Subjective Patient Perception Research Articles

The influence of leg length difference on clinical outcome after revision TKA

BackgroundThe purpose of this paper was to document the incidence of leg length changes after revision total knee arthroplasty (TKA) and its effect on clinical outcome. MethodsLeg length difference (LLD) was prospectively measured in 85 patients using digital standing full leg radiography before and after revision TKA. Additionally the patient's subjective perception of LLD was assessed postoperatively. Linear regression models were used to study the correlation between each of these parameters and the clinical outcome after 1year. Clinical outcome was evaluated by means of the Knee Society Score (KSS). ResultsRevision TKA resulted on average in an increased leg length of 5.3mm. Sixty-five legs (76%) were lengthened with the procedure, 17 (20%) were shortened and three (4%) remained of identical length. Increased leg length after revision was positively correlated with clinical outcome at 3months (Spearman r=0.22, p=0.044) and 1year (Spearman r=0.26, p=0.027). The evidence for this correlation remained after correction for age, gender and diagnosis (p=0.012). The most important contributors to improved clinical outcome scores were improved pain score (Spearman r=0.19, p=0.09) and increased stability (Spearman r=0.13, p=0.24), rather than range of motion (Spearman r=−0.02, p=0.85). ConclusionsThe results from our work indicate that revision TKA tends to lengthen the leg by approximately 5mm. Contrary to what might be expected, leg lengthening after revision TKA is correlated with improved clinical outcome. Level of evidenceLevel 2b.

Subjective and functional deterioration in recurrences of neovascular AMD are often preceded by morphologic changes in optic coherence tomography

BackgroundDifferent tests were applied to test the sensitivity of patient self-control; Amsler grid and visual acuity (VA) assessment, as well as fundus examinations to reveal recurrent choroidal neovascularisation (CNV) activity...

Correlations between M-CHARTS and PHP Findings and Subjective Perception of Metamorphopsia in Patients with Macular Diseases

To assess the correlations between a patient's subjective perception of metamorphopsia and the clinical measurements of metamorphopsia by M-CHARTS and PreView PHP (PHP). The authors designed a 10-item questionnaire focusing on the symptoms of metamorphopsia and verified its validity with a Rasch analysis. M-CHARTS measured the minimum visual angle of a dotted line needed to detect metamorphopsia, and PHP used the hyperacuity function for detection. Subjects were 39 patients with idiopathic epiretinal membrane (ERM), 22 patients with idiopathic macular hole (M-hole), 19 patients with age-related macular degeneration (AMD), and 51 healthy controls. Rasch analysis suggested the elimination of one question. The nine-item questionnaire score significantly correlated to the M-CHARTS score in ERM (r = 0.59; P = 0.0004) but not in M-hole and to the PHP result in AMD (r = -0.29; P = 0.04) but not in ERM. Eighty percent of ERM patients with greater horizontal M-CHARTS score subjectively perceived horizontal metamorphopsia more often. M-CHARTS showed better sensitivities than PHP in both ERM (89% vs. 42%) and AMD (74% vs. 68%) and better specificity (100% vs. 71%) in healthy controls. Rasch analysis indicated that the present form of the questionnaire is better suited for moderate to severe cases of metamorphopsia than for mild cases. The questionnaire appears to be a valid assessment of patient subjective perception of metamorphopsia and can be used to supplement the clinical measurements of metamorphopsia by M-CHARTS and PHP in patients with macular diseases.

Patient Perception of Combined Awake Brain Tumor Surgery and Intraoperative 1.5-T Magnetic Resonance Imaging

To assess patients' perspective of combined awake craniotomy and intraoperative magnetic resonance imaging (MRI) in a prospective study. We evaluated 25 consecutive patients prospectively. Qualitative and quantitative results were obtained by a psychologist via a structured interview 5 +/- 2 days postoperatively, supplemented by preoperative and postoperative assessment of the patients' mood with the Hospital Anxiety and Depression Scale, as well as parts of a structured clinical interview during the postoperative assessment. Satisfaction with the experience was high in almost all cases. Only 1 patient recalled experiencing considerable discomfort during the operation. About one-third (39%) of our sample described minor to moderate difficulties; the remaining were entirely satisfied. Although the combination of awake craniotomy and intraoperative MRI is demanding, it was both tolerable and reasonable for the patients. Our data confirm that intraoperative MRI appears to have no additional significant impact on the subjective patient perception, although it does prolong the procedure.

