Prospective Diary Research Articles

Somnolence syndrome in adults following cranial irradiation for primary brain tumours

The purpose of this study was to assess the incidence, pattern and severity of somnolence and fatigue in patients treated with cranial irradiation for primary brain tumours and to identify factors that may influence or mediate symptoms. A detailed prospective study was carried out of 19 patients who received high-dose (45–55 Gy) cranial irradiation as treatment for primary brain tumours. Data were collected for each patient over a 3 month period using a prospective diary utilizing visual analogue scales of common somnolence symptoms and fatigue, and detailed interviews at 2, 6 and 12 weeks following the completion of treatment. Sixteen patients developed somnolence syndrome following treatment. Time series analysis identified a cyclical pattern to the symptoms, with a period of drowsiness and fatigue occurring from day 11 to day 21 and from day 31 to day 35 after radiotherapy. The principal symptoms were those of excessive drowsiness, feeling clumsy, an inability to concentrate, lethargy, being mentally slow and fatigue. Patients treated with accelerated ( n = 11) compared with more conventional ( n = 8) fractionation experienced more severe drowsiness and fatigue ( P< 0.01), although there was no difference in the pattern or the incidence of symptoms. Interview data suggested that patients frequently attributed their symptoms of somnolence to 'flu or other ailments. The unexplained and overwhelming nature of the symptoms was a cause of anxiety. The prospective assessment of symptoms following radiotherapy highlighted a more detailed definition of the symptom complex and pattern of occurrence. Somnolence syndrome is a collection of symptoms consisting of drowsiness, lethargy and fatigue. Forewarning patients and planning supportive management around times of drowsiness and fatigue can help to reduce the anxiety that these symptoms cause.

Discussion: Epidemiology of urinary incontinence

T ables I and II represent a sample of definitions of urinary incontinence (UI) used in epidemiologic research.‘-’ 5 Table II lists the mean number of weekly incontinent episodes for 287 consecutive incontinent women referred to our laboratory. There is an obvious difference between the epidemiologic and clinical threshold for UI, a fact of which we must all remain cognizant. In the article in this supplement, Hampel et a116 have done an excellent job of raising our sensitivity to this issue. I congratulate these authors for their comprehensive and accurate review and analysis of the world’s epidemiologic literature regarding UI in women. They correctly emphasize the limitations of our current knowledge related to risk factors for and the prevalence, incidence, and natural history of female UI. They make several sensible recommendations for defining UI in epidemiologic studies, including 1) objective demonstration of loss, 2) documentation of the frequency and severity of loss, and 3) assessment of the distress or bother created by the UI. I would like to comment briefly on these recommendations and provide some observations from a recent pilot study we have completed. How does one objectively demonstrate UI? Most of us interpret the International Continence Society criteria as demanding that we observe leakage. Many of us feel comfortable only if we use urodynamics to define the condition causing UI. Most are willing to accept a positive quantitative pad test as an acceptable objective surrogate for direct observation. However, many balk at the suggestion that a validated, prospective urinary diary or a standardized and validated UI clinametric instrument is objective, branding them with the pejorative “subjective” label. However, many of these “subjective” measures have been more thoroughly studied for their reproducibility and reliability than some of our revered “objective” laboratory measures. In the end, no one of these domains stands alone as the gold standard for proving or disproving UI. Epidemiologic studies should try to assess as many domains as possible and should use only standardized and validated instruments. In most instances, the universal assessment of some domains (eg, determination of the physiologic subtype of UI by urodynamic testing) is not feasible. Evaluation of a portion of the surveyed population is acceptable and generalizable only if performed on a scientifically valid and representative portion of the population. Finally, no studies should be undertaken on anything other than a random sample population, with special efforts made to include racial and ethnic groups largely ignored by a half-century of epidemiologic research. How does one document bother? It is no longer enough to ask only, “Does this bother you?” or “Is this a social or hygienic problem?” Validated, condition-specific, quality-of-life instruments exist to assess both the distress caused by and the impact of U1.17 Researchers should either use established instruments or standardize and validate their own instruments and scales. Figure 1A represents a theoretic and nonvalidated model for

Cognitive functioning in premenstrual syndrome

To evaluate cognitive functioning in women with premenstrual syndrome (PMS) and controls during the follicular and luteal phases of the menstrual cycle. Thirty women with PMS and 31 controls were selected on the basis of psychiatric interview and prospective daily diary recordings. Subjects were tested on two occasions, follicular (days 8-10) and luteal (days 24-26), using complex tasks consisting of measures validated previously for the assessment of "executive" frontal-lobe functions. Tests were counterbalanced for order across subjects. The Beck Depression Inventory scores were significantly different between the groups and across time (P < .001). Women with PMS had a mean luteal phase Beck score of 13.3 consistent with mild-to-moderate premenstrual depression. There were no statistically significant score differences in tests for attention, memory, cognitive flexibility, and overall mental agility. The evaluation of our preliminary data with 30 PMS subjects and 31 controls indicated a very small effect size (.02). To detect an effect size this small (if in fact one exists) with a power of .8 would require a sample of more than 1000 subjects per group. Our sample of women with PMS failed to demonstrate objective evidence of diminished cognitive performance, despite subjective feelings of inadequacy.

Benefits of including a prospective exercise diary in the management of NIDDM diabetes: A preliminary report

AbstractThis short report describes exercise levels reported by a group of outpatients with NIDDM who completed two measures of exercise frequency; a single retrospective item about activity levels in the last three months, and a two week prospective diary. Of 46 respondents, 21 were female and 25 male, with a mean age of 60.3 years; 82% had been diagnosed in the previous 12 months; 59% were treated with diet and exercise instruction and 41% had additional oral agent therapy. The proportions reporting exercising one or more days per week were: 63% by questionnaire recall (95% Cl 49.5–76.5); 94% by prospective diary (95% Cl 77–107). The proportions exercising five days or more per week were: 24% by recall (95% Cl 11.7–36.3); 70% by prospective diary (95% Cl 56.6–83.2) Eighty‐two percent of those people reporting no exercise at baseline had adopted some exercise during the two week diary phase. In conclusion, it would appear that the stimulus of prospective diary entries had an impact on exercise frequency, but it is unknown to what degree the diary increased exercise adoption in the longer‐term. This report highlights two areas for further investigation in NIDDM: understanding how different techniques such as diaries can motivate and sustain exercise adoption and maintenance, and the need to collect comprehensive data on exercise patterns over time.

A longitudinal study of risk factors for the occurrence, duration and severity of menstrual cramps in a cohort of college women.

To describe how menstrual cramps vary from cycle to cycle within a woman over time. To examine the influence of weight and lifestyle factors on occurrence, duration, and severity of menstrual pain. A one-year prospective menstrual diary study. One hundred and sixty-five women aged 17 to 19 years entering a local university in 1985. The occurrence, length, and maximum severity of pain during a menstrual period. Menstrual pain occurred during 71.6% of observed menstrual bleeds, most commonly beginning the first day of menses. The median duration was two days. Sixty percent of women reported at least one episode of severe pain, while 13% reported severe pain more than half the time. Earlier age at menarche and long menstrual periods increased the occurrence, duration and severity of pain. In smokers, cramps tended to last longer. Being overweight was an important risk factor for menstrual cramps and doubled the odds of having a long pain episode. Frequent alcohol consumption decreased the probability of having menstrual cramps, but in women who had pain it increased duration and severity. Physical activity was not associated with any pain parameter. Women who have pain lasting three days are an important target group for prophylactic therapy. The occurrence and severity of menstrual cramps is influenced by potentially modifiable characteristics including weight, smoking, and alcohol consumption. Doctors may wish to counsel women presenting with dysmenorrhoea about the importance of healthy lifestyles and about the inefficacy of alcohol consumption as a treatment for dysmenorrhoea.

