RESUMEN
OBJECTIVE: To evaluate the costs and non-inferiority of a strategy starting with the levonorgestrel intrauterine system (LNG-IUS) compared with endometrial ablation (EA) in the treatment of heavy menstrual bleeding (HMB). DESIGN: Cost-effectiveness analysis from a societal perspective alongside a multicentre randomised non-inferiority trial. SETTING: General practices and gynaecology departments in the Netherlands. POPULATION: In all, 270 women with HMB, aged ≥34 years old, without intracavitary pathology or wish for a future child. METHODS: Randomisation to a strategy starting with the LNG-IUS (n = 132) or EA (n = 138). The incremental cost-effectiveness ratio was estimated. MAIN OUTCOME MEASURES: Direct medical costs and (in)direct non-medical costs were calculated. The primary outcome was menstrual blood loss after 24 months, measured with the mean Pictorial Blood Assessment Chart (PBAC)-score (non-inferiority margin 25 points). A secondary outcome was successful blood loss reduction (PBAC-score ≤75 points). RESULTS: Total costs per patient were 2,285 in the LNG-IUS strategy and 3,465 in the EA strategy (difference: 1,180). At 24 months, mean PBAC-scores were 64.8 in the LNG-IUS group (n = 115) and 14.2 in the EA group (n = 132); difference 50.5 points (95% CI 4.3-96.7). In the LNG-IUS group, 87% of women had a PBAC-score ≤75 points versus 94% in the EA group (relative risk [RR] 0.93, 95% CI 0.85-1.01). The ICER was 23 (95% CI 5-111) per PBAC-point. CONCLUSIONS: A strategy starting with the LNG-IUS was cheaper than starting with EA, but non-inferiority could not be demonstrated. The LNG-IUS is reversible and less invasive and can be a cost-effective treatment option, depending on the success rate women are willing to accept. TWEETABLE ABSTRACT: Treatment of heavy menstrual bleeding starting with LNG-IUS is cheaper but slightly less effective than endometrial ablation.
Asunto(s)
Técnicas de Ablación Endometrial/economía , Dispositivos Intrauterinos Medicados/economía , Levonorgestrel/economía , Menorragia/economía , Menorragia/terapia , Adulto , Análisis Costo-Beneficio , Femenino , Humanos , Levonorgestrel/administración & dosificación , Países Bajos , Resultado del TratamientoRESUMEN
OBJECTIVE: To compare effects and cost-effectiveness of pelvic floor muscle training (PFMT) and watchful waiting in women with pelvic organ prolapse. DESIGN: Randomised controlled trial. SETTING: Dutch general practice. POPULATION: Women (≥55 years) with symptomatic mild prolapse, identified by screening. METHODS: Linear multilevel analysis. MAIN OUTCOME MEASURES: Primary outcome was change of pelvic floor symptoms (Pelvic-Floor-Distress-Inventory-20 [PFDI-20]) during 24 months. Secondary outcomes were condition-specific and general quality of life, costs, sexual functioning, prolapse stage, pelvic floor muscle function and women's perceived improvement of symptoms. RESULTS: PFMT (n = 145) resulted in a 12.2-point (95% CI 7.2-17.2, P < 0.001) greater improvement in PFDI-20 score during 24 months compared with watchful waiting (n = 142). Participants randomised to PFMT more often reported improved symptoms (43% versus 14% for watchful waiting). Direct medical costs per person were 330 for PFMT and 91 for watchful waiting but costs for absorbent pads were lower in the PFMT group (40 versus 77). Other secondary outcomes did not differ between groups. Post-hoc subgroup analysis demonstrated that PFMT was more effective in women experiencing higher pelvic floor symptom distress at baseline. CONCLUSION: PFMT resulted in greater pelvic floor symptom improvement compared with watchful waiting. The difference was statistically significant, but below the presumed level of clinical relevance (15 points). PFMT more often led to women's perceived improvement of symptoms, lower absorbent pads costs, and was more effective in women experiencing higher pelvic floor symptom distress. Therefore, PFMT could be advised in women with bothersome symptoms of mild prolapse. TWEETABLE ABSTRACT: Pelvic floor muscle training can be effective in women with bothersome symptoms of mild prolapse.
