How is your health in general? A qualitative study on self-assessed health.

BACKGROUND: The single-item measure on self-assessed health has been widely used, as it presents researchers with a summary of an individual's general state of health. A qualitative study was initiated to find out which particular aspects are included in health self-assessments; which aspects do people consider when answering the question 'How is your health in general?'. Subgroup differences were studied with respect to gender, age, health status and health assessment. METHODS: Qualitative study with stratification by background characteristic, health status and health assessment (n=40). RESULTS: Almost 80% of the participants referred to one or more physical aspects (chronic illness, physical problems, medical treatment, age-related complaints, prognosis, bodily mechanics, and resilience). However, when assessing their health, participants also include aspects that go beyond the physical dimension of health. In total, 80 percent of the participants-whether or not in addition to physical aspects-referred to other health dimensions. Besides physical aspects, participants considered the extent to which they are able to perform (functional dimension -28%), the extent to which they adapted to, or their attitude towards an existing illness (coping dimension -28%), and simply the way they feel (wellbeing dimension -20%). In this study, health behaviour or lifestyle factors (behavioural dimension -3%) proved to be relatively unimportant in health self-assessments. CONCLUSIONS: Self-assessed health proved to be a multidimensional concept. For most part, subgroup differences in self-assessed health could be attributed to experience with ill health: being relatively inexperienced with health problems versus having a history of health problems.

Patients with multiple sclerosis prefer early diagnosis.

The new diagnostic criteria for multiple sclerosis (MS) allow for a definite diagnosis in earlier stages of the disease. Yet, clinicians may hesitate to pursue a diagnosis of multiple sclerosis at the presentation of first symptoms because they consider an early diagnosis of limited benefit to patients. It is unknown whether patients themselves prefer to be informed in an early phase. We studied satisfaction with the timing of diagnosis in patients recently diagnosed with MS and found that 75% was satisfied, 24% favoured an earlier, and only 6% a later disclosure of the diagnosis. Patients who preferred an earlier diagnosis had a significantly longer interval between their first visit to the neurologist and the disclosure of diagnosis (P < 0.001). The probability that the patient was satisfied with the timing of diagnosis did not substantially decrease in the months following the first visit to the neurologist, leaving ample opportunity for a thorough evaluation of the early clinical course. We conclude that patients with MS prefer an early diagnosis.

Impact of recently diagnosed multiple sclerosis on quality of life, anxiety, depression and distress of patients and partners.

OBJECTIVES: Studies demonstrating reduced quality of life and psychological well-being in multiple sclerosis (MS) have typically investigated patients within more advanced stages of disease. The aim of the present paper was to evaluate the emotional burden and quality of life of recently diagnosed MS patients and their partners. METHODS: Data on health-related quality of life (SF-36), anxiety and depression (Hospital Anxiety and Depression Scale) and disease-related distress (Impact of Event Scale) were obtained in 101 patients and their partners (n=78). RESULTS: On average 8 months after diagnosis (range 0-24 months), 34% of the patients and 40% of the partners had clinically high levels of anxiety, and 36% of the patients and 24% of the partners had levels of severe distress. Scores of anxiety, depression and distress were higher in patients with more functional limitations (Expanded Disability Status Scale=3.0). Quality of life was significantly poorer in patients compared with controls, particularly among those with higher disability. CONCLUSIONS: Both patients and their partners demonstrated high levels of anxiety and distress in the early period after the diagnosis. These findings indicate careful attention by health care professionals to identify those who may benefit from further psychological support.

Anxiety and depression influence the relation between disability status and quality of life in multiple sclerosis.