The monetary costs of childhood cancer to the families of patients

The medical costs of cancer treatment are well described, but there are few reports of expenses incurred by families of children with malignant disease. The objective of this study was to describe the monetary costs borne by families of patients with childhood cancer and to determine whether these costs represent an important component of the burden of illness. Families completed a prospective diary survey about daily expenses incurred during each sample week of therapy. We also undertook a retrospective, cross-sectional questionnaire survey about expenses, incurred during the entire duration of treatment, associated with major or one-time cost items. Seventy families of children treated for high risk acute lymphoblastic leukemia, 19 families of children treated for Wilms' tumor stages 2-5, and 16 families of children treated for neuroblastoma stages 3 and 4 completed diaries or questionnaires detailing the costs resulting from the diseases and their treatment. The mean total expenses (in 1986 Canadian dollars) incurred by families of childhood cancer patients over the entire course of therapy are $26,070 for acute lymphoblastic leukemia? $20,074 for Wilms' tumour, and $10,376 for neuroblastoma. On-going weekly costs rather than major one-time purchases account for the largest share of expenses. Overall, in spite of universal first dollar coverage for medical care in Canada, family-borne costs during the course of these illnesses are at least one-third of the average family's after-tax income.

Correlation of urodynamic measures of urethral resistance with clinical measures of incontinence severity in women with pure genuine stress incontinence

OBJECTIVE: Our aim was to correlate multiple measures of urethral resistance with five clinical measures of incontinence severity in women with pure genuine stress incontinence.STUDY DESIGN: Seventy-five women with pure genuine stress incontinence underwent passive and dynamic urethral pressure profilometry and Valsalva leak point pressure determinations. The standardized and validated measures of incontinence severity included (1) the number of incontinent episodes, (2) the number of continence pads used recorded in a prospective 1-week urinary diary, (3) grams of fluid loss on a pad quantitation test, and (4) two condition-specific quality-of-life scales, the urogenital distress inventory and the incontinence impact questionnaire. The urodynamic and severity measures were compared with Pearson product-moment correlation analysis.RESULTS: There were no significant correlations betweendynamic urethral pressure profile pressure transmission ratios and any measure of incontinence severity. Passive urethral pressure profile variables correlated significantly with incontinence episodes and pad use. Valsalva leak point pressures correlated significantly with pad use and quantitation testing. None of the urodynamic measurements was significantly correlated with either of the quality-of-life scales, but our power to demonstrate a correlation was limited.CONCLUSIONS: Both passive urethral pressure profile measures and Valsalva leak point pressures correlate with some severity measures of genuine stress incontinence. Although inefficient pressure transmission during stress is critical to the pathogenesis of genuine stress incontinence, the severity of the pressure transmission defect is not related to clinical severity. Conversely, impairment of intrinsic urethral resistance is not essential to the pathogenesis of genuine stress incontinence, but the degree of sphincteric impairment is related to severity once the condition exists.

Reduced awareness of hypoglycemia in adults with IDDM. A prospective study of hypoglycemic frequency and associated symptoms.

To prospectively evaluate the frequency and severity of hypoglycemic episodes in IDDM subjects who declare themselves to have reduced awareness of hypoglycemia, to validate their self-designations in their natural environment, and to determine objectively the presence or absence of autonomic and neuroglycopenic symptoms associated with their low blood glucose (BG) levels. A total of 78 insulin-dependent diabetes mellitus (IDDM) subjects (mean age 38.3 +/- 9.2 years; duration of diabetes 19.3 +/- 10.4 years) completed two sets of assessments separated by 6 months. The assessments included reports of frequency and severity of low BG, symptoms associated with low BG, and a BG symptom/estimation trial using a hand-held computer (HHC). Diaries of hypoglycemic episodes were kept for the intervening 6 months. HbA1 levels were determined at each assessment. Of the subjects, 39 declared themselves as having reduced awareness of hypoglycemia (reduced-awareness subjects). There were no differences between these reduced-awareness subjects and aware subjects with regard to age, sex, disease duration, insulin dose, or HbA1. During the HHC trials, reduced-awareness subjects were significantly less accurate in detecting BG < 3.9 mmol/l (33.2 +/- 47 vs. 47.6 +/- 50% detection, P = 0.001) and had significantly fewer autonomic (0.41 +/- 0.82 vs. 1.08 +/- 1.22, P = 0.006, reduced-awareness vs. aware) and neuroglycopenic (0.44 +/- 0.85 vs. 1.18 +/- 1.32, P = 0.004, reduced-awareness vs. aware) symptoms per subject. Prospective diary records revealed that reduced-awareness subjects experienced more moderate (351 vs. 238, P = 0.026) and severe (50 vs. 17, P = 0.0062) hypoglycemic events. The second assessment results were similar to the first and verified the reliability of the data. IDDM subjects who believe they have reduced awareness of hypoglycemia are generally correct. They have a history of more moderate and severe hypoglycemia, are less accurate at detecting BG < 3.9 mmol/l, and prospectively experience more moderate and severe hypoglycemia than do aware subjects. Neither disease duration nor level of glucose control explains their reduced awareness of hypoglycemia. Reduced-awareness individuals may benefit from interventions designed to teach them to recognize all of their potential early warning symptoms.

