Importance of factors determining the low health-related quality of life in people presenting with a diabetic foot ulcer: the Eurodiale study.

AIM: To identify the factors responsible for the low health-related quality of life associated with foot ulcers and the relative importance of these factors. METHODS: A total of 1232 patients with a new foot ulcer, who presented at one of the 14 centres in 10 European countries participating in the Eurodiale study, were included in this cross-sectional study. Patient and ulcer characteristics were obtained as well as results from the Euro-Qol-5D questionnaire, a health-related quality of life instrument with five domains (mobility, self-care, usual activities, pain/discomfort and anxiety/depression). To analyse the relative importance of comorbidities and ulcer- and patient-related factors for health-related quality of life, linear regression models were used to calculate the relative contributions of each factor to the fit (R(2) ) of the model. RESULTS: Patients reported poor overall health-related quality of life, with problems primarily in the mobility and pain/discomfort domains. Among the comorbidities, the inability to stand or walk without help was the most important determinant of decreased health-related quality of life in all five domains. Among ulcer-related factors, ulcer size, limb-threatening ischaemia and elevated C-reactive protein concentration also had high importance in all domains. The clinical diagnosis of infection, peripheral arterial disease and polyneuropathy were only important in the pain/discomfort domain. CONCLUSIONS: The factors that determine health-related quality of life are diverse and to an extent not disease-specific. To improve health-related quality of life, treatment should not only be focused on ulcer healing but a multifactorial approach by a specialized multidisciplinary team is also important.

Effect of exercise on mobility, balance, and health-related quality of life in osteoporotic women with a history of vertebral fracture: a randomized, controlled trial.

UNLABELLED: The aim of this randomized controlled trial was to evaluate the effect of a 3-month course of exercises on mobility, balance, disease-specific, and generic health-related quality of life (HRQOL) for women with osteoporosis and a history of vertebral fractures. Our results showed that exercises improved their mobility, balance, and HRQOL. INTRODUCTION: The aim was to evaluate the effect of a 3-month course of circuit exercises plus a 3-h lesson on how to cope with osteoporosis on mobility, balance, and the HRQOL for postmenopausal women (60-84 years) with osteoporosis and a history of vertebral fracture. Our hypothesis was that a 3-month course would have a significantly positive effect on the women's mobility and balance as well as on their HRQOL. METHODS: The participants (89) were randomized to an intervention group (IT) or a control group (CT) and assessed at baseline at 3 months and at 12 months with measurement of maximum walking speed (MWS), Timed Up and GO (TUG), Functional Reach (FR), the Quality of Life Questionnaire issued by the European Foundation for Osteoporosis ('QUALEFFO-41') and the General Health Questionnaire (GHQ-20). The sample size was calculated with reference to walking speed (primary outcome), and the statistical approaches used were Student's t test or the chi-square test. RESULTS: At 3 months, better results were registered on the primary outcome, MWS as well as TUG, FR, sum score of GHQ-20, and "QUALEFFO-41: mental function" in the IT compared with the CT. At 12 months, those in the IT had a better result on the primary outcome, MWS as well as TUG, "QUALEFFO-41: total score" "QUALEFFO-41: mental function", "QUALEFFO-41: physical function", and "QULEFFO-41: pain" compared with CT. CONCLUSION: Circuit exercises will improve mobility and health-related quality of life of elderly women with osteoporosis and a history of vertebral fractures.

Effect of CT screening on smoking habits at 1-year follow-up in the Danish Lung Cancer Screening Trial (DLCST).

BACKGROUND: The effect of low-dose CT screening for lung cancer on smoking habits has not been reported in large randomised controlled trials. METHODS: This study evaluated the effect on smoking habits of screening with low-dose CT at 1-year follow up in the Danish Lung Cancer Screening Trial (DLCST), a 5-year randomised controlled trial comprising 4104 subjects; 2052 subjects received annual low-dose CT scan (CT group) and 2052 received no intervention (control group). Participants were healthy current and former smokers (>4 weeks since smoking cessation) with a tobacco consumption of >20 pack years. Smoking habits were determined at baseline and at annual screening. Smoking status was verified using exhaled carbon monoxide levels. Lung function tests, nicotine dependency and motivation to quit smoking were assessed. Quit rates and relapse rates were determined at 1-year follow-up for all subjects. RESULTS: At 1 year the quit rates among smokers were 11.9% in the CT group and 11.8% in the control group (p = 0.95). Relapse rates for former smokers were 10.0% and 10.5% in the CT and control groups, respectively (p = 0.81). Significant predictors (p<0.05) for smoking cessation were: high motivation to quit, low dependency, low ratio of forced expiratory volume in 1 s to forced vital capacity, low pack years, higher age, longer period of abstinence and CT findings necessitating 3-month repeat CT scans. CONCLUSIONS: Overall, quit rates were similar in the CT and control group at 1-year follow-up, with a net quit rate of 6.0%. Quit rates were higher and relapse rate lower among subjects with initial CT findings that necessitated a repeat scan 3 months later.

