Sexual Function Following Treatment for Stress Urinary Incontinence With Bulk Injection Therapy and Mid-Urethral Sling Surgery.

BACKGROUND: Peri-urethral bulking injections (PBI) gain popularity for the treatment of stress urinary incontinence (SUI), but - in contrast to mid-urethral sling (MUS) surgery - little is known about its impact on sexual function. METHODS: This was a secondary analysis of a prospective cohort study that included patients with moderate to severe SUI undergoing either MUS surgery or PBI with polydimethylsiloxane Urolastic (PDMS-U). The validated Dutch and English version of the 'Pelvic Organ Prolapse and/or Urinary Incontinence Sexual Function Questionnaire - IUGA Revised' (PISQ-IR) was used to assess sexual function at baseline, at 6 and 12 months of follow-up. For between-group analysis, differences in baseline characteristics were corrected using multivariate analysis of covariance. OUTCOMES: The primary outcome was the PISQ-IR single summary score of sexually active (SA) women following both procedures, calculated by mean calculation. Secondary outcomes were the PISQ-IR subscale scores of SA and non-sexually active (NSA) women, the proportions of sexual activity and subjective improvement ('Patient Global Impression of Improvement' (PGI-I)). RESULTS: A total of 259 women (MUS: n = 146, PBI: n = 113) were included in this study. The PISQ-IR single summary score of SA women improved following both interventions (in the MUS group from 3.2 to 3.4 and in the PBI group from 3.0 to 3.3 after 12 months). After correcting for differences in baseline characteristics, the PISQ-IR summary score at 6 and 12 months was similar for both treatment groups. For SA women, condition-specific and condition-impact subscale scores significantly improved following both procedures. CLINICAL IMPLICATIONS: In treating SUI, PBI is inferior to MUS surgery. However, there is a need for less invasive strategies, especially for women who are unfit for surgery or have contraindications. Sexual function improves after PBI using PDMS-U, which is relevant for the counselling of women with SUI about available treatment options. STRENGTHS & LIMITATIONS: Strength: until this study, there was a lack of knowledge about the effects of PBI on sexual function. LIMITATION: there may be indication bias as we did not perform a randomized controlled trial. CONCLUSION: PBI using PMDS-U and MUS surgery for the treatment of SUI improve sexual function equally in SA women, mainly by decreasing the condition's impact on sexual activity and quality. Latul YP, Casteleijn FM, Zwolsman SE, et al. Sexual Function Following Treatment for Stress Urinary Incontinence With Bulk Injection Therapy and Mid-Urethral Sling Surgery. J Sex Med 2022;19:1116-1123.

The effects of oestrogen on vaginal wound healing: A systematic review and meta-analysis.

AIMS: To determine the effects of oestrogen or oestrogen deprivation on vaginal wound healing. Impaired wound healing following prolapse surgery may increase the risk of recurrent prolapse in the future. Vaginal oestrogen therapy may improve wound healing, hereby possibly improving surgical outcomes. METHODS: A systematic search of OVID MEDLINE, OVID Embase, and Web of Science was conducted up to January 28, 2020. We included original studies comparing wound healing-related outcomes of oestrogen exposed subjects (female animals and women) to hypo-oestrogenic subjects after vaginal surgery. Data on wound healing-related outcome measures were extracted. For each individual comparison, the standardised mean difference (Hedges' g; SMD) and 95% confidence interval (CI) were calculated. RESULTS: Of the 1474 studies reviewed, 14 studies were included for review, and 11 provided data for meta-analysis. Oestrogen improves neovascularisation (SMD: 1.13, 95% CI: 0.67-1.60), microscopic wound closure (SMD: 0.98, 95% CI: 0.66-1.29), collagen synthesis (SMD: 1.08, 95% CI: 0.42-1.74), and tissue strength (SMD: 1.26, 95% CI: 0.53-1.99) in animals. Oestrogen increases granulation (SMD: 1.67, 95% CI: 0.54-2.79) and accelerates macroscopic wound closure (SMD: 1.82, 95% CI: 1.22-2.42) in women and animals. Oestrogen decreases the inflammatory response (SMD: -0.58, 95% CI: -1.14 to -0.02) in women and animals and reduces levels of transforming growth factor (TGF)-ß1 (SMD: -1.68, 95% CI: -2.52 to -0.83) in animals. All results were statistically significant. CONCLUSIONS: Oestrogen therapy has a positive effect on vaginal wound healing. Future studies should determine whether oestrogen therapy has the potential to improve surgical outcomes.

