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OBJECTIVE: Troublesome hot flushes and night sweats (HFNS) are experienced by many women after treatment for breast cancer, impacting significantly on sleep and quality of life. Cognitive behavioural therapy (CBT) is known to be effective for the alleviation of HFNS. However, it is not known if it can effectively be delivered by specialist nurses. We investigated whether group CBT, delivered by breast care nurses (BCNs), can reduce the impact of HFNS.METHODS: We recruited women with primary breast cancer following primary treatment with seven or more HFNS/week (including 4/10 or above on the HFNS problem rating scale), from six UK hospitals to an open, randomised, phase 3 effectiveness trial. Participants were randomised to Group CBT or usual care (UC). The primary endpoint was HFNS problem rating at 26 weeks after randomisation. Secondary outcomes included sleep, depression, anxiety and quality of life.RESULTS: Between 2017 and 2018, 130 participants were recruited (CBT:63, control:67). We found a 46% (6.9-3.7) reduction in the mean HFNS problem rating score from randomisation to 26 weeks in the CBT arm and a 15% (6.5-5.5) reduction in the UC arm (adjusted mean difference -1.96, CI -3.68 to -0.23, P = .039). Secondary outcomes, including frequency of HFNS, sleep, anxiety and depression all improved significantly.CONCLUSION: Our results suggest that specialist nurses can be trained to deliver CBT effectively to alleviate troublesome menopausal hot flushes in women following breast cancer in the NHS setting.

Background: Personalised information and support can be provided to cancer survivors using a structured approach. Assessment tools such as the Holistic Needs Assessment (HNA) in the UK and the Comprehensive Problem and Symptom Screening (COMPASS) in Canada have been recommended for use in practice. However, completion of the HNA/COMPASS is not widely embedded into practice and Clinical Nurse Specialists (CNSs) express concern about their ability to respond to issues raised by patients. Aims: To investigate CNS's views on HNAs/COMPASS and identify barriers and facilitators to implementation. Methods: This international on‐line survey using a snowball technique recruited CNSs across the UK and one Canadian province (Manitoba) in 2017. Results: A total of 306 CNSs in the UK and 162 in Canada completed the on‐line survey. In the UK, HNAs were completed primarily prior to and immediately after treatment. In Canada, COMPASS was usually completed at every appointment. Participants expressed concerns that HNAs/COMPASS were becoming “tick‐box exercises” which did not meet patients' needs. Barriers to completion were time, staff shortages, lack of confidence, privacy and signposting of resources. Facilitators were privacy for confidential discussions, training, confidence in knowledge and skills, and signposting of resources. Conclusions: That so many busy CNSs completed this survey demonstrates the importance they attach to HNAs and COMPASS. The challenges faced with implementing these assessments into everyday practice require training, time, support services and an appropriate environment. It is vital that the HNA and COMPASS are conducted at optimum times for patients to make the best use of time and resources.

The termination of pregnancy trial (Newcastle upon Tyne, UK), is the only randomised trial on termination of pregnancy methods incorporating a qualitative element that aimed to understand the experiences of women participating in the trial. Based on the results of this qualitative work, this article aims to provide insights into two strands of understanding; firstly, women's experience of participating in research about abortion and secondly, their experience of participating in a randomised preference trial. Semi-structured interviews were conducted of up to 90 minutes with 30 participants recruited at a single hospital site. A total of 20 women from the preference arm and 10 from the random arm were interviewed. The analysis and discussion of our findings use reflexive modernisation as a framework for understanding and interpreting some of the actions of social agents, that is, the participants and trial recruiters in the course of a clinical trial as an expert system. We found that the factors that shape women's experiences and decisions include trust in the expert system and reflexivity and agency on the part of both participants and trial recruiters.

