Process evaluation of a multidisciplinary care program for patients undergoing gynaecological surgery.

PURPOSE: This study describes the process evaluation of an innovative multidisciplinary care program for patients undergoing benign gynaecologic surgery. This care program aims at improving recovery and preventing delayed return to work and consists of two steps: (1) an interactive e-health intervention for all participants, and (2) integrated clinical and occupational care management for those participants whose sick leave exceeds 10 weeks. METHODS: Eligible for this study were employed women aged between 18-65 years scheduled for a laparoscopic adnexal surgery and/or hysterectomy. Data were collected from patients, their supervisors and their gynaecologists, by means of electronic questionnaires during a 6 month follow-up period and an automatically generated, detailed weblog of the patient web portal ( www.ikherstel.nl ). Investigated process measures included: reach, dose delivered, dose received, and fidelity. In addition, attitudes towards the intervention were explored among all stakeholders. RESULTS: 215 patients enrolled in the study and accounted to a reach of 60.2 % (215/357). All intervention group patients used their account at least once and total time spent on the patient web portal was almost 2 h for each patient (median 118 min, IQR 64-173 min). Most patients visited the website several times (median 11 times, IQR 6-16). Perceived effectiveness among patients was high (74 %). In addition, gynaecologists (76 %) and employers (61 %) were satisfied with the web portal as well. Implementation of the second step of the intervention was suboptimal. Motivating patients to consent to additional guidance and developing an accurate return-to-work-prognosis were two important obstacles. CONCLUSIONS: The results of this study indicate good feasibility for implementation on a broad scale of the e-health intervention for patients undergoing benign gynaecological surgery. To enhance the implementation of the second step of the perioperative care program, adaptations in the integrated care protocol are needed.

Methotrexate or expectant management in women with an ectopic pregnancy or pregnancy of unknown location and low serum hCG concentrations? A randomized comparison.

STUDY QUESTION: What is the treatment success rate of systemic methotrexate (MTX) compared with expectant management in women with an ectopic pregnancy or a pregnancy of unknown location (PUL) with low and plateauing serum hCG concentrations? SUMMARY ANSWER: In women with an ectopic pregnancy or a PUL and low and plateauing serum hCG concentrations, expectant management is an alternative to medical treatment with single-dose systemic MTX. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: MTX is often used in asymptomatic women with an ectopic pregnancy or a PUL with low and plateauing serum hCG concentrations. These pregnancies may be self-limiting and watchful waiting is suggested as an alternative, but evidence from RCTs is lacking. The results of this RCT show that expectant management is an alternative to treatment with systemic MTX in a single-dose regimen in these women. STUDY DESIGN, SIZE, DURATION: A multicentre RCT women were assigned to systemic MTX (single dose) treatment or expectant management, using a web-based randomization program, block randomization with stratification for hospital and serum hCG concentration (<1000 versus 1000-2000 IU/l). The primary outcome measure was an uneventful decline of serum hCG to an undetectable level (<2 IU/l) by the initial intervention strategy. Secondary outcome measures included additional treatment, side effects and serum hCG clearance time. PARTICIPANTS, SETTING, METHODS: From April 2007 to January 2012, we performed a multicentre study in The Netherlands. All haemodynamically stable women >18 years old with both an ectopic pregnancy visible on transvaginal sonography and a plateauing serum hCG concentration <1500 IU/l or with a PUL and a plateauing serum hCG concentration <2000 IU/l were eligible for the trial. MAIN RESULTS: We included 73 women of whom 41 were allocated to single-dose MTX and 32 to expectant management. There was no difference in primary treatment success rate of single-dose MTX versus expectant management, 31/41 (76%) and 19/32 (59%), respectively [relative risk (RR) 1.3 95% confidence interval (CI) 0.9-1.8]. In nine women (22%), additional MTX injections were needed, compared with nine women (28%) in whom systemic MTX was administered after initial expectant management (RR 0.8; 95% CI 0.4-1.7). One woman (2%) from the MTX group underwent surgery compared with four women (13%) in the expectant management group (RR 0.2; 95% CI 0.02-1.7), all after experiencing abdominal pain within the first week of follow-up. In the MTX group, nine women reported side effects versus none in the expectant management group. No serious adverse events were reported. Single-dose systemic MTX does not have a larger treatment effect compared with expectant management in women with an ectopic pregnancy or a PUL and low and plateauing serum hCG concentrations. WIDER IMPLICATIONS OF THE FINDINGS: Sixty percent of women after expectant management had an uneventful clinical course with steadily declining serum hCG levels without any intervention, which means that MTX, a potentially harmful drug, can be withheld in these women. BIAS, LIMITATION AND GENERALISABILITY: A limitation of this RCT is that it was an open (not placebo controlled) trial. Nevertheless, introduction of bias was probably limited by the strict criteria to be fulfilled for treatment with MTX. STUDY FUNDING: This trial is supported by a grant of the Netherlands Organization for Health Research and Development (ZonMw Clinical fellow grant 90700154). TRIAL REGISTRATION: ISRCTN 48210491.

