Acceptability of a computer-tailored and pedometer-based socio-cognitive intervention in a secondary coronary heart disease prevention program: A qualitative study.

When developing an innovative intervention, its acceptability to patients, health care professionals and managers must be considered to ensure the implementation into practice. This study aims to identify factors influencing the acceptability of a computer-tailored and pedometer-based socio-cognitive intervention for patients with heart disease. Focus group interviews were conducted in two outlying regions of the province of Quebec (Canada). The Theory of Planned Behavior formed the theoretical basis of the interview guide. Two researchers performed verbatim analysis independently until consensus was achieved. The sample included 44 participants divided into six groups (patients n = 7 + 8, health care professionals n = 8 + 8, managers n = 6 + 7). Health care professionals and managers mentioned benefits concerning partners' opportunity to improve assessment and monitoring. Patients believed the intervention could be useful to improve adherence to physical activity. Additional benefits indicated were self-monitoring behavior and improved health-related outcomes. However, patients expressed concern about the online security, fearing possible data breach. Some clinicians felt the pedometer may not be able to evaluate physical activities other than walking. With regard to behavioral control, a web application and pedometer must be easy to use and compatible with services already in place. Further barriers include level of literacy, cost and the various difficulties associated with wearing a pedometer. Findings suggest that, to improve the acceptability of a computer-tailored and pedometer-based socio-cognitive intervention, users must be assured of a secure website, validated, affordable and easy-to-use pedometers, and an intervention adapted to their level of literacy.

[The Virtual Emotional Drowning Theory: a Grounded Theory on Information and Communication Technologies (ICT) Help-Seeking Process of Adolescents at Risk of Suicide]. / La théorie de la noyade émotive virtuelle : une théorisation ancrée sur le processus de recherche d'aide d'adolescents à risque de suicide.

The use of Information and Communication Technologies (ICT) for help-seeking is becoming more and more common for adolescents at risk of suicide. Objectives The aim of this current study was to better understand the help-seeking process of adolescents at risk for suicide. Methods A grounded theory methodology was used to describe the experience of adolescents at risk of suicide and gain a deeper understanding of their ICT help-seeking process. Data was collected through semi-structured interviews, an ICT help-seeking questionnaire and live observations of ICT help-seeking strategies by the adolescents of this study. Theoretical saturation was reached with a total of 15 adolescents, aged 13 to 17, at risk of suicide. Results The grounded theory that emerged gravitated towards the fact that adolescents chose to virtually deal with emotional drowning. A specific context allowed this central category to emerge and included the adolescents' state, their personal triggers, their social environment as well as their desire to use ICT. The ICT strategies used by the adolescents to deal with their emotional drowning were to distract themselves, to get informed, to reveal themselves or to help others. Adolescents in this study used different ways to distract themselves with ICT. This included reading texts, watching online videos, listening to music and playing games. They also increased their literacy by informing themselves on suicide and mental health problems. However, many adolescents also searched for ways to help them commit suicide. Although most of the results were suicide prevention related, the keywords used by the adolescents remain preoccupying. Revealing their thoughts and their feelings about their emotional state seemed to be easier through ICT. They sometimes chose to reveal themselves anonymously but most of the time, they revealed themselves to use ICT to friends they already had in real life. Also, helping friends through ICT seemed to be very rewarding and helpful to the adolescents of our study even when they were in a state of emotional drowning. These different strategies to virtually deal with their emotional drowning hindered many different consequences which were to grow emotionally, to get help, to get temporary relief, to stay indifferent, to worsen their suicidal thoughts or to attempt suicide. Conclusion Although some negative consequences of ICT emerge from this study, a great deal of the consequences was positive and helpful for these adolescents. Overall, this study shows that ICT offer great opportunities for adolescent suicide prevention. Implications for practice, training and research are further discussed.

The Actual Use of an Electronic Medical Record (EMR) by Acute Care Nurses: Examining a Multidimensional Measure at Different Adoption Stages.

An EMR should support the informational needs of nursing practice. However, a multidimensional measure of the actual use of an EMR in hospitals ranked at different adoption stages revealed significant results that should be addressed to enable nurses to bring their full contribution to their patients and to the healthcare team.

Which priority indicators to use to evaluate nursing care performance? A discussion paper.