Disability status, depression and anxiety are important determinants of quality of life (QoL) in patients with multiple sclerosis (MS). We investigated whether anxiety and depression influence the relation between disability status and QoL in our cohort of recently diagnosed patients. Disability status [Expanded Disability Status Scale (EDSS)], anxiety and depression [Hospital Anxiety and Depression Scale (HADS)], and QoL (SF-36) were prospectively obtained in 101 MS patients. The relation between EDSS and SF-36 scales was examined using regression analyses, without and with adjustment for anxiety and depression. Interaction effects were investigated by comparing the relation between EDSS and QoL in patients with high and low anxiety and depression. In the unadjusted analyses, EDSS was significantly related to all SF-36 physical and mental health scales. After adjustment for anxiety and depression, EDSS was significantly related only to the SF-36 physical functioning, role-physical functioning and bodily pain scales. The relation between EDSS and these SF-36 scales was consistently higher in patients with more symptoms of anxiety or depression, suggesting that anxiety and depression strengthened the association of EDSS in these SF-36 physical health scales. After adjustment for anxiety and depression, EDSS was not significantly related to the SF-36 mental health scales and the general health scale. This finding is compatible with the hypothesis that anxiety and depression are intermediate factors in the association of EDSS with these SF-36 scales. Screening for symptoms of anxiety and depression is recommended in studies that use QoL as an outcome measure of treatment or intervention efficacy.

Expectations of wheelchair-dependency in recently diagnosed patients with multiple sclerosis and their partners.

The aim of the present paper was to quantify expectations of wheelchair-dependency in patients recently diagnosed with MS (n = 101) and their partners (n = 78). Expectations focused on the risk and seriousness of becoming wheelchair-dependent in 2 years, 10 years or lifetime. Expectations were compared with natural history data, compared between patients and their partners, and related to clinical characteristics. Our results show that patients overestimated their 2-year and 10-year risks of wheelchair-dependency, but underestimated their lifetime risks. A large number of patients were uncertain about their 2-year risk, even those with no or only minimal disability [Expanded Disability Status Scale (EDSS) <3.0]. One-third of the patients perceived the 10-year and lifetime risk to be 50%, which, as they explained in the interviews, reflected their uncertainty: they did not know what to expect - it might happen or not. Patients with more functional limitations had higher perceptions of risk, but lower perceptions of seriousness. Concordance in perceived risk and seriousness between patients and partners was moderate. The overestimation of the short-term risks and the substantial differences in expectations within couples warrant further research on the impact of expectations on their treatment decisions and psychological well-being.

The association between physiological and behavioral pain measures in 0- to 3-year-old infants after major surgery.

To estimate the association between behavioral and physiological pain measures and to identify determinants predicting the level of association, the COMFORT 'behavior' scale, heart rate (HR), mean arterial pressure (MAP), and the variability of HR and MAP (HRV and MAPV) were assessed every 3 hours after major abdominal or thoracic surgery. Subjects were 204 infants aged 0-3 years. The within-subject correlations, using the repeated measures, were 0.37, 0.44, 0.48, and 0.49 for COMFORT 'behavior' with HRV, HR, MAP, and MAPV, respectively. Neonates had lower behavior-physiology correlations than the older infants, due to low pain scores. Pain characteristics significantly predicted the COMFORT 'behavior'-HR/MAP correlations, suggesting that the behavior-physiology correlations increase with increasing pain. The behavior-physiology correlations were not greatly affected by physical condition. These data demonstrate large interindividual differences in behavior-physiology correlations after major surgery in 0- to 3-year-old infants. These differences should be further explored in future research.

A psychometric comparison of health-related quality of life measures in chronic liver disease.

Four generic [the Sickness Impact Profile (SIP-68), Short-Form Health Survey (SF-36), EuroQol instrument (EQ-5D), COOP/WONCA charts], two domain-specific health-related quality of life measures [the sexuality scale of the HIV Overview Problems Evaluating System (HOPES), Multi-dimensional Fatigue Index (MFI-20)], and a self-developed 12-item symptom index were compared in terms of feasibility, test-retest reliability, internal consistency reliability, construct validity, and known groups validity in patients with chronic liver disease. All instruments could be completed within 10 min and exhibited a good psychometric performance in patients with chronic liver disease. The SF-36 and the MFI-20 performed relatively best in terms of reliability, construct validity, and discriminative ability. The sexuality scale of the HOPES demonstrated a relatively poor performance, as the missing value rate was higher than 5%. Further research is needed into the sensitivity to important clinical changes of the instruments.

Which chronic conditions are associated with better or poorer quality of life?

