Self-assessment Of Symptoms Research Articles

MIDOS--an electronic database for the palliative care unit

A minimal documentation system (MIDOS) has been developed for self-assessment of pain and other symptoms by the patients on palliative care units. To decrease the administrative burden and thereby increase the acceptance of the system an electronic database was developed to facilitate data entry and documentation. The database is based on Microsoft Access. Screen masks are used for navigation and data entry. According to the type of data items may be chosen in checklists or pull-down menus or entered as free text. The main menu documents personal data from the patient. Submenus can be reached from the main screen mask. Submenus included are the core documentation of the working group of the German Ministry of Health, the German versions of the Brief Pain Inventory, the quality of life questionnaire SF-12 and the Mini Mental State Examination for assessment of cognitive impairment. Data from these instruments may be assessed repeatedly for the same patient. Documentation of follow-up consultations include self-assessment of pain and other symptoms by the patient (MIDOS) and the analgesic regimen. These informations should be documented for each consultation. This data base was used in two trials on the palliative care unit of the university of Cologne, confirming data safety and convenience of the programme. We recommend the use of this data base in combination with MIDOS and the core documentation for routine assessment on the palliative care ward.

MIDOS--validation of a minimal documentation system for palliative medicine

Repeated assessment of pain and other symptoms is required for quality assurance in palliative care. However, physical and cognitive impairment of the patients may impede the use of standardized questionnaires and documentation systems in palliative care setting. We developed a minimal documentation system (MIDOS) for the specific requirements in this setting. The German versions of the Brief Pain Inventory (BPI) and the quality of life questionnaire SF-12 were completed for all patients admitted to the palliative care unit. Cognitive impairment was assessed with the Mini Mental State Examination (MMSE). With admission as well as on subsequent consultations patients self-assessed average and maximum pain intensity on numeric rating scales and the intensity of drowsiness, nausea, constipation, dyspnea, weakness, anxiety and well-being on verbal categorical scales. From August 1998 to June 1999 128 patients were documented consecutively. Fifty-nine percent of these patients were treated with WHO-step 3 opioids. Cognitive impairment (MMSE<24) was present in 37% of the patients. Self-assessment with MIDOS was possible for 114 patients at the time of admission, and for 108 patients at the end of therapy. Pain, drowsiness and weakness were documented by most patients, whereas the other symptoms were reported less frequently. Factor analysis showed one factor for pain and two factors for the other symptoms. The pain sum score of MIDOS correlated with the factors of the BPI, the symptom sum score of MIDOS correlated with the factors of the BPI and the mental sum score of the SF-12, though on a lower level. MIDOS sum scores showed good pain relief and symptom control for patients discharged home or to other services, whereas the symptom sum score gave an indication of the deterioration in the terminal phase for those patients who died during in-patient treatment. Test-retest stability was good for a subgroup of patients with stable opioid doses. We conclude that MIDOS is a valid instrument for self-assessment of the patient's symptoms and may be used to monitor the efficacy of symptom management.

Underestimation of case severity by emergency department patients: Implications for managed care

The objective was to examine differences in symptom severity assessment by emergency department (ED) patients and by emergency physicians (EPs) and to relate these assessments with case management and disposition. The design was prospective convenience sample of ED patients. The setting was a U.S. university hospital ED with an annual ED patient census 28,000. The participants were all ED patients registered when first author was in ED; excluded were patients treated by the major trauma response team and those with a psychiatric chief complaint. All patients were interviewed by the first author and asked to classify their symptoms as emergent, urgent, or nonurgent; the EP attending classed patients' symptoms at presentation and after work-up was complete. Three hundred-one cases were entered in the study from May to August 1996. Although 28% of ED patients self-rated their symptoms as nonurgent, 5% of this group required hospital admission. Of this group 35% were assessed by the EP attending as having required emergent or urgent ED care. Of this group 5% also rated by the EP initially as nonurgent had their case severity upgraded after work-up. Reliance on either patient symptom self-assessment or physician screening assessment by telephone to determine appropriateness of an ED visit is not reliably safe for at least 5% of presenting patients. Even prospective ED visit severity assessment does not reliably identify “unnecessary” ED visits.

A Phase II Trial of Triamcinolone Hexacetanide for Symptomatic Recurrent Malignant Ascites

Ascites is a common complication of advanced cancer and frequently requires paracentesis to reduce symptoms of pain, anorexia, and dyspnea. For many patients repeat paracenteses are required at short intervals. We prospectively studied 15 patients with recurrent ascites of malignancy to determine if intraperitoneal triamcinolone hexacetonide, a slowly metabolized corticosteroid, produced objective and symptomatic responses. After biochemical, radiological, and symptom assessment and the establishment of the interval between paracenteses, patients underwent large-volume paracentesis followed by intraperitoneal triamcinolone hexacetonide 10 mg/kg. Patients were followed after treatment for assessment of symptoms and physical signs of ascites. Repeat paracentesis was performed when symptomatic ascites recurred. Symptomatic ascites recurred in 13 of 15 patients, but the interval between paracenteses was extended from 9.5 ± 1.6 days to 17.5 days (P = 0.0086). Symptom questionnaire scores assessing well-being, nausea, abdominal pain, dyspnea, appetite, appearance, and change in abdominal size on a scale from 0 to 6 averaged 3.2 ± 0.3 at entry and 2.5 ± 0.2 at the 2-week assessment (P = 0.026). Self-assessed symptoms, feeling of well-being, abdominal distention, and physical appearance improved significantly. The mean serum cortisol decreased from baseline, suggesting that some systemic corticosteroid absorption occurred. Thirteen of 15 patients have died, with a median survival of 42 days. Potential adverse effects included 1 episode each of transient abdominal pain, bacterial peritonitis, and localized herpes zoster infection. In patients with ascites of malignancy, intraperitoneal triamcinolone hexacetonide appears to postpone the requirement for repeat paracentesis and improve symptoms of malignant ascites.

A randomized trial of ecadotril versus placebo in patients with mild to moderate heart failure: The U.S. Ecadotril Pilot Safety Study

Objective To determine the short-term safety and tolerability of the addition of ecadotril to conventional therapy in patients with mild to moderate heart failure. Methods Fifty ambulatory patients, 18 to 75 years of age, with mild to moderate heart failure, left ventricular ejection fraction ≤35%, taking stable doses of angiotensin-converting enzyme inhibitor, diuretics, and optionally digoxin were enrolled in a randomized, double-blind, placebo-controlled dose-escalation study of ecadotril 50 to 400 mg twice daily versus conventional therapy alone. Results: No increases in deaths, serious adverse events, or dropouts from adverse events were observed for the ecadotril group compared with placebo. The serum measures of neurohormonal activation were highly variable. Changes in signs and symptoms of heart failure, New York Heart Association class, and patient self-assessment of symptoms were not observed with ecadotril therapy; however, the study was not designed to detect differences in these parameters. Conclusion In this small pilot study, ecadotril in doses of 50 to 400 mg twice daily was generally well-tolerated and without severe short-term adverse effects in patients with mild to moderate heart failure. Evaluation of the clinical efficacy and long-term safety of ecadotril and other neutral endopeptidase inhibitors in patients with heart failure requires further study. (Am Heart J 1999;138:1140-8.)

Self-assessment of somatic and psychic symptoms during a two months period of hormone replacement therapy in perimenopausal women

The drastic decrease in sex steroids production at menopause is often related to the development of somatic and psychic symptoms in women. We examined the effects of a two months hormone replacement therapy (HRT) on weekly self-assessments of menopausal symptoms, mood and sleep disturbances. In addition, spatial perception and motor performances abilities were measured before and after 8 weeks of HRT. Twentythree healthy perimenopausal women (mean 50 ± 4.8 years of age) with no previous hormone therapy and a Kuppermann-Index ≥15 were included. Before therapy and in weekly intervals during two months of treatment women reported upon their menopausal symptoms (MENOI), their mood state (POMS) and sleep disturbances (VISM). Psychological examinations were done before HRT and two months later under hormone replacement therapy. All 23 patients showed a significant improvement of the self report of climacteric, affective symptoms and of sleep disturbances, and a tendency to improvement in cognitive performance with respect to pretreatment measures. This indicates that hormone replacement therapy in perimenopausal women is associated with clinical improvement in somatic and psychic symptoms and a cognitive enhancement in some aspects. These benefits of the HRT must play a role in cost-effectiveness analyses of HRT.

Shift work-related problems in 16-h night shift nurses (1): Development of an automated data processing system for questionnaires, heart rate, physical activity and posture.

