The experience of stigma in inflammatory bowel disease: An interpretive (hermeneutic) phenomenological study.

AIM: To explore experiences of stigma in people with inflammatory bowel disease. BACKGROUND: Diarrhoea, urgency and incontinence are common symptoms in inflammatory bowel disease. Social rules stipulate full control of bodily functions in adulthood: poor control may lead to stigmatization, affecting patients' adjustment to disease. Disease-related stigma is associated with poorer clinical outcomes, but qualitative evidence is minimal. DESIGN: An interpretive (hermeneutic) phenomenological study of the lived experience of stigma in inflammatory bowel disease. METHODS: Forty community-dwelling adults with a self-reported diagnosis of inflammatory bowel disease were recruited purposively. Participants reported feeling stigmatized or not and experiencing faecal incontinence or not. Unstructured interviews took place in participants' homes in the United Kingdom (September 2012 - May 2013). Data were analysed using Diekelmann's interpretive method. FINDINGS: Three constitutive patterns-Being in and out of control, Relationships and social Support and Mastery and mediation-reveal the experience of disease-related stigma, occurring regardless of continence status and because of name and type of disease. Stigma recedes when mastery over disease is achieved through development of resilience-influenced by humour, perspective, mental well-being and upbringing (childhood socialization about bodily functions). People travel in and out of stigma, dependent on social relationships with others including clinicians and tend to feel less stigmatized over time. CONCLUSION: Emotional control, social support and mastery over disease are key to stigma reduction. By identifying less resilient patients, clinicians can offer appropriate support, accelerating the patient's path towards disease acceptance and stigma reduction.

Telemedicine as a means of effective speech evaluation for patients with cleft palate.

Providing long-term multidisciplinary care for cleft lip/palate is a challenge for international humanitarian organizations that perform surgery across borders. The use of telemedicine as a means of evaluating speech in patients with cleft lip/palate has not been studied previously. We looked at determining whether a speech evaluation performed by a speech-language pathologist (SLP) using telemedicine would be equivalent to a speech evaluation performed in-person, in an international setting between Tijuana, Mexico and San Diego, CA. Spanish-speaking SLPs developed an informal protocol to evaluate several speech characteristics. Patients were simultaneously evaluated by 2 SLPs, one in-person in Tijuana and the other over telemedicine videoconference from San Diego, CA. In addition, we obtained data regarding the parents experience with telemedicine through a satisfaction survey. Results showed no statistically significant differences between the 2 methods of speech evaluation, particularly in oral muscle tone, resonance, lingual lateralization, oral pressure, and dentition. The satisfaction survey showed family satisfaction with the speech evaluation performed using telemedicine. Thus, telemedicine represents an effective medium for conducting speech assessment in patients with cleft lip/palate, allowing for increased access to care for underserved populations.

A 10-year review of single medication double-dose ingestions in the nation's largest poison control system.

BACKGROUND: Most Americans take at least one medication on a daily basis. Inadvertently ingesting a double-dose of a medication with a narrow therapeutic index may lead to adverse effects. When a patient or medical professional contacts the local poison center after an overdose, a poison specialist fields the incoming information and, depending on the caller, provides specific recommendations. We sought to determine which medication classes were most likely to lead to significant adverse outcomes when an extra dose was ingested. METHODS: This was a retrospective review of all double-dose medication ingestions reported to the California Poison Control System (CPCS) between January 2006 and December 2015. Inclusion criteria were single-instance, single-medication ingestions where the dose was known. All ages and both sexes were included. We evaluated generalized outcomes per AAPCC criteria stratified as no effect, minor, moderate, major or death. We also documented specific symptoms and interventions noted by the poison control specialists. RESULTS: Out of 1286 cases, 876 ingestions met the inclusion criteria. Medications with antihypertensive and behavior modulating effects each accounted for over a third of all moderate and major effects. The medications/medication classes implicated in the 12 major outcomes included propafenone, beta blockers (ßBs), calcium channel blockers (CCBs), bupropion, and tramadol. Of these, vasoactive medications were associated with the most severe effects requiring cardiac pacing and vasopressor drips. Analgesics, antimicrobials, and anti-allergy medications were well tolerated. There were no deaths. CONCLUSIONS: Major adverse outcomes after a double dose ingestion were rare. Most double dose medication ingestions can be safely monitored at home, albeit with a few exceptions. Vigilance is warranted in cases of ßB and CCB ingestion due to the risk of hemodynamic collapse or seizures with tramadol and bupropion.