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Terapia por Ejercicio/métodos , Diafragma Pélvico/fisiopatología , Prolapso de Órgano Pélvico/terapia , Espera Vigilante/métodos , Anciano , Análisis Costo-Beneficio , Terapia por Ejercicio/economía , Femenino , Estudios de Seguimiento , Medicina General , Humanos , Persona de Mediana Edad , Países Bajos , Atención Primaria de Salud , Calidad de Vida , Encuestas y Cuestionarios , Resultado del Tratamiento , Espera Vigilante/economíaRESUMEN
OBJECTIVE: To estimate the cost-effectiveness and cost-utility of actively encouraging older community-dwelling women with urinary incontinence to be diagnosed and treated. DESIGN: The study was designed as cost-effectiveness and cost-utility analyses alongside a cluster randomised controlled trial. Analyses were performed from a societal perspective. Direct medical and nonmedical costs were taken into account and valued according to the standard Dutch guidelines for economic evaluations. SETTING: Primary care. POPULATION: Study participants were 350 community-dwelling women 55 years or older with urinary incontinence. METHODS: Women in the intervention group were invited for diagnostic testing and treatment. The control group received usual care according to the Dutch guideline on urinary incontinence. Follow-up period was 12 months. MAIN OUTCOME MEASURES: Incontinence Impact Adjusted Life Years (IIALY), Quality Adjusted Life Years (QALY) and incremental costs calculated per IIALY and per QALY gained. RESULTS: Costs per extra life year without impact on daily life from urinary incontinence amounted to 5179 (95% CI -17 323 to 36 260). Costs per QALY amounted to 23 907 (95% CI -124 849 to 121 849). Assuming a ceiling ratio of 20 000, the probability that the intervention was cost-effective based on IIALYs was 91% and 46% based on QALYs. CONCLUSIONS: Improvements in severity of incontinence in older community-dwelling women can be achieved against reasonable costs, with an improvement of symptom-specific QALYs. Findings support an active role of primary care physicians towards women who hesitate to ask for help for urinary incontinence. TWEETABLE ABSTRACT: Encouraging women with urinary incontinence to be treated, improves symptoms and QOL against reasonable costs.
Asunto(s)
Incontinencia Urinaria/economía , Actividades Cotidianas , Anciano , Análisis por Conglomerados , Análisis Costo-Beneficio , Femenino , Promoción de la Salud/economía , Humanos , Persona de Mediana Edad , Países Bajos , Años de Vida Ajustados por Calidad de Vida , Resultado del Tratamiento , Incontinencia Urinaria/prevención & controlRESUMEN
OBJECTIVES: To determine the DA and cost-effectiveness of the dermoscope in primary care for skin lesions suspected of malignancy. METHODS: In a cluster randomized clinical trial, 48 Dutch general practices were randomized to either intervention group using a dermoscope or control group using only naked-eye examination. A total of 194 lesions from 170 patients in the intervention group and 222 lesions from 211 patients in the control group were analysed for DA and cost-effectiveness. RESULTS: The percentage of correctly diagnosed lesions in intervention group and control group was 50.5% and 40.5% respectively. This was 61.5% and 22.2% for melanomas. In the intervention group, three malignancies were treated with the expectative treatment option compared to none in the control group. The odds ratio (OR) of a correct diagnosis in the intervention group, compared to control group, was 1.51 (95% CI: 0.962.37) P = 0.07. Consequently, the relative risk was 1.25. The incremental cost-effectiveness ratio was 89 (95% CI −60 to 598), indicating that using a dermoscope costs an additional 89 for one additional correctly diagnosed patient. Additional analyses showed better effects of dermoscopy compared to the control group for 98% of the bootstrap resamples. CONCLUSIONS: The probability of a correct diagnosis was 1.25 times higher using a dermoscope than without a dermoscope. Although this difference is marginally not statistically significant, dermoscopy in general practice appears to be cost effective. We therefore think that GPs should be trained to use a dermoscope, although they should realize that even with the use of a dermoscope not all lesions will be diagnosed correctly.