Competent examination of the pediatric musculoskeletal (MSK) system is a vital component of clinical assessment of children with MSK presentations. The aim was to develop a regional MSK examination for school-age children that is age appropriate and reflects clinical practice.Qualitative and quantitative analyses involving video observation of clinical examination technique, systematic review, and expert consensus were employed to reveal descriptions, frequencies, and variations in technique for joint regions in various clinical scenarios. Systematic review and data from clinical observation were combined with feedback from a group of pediatric MSK experts through a web-based survey. All results were collated and discussed by consensus development groups to derive the pediatric Regional Examination of the Musculoskeletal System (pREMS).A total of 48 pediatric MSK expert clinicians were involved to derive pREMS. Systematic review revealed a paucity of evidence about regional pediatric MSK examination. Video observations of MSK examinations (a total of 2,901 maneuvers) performed by pediatric MSK experts (n = 11 doctors and 8 therapists) of 89 school-age children attending outpatient clinics in 7 UK pediatric rheumatology centers were followed by semistructured interviews with 14 of 19 clinicians. Video observation showed variation in examination techniques, most frequently at the hip and knee in the context of mechanical and inflammatory clinical scenarios.pREMS is the first practice- and consensus-based regional pediatric MSK examination for school-age children. The structured approach is an important step toward improved pediatric MSK clinical skills relevant to clinical training.

Background Young people with complex healthcare needs (CHNs) face the challenge of transferring from child to adult health services. This study sought to identify successful models of transitional care for young people with CHNs. Three conditions were used as exemplars: cerebral palsy, autism spectrum disorders and diabetes. Methods Scoping review: using search terms concerning transitional care, four databases were systematically searched for papers published in English between 1980 and April 2010. Additional informal search methods included recommendations from colleagues working with young people with each of the three conditions and making contact with clinical and research teams with expertise in transitional care. Inclusion and exclusion criteria were applied to define the papers selected for review. A separate review of policy documents, adolescent health and transition literature was also undertaken; 10 common summary categories for the components of high-quality services were identified. All papers were coded using a framework analysis which evaluated the data in two ways using the 10 transition categories and four elements of Normalization Process Theory that are important for successful implementation and integration of healthcare interventions. Results Nineteen papers were selected for review. A very limited literature of models of service provision was identified for young people with cerebral palsy and diabetes. No models were identified for young people with autism spectrum disorders. Furthermore most publications were either descriptions of new service provision or time-limited pilot studies with little service evaluation or consideration of key elements of effective implementation. Conclusions Despite agreement about the importance of effective transitional care, there is a paucity of evidence to inform best practice about both the process of and what constitutes effective transitional care. There is therefore an urgent need for research to evaluate current transitional care practices for young people with CHNs. Introduction Transitions

Objectives To examine the evidence base for telemonitoring designed for patients who have chronic obstructive pulmonary disease and heart failure, and to assess whether telemonitoring fulfils the principles of monitoring and is ready for implementation into routine settings. Design Qualitative data collection using interviews and participation in a multi-path mapping process. Participants Twenty-six purposively selected informants completed semi-structured interviews and 24 individuals with expertise in the relevant clinical and informatics domains from academia, industry, policy and provider organizations and participated in a multi-path mapping workshop. Results The evidence base for the effectiveness of telemonitoring is weak and inconsistent, with insufficient cost-effectiveness studies. When considered against an accepted definition of monitoring, telemonitoring is found wanting. Telemonitoring has not been able so far to ensure that the technologies fit into the life world of the patient and into the clinical and organizational milieu of health service delivery systems. Conclusions To develop effective telemonitoring for patients with chronic disease, more attention needs to be given to agreeing the central aim of early detection and, to ensure potential implementation, engaging a wide range of stakeholders in the design process, especially patients and clinicians.

Recent critiques of depression have contested its coherence as a concept and highlighted its performance in medicalising distress. Studies of depression in a cross-cultural context have focused on language and belief systems as technical barriers to practice that need to be overcome in enacting depression work. This paper seeks to locate culture within the broader socio-structural context of depression care in general practice. The paper draws on interviews with five general practitioners (GPs), and 24 patients from Vietnamese and East Timorese backgrounds who predominantly have left their home as refugees. Each had been diagnosed with depression or prescribed antidepressants. These patients gave accounts of distress deeply embedded within, and inseparable from, lives fraught with frightening pre-migration experiences, traumatic escape and profound dislocation and alienation in their new 'home'. Fragmented lives were contrasted with the nourishing social fabric of homes left behind. GP participants were involved in a process of engaging with a profoundly communal and structural account of emotional distress while defending and drawing on an individualised notion of depression in performing their work and accounting for the pain presented to them.