AIMS: A discussion of an optimal set of indicators that can be used on a priority basis to assess the performance of nursing care. BACKGROUND: Recent advances in conceptualization of nursing care performance, exemplified by the Nursing Care Performance Framework, have revealed a broad universe of potentially nursing-sensitive indicators. Organizations now face the challenge of selecting, from this universe, a realistic subset of indicators that can form a balanced and common scorecard. DESIGN: Discussion paper drawing on a systematic assessment of selected performance indicators. DATA SOURCES: Previous works, based on systematic reviews of the literature published between 1990 - 2014, have contributed to the development of the Nursing Care Performance Framework. These works confirmed a robust set of indicators that capture the universe of content currently supported by the scientific literature and cover all major areas of nursing care performance. Building on these previous works, this study consisted in gathering the specific evidence supporting 25 selected indicators, focusing on systematic syntheses, meta-analyses and integrative reviews. IMPLICATIONS FOR NURSING: This study has identified a set of 12 indicators that have sufficient breadth and depth to capture the whole spectrum of nursing care and that could be implemented on a priority basis. CONCLUSIONS: This study sets the stage for new initiatives aiming at filling current gaps in operationalization of nursing care performance. The next milestone is to set up the infrastructure required to collect data on these indicators and make effective use of them.

Design and application of a tool for structuring, capitalizing and making more accessible information and lessons learned from accidents involving machinery.

Accident reports are published in order to communicate the information and lessons learned from accidents. An efficient accident recording and analysis system is a necessary step towards improvement of safety. However, currently there is a shortage of efficient tools to support such recording and analysis. In this study we introduce a flexible and customizable tool that allows structuring and analysis of this information. This tool has been implemented under TEEXMA®. We named our prototype TEEXMA®SAFETY. This tool provides an information management system to facilitate data collection, organization, query, analysis and reporting of accidents. A predefined information retrieval module provides ready access to data which allows the user to quickly identify the possible hazards for specific machines and provides information on the source of hazards. The main target audience for this tool includes safety personnel, accident reporters and designers. The proposed data model has been developed by analyzing different accident reports.

Mixed method exploration of the medical, service-related, and emotional reasons for emergency room visits of older cancer patients.

PURPOSE: When dealing with health issues, older cancer patients are likely to visit emergency rooms (ER), which are known to expose these patients to the risk of adverse outcomes. Little is known about the profile and reasons for such visits. The aim of this study is (1) to describe the profile of elderly cancer patients aged 70 years and older who visited the ER of a regional hospital in Québec, Canada, and (2) to explain the medical reasons and factors determining such visits from the patients' perspective. METHODS: A concurrent mixed method design was used. Descriptive analysis of administrative databases was conducted to describe the socio-demographic, clinical, and service utilization profile of 792 cancer patients aged 70 years and older. Content analysis of 11 semi-structured interviews of a sub-sample was subsequently performed to better understand the experience and meaning these patients attribute to this health behaviour. RESULTS: The sample of 792 older cancer patients made a total of 1572 ER visits. Most visits occurred during the daytime. More than half (53 %) of the patients were discharged, and close to 40 % were hospitalized. The most frequent reasons for consulting were respiratory (15.8 %), digestive (13.4 %), neurological (8.3 %), fever or infection-related (8.3 %), and cardiovascular (8.2 %). Content analysis of the qualitative data suggested that patients made ER visits mostly when other cancer care services were unavailable or because of a serious life-threatening health condition. CONCLUSIONS: The study suggests areas of improvement to prevent ER visits when health issues can be addressed by other care services.

An exploration of factors associated with post-traumatic stress in ER nurses.

BACKGROUND: Emergency room (ER) nurses are frequently exposed to traumatic events (TE) at work. These events can lead to symptoms of post-traumatic stress disorder (PTSD). AIM: The goal of the present study was to describe the factors associated with PTSD symptoms. METHODS: A cross-sectional descriptive correlational design was used. The sample consisted of 35 nurses from an ER in Québec (Canada). Data were collected through self-administered questionnaires. RESULTS: TEs presenting a grief component (e.g. intentional injury to a child and patient suicide) are positively associated with peritraumatic distress (PD) in the days after the event. PD is positively associated with PTSD symptoms. Two personality traits (neuroticism and extraversion) should also be considered. Neuroticism is positively associated with PD whereas extraversion is negatively associated with PD and PTSD symptoms. CONCLUSION: The results are consistent with the literature, but some of these results are new to nurses. They suggest that in this population, TEs in the ER represent 'red flags'. Their occurrence should mobilise support structures. PD and its personality traits are also key factors to consider. IMPLICATION FOR NURSING MANAGEMENT: To provide adequate support for nurses, ER managers should be on the alert for these conditions. Interventions should be adapted to these findings.