Asunto(s)
Análisis Costo-Beneficio , Dermoscopía/economía , Atención Primaria de Salud/métodos , Enfermedades de la Piel/diagnóstico , Neoplasias Cutáneas/diagnóstico , Adulto , Anciano , Carcinoma Basocelular/diagnóstico , Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/patología , Análisis por Conglomerados , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Melanoma/diagnóstico , Melanoma/patología , Persona de Mediana Edad , Atención Primaria de Salud/economía , Enfermedades de la Piel/patología , Neoplasias Cutáneas/patologíaRESUMEN
BACKGROUND: Continuity of end-of-life care for patients receiving palliative care is an important challenge for out-of-hours services in general practice. AIM: To investigate how frequent information is transferred on patients receiving palliative care from GPs to the out-of-hours services, to explore the perceptions of GP's on this information transfer and to study the relation between information transfer and the used GP information systems. METHODS: This is a mixed-method design study. The frequency of information transfer to the out-of-hours services was investigated by analyzing a regional out-of-hours database. Barriers and promoting factors for this transfer of information were investigated by using semi-structured interviews among a purposive sample of GPs from the same region. The relation between information transfer and the GP information system was investigated by a postal questionnaire in a national random selection of GPs. RESULTS: When a palliative patient contacted the out-of-hours service, for 20% of these patients, a transfer of information was available and only half of these transfers included an anticipating end-of-life plan. All interviewed GPs considered continuity of care for these patients as important. However, some doubted whether a transfer of information is relevant for the quality of care. There was no relation between the information transfer and the used GP information systems. CONCLUSION: For only a minority of patients receiving palliative care, a transfer of information including an anticipating management plan was present. There is a large variation in the opinions of GPs on how to organize continuity of end-of-life care.
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Atención Posterior , Continuidad de la Atención al Paciente , Medicina General , Servicios de Atención de Salud a Domicilio , Comunicación Interdisciplinaria , Cuidados Paliativos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Sistemas de Información , Relaciones Interprofesionales , Masculino , Persona de Mediana Edad , Países Bajos , Estudios Retrospectivos , Encuestas y CuestionariosRESUMEN
OBJECTIVES: To assess possible relationships between disease activity, foot-related impairments, activity limitations and participation restrictions in children with juvenile idiopathic arthritis (JIA). METHODS: Thirty-four children were studied. Disease activity was assessed with the Juvenile Arthritis Disease Activity Score in 71 joints (JADAS-71). Foot-related impairments, activity limitations and participation restrictions were measured with the Juvenile Arthritis Foot Disability Index (JAFI), the Childhood Health Assessment Questionnaire (CHAQ), self-reported or parent-reported and doctor-reported VAS scales. Relationships were quantified with Spearman's correlation coefficient. RESULTS: The mean age was 12.4±3.7 years, the median disease duration 1.5 years (interquartile range (IQR) 1.0-4.0), 88% were girls, and 76% had polyarticular disease course. The median JADAS-71 score (range 0-101) was 6 (IQR 1-13). On the JAFI sub-scores (range 0-4) 88% of the children reported some foot-related impairments (median 1.1, IQR 0.4-2.0); 82% reported some foot-related activity limitations (median 0.9, IQR 0.3-2.0), and 65% reported some foot-related participation restrictions (median 0.6, IQR 0-2.1). The median CHAQ score was 0.9 (IQR 0.1-1.8). The JADAS-71 correlated with all impairment, activity limitation and participation restriction variables (r=0.48-0.81, p<0.01). Most of the impairment variables correlated with activity limitation (r=0.39, p<0.05 to r=0.92, p<0.01) and participation restriction variables (r=0.44, p<0.05 to r=0.81, p<0.01). All activity limitation variables correlated with participation restriction variables (r=0.62-0.84, p<0.01). CONCLUSIONS: We observed strong relationships between disease activity, foot-related impairments, activity limitations and participation restrictions in children with JIA, and therefore suggest that standard screening for foot problems should be included in follow-up care for JIA patients.