The objective of the present study is to compare the QL of a wide range of chronic disease patients. Secondary analysis of eight existing data sets, including over 15,000 patients, was performed. The studies were conducted between 1993 and 1996 and included population-based samples, referred samples, consecutive samples, and/or consecutive samples. The SF-36 or SF-24 were employed as generic QL instruments. Patients who were older, female, had a low level of education, were not living with a partner, and had at least one comorbid condition, in general, reported the poorest level of QL. On the basis of rank ordering across the QL dimensions, three broad categories could be distinguished. Urogenital conditions, hearing impairments, psychiatric disorders, and dermatologic conditions were found to result in relatively favorable functioning. A group of disease clusters assuming an intermediate position encompassed cardiovascular conditions, cancer, endocrinologic conditions, visual impairments, and chronic respiratory diseases. Gastrointestinal conditions, cerebrovascular/neurologic conditions, renal diseases, and musculoskeletal conditions led to the most adverse sequelae. This categorization reflects the combined result of the diseases and comorbid conditions. If these results are replicated and validated in future studies, they can be considered in addition to information on the prevalence of the diseases, potential benefits of care, and current disease-specific expenditures. This combined information will help to better plan and allocate resources for research, training, and health care.

The reliability and validity of the COMFORT scale as a postoperative pain instrument in 0 to 3-year-old infants.

The aim of this study was to test the reliability and validity of the COMFORT scale as a postoperative pain instrument for children aged 0-3 years. Subjects were 158 neonates and toddlers after major abdominal or thoracic surgery. Trained nurses rated the children's pain at 3, 6 and 9 h postoperative on the Pediatric Surgical Intensive Care Unit using the COMFORT and a VAS for pain. Interrater reliability of the COMFORT items proved to be good (Kappa 0.63-0.93) for all items with the exception of the item 'Respiratory response', which was moderate (Kappa 0.54). LISREL analyses showed that the structure of the COMFORT data was best represented by three latent variables: COMFORT 'behaviour' with loadings from the behavioural items (Alertness, Calmness, Respiratory response/Crying, Physical movement, Muscle tone and Facial tension) and separate latent variables for 'Heart rate baseline' (HR) and 'Mean arterial blood pressure baseline' (MAP). Factor loadings of the items were invariant across time, indicating stability of the structure. The latent variables COMFORT 'behaviour' and VAS pain were highly interrelated indicating congruent validity. Stability of COMFORT 'behaviour' and VAS pain was moderate which might be due to varying painful episodes in this sample. HR and MAP, although stable across time, were weakly related to VAS pain and COMFORT 'behaviour'. These findings support the use of the COMFORT 'behaviour' scale to assess postoperative pain in neonates and infants.

Impact of diarrhoea and faecal incontinence on the daily life of HIV-infected patients.

Diarrhoea in HIV-1 infected persons is an important clinical problem. To improve care and counselling, information about the way, and the extent to which, diarrhoea influences the daily life of these patients can be useful. A cross-sectional descriptive study was performed at the HIV infection clinic of three major hospitals in Amsterdam. A diary, the Coates card system (to determine the relative severity of the symptoms) and an interview were used as outcome measures. Sixty-two patients participated and were classified into four groups: group 1 (minor diarrhoea, n = 26), group 2 (mild diarrhoea, n = 18), group 3 (moderate diarrhoea, n = 7) and group 4 (severe diarrhoea, n = 11). Diarrhoea was considered a very severe symptom in groups 2, 3 and 4. Even mild diarrhoea may have a debilitating impact on the day-to-day life of HIV-infected patients. Faecal incontinence occurs frequently. Patients can worry about their diarrhoea because of lack of information. Patients who do not have diarrhoea according to current definitions of it, consider diarrhoea to be equally problematic as those with (moderate) diarrhoea. More information on prognosis and practical solutions for patients are recommended.

A study of the reliability, validity and responsiveness of the HIV overview of problems evaluation system (HOPES) in assessing the quality of life of patients with AIDS and symptomatic HIV infection.

