Misoprostol for cervical priming prior to hysteroscopy in postmenopausal and premenopausal nulliparous women; a multicentre randomised placebo controlled trial.

OBJECTIVE: To evaluate the reduction of pain by misoprostol compared with placebo prior to hysteroscopy in postmenopausal and premenopausal nulliparous women. DESIGN: Randomised multicentre double-blind placebo controlled trial. SETTING: Two Dutch teaching hospitals and one Dutch university medical centre. POPULATION: Postmenopausal and premenopausal nulliparous women undergoing office hysteroscopy. METHODS: Patients were randomised to receive either 400 microgram misoprostol or placebo 12 and 24 hours before hysteroscopy. Pain was quantified by the use of real time pain measurement using the continuous pain score meter (CPSM) and VAS scores. MAIN OUTCOME MEASURES: Primary outcome was pain measured by the CPSM during passage of the hysteroscope through the cervical canal, quantified by the area under the curve (AUC). Secondary outcomes included VAS scores, other CPSM parameters, failures and side effects. RESULTS: In all, 149 patients were randomly assigned to either misoprostol (n = 74) or placebo (n = 75). The AUC during introduction did not significantly differ between the intervention and the placebo group. The VAS score during introduction, however, demonstrated a significant difference in premenopausal nulliparous women favouring misoprostol: 2.9 (95% CI 1.3-4.4) versus placebo 5.5 (95% CI 3.9-7.1), P = 0.02, as well as the AUC during the entire procedure: 618 (95% CI 410-827) versus 1126 (95% CI 671-1580), P = 0.04. Failures were equally distributed between the misoprostol (16%) and placebo group (13%). Intestinal side effects occurred significantly more frequently in the misoprostol group (67%) than in the placebo group (32%) [OR 4.2 (95% CI 2.1-8.3), P < 0.01]. CONCLUSION: Misoprostol prior to hysteroscopy reduces pain in premenopausal nulliparous women but not in postmenopausal women. It does cause side effects. TWEETABLE ABSTRACT: RCT: misoprostol versus placebo prior to hysteroscopy in 149 women significantly reduces some pain parameters.

[Clinical application of ROM in psychosis]. / Klinische toepassing van ROM bij psychose.

AIM: The use of 'routine outcome monitoring' (ROM) in mental health care has increased widely during the past decade. However, little is known about the use of ROM outcome in daily clinical practice. We investigated to what extent ROM results were reflected in psychotic patients' treatment plans. DESIGN: Cross-sectional study. METHOD: The ROM-Phamous, a ROM-protocol for patients with psychotic disorders in which data is collected on the basis of interviews, questionnaires and physical examination was implemented in the northern Netherlands. A random sample of 100 patients was extracted from the 2010 ROM database (n = 1040), from which we determined the prevalence of a number of problem areas. We then investigated whether these problems were reflected in patients' treatment plans. RESULTS: The sample consisted of 63 men and 37 women, with a mean age of 44 years and a mean duration of illness of 18 years. The prevalence of symptoms and psychosocial problems was 13-37%; the prevalence of cardiovascular risk factors was 11-86%. The majority of problems identified with ROM were not reflected in patients' treatment plans; the opposite also occurred: psychosocial problems, in particular, mentioned in the treatment plans were not always identified with ROM. CONCLUSION: ROM and treatment should ideally be integrated in mental-health services, but currently appear to be separate processes. If improvement of integration of ROM and clinical practice succeeds it could lead to improvement of care for psychiatric patients. Further investigation is warranted. Conflict of interest and financial support: ICMJE forms provided by the authors are available online along with the full text of this article.

Exploring the use of Routine Outcome Monitoring in the treatment of patients with a psychotic disorder.

BACKGROUND: Routine Outcome Monitoring (ROM) has become part of the treatment process in mental health care. However, studies have indicated that few clinicians in psychiatry use the outcome of ROM in their daily work. The aim of this study was to explore the degree of ROM use in clinical practice as well as the explanatory factors of this use. METHODS: In the Northern Netherlands, a ROM-protocol (ROM-Phamous) for patients with a psychotic disorder has been implemented. To establish the degree of ROM-Phamous use in clinical practice, the ROM results of patients (n=204) were compared to the treatment goals formulated in their treatment plans. To investigate factors that might influence ROM use, clinicians (n=32) were asked to fill out a questionnaire about ROM-Phamous. RESULTS: Care domains that were problematic according to the ROM-Phamous results were mentioned in the treatment plan in 28% of cases on average (range 5-45%). The use of ROM-Phamous in the treatment process varies considerably among clinicians. Most of the clinicians find ROM-Phamous both useful and important for good clinical practice. In contrast, the perceived ease-of-use is low and most clinicians report insufficient time to use ROM-Phamous. CONCLUSIONS: More frequent ROM use should be facilitated in clinicians. This could be achieved by improving the fit with clinical routines and the ease-of-use of ROM systems. It is important for all stakeholders to invest in integrating ROM in clinical practice. Eventually, this might improve the diagnostics and treatment of patients in mental health care.