British OsteoNEcrosis Study (BONES) protocol: a prospective cohort study to examine the natural history of osteonecrosis in older children, teenagers and young adults with acute lymphoblastic leukaemia and lymphoblastic lymphoma.

INTRODUCTION: Osteonecrosis is a well-recognised treatment-related morbidity risk in patients diagnosed with acute lymphoblastic leukaemia (ALL) and lymphoblastic lymphoma (LBL), with a high rate of affected patients requiring surgical intervention. Patients may have asymptomatic changes on imaging studies that spontaneously regress, and little is known about the natural history of osteonecrotic changes seen. The main aim of the British OsteoNEcrosis Study (BONES) is to determine the incidence of symptomatic and asymptomatic osteonecrosis in the lower extremities of survivors of ALL or LBL diagnosed aged 10-24 years in the UK at different time points in their treatment. This study also aims to identify risk factors for progression and the development of symptomatic osteonecrosis in this population, as well as specific radiological features that predict for progression or regression in those with asymptomatic osteonecrosis METHODS AND ANALYSIS: BONES is a prospective, longitudinal cohort study based at principal treatment centres around the UK. Participants are patients aged 10-24 years diagnosed with ALL or LBL under standard criteria. Assessment for osteonecrosis will be within 4 weeks of diagnosis, at the end of delayed intensification and 1, 2 and 3 years after the start of maintenance therapy. Assessment will consist of MRI scans of the lower limbs and physiotherapy assessment. Clinical and biochemical data will be collected at each of the time points. Bone mineral density data and vertebral fracture assessment using dual-energy X-ray absorptiometry will be collected at diagnosis and annually for 3 years after diagnosis of malignancy. ETHICS AND DISSEMINATION: Ethical approval has been obtained through the Yorkshire and Humber Sheffield Research Ethics Committee (reference number: 16/YH/0206). Study results will be published on the study website, in peer-reviewed journals and presented at relevant conferences and via social media. TRIAL REGISTRATION NUMBER: NCT02598401; Pre-results.

Exploring relationships in teenage pregnancy.

The aim of this paper is to report a study exploring aspects of teenage pregnant women relationships with the fathers of their unborn children within the context of two contrasting demographic areas of the UK. The perceptions of teenage pregnant women on how they view their relationship with the fathers of their unborn babies has not been fully investigated. Three major categories emerged from the perspectives of 47 teenage pregnant women: (i) age of baby's father; (ii) education and employment status of baby's father; and (iii) ability of baby's father to provide financial support. Teenage pregnant women living in the south-east were more likely to maintain the relationship with fathers of their babies than those living in the north-west. This was found to be statistically significant. The age, employment status and education of the baby's father can influence the continuance of the partnership between the participant and of the father of her baby. The statistical difference in the maintenance of the relationship between the prospective parents may be associated with the continuing demographic and cultural characteristics of the north-west, where teenage pregnancy remains high and the south-east where the rates are low.

Visual perceptions of ageing; A longitudinal mixed methods study of UK undergraduate student nurses' attitudes and perceptions towards older people.