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Actividades Cotidianas , Artritis Juvenil/fisiopatología , Articulaciones del Pie/fisiopatología , Relaciones Interpersonales , Índice de Severidad de la Enfermedad , Adolescente , Niño , Estudios Transversales , Evaluación de la Discapacidad , Femenino , Encuestas Epidemiológicas , Humanos , MasculinoRESUMEN
OBJECTIVE: To assess the relationship between disease duration and foot function (expressed as pressure and gait parameters), foot pain and disability, in patients with foot complaints secondary to rheumatoid arthritis (RA). METHODS: Sixty-two patients with RA-related foot complaints were included. Disease duration was defined as the time since RA was diagnosed. A pressure platform was used to measure both pressure parameters (i.e. pressure-time integrals and peak pressures in the forefoot) and gait parameters (i.e. total loading time and loading time in different foot regions). In addition, measurements of foot pain, disability (i.e. walking time and self reported disability), forefoot joint damage and disease activity were obtained. Data were analysed using partial correlations (Spearman), correcting for age. RESULTS: Disease duration was significantly correlated with the maximum pressure-time integral (PTI) measured under the forefoot (r = 0.330, p = 0.01). Disease duration was also significantly correlated with gait parameters, i.e. total loading time (r = 0.265, p = 0.04), duration of heel loading and duration of toe loading (r = 0.326, p = 0.01 and r = -0.288, p = 0.03 respectively), and walking time (r = 0.297, p = 0.02). Disease duration did not correlate with self-reported foot pain or disability. CONCLUSION: In patients with RA-related foot complaints, longer disease duration is associated with impaired foot function and reduced walking speed. These findings are interpreted as an alteration in pressure distribution and gait pattern during the course of disease, with a shift from a heel-to-toe roll-over process to a more shuffling gait.
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Artritis Reumatoide/complicaciones , Artritis Reumatoide/fisiopatología , Evaluación de la Discapacidad , Pie/fisiopatología , Dolor/etiología , Actividades Cotidianas , Adulto , Anciano , Progresión de la Enfermedad , Femenino , Marcha/fisiología , Humanos , Masculino , Persona de Mediana Edad , Factores de Tiempo , Caminata/fisiología , Soporte de Peso/fisiologíaRESUMEN
The 1995 guideline on pelvic inflammatory disease (PID) has been updated. The general practitioner should consider PID whenever a woman of childbearing age complains of lower abdominal pain; the diagnosis should then be based on 5 criteria: (a) non-acute lower abdominal pain; (b) pain on upward movement or adnexal tenderness during vaginal touch; (c) painful or swollen adnexae; (d) ESR > or = 15 mm in the 1st hour or a temperature > 38 degree C, and (e) no indications for other diseases, such as appendicitis or an extra-uterine pregnancy. In case of diagnostic doubt, a gynaecologist must be consulted. Rapid treatment with antibiotics diminishes symptoms, shortens the course of disease, and may prevent complications such as infertility or extra-uterine pregnancy. Treatment should be started with ofloxacin and metronidazole. Due to the increasing antibiotic resistance of Neisseria gonorrhoeae, when there are indications for this pathogen the medicinal treatment should immediately be directed at it by means of cefotaxim, doxycycline and metronidazole. In his or her information to the patient, the general practitioner should devote attention to the major role of sexually transmissible micro-organisms and give advice, if necessary, regarding high-risk behaviour.
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Antibacterianos/uso terapéutico , Medicina Familiar y Comunitaria/normas , Enfermedad Inflamatoria Pélvica/diagnóstico , Enfermedad Inflamatoria Pélvica/tratamiento farmacológico , Pautas de la Práctica en Medicina , Diagnóstico Diferencial , Farmacorresistencia Bacteriana , Femenino , Humanos , Países Bajos , Asunción de Riesgos , Conducta Sexual , Sociedades MédicasRESUMEN
The 1996 practice guideline of the Dutch College of General Practitioners (NHG) on vaginal discharge has been updated. Most women who visit their doctor with complaints about vaginal discharge do not have an increased risk of a sexually-transmitted disease. Investigations into vaginal discharge comprise history taking, physical examination and microscopic analysis in the laboratory of the general practitioner. Additional investigation into Chlamydia, gonorrhoea and Trichomonas infection is only necessary if the patient history reveals an increased risk of a sexually-transmitted disease. A Candida infection or bacterial vaginosis should only be treated if the patient experiences bothersome complaints. Treatment of a Candida infection consists of a vaginally applied imidazole compound. Bacterial vaginosis can be treated with oral administration of metronidazole. Patients with vaginal fluor can be examined and, if necessary, treated by their general practitioner. Referral to a gynaecologist is rarely necessary.