Interprofessional ethics rounds concerning dialysis patients: staff's ethical reflections before and after rounds.

OBJECTIVE: To evaluate whether ethics rounds stimulated ethical reflection. METHODS: Philosopher-ethicist-led interprofessional team ethics rounds concerning dialysis patient care problems were applied at three Swedish hospitals. The philosophers were instructed to stimulate ethical reflection and promote mutual understanding between professions but not to offer solutions. Questionnaires directly before and after rounds were answered by 194 respondents. The analyses were primarily content analysis with Boyd's framework but were also statistical in nature. FINDINGS: Seventy-six per cent of the respondents reported a moderate to high rating regarding new insights on ethical problem identification, but the ethics rounds did not seem to stimulate the ethical reflection that the respondents had expected (p < 0.001). Dominant new insights did not seem to fit into traditional normative ethics but were instead interpreted as hermeneutic ethics. This was illustrated in the extended perspective on the patient and increased awareness of relations to other professions. Regarding insights into how to solve ethical problems, the request for further interprofessional dialogue dominated both before and after rounds. CONCLUSION: The findings show the need for interprofessional reflective ethical practice but a balance between ethical reflection and problem solving is suggested if known patients are discussed. Further research is needed to explore the most effective leadership for reflective ethical practice.

Learning a way through ethical problems: Swedish nurses' and doctors' experiences from one model of ethics rounds.

OBJECTIVE: To evaluate one ethics rounds model by describing nurses' and doctors' experiences of the rounds. METHODS: Philosopher-ethicist-led interprofessional team ethics rounds concerning dialysis patient care problems were applied at three Swedish hospitals. The philosophers were instructed to promote mutual understanding and stimulate ethical reflection, without giving any recommendations or solutions. Interviews with seven doctors and 11 nurses were conducted regarding their experiences from the rounds, which were then analysed using content analysis. FINDINGS: The goal of the rounds was partly fulfilled. Participants described both positive and negative experiences. Good rounds included stimulation to broadened thinking, a sense of connecting, strengthened confidence to act, insight into moral responsibility and emotional relief. Negative experiences were associated with a sense of unconcern and alienation, as well as frustration with the lack of solutions and a sense of resignation that change is not possible. The findings suggest that the ethics rounds above all met the need of a forum for crossing over professional boundaries. The philosophers seemed to play an important role in structuring and stimulating reasoned arguments. The nurses' expectation that solutions to the ethical problems would be sought despite explicit instructions to the contrary was conspicuous. CONCLUSION: When assisting healthcare professionals to learn a way through ethical problems in patient care, a balance should be found between ethical analyses, conflict resolution and problem solving. A model based on the findings is presented.

International development of the Quality of Life in Depression Scale (QLDS).

BACKGROUND: The Quality of Life in Depression Scale (QLDS) employs the needs-based model of quality of life (QoL) and was developed in the UK and The Netherlands as an outcome measure for clinical trials. This paper describes the production and psychometric assessment of nine new language versions for Canada (French and English), Denmark, France, Germany, Italy, Morocco, Spain and the US. METHODS: Three adaptation stages were employed; production of conceptually equivalent translations, field-test interviews and assessment of reliability and construct validity by survey of patients with major depression. RESULTS: Few problems were experienced with producing conceptually equivalent translations, except in Morocco. Patients in the field-test interviews found the instrument to have appropriate content and to be easy to complete. Internal consistency and test-retest reliability were excellent for all language versions and scores were found to relate appropriately to measures of depression severity and health status. LIMITATIONS: Further investigation is required of the ability of the measure to assess individuals at the extremes of the QoL continuum. Data collected with the Arabic QLDS should not be combined with those from other countries. CONCLUSIONS: The QLDS is the first instrument designed to assess QoL in depression based on a coherent model of the construct. Each language version has been shown to be well accepted by respondents and to have excellent psychometric properties. As the instrument is now available in a large number of languages, the QLDS is the QoL instrument of choice for inclusion in clinical trials of interventions for depression.

[Low energy laser treatment--effect in localized fibromyalgia in the neck and shoulder regions]. / Lav-energi laserbehandling--effekt ved lokaliseret fibromyalgi i nakke- og skulderregioner.