Despite growing evidence of the effectiveness of counselling in primary care, questions arise concerning the role of general practitioners in the referral process. This involves both liaison with counsellors and the management of people who do not wish to see counsellors. Respondents (n=23) in this qualitative study of general practitioners’ perceptions were clear about which patients should be referred to counsellors, based on guidelines. Additionally, these doctors perceived their role and skills as negotiating with their patients about referral to a counsellor, and managing patients who are either waiting to see a counsellor or who prefer not to see a counsellor. These doctors feel inadequately trained in managing this latter group, whose outcome they perceive as unclear. Despite this, respondents accept a role in ongoing support for their patients with consequent training issues for doctors and opportunities for liaison and mentoring by counsellors.

Background: as well as hearing a story at the start of an interaction, listening in medicine involves picking up and checking out patients' cues. Despite this, cues are frequently missed or ignored by doctors. Aim: to explore the perceptions of general practitioners (GPs) about initiating listening and choosing not to listen during interactions. Study design: qualitative study constant comparison. Methods General practitioners with over 5 years' experience in practice in a semi-rural area of England took part in a single, semistructured, audiotaped interview which was piloted initially. Interviews were transcribed and analysed according to the precepts of constant comparison. Results: in total, 23 of 24 eligible doctors participated. The data emphasise the importance of spotting cues during interactions. Factors influencing judgements on whether or not to attend to cues included pressure of work, the doctor's mood or feelings about the patient, and the context of the interaction. Methods of limiting, blocking or resisting listening included reassuring, changing the subject, interrupting, being directive or making a plan, reducing sympathy and using body language. A tramline metaphor of choice in listening emerged (the listening loop: a definite period of listening by the GP within the interaction, generally separate to hearing the patient's initial story). Conclusion: the listening loop offers a simple model of listening that emphasises choice and judgement in response to patients' cues within interactions. Emphasising this choice highlights both picking up cues and pragmatic limits and resistance to attending to them, with implications for teaching

Background: the issue of diagnostic disclosure in dementia has been debated extensively in professional journals, but empirical data concerning disclosure in dementia has not previously been systematically reviewed. Objective: to review empirical data regarding diagnostic disclosure in dementia. Methods: five electronic databases were searched up to September 2003 (Medline, Embase, Cinahl, Sociological Abstracts, Web of Science). Additional references were identified through hand searches of selected journals and bibliographies of relevant articles and books. The title and abstract of each identified paper were reviewed independently by two reviewers against pre-determined inclusion criteria: original data about disclosure were presented and the paper was in English. Any disagreements were resolved by discussion until consensus was reached. Data were extracted independently by two reviewers using a structured abstraction form. Data quality were not formally assessed although each study was critically reviewed in terms of methodology, sampling criteria, response rates and appropriateness of analysis. Results: fifty-nine papers met the inclusion criteria for detailed review. Many of the studies had methodological shortcomings. The studies reported wide variability in all areas of beliefs and attitudes to diagnostic disclosure and reported practice. Studies of the impact of disclosure indicate both negative and positive consequences of diagnostic disclosure for people with dementia and their carers. Conclusions: existing evidence regarding diagnostic disclosure in dementia is both inconsistent and limited with the perspectives of people with dementia being largely neglected. This state of knowledge seems at variance with current guidance about disclosure

Incontinence remains a taboo where myths and misconceptions abound. The objectives of this study were to explore the impact of incontinence on an individual’s sexuality and to identify the impact of health interventions for the management of incontinence on sexuality. A quota sample of subjects whose incontinence was regarded as being either successfully managed (n=14) or unsuccessfully managed (n=12) by continence advisers, community nurses and health visitors from two National Health Service Trusts were interviewed. A further subject whose incontinence was not classified was also interviewed, bringing the total number of interviews to 27. One Trust had an established continence advisory service of some 19 years, while the other Trust did not have a specific continence advisory service and relied upon members of the primary health care team to meet the needs of individuals suffering from incontinence. The qualitative data from this study were analysed using the constant comparative technique and were grouped into themes relating to clothing and appearance, intimacy and caring, management techniques and relationships and life trajectory. This is the first study to have examined management techniques for incontinence and their relationship to an individual’s sexuality and therefore has important implications for clinical practice. It has also set the findings of incontinence and sexuality in the context of chronic conditions and their related patient careers and life trajectory.