Efficacy of surgical revision of mesh complications in prolapse and urinary incontinence surgery.

INTRODUCTION AND HYPOTHESIS: Women with mesh-related complications in prolapse (POP) and stress-urinary incontinence (SUI) surgery may benefit from operative mesh resection to alleviate symptoms. We hypothesized that mesh resection would alleviate symptoms and aimed to evaluate risks and benefits in these women. METHODS: We carried out a cross-sectional study. Primary outcome was improvement specified as better, unchanged or worsened symptoms after mesh revision surgery. Secondary outcomes were health-related quality of life (HrQol) scores of validated questionnaires, surgical characteristics and physical findings at follow-up visits. Descriptive data were reported with mean and medians. Associations were calculated with Spearman correlation coefficient and chi-square test to determine statistical differences between groups. RESULTS: Fifty-nine women who underwent mesh revision surgery between 2009 and 2016 were included. After a median follow-up of 1.7 (IQR: 1.1-2.4) years, 44 women (75%) reported improvement of symptoms. No significant surgical or patient characteristics were identified that could differentiate which patients did or did not experience cure or complications.A trend was observed to better HrQol scores in women who reported overall improvement after mesh revision surgery. Seventeen (29%) women needed a subsequent operation after mesh removal. CONCLUSIONS: This cross-sectional study shows that mesh revision surgery alleviates symptoms in 75% of women with mesh-related complications. Type of revision surgery and individual characteristics did not seem to matter to the individual chance of cure or complications. These data can facilitate the counseling of women considering mesh revision surgery.

Cost-Effectiveness of perioperative Vaginally Administered estrogen in postmenopausal women undergoing prolapse surgery (EVA trial): study protocol for a multicenter double-blind randomized placebo-controlled trial.

BACKGROUND: Surgery for pelvic organ prolapse (POP) is associated with high recurrence rates. The costs associated with the treatment of recurrent POP are huge, and the burden from women who encounter recurrent POP, negatively impacts their quality of life. Estrogen therapy might improve surgical outcome for POP due to its potential beneficial effects. It is thought that vaginal estrogen therapy improves healing and long-term maintenance of connective tissue integrity. Hence, this study aims to evaluate the cost-effectiveness of perioperative vaginal estrogen therapy in postmenopausal women undergoing POP surgery. METHODS: The EVA trial is a multi-center double-blind randomized placebo-controlled trial conducted in the Netherlands comparing the effectiveness and costs-effectiveness of vaginal estrogen therapy. This will be studied in 300 postmenopausal women undergoing primary POP surgery, with a POP-Q stage of ≥ 2. After randomization, participants administer vaginal estrogen cream or placebo cream from 4 to 6 weeks preoperative until 12 months postoperative. The primary outcome is subjective improvement of POP symptoms at 1 year follow-up, measured with the Patient Global Impression of Improvement (PGI-I) scale. Secondary outcomes are POP-Q anatomy in all compartments, re-interventions, surgery related complications, general and disease specific quality of life, sexual function, signs and complaints of vaginal atrophy, vaginal pH, adverse events, costs, and adherence to treatment. Follow up is scheduled at 6 weeks, 6 months and 12 months postoperative. Data will be collected using validated questionnaires and out-patient visits including gynecological examination performed by an independent gynecologist. DISCUSSION: This study investigates whether perioperative vaginal estrogen will be cost-effective in the surgical treatment of POP in postmenopausal women. It is hypothesized that estrogen therapy will show a reduction in recurrent POP symptoms and a reduction in reoperations for POP, with subsequent improved quality of life among women and cost savings. Trial registrationNetherlands Trial Registry: NL6853; registered 19-02-2018, https://www.trialregister.nl/trial/6853 . EudraCT: 2017-003144-21; registered: 24-07-2017.