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Medicina Familiar y Comunitaria/normas , Pautas de la Práctica en Medicina , Enfermedades de Transmisión Sexual/diagnóstico , Excreción Vaginal/diagnóstico , Antifúngicos/uso terapéutico , Candidiasis Vulvovaginal/diagnóstico , Candidiasis Vulvovaginal/tratamiento farmacológico , Candidiasis Vulvovaginal/microbiología , Candidiasis Vulvovaginal/patología , Femenino , Humanos , Países Bajos , Examen Físico , Factores de Riesgo , Enfermedades de Transmisión Sexual/epidemiología , Enfermedades de Transmisión Sexual/patología , Excreción Vaginal/tratamiento farmacológico , Excreción Vaginal/microbiología , Excreción Vaginal/patologíaRESUMEN
- The Dutch College of General Practitioners' (NHG) practice guideline 'Urinary incontinence in women' provides guidelines for diagnosis and management of stress, urgency and mixed urinary incontinence in adult women.- General practitioners (GPs) should be alert to signals for urinary incontinence in women and offer active diagnosis and treatment if necessary.- Shared decision making is central in the guideline; the GP and the patient should discuss therapeutic options and decide on treatment policy in mutual consultation.- Women with stress urinary incontinence can choose between pelvic floor exercises or a pessary as initial treatment. Placing a midurethral sling (MUS) will be discussed if initial treatment is insufficiently effective or in the case of serious symptoms.- When bladder training is ineffective in urgency incontinence, the GP will discuss the pros and cons of adding an anticholinergic agent.- Exercise therapy can take place in the GPs practice or under supervision of a pelvic physical therapist.
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Medicina General/métodos , Incontinencia Urinaria/diagnóstico , Incontinencia Urinaria/terapia , Adulto , Terapia por Ejercicio/métodos , Femenino , Médicos Generales , Humanos , Países Bajos , Sociedades Médicas , Cabestrillo SuburetralRESUMEN
The prevalence of sexually transmitted diseases (STDs) increased in the Netherlands in the years 2000-2003. A recent population-based study showed that Chlamydia infections were a problem in urbanised areas; prevalence in rural areas was low. In 2004, the Dutch Health Council advised against a national screening programme for Chlamydia. However, the newest figures on the distribution of Chlamydia infections suggest that screening in large cities might be cost-effective. Much can be learned from the screening programme in the United Kingdom.
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Infecciones por Chlamydia/diagnóstico , Chlamydia/aislamiento & purificación , Tamizaje Masivo/métodos , Adulto , Infecciones por Chlamydia/epidemiología , Infecciones por Chlamydia/prevención & control , Análisis Costo-Beneficio , Femenino , Guías como Asunto , Humanos , Países Bajos/epidemiología , Prevalencia , Salud Rural , Enfermedades Bacterianas de Transmisión Sexual/diagnóstico , Enfermedades Bacterianas de Transmisión Sexual/epidemiología , Enfermedades Bacterianas de Transmisión Sexual/prevención & control , Salud UrbanaRESUMEN
OBJECTIVE: To assess the value of fasting blood glucose as a parameter for glycemic control in type 2 diabetic patients not using insulin. RESEARCH DESIGN AND METHODS: In 1,020 type 2 diabetic patients treated with diet or oral hypoglycemic agents (OHAs), measurements of fasting plasma glucose (FPG) and HbA1c were taken. In 617 patients, the measurement could be repeated after 3 months. Cross-sectional correlation coefficients were calculated for the association between HbA1c and FPG. Receiver-operating characteristic (ROC)-curve analyses were applied to examine the performance of FPG as a diagnostic test for HbA1c. Longitudinally, the change in FPG was compared with the change in HbA1c, with both correlation measures and ROC curve analyses. RESULTS: Correlation coefficients between HbA1c and FPG and between FPG change and HbA1c change were 0.77 and 0.65, respectively. ROC curve analysis showed that HbA1c is difficult to predict from FPG values: 66% of the patients with good HbA1c (< 7.0%) were identified as such by FPG values < 7.8 mmol/l. As a test for HbA1c change, FPG change performed moderately: the highest combined values of sensitivity and specificity (87.7 and 57%, respectively) were reached at a cutoff point of zero in the range of FPG change values. CONCLUSIONS: FPG and HbA1c values that do not correspond are not rare in type 2 diabetic patients on diet or OHA treatment. HbA1c is difficult to predict from FPG values, and even more difficult is the prediction of HbA1c changes from FPG changes.
