Patient preferences for expectant management vs. surgical evacuation in first-trimester uncomplicated miscarriage

OBJECTIVE

Expectant and surgical management are widely accepted treatment options in case of a miscarriage. In the absence of differences in complications, the choice between both options can be based on patient preferences.

STUDY DESIGN AND SETTING

We studied treatment preferences for future miscarriages in women with a miscarriage randomized to expectant or surgical treatment or managed according to their own choice.

RESULTS

Data from 136 patients were analyzed. Women randomized either to expectant or surgical management opted for the allocated treatment in future in 55 and 74%, respectively. Of the women randomized to expectant management and with a successful spontaneous loss, 71% opted again for this treatment. Women who were managed according to their own treatment choice, held on to their initial treatment preference (expectant vs. surgical management; 84 and 88%, respectively). Preferences after treatment were strong.

CONCLUSION

A strong treatment preference should be taken into account in the counseling process. Women without a preference should be well informed on all medical aspects of the two options in order to facilitate informed-shared decision-making.

The symptom monitor. A diary for monitoring physical symptoms for cancer patients in palliative care: feasibility, reliability and compliance

The aim of this study was to evaluate the feasibility, reliability and compliance of a new instrument, a diary to monitor physical symptoms for patients with cancer in the palliative phase of their illness. The development of the diary took place in three phases: two pilot studies and one intervention study. In Pilot I, reliability was tested within 13 pairs of patients and their proxy in a patient-proxy comparison. Pilot II was performed to test the feasibility of the instrument among 47 frail elderly. In the intervention study among patients with cancer in the palliative phase, the feasibility as well as the compliance has been tested. The phases have been completed with good results: reliability (ICC) of prevalent symptoms was above 0.75, good feasibility and good compliance. The Symptom Monitor can be used by patients and doctors as an instrument to monitor physical symptoms. The effectiveness of the use of this diary for improvement in treatment of symptoms in the palliative phase of cancer is being tested in a randomized clinical trial.

The influence of COPD on health-related quality of life independent of the influence of comorbidity

BACKGROUND/OBJECTIVES

The goal of this study was to determine the influence of chronic obstructive pulmonary disease (COPD) on health-related quality of life (HRQL) independent of comorbidity.

METHODS

Patients with COPD in general practice, >/=40 years, were selected. To recruit controls, a random sample of persons without COPD and >/=40 years, was taken. HRQL was assessed with the SF-36 and comorbidity was determined by questionnaire.

RESULTS

The influence of COPD on HRQL independent of comorbidity (represented by adjusted regression coefficients) was significant for physical functioning (-27.6), role functioning due to physical problems (-21.6), vitality (-14.4), and general health (-25.7), and was minor and not significant for social functioning (-5.6), mental health (-1.3), role functioning due to emotional problems (-2.7), and bodily pain (-2.5). Comorbidity contributed significantly to the HRQL of all domains (-7.6 to -27.1).

CONCLUSIONS

COPD patients can be impaired in all domains of HRQL. However, impairments in physical functioning, vitality, and general health are related to COPD and to some extent to comorbidity, while impairments in social and emotional functioning do not seem to be related to COPD, but only to comorbidity.

QUOTE-HIV: an instrument for assessing quality of HIV care from the patients' perspective

BACKGROUND

An HIV-specific version of the QUOTE questionnaire was developed to measure the quality of care of patients infected with HIV from the patients' perspective. The consistency and validity of the questionnaire was assessed.

METHODS

Focus group discussions were held to select aspects for inclusion in the questionnaire that are important to patients with HIV. Item and inter-item analysis, factor analysis, and reliability analysis were performed to test the internal consistency and validity of the questionnaire.

RESULTS

Twenty seven items (13 generic and 14 HIV specific) were used in the QUOTE-HIV questionnaire. Separate factor analyses of the generic and HIV specific aspects indicated that each loaded onto a single factor. The internal consistency of the total questionnaire was good (Cronbach's alpha >/=0.80). Feasibility of the questionnaire was shown by the diversity of importance and performance scores for general practitioners as well as for HIV specialists and AIDS nursing consultants.