To assess the shift work-related problems associated with a 16-h night shift in a two-shift system, we took the following important factors into consideration; the interaction between circadian rhythms and the longer night shift, the type of morningness and eveningness experienced, the subjective sleep feeling, the subjects' daily behavior, the effectiveness of taking a nap during the long night shift, and finally the effectiveness of using several different kinds of measuring devices. Included among the measuring devices used were a standard questionnaire, repetitive self-assessment of subjective symptoms and daily behavior at short intervals, and a continuous recording of such objective indices as physical activity and heart rate. A potential problem lies in the fact that field studies that use such measures tend to produce a mass of data, and are thus faced with the accompanying technical problem of analyzing such a large amount of data (time, effort and cost). To solve the data analysis problem, we developed an automated data processing system. Through the use of an image scanner with a paper feeder, standard paper, an optical character recognition function and common application software, we were able to analyze a mass of data continuously and automatically within a short time. Our system should prove useful for field studies that produce a large amount of data collected with several different kinds of measuring devices.

Cold intolerance is not more common or disabling after digital replantation than after other treatment of compound digital injuries.

Cold intolerance is a common reason for disability after hand injury. In this study of posttraumatic cold intolerance, 20 patients with a history of digital replantation were matched with 20 control subjects who had not undergone replantation. The incidence and intensity of cold-related symptoms among patients in the two groups was investigated through the use of individual interviews and a grading scale for self-assessment of symptoms. The analysis of data indicates that although the pattern of symptoms may vary, the condition is neither more common nor more disabling among those who have undergone digital replantation. Cold intolerance after digital replantation seems, therefore, to be defined by the initial trauma and not by the subsequent reconstructive surgery.

Comparison of self-assessment of premenstrual symptoms with scores on the modified Menstrual Distress Questionnaire.

Premenstrual symptoms were assessed in a sample of 267 women (M age 31.4 yr.) using a single self-identification question and the modified Menstrual Distress Questionnaire of Clare and Wiggins. The-self-identification question asked to what degree the women experienced premenstrual symptoms. The responses were 34 (13%) for none, 116 (43%) for slight, 99 (37%) for moderate, and 18 (7%) for severe. The mean score on the questionnaire was 23.5 (SD = 17.5). Correlations indicated significant relationships between self-identification and questionnaire scores (rho = .76, p < .001). When the women were classified according to Clare's (1983) criterion, almost a third of them assessed their symptoms differently, i.e., while they classified themselves as "nonsufferers" on the self-identification question, their responses on the questionnaire identified them as "sufferers."

Sense of coherence, socioeconomic conditions and health. Interrelationships in a nation-wide Swedish sample

This study explores the distribution of sense of coherence (SOC) in common demographic and socioeconomic subgroups in a nation-wide representative sample. It also explores the relationship between SOC and these conditions, on the one hand and self-reported indicators of health, on the other. The sample consisted of 2,003 Swedes; 976 men and 1,027 women. The mean age was 44.2 years (SD = 16.6 years). The sample was selected by SIFO, the biggest Swedish market research institute, to be representative of the Swedish population between the ages of 15 and 75 years. All participants responded to a mailed questionnaire including Antonovsky's short SOC questionnaire, common socioeconomic and sodal situation variables and health questions. The distribution of SOC scores in different subgroups was partly inconsistent with previous studies. A sex difference was found; men scored significantly higher on the SOC scale than women. Regarding age, SOC scores increased with increasing age. Bivariate statistics showed that SOC was more strongly related to general well-being and psychological symptoms than to overall physical health and somatic symptoms. SOC was also more strongly related to health among women than men. Multivariate statistics (separately for men and women) indicated that SOC was more strongly related to the health indicators than age, education and income levels, number of persons in the household and number of friends. The possibility of a conceptual overlap between SOC and self-assessments of health, well-being and psychological symptoms in particular is discussed.

Trial of a “credit card” asthma self-management plan in a high-risk group of patients with asthma

BACKGROUND: The “credit card” asthma self-management plan provides the adult asthmatic patient with simple guidelines for the self-management of asthma, which are based on the self-assessment of peak expiratory flow rate recordings and symptoms. OBJECTIVE: The study was a trial of the clinical efficacy of the credit card plan in a high-risk group of asthmatic patients. METHODS: In this “before-and-after” trial, patients discharged from the emergency department of Wellington Hospital, after treatment for severe asthma were invited to attend a series of hospital outpatient clinics at which the credit card plan was introduced. Questionnaires were used to compare markers of asthma morbidity, requirement for emergency medical care, and medication use during the 6-month period before and after intervention with the credit card plan. RESULTS: Of the 30 patients with asthma who attended the first outpatient clinic, 26 (17 women and 9 men) completed the program. In these 26 participants, there was a reduction in both morbidity and requirement for acute medical services: specifically, the proportion waking with asthma more than once a week decreased from 65% to 23% ( p = 0.005) and the proportion visiting the emergency department for treatment of severe asthma decreased from 58% to 15% ( p = 0.004). The patients attending the clinics commented favorably on the plan, in particular on its usefulness as an educational tool for monitoring and treating their asthma. CONCLUSIONS: Although the interpretation of this study is limited by the lack of a randomized control group, the findings are consistent with other evidence that the credit card asthma self-management plan can be an effective and acceptable system for improving asthma care in a high-risk group of adult patients with asthma. (J A LLERGY C LIN I MMUNOL 1996;97:1085-92.)

Lack of correlation between the mean tender point score and self‐reported pain in fibromyalgia

To study the validity and nature of self-assessed symptoms among patients with fibromyalgia syndrome (FMS) and to compare our data with findings reported in the US. To determine whether tender point scores correlate with self-reported pain and other symptoms and to study the influence of disease duration. Tender point scores were assessed in 113 consecutive patients with FMS. All patients completed 2 self-assessment questionnaires (an extended Campbell list, the Enschede Fibromyalgia Questionnaire, and the Dutch Arthritis Impact Measurement Scales). The self-assessed symptoms of the Dutch FMS patients seem to be valid and are comparable with those of American patients. No association between disease duration and number of self-reported symptoms was found. An association between self-reported pain and mean tender point score was lacking for patients with disease of shorter duration and was weak for patients with disease of longer duration. The use of a self-report questionnaire for patients with FMS is feasible and appears to be valid. Tender point scores and self-reported pain represent very different aspects of pain in FMS.

Lack of correlation between the mean tender point score and self-reported pain in fibromyalgia

To study the validity and nature of self-assessed symptoms among patients with fibromyalgia syndrome (FMS) and to compare our data with findings reported in the US. To determine whether tender point scores correlate with self-reported pain and other symptoms and to study the influence of disease duration.Tender point scores were assessed in 113 consecutive patients with FMS. All patients completed 2 self-assessment questionnaires (an extended Campbell list, the Enschede Fibromyalgia Questionnaire, and the Dutch Arthritis Impact Measurement Scales).The self-assessed symptoms of the Dutch FMS patients seem to be valid and are comparable with those of American patients. No association between disease duration and number of self-reported symptoms was found. An association between self-reported pain and mean tender point score was lacking for patients with disease of shorter duration and was weak for patients with disease of longer duration.The use of a self-report questionnaire for patients with FMS is feasible and appears to be valid. Tender point scores and self-reported pain represent very different aspects of pain in FMS.

A randomized controlled trial of citalopram in the treatment of fibromyalgia

Amitriptyline and cyclobenzaprine have shown some efficacy in treatment of the generalised pain syndrome, fibromyalgia. The aim of this study was to examine the efficacy of antidepressant dosages of the serotonin re-uptake inhibitor citalopram in fibromyalgia. In a double-blind, placebo-controlled study 22 patients with fibromyalgia were randomized to treatment with citalopram for 4 weeks at a dosage of 20 mg a day while 21 received placebo. After 4 weeks the dosage was increased to 40 mg for a further 4 weeks if the subjects did not report a marked improvement. After the end of treatment (8 weeks) no changes were observed in self-assessment of symptoms, physician's global assessment, tender points, Beck depression score or voluntary muscle strength and no differences were observed between the groups. Citalopram showed no demonstrable effect on this group of pain patients. The strength of the study was sufficient to exclude an effect of citalopram of more than 1 steps of 10 on the categoric scales for pain, fatigue and general condition (95% confidence limit), which indicates that the sample size was sufficiently large.

P50 Validity, reliability, and responsiveness of subjective self-assessment of symptoms in asthma clinical trials

P50 Validity, reliability, and responsiveness of subjective self-assessment of symptoms in asthma clinical trials

P50 Validity, reliability, and responsiveness of subjective self-assessment of symptoms in asthma clinical trials

P50 Validity, reliability, and responsiveness of subjective self-assessment of symptoms in asthma clinical trials

Do patients' evaluations of a future health state change when they actually enter that state?

Fundamental to using utilities for future health states for clinical decision analysis is the assumption that the utilities are stable. The purpose of this study was to determine if cancer patients' prior evaluations of a treatment-induced health state remain stable when they later experience that state. Before a four-week course of radiation therapy, 66 laryngeal cancer patients evaluated three common treatment-induced outcome scenarios (mild/moderate/severe) using rating scales and the time trade-off, and provided self-assessments of voice symptoms, voice function, and general health. Evaluations and self-assessments were repeated at the end of therapy, and respondents indicated which outcome scenario described their actual end-of-therapy state. Twenty-four patients identified the mild scenario as their outcome state, 36 the moderate, and 6 the severe. No across-time differences in evaluations were detected, although significant (P < .0001) downward shifts in scores for voice symptoms (t = 5.67), voice function (t = 5.10), and general health (t = 6.69) indicated that actual change in health status had occurred. These results imply that patients' evaluations of imagined short-term health states encountered during radiation therapy for laryngeal cancer remain consistent when those states are experienced at a later time. The design of this project provides a model for determining if this consistency appears in other clinical situations.

12 Running a menopause clinic

A menopause clinic can be run either by a general practitioner as a primary referral clinic or in a hospital by a team of specialists and paramedical personnel as a secondary referral centre. Both can be run efficiently and with sensitivity. The importance of giving adequate information and education through combined video, written and verbal information is stressed. The partner should be included where possible. Self-assessment and monitoring of menopausal symptoms facilitates titration of the therapy, control of side-effects and compliance. Although all normal health checks, e.g. cervical smear and mammography should be offered, their frequency is not influenced by the use of HRT and medicolegally no extra laboratory tests are required before or after prescription of HRT. However, some extra selected tests can be useful such as lipid profile, liver enzymes and bone densitometry. A menopause clinic should offer comprehensive counselling on all lifestyle factors such as smoking, exercise, diet, alcohol and stress factors. Liaison with other health professionals such as physicians, psychiatrists, social workers, physiotherapists and dietitians, enhances the opportunity for appropriate counselling in selected cases. However, for most women personalized care by an informed general practitioner over 3-4 visits will allow titration of therapy, adequate counselling and a high rate of compliance. Compliance is also helped by a 5-7 day-a-week question line where telephone queries can be dealt with quickly by trained staff.

U.S. experience with omeprazole in duodenal ulcer

To assess the comparative efficacy of omeprazole 20 mg, a proton pump inhibitor, versus ranitidine 150 mg twice a day, an H2-receptor antagonist, in healing duodenal ulcers we performed a randomized, double-blind, multicenter trial in 309 patients with endoscopically diagnosed ulcers. Patients were treated for up to four weeks and were seen at week 2 and at week 4, if unhealed at week 2, for determination of ulcer status by endoscopy, review of daily self-assessment symptom diaries, and clinical laboratory including fasting serum gastrin. Gastrin levels were repeated two weeks after cessation of study medication. Evaluation of baseline demographic and laboratory parameters demonstrated no significant differences between the two groups at entry. At week 2, 42% of the omeprazole and 34% of the ranitidine-treated patients were healed (P=NS). At week 4, there was a 19% advantage in ulcer healing for the omeprazole-treated patients in comparison to those treated with ranitidine (82% vs 63%, respectively,P -1.0 cm.

Quality of life in postmyocardial infarction patients in relation to drug therapy.

Quality of life (QL) was assessed in relation to drug therapy in 539 patients who were still alive five years after myocardial infarction (MI), and the interaction between drug therapy and QL was investigated. The patients originally participated in a double-blind trial that evaluated the effect of early administration of the beta blocker metoprolol. A cardiac follow-up questionnaire (CFQ) and the Nottingham Health Profile (NHP) were answered by 82%. In the CFQ, sel-fassessed cardiac symptoms, medication (diuretics, digitalis, antiarrhythmics, long-acting nitrates, beta blockers, psychoactive drugs), smoking habits, and work status were described. NHP described QL within the sections of mobility, energy, pain, sleep, emotional reactions, and social isolation. The independent relation between morbidity, drugs, and QL was analyzed multivariately. Apart from symptoms of angina pectoris and dyspnoea, anxiety resulted in impaired QL. A relation between diuretics and decreased QL was found, but no indications of adverse effects of the beta blocker metoprolol.