Quality of life after traumatic brain injury: The clinical use of the QOLIBRI, a novel disease-specific instrument

Objective: To report the clinical use of the QOLIBRI, a disease-specific measure of health-related quality-of-life (HRQoL) after traumatic brain injury (TBI).Methods: The QOLIBRI, with 37 items in six scales (cognition, self, daily life and autonomy, social relationships, emotions and physical problems) was completed by 795 patients in six languages (Finnish, German, Italian, French, English and Dutch). QOLIBRI scores were examined by variables likely to be influenced by rehabilitation interventions and included socio-demographic, functional outcome, health status and mental health variables.Results: The QOLIBRI was self-completed by 73% of participants and 27% completed it in interview. It was sensitive to areas of life amenable to intervention, such as accommodation, work participation, health status (including mental health) and functional outcome.Conclusion: The QOLIBRI provides information about patient's subjective perception of his/her HRQoL which supplements clinical measures and measures of functional outcome. It can be applied across different populations and cultures. It allows the identification of personal needs, the prioritization of therapeutic goals and the evaluation of individual progress. It may also be useful in clinical trials and in longitudinal studies of TBI recovery.

Patients’ prediction of extubation success

The spontaneous breathing trial (SBT)-relying on objective criteria assessed by the clinician-is the major diagnostic tool to determine if patients can be successfully extubated. However, little is known regarding the patient's subjective perception of autonomous breathing. We performed a prospective observational study in 211 mechanically ventilated adult patients successfully completing a SBT. Patients were randomly assigned to be interviewed during this trial regarding their prediction of extubation success. We compared post-extubation outcomes in three patient groups: patients confident (confidents; n = 115) or not (non-confidents; n = 38) of their extubation success and patients not subjected to interview (control group; n = 58). Extubation success was more frequent in confidents than in non-confidents (90 vs. 45%; p < 0.001/positive likelihood ratio = 2.00) or in the control group (90 vs. 78%; p = 0.04). On the contrary, extubation failure was more common in non-confidents than in confidents (55 vs. 10%; p < 0.001/negative likelihood ratio = 0.19). Logistic regression analysis showed that extubation success was associated with patient's prediction [OR (95% CI): 9.2 (3.74-22.42) for confidents vs.non-confidents] as well as to age [0.72 (0.66-0.78) for age 75 vs. 65 and 1.31 (1.28-1.51) for age 55 vs. 65]. Our data suggest that at the end of a sustained SBT, extubation success might be correlated to the patients' subjective perception of autonomous breathing. The results of this study should be confirmed by a large multicenter trial.

Cognitive rehabilitation in posterior cortical atrophy

Posterior cortical atrophy (PCA) is a rare early-onset dementing syndrome presenting with visuo-perceptual deficits. Clinicopathologically, it is most commonly considered a form of Alzheimer's disease. We present the case of a 64-year-old male patient with posterior cortical atrophy who took part in a cognitive rehabilitation programme that included psychoeducation, compensatory strategies, and cognitive exercises. After the cognitive rehabilitation programme, subtle differences were found in visuoperceptual tasks and in the patient's subjective perception of difficulties. Cognitive rehabilitation may temporarily improve functioning in patients with posterior cortical atrophy.