CONCLUSION

The QUOTE-HIV questionnaire is a useful instrument for measuring the quality of care from the perspective of HIV infected patients.

Threatened miscarriage in general practice: diagnostic value of history taking and physical examination

BACKGROUND

Ultrasonography, the gold standard for establishing a diagnosis in first-trimester vaginal bleeding, is not always readily avaliable. Medical history and gynaecological examination are then used instead, to make a provisional diagnosis.

AIM

To determine the diagnostic value of history taking and physical examination in first-trimester bleeding, to differentiate between patients requiring immediate further diagnostic examination from those in whom an expectant policy will initially suffice.

DESIGN OF STUDY

Prospective population-based cohort study.

SETTING

Seventy-four general practices in Amsterdam.

METHOD

Two hundred and twenty-five patients with first trimester vaginal bleeding were referred for an early pregnancy assessment. The data from 204 patients were analysed. Two diagnostic models were constructed based on symptoms and the results of gynaecological examination to identify diagnostic subgroups relevant to clinical practice.

RESULTS

Model 1, which separates viable pregnancies from other diagnoses, increased pre-test probability from 47% to a post-test probability of 70%. Model 2, which enabled the identification of complete miscarriages, resulted in a post-test probability of 41% of a complete miscarriage, given a pre-test sample probability of 25%. The tentative diagnosis of a general practitioner, based entirely on clinical judgement, turned out to be a poor predictor for the ultrasonographically confirmed diagnosis (pre-test probability of 47% changed to a post-test probability of 58%).

CONCLUSION

This study shows that, in first trimester bleeding, neither statistical prediction models based on signs and symptoms, nor clinical judgement, are valid replacements for ultrasonographic assessment in establishing a diagnosis.

Management of miscarriage: a randomized controlled trial of expectant management versus surgical evacuation

BACKGROUND

In many countries, surgical uterine evacuation is the standard treatment for women with a miscarriage, but expectant management has been advocated as an alternative. The choice between the two options cannot be based on published evidence alone, because randomized clinical trials are scarce while generalizability of findings to patients with a strong preference for either management options is unclear.

METHODS

In a randomized controlled trial, the complications and efficacy of either expectant or surgical management for miscarriages were compared, and the results in patients who refused randomization and were managed according to their own preference were studied. In total, 122 patients were randomized and 305 were managed according to their choice.

RESULTS

No differences were found in the number of emergency curettages and complications between expectant and surgical management. Efficacy at 6 weeks was 30/64 (47%) in women allocated to expectant management, and 55/58 (95%) in women allocated to surgical evacuation. After 7 days, 37% of expectantly managed women had a spontaneous complete miscarriage. After 6 weeks, intention-to-treat analysis including cross-overs showed similar effectiveness (92% versus 100%). Results in the preference groups were comparable with those in the randomized groups.

CONCLUSION

In our experience a waiting period of 7 days after diagnosis may prevent 37% of surgical procedures.

[Contacts outside of office hours: complaints presented to the general practitioner and to the emergency department]

OBJECTIVE

To determine the differences between the problems presented out-of-hours to general practitioners (GPs) or to the Accident & Emergency (A&E) department of a hospital, and to assess whether the physicians believed the patient was justified in contacting them.

DESIGN

Descriptive.

METHOD

All the out-of-hours contacts that 33,000 patients on the lists of 22 general practices had with either a duty GP or the A&E department of a nearby hospital (so-called 'self-referrers') were counted during two 3-month periods. In addition, symptoms were classified in both settings using the International Classification of Primary Care (ICPC).

RESULTS

The ratio for contacts between general practice and A&E was 2:1 in the evening and 3:1 at night. The majority of problems presented to the GP was dealt with by telephone. At the A&E, trauma was seen most commonly, while GPs were contacted for infections and (complications of) chronic diseases. A&E physicians judged one out of five reasons for encounter as 'unjustified', while this ratio was one in seven in the case of GPs.

CONCLUSIONS

There was only a partial overlap in the nature of the problems presented to an A&E department and those presented to GPs; instead, the two settings appeared to complement each other. The results were influenced by the fact that the A&E department lacked the possibility of dealing with patients by telephone. Both the A&E department and the GPs were contacted by patients who did not need (acute) medical care.

Expectant management versus surgical evacuation in first trimester miscarriage: health-related quality of life in randomized and non-randomized patients

BACKGROUND

Expectant management, although less effective, is an alternative treatment option for surgical evacuation in women with a miscarriage. We assessed health-related quality of life (HRQL) differences over time between expectant and surgical management in women with a miscarriage.

METHODS

Women with a miscarriage were randomized to either expectant (n = 64) or surgical (n = 58) management, and 305 eligible women who refused randomization because of a preference for either treatment option were managed according to their choice following the same clinical protocol (126 expectant, 179 surgical). The main outcome measures were score differences of HRQL during 12 weeks. Repeated measures analysis was applied.

RESULTS

Out of a total of 427 women, 198 were excluded in the questionnaire follow-up, leaving 229 women who participated. Mental health of women allocated to expectant management improved more and earlier (treatment effect) than of women allocated to surgical evacuation. Mental health scores were significantly better in women who chose, rather than women who were randomized, to curettage. The groups managed according to their own preference showed no differences in mental health scores.

CONCLUSION

Women with a miscarriage who chose their own treatment had the best HRQL over time, supporting the role of free choice from a clinical point of view. Women without a treatment preference should be encouraged to start with expectant management for psychological reasons.

Risk of depression in patients with chronic obstructive pulmonary disease and its determinants

BACKGROUND

Although it has been repeatedly suggested that chronic obstructive pulmonary disease (COPD) is associated with depression, no conclusion has so far been reached. A study was undertaken to investigate whether depression occurs more often in patients with COPD than in controls. The demographic and clinical variables associated with depression were also determined.

METHODS

Patients with a registered diagnosis of obstructive airway disease in general practice, aged > or=40 years, forced expiratory volume in 1 second (FEV(1)) <80% predicted, FEV(1) reversibility <or =12%, FEV(1)/VC < or = predicted - 1.64 x SD, and a history of smoking were selected. A random sample of subjects without a registered diagnosis of asthma or COPD aged 40 years or older acted as controls. Depression was assessed using the Centers for Epidemiologic Studies Depression (CES-D) scale.

RESULTS

In patients with severe COPD (FEV(1) <50% predicted), the prevalence of depression was 25.0% compared with 17.5% in controls and 19.6% in patients with mild to moderate COPD. When the results were adjusted for demographic variables and comorbidity, the risk for depression was 2.5 times greater for patients with severe COPD than for controls (OR 2.5, 95% CI 1.2 to 5.4). In patients with mild to moderate COPD this increased risk of depression was not seen. Living alone, reversibility of FEV(1) % predicted, respiratory symptoms and physical impairment were significantly associated with the scores on the CES-D scale.

CONCLUSION

Patients with severe COPD are at increased risk of developing depression. The results of this study underscore the importance of reducing symptoms and improving physical functioning in patients with COPD.

The patient as a source to improve the medical record

BACKGROUND

The problem list is an important tool in general practice for care as well as research purposes. As the central part of the problem-oriented medical record, it lists the main medical problems which the GP wants to have knowledge of during any patient encounter. The assessment of its quality is usually made by comparing with other sources of information on the patient's problems.

OBJECTIVE

This study addresses the question of to what extent the problem list can be improved by asking the patient about their own medical problems.

METHODS

During 7 weeks, all patients who visited three GPs in a health care centre in an Amsterdam suburb were interviewed. During the interview, they were confronted with the problem list made by their own GP and stimulated to make suggestions for addition or removal of problems.

RESULTS

All in all, patients were in agreement with 88% of all listed problems. The completeness of the problem list could be increased by 28%, while 4% ultimately were removed: a net gain of 24%.