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Glucemia/análisis , Diabetes Mellitus Tipo 2/sangre , Hemoglobina Glucada/análisis , Glucemia/metabolismo , Cromatografía Líquida de Alta Presión/métodos , Estudios Transversales , Diabetes Mellitus Tipo 2/dietoterapia , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Dieta para Diabéticos , Ayuno , Humanos , Hipoglucemiantes/uso terapéutico , Estudios Longitudinales , Reproducibilidad de los Resultados , Factores de TiempoRESUMEN
UNLABELLED: Background and Purpose-Hemiplegic shoulder pain is not uncommon after stroke. Its origin is still unknown, and although many different methods of treatment are applied, none have yet been proved to be effective. We sought to study the efficacy of 3 injections of intra-articular triamcinolone acetonide on pain and arm function in stroke patients with hemiplegic shoulder pain. METHODS: -In a multicenter, randomized, placebo-controlled clinical trial, patients with hemiplegic shoulder pain received either 3 intra-articular injections of 40 mg triamcinolone acetonide or 1 mL physiological saline solution (placebo). Primary outcomes were pain measured according to 3 visual analogue scales (score range, 0 to 10), and arm function was measured by means of the Action Research Arm test and the Fugl-Meyer assessment scale; secondary outcomes were passive external rotation of the shoulder and general functioning measured according to Barthel Index and the Rehabilitation Activities Profile. RESULTS: -In the triamcinolone group (n=18), the median decrease in pain, 3 weeks after the last injection, was 2.3 (interquartile range, 0.3 to 4.3) versus 0.2 (interquartile range, -0.5 to 2.2) in the placebo group. This result was not statistically significant. The change in the other outcome measures did not differ significantly between the 2 treatment groups. Twenty-five patients reported side effects. CONCLUSIONS: -In the 37 participants included in this study, triamcinolone injections seemed to decrease hemiplegic shoulder pain and to accelerate recovery, but this effect was not statistically significant. Therefore, on the basis of the results of this study, these injections cannot be recommended for the treatment of patients with hemiplegic shoulder pain.
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Hemiplejía/complicaciones , Dolor de Hombro/tratamiento farmacológico , Accidente Cerebrovascular/complicaciones , Triamcinolona Acetonida/administración & dosificación , Femenino , Humanos , Inyecciones , Masculino , Persona de Mediana Edad , Dimensión del Dolor/efectos de los fármacos , Rango del Movimiento Articular/efectos de los fármacos , Dolor de Hombro/etiología , Resultado del TratamientoRESUMEN
Vaginal symptoms are frequently presented by women to general practitioners. In many cases, the aetiology of these symptoms remains unknown. This study focused on the factors associated with microbiologically unexplained vaginal symptoms, the course of symptoms and signs in these cases, and factors modifying this course. In a group of 610 women presenting to their general practitioner with vaginal symptoms (itching, irritation, abnormal but non-bloody discharge) the distribution of diagnoses was studied and factors associated with symptoms of unknown aetiology were identified using logistic regression analysis. During a three month follow up, the course of symptoms and signs was studied in 139 women with unexplained vaginal symptoms, using survival analysis methods. It was found that 25% of all the women had symptoms of unknown aetiology. A larger number of these women, compared with women with other diagnoses, were Caucasian, married, more highly educated, used oral contraceptives and reported psychological distress. During the follow-up period, a specific infection was diagnosed in less than 20% of the women with unexplained vaginal symptoms. Over half of the women (54%) recovered within three months. Short duration of symptoms before presentation was associated with a higher probability of recovery. From the study, it was found that many women visiting the general practitioner for vaginal symptoms had no demonstrable microbial disorder. Often these symptoms were transient and disappeared without intervention. Persistent symptoms may call for further examination where somatic, as well as psychosocial, factors should be taken into account.