Patients' satisfaction and safety of bulk injection therapy Urolastic for treatment of stress urinary incontinence: A cross-sectional study.

AIMS: Primary outcome was to evaluate patients' satisfaction after being treated with bulk injection therapy polydimethylsiloxane Urolastic (PDMS-U) for stress urinary incontinence (SUI). Secondary outcomes were: subjective cure, objective cure, severity of SUI symptoms, complications, reintervention rate, and disease-specific quality of life. Furthermore, to determine if outcomes worsened during time-after-treatment (time-frames: 0-12, 13-24, and ≥25 months). METHODS: In a cross-sectional design, patients treated with PDMS-U were recruited for hospital revisit. The primary outcome, patients' satisfaction, was assessed by the surgical satisfaction questionnaire. Subjective cure, objective cure, and severity of symptoms were assessed by the patients global impression of improvement, standardized cough stress test, and Sandvik severity scale, respectively. Medical charts and face-to-face interviews were used to determine complications and reinterventions. RESULTS: About 110 patients participated, 87 revisited the hospital. Median follow-up was 25 months (interquartile range: 14;35 months). Patients' satisfaction rate was 51%. Subjective and objective cure were respectively 46% and 47%. Most prevalent complications were: urinary retention (22%), pain (15%), and dyspareunia (15%). Exposure and erosion occurred in 7% and 5%, respectively. Reintervention rate of reinjection and excision of bulk material was 6% and 18.0%, respectively. Objective cure significantly worsened during time-after-treatment (P = < .05). CONCLUSIONS: About half of the patients being treated with PDMS-U were satisfied and subjectively cured 2 years after treatment, although the majority still experienced symptoms of SUI. Most complications were mild and transient, however, in 18% excision of bulk material was indicated for severe or persistent complications such as pain, exposure, or erosion.

How cure rates drive patients' preference for urethral bulking agent or mid-urethral sling surgery as therapy for stress urinary incontinence.

AIMS: To assess the patients' median-accepted threshold of cure rate for urethral bulking agent (UBA) treatment compared to mid-urethral sling (MUS) surgery for treatment of female stress urinary incontinence (SUI). Secondly, to determine the correlation between treatment trade-off point and patient characteristics. METHODS: Women older than 18 years, with predominant SUI, seeking treatment, underwent a structured interview. The treatment trade-off point was determined in scenario one: UBA vs transobturator standard MUS surgery (SMUS) performed under general/spinal anesthesia with one-night hospital stay, and scenario 2: UBA compared to single-incision MUS surgery (SIMS) performed under local analgesia (with sedation) in a daycare setting. The treatment trade-off point was assessed by decreasing the cure rate of UBA from 85% to 10% with steps of 2% until the patient's treatment preference switched to SMUS/SIMS. RESULTS: One hundred and five patients were interviewed. Mean age was 52 years (SD, ±13.4). The median trade-off point for scenarios 1 and 2 was 79% (interquartile range [IQR]: 69, 85) and 85% (IQR: 71, 85), respectively. Patients with longer duration of SUI symptoms were willing to trade more efficacy to prefer UBA treatment. CONCLUSIONS: Patients with SUI are willing to trade a lower cure rate to prefer UBA over SMUS to avoid hospitalization and general anesthesia. When SIMS is performed in a daycare setting under local analgesia, the majority of patients with SUI are of the opinion that cure rates of UBA should be at least as high as SIMS to be worth considering. The treatment preference is not strongly correlated with the patients' characteristics.

Stress urinary incontinence after vaginal prolapse repair: development and internal validation of a prediction model with and without the stress test.

OBJECTIVE: To develop a prediction model for stress urinary incontinence (SUI) after vaginal prolapse repair (postoperative stress urinary incontinence [POSUI]) and assess the value of a preoperative stress test. PATIENTS AND METHODS: Secondary analysis of two trials in which women were randomised for prolapse repair with or without a midurethral sling (MUS). The trials included women with (CUPIDO-1, n = 134) and without (CUPIDO-2, n = 225) coexisting SUI. POSUI was defined as bothersome SUI one year after surgery and/or treatment of SUI in the first postoperative year. Logistic regression analysis was used to define a reference model, which was extended with the preoperative stress test. The stress test was performed with and without reduction of the prolapse. Missing values were imputed 20 times, with bootstrap resampling for internal validation of discriminatory ability. RESULTS: Three hundred fifty-six women could be included. POSUI occurred in 17% of the women (n = 61). The reference model included age (<55 years), point Ba of the pelvic organ prolapse quantification system (<-1), vaginal parity (≤3), subjective urinary incontinence, and MUS. The stress test had an odds ratio of 2.4 (95% confidence interval [CI], 1.2-4.6) in the extended model, which increased the optimism-corrected area under the receiver-operating curve from 0.74 to 0.76. The stress test was especially valuable in women with a 10% to 30% POSUI risk, where a stress test substantially impacted the POSUI risk. In more than 50% of the women, the stress test had no additional value in predicting POSUI. CONCLUSION: A preoperative stress test is not valuable for women at low risk of SUI after vaginal prolapse repair.

Results of an innovative bulking agent in patients with stress urinary incontinence who are not optimal candidates for mid-urethral sling surgery.

AIMS: To assess the efficacy and safety of peri-urethral bulking injections (PBI) with an innovative bulking material (PDMS-U) in women with stress-urinary incontinence (SUI) who are not optimal candidates for mid-urethral sling surgery. METHODS: A prospective study was performed in women with SUI who, for several reasons, have a relative contraindication for a mid-urethral sling procedure. These reasons include: (i) recurrent SUI after a prior SUI surgical procedure; (ii) a history of oncologic gynaecological surgery; (iii) a history of neurologic disease resulting in voiding problems; (iv) a maximal flow rate of less than 15 mL per second or; (v) women with a contraindication for surgery with general or regional anaesthesia. All women were treated with PBI consisting of PDMS-U, a bulking agent that polymerizes in situ. The primary outcome was subjective improvement, defined as "a little better" to "very much better" on the PGI-I. Secondary outcomes included objective cure, disease specific quality of life and adverse events. RESULTS: Subjective improvement was reported by 18 (90%) of the 20 included patients. The subjective cure rate was 56% and the objective cure rate was 65%. There was a statistically significant improvement of all domain scores of the UDI-6, IIQ-7, and PISQ-12 at 6 months follow up. Abnormal post voiding residual volume (>150 mL) was the most common adverse event (40%), but persisted in only one patient, based on the patient's preference for a catheter. CONCLUSIONS: PBI with PDMS-U is a viable treatment option in women with a relative contra-indication for mid-urethral sling surgery.

The predictive value of demonstrable stress incontinence during basic office evaluation and urodynamics in women without symptomatic urinary incontinence undergoing vaginal prolapse surgery.

AIMS: Women with pelvic organ prolapse without symptoms of urinary incontinence (UI) might demonstrate stress urinary incontinence (SUI) with or without prolapse reduction. We aimed to determine the value of demonstrable SUI during basic office evaluation or urodynamics in predicting SUI after vaginal prolapse repair in these women. METHODS: Women included in the CUPIDO trials without bothersome UI or UI more than once a week were eligible if they had undergone prolapse repair without incontinence surgery. The diagnostic and predictive value of demonstrable SUI was studied for postoperative SUI (POSUI). POSUI was defined as bothersome SUI at 1-year follow-up or treatment for SUI in the first postoperative year. RESULTS: In 45% (77/173) of the included women urodynamics was performed. In 19% (32/172) SUI was demonstrated with basic office evaluation, against 29% (22/77) with urodynamics. Nine percent (16/172) developed POSUI, six women underwent surgery for de novo SUI. Women with demonstrable SUI were more at risk to face POSUI: twenty-eight percent versus five percent (Diagnostic Odds Ratio: 7; 95%CI 3-22). Urodynamics predicted one more woman having POSUI, but all women who underwent treatment for de novo SUI showed SUI during basic office evaluation. Test performance did not improved with the adding of urodynamics. CONCLUSIONS: The predictive value of demonstrable SUI in symptomatically continent women undergoing vaginal prolapse repair is limited. Urodynamics added no value. The twenty-eight percent POSUI risk must be balanced against the increased complication risk if a prophylactic midurethral sling is considered.