Ageism and negative attitudes are said to be institutionally embedded in healthcare during a time when there are unprecedented increases in older population numbers. As nurses' care for older people in a range of environments it is important to examine attitudes and perceptions of undergraduate nurses towards older people. A longitudinal mixed methods study in conjunction with a three-year undergraduate UK nursing programme 2009-2012 was conducted with 310 undergraduate nurses. A questionnaire incorporating Kogan's attitude towards older people scale and a drawing of a person aged 75 years was completed three times, once each year. Thurstone scale and photo elicitation were also employed. Comparisons were made between individual participant's attitude score and drawing. The study established 75% of participants had moderately positive attitudes towards older people when the programme began, at the programme end this had increased to 98%. Age, gender, educational qualifications, practice learning, nursing field and contact with older people influenced participants' overall attitude score. Drawings provided a visual narrative of participants' perceptions of older people, appearance was a dominant discourse and the images were socially constructed. The study established the undergraduate nursing programme influenced attitudes and perceptions towards older people and suggests nurse education can influence changing attitudes. To date there is no known study that has advanced this understanding.

The future of nursing: career choices in potential student nurses.

Young people leaving schools and sixth-form colleges have the opportunity to choose a career path from an increasing number of courses in colleges of further and higher education. Nursing studies are now competing with a range of health-related disciplines such as health studies, psychology and complementary therapy. Compared with nursing studies, many of these courses appear more exciting and appealing to students who are in the process of choosing a career or programme of study. While the increased choice is a positive move for students, it may contribute to the shortage of students currently entering some areas of nursing. Indeed, some specialties in nursing, including mental health and learning disabilities, are so depleted in students that they are reaching a point of crisis. There is also concern that recruitment into nursing remains predominately female and white British. Given the diversity of the UK population and the reliance on school leavers as a potential source of supply, it is important to understand why male students and those from multiracial and multicultural environments choose, or do not choose, nursing studies. This research study involved a sample of 106 16-year-old students from three secondary schools in the north-west and south-east of England. The questionnaire results, collected in schools, revealed that students held traditional views or knew very little about the nursing profession.

Assessment of risk and special observations in mental health practice: a comparison of forensic and non-forensic settings.

The use of special observations in psychiatric practice may be employed as an alternative to more restrictive methods such as the use of seclusion and restraint. From the literature, special observations are used for a complex array of signs and symptoms (and risk behaviours) which include suicidal intent, self-injurious behaviour, hallucinatory experiences, and absconding. This paper reports on research into the use of special observations in both forensic and non-forensic psychiatric settings. A comparative approach was adopted to establish if the perceived risk factors leading to the adoption of special observations were similar in both settings. Three groups of nursing staff were requested to assess 30 patients who were placed on special observations. Before this, nurses were requested to rate the risk factors in terms of their severity on a 7-point Likert scale. The rank-ordering analysis revealed a similarity of identified risk factors and anova (one-way, unrelated) and the Jonckheere Trend Test revealed that there were significant differences between the scores in the forensic and the non-forensic settings. The statistical differences existed for risk factors relating to harm to self and others but not for psychiatric symptomatology.

Mothers and midwives perceptions of birthing position and perineal trauma: An exploratory study.

BACKGROUND: Studies have associated lithotomy position during childbirth with negative consequences and increased risk of perineal injuries. AIMS: To identify prevalence rates of different birthing position and episiotomy and to explore the differences in perspectives of mothers and midwives about birthing positions and perineal trauma. METHODS: A survey involving 110 mothers and 110 midwives at two hospitals. Participants were mothers who had a vaginal birth/perineal injury and midwives who attended births that resulted in perineal injuries. Perceptions of mothers and midwives were analysed. Pearson's chi-square test was used to measure association between birthing positions and perineal trauma. FINDINGS: Mothers, n=94 (85%) and midwives, n=108 (98%) reported high rates of lithotomy position for birth. N=63 (57%) of mothers perceived lithotomy position as not being helpful for birth. In contrast, a similar number of midwives perceived lithotomy position as helpful, n=65 (59%). However, a high majority of mothers, n=106 (96%) and midwives, n=97 (88%) reported they would be willing to use alternative positions. Majority of mothers had an episiotomy, n=80 (73%) and n=76 (69%) reported they did not give their consent. N=59 (53%) reported they were not given local anaesthesia for an episiotomy. n=30 (27%) of midwives confirmed they performed an episiotomy without local anaesthesia. CONCLUSION: Care is not based on current evidence and embedded practices, i.e. birthing in lithotomy position and routine episiotomies are commonly used. However, this survey did find a willingness to change, adapt practice and consider different birthing positions and this may lead to fewer episiotomies being performed.