Host factors that influence the duration of menstrual bleeding.

We assessed the association between weight, exercise, and stress and the duration of menstrual bleeding in a 1-year prospective menstrual diary study of 166 college first-year women, age 17-19 years. Low weight-for-height increased expected bleed duration by 0.39 day. Dieting to lose weight reduced bleed length by 0.43 day. Women who did no moderate or hard exercise bled about a quarter of a day longer than women at the median level of physical activity.

Premenstrual exacerbation of symptoms in women with panic disorder

Women with panic disorder commonly report a premenstrual worsening of panic symptoms, but to date this report has not been confirmed in prospective trials. The present study investigated fluctuations in panic symptomatology across the menstrual cycle, with particular attention to the discrepancies between retrospective and prospective studies. Ninety-four women with panic disorder reported their history of premenstrual symptoms of panic, and 24 of these patients completed prospective diaries comprising two full menstrual cycles. Similar to previous studies, 41% of the sample provided a retrospective report of premenstrual worsening of panic symptoms. Unlike previous investigations, a significant increase in panic frequency during the premenstruum was found in our prospective study, with 50% of subjects reporting at least a 100% increase in panic frequency. Women who experienced negative mood premenstrually were more likely to accurately report exacerbation of panic symptoms during the premenstruum.

Use of a 7-day diary for urinary symptom recording.

A cohort of 254 men, aged 40-79 years, was followed up at 1 year in a community-based survey of benign prostatic hyperplasia. Immediately after completing a questionnaire about the occurrence of 12 urinary symptoms over the previous month, the men were invited to keep a prospective diary asking about the same symptoms over 7 consecutive days in order to assess the amount of day-to-day variation in symptoms and to examine to what extent the findings reflected those of the retrospective questionnaire. The majority of men reported minor degrees of daily fluctuations in symptoms. Only modest correlations existed between the diary mean and maximum score for each symptom and the corresponding retrospective questionnaire score. Where repeated assessments of urinary symptom status are considered necessary a prospective diary may be more appropriate than a retrospective questionnaire.

Is hypersomnolence a feature of seasonal affective disorder?

We examined hypersomnolence as experienced among individuals meeting standardized diagnostic criteria for Seasonal Affective Disorder (SAD). Data were available from 115 individuals attending a mood disorders clinic specializing in treatment of this disorder. Three models of assessment were employed: retrospective self-reports (Seasonal Patterns Assessment Questionnaire), cross-sectional interviews (Standardized Interview Guide for the Hamilton Depression Scale, SAD Version), and prospective sleep diaries. Results indicated that self-reported total hours of sleep varied significantly across the seasons, with longest sleep occuring in winter and shortest sleep in summer. Seasonal sleep changes, as indicated by the SPAQ did not correlate significantly, however, with severity of depressive symptoms as indicated by the Hamilton scale. Multiple regression analyses indicated that only social activity levels (one of seven SPAQ items) was significantly and uniquely related to the severity of depression. When data obtained by the three instruments were compared, self-reported hours of sleep (whether measured by SPAQ or Hamilton interview) were significantly higher than indicated by prospective sleep diaries. We conclude that hypersomnolence may not be a central feature of SAD and that the validity of the SPAQ as an index of this disorder requires further investigation.

A prospective study of proneness to acute respiratory illness in the first two years of life.

This study sought explanations for the proneness to respiratory events in young Australian children. Prospective respiratory symptom diaries on 836 children collected data on respiratory symptoms and episodes. Questionnaires to mothers and birth and pregnancy records provided 56 known and possible predictors which were tested against two summary respiratory outcomes in each of the first and second years of life. The two summary respiratory variables recorded for first and second year of life give four outcome variables. In fitting multivariate regression models to predict outcomes, use of child care in early childhood and mothers' experience of respiratory illness in the 12 months before birth were significant predictors for all four outcomes. Number of siblings was a predictor for three of the four outcomes. Sleep difficulty during pregnancy in the mother, and respiratory hospitalization of the infant in the first year, were significant predictors for both first-year outcomes. Unexpected and unexplained findings emerged for alcohol intake during pregnancy, passive smoking and breastfeeding in relation to the second year respiratory outcomes. Less than 9% of variance in outcome scores was explained in any of the four multiple regression models but this rose to between 24% and 31% when a corresponding score from the other year was added to the model. Proneness to respiratory illness is an important entity; its determinants are largely unknown and events in pregnancy or the perinatal period explain only a small proportion of the between-infant variability.

Medical Record Documentation of Chronic Abdominal Pain

Name: Martha McCue1 Date of birth: June 24, 19842 Drug allergies: None known3 Immunizations: Complete4 Thursday, December 3, 1992 CHIEF COMPLAINT: "She's been having stomach aches since summer." PRESENT ILLNESS: (without prospective diary) Stomach hurting off and on since end of summer. May have started on vacation. Says stomach hurts "lots of days." Many times too uncomfortable to go to school or mother has to get her. School nurse worried there is something wrong. Pain is usually "in middle." No obvious relation to meals; "can happen anytime." Not sure if it wakes her up, "but sometimes I have bad dreams." Pain lasts "a long time." Appetite normal for her; picky eater. No obvious relation to specific foods. Thinks bowel movements are normal; can't remember how often. No discomfort urinating. Has not had temperature taken. Remembers vomiting once. Mother thinks one bout was related to taking antibiotic. PRESENT ILLNESS: (with prospective diary) Father had vomiting and diarrhea mid-August on vacation; better in 4 days. Martha caught it and had pronounced cramps. Not a week without abdominal pain since then. Several bouts a week. Diary shows pronounced pain on Sunday evenings, Monday mornings, Tuesday mornings, causing school absence 3 days. Milder discomfort on other days. No pain over Thanksgiving vacation until Sunday night.

Medical Record Documentation of Chronic Abdominal Pain

Name: Martha McCue1 Date of birth: June 24, 19842 Drug allergies: None known3 Immunizations: Complete4 Thursday, December 3, 1992 CHIEF COMPLAINT: She9s been having stomach aches since PRESENT ILLNESS: (without prospective diary) Stomach hurting off and on since end of summer. May have started on vacation. Says stomach hurts lots of Many times too uncomfortable to go to school or mother has to get her. School nurse worried there is something wrong. Pain is usually middle. No obvious relation to meals; can happen anytime. Not sure if it wakes her up, but sometimes I have bad dreams. Pain lasts long time. Appetite normal for her; picky eater. No obvious relation to specific foods. Thinks bowel movements are normal; can9t remember how often. No discomfort urinating. Has not had temperature taken. Remembers vomiting once. Mother thinks one bout was related to taking antibiotic. PRESENT ILLNESS: (with prospective diary) Father had vomiting and diarrhea mid-August on vacation; better in 4 days. Martha caught it and had pronounced cramps. Not a week without abdominal pain since then. Several bouts a week. Diary shows pronounced pain on Sunday evenings, Monday mornings, Tuesday mornings, causing school absence 3 days. Milder discomfort on other days. No pain over Thanksgiving vacation until Sunday night.