Lessons from Holland: hospital visiting as an instrument to assess the quality of obstetric and gynecological care.

OBJECTIVE: to assess and improve the quality of hospital based obstetric and gynecological care. STUDY DESIGN: in 1991 a hospital visiting scheme by peers was launched by the Dutch Society of Obstetrics and Gynecology. The present study gives a full description of the scheme and its potential impact on the quality of obstetric and gynecological care in all of the group practices in non-teaching hospitals in the Netherlands (n=87). Comprehensive and multifaceted assessment was done in a standardised way, thereby focusing on the process of care rather than health care outcome. Following each visitation by an ad hoc visiting committee, consisting of three experienced gynecologists, the plenary visitation committee issues a formal report to the participating obstetric and gynecological centre. Apart from the condensed summary of the findings of the visiting committee during the 1 day visit, the report contains recommendations for the improvement of obstetric and gynecological care. RESULTS: problems most commonly encountered during visits were in the areas of communication. Other problem areas frequently encountered include deficient medical record keep and lack of adherence to the standards for postgraduate education. CONCLUSIONS: given the willingness of gynecologists to participate in a constructive way and their readiness to comply with the recommendations, it is concluded that formal visiting could provide an important means of improving obstetric and gynecological care in a hospital setting.

Prepregnancy care and prevention of birth defects.

Birth defects and disturbances in growth and development need an increasing attention in perinatal medicine. It is remarkable that so little attention has been paid to the pathogenesis of malformations in the literature in an approach to find aspects of prevention. Primary prevention of birth defects is an important public health issue as malformations have important consequences both for society and the individuals concerned. Prepregnancy care as a logical precursor to antenatal care, offers risk-assessment, advice and occasionally treatment before pregnancy, in order to avoid congenital malformations. It is therefore that we started a research program with emphasis on primary prevention of congenital malformations. In this respect medication, maternal nutritional status, diabetes mellitus and neural tube defects are discussed.

Effects of chronic hyperglycemia on electrocortical activity states in unanesthetized fetal lambs.

Electrocortical activity (ECoG), tracheal pressure and nuchal muscle activity were recorded in utero in 8 chronically hyperglycemic and 10 control unanesthetized fetal lambs to investigate the effects of chronic hyperglycemia on fetal electrocortical activity states. The chronically hyperglycemic state, induced by alloxan administered to the ewes, existed for at least 40 days prior to the experiments. The mean duration of episodes of high voltage (HV) ECoG was significantly increased in the hyperglycemic group (mean +/- SD: 21.8 +/- 9.2 min) compared with the control group (14.8 +/- 3.3 min), but the incidence of low voltage (LV) ECoG was not different between the groups. ECoG power spectra were not different between the groups. During LV ECoG, the proportions of time with neck movements were significantly less in the hyperglycemic than in the control group. No difference in percentages of time with long neck muscle activity was seen during the HV state in both groups. The incidence of breathing movements was equal in both groups, during HV as well as LV ECoG. No differences in breathing interval were observed.

Chronic hyperglycemia and insulin concentrations in fetal lambs.

Insulin concentrations were measured in 20 chronically instrumented fetuses of 10 sheep with alloxan-induced chronic hyperglycemia and 10 control sheep to examine if the hyperglycemia resulted in high fetal insulin concentration. Additionally, in six neonatal lambs of three chronically hyperglycemic ewes and three control sheep, insulin concentrations were measured after intravenous glucose injection. After a 2-month period of significant maternal hyperglycemia, no relationship between concentrations of fetal glucose and insulin could be detected. The mean fetal glucose concentration was 3.5 +/- 0.5 mmol/L in the hyperglycemic group and 0.6 +/- 0.1 mmol/L in the control group. Mean fetal insulin levels were 12.5 +/- 1.4 and 10.7 +/- 1.3 microU/ml, respectively. The neonatal lambs of the hyperglycemic and control ewes showed comparable concentrations of glucose and insulin after infusion of glucose. It is presumed that persistent high glucose levels depress the insulin secreting capacity of the fetal pancreas.

Alloxan-induced diabetes mellitus in pregnant sheep and chronic fetal catheterization.

25 female sheep of the Texel breed were made hyperglycaemic by administration of alloxan monohydrate (ALX) in early pregnancy and 15 ewes served as controls. Average venous glucose levels (mean +/- standard deviation) increased from 3.5 +/- 0.2 to 14.0 +/- 1.8 mmol/l. All hyperglycaemic sheep were treated with long-acting insulin in doses adjusted individually (0.2-1.0 U/kg per day) to keep glucose levels above 8 mmol/l. After a temporary significant increase, maternal venous concentrations of urea and creatinine returned to normal levels. One sheep died on day 6 after administration of ALX. Another hyperglycaemic sheep died at induction of anaesthesia. Eight hyperglycaemic ewes aborted between days 90 and 128 of gestation. Between days 103 and 135 of gestation the remaining hyperglycaemic (n = 15) and control (n = 15) ewes were operated upon and the fetuses were provided with EEG, nuchal EMG and ECG electrodes and catheters in the trachea, amniotic fluid, jugular vein and carotid artery. Use of the chronic sheep preparation for the study of diabetes mellitus and fetal reactions was successful in 10 out of 25 cases, as in the diabetic group postoperative intra-uterine fetal survival varied between 2 and 19 days and in 10 cases was at least 5 days. Postoperative intrauterine fetal survival in the controls was significantly longer and varied between 4 and 28 days, and in 13 cases was at least 5 days. A highly significant correlation (P less than 10-6) between maternal and fetal blood glucose levels was seen.(ABSTRACT TRUNCATED AT 250 WORDS)

Binding of adenosine diphosphate to human blood platelets and to isolated blood platelet membranes.

The equilibrium binding of 14C-labeled ADP to intact washed human blood platelets and to platelet membranes was investigated. With both intact platelets and platelet membranes a similar concentration dependence curve was found. It consisted of a curvilinear part below 20 microM and a rectilinear part above this concentration. At high ADP concentrations, the rectilinear part appeared to be saturable. Because of this, two classes of saturable ADP binding sites were proposed. ADP was partly converted to ATP and AMP with intact platelets while this conversion was virtually absent in isolated platelet membranes. ADP was bound to platelet membranes with the same type of curves found for intact platelets. The ADP binding to the high affinity system, which was stimulated by calcium ions, was nearly independent of temperature and had a pH optimum at 7.8. A number of agents were investigated for inhibiting properties. Of the sulfhydryl reagents only p-chloromercuribenzene sulfonate inhibited both high and low affinity binding systems while iodoacetamide and N-ethylmaleimide were without effect. Compounds acting via cyclic AMP on platelet aggregation, such as adenosine and cyclic AMP itself, had no influence on binding. Some nucleosidediphosphates and nucleotide analogs at a concentration of 100 microM had no, or only a slight, effect on high affinity ADP binding. For some other nucleotides inhibitor constants were determined for both platelet ADP aggregation and ADP binding. The inhibitor constants of ATP, adenyl-5'-yl-(beta,gamma-methylene)diphosphate, IDP, adenosine-5'(2-O-thio)diphosphate, for aggregation and high affinity binding were in good correlation with each other. Exceptions formed fluorosulfonylbenzoyl adenosine and AMP. The ATP formation found with intact platelets could be attributed to a nucleosidediphosphate kinase. It was investigated in some detail. The enzyme was magnesium dependent, had a Q10 value of 1.41, a pH optimum at 8.0, was competitively inhibited by AMP and reacted via a ping pong mechanism. All findings described in this paper indicate that platelets as well as platelet membranes bind ADP with the same characteristics and they suggest that the high affinity binding of ADP is involved in platelet aggregation induced by ADP. The results on nucleosidediphosphate kinase did not permit a firm conclusion about the role of the enzyme in induction of platelet aggregation by ADP.

