The British Journal of General Practice最新文献

{"title":"Can early cancer detection be improved in deprived areas by involving community pharmacists?","authors":"J. Konya, Richard Neal, C. Clark, D. Bearman, J. Campbell","doi":"10.3399/bjgp22X718865","DOIUrl":"https://doi.org/10.3399/bjgp22X718865","url":null,"abstract":"The key to the success of cancer treatments and better clinical outcomes is early detection. The incidence and mortality from cancer is higher in patients with lower socioeconomic status compared to that for more affluent patients.1 General practice is crucial for the early diagnosis of cancer. The COVID-19 pandemic highlighted pre-existing GP workforce and access inequalities, which are expected to get worse.2 The 2020 General Practice Patient Survey suggests that patients from deprived areas have more difficulties accessing general practice than patients from affluent areas.3 Secondary care treatment waiting times have also become longer compared to pre-pandemic levels, and have increased significantly in deprived populations.4","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"28 1","pages":"153 - 154"},"PeriodicalIF":0.0,"publicationDate":"2022-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83593839","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Pre-diagnostic clinical features and blood tests in patients with colorectal cancer: a retrospective linked-data study","authors":"Marie Moullet, G. Funston, L. Mounce, G. Abel, N. D. de Wit, F. Walter, Yin Zhou","doi":"10.3399/BJGP.2021.0563","DOIUrl":"https://doi.org/10.3399/BJGP.2021.0563","url":null,"abstract":"Background The majority of colorectal cancer is diagnosed in patients following symptomatic presentation in the UK. Aim To identify windows of opportunity for timely investigations or referrals in patients presenting with colon and rectal cancer-relevant symptoms or abnormal blood tests. Design and setting A retrospective cohort study was undertaken using linked primary care and cancer registry data for patients with colorectal cancer diagnosed in England between 2012 and 2015. Method Monthly consultation rates for relevant clinical features (change in bowel habit, rectal bleeding, abdominal pain, abdominal mass, constitutional symptoms, and other bowel symptoms) and abnormal blood test results (low haemoglobin, high platelets, and high inflammatory markers) up to 24 months pre-diagnosis were calculated. Poisson regression adjusted for age, sex, and relevant comorbidities was used to estimate the most likely month when consultation rates increased above baseline. Results In total, 5033 patients with colon cancer and 2516 with rectal cancer were included. Consultations for all examined clinical features and abnormal blood tests increased in the year pre-diagnosis. Rectal bleeding was the earliest clinical feature to increase from the baseline rate: at 10 months (95% confidence interval [CI] = 8.3 to 11.7) pre-diagnosis for colon cancer and at 8 months (95% CI = 6.1 to 9.9) pre-diagnosis for rectal cancer. Low haemoglobin, high platelets, and high inflammatory markers increased from as early as 9 months pre-diagnosis. Conclusion This study found evidence for an early increase in rates of consultation for relevant clinical features and abnormal blood tests in patients with colorectal cancer, suggesting that earlier instigation of cancer-specific investigations or referrals may be warranted in some patients who were symptomatic.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"53 1","pages":"e556 - e563"},"PeriodicalIF":0.0,"publicationDate":"2022-03-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76261930","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Accuracy of the NICE traffic light system in children presenting to general practice: a retrospective cohort study","authors":"Amy Clark, R. Cannings‐John, Megan Blyth, Alastair D Hay, Christopher C. Butler, K. Hughes","doi":"10.3399/BJGP.2021.0633","DOIUrl":"https://doi.org/10.3399/BJGP.2021.0633","url":null,"abstract":"Background The National Institute for Health and Care Excellence (NICE) traffic light system was created to facilitate the assessment of unwell children in primary care. To the authors’ knowledge, no studies have validated this tool in UK general practice. Aim To evaluate the accuracy of this system for detecting serious illness in children presenting to general practice. Design and setting A retrospective diagnostic accuracy study was undertaken, using a cohort of acutely unwell children aged <5 years presenting to general practice in England and Wales. Method The traffic light categories of 6703 children were linked with hospital data to identify admissions and diagnoses. The sensitivity and specificity of these categories were calculated against the reference standard: a hospital-diagnosed serious illness within 7 days of GP consultation, measured using International Classification of Diseases, 10th Revision codes. Results In total, 2116 (31.6%) children were categorised as ‘red’; 4204 (62.7%) as ‘amber’; and 383 (5.7%) as ‘green’. There were 139 (2.1%) children who were admitted to hospital within 7 days of consultation, of whom 17 (12.2%; 0.3% overall) had a serious illness. The sensitivity of the red category (versus amber and green) was 58.8% (95% confidence interval [CI] = 32.9 to 81.6) and the specificity 68.5% (95% CI = 67.4 to 69.6). The sensitivity and specificity of red and amber combined (versus green) was 100% (95% CI = 80.5 to 100) and 5.7% (95% CI = 5.2 to 6.3), respectively. Conclusion The NICE traffic light system did not accurately detect children admitted with a serious illness, nor those not seriously ill who could have been managed at home. This system is not suitable for use as a clinical tool in general practice. Further research is required to update or replace the system.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"8 1","pages":"e398 - e404"},"PeriodicalIF":0.0,"publicationDate":"2022-03-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82423057","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Remote primary care during the COVID-19 pandemic for people experiencing homelessness: a qualitative study","authors":"K. Howells, Mat Amp, Martin Burrows, Jo-Ann Brown, R. Brennan, Joanne Dickinson, Shaun Jackson, Wan-Ley Yeung, D. Ashcroft, S. Campbell, T. Blakeman, C. Sanders","doi":"10.3399/BJGP.2021.0596","DOIUrl":"https://doi.org/10.3399/BJGP.2021.0596","url":null,"abstract":"Background The COVID-19 pandemic has caused unprecedented disruption and change to the organisation of primary care, including for people experiencing homelessness who may not have access to a phone. Little is known about whether the recent changes required to deliver services to people experiencing homelessness will help to address or compound inequality in accessing care. Aim To explore the experience and impact of organisational and technology changes in response to COVID-19 on access to health care for people experiencing homelessness. Design and setting An action-led and participatory research methodology was employed in three case study sites made up of primary care services delivering care for people experiencing homelessness. Method Individual semi-structured interviews were conducted with 21 people experiencing homelessness and 22 clinicians and support workers. Interviews were analysed using a framework approach. Results The move to remote telephone consultations highlighted the difficulties experienced by participants in accessing health care. These barriers included problems at the practice level associated with remote triage as participants did not always have access to a phone or the means to pay for a phone call. This fostered increased reliance on support workers and clinicians working in the community to provide or facilitate a primary care appointment. Conclusion The findings have emphasised the importance of addressing practical and technology barriers as well as supporting communication and choice for mode of consultation. The authors argue that consultations should not be remote ‘by default’ and instead take into consideration both the clinical and social factors underpinning health.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"114 1","pages":"e492 - e500"},"PeriodicalIF":0.0,"publicationDate":"2022-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77714718","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Characterisation of type 2 diabetes subgroups and their association with ethnicity and clinical outcomes: a UK real-world data study using the East London Database","authors":"R. Mathur, S. Hull, S. Hodgson, S. Finer","doi":"10.1101/2021.08.26.21262657","DOIUrl":"https://doi.org/10.1101/2021.08.26.21262657","url":null,"abstract":"Background: Subgroups of type 2 diabetes (T2DM) have been well characterised in experimental studies. However, it is unclear whether T2DM subgroups can be identified in UK based real-world populations and if they impact clinical outcomes. Aim: To derive T2DM subgroups using primary care data from a multi-ethnic population, evaluate associations with glycaemic control, treatment initiation and vascular outcomes, and understand how these vary by ethnicity. Design and setting: An observational cohort study in the East London Primary Care Database from 2008-2018. Method: Latent class analysis using age, sex, glycated haemoglobin, and body mass index at diagnosis was used to derive T2DM subgroups in White, South Asian, and Black groups. Time to treatment initiation and vascular outcomes was estimated using multivariable Cox-proportional hazards regression. Results: 31,931 adults with T2DM were included: 47% south Asian, 25% White, 20% Black. We replicated two previously described subgroups, \"Mild Age-Related Diabetes\" (MARD), \"Mild Obesity-related Diabetes\" (MOD), and characterised a third \"Severe Hyperglycaemic Diabetes\" (SHD). Compared to MARD, SHD had the poorest long term glycaemic control, fastest initiation of antidiabetic treatment (HR 2.02, 1.76-2.32), and highest risk of microvascular complications (HR 1.38, 1.28-1.49). MOD had the highest risk of macrovascular complications (HR 1.50, 1.23-1.83). Subgroup differences in treatment initiation were most pronounced for the White group, and vascular complications for the Black group. Conclusions: Clinically useful T2DM subgroups, identified at diagnosis, can be generated in routine real-world multi-ethnic populations, and may offer a pragmatic means to develop stratified primary care pathways and improve healthcare resource allocation.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"15 1","pages":"e421 - e429"},"PeriodicalIF":0.0,"publicationDate":"2021-08-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85703529","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Integrating primary care and social services for older adults with multimorbidity: a qualitative study","authors":"H. Dambha‐Miller, G. Simpson, Lucy Hobson, Doyinsola Olaniyan, S. Hodgson, P. Roderick, S. Fraser, P. Little, H. Everitt, M. Santer","doi":"10.1101/2021.01.30.21250563","DOIUrl":"https://doi.org/10.1101/2021.01.30.21250563","url":null,"abstract":"Background: Growing demand from an ageing population, chronic preventable disease and multimorbidity has resulted in complex health and social care needs requiring more integrated services. Integrating primary care with social services could more efficiently utilise resources, and improve experiences for patients, their families and carers. There is limited evidence on progress including key barriers and drivers of integration to inform large-scale national change. Aim: To elicit stakeholder views on drivers and barriers of integrated primary care and social services. and highlight opportunities for successful implementation. Design and setting: A qualitative interview study. Method: Semi-structured interviews with maximum variation sampling to capture stakeholder views across services and professions. Results: Thirty-seven interviews were conducted across England including GPs, nurses, social care staff, commissioners, local government, voluntary and private sectors, patients and carers. Drivers of integration included groups of like-minded individuals supported by good leadership, expanded interface roles to bridge gaps between systems and co-location of services. Barriers included structural and interdisciplinary tension between professions, organisational self-interest and challenges in record-sharing. Conclusions: Drivers and barriers to integration identified in other contexts are also present in primary care and social services. Benefits of integration are unlikely to be realised if these are not addressed in the design and execution of new initiatives. Efforts should go beyond local and professional level change to include wider systems and policy-level initiatives. This will support a more systems-wide approach to integrated care reform, which is necessary to meet the complex and growing needs of an ageing multimorbid population.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"1 1","pages":"e753 - e761"},"PeriodicalIF":0.0,"publicationDate":"2021-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88608731","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Evaluation of a primary care-based opioid and pain review service: a mixed-methods evaluation in two GP practices in England.","authors":"Lauren J Scott, Joanna M Kesten, Kevin Bache, Matthew Hickman, Rona Campbell, Anthony E Pickering, Sabi Redwood, Kyla Thomas","doi":"10.3399/bjgp19X707237","DOIUrl":"10.3399/bjgp19X707237","url":null,"abstract":"<p><strong>Background: </strong>Opioid prescribing to treat chronic non-cancer pain has rapidly increased, despite a lack of evidence for long-term safety and effectiveness. A pain review service was developed to work with patients taking opioids long-term to explore opioid use, encourage non-drug-based alternatives, and, where appropriate, support dose reduction.</p><p><strong>Aim: </strong>To evaluate the service and its potential impact on opioid use, health and wellbeing outcomes, and quality of life (QoL).</p><p><strong>Design and setting: </strong>Mixed-methods evaluation of a one-to-one service based in two GP practices in South Gloucestershire, England, which took place from September 2016 to December 2017.</p><p><strong>Method: </strong>Quantitative data were collected on baseline demographics; data on opioid use, misuse, and dose, health, wellbeing, QoL, and pain and interference with life measures were collected at baseline and follow-up. Twenty-five semi-structured interviews (<i>n</i> = 18 service users, <i>n</i> = 7 service providers) explored experiences of the service including perceived impacts and benefits.</p><p><strong>Results: </strong>Of 59 patients who were invited, 34 (57.6%) enrolled in the service. The median prescribed opioid dose reduced from 90 mg (average daily morphine equivalent; interquartile range [IQR] 60 to 240) at baseline to 72 mg (IQR 30 to 160) at follow-up (<i>P</i><0.001); three service users stopped using opioids altogether. On average, service users showed improvement on most health, wellbeing, and QoL outcomes. Perceived benefits were related to wellbeing, for example, improved confidence and self-esteem, use of pain management strategies, changes in medication use, and reductions in dose.</p><p><strong>Conclusion: </strong>The service was well received, and health and wellbeing outcomes suggest a potential benefit. Following further service development, a randomised controlled trial to test this type of care pathway is warranted.</p>","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"37 1","pages":"e111-e119"},"PeriodicalIF":0.0,"publicationDate":"2020-01-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6890470/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88369864","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Factors affecting use of unscheduled care for people with advanced cancer: a retrospective cohort study in Scotland.","authors":"Sarah Mills, Deans Buchanan, Bruce Guthrie, Peter Donnan, Blair Smith","doi":"10.3399/bjgp19X706637","DOIUrl":"10.3399/bjgp19X706637","url":null,"abstract":"<p><strong>Background: </strong>People with advanced cancer frequently attend unscheduled care, but little is known about the factors influencing presentations. Most research focuses on accident and emergency (A&E) and does not consider GP out-of-hours (GPOOH).</p><p><strong>Aim: </strong>To describe the frequency and patterns of unscheduled care use by people with cancer in their last year of life and to examine the associations of demographic and clinical factors with unscheduled care attendance.</p><p><strong>Design and setting: </strong>Retrospective cohort study of all 2443 people who died from cancer in Tayside, Scotland, during 2012-2015. Clinical population datasets were linked to routinely collected clinical data using the Community Health Index (CHI) number.</p><p><strong>Method: </strong>Anonymised CHI-linked data were analysed in SafeHaven, with descriptive analysis, using binary logistic regression for adjusted associations.</p><p><strong>Results: </strong>Of the people who died from cancer, 77.9% (<i>n</i> = 1904) attended unscheduled care in the year before death. Among unscheduled care users, most only attended GPOOH (<i>n</i> = 1070, 56.2%), with the rest attending A&E only (<i>n</i> = 204, 10.7%), or both (<i>n</i> = 630, 33.1%). Many attendances occurred in the last week (<i>n</i> =1360, 19.7%), last 4 weeks (<i>n</i> = 2541, 36.7%), and last 12 weeks (<i>n</i> = 4174, 60.3%) of life. Age, sex, deprivation, and cancer type were not significantly associated with unscheduled care attendance. People living in rural areas were less likely to attend unscheduled care: adjusted odds ratio (aOR) 0.64 (95% confidence interval = 0.50 to 0.82). Pain was the commonest coded clinical reason for presenting (GPOOH: <i>n</i> = 482, 10.5%; A&E: <i>n</i> = 336, 28.8%). Of people dying from cancer, <i>n</i> = 514, 21.0%, were frequent users (≥5 attendances/year), and accounted for over half (<i>n</i> = 3986, 57.7%) of unscheduled care attendances.</p><p><strong>Conclusion: </strong>Unscheduled care attendance by people with advanced cancer was substantially higher than previously reported, increased dramatically towards the end of life, was largely independent of demographic factors and cancer type, and was commonly for pain and palliative care.</p>","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"115 1","pages":"e860-e868"},"PeriodicalIF":0.0,"publicationDate":"2019-11-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6863679/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91047179","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Non-attendance at urgent referral appointments for suspected cancer: a qualitative study to gain understanding from patients and GPs","authors":"L. Jefferson, K. Atkin, Rebecca Sheridan, S. Oliver, U. Macleod, G. Hall, Sarah Forbes, T. Green, V. Allgar, P. Knapp","doi":"10.3399/bjgp19X706625","DOIUrl":"https://doi.org/10.3399/bjgp19X706625","url":null,"abstract":"Background The 2-week-wait urgent referral policy in the UK has sought to improve cancer outcomes by accelerating diagnosis and treatment. However, around 5–7% of symptomatic referred patients cancel or do not attend their hospital appointment. While subsequent cancer diagnosis was less likely in non-attenders, those with a diagnosis had worse early mortality outcomes. Aim To examine how interpersonal, communication, social, and organisational factors influence a patient’s non-attendance. Design and setting Qualitative study in GP practices in one Northern English city. Method In-depth, individual interviews were undertaken face-to-face or by telephone between December 2016 and May 2018, followed by thematic framework analysis. Results In this study 21 GPs, and 24 patients who did not attend or had cancelled their appointment were interviewed, deriving a range of potential explanations for non-attendance, including: system flaws; GP difficulties with booking appointments; patient difficulties with navigating the appointment system, particularly older patients and those from more deprived areas; patients leading ‘difficult lives’; and patients’ expectations of the referral, informed by their beliefs, circumstances, priorities, and the perceived prognosis. GPs recognised the importance of communication with the patient, particularly the need to tailor communication to perceived patient understanding and anxiety. GPs and practices varied in their responses to patient non-attendance, influenced by time pressures and perceptions of patient responsibility. Conclusion Failure to be seen within 2 weeks of urgent referral resulted from a number of patient and provider factors. The urgent referral process in general practice and cancer services should accommodate patient perceptions and responses, facilitate referral and attendance, and enable responses to patient non-attendance.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"36 1","pages":"e850 - e859"},"PeriodicalIF":0.0,"publicationDate":"2019-11-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73962424","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Influence of past trauma and health interactions on homeless women’s views of perinatal care: a qualitative study","authors":"Annabelle Gordon, David B. Lehane, J. Burr, C. Mitchell","doi":"10.3399/bjgp19X705557","DOIUrl":"https://doi.org/10.3399/bjgp19X705557","url":null,"abstract":"Background Homeless women are twice as likely to become pregnant and are less likely to receive antenatal care than women who are not homeless. Prevalent biopsychosocial complexity and comorbidities, including substance use and mental illness, increase the risk of obstetric complications, postnatal depression, and child loss to social services. Aim To explore the perspectives of women who have experienced pregnancy and homelessness to ascertain how to improve perinatal care. Design and setting A qualitative study with a purposive sample of women who had experienced pregnancy and homelessness, recruited from three community settings. Method Semi-structured interviews continued to data saturation and were recorded, transcribed, and analysed thematically using a self-conscious approach, with independent verification of emergent themes. Results Eleven women, diverse in age (18–40 years) and parity (one to five children), participated. Most women had experienced childhood trauma, grief, mental illness, and substance use. Overarching themes of ‘mistrust‘ and ‘fear of child loss to social services’ (CLSS) influenced their interactions with practitioners. The women experienced stigma from practitioners, and lacked effective support networks. Women who mistrusted practitioners attended appointments but concealed their needs, preventing necessary care. Further themes were being seen to do ‘the best for the baby’; pregnancy-enabled access to necessary holistic biopsychosocial care; and lack of postnatal support for CLSS or parenting. Conclusion Pregnancy offered a pivotal opportunity for homeless women to engage with care for their complex needs and improve self-care, despite mistrust of practitioners. Poor postnatal support and the distress of CLSS reinforced an ongoing cycle of grief, mental health crises, substance use relapse, and homelessness.","PeriodicalId":22333,"journal":{"name":"The British Journal of General Practice","volume":"33 1","pages":"e760 - e767"},"PeriodicalIF":0.0,"publicationDate":"2019-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89634151","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}