Using process-oriented groups reflections with health care providers to improve childbirth care in the Democratic Republic of Congo – An implementation study

ObjectiveThe ability to systematically reflect on care during labour and birth needs to be developed among health care providers. This study investigates the experiences of health care providers who have participated in process-oriented group reflections. The activity of group reflections was one of the three pillars of a training intervention seeking to implement evidence-based care routines during labour and birth that could contribute to reduced mortality and improved maternal and newborn health in the Democratic Republic of Congo (DRC).MethodsUsing a qualitative approach, we interviewed 131 health care providers, in focus groups (n = 19) and individually (n = 2). Analysis of transcribed interviews was conducted using qualitative content analysis according to Elo and Kyngäs.ResultsGroup reflections added essential knowledge to the other components of the three-pillar training intervention. Through sharing and analysing care situations health care providers got increased self-awareness, tools to achieve structured and safe care routines, and to practice teamworking.ConclusionUsing a structured model of process-oriented group reflection for health care providers on care during labour and birth proved to be a vital aspect of the training intervention, as it added knowledge to the skills gained through theoretical and simulation-based education. The three-pillar training intervention improved care routines that supported healthy births and management of complications. We recommend that structured and secure group reflections be included in similar training activities in the DRC and elsewhere, and assessed in further studies.     

Does palliative care improve outcomes for patients with HIV/AIDS? A systematic review of the evidence

BACKGROUND: The need for palliative care in HIV management is underlined by the high prevalence of pain and symptoms, the toxicity, side effects, and virological failure associated with antiretroviral therapy, emergence of co-morbidities, continued high incidence of malignancies, late presentation of people with HIV disease, and the comparatively higher death rates among the infected individuals. METHODS: A systematic review was undertaken to appraise the effect of models of palliative care on patient outcomes. A detailed search strategy was devised and biomedical databases searched using specific terms relevant to models of palliative care. Data from papers that met the inclusion criteria were extracted into common tables, and evidence independently graded using well described hierarchy of evidence. RESULTS: 34 services met the inclusion criteria. Of these, 22 had been evaluated, and the evidence was graded as follows: grade 1 (n = 1); grade 2 (n = 2); grade 3 (n = 7); grade 4 (n = 1); qualitative (n = 6). Services were grouped as: home based care (n = 15); home palliative care/hospice at home (n = 7); hospice inpatient (n = 4); hospital inpatient palliative care (n = 4); specialist AIDS inpatient unit (n = 2); and hospital inpatient and outpatient care (n = 2). The evidence largely demonstrated that home palliative care and inpatient hospice care significantly improved patient outcomes in the domains of pain and symptom control, anxiety, insight, and spiritual wellbeing. CONCLUSIONS: Although the appraisal of evidence found improvements across domains, the current body of evidence suffers from a lack of (quasi) experimental methods and standardised measures. The specialism of palliative care is responding to the clinical evidence that integration into earlier disease stages is necessary. Further studies are needed to both identify feasible methods and evaluate the apparent beneficial effect of palliative care on patient outcomes in the post-HAART era.     

Psychological factors associated with hand dermatoses: which subgroup needs additional psychological care?

BACKGROUND: The aetiology of hand dermatoses (HD) is very heterogeneous. Psychological influences on severity and coping in hand eczema have been only rarely investigated. OBJECTIVES: To investigate whether psychological factors correlate with somatic factors, in order to be able to estimate the possible need for psychosocial treatment of these patients. METHODS: In a cross-sectional study 101 hand dermatosis patients (49F, 52M) with psoriasis (n = 26), vesicular hand eczema (n = 33) or contact dermatitis (n = 42) were examined with regard to dermatological [diagnosis, severity, Erlanger Atopy Score (EAS)], allergic (patch test) and psychological aspects [Coping with Chronic Skin Diseases questionnaire (CSD), Allover Depression Scale (ADS), Social Readjustment Rating Scale (SRRS), questionnaire for measuring Factors of Aggression (FAF)],and Visual Analogue Scales (VAS) concerning itching, scratching and impairment. Subgroups of high stress responders (high-SR) vs. low stress responders (low-SR) were also examined. RESULTS: Of the patients with HD, 47.52% are convinced that 'stress' influences the course of their disease. Analysis of variance shows that the subjective reaction to stress (high-SR) correlates with higher severity scores, more itching, higher depression scores and more life events. High-SRs were younger and the onset of the disease was earlier compared with patients without a subjective reaction to stress (low-SR). In the CSD those with especially high-SR but negative patch-test results stated significantly higher values for itching, helplessness and search for information. CONCLUSIONS: Psychological factors should be taken into consideration in the treatment of patients with HD. High-SR patients with a negative patch-test seem to require more adjuvant psychological care.     

Evidence map of recommendations on diabetic foot ulcers care：A systematic review of 22 guidelines

BackgroundDiabetic foot ulcers (DFUs) are one of the major complications of diabetes, representing a leading cause of hospitalization and non-traumatic lower limb amputations. Clinical practice guidelines (CPGs) are statements that include recommendations intended to improve patients' outcomes by providing recommendations for key clinical issues with alternative care options. The aim of this study is to systematically review CPGs on DFUs care and generate an evidence-map for visualizing research trends and gaps in the CPGs.MethodsA search of the PubMed, Embase, and Web of Science, guideline databases and website of diabetes society was performed to include the diabetic CPGs. We exacted the basic information, methodological quality and reporting quality of CPGs, recommendations for DFUs care by the Excel 2016. Four researchers evaluated the methodological and reporting quality of diabetic foot CPGs by AGREE Ⅱ instrument and RIGHT checklist. The bubble plot format of evidence map was reduced by R (3.5.1) software.Results22 CPGs proved eligible, which included 10 diabetic foot guidelines and 12 comprehensive diabetes guidelines. According to the recommendations of diabetic CPGs, current standard of care for DFUs care mainly involves offloading of pressure, wound care, choice of shoes and adjunctive treatment. Recommendations on offloading of pressure and wound care were consistent in 22 CPGs. However, there were some conflicts on adjunctive treatment recommendations and recommendations for choice of shoes were not accurate.ConclusionThere is mixed quality evidence of CPGs for DFUs care, and some recommendations are inconsistent. This evidence map could provide new perspectives in presentation of evidence and help us know the need for future research to address the current gaps, as well as areas of opportunity for CPG development.     

