The diagnosis and lived experience of polycystic ovary syndrome: A qualitative study.

AIMS: To explore the impact of the diagnosis of polycystic ovary syndrome on health/ill health identity, how women experience this diagnosis and their health beliefs. BACKGROUND: Polycystic ovary syndrome is a common and heterogeneous condition, giving rise to a wide range of different health concerns. Previous research on polycystic ovary syndrome has been dominated by the medical perspective and less is known about the experiences and needs of women. DESIGN: A qualitative study of 32 premenopausal adult women with polycystic ovary syndrome (diagnosis confirmed by Rotterdam criteria), aged between 18 and 45 years, recruited from a primary and secondary care setting. METHODS: Thematic analysis of transcripts from 11 focus groups conducted between 2013-2015. RESULTS/FINDINGS: Women identified a range of concerns affecting personal and reproductive identity, health knowledge and beliefs: (1) delays and barriers to diagnosis; (2) general lack of empathy by the medical profession; (3) difficulty in accessing specialist referral; (4) lack of information from professionals; (5) inconsistent and sometimes unsatisfactory experiences with medications; (6) insufficient help and advice regarding in/fertility; (7) relative lack of awareness or concern about longer term risks such as diabetes; and (8) significant discrepancies between the beliefs of women with polycystic ovary syndrome and how they experienced the attitudes of healthcare professionals. CONCLUSIONS: There appears to be a divergence between women's experience and attitudes of healthcare professionals. The diagnosis, support and lived experience of women with polycystic ovary syndrome could be enhanced by better professional recognition of these concerns, improved knowledge and communication about polycystic ovary syndrome and better access to support and specialist advice.

Exploring reasons for variation in ordering thyroid function tests in primary care: a qualitative study.

BACKGROUND: The ordering of thyroid function tests (TFTs) is increasing but there is not a similar increase in thyroid disorders in the general population, leading some to query whether inappropriate testing is taking place. Inconsistent clinical practice is thought to be a cause of this, but there is little evidence of the views of general practitioners, practice nurses or practice managers on the reasons for variation in the ordering of TFTs. AIM: To find out the reasons for variation in ordering of TFTs from the perspective of primary healthcare professionals Methods: Fifteen semi-structured interviews were carried out with primary healthcare professionals (general practitioners, practice nurses, practice managers) that used one laboratory of a general hospital in South West England for TFTs. Framework Analysis was used to analyse views on test ordering variation at the societal, practice, individual practitioner and patient level. RESULTS: A number of reasons for variation in ordering across practices were suggested. These related to: primary healthcare professionals awareness of and adherence to national policy changes; practices having different protocols on TFTs ordering; the set-up and use of computer systems in practices; the range of practice healthcare professionals able to order TFTs; greater risk-aversion amongst general practitioners and changes in their training and finally how primary healthcare staff responded to patients who were perceived to seek help more readily than in the past. CONCLUSION: The reasons for variation in TFTs ordering are complex and interdependent. Interventions to reduce variation in TFTs ordering need to consider multiple behavioural and contextual factors to be most effective.

Pin site care for preventing infections associated with external bone fixators and pins.

BACKGROUND: Metal pins are used to apply skeletal traction or external fixation devices in the management of orthopaedic fractures. These percutaneous pins protrude through the skin, and the way in which they are treated after insertion may affect the incidence of pin site infection. This review set out to summarise the evidence of pin site care on infection rates. OBJECTIVES: To assess the effect on infection rates of different methods of cleansing and dressing orthopaedic percutaneous pin sites. SEARCH METHODS: In September 2013, for this third update, we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. SELECTION CRITERIA: We evaluated all randomised controlled trials (RCTs) that compared the effect on infection and other complication rates of different methods of cleansing or dressing orthopaedic percutaneous pin sites. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the citations retrieved by the search strategies for reports of relevant RCTs, then independently selected trials that satisfied the inclusion criteria, extracted data and undertook quality assessment. MAIN RESULTS: A total of eleven trials (572 participants) were eligible for inclusion in the review but not all participants contributed data to each comparison. Three trials compared a cleansing regimen (saline, alcohol, hydrogen peroxide or antibacterial soap) with no cleansing (application of a dry dressing), three trials compared alternative sterile cleansing solutions (saline, alcohol, peroxide, povidone iodine), three trials compared methods of cleansing (one trial compared identical pin site care performed daily or weekly and the two others compared sterile with non sterile techniques), one trial compared daily pin site care with no care and six trials compared different dressings (using different solutions/ointments and dry and impregnated gauze or sponges). One small blinded study of 38 patients found that the risk of pin site infection was significantly reduced with polyhexamethylene biguanide (PHMB) gauze when compared to plain gauze (RR 0.23, 95% CI 0.12 to 0.44) (infection rate of 1% in the PHMB group and 4.5% in the control group) but this study was at high risk of bias as the unit of analysis was observations rather than patients. There were no other statistically significant differences between groups in any of the other trials. AUTHORS' CONCLUSIONS: The available trial evidence was not extensive, was very heterogeneous and generally of poor quality, so there was insufficient evidence to be able to identify a strategy of pin site care that minimises infection rates. Adequately-powered randomised trials are required to examine the effects of different pin care regimens, and co-interventions - such as antibiotic use - and other extraneous factors must be controlled in the study designs.

Variability in thyroid function test requests across general practices in south-west England.

BACKGROUND: The number of thyroid function tests (TFTs) performed in the UK and other countries has increased considerably in recent years. Inconsistent clinical practice associated with inappropriate requests for tests is thought to be an important cause for this increase. AIM: To study the extent of variability in requests for TFTs from general practices. METHODS: We analysed routine data on all TFTs on patients aged 16 years and over carried out by two hospitals in south-west England (Royal Cornwall Hospital and Royal Devon & Exeter Hospital) during 2010 at the request of 107 general practices. RESULTS: A total of 195 309 TFT requests were made for 148 412 patients (63% female). The total requests included 192 108 tests for thyroid-stimulating hormone (TSH), 43 069 for free thyroxine (FT4) and 1972 for free tri-iodothyronine (FT3). The number of TSH tests per 1000 list size varied widely across the practices, ranging from 84 to 482. Most of the variation was due to heterogeneity across practices and only 24% of this was accounted for by prevalence of hypothyroidism and socio-economic deprivation. CONCLUSIONS: There is wide variation in TFT requests from general practice and scope to reduce both unnecessary TFTs and the variability in the clinical practice. Further studies are required to understand the causes for the variability in testing thyroid function.

Raising awareness of polycystic ovary syndrome.

AIM: To identify women's experience of receiving information about polycystic ovary syndrome (PCOS), and develop an information booklet. METHOD: Women from Cornwall with a diagnosis of PCOS participated in focus groups to discuss their experiences of the condition. FINDINGS: Participants described difficulties in sourcing credible and helpful information about PCOS. CONCLUSION: A booklet was produced for women with PCOS to improve their knowledge of the condition.

A qualitative study of patients' experiences before, during and after surgical treatment for periprosthetic knee joint infection; "I assumed it had to be like that ".

BACKGROUND: Periprosthetic joint infection (PJI) of the knee is associated with extended hospital stay, high doses of antibiotics, lengthy rehabilitation, and pain. Standard treatment is a two-stage procedure comprising two surgeries and two hospitalizations. To facilitate exploration of patients' perspectives, the qualitative study presented here was an adjunct to a Danish randomized controlled trial comparing one-stage and two-stage revision surgery. AIM: To explore patient experiences, before, during and after hospitalization and surgical treatment with one- or two-stage revision for PJI of the knee. MATERIAL AND METHODS: Qualitative, semi-structured telephone interviews were conducted with 10 individuals who had undergone either one- or two-stage revision because of PJI. Thematic analysis was employed. RESULTS: The essence of the findings was that the infection was a transition point in a possible life-changing illness. The three themes representing this comprised: 1) physical, 2) psychological, and 3) social implications. Each theme is further illuminated with subthemes. CONCLUSIONS: Infection is a transition point in a possible life changing illness. Late diagnosis and delayed treatment are major issues. Individuals suffer from pain, weight loss, fatigue, and reduced mobility as well as dependency on family members, leading to psychological challenges including depression. IMPLICATIONS FOR CLINICAL PRACTICE: Patients with PJI of the knee could be better informed, educated and involved before and during treatment. Information is needed not only about the physical consequences, but also the psychological and social consequences. More patient involvement and inter-professional and care sector coordination is important when caring for patients with PJI.

Exploration of transformational and distributed leadership.

Throughout government policy in Scotland, a new emphasis has been placed on clinical leaders as a way to improve quality and restore the public's confidence in health care. This article reports on a study that explored the leadership styles of senior charge nurses and the effects these may have on clinical teams. Findings suggest that, where there is transformational leadership and sharing of leadership roles across teams, staff are more engaged and organisational goals are met. The findings also highlight the need for better communication between senior management and clinical teams to ensure sustainable, good services.

Calm, irritated or infected? The experience of the inflammatory states and symptoms of pin site infection and irritation during external fixation: a grounded theory study.

AIM: To explore patients' experiences of the symptoms of suspected wound infection in external fixator pin sites. BACKGROUND: Pin site infection is painful and distressing and can threaten the success of treatment. It is difficult for patients and clinicians to differentiate between pin site infection and irritation or foreign body reaction to the pin. There is no validated outcome measure for infection that enables the success of interventions for prevention and management to be evaluated. There is a need to develop accurate patient-orientated assessment criteria. DESIGN: Qualitative design, using grounded theory. METHOD: Following written informed consent, a theoretical sample of 16 adults with an external fixation device that had been in situ for at least 12 weeks was recruited. They had experienced a pin site infection in the previous four weeks. Data were collected using semistructured interviews, and data collection was stopped when saturation was achieved. Analysis took place using constant comparative analysis. RESULTS: Participants described three 'clinical states' of pin site wounds: calm, irritated and infected. They described the differences in each state in relation to pain, redness, swelling, discharge and general symptoms. Symptoms were absent or varied in intensity depending on whether the pin sites were calm, irritated or infected. CONCLUSION: This study provides insight into patients' experiences of the symptoms of pin site infection resulting in an emerging theory based on conceptualisation of this experience, which is that of dimensions of inflammatory pin site states. The detail given will enable clinicians and researchers to be more accurate in recognising infection and begins to clarify the difference between a wound that is irritated and a wound that is infected. The findings will enable the development of a patient-orientated outcome questionnaire for pin site infection. RELEVANCE TO CLINICAL PRACTICE: There is a need for patients and clinicians to be able to differentiate between infected, not infected and irritated pin sites.

Using the SSKIN care bundle to prevent pressure ulcers in the intensive care unit.

Pressure ulcers develop when the skin and underlying tissues are subjected to pressure, friction and/or shear, and, in many cases, moisture. These factors lead to impaired blood supply and injury to the skin and underlying tissues. Patients being cared for in intensive care units are particularly at risk of pressure ulcers because they often lack the ability to change position independently. Also, their consciousness and sensory perception are impaired due to sedation and anaesthesia, diminished circulation and malnutrition. This article examines pressure ulcer prevention in this vulnerable group of patients and outlines the five-step SSKIN (surface, skin inspection, kinetics/keep moving, incontinence/moisture, nutrition/hydration) pressure ulcer prevention care bundle.

Empowerment of whom? The gap between what the system provides and patient needs in hip fracture management: A healthcare professionals' lifeworld perspective.

AIMS AND OBJECTIVES: To use a Habermasian lifeworld theoretical perspective to illuminate a treatment gap for hip fracture patients in a Danish university hospital to guide future healthcare services. BACKGROUND: Most healthcare systems focus on systematised guidelines to help reduce hospital length of stay in response to increasing demand because of the ageing of the global population. For patients with hip fractures, a previous study demonstrated that there is a lack of patient empowerment and a gap between patients' needs and wishes and what was provided by the healthcare system. DESIGN: In this follow-up study, the previous findings were introduced to a mixed group of health professionals (HPs) who participated in focus group discussions (n = 3, with a total of 18 HPs). METHODS: Data were analysed using qualitative content analysis. By analysing the discourse of the discussions using Habermas' perspective, the lack of patient-empowerment was illuminated and facilitated, describing it in terms of the gap it creates in communicative actions between HPs and patients. RESULTS: Information and education of patients in systematised pathways, such as those for patients with hip fractures, are dominated by a biomedical discourse. Patients are overwhelmed by the psycho-social implications of the hip fracture, leaving them in a shock-like state of mind. CONCLUSION: Empowerment of patients should involve empowerment of HPs by providing them with skills to support patients in a shock-like state of mind. There is also a need to provide HPs with a more individually targeted means of informing and educating patients.

Patient-reported symptoms of 'calm', 'irritated' and 'infected' skeletal external fixator pin site wound states; a cross-sectional study.

OBJECTIVE: To explore the frequency, severity and variances in patient-reported symptoms of calm, irritated and infected skeletal pin sites. METHODS: A cross-sectional within-subjects repeated-measures study was conducted, employing a self-report questionnaire. Patients (n = 165) treated with lower limb external fixators at 7 English hospitals completed a designed questionnaire. Three sets of retrospective repeated-measures data were collected relating to calm, irritated and infected pin sites. RESULTS: Significant differences were revealed between each of the three pin site states (calm, irritated & infected) in the degree of: redness, swelling, itchiness, pain, wound discharge, heat/burning, shiny skin and odour. In relation to difficulty or pain using the affected arm or leg, difficulty weight bearing on the leg, nausea and/or vomiting, feeling unwell or feverish, shivering, tiredness/lethargy and disturbed sleep, significant differences were demonstrated between infected and irritated states and infected and calm states, but not between irritated and calm. CONCLUSIONS: The findings provide greater depth of understanding of the symptoms of pin site infection and irritation. Patients may be able to differentiate between different pin site states by comparing the magnitude of the inflammatory symptoms and the presence of other specific symptoms that relate solely to infection and no other clinical state. The irritated state is probably caused by a different pathological processother than infection and may be an indication of contact dermatitis.

Nursing care of fragility fracture patients.

The challenge of caring for patients with fragility fractures is particularly acute for nursing teams who are in short supply and work with patients following fracture on a 24 h basis, coordinating as well as providing complex care. This paper considers the role of nurses within the orthogeriatric team and highlights the value of effective nursing care in patient outcomes. It explores the nature of nursing for patients with fragility fracture with a focus on the provision of safe and effective care and the coordination of care across the interdisciplinary team. It also highlights the need for specific skills in orthopaedic and geriatric nursing as well as specialist education.

Acute limb compartment syndrome in the lower leg following trauma: assessment in the intensive care unit.

Acute limb compartment syndrome (ALCS) is a serious complication of traumatic injury. Although ALCS can occur in any limb, it most commonly occurs following injury to the lower leg, particularly in fractures of the tibia. Practitioners should recognise and treat ALCS as early as possible to prevent the development of further, potentially serious, complications. Most of the literature recommends that patients at risk of ALCS should be carefully monitored, with a focus on pain as the main symptom. However, patients in the intensive care unit (ICU) who are unconscious or sedated may be unable to report pain or are unreliable in doing so, therefore it is necessary to consider alternative assessments for ALCS. This article provides an overview of the evidence and guidelines in relation to ALCS in the lower leg and how to undertake an effective assessment for the condition in patients in the ICU. This will enable practitioners to make evidence-based clinical decisions to improve practice and patient safety.