A Comparison of the Dynamics and Pharmacokinetics of Ropivacaine 7.5 mg/mL with and without Epinephrine Used for Epidural Anaesthesia in Urological Surgery.

OBJECTIVE: To investigate the effects of adding a vasoconstrictor to ropivacaine for epidural anaesthesia. PATIENTS AND METHODS: This randomised, double-blind study included 44 adults scheduled for urological surgery. Patients received either 20mL ropivacaine 7.5 mg/mL (group R, n = 22) or 20mL ropivacaine 7.5 mg/mL plus epinephrine 5 mug/mL (group R+E, n = 22) epidurally. Sensory and motor blocks were assessed and the pharmacokinetics of ropivacaine determined. Haemodynamic responses and adverse events were recorded. Patients were followed up for a maximum of 14 days. RESULTS: The groups were similar with respect to epidural block characteristics. Only one patient in each group experienced inadequate blocks. Median onset of sensory block at surgically relevant dermatomes ranged between 5 and 10 minutes in both groups. No significant difference in onset time was observed between groups. Median duration of sensory block at relevant dermatomes ranged from 3.6 to 5.7h in group R and from 3.3 to 5.9h in group R+E. Haemodynamic changes were moderate and were not considered clinically relevant. The incidence of adverse events was similar between groups. Plasma concentrations of ropivacaine peaked around 30 minutes in both groups; the mean maximum concentration was slightly higher in group R (1.4 mg/L) than in group R+E (1.1 mg/L). CONCLUSIONS: Ropivacaine 7.5 mg/mL with and without epinephrine 5 mug/mL produced equally effective and well tolerated epidural anaesthesia in urological patients. The addition of epinephrine did not offer any pharmacodynamic or pharmacokinetic advantages over ropivacaine alone.

Passed without a stroke: a UK mixed method study exploring student nurses' knowledge of stroke.

AIMS AND OBJECTIVES: To evaluate third year student nurses' knowledge and experiences of stroke education. To identify how student nurses can develop their understanding of stroke and its application to clinical nursing practice. BACKGROUND: Stroke is an international health issue and a major cause of morbidity and mortality in many countries throughout the world. Nurses have a significant role to play in reducing death and disability in people who have suffered a stroke and it has been suggested that some nurses may not be educationally prepared to meet the challenges of this complex condition. DESIGN: This evaluative study was based on a mixed method evaluative design. These quantitative and qualitative approaches involved the implementation of focus groups and questionnaires. METHOD: The following outcomes were measured during students' final year of their nursing studies: students' profiles and an assessment of students' knowledge of stroke. RESULTS: There was a mixed picture of student nurses' knowledge of stroke; a lack of awareness of some fundamental aspects of stroke including common symptoms, complications, risk factors and the long term treatment. Reassuringly, students expressed decisively the importance for nurses to be equipped with a sound foundation of stroke knowledge for clinical practice. CONCLUSIONS: All nursing students should have experience of being in contact with people who have had a stroke - and at present this does not always happen. A national intervention study is now suggested with a view to providing stroke education which is proportionate to its significance as a major health issue. RELEVANCE TO CLINICAL PRACTICE: Nurses draw upon their fundamental clinical skills to care and treat patients who have survived a stroke. Additionally, stroke survivors also require enhanced knowledge and this is recognised in the growth of specialist stroke nurses. Improving stroke mortality and morbidity is the responsibility of all of us involved in nurse education - introducing creative evaluative interventions could hold the most promising way forward.