The objective of this study was to evaluate the feasibility, reliability, validity and responsiveness of the HIV Overview of Problems Evaluation System (HOPES) in a Dutch sample. The HOPES was administered three times in a one-year period to a sample of 106 outpatients with a symptomatic HIV-infection (n = 23) or AIDS (n = 83). The HOPES is a self-report HIV-specific quality of life (QOL) questionnaire including five scales: physical, psycho-social and sexual functioning, medical interaction and partner relationship. QOL was also assessed with the EORTC Quality of Life Questionnaire (EORTC QLQ-C30), a 30-item self-report instrument. Clinical data included Centers for Disease Control and Prevention (CDC) stage, date of diagnosis and CD4 cell count. Patients needed approximately 20-30 minutes to complete the questionnaire. The five scales had good internal consistency reliability. Multitrait scaling analysis provided moderate support for item discriminant and convergent validity. The HOPES exhibited adequate levels of construct validity: (1) the inter-scale correlations and correlations with the EORTC QLQ-C30 were in the predicted direction; (2) it discriminated clearly between patients with AIDS and ARC and (3) it was able to document changes in QOL over time. Moreover, the HOPES was responsive to changes in clinical status over time as indicated by CD4 counts. This study provides further evidence of the reliability and validity of the HOPES and shows that this instrument is responsive to changes in CD4 cell counts.

Health-related quality-of-life evaluation in HIV-infected patients. A review of the literature.

This article presents a review of the literature on health-related quality-of-life (HRQOL) measurements in HIV-infected patients by means of multidimensional self-report questionnaires. Since 1989, 11 HRQOL instruments have been used, the most frequently employed scales and items being derived from the Medical Outcomes Study. The 9 instruments that were evaluated for their internal consistency reliability and validity generally met the conventional levels of psychometric performance. Descriptive longitudinal and psychometric studies that examined the ability of HRQOL instruments to distinguish between diagnostic groups consistently showed that, over time, patients developed more symptoms and reported poorer physical, role and sexual functioning. Patients' psychological functioning improved or remained at approximately the same level. Despite some methodological limitations, the 4 HRQOL studies performed as part of clinical trials provided valuable information for both patients and doctors about the impact of treatment with zidovudine, interferon-alpha or epoetin (recombinant human erythropoietin) on patients' HRQOL. Future studies are needed that provide more information on the feasibility, stability and responsiveness of existing HRQOL instruments. In addition, future studies should focus on the natural history of HRQOL in HIV-infected patients, and on the impact of commonly prescribed prophylactic and antiretroviral drugs on patients' HRQOL. There is an urgent need for translations and cultural adaptations of HRQOL instruments for use in different HIV-infected populations, including women, children, intravenous drug users and patients from African and other developing countries.

Zidovudine and interferon-alpha combination therapy versus zidovudine monotherapy in subjects with symptomatic human immunodeficiency virus type 1 infection.

Forty-five subjects with symptomatic human immunodeficiency virus type 1 (HIV-1) infection, CD4+ lymphocyte counts of > or = 150 x 10(6)/L, and Karnofsky scores > or = 60 were enrolled in a multicenter, randomized, controlled trial that compared zidovudine monotherapy and combination therapy for 48 weeks with zidovudine and interferon-alpha (IFN-alpha). Zidovudine with IFN-alpha (n = 25) had a favorable effect on CD4+ cell counts compared with zidovudine alone (n = 20). At all time points analyzed, the mean change from baseline was higher, reaching significance at week 24 (+10% versus -21%; P = .029). At week 48 the difference was -12% versus -45% (P = .07). Anti-CD3 monoclonal antibody-induced T cell reactivity improved temporarily in both groups. Serum HIV p24 antigen levels decreased maximally during the first 12 weeks of treatment. At weeks 0 and 48, polymerase chain reaction analysis for mutations at codons 67 and 215 of the HIV-1 reverse transcriptase gene conferring zidovudine resistance was conducted in 10 subjects receiving zidovudine and in 8 subjects receiving combination therapy. At week 48, 1 of 8 and 4 of 6 samples from the groups receiving zidovudine only or combination therapy, respectively, contained wild type virus at codon 215. Grade 3 or 4 toxicity was uncommon. Drug-related malaise and anorexia were observed more frequently in patients receiving both zidovudine and IFN-alpha.

Report of a symposium on: diagnosis and treatment of cutaneous head and neck melanoma.

A series of presentations and discussions was held during a symposium on the diagnosis and treatment of cutaneous head and neck melanoma. The purpose of this meeting was to define certain guidelines on diagnosis and treatment of head and neck melanoma. The results of this symposium are summarized and condensed in this report. Recommendations are made for diagnostic strategies and for treatment. It is indicated that research efforts in immunology need to be expanded to develop rational immunotherapy.