Skin Biopsy for Diagnosis of Small Fiber Neuropathy

Patients with lower extremity sensory symptoms and pain but without clinical or standard neurophysiological examination abnormalities may have a small fiber neuropathy. Skin biopsy with intraepidermal nerve fiber density (IENFD) assessment has been promoted as a diagnostic tool for such patients. To evaluate the diagnostic utility of skin biopsy with IENFD in patients with suspected small fiber neuropathy. The objective was addressed through the development of a structured critically appraised topic. This included a clinical scenario, structured question, search strategy, critical appraisal, results, evidence summary, commentary, and bottom line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of neuromuscular neurology. One primary article was selected for review. A retrospective study using skin biopsy with IENFD detected abnormalities in 88.1% of 67 patients who had symptoms suggestive of sensory neuropathy but normal nerve conduction studies compared with 10% of healthy controls. Skin biopsy was more often abnormal in this setting than either the clinical examination (signs of small fiber impairment) or quantitative sensory testing but formal evaluation of sensitivity and specificity are compromised by inclusion of the diagnostic tests within the definition of the reference standard. Skin biopsy with IENFD was abnormal in 81% of patients clinically diagnosed with mixed large and small fiber neuropathy, 0/22 patients with large fiber neuropathy and 0/16 patients with nonperipheral neuropathic disorders. Detection of reduced IENFD using skin biopsy may be sensitive and specific for clinically-defined syndromes consistent with small fiber neuropathy. Skin biopsy appears to have greater diagnostic utility than the neurologic examination and quantitative sensory testing, both of which rely heavily on subjective patient perception. Prospective studies that evaluate quantitative methodology (rather than modalities that rely on patient report) and do not include the diagnostic tests in the reference standard are needed. Consensus is needed regarding a reference standard definition for small fiber neuropathy.

Post radical hysterectomy urinary incontinence: A prospective study of transurethral bulking agents injection

Objective(s) The aim of the present study is to prospectively investigate the efficacy and complications of macroplastique transurethral implantation in cervical cancer patients affected by stress urinary incontinence (SUI) after radical hysterectomy (RH). Methods Patients affected by de novo SUI post type 3 RH were considered for eligibility in this study. Preoperative and postoperative assessment included a standardized urogynecological history, urogynecological and neurological physical examination, evaluation of severity of SUI symptoms, a 3-day voiding diary, urine culture and urodynamic assessment. All patients underwent transurethral implantation using Macroplastique Implantation System (MIS). Patient follow-up was performed 6 and 12 months after surgery. Results A total of 24 consecutive patients were enrolled. At the 12 month follow up SUI cure rate was 42% (10 of 24 patients), the improvement rate was 42% (10 of 24) and the failure rate was 16% (4 of 24). The overall success rate was 84% (10 patients cured and 10 improved). No intraoperative or postoperative early complications were found. The 4 patients in whom treatment was not a success had preoperative urethral hypermobility. Subjective patient perception of SUI symptom severity showed significant improvement (mean severity of urinary loss perception 6.6 ± 1.8 vs 2.3 ± 3.3, p < 0.05). The frequency of incontinence on the 3-day voiding diary was significantly reduced at the follow up (14.5 ± 5.8 vs 4.3 ± 7.9 episodes per 3 days, p < 0.05). Conclusion(s) Bulking agents urethral injection could be a valid option having no surgical complications. This therapeutic strategy is able to treat SUI and improve well being of cervical cancer patients after radical surgery.

Transurethral Polydimethylsiloxane Injection: A Valid Minimally Invasive Option for the Treatment of Postradical Hysterectomy Urinary Incontinence

Urinary incontinence (UI) is a common complication after radical hysterectomy, ranging between 21% and 53%. Two cases of postradical hysterectomy UI treated with transurethral macroplastique injection are reported here. At 1-year follow-up, 1 patient showed no episodes of incontinence in voiding diary. The second patient showed a positive cough stress test only in standing position at 400 mL of bladder emptying. The frequency of UI according to a 3-day voiding diary was 3 episodes. Preoperative and postoperative subjective patient perception of UI symptom severity (visual analog scale) was 7-0 and 8-2 for cases 1 and 2, respectively. Bulking agents urethral injection could be a minimally invasive option to improve well-being of patients with cervical cancer after radical surgery.

The Role of Unilateral Adrenalectomy in ACTH‐Independent Macronodular Adrenal Hyperplasia (AIMAH)

ACTH-independent macronodular adrenal hyperplasia (AIMAH) is a rare cause of Cushing's syndrome. Bilateral adrenalectomy is considered the treatment of choice, