provision. The contribution of assisted reproductive technologies to the increase in risk needs further research. The deficit of chromosomal anomalies among multiple births has relevance for prenatal risk counselling.

The role of qualitative risk assessment in environmental management: A Kazakhstani case study

Successful environmental management is partly contingent on the effective recognition and communication of environmental health risks to the public. Yet risk perceptions are known to differ between experts and laypeople; laypeople often exhibit higher perceptions of risk in comparison to experts, particularly when these risks are associated with radiation, nuclear power, or nuclear waste. This paper consequently explores stakeholder risk perceptions associated with a mercury-contaminated chloralkali production facility in Kazakhstan. Using field observations and in-depth interviews conducted in the vicinity of the Pavlodar Chemical Plant, this work assesses the relevance of the substantial on-site mercury contamination to the health and livelihoods of the local population with the goal of informing remediation activity through a combination of quantitative and qualitative risk assessments. The findings of this research study cannot be broadly generalized to all the primary stakeholders of the site due to the small sample size; however, the indifference of the local population towards both the possibility of mercury-related health risks and the need for mitigation activity could pose a substantial barrier to successful site remediation and also suggests that a qualitative understanding of stakeholder risk perceptions could play an important role in striving towards sustainable, long-term environmental risk management.

Folic acid supplement use in the prevention of neural tube defects

In 2008, planned folic acid fortification for the prevention of Neural Tube Defects (NTD) was postponed. Concurrently, the economic recession may have affected dietary folic acid intake, placing increased emphasis on supplement use. This study examined folic acid supplement use in 2009. A cross-sectional survey of 300 ante-natal women was undertaken to assess folic acid knowledge and use. Associations between demographic, obstetric variables and folic acid knowledge and use were examined. A majority, 284/297 (96%), had heard of folic acid, and 178/297 (60%) knew that it could prevent NTD. Most, 270/297 (91%) had taken it during their pregnancy, but only 107/297 (36%) had used it periconceptionally. Being older, married, planned pregnancy and better socioeconomic status were associated with periconceptional use. Periconceptional folic acid use in 2009 was very low, little changed from economic status were associated with periconceptional use. Periconceptional folic acid use in 2009 was very low, little changed from earlier years. Continuous promotion efforts are necessary. Close monitoring of folic acid intake and NTD rates is essential, particularly in the absence of fortification.

Congenital anomalies and proximity to landfill sites

The occurrence of congenital anomalies in proximity to municipal landfill sites in the Eastern Region (counties Dublin, Kildare, Wicklow) was examined by small area (district electoral division), distance and clustering tendancies in relation to 83 landfills, five of which were major sites. The study included 2136 cases of congenital anomaly, 37,487 births and 1423 controls between 1986 and 1990. For the more populous areas of the region 50% of the population lived within 2-3 km of a landfill and within 4-5 km for more rural areas. In the area-level analysis, the standardised prevalence ratios, empirical and full Bayesian modelling, and Kulldorff's spatial scan statistic found no association between the residential area of cases and location of landfills. In the case control analysis, the mean distance of cases and controls from the nearest landfill was similar. The odds ratios of cases compared to controls for increasing distances from all landfills and major landfills showed no significant difference from the baseline value of 1. The kernel and K methods showed no tendency of cases to cluster in relationship to landfills. In conclusion, congenital anomalies were not found to occur more commonly in proximity to municipal landfills.

Epidemiology of MRSA: the North/South study of MRSA in Ireland 1999

The North/South Study of methicillin-resistant Staphylococcus aureus (MRSA) in Ireland, 1999, includes a joint review of the epidemiology of MRSA across both jurisdictions on the island of Ireland. Data were gathered on all MRSA cases identified in laboratories in Northern Ireland (the North) and in the Republic of Ireland (the South) over a two-week period. The prevalence rate per 100000 population was 11.4 in the North and 14.0 in the South, with a marked variation across geographical regions. MRSA cases were located throughout hospitals and the community, were slightly more common in males than females, and occurred in all age groups, especially in the elderly. The majority of cases were inpatients in acute hospitals and were distributed across all types of wards. Most cases were colonized with MRSA but 5% of cases in the North and 10% in the South had invasive infection. Invasive infection was associated with intravascular lines and invasive procedures/surgery. Continuous surveillance is recommended to monitor the epidemiology of MRSA and the effectiveness of control measures.

Helicobacter Pylori eradication therapy: getting research into practice

Helicobacter Pylori (H. Pylori) is the primary cause of duodenal ulcer (DU). Guidelines recommend that all patients with DU be considered for Helicobacter Pylori Eradication Therapy (HPET). However, the proportion of patients with DU on long term anti-ulcer medication receiving HPET is small. This study examined the effectiveness of the continuing medical education (CME) network of the Irish College of General Practitioners (ICGP) in promoting best practice in DU treatment among GPs in an eastern region of Ireland. Ninty eight GPs recruited from the CME network of the ICGP were randomised in two cohorts. Cohort 1 received an (early) intervention; GPs were asked to identify their patients with DU receiving long term anti-ulcer medication and prescribe HPET according to defined criteria. Cohort 2 received the intervention later. Prescribing of HPET was monitored using routine prescribing data. Twenty per cent (286/1,422) of patients in cohort 1 and 19.2% (127/661) in cohort 2 had a DU. After exclusions, 53% (152/286) in cohort 1 and 30.7% (39/127) in cohort 2, were eligible for HPET. A significantly higher proportion of patients in cohort 1 received HPET compared with cohort 2 during the early intervention period (13.8% vs 0.0%, p<0.05). Reasons for not prescribing HPET included concurrent illness in patients, failure to comply with treatment. Best practice guidelines on HPET treatment of DU can be successfully applied using CME networks. This model could be repeated in another therapeutic area where established research is not yet current practice.

Changing trend in congenital abdominal wall defects in eastern region of Ireland

In the past six years, there have been reports from abroad of an unexplained rise in the birth prevalence rate of the congenital abdominal wall defect gastroschisis, while rates for the macroscopically similar anomaly omphalocoele have remained stable. The Dublin EUROCAT Registry of congenital anomalies monitors trends in the birth prevalence of birth defects in the eastern region of Ireland. We analysed births of children with omphalocoele and gastroschisis born in the period 1981-2000, with comparisons of a number of demographic and obstetric variables. During the 20 year period the birth prevalence rate for omphalocoele remained stable at 2.5/10,000 births, whereas the rate for gastroschisis increased significantly during the 1990s from 1.0/10,000 in 1991 to 4.9/10,000 in 2000. Most of the increase occurred among mothers under 25 years of age. Omphalocoele was associated with a relatively high proportion of other major congenital anomalies. This study showed that there has been an unexpected rise in the birth prevalence of gastroschisis in the region, similar to that experienced in other countries in the same time period and likely to have common aetiological features.

Methicillin-resistant Staphylococcus aureus: laboratory detection methods in use in the Republic of Ireland and Northern Ireland

There is no universally agreed laboratory protocol for the detection of methicillin-resistant Staphylococcus aureus (MRSA) and hence a variety of approaches are used. As part of an all-island survey of MRSA in the Republic of Ireland (the South) and Northern Ireland (the North), a questionnaire was circulated to 14 participating laboratories in the North and 49 in the South, to determine the methods used to isolate MRSA from clinical specimens, identify S. aureus and test for susceptibility to methicillin. Almost two-thirds (64%) of laboratories in the North but only 16% of laboratories in the South use enrichment culture. There is heavy reliance on commercial kits to confirm the identification of S. aureus in the South but all laboratories in the North use the staphylocoagulase test. More than 90% of all laboratories use a disc method for susceptibility testing and 71% of laboratories in the North supplement this with the E-test; however, a range of methicillin disk concentrations are in use. There is a need to review current laboratory methods used to detect MRSA, with follow-up audit on their implementation. Additional resources may be needed in some laboratories to comply with revised guidelines, and reference facilities are required to assess new commercially available techniques and to confirm the identification of unusual or difficult strains.

What happens to stroke patients after hospital discharge?

Of 231 stroke patients discharged from hospital, 34 patients (14.7%) had died when reviewed 6 months later. Of 195 survivors, 115 (58%) were independent and living in the community. The remaining 80 (42%) patients were dependent. The majority of dependent patients were in institutional care but 29 (36%) were residing in the community of whom a substantial number were not receiving physiotherapy, occupational therapy or day care. Patients who were dependent in nursing homes were less likely to have received physiotherapy (48% versus 70%) or occupational therapy (28% versus 60%) compared to disabled patients in hospital based extended nursing care. 45 patients (24%) had been re-admitted to hospital although only 48% of patients had been reviewed in hospital outpatients since discharge. 64% of patients were on anti-thrombotic treatment. This survey suggests that 6 months after hospital discharge, most stroke patients are still alive and living in the community. Many of the dependent survivors have ongoing unmet medical and rehabilitation needs.

Effect of death of Diana, princess of Wales on suicide and deliberate self-harm

BACKGROUND

The death of the Princess of Wales in 1997 was followed by widespread public mourning. Such major events may influence suicidal behaviour.

AIMS

To assess the impact of the Princess's death on suicide and deliberate self-harm (DSH).

METHOD

Analysis, using Poisson regression, of the number of suicides and open verdicts ('suicides') in England and Wales following the Princess's death compared to the 3 months beforehand, and the equivalent periods in 1992-1996. Similar analysis on DSH presentations to a general hospital.

RESULTS

Suicides increased during the month following the Princess's funeral (+17.4%). This was particularly marked in females (+33.7%), especially those aged 25-44 years (+45.1%). Suicides did not fall in the week between the death and the funeral. Presentations for DSH increased significantly during the week following the death (+44.3%), especially in females (+65.1%). Examination of case notes suggested that the influence of the death was largely through amplification of personal losses or exacerbation of existing distress.

CONCLUSIONS

The death of a major public figure can influence rates of suicidal behaviour. For DSH, the impact may be immediate, but for suicide it may be delayed.

Prevalence of risk factors for ischaemic stroke and their treatment among a cohort of stroke patients in Dublin

BACKGROUND

The majority of strokes are due to ischaemia. Risk factors include atrial fibrillation, hypertension and smoking. The incidence can be reduced by addressing these risk factors. This study examines the prevalence of risk factors and their treatment in a cohort of patients with ischaemic stroke registered on a Dublin stroke database.

METHODS

Patients admitted to any of three acute hospitals with a diagnosis of stroke during a one-year period in 1997/98 were registered on a database using the European Stroke Database format. Data relating to common risk factors were analysed.

RESULTS

There were 238 ischaemic stroke cases registered. The most frequent medical risk factors were: hypertension (45%), atrial fibrillation (27.3%), and previous disabling or non-disabling stroke (33.2%). There was an increasing trend with advancing age for atrial fibrillation (p < 0.001). Some 23% (54/233) were current smokers. A significantly higher proportion of patients with no medical risk factors were smokers or consumed excessive alcohol compared with those who had medical risk factors.

CONCLUSION

Medical risk factors for stroke were common among stroke patients and not optimally treated, particularly with regard to atrial fibrillation and previous stroke. Smoking was a major behavioural risk factor among younger patients and much health gain could be achieved in this group through primary prevention strategies.

Hospital-based stroke care in Ireland: results from one regional register

BACKGROUND

Most patients with acute stroke are admitted to hospital. If stroke services in this country are to be improved, we need accurate and reliable information about the types of stroke patients being admitted, their present management and outcome.

AIMS

To examine the demography, severity, level of investigation, length of stay, mortality and discharge location of prospectively identified consecutive stroke admissions to three general hospitals in South East Dublin.

RESULTS

Three hundred and twenty nine consecutive stroke admissions to three general hospitals in South East Dublin were registered using the European Stroke Database over 50 weeks. The mean age was 73.3 years, whilst 20.1% patients were under 65 years. Prior to admission, 90% of patients were community dwelling with 14.9% of patients being dependent in activities of daily living. 22.4% of patients had some depression in level of consciousness on admission. The overall mortality rate was 26.1% whilst 136 (41.3%) were discharged home, 50 (15.2%) went to institutional care and 45 (13.7%) went to non general hospitals secondary rehabilitation units. The mean length of stay was 31.3 days. The combined poor outcome measure (mortality plus percentage of patients discharged to institutional care), was lower in one hospital compared to the other two hospitals (29.3% versus 44.65%, p > or = 0.05) probably reflecting case mix. Stroke accounted for 4.2% of all bed days in the major general hospital in this area. The overall CT scan rate was 84.5%, with 18.2% of CT scans showing a haemorrhagic component and two patients (0.8%) having brain tumours. Carotid doppler examinations were carried out in 37% of patients.