Longitudinal study on the Quality of Life of symptomatic HIV-infected patients in a trial of zidovudine versus zidovudine and interferon-alpha.

OBJECTIVES: To compare the effect of treatment with zidovudine (ZDV) or a combination of ZDV and interferon-alpha (IFN-alpha) on patient Quality-of-Life (QoL); and to document changes over time in QoL. DESIGN: This study is part of a longitudinal, randomized, controlled clinical trial comparing the efficacy and tolerance of ZDV monotherapy and ZDV plus IFN-alpha. Patients were followed-up for 1 year. SETTING: Seven academic or general medical hospitals. PARTICIPANTS: Thirty-six symptomatic HIV-infected patients (Centers for Disease Control and Prevention stage IV) with a CD4+ count > or = 150 x 10(6)/l and Karnofsky Performance Status score > or = 60, who had not received ZDV or IFN-alpha before. METHODS: QoL was assessed using two self-report questionnaires (the European Organization for Research and Treatment of Cancer Core Quality-of-Life Questionnaire and an AIDS-specific questionnaire), administered before and every 3 months after the start of the treatment. RESULTS: There were no significant differences in QoL between the two treatment groups over a 1-year period. Emotional, cognitive and social functioning improved in the entire group, and patients reported fewer symptoms (for example, shortness of breath, nausea and vomiting, influenza-like symptoms, diarrhoea, lack of appetite, taste disturbances, dizziness, weight loss, trouble in vision) and a better overall QoL until month 9. Thereafter, emotional, cognitive and social functioning and overall QoL deteriorated and patients reported more symptoms. Major complaints at baseline and follow-up were associated with fatigue and emotional functioning: patients reported a strong need to rest, and felt very tired, worried, tense and irritable. CONCLUSIONS: These results show that both treatments may have a temporary beneficial effect on patient QoL. QoL research may contribute to evaluation of clinical trials and provide patients with information about the effects of treatment on their QoL, thus enabling them to make informed decisions.

[Reconstructive surgery of the head and neck region using free muscle flaps]. / Reconstructieve chirurgie van het hoofd-halsgebied met behulp van vrije spierlappen.

Twenty-seven patients who underwent microvasculosurgical free tissue transfers for head and neck reconstruction with a M. rectus abdominis or M. latissimus dorsi flap are reviewed. In this series the flap reconstruction was completed in 15 patients with extraoral defects, in six patients with an intraoral defect and in six patients with a combined intra and extraoral defect. Split thickness skin graft coverage was used in all cases. All free muscle grafts survived and good take of the split skin was obtained. In extraoral defects coverage of free muscle transfer with split thickness skin grafts results in a better color match than with musculocutaneous flaps and complements the appearance and pliability of the free muscle flap. Reshaping and three-dimensional positioning made reconstruction of every intraoral defect and combined intra and extraoral defects possible. In skilled hands, free tissue transfer provides a reliable method for reconstruction of almost every defect in the head and neck.

Free muscle transfer with split thickness skin graft coverage in head and neck reconstructive surgery.

Sixteen patients (eight females and eight males) who underwent microsurgical free tissue transfers for head and neck reconstruction are reviewed. In this series, the flap reconstruction was completed on eleven patients with extra-oral defects and five with intra-oral defects. Split thickness skin graft coverage was used in all cases. The rectus abdominis free muscle flap was used in nine patients and the latissimus dorsi free muscle flap in seven patients. The choice of tissue reconstruction was decided by the size of the surgical defect. There were no failures of the tissue transfers and skin grafts. In skilled hands, free tissue transfer provides a reliable method of head and neck reconstruction, with a low incidence of recipient and donor site complications. In extra-oral defects, coverage of free muscle transfer with split thickness skin grafts, results in a better colour match than musculocutaneous flaps, and complements the appearance and pliability of the free muscle flap.

[Maxillofacial injuries due to firearms. Retrospective study apropos of 60 cases]. / Traumatismes maxillo-faciaux par armes à feu. Etude rétrospective à propos de 60 cas.

Sixty cases have been treated between 1969 and 1986. The same primary treatment's principles have left for the last twenty years. Secondary treatment only, realized between the second and the third month has much benefited by plastic surgery's progress.