The effect of low-level laser therapy (GaAlAs, 830 nm, continuous) for chronic myofascial pain in the neck and shoulder girdle was assessed in a double-blind randomized study with 36 female participants. Treatments were given six times during two weeks with a total effect of 4.5-22.5 J per treatment depending on the number of tender points. No significant effect was found, neither in pain relief nor in tablet intake between the laser and the placebo group. None of the participants reported any side-effects.

[Individual registration of children in the national health service. New possibilities for epidemiological research in primary health care]. / Eget sygesikringsbevis til børn. Nye muligheder for epidemiologisk forskning i den primaere sundhedssektor.

Since January 1st 1996 all Danish citizens, children included, have been recorded individually in The National Health Service Register (SSR). Services rendered to children are no longer registered with an adult person. This article describes the implementation of this new arrangement. The part of health services to children recorded under an adult personal identification number is getting asymptotically closer to a minimum of about four percent, which is determined by the average time of naming of children. After the introduction of individual registration of children the SSR has improved considerably as a basis for epidemiological studies in Danish primary care.

Violation of the patient's integrity, seen by staff in long-term care.

The aim of the study was to describe the views held by staff (n = 233) in long-term care on what they regard as a violation of patient's integrity and to define the concept "integrity" in simple terms. The design of the investigation was inductive. The answers were coded into 775 items. Agreement was reached between the authors on 770 of the items when sorted into 13 categories: the unique personality, autonomous self, personal opinions, secret self, personal competence, professional self, family self, cultural self, information self, personal properties, private territory, corporal self, and ridiculing. The number of categories shows a great variation in the ordinary language definitions given by staff. It was also shown in two other ways: the difference in the level of abstraction in the items, and the fact that integrity referred to the patient, directly or indirectly. Our conclusion is that integrity by the staff reflects an ethical value and not a personal trait. If the staff have to violate the patient's integrity, because other vital values are involved, it is absolutely essential that they consider the ethical aspects of the situation carefully. Such violation demands that they preserve their respect for the patient to the greatest extent possible. It seems important in the training of different staff groups to show the complexity in the concept "integrity" and the ethical dilemmas that arise, especially in the interaction with vulnerable patients who are not able to protect and maintain their own integrity.

Perceived health in three groups of elderly people. A validity study of the Danish version of the Nottingham Health Profile.

The Nottingham Health Profile (NHP) is a measure of physical, emotional and social distress. It was developed in the United Kingdom and has been adapted and translated into Danish. The Danish version of the NHP has been shown to be reliable. In order to establish the validity of the measure it was administered to three groups of people, all over the age of 60, who were expected to differ in health status. These groups consisted of 120 persons attending fitness classes on a regular basis, 64 patients with low back pain and/or pain in the lower extremities referred by their general practitioner for treatment at an out-patient clinic and 72 patients with osteoarthrosis of the hip awaiting hip replacement operation. As predicted, the patients awaiting hip replacement surgery scored higher (indicating greater distress) on all six sections of the measure than did the patients attending the out-patient clinic. Both these groups scored higher on all sections of the NHP than the fitness class members. It is concluded that the Danish version of the NHP has been found valid insofar as it shows expected differences between three groups of elderly people.

The Danish version of the Nottingham Health Profile: its adaptation and reliability.

OBJECTIVE: To test the reliability of the Danish version of the Nottingham Health Profile. DESIGN: Test-retest reliability with an interval of four weeks between administrations of the measure. SETTING: Copenhagen. PARTICIPANTS: Seventy patients suffering from osteoarthrosis, living at home and awaiting hip-replacement operation. The patients' ages ranged from 37 to 90 years, with a median of 72 years. OUTCOME MEASURE: The Danish version of the Nottingham Health Profile, a measure of perceived health status, widely used in Europe. The measure consists of six sections; pain, physical mobility, energy level, sleep, social isolation, and emotional reactions. RESULTS: The respondents scored highly on the measure, particularly on the pain, physical mobility, and energy sections. No major differences in scores associated with age or sex were found. The test-retest correlation coefficients obtained for the six sections were high (ranging from 0.76 to 0.86) and comparable with those found in Sweden and the UK. The test-retest correlation for the whole measure was 0.93. CONCLUSION: The Danish version of the Nottingham Health Profile has been shown to be reliable and to be acceptable and relevant to patients with chronic disability. Should the formal tests of validity currently in progress prove satisfactory, Danish clinicians and researchers will have a valuable tool available for gaining insight into the impact of illness and its treatment on patients.

Influence of follow-up on health-related quality of life after radical surgery for colorectal cancer.