Patients' perspectives on urethral bulk injection therapy and mid-urethral sling surgery for stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to identify all treatment decision factors that determined the preference for peri-urethral bulk injection therapy (PBI) or mid-urethral sling (MUS) surgery in patients with primary stress urinary incontinence (SUI). Second, we explored what patients expect from treatment for SUI and whether patients would consider PBI as a primary treatment option. METHODS: In a qualitative design, 20 semi-structured, face-to-face interviews were conducted in women with primary SUI. Exclusion criteria were: previous PBI or MUS surgery; predominating urgency. Interviews were guided by three open-ended questions and a topic list. PBI treatment and MUS surgery were described in detail, and the efficacy was stated as 70% and 90%, respectively. Data saturation was reached when no new treatment decision factors were identified in three consecutive interviews. Interviews were audiotaped and fully transcribed. Thematic analysis by a coding process was done independently by two researchers. RESULTS: Sixteen procedural, personal, professional, social and external treatment decision factors were identified. Regarding expectations about treatment for SUI, women believed 'becoming dry' was wishful thinking. The majority of patients accepted a small degree of persistent urinary incontinence after treatment. Regardless of their treatment preference, patients indicated that women should be informed about PBI as a primary treatment option. CONCLUSION: Patients with primary SUI are open to PBI as an alternative treatment option even with lower cure rates compared with MUS surgery performed under general or spinal anesthesia. Patients indicated that women with primary SUI seeking treatment should be informed about PBI as a treatment option.

A randomized, nonblinded extension study of single-incision versus transobturator midurethral sling in women with stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Midurethral sling procedures are the first surgical option in women undergoing surgery for stress urinary incontinence (SUI). Single-incision midurethral-slings (SIMS) were designed to provide similar efficacy to traditional midurethral slings but with reduced morbidity. In this international trial we compared the efficacy of a SIMS (MiniArc) and a transobturator standard midurethral sling (SMUS; Monarc) in the treatment of SUI in terms of subjective and objective cure rates and morbidity over a long-term follow-up. METHODS: This was a randomized controlled nonblinded extended trial with a follow-up period of 36 months. Women with symptomatic SUI were eligible. The primary outcome was subjective cure, defined as an improvement in the Patient Global Impression of Improvement (PGI-I) score. Secondary outcomes were objective cure (negative cough stress test), disease-specific quality of life, surgical parameters and morbidity. An intention to treat analysis was performed. Differences in dichotomous variables were tested using the chi-squared test. Differences in continuous variables were tested using Student's t test or the Mann-Whitney U test. We hypothesized that MiniArc would be noninferior to Monarc concerning subjective cure. RESULTS: We randomized 97 women to the MiniArc group and 96 to the Monarc group. The attrition rate was 23% in the MiniArc group and 22% in the Monarc group after 3 years. At 36 months, the subjective cure rates were 86% in the MiniArc group and 87% in the Monarc group (risk difference -0.6%, 95% CI -12 to 11%). The objective cure rates were 89% and 88%, respectively (risk difference 1.3%, 95% CI -9 to 11%). Both procedures were associated with low complication rates. CONCLUSIONS: After a follow-up of 36 months, MiniArc (SIMS) is non-inferior to Monarc (SMUS) with respect to subjective and objective cure.

Tools to assess evidence-based practice behaviour among healthcare professionals.

OBJECTIVE: To identify and compare tools to assess Evidence-Based Practice (EBP) behaviour among healthcare professionals. DESIGN: Systematic review. DATA SOURCES: MEDLINE, EMBASE, Cochrane Library, PsychInfo and CINAHL up to July 2011. STUDY SELECTION: Titles, abstracts and eligible full text articles were screened by two reviewers independently. DATA EXTRACTION: Relevant data were extracted by one reviewer and checked by a second reviewer. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: original studies among all healthcare professionals that described the development or use of EBP behaviour assessment tools. RESULTS: Of 19 310 identified articles, 172 studies were included. We identified 117 questionnaires, 10 interviews or focus groups, nine observational studies, 27 chart evaluations and nine studies used a combination of methods. Psychometric properties of the questionnaires used were reported in about half of the studies, in seven studies that assess a single EBM step and in six studies that assess a combination of EBM steps. One of these assessed all five steps of EBP. CONCLUSIONS: Valid and reliable EBP behaviour assessment tools are available. However, only one questionnaire validly assessed all five EBP steps, covering the entire concept of EBP.