Integrated Primary Care Teams (IPCT) pilot project in Quebec: a protocol paper.

INTRODUCTION: The overall aim of this project is to help develop knowledge about primary care delivery models likely to improve the accessibility, quality and efficiency of care. Operationally, this objective will be achieved through supporting and evaluating 8 primary care team pilot sites that rely on an expanded nursing role within a more intensive team-based, interdisciplinary setting. METHODS AND ANALYSIS: The first research component is aimed at supporting the development and implementation of the pilot projects, and is divided into 2 parts. The first part is a logical analysis based on interpreting available scientific data to understand the causal processes by which the objectives of the intervention being studied may be achieved. The second part is a developmental evaluation to support teams in the field in a participatory manner and thereby learn from experience. Operationally, the developmental evaluation phase mainly involves semistructured interviews. The second component of the project design focuses on evaluating pilot project results and assessing their costs. This component is in turn made up of 2 parts. Part 1 is a pre-and-post survey of patients receiving the intervention care to analyse their care experience. In part 2, each patient enrolled in part 1 (around 4000 patients) will be matched with 2 patients followed within a traditional primary care model, so that a comparative analysis of the accessibility, quality and efficiency of the intervention can be performed. The cohorts formed in this way will be followed longitudinally for 4 years. ETHICS AND DISSEMINATION: The project, as well as all consent forms and research tools, have been accepted by 2 health sciences research ethics committees. The procedures used will conform to best practices regarding the anonymity of patients.

[Looking for help on the Internet by adolescents with suicidal thoughts: a concept analysis]. / La recherche d'aide sur Internet chez des adolescents ayant des idées suicidaires: une analyse de concept.

The help-seeking concept is largely used in the healthcare system and seems relatively well understood by healthcare professionals even though no consensus on this concept has yet been reached. More specifically, the Internet help-seeking concept by adolescents with suicidal thoughts has yet to be explored. To clarify this concept and eventually develop tools for future research in nursing, a concept analysis using the Walker and Avant method was conducted. Three main help-seeking attributes were identified as a result of the analysis: problem-oriented, intentional action and use of an external mean. The antecedents that precede the concept are: problem recognition and perception influenced by beliefs, desired relief, help-source selection and decision to act. The consequents that follow help-seeking are relef, maintenance or exacerbation of the problem. Many empirical referents are identified but none seem to evaluate or conceptually define the attributes of the concept. Finally, a deeper meaning of Internet help-seeking by adolescents with suicidal thoughts is reached by this concept analysis and further research and practice recommendations are given.

Modeling factors explaining the acceptance, actual use and satisfaction of nurses using an Electronic Patient Record in acute care settings: an extension of the UTAUT.

BACKGROUND AND PURPOSE: End-user acceptance and satisfaction are considered critical factors for successful implementation of an Electronic Patient Record (EPR). The aim of this study was to explain the acceptance and actual use of an EPR and nurses' satisfaction by testing a theoretical model adapted from the Unified Theory of Acceptance and Use of Technology (UTAUT). METHODS: A multicenter cross-sectional study was conducted in the medical-surgical wards of four hospitals ranked at different EPR adoption stages. A randomized stratified sampling approach was used to recruit 616 nurses. Structural equation modeling techniques were applied. RESULTS: Support was found for 13 of the model's 20 research hypotheses. The strongest effects are those between performance expectancy and actual use of the EPR (r=0.55, p=0.006), facilitating conditions and effort expectancy (r=0.45, p=0.009), compatibility and performance expectancy (r=0.39, p=0.002). The variables explained 33.6% of the variance of actual use, 54.9% of nurses' satisfaction, 50.2% of performance expectancy and 52.9% of effort expectancy. CONCLUSIONS: Many results of this study support the conclusions of prior research, but some take exception, such as the non-significant relationship between the effort expectancy construct and actual use of the EPR. The results highlight the importance of the mediating effects of the effort expectancy and performance expectancy constructs. Compatibility of the EPR with preferred work style, existing work practices and the values of nurses were the most important factors explaining nurses' satisfaction. The results reveal the complexity of this change and suggest several avenues for future research and for the implementation of IT in healthcare.

Development of integrated care pathways: toward a care management system to meet the needs of frail and disabled community-dwelling older people.

INTRODUCTION: The home care and services provided to older adults with the same needs are often inadequate and highly varied. Integrated care pathways (ICPs) can resolve these issues. The aim of this study was to develop the content of ICPs to follow-up frail and disabled community-dwelling older people. THEORY AND METHOD: A RIGOROUS PROCESS WAS APPLIED ACCORDING TO A SERIES OF STEPS: identification of desirable characteristics and a theoretical framework; review of evidence-based practices and current practices; and determination of ICPs by an interdisciplinary task team. RESULTS: ICPs are intended to prevent specific problems, maximize independence, and promote successful aging. They are organized according to a dynamic process: (1) needs assessment and assessment of risk/protection factors; (2) data-collection summary and goals identification; (3) planning of interventions from a client-centered view; (4) coordination, delivery, and follow-up; and (5) identification of variances, as well as review and adjustment of plans. CONCLUSION: Once computerized, these ICPs will facilitate the exchange of information as well as the clinical decision-making process with a perspective to adequately matching the needs of an individual person with resources that delay or slow the progression of frailty and disability. Once aggregated, the data will also support managers in organizing teamwork and follow-up for clients.

[Good palliative care in the intensive care unit]. / Conditions facilitant les "bons soins" palliatifs aux soins intensifs selon la perspective infirmière.

UNLABELLED: The aging population, the complexity and irreversibility of certain conditions lead to the deaths of 20% of patients admitted to intensive care units (ICU). However, in Quebec, as elsewhere in America, few of them currently receive palliative care. METHOD: inspired by a conceptual model considering nursing as a moral practice, this phenomenological study was conducted in four phases: focus groups (n = 6) observation sessions (n = 6) followed by individual interviews and group validation activities (n = 5). In its first part, this study shows that through several caring behaviours, "good palliative care" in the ICU is manifested by the consideration of six dimensions of the person, physical, relational, psychological, moral, social and spiritual. This article presents the second part of this study and reveals three main themes summarizing the conditions facilitating "good the palliative care" according to ICU nurses: Sharing a common vision enhanced by a collective and specific palliative care knowledge, an informed and concerted decision-making process in a favourable organisational and physical environment.

Users' perspectives of key factors to implementing electronic health records in Canada: a Delphi study.

BACKGROUND: Interoperable electronic health record (EHR) solutions are currently being implemented in Canada, as in many other countries. Understanding EHR users' perspectives is key to the success of EHR implementation projects. This Delphi study aimed to assess in the Canadian context the applicability, the importance, and the priority of pre-identified factors from a previous mixed-methods systematic review of international literature. METHODS: A three-round Delphi study was held with representatives of 4 Canadian EHR user groups defined as partners of the implementation process who use or are expected to use EHR in their everyday activity. These groups are: non-physician healthcare professionals, health information professionals, managers, and physicians. Four bilingual online questionnaire versions were developed from factors identified by the systematic review. Participants were asked to rate the applicability and the importance of each factor. The main outcome measures were consensus and priority. Consensus was defined a priori as strong (≥ 75%) or moderate (≥ 60-74%) according to user groups' level of agreement on applicability and importance, partial (≥ 60%) when participants agreed only on applicability or importance, or as no consensus (< 60%). Priority for decision-making was defined as factors with strong consensus with scores of 4 or 5 on a five-point Likert scale for applicability and importance. RESULTS: Three Delphi rounds were completed by 64 participants. Levels of consensus of 100%, 64%, 64%, and 44% were attained on factors submitted to non-physician healthcare professionals, health information professionals, managers, and physicians, respectively. While agreement between and within user groups varied, key factors were prioritized if they were classified as strong (≥ 75% from questionnaire answers of user groups), for decision-making concerning EHR implementation. The 10 factors that were prioritized are perceived usefulness, productivity, motivation, participation of end-users in the implementation strategy, patient and health professional interaction, lack of time and workload, resources availability, management, outcome expectancy, and interoperability. CONCLUSIONS: Amongst all factors influencing EHR implementation identified in a previous systematic review, ten were prioritized through this Delphi study. The varying levels of agreement between and within user groups could mean that users' perspectives of each factor are complex and that each user group has unique professional priorities and roles in the EHR implementation process. As more EHR implementations in Canada are completed it will be possible to corroborate this preliminary result with a larger population of EHR users.

[Good palliative care in the intensive care unit: for nurses, a way to prospect]. / De "bons soins" palliatifs aux soins intensifs: une perspective infirmière.

Caring for dying patients is part of daily practice for the nurses working in intensive care unit (ICU). Few studies have documented what nurses consider to be "good palliative care" in this context. This phenomenological study was conducted in four phases and was designed to understand how the provision of "good palliative care" is expressed according to nurses' perspectives. Data were collected through group interviews, observation sessions followed by individual interviews and group validation sessions. "good palliative care" is expressed by the consideration of six dimensions of the person, as proposed by Gastmans et al. (1998), namely: physical, relational, psychological, moral, social and spiritual.

Comparison of user groups' perspectives of barriers and facilitators to implementing electronic health records: a systematic review.

BACKGROUND: Electronic health record (EHR) implementation is currently underway in Canada, as in many other countries. These ambitious projects involve many stakeholders with unique perceptions of the implementation process. EHR users have an important role to play as they must integrate the EHR system into their work environments and use it in their everyday activities. Users hold valuable, first-hand knowledge of what can limit or contribute to the success of EHR implementation projects. A comprehensive synthesis of EHR users' perceptions is key to successful future implementation. This systematic literature review was aimed to synthesize current knowledge of the barriers and facilitators influencing shared EHR implementation among its various users. METHODS: Covering a period from 1999 to 2009, a literature search was conducted on nine electronic databases. Studies were included if they reported on users' perceived barriers and facilitators to shared EHR implementation, in healthcare settings comparable to Canada. Studies in all languages with an empirical study design were included. Quality and relevance of the studies were assessed. Four EHR user groups were targeted: physicians, other health care professionals, managers, and patients/public. Content analysis was performed independently by two authors using a validated extraction grid with pre-established categorization of barriers and facilitators for each group of EHR users. RESULTS: Of a total of 5,695 potentially relevant publications identified, 117 full text publications were obtained after screening titles and abstracts. After review of the full articles, 60 publications, corresponding to 52 studies, met the inclusion criteria. The most frequent adoption factors common to all user groups were design and technical concerns, ease of use, interoperability, privacy and security, costs, productivity, familiarity and ability with EHR, motivation to use EHR, patient and health professional interaction, and lack of time and workload. Each user group also identified factors specific to their professional and individual priorities. CONCLUSIONS: This systematic review presents innovative research on the barriers and facilitators to EHR implementation. While important similarities between user groups are highlighted, differences between them demonstrate that each user group also has a unique perspective of the implementation process that should be taken into account.

Post-traumatic stress disorder symptoms among emergency nurses: their perspective and a 'tailor-made' solution.

AIM: The goal of this study was to identify support activities for emergency room nurses who have been exposed to traumatic events, in order to prevent post-traumatic stress disorder. BACKGROUND: Emergency room nurses experience stress during traumatic events, for which they need support. It turns out that such support is insufficient, ineffective or non-existent. METHODS: This qualitative study was carried out among twelve emergency room nurses from January to May 2007. Semi-structured interviews and a focus group were conducted. Content analysis fulfilled the objectives of our research. RESULTS: The frequency of traumatic events leading to contextual exposure and exposure as a witness increases with years of experience (r=0·67 and r=0·57). The frequency of post-traumatic stress disorder symptoms decreases with age (r=-0·83). The data demonstrate the importance of having a supportive social network and being able to talk things over with colleagues. The support activities considered include all types of prevention. They consist primarily of a peer support system, psycho-education and emergency room simulations. CONCLUSION: A three-level complex of support activities represents a promising solution to prevent and treat post-traumatic stress disorder among emergency room nurses. A further study to test its effectiveness is currently underway.

Nursing students' perceptions of their resources toward the development of competencies in nursing informatics.

PURPOSE: This article presents the findings of a doctoral study about the internal and external resources required to develop nursing informatics competencies in student nurses. BACKGROUND: Colleges and universities are responsible for training nursing students, including in the area of nursing informatics. Even though nursing informatics is a specialty recognized by the American Nursing Association (2001), it has received limited attention in Quebec, Canada. METHOD: A total of 131 college-level nursing students were randomly surveyed with a mail questionnaire designed to describe their perceptions about their internal and external resources in nursing informatics. RESULTS: Nursing students perceive that their internal and external resources necessary to ensure "knowledge to act" in nursing informatics is moderately high. They said they lacked knowledge about using spreadsheet programs, presentation software, and courseware, about data security, and about how to analyze the quality of a health-related Web site and search electronic scientific databases. CONCLUSION: These results show that, even if nursing students have access to a computer and the Internet at home and even if they feel competent using informatics in nursing, they still lack important resources for developing competencies in nursing informatics. We recommend that faculties and colleges focus on these elements.

Users' perspectives of barriers and facilitators to implementing EHR in Canada: a study protocol.

BACKGROUND: In Canada, federal, provincial, and territorial governments are developing an ambitious project to implement an interoperable electronic health record (EHR). Benefits for patients, healthcare professionals, organizations, and the public in general are expected. However, adoption of an interoperable EHR remains an important issue because many previous EHR projects have failed due to the lack of integration into practices and organizations. Furthermore, perceptions of the EHR vary between end-user groups, adding to the complexity of implementing this technology. Our aim is to produce a comprehensive synthesis of actual knowledge on the barriers and facilitators influencing the adoption of an interoperable EHR among its various users and beneficiaries. METHODS: First, we will conduct a comprehensive review of the scientific literature and other published documentation on the barriers and facilitators to the implementation of the EHR. Standardized literature search and data extraction methods will be used. Studies' quality and relevance to inform decisions on EHR implementation will be assessed. For each group of EHR users identified, barriers and facilitators will be categorized and compiled using narrative synthesis and meta-analytical techniques. The principal factors identified for each group of EHR users will then be validated for its applicability to various Canadian contexts through a two-round Delphi study, involving representatives from each end-user groups. Continuous exchanges with decision makers and periodic knowledge transfer activities are planned to facilitate the dissemination and utilization of research results in policies regarding the implementation of EHR in the Canadian healthcare system. DISCUSSION: Given the imminence of an interoperable EHR in Canada, knowledge and evidence are urgently needed to prepare this major shift in our healthcare system and to oversee the factors that could affect its adoption and integration by all its potential users. This synthesis will be the first to systematically summarize the barriers and facilitators to EHR adoption perceived by different groups and to consider the local contexts in order to ensure the applicability of this knowledge to the particular realities of various Canadian jurisdictions. This comprehensive and rigorous strategy could be replicated in other settings.

Pregnancy-related hip diseases: incidence and diagnoses.

BACKGROUND: Pregnancy-related hip diseases epidemiology has been poorly evaluated. We report our experience of gestational and postpartum hip diseases and evaluate their incidence. METHODS: (1) Prospective survey: all pregnant or early postpartum women suspected to have hip involvement during their follow-up in an Obstetric unit were referred to a rheumatologist. If clinically confirmed, magnetic resonance imaging (MRI) and additional investigations as needed were performed. This survey had 2 years duration. (2) Retrospective study: all cases of definite (with MRI confirmation) pregnancy-related hip disease referred to our Rheumatology unit during the past 15 years were analyzed. RESULTS: During the 2-year prospective survey, 3 patients (4 hips) of pregnancy-related hip disease were observed over 4900 pregnancies (1 case of transient osteoporosis of the hip (TOH) and 2 cases of occult fracture of the femoral head). During the 15-year retrospective study, 12 patients (17 hips) with hip diseases during pregnancy or early postpartum were identified. There were 6 patients (9 hips) with TOH, 4 patients (6 hips) with occult fracture of the femoral head, 1 patient with osteonecrosis of the femoral head, and 1 coxitis in a patient with ankylosing spondylitis. Differentiating diagnosis between TOH and occult fractures could only be made by MRI. Five of the 6 women with TOH had osteopenia at the lumbar spine at dual energy X-ray absorptiometry (DEXA). The 4 women with occult fractures had either osteopenia or osteoporosis at the lumbar spine. CONCLUSION: Hip diseases are infrequent during pregnancy and early postpartum. Transient osteoporosis of the hip and occult stress fractures of the femoral head appear the main causes and those diagnoses justify evaluation for an underlying bone fragility. Osteonecrosis is very rare in this setting.