BACKGROUND: The possible benefit for patients of follow-up examinations after curative surgery for colorectal cancer is at present not proven. The purpose of this study was to evaluate the influence of follow-up examinations on health-related quality of life and to assess the attitude of the patients to check-ups. METHODS: A total of 350 patients who had had curative surgery for colorectal cancer and who had been subsequently randomized to either frequent follow-up or virtually no follow-up completed the Nottingham Health Profile and a second questionnaire assessing their attitude to the follow-up visits. RESULTS: The patients who were receiving more frequent follow-up had greater confidence in the check-ups, but the improvement in the health-related quality of life was only marginally better than that of those receiving few follow-up visits. CONCLUSION: The relatively small benefit for health-related quality of life does not justify expensive frequent routine examinations after surgery for colorectal cancer. The Nottingham Health Profile proved to be a reliable instrument within this patient group.

Nottingham health profile scores predict the outcome and support aggressive revascularisation for critical ischaemia.

AIMS: to assess changes in health related quality of life (HRQoL) following peripheral arterial reconstruction for critical limb ischaemia (CLI). METHODS: sixty patients with CLI were prospectively evaluated with the Nottingham Health Profile (NHP) before and 3 and 12 months after arterial reconstruction. In addition, at 12 months, patients were asked if their expectations of the revascularisation had been met and whether they considered the surgical treatment had been worthwhile. RESULTS: primary amputations and mortality were 5% and 3% and after 12 months 12% and 12% respectively. Three months after surgery scores on the pain and sleep sections of the NHP had improved significantly (p < 0.05). These improvements were maintained at 12 months. CONCLUSION: revascularisation for CLI improves HRQoL and pre-operative health perceptions are related to surgical outcome.

The purpose of the general practice consultation from the patient's perspective--theoretical aspects.

BACKGROUND: Medical practice and research are paying increasing attention to what patients want, as reflected by the growth of routine surveys of patients' satisfaction and more formal studies of patients' views of medical care. However, the field lacks conceptual clarity. OBJECTIVES: The aim of this study was to propose a theoretical clarification of the concept of the patients' purpose of a consultation by presenting a patient-centred definition, applicable for clinical work and research in general practice. METHODS: An extensive literature review was conducted to explore presumptions and definitions reported by previous studies. Most authors failed to define or distinguish the concept under investigation. We took these shortcomings as our starting point, added some significant dimensions drawn from a few selected authors who had discussed relevant perspectives in their work and arrived at a proposed working definition of the 'purpose' concept. RESULTS: The proposed definition allows for multiple purposes for the consultation. We incorporate what the patient hopes to gain from the consultation, as opposed to their 'expectations of the most likely outcome'. Our working definition aims to identify patients' a priori wishes and hopes for a specific process and outcome, while acknowledging that these may not be voiced and may be modified by the patient during the consultation. General characteristics of the doctor, such as being considerate or professionally skillful, are not included.

The Danish National Health Service Register. A tool for primary health care research.

The purpose of the article is to describe the Danish National Health Service Register and its value in primary health care research, using mainly general practice as an example. The Danish National Health Service Register is a data system available for counties and municipalities to manage the National Health Insurance covering primary health care providers. The counties use the register for administrative purposes, especially for the settling of accounts with providers. The register contains data on all citizens, providers, and health care services reimbursed by the health authorities, but holds no data regarding health status. The accuracy and degree of completeness of persons and variables in the National Health Service Register rests on the fact that most primary health care services in Denmark are reimbursed and, therefore, included in the data base. This tie to the economy of both health care authorities and providers is supposed to confer the final register with a high degree of completeness. It is a clear advantage that almost all citizens in Denmark are assigned to only one general practice, and that the attitude towards research is positive among Danish patients and doctors. The register has so far only been used occasionally for research purposes. To take advantage of the register for research purposes within clinical and health services research, however, one must possess not only a detailed knowledge of the Danish society, including the structure of the Danish health care system, but also an intimate acquaintance with rather complex agreement system and the actual interpretation of this.

Adaptation into Danish of the Stanford Health Assessment Questionnaire (HAQ) and the Rheumatoid Arthritis Quality of Life Scale (RAQoL).

OBJECTIVES: The study was designed to adapt the Stanford Health Assessment Questionnaire (HAQ) and the Rheumatoid Arthritis Quality of Life Questionnaire (RAQoL) for use in Denmark. METHOD: The instruments were translated into Danish and then field-tested with 10 RA patients for relevance, and face and content validity. Reliability and validity were assessed by administering the new measures and a comparator instrument (the Danish Nottingham Health Profile) to 80 RA patients on two occasions. RESULTS: Patients found both measures acceptable and easy to complete. They had good test-retest reliability (>0.90) and internal consistency and were both able to discriminate between groups with different levels of functional status and self-perceived severity. When compared with the NHP sections, both measures showed expected convergence and divergence. CONCLUSION: Given the excellent psychometric properties of the Danish versions of the RAQoL and HAQ, both are recommended for inclusion in clinical trials and studies.