Sign of Leser-Trélat associated with adenocarcinoma of the rectum

The acute onset and/or rapid increase in size and number of multiple seborrheic keratoses associated with internal malignancy is called sign of Leser-Trélat. Although some authors reject its existence, there are more than 80 well-documented case reports in the literature. Here, we report a 75-year-old man who presented with abrupt appearance of multiple seborrheic keratoses without any suspicious symptom of cancer. The screening for malignant neoplasms let us detect a rectal adenocarcinoma that was in a curative stage. This case-report illustrates a true sign of Leser-Trélat, and proves that these patients must be appropriately investigated for underlying malignancy.     

Association of class I HLA antigens with the clinical manifestations of Turkish patients with Behçet's disease

Summary Genetic factors appear to be important in the pathogenesis of Behçet's disease. Although it is known to be strongly associated with HLA‐B51, the association of HLA class I antigens with specific clinical findings of the disease has not been studied extensively and the few studies are conflicting. The aim of this study was to investigate the association of HLA class I alleles with the manifestations of Behçet's disease in Turkish patients. Eighty‐five patients with Behçet's disease were typed for HLA‐A, B, and C antigens with the serologic, standard microlymphocytotoxicity technique. Possible associations of the HLA complex with clinical findings of Behçet's disease were examined. Statistically significant findings are as follows (P < 0.05): increased HLA‐B51 and decreased HLA‐B35 frequency in patients with thrombophlebitis, increased HLA‐A29 and decreased HLA‐Bw6 frequency in patients with ocular involvement, decreased HLA‐Cw2 frequency in patients with erythema nodosum, and decreased HLA‐Cw7 frequency in patients with genital ulceration. Of particular note, the results of this study suggest that the presence of HLA‐B51 and the absence of HLA‐B35 can be regarded as laboratory risk factors of venous thrombosis in patients with Behçet's disease.     

Why freebirth in a maternity system with free midwifery care? A qualitative study of Danish women’s motivations and preparations for freebirth

ObjectiveEven in maternity care systems with free midwifery care, some women intentionally choose to birth unattended by any health professional (freebirth). Women who choose freebirth represent an enigma for many, and a provocation to some. However, people who do not conform to dominant medical practices are a source of valuable insights that can reveal shortcomings in the mainstream health care system. Thus, the aim of this study was to explore and understand women's motivations and preparations for freebirth.MethodsThe study was informed by the theoretical lens of the 'undisciplined patient'. Qualitative, in-depth interviews were performed with ten Danish women, who for their most recent birth had planned to freebirth. Data were analysed using reflexive thematic analysis.ResultsFour themes were identified. “The standard system is not for me” describes negative experiences during previous births and the desire for more individualised support. “Re-establishing trust in myself” describes the women's quest for recognizing their own needs and re-building autonomy and inner strength. “I do my research” describes how the women sought new ways of knowing and prioritised experiential knowledge. And finally, “I create my safe space” describes the women's efforts to create the best possible physical and emotional space for themselves and their babies in order to have a safe and autonomous birth experience.ConclusionFreebirth is not undertaken lightly or without preparation by women. Improved continuity of care as well as greater flexibility in hospital guidelines could accommodate some of these women's demand for autonomy in birth.     

Obstetric care. Is there risk of pressure damage after epidural anaesthesia?

Anecdotal evidence suggests that there is an increase in the incidence of pressure damage to women in labour. This appears to be associated with epidural anaesthesia. Epidural anaesthesia used to control pain in childbirth causes loss of sensation and a degree of motor block, which removes the women's reflexes and ability to reposition to prevent pressure damage. The large amount of fluids present during childbirth may also increase the risk of pressure damage, especially in association with shear and friction. A combination of unfamiliarity of pressure ulcer prevention techniques among midwives, and the type of delivery room equipment, that is currently available, may leave young healthy women at risk of developing pressure ulcers.     

A midwifery model of woman-centred childbirth care – In Swedish and Icelandic settings

BackgroundTheoretical models for health care practice are important both as tools for guiding daily practice and for explaining the philosophical basis for care.AimThe aim of this study was to define and develop an evidence-based midwifery model of woman-centred care in Sweden and Iceland.MethodUsing a hermeneutic approach we developed a model based on a synthesis of findings from 12 of our own published qualitative studies about women’s and/or midwives’ experiences of childbirth. For validity testing, the model was assessed in six focus group interviews with 30 practising midwives in Iceland and Sweden.FindingsThe model includes five main themes. Three central intertwined themes are: a reciprocal relationship; a birthing atmosphere; and grounded knowledge. The remaining two themes, which likewise influence care, are the cultural context (with hindering and promoting norms); and the balancing act involved in facilitating woman-centred care.ConclusionThe model shows that midwifery care in this era of modern medical technology entails a balancing act for enhancing the culture of care based on midwifery philosophies. The next step will be to implement the model in midwifery programmes and in clinical practice, and to evaluate its applicability.