Sicily statement on classification and development of evidence-based practice learning assessment tools.

BACKGROUND: Teaching the steps of evidence-based practice (EBP) has become standard curriculum for health professions at both student and professional levels. Determining the best methods for evaluating EBP learning is hampered by a dearth of valid and practical assessment tools and by the absence of guidelines for classifying the purpose of those that exist. Conceived and developed by delegates of the Fifth International Conference of Evidence-Based Health Care Teachers and Developers, the aim of this statement is to provide guidance for purposeful classification and development of tools to assess EBP learning. DISCUSSION: This paper identifies key principles for designing EBP learning assessment tools, recommends a common taxonomy for new and existing tools, and presents the Classification Rubric for EBP Assessment Tools in Education (CREATE) framework for classifying such tools. Recommendations are provided for developers of EBP learning assessments and priorities are suggested for the types of assessments that are needed. Examples place existing EBP assessments into the CREATE framework to demonstrate how a common taxonomy might facilitate purposeful development and use of EBP learning assessment tools. SUMMARY: The widespread adoption of EBP into professional education requires valid and reliable measures of learning. Limited tools exist with established psychometrics. This international consensus statement strives to provide direction for developers of new EBP learning assessment tools and a framework for classifying the purposes of such tools.

How learning style affects evidence-based medicine: a survey study.

BACKGROUND: Learning styles determine how people manage new information. Evidence-based medicine (EBM) involves the management of information in clinical practice. As a consequence, the way in which a person uses EBM can be related to his or her learning style. In order to tailor EBM education to the individual learner, this study aims to determine whether there is a relationship between an individual's learning style and EBM competence (knowledge/skills, attitude, behaviour). METHODS: In 2008, we conducted a survey among 140 novice GP trainees in order to assess their EBM competence and learning styles (Accommodator, Diverger, Assimilator, Converger, or mixed learning style). RESULTS: The trainees' EBM knowledge/skills (scale 0-15; mean 6.8; 95%CI 6.4-7.2) were adequate and their attitudes towards EBM (scale 0-100; mean 63; 95%CI 61.3-64.3) were positive. We found no relationship between their knowledge/skills or attitudes and their learning styles (p = 0.21; p = 0.19). Of the trainees, 40% used guidelines to answer clinical questions and 55% agreed that the use of guidelines is the most appropriate way of applying EBM in general practice. Trainees preferred using evidence from summaries to using evidence from single studies. There were no differences in medical decision-making or in EBM use (p = 0.59) for the various learning styles. However, we did find a link between having an Accommodating or Converging learning style and making greater use of intuition. Moreover, trainees with different learning styles expressed different ideas about the optimal use of EBM in primary care. CONCLUSIONS: We found that EBM knowledge/skills and EBM attitudes did not differ with respect to the learning styles of GP trainees. However, we did find differences relating to the use of intuition and the trainees' ideas regarding the use of evidence in decision-making.

Validation of noninvasive focal depth measurements to determine epithelial thickness of the vaginal wall.

OBJECTIVE: This study investigates whether noninvasive focal depth (FD) measurements correlate with vaginal wall epithelial thickness (ET). If FD accurately reflects ET of the vaginal wall, this would allow noninvasive longitudinal assessment of (newly developed) treatment modalities aiming to increase ET, without the need for invasive biopsies. METHODS: Fourteen women, median age 62 years (inter quartile ranges: 57-65), undergoing vaginal prolapse surgery because of anterior and/or posterior compartment pelvic organ prolapse were included. We used the CytoCam, a handheld video microscope based on incident dark field imaging, and performed FD measurements of the vaginal wall before surgery. Histology was performed on tissue that was removed during the surgical procedure, and ET was measured in stained sections. We compared ET with FD interindividually, and determined the expected linear correlation and agreement between the two measurements. RESULTS: Seventeen ET measurements (mean 125 µm ±â€Š38.7, range 48-181 µm) were compared with 17 FD measurements (mean 128 µm ±â€Š34.3, range 68-182 µm). The lineair correlation between the two measurements was strong (r = 0.902, P < 0.01). Bland-Altman analysis demonstrated a mean difference of 13.5 µm when comparing ET to FD. CONCLUSIONS: The results demonstrate good agreement between ET and FD measurements. We consider the mean difference demonstrated with Bland-Altman analysis acceptable for these measurements. This suggests that FD accurately reflects ET, which further supports the use of FD to measure ET of the vaginal wall. For a complete assessment of the vaginal wall, FD measurements are preferably combined with the assessment of vaginal angioarchitecture.

Patient Preferences and Experiences in Hyperemesis Gravidarum Treatment: A Qualitative Study.

INTRODUCTION: Hyperemesis gravidarum (HG) medical therapies are currently of limited effect, which creates a larger role for patient preferences in the way HG care is arranged. This is the first study using in-depth interviews to investigate patients' preferences and experiences of HG treatment. MATERIALS AND METHODS: We conducted individual in-depth interviews among women who had been hospitalized for HG in North Holland at least once in the past 4 years. We asked them about their experiences, preferences, and suggestions for improvement regarding the HG treatment they received. The sample size was determined by reaching data saturation. Themes were identified from analysis of the interview transcripts. RESULTS AND DISCUSSION: 13 women were interviewed. Interviewees emphasized the importance of early recognition of the severity of HG, increasing caregivers' knowledge on HG, early medical intervention, and nasogastric tube feeding. They valued a single room in hospital, discussion of treatment options, more possibilities of home-treatment, psychological support during HG and after childbirth, and more uniform information and policies regarding HG treatment. CONCLUSION: Further research is needed to establish whether the suggestions can lead to more (cost) effective care and improve the course of HG and outcomes for HG patients and their children.

Observations of evidence-based medicine in general practice.

No objective measures are available for assessing the practice of evidence-based medicine (EBM) in general practitioner (GP) trainees, as there is no description of the EBM behaviour that is expected from trainees. As a first step to do so, we aimed to identify which expressions of EBM (defined as the integration of evidence, clinical experience and patient situation) can be observed in daily GP practice. Secondly, we aimed to identify which considerations GPs had regarding EBM but did not share with the patient during consultations. We performed a qualitative study, in which GPs were observed during and interviewed after clinical consultations, with a focus on expressions and considerations related to EBM during clinical decision-making. We observed 147 consultations by 34 GPs (17 trainers and 17 trainees). EBM behaviour was rarely visible in GPs' decision-making. When interviewing the GPs, we found that aspects of EBM that played a role in decision-making were not discussed with the patient. Explicit consideration of all aspects of EBM would make EBM measurable and GPs more aware of the foundations of their decisions. EBM behaviour is difficult to observe during GP consultations and therefore cannot be assessed through observations alone.

Barriers to the use of evidence-based medicine: knowledge and skills, attitude, and external factors.

Although efforts are made to integrate evidence-based medicine (EBM) into clinical practice, physicians experience significant barriers to its implementation. The aim of this study is to quantify the barriers that general practice (GP) trainees experience when using EBM in practice. In September 2008, a questionnaire was administered to 140 GP trainees from three Dutch GP Speciality Training Institutes. The questionnaire focused on barriers that GP trainees meet when using EBM in practice. Factor analysis identified components in which barriers exist, and the validity and reliability of the questionnaire were established. After removing four items that did not fit the questionnaire structure, factor analysis identified three relevant components. All three components had similar mean scores, indicating a similar negative influence of these components on the practice of EBM: knowledge/skills (α = 0.72, mean score 2.9 ± 0.8), attitude (α = 0.70, mean score 2.9 ± 0.6), and external factors (α = 0.66, mean score 3.0 ± 0.5). The barrier that trainees experienced most was lack of time to practise EBM. Barriers to the use of EBM were present in three components: knowledge/skills, attitude, and external factors.