Rapid separation of cytosol and particle fraction of human platelets by digitonin-induced cell damage.

Current cell disruption and fractionation techniques are time consuming and unsuitable for metabolic studies. We have developed a rapid method for platelets in which separation of cytosol and particle fraction is obtained within 50 s. Isolated platelet suspensions were incubated with low concentrations of digitonin followed by separation of soluble and particle fraction by centrifugation through a phthalate layer. Cell disruption was 90.1+/-4.2% (mean+/-SD, n=18; lactate dehydrogenase leakage). Contamination of granules: acid hydrolase vesicles 16.2+/-3.6% (n=18, beta-N-acetylglucosaminidase), dense granules 7--9% (n=3, 14C-serotonin), mitochondrial matrix 0.6+/-0.1% (n=18, glutamate dehydrogenase). Low concentrations of digitonin did not affect sialic acid content, nucleoside diphosphate kinase and phosphodiesterase activity in isolated membranes. The method showed that most enzymes of glycolysis and hexose monophosphate shunt were localized in the cytosol except for hexokinase (96% particle bound), phosphoglucose isomerase (10% bound) and glutathion reductase (26% bound). About half the total ATP+ADP and most glycolytic intermediates were found partly particle bound, especially fructose 1,6-diphosphate (40% bound). The data suggest that in platelets glycolysis occurs in different cell compartments.

Evaluation of platelet tests for measurement of cell integrity.

Various tests were evaluated for their capacity to differentiate between platelet suspensions with different degrees of cell damage. Those suspensions were prepared by simultaneous isolation of platelets from the same platelet-rich plasma (PRP) using the following procedures: 1. centrifugation at 4 degrees C with EDTA 2. gel filtration in Tangen's buffer 3. gel filtration in Ca2+-free Tyrode's soltuion 4. gel filtration in Ca2+-free Tyrode followed by dehydration against polyethylene glycol 20,000 and 5. albumin density gradient centrifugation. In these suspensions and in the original PRP the following parameters were studied: 1. morphology; 2. aggregability upon ADP addition; 3. platelet factor 3 availability; 4. uptake of 14C-serotonin and 3H-adenine; 5. metabolism of 3H-adenine and adenylate energy charge; 6. endogenous total ATP, ADP and serotonin and 7. lactate dehydrogenase (LDH) activity. Quantitation of pseudopod formation in the light or electron microscope and log dose response studies for ADP-induced aggregation proved to be the most sensitive and reproducible of the tests studied. Additional information could be obtained from measurement of the 3H-label in the ATP and hypoxanthine-inosine fractions and calculation of the adenylate energy charge. Determination of platelet factor 3 availability or uptake studies of 14C-serotonin and 3H-adenine were less suitable for discriminating between cell suspensions. Data for total ATP and serotonin concentrations and LDH activity differed between the cell suspensions but instead of detecting various degrees of cell damage they reflected alterations in platelet population caused by the isolation procedures.

Transport and metabolism of adenosine in human blood platelets.

The uptake and metabolism of [14C]- or E[3H] adenosine have been studied in suspensions of washed platelets and in platelet rich plasma. The appearance of radioactivity in the platelets and the formation of radioactive adenosine metabolites have been used to determine the uptake. Adenosine is transported into human blood platelets by two different systems: a low Km system (9.8 muM) which is competitively inhibited by papaverine, and a high Km system (9.4 mM) which is competitively inhibited by adenine. Adenosine transported via the low Km system is probably directly incorporated into adenine nucleotides, while adenosine transported through the high Km system arrives unchanged inside the platelet and is then converted into inosine and hypoxanthine or incorporated into adenine nucleotides.