Sociological studies of complementary and alternative therapies have largely focused on the activities and experiences of lay practitioners and users. In contrast, this paper explores some of the ways that a group of medically qualified general practitioners employ homeopathic treatments in their everyday work within the NHS. We explore the ways in which homeopathic medicine accords with an expansive view of the consultation in general practice, and offers doctors a means of avoiding the iatrogenic effects of modern drug treatments. We also point to the ways that this involves practitioners in engaging with contests about the utility of treatments that are rejected by contemporary bioscience.

Parents of children born with a disability often suffer feelings of inappropriate guilt and shame. Although some genetic counselors see their main task to be that of diagnosis and education, they also aim to relieve these feelings of guilt and shame. Little is known about the process of genetic counseling, and whether or not counselors achieve this aim. An exploratory study of one clinic, and one geneticist working with 30 families, using video recordings and taped interviews, indicated that this particular doctor sometimes succeeded in reducing guilt, either intentionally or unintentionally, but on one occasion guilt was iatrogenic, and increased rather than decreased. Further research is needed to examine other types and other styles of genetic counseling so that in future iatrogenic guilt can be avoided, and the distressing aspects of inappropriate guilt and shame reduced as much as possible.

Although sociologists interested in health and illness have extensively deployed the work of Michel Foucault in recent years, few studies have examined the ways in which this is of use in understanding nursing practice. This paper explores the ways in which nurses' accounts of their work and relationships with patients reflect a discourse of the social. While these accounts reflect a thoroughgoing accommodation of the importance of ‘knowing’ the patient as more than an object of clinical practice and procedure, they also reveal the practical problems that must be negotiated in attempting to do so. Foucault's notion of the clinical gaze is deployed in interpreting these accounts, and the question of power and resistance in nursing work is discussed.

This paper explores ideas about the appropriate basis for nurse-patient relationships which underwrite the nursing practice of experienced staff nurses on the acute surgical and medical wards of a Scottish general hospital. Three central features of involvement with patients are identified, knowledge, reciprocity and investment, and these are related to three general models of the nurse-patient relationship, characterized as primary, demonstrative and associational. The implications of the nursing practice on which these models are based are discussed in the context of issues of quality of care and orientation to work.

Lyme disease is a chronic, multisystemic, inflammatory disorder of man and animals associated with infection by the tick-borne spirochaete, Borrelia burgdorferi. Lyme disease was recently reported for the first time in a dog in the UK (May and others 1990). Using an enzyme-linked immunosorbent assay (ELISA), we have performed a serological survey to investigate the prevalence of antibodies to B burgdorferi in UK dogs. The survey has shown that dogs from many areas in the UK have serum antibodies to B burgdorferi, that the presence of serum antibodies is associated with known exposure to ticks and that some dogs seropositive for B burgdorferi have clinical signs consistent with Lyme disease. High levels of serum anti-Borrelia antibodies are not diagnostic for canine Lyme disease, but, in association with appropriate clinical signs, they help to confirm the diagnosis in suspected cases.

Background. The mere presence of catarrh does not, in itself, compel medical help-seeking: many experience catarrh and never seek help for it, while others do so after months or even years. We aimed to explore the triggers of help-seeking in chronic catarrh patients, along with their general health beliefs and the expectations that they hold about the health services that they approach. Method. A qualitative study using digitally taped semi-structured interviews of 19 chronic catarrh patients, with full ethical approval. Narrative analysis was performed on the transcribed interviews, using a constant comparative technique approach to the generation of grounded theory, through a process of manual coding and categorisation. Emergent categories were checked for goodness of fit. Results. Catarrh came to prominence for sufferers through a global shift in body concerns or a relative shift in symptom heirarchy subsequent to a lack of explanation or treatments. Catarrh sufferers had narrow, family-based lay networks which they found to be frequently dismissive. Temporalisation and worsening of symptoms were the predominant triggers for seeking help. Sufferers attended GPs for a ‘quick-fix’ and hospitals for ‘investigations’. Short-term sufferers sought a cure for their symptoms whilst long-term sufferers accepted reassurance. Conclusions. Explanantion and closure should be primary aims in managing catarrh patients. Although resolution of symptoms is the pervading hope of chronic catarrh sufferers, a significant majority of interviewees, particularly long-term sufferers, admitted that they could live with their symptoms so long as they could be given reassurance that pathology was absent and no treatment option overlooked.