CONCLUSION

The results demonstrate the high mortality and prolonged hospital stay for stroke patients in this area and emphasise the need for co-ordinated stroke care and regular audit to ensure most effective use of hospital resources.

Determinants of folic acid knowledge and use among antenatal women

BACKGROUND

Although recommendations on folic acid use were issued by health authorities in a number of countries in the early 1990s, uptake of peri-conceptional folic acid is still disappointingly low. Regardless of food fortification policies, folic acid promotion will probably be required in most countries to optimize folate levels among women of child-bearing age. The aim of this study was to examine folic acid knowledge and use, and their determinants among antenatal women in the east of Ireland in 1997.

METHODS

Three hundred antenatal women attending their initial booking appointment in three Dublin maternity hospitals were surveyed. An interviewer-administered questionnaire was used with questions on folic acid knowledge and use, and demographic and obstetric questions. A univariate analysis of data was undertaken followed by a multivariate analysis using logistic regression to determine factors predicting knowledge and use of folic acid.

RESULTS

Seventy-six per cent of respondents had heard of folic acid, 16 per cent had taken it before pregnancy and 51 per cent during pregnancy. Women who had planned their pregnancy, were married and were relatively affluent were significantly more likely to have heard of folic acid, to know that it could prevent neural tube defects and to have taken it peri-conceptionally. Less affluent women tended to use their general practitioner (GP) more as a source of information and advice than those who were better off. In multivariate analysis, marriage and planned pregnancy were important predictors of folic acid knowledge whereas planned pregnancy advice given before pregnancy and relative affluence were predictive of peri-conceptional use.

CONCLUSIONS

Many women know of folic acid but do not take it peri-conceptionally. Women may associate folic acid with pregnancy and less with pre-pregnancy. Greater emphasis on peri-conceptional use should improve folic acid uptake. Focusing on less affluent women for folic acid promotion by GPs and other primary care professionals is also important.

Suicide within 12 months of contact with mental health services: national clinical survey

OBJECTIVE

To describe the clinical circumstances in which psychiatric patients commit suicide.

DESIGN

National clinical survey.

SETTING

England and Wales.

SUBJECTS

A two year sample of people who had committed suicide, in particular those who had been in contact with mental health services in the 12 months before death.

MAIN OUTCOME MEASURES

Proportion of suicides in people who had had recent contact with mental health services; proportion of suicides in inpatients; proportion of people committing suicide and timing of suicide within three months of hospital discharge; proportion receiving high priority under the care programme approach; proportion who were recently non-compliant and not attending.

RESULTS

10 040 suicides were notified to the study between April 1996 and March 1998, of whom 2370 (24%; 95% confidence interval 23% to 24%) had had contact with mental health services in the year before death. Data were obtained on 2177, a response rate of 92%. In general these subjects had broad social and clinical needs. Alcohol and drug misuse were common. 358 (16%; 15% to 18%) were psychiatric inpatients at the time of death, 21% (17% to 25%) of whom were under special observation. Difficulties in observing patients because of ward design and nursing shortages were both reported in around a quarter of inpatient suicides. 519 (24%; 22% to 26%) suicides occurred within three months of hospital discharge, the highest number occurring in the first week after discharge. 914 (43%; 40% to 44%) were in the highest priority category for community care. 488 (26% excluding people whose compliance was unknown; 24% to 28%) were non-compliant with drug treatment while 486 (28%; 26% to 30%) community patients had lost contact with services. Most people who committed suicide were thought to have been at no or low immediate risk at the final service contact. Mental health teams believed suicide could have been prevented in 423 (22%; 20% to 24%) cases.

CONCLUSIONS

Several suicide prevention measures in mental health services are implied by these findings, including measures to improve compliance and prevent loss of contact with services. Inpatient facilities should remove structural difficulties in observing patients and fixtures that can be used in hanging. Prevention of suicide after discharge may require earlier follow up in the community. Better suicide prevention in psychiatric patients is likely to need measures to improve the safety of mental health services as a whole, rather than specific measures for people known to be at high risk.

Mental disorder and clinical care in people convicted of homicide: national clinical survey

OBJECTIVES

To estimate the rate of mental disorder in those convicted of homicide and to examine the social and clinical characteristics of those with a history of contact with psychiatric services.

DESIGN

National clinical survey.

SETTING

England and Wales.

SUBJECTS

Eighteen month sample of people convicted of homicide.

MAIN OUTCOME MEASURES

Offence related and clinical information collected from psychiatric court reports on people convicted of homicide. Detailed clinical data collected on those with a history of contact with psychiatric services.

RESULTS

718 homicides were reported to the inquiry between April 1996 and November 1997. Of the 500 cases for whom psychiatric reports were retrieved, 220 (44%; 95% confidence interval 40% to 48%) had a lifetime history of mental disorder, while 71 (14%; 11% to 17%) had symptoms of mental illness at the time of the homicide. Of the total sample, 102 (14%; 12% to 17%) were confirmed to have been in contact with mental health services at some time, 58 (8%; 6% to 10%) in the year before the homicide. The commonest diagnosis was personality disorder (20 cases, 22%; 13% to 30%). Alcohol and drug misuse were also common. Only 15 subjects (18%; 10% to 26%) were receiving intensive community care, and 60 (63%; 53% to 73%) were out of contact at the time of the homicide.

CONCLUSIONS

There are substantial rates of mental disorder in people convicted of homicide. Most do not have severe mental illness or a history of contact with mental health services. Inquiry findings suggest that preventing loss of contact with services and improving the clinical management of patients with both mental illness and substance misuse may reduce risk, but clinical trials are needed to examine the effectiveness of such interventions.

Folic acid knowledge and use among expectant mothers in 1997: a comparison with 1996

This study examined changes in folic acid knowledge and use among antenatal women in Dublin maternity hospitals between 1996 and 1997, following a campaign to improve the very low uptake of peri-conceptional folic acid. The results showed significant improvements between the two years. Almost 76% of respondents had heard of folic acid in 1997 compared with 54% in 1996 (p < 0.01), with a shift in the proportion of people hearing of folic acid from hospital doctors to general practitioners (GP). Almost 43% of respondents in 1997 knew that folic acid can prevent spina bifida compared with 21% in 1996 (p < 0.01). A higher proportion was taking folic acid prior to conception in 1997 (16% vs 6%, p < 0.01). We conclude that the improvements may have been in part due to the promotional campaign among health professionals, women's groups and the media. However, less than a fifth of women were taking folic acid peri-conceptionally in 1997 and there is still scope for much improvement.

Knowledge and use of peri-conceptional folic acid among antenatal patients

Peri-conceptional folic acid can prevent more than half of all neural tube defects (NTDs). A cross-sectional interviewer administered study was undertaken among 300 women attending their first antenatal appointment in the three major Dublin maternity hospitals. The aim of the study was to monitor knowledge and behaviour with respect to peri-conceptional folic acid among antenatal patients. There was a 98% (295/300) response rate. 53.6% (158/295) had heard of folic acid. Such knowledge was significantly associated with age over 30 years (p < 0.001), a planned pregnancy (p < 0.001) and being married (p < 0.001). The majority (58.2%) found out about folic acid from lay sources such as friends or the media. One eighth (12.9%, 38/295) had been advised to take folic acid before pregnancy, the majority (58.3%, 21/38) having been advised by doctors. 21% (62/295) knew that it prevented spina bifida. 5.8% (17/295) had taken it before becoming pregnant. Taking folic acid before pregnancy was significantly associated with having a planned pregnancy (p < 0.005) and being married (p < 0.005). This study highlights the poor impact of health promotion campaigns to date and provides a challenge to health professionals.

Using research to implement change: the introduction of group activities on a psychiatric unit

Staff in a psychiatric unit of a general hospital proposed the introduction of a programme of structured group activities, based on their casual observation that patients were sometimes unoccupied and bored. It was decided to collect data systematically in order to inform the implementation of activities. An activities record sheet was developed to list all activities taking place over a 1-week period. Questionnaires were administered to patients (n = 23) and staff (n = 20) on the unit to seek their views on the value, type, timing, frequency and location of activities as well as on other related aspects. Overall, staff made practical and realistic suggestions regarding the implementation of structured group activities. The data collected, although useful in planning change, raised questions about the poor quality of patients' responses and the low response rate (50%) from staff. Implications of these and other issues are discussed.