Medical Record Review

Evaluation of the child with chronic or recurrent abdominal pain can give the pediatrician a stomach ache, especially since the majority of these children do not have clear-cut causes for their pain and because the sorting out of organic and emotional factors is difficult. At the very least, the clinician deserves to have complete and accurate information on which to base an evaluation. Essential elements of such an evaluation are presented in the Guide for Record Review distributed with this issue. Unfortunately, the history given by patient and parents often is vague and incomplete, since this is a condition that has been going on for a while and may have variable manifestations. If a prospective diary is kept for 2 or 3 weeks, the specific details of the child's condition will be recorded as they occur, and a variety of relevant factors, such as diet and activity, can be noted at the same time, so that correlations can be detected. The focus on accurate data collection also will induce the child and parents to recall with more clarity those events that have occurred before. Information from outside sources, such as relatives and school personnel, is more likely to be accurate if the family is oriented toward good history taking.

Medical record review. Same patient, same problem, two different stories: the value of a prospective diary in assessing chronic abdominal pain.

Medical record review. Same patient, same problem, two different stories: the value of a prospective diary in assessing chronic abdominal pain.

Comparisons of retrospective and current reports of alcoholics and their spouses on drinking behavior

This study examined the correspondence between reports of alcoholic husbands and their wives on multiple dimensions of alcohol consumption and drinking-related events. Retrospective reports as well as prospective diaries (90 day period) were obtained from both spouses on husbands' behaviors, and correspondence was assessed at group and individual levels. Although there was some variability in agreement between individual husband-wife pairs, overall results indicated that husband-wife correspondence was robust not only for global measures, but also for more specific dimensions of day-to-day consumption. Findings were discussed in terms of issues that affect the validity of alcoholics' reports.

A comparison of prospective and retrospective diary methods of assessing alcohol use among university undergraduates

The objective of this study is to compare data about the quantity of alcohol consumed by university undergraduates using a prospective diary with those data collected using a retrospective diary. Five hundred and ninety-eight subjects were randomly selected and divided into two groups matched for age, sex, year of study and subject group; one group received a prospective and one a retrospective questionnaire-301 students received prospective and 297 retrospective questionnaires. Sixty-eight per cent responded to the prospective and 75 per cent to the retrospective survey. There was no significant difference in the median alcohol consumption detected for men or women in this study (p = 0.13; p = 0.47). However, the prospective diary recorded a greater proportion of heavy drinkers, this difference being significant for men and women (p less than 0.05). The quantitative results of the retrospective diary are similar to those obtained by a similar method in a previous survey. The conclusion is that a prospective diary detects a greater proportion of heavy drinkers than a retrospective diary. The prospective survey may be the most appropriate method for assessing alcohol use in certain situations.

Measuring quantity and frequency of drinking in a general population survey: a comparison of five indices.

This article compares five indices of alcohol consumption in a general population survey conducted in 1985 in the Netherlands. Self-reports of consumption were obtained with a prospective diary, a retrospective 7-day recall method, and three summary measures, such as a quantity-frequency index. The coverage of sales data appeared highest for the diary (67%), which suggests a higher validity. Special attention was given to comparisons of quantity and frequency of drinking between the diary, on the one hand, and the weekly recall and summary measures, on the other. It was found that underreporting, relative to the diary reports, was generally higher in the frequency than in the quantity domain. This result, together with the finding from longitudinal studies that intraindividual variation is also higher for drinking frequency, leads to the conclusion that forgetting is a potent source of undercoverage in surveys and to the hypothesis that large differences in overall drinking pattern between populations (e.g., in regularity of drinking) may account for the large differences in coverage rates of sales data. Furthermore, the subjectively assessed probability of drinking by means of a "usual" frequency question appeared a poor predictor of (diary) drinking frequency for respondents reporting a low or moderate frequency. For subjects claiming a high "usual" drinking frequency, a reasonable correspondence between diary and summary measures was found. This mitigates the fear often expressed that heavy drinkers particularly underreport their consumption.