Understanding the association between teenage pregnancy and inter-generational factors: a comparative and analytical study.

OBJECTIVES: (1) to identify the number of teenage pregnant women who also have mothers who became pregnant when they were in their teenage years and (2) to explore the importance of this intergenerational experience on the teenagers themselves, their significant family, friends and society as a whole. DESIGN: semi-structured interviews with the subjects allowed for both breadth and depth exploration. SAMPLE: the total research sample was 95 teenage women, which included 48 pregnant (51%) and 47 non-pregnant (49%) women. Stage 1 reports on the findings relating to the intergenerational phenomena and stage 2 focuses on related historical experiences of a further 8 interviews with subjects who had experienced this intergenerational phenomenon. The subjects in both stages of this study came from two contrasting demographic areas of the UK: North West and South East. MEASUREMENTS: data were analysed using an appropriate qualitative software package. The specific categories of experience were constructed using a grounded theory approach. FINDINGS: the findings of stage 1 of the study showed that the number of teenage women who reported that they had a mother who's first baby was born to her when she was under 20 years of age was 33 (69%) for the pregnant group and 12 (26%) for the non-pregnant group. This was found to be statistically significant (chi(2)=6.51, df=1, p=<0.011). In this study (from a sub-set of 19 themes) three major themes emerged: (a) reflection, (b) peer group pressure and (c) intergenerational factors. CONCLUSIONS: reflection, peer group pressure and intergenerational factors were the major thematic findings of this study. Midwives working collaboratively with other health, social and educational colleagues have a pivotal role to work with families in addressing the complexities of intergenerational teenage pregnancy. A national multi-method research study is now required to explore the breadth of intergenerational teenage pregnancy and the experiences of those families where this social construct is prevalent.

Social aspects of clinical errors.

Clinical errors, whether committed by doctors, nurses or other professions allied to healthcare, remain a sensitive issue requiring open debate and policy formulation in order to reduce them. The literature suggests that the issues underpinning errors made by healthcare professionals involve concerns about patient safety, professional disclosure, apology, litigation, compensation, processes of recording and policy development to enhance quality service. Anecdotally, we are aware of narratives of minor errors, which may well have been covered up and remain officially undisclosed whilst the major errors resulting in damage and death to patients alarm both professionals and public with resultant litigation and compensation. This paper attempts to unravel some of these issues by highlighting the historical nature of clinical errors and drawing parallels to contemporary times by outlining the 'compensation culture'. We then provide an overview of what constitutes a clinical error and review the healthcare professional strategies for managing such errors.

Relation of pregnancy and neonatal factors to subsequent development of childhood epilepsy: a population-based cohort study.

OBJECTIVE: We examined the effect of pregnancy and neonatal factors on the subsequent development of childhood epilepsy in a population-based cohort study. PATIENTS AND METHODS: Children born between January 1986 and December 2000 in Nova Scotia, Canada were followed up to December 2001. Data on pregnancy and neonatal events and on diagnoses of childhood epilepsy were obtained through record linkage of 2 population-based databases: the Nova Scotia Atlee Perinatal Database and the Canadian Epilepsy Database and Registry. Factors analyzed included events during the prenatal, labor and delivery, and neonatal time periods. Cox proportional hazards regression models were used to estimate relative risks and 95% confidence intervals. RESULTS: There were 648 new cases of epilepsy diagnosed among 124,207 live births, for an overall rate of 63 per 100,000 person-years. Incidence rates were highest among children <1 year of age. In adjusted analyses, factors significantly associated with an increased risk of epilepsy included eclampsia, neonatal seizures, central nervous system (CNS) anomalies, placental abruption, major non-CNS anomalies, neonatal metabolic disorders, neonatal CNS diseases, previous low birth weight infant, infection in pregnancy, small for gestational age, unmarried, and not breastfeeding infant at the time of discharge from hospital. CONCLUSIONS: Our study supports the concept that prenatal factors contribute to the occurrence of subsequent childhood epilepsy.