CONCLUSION

The patient can be used as a sourcetool for improvement of the quality of the problem list when its prime function is patient care. It becomes more complicated when the problem list also serves a research purpose. Clear inclusion rules will then have to be formulated.

Do levels of immunoglobulin G antibodies to foods predict the development of immunoglobulin E antibodies to cat, dog and/or mite?

BACKGROUND

In children at high risk of inhalation allergy, food sensitization is associated with an increased risk for sensitization to inhalant allergens. Furthermore, this association was also found in a cross-sectional study.

OBJECTIVE

To examine in a prospective study, whether levels of IgG to foods (i.e. mixture of wheat and rice, mixture of soy bean and peanut, egg white, cow's milk, meat, orange and potato) indicate an increased risk for the future development of IgE antibodies to inhalant allergens in a low-risk population and whether they can be used as predictors of the subsequent development of IgE antibodies in young, initially IgE-negative children.

METHODS

Coughing children, aged 1-5, visiting their GPs, were tested for IgE antibodies to mite, dog and cat (RAST) and IgG (ELISA) to foods. All IgE-negative children were retested for IgE antibodies after two years. The IgG results (66 percentiles) of the first blood sample were compared to the RAST-scores of the second blood sample.

RESULTS

After two years, 51 out of 397 (12.8%) originally IgE-negative children, had become IgE-positive for cat, dog and/or mite. An increased IgG antibody level to wheat-rice (OR = 2.2) and to orange (OR = 2.0) indicated an increased risk of developing IgE to cat, dog or mite allergens. In addition to IgG to a mixture of wheat-rice and orange; total IgE, breastfeeding, eczema as a baby and age were the most important predictors for the subsequent development of IgE to inhalant allergens.

DISCUSSION

An increased IgG antibody level to a mixture of wheat-rice or orange, indicates an increased risk of developing IgE to cat, dog or mite allergens. This indicates that excessive activity of the mucosal immune system is present before IgE antibodies to airborne allergens can be demonstrated. Nevertheless, IgG to foods is not very helpful (with a positive predictive value of 16.5%, and negative predictive value of 90.6%) in identifying individual children at risk in clinical practice. However, besides other risk factors, IgG to wheat-rice and to orange could be useful as a screening test for studies in the early identification, i.e. before IgE antibodies can be detected, of children with an increased risk of developing IgE antibodies in the future.

How do primary care physicians use long-term acid suppressant drugs? A population-based analysis of Dutch general practices

OBJECTIVES

A considerable proportion of the medication budget of Dutch general practitioners is spent on prescribed long-term acid suppressant drugs. We investigated the magnitude of long-term prescription of acid suppressant drugs in general practice and the frequency and means of confirming the primary working diagnosis.

STUDY DESIGN

We used a retrospective descriptive study of 24 general practices in the Amsterdam region.

POPULATION

We identified those receiving long-term acid suppressant therapy (12 or more weeks/year) from a total of 46,813 patients by extracting data from pharmacy databases.

OUTCOMES MEASURED

We measured the amount and duration of prescriptions for each medication, indications for prescription, and investigations performed by general practitioners.

RESULTS

Of the 46,813 patients, 922 (2%) received long-term acid suppressant therapy. The duration of prescription varied from 12 weeks in 8% of patients to &gt 52 weeks in 23% of patients (mean = 33 weeks). In 25% of patients, no investigations were performed; 75% of patients underwent endoscopy or ingested a barium meal. The predominant diagnoses in investigated patients were ulcer disease (39%), gastroesophageal reflux disease (49%), and functional dyspepsia (gastritis, normal aspect; 18%). Helicobacter pylori status was available in 29% of patients with ulcer disease. Eradication therapy was reported in 44% of these patients.

CONCLUSIONS

Among patients of physicians in general practice in the Amsterdam region, 2% used long-term acid suppressants. Patients with ulcer disease may stop taking acid suppressants after apparent successful H pylori eradication. Tapering strategies must be developed for patients with mild reflux disease or functional dyspepsia.