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Enfermedades Vaginales/etiología , Adolescente , Adulto , Diagnóstico Diferencial , Medicina Familiar y Comunitaria , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Países Bajos , Estudios Prospectivos , Factores de Tiempo , Enfermedades Vaginales/diagnósticoRESUMEN
OBJECTIVE: To determine the prevalence and determinants of Chlamydia trachomatis (CT) infections among asymptomatic men and women in general practice. To determine participation rates in a systematic screening programme in general practice, using home obtained mailed urine samples. DESIGN: Cross-sectional study. METHODS: In 15 general practices in Amsterdam, the Netherlands, a sample of 11,005 persons (5541 women and 5464 men), aged 15-40 were invited to send in a urine sample and a completed questionnaire by mail. The urine samples were tested using the ligase chain reaction for DNA amplification. Patients diagnosed with CT were treated and partner notification was performed. RESULTS: 33% of invited males (1809/5464) and 50% of females (2751/5541) sent in the study material. Older patients participated more frequently than younger patients. Participation rates among persons with a Dutch background were higher than rates among persons from other ethnic groups. In 42 men and 79 women a CT infection was identified (2.3% and 2.9% respectively). Infections were more prevalent in patients from Surinam and the Dutch Antilles and in the age category 21-25 years. Type of health insurance as a proxy measure of socioeconomic status was not an indicator of infection. CONCLUSION: The participation in this systematic screening using mail-sent urine samples was 33% in men and 50% in women. The CT prevalences among asymptomatic men and women were 2.3% and 2.9% respectively.
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Infecciones por Chlamydia/diagnóstico , Chlamydia trachomatis/aislamiento & purificación , Enfermedades de los Genitales Femeninos/diagnóstico , Enfermedades de los Genitales Masculinos/diagnóstico , Tamizaje Masivo/métodos , Cooperación del Paciente/estadística & datos numéricos , Adolescente , Adulto , Distribución por Edad , Infecciones por Chlamydia/epidemiología , Infecciones por Chlamydia/orina , Estudios Transversales , Femenino , Enfermedades de los Genitales Femeninos/orina , Enfermedades de los Genitales Masculinos/orina , Encuestas Epidemiológicas , Humanos , Masculino , Tamizaje Masivo/estadística & datos numéricos , Países Bajos/epidemiología , Antillas Holandesas/etnología , Prevalencia , Distribución por Sexo , Suriname/etnologíaRESUMEN
AIM: The aim of this study was to explore which factors are associated with a successful treatment outcome in chronic pain patients and professionals participating in a multidisciplinary rehabilitation program, with a specific focus on the patient-professional interaction. METHODS: Patients (n = 16) and professionals (n = 10) were interviewed and/or observed. The transcribed interviews and observations were analyzed and themes were described. RESULTS: Patients with a positive treatment outcome came to a shared understanding of their pain with their professional, demonstrated new learned behavior and were able to continue their learning process at home. Patients with a negative treatment outcome did not reach a shared understanding of their pain with their professional, were not able to change their behavior and wanted more help to achieve this. Both patient groups experienced organizational barriers within the treatment process. Factors associated with a high quality of patient-professional interaction included the patient experience of being taken seriously, the involvement of the professional with the patient, a clear explanation of the pain, and an open interaction between patient and professional. CONCLUSION: This study provides insight into factors which were related to a positively or negatively experienced outcome of pain rehabilitation. A good match within the patient-professional interaction seems essential. IMPLICATIONS OF REHABILITATION: Within chronic pain rehabilitation good didactic skills and a client-centered attitude of the professional may be helpful in order to make the patient feel being taken seriously. An assessment of the patient's learning style might lead to a better fit of the patient education and training according to an individual's learning style. Relapse might be prevented by paying special attention to the integration of new behavior within important life areas as work and sports.
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Dolor Crónico/rehabilitación , Satisfacción del Paciente , Relaciones Profesional-Paciente , Adulto , Comunicación , Femenino , Conductas Relacionadas con la Salud , Humanos , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , MotivaciónRESUMEN
OBJECTIVE: Depression among older adults is associated with both disability and somatic disease. We aimed to further understand this complicated relationship and to study the possible modifying effect of increasing age. DESIGN: Cross sectional survey. SETTING: Outpatient and inpatient clinics of regional facilities for mental health care and primary care. PARTICIPANTS: Elderly people, 60 years and older, 378 persons meeting DSM-IV criteria for a depressive disorder and 132 non-depressed comparisons. MEASUREMENTS: Depression diagnoses were assessed with the CIDI version 2.1. Disability was assessed with the WHO Disability Assessment Schedule (WHODAS). Social-demographic information and somatic diseases were assessed by self-report measurements. RESULTS: Disability, in general and on all its subscales, was strongly related to depression. Presence of somatic disease did not contribute independently to variance in depression. The relationship was stronger for people of 60-69 years old than for those older than 70 years. Important aspects of disability that contributed to depression were disability in participation, self-care and social activities. LIMITATIONS: Results are based on cross sectional data. No inferences about causal relationships can be drawn. CONCLUSION: Disability, especially disability regarding participation, self-care, or social activities is strongly related to late-life depression. Somatic diseases in itself are less of a risk for depression, except that somatic diseases are related to disability.
Asunto(s)
Depresión/epidemiología , Trastorno Depresivo/epidemiología , Personas con Discapacidad/estadística & datos numéricos , Autocuidado , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Atención Primaria de Salud/estadística & datos numéricosRESUMEN
AIM: Drop-out of rehabilitation treatment in non-native patients with chronic low back pain has been reported to be higher than in native Dutch patients. It was expected that drop-out in non-native patients would be due to different expectations on the content of rehabilitation treatment and due to language or communication problems. Aim of this study was to determine differences in reasons for drop-out between native patients and non-native patients with chronic non-specific low back pain participating in a rehabilitation program. METHODS: A retrospective study in medical files (N.=99) of patients who dropped out of treatment was performed in two rehabilitation centers and two rehabilitation departments of general hospitals. Patient files were checked for diagnosis, status of origin, gender, age and reason for drop-out. The differences in frequency in reasons for drop-out between native and non-native patients were tested by Chi-square tests. RESULTS: Withdrawal due to different expectations on the content of rehabilitation treatment occurred significantly more frequently in non-native patients (P=0.035). Withdrawal due to refusal to participate (no further reason given) occurred more often (P=0.008) in native Dutch patients than in non-native patients. No significant differences between non-native patients and native Dutch patients were reported regarding withdrawal due to language or communication problems, and no show (patient did not show up at consultation sessions without informing about the reason and without making an appointment for a new consultation). CONCLUSION: The present study provided evidence that drop-out in non-native patients is often related to different expectations regarding the content of rehabilitation treatment.
Asunto(s)
Dolor de la Región Lumbar/rehabilitación , Pacientes Desistentes del Tratamiento/psicología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Actitud Frente a la Salud , Distribución de Chi-Cuadrado , Enfermedad Crónica , Barreras de Comunicación , Escolaridad , Femenino , Humanos , Dolor de la Región Lumbar/diagnóstico , Dolor de la Región Lumbar/psicología , Masculino , Persona de Mediana Edad , Grupos Minoritarios , Marruecos/etnología , Países Bajos/etnología , Relaciones Médico-Paciente , Estudios Retrospectivos , Suriname/etnología , Encuestas y Cuestionarios , Turquía/etnologíaRESUMEN
PURPOSE: To explore which factors lead to tension in the patient-physician interaction in the first consultation by rehabilitation physicians of patients with chronic non-specific low back pain of Turkish and Moroccan origin. METHOD: In-depth semi-structured, face to face interviews were conducted with 12 patients of Moroccan and Turkish origin and four native Dutch rehabilitation physicians. Interviews were transcribed and/or summarised. All interviews were subsequently coded and analysed according to themes. RESULTS: Factors that lead to tension in the patient-physician interaction were as follows: differences in expectations regarding the aim of treatment, symptom presentation, views on responsibilities with regard to rehabilitation treatment, lack of trust, contradicting views of physicians from patients' country of origin with regard to the cause and treatment of pain and communication problems. CONCLUSION: Sources of tension were identified during the interaction between Dutch physicians and patients of Turkish and Moroccan origin. These factors potentially are associated with future drop-out. Future research should clarify whether these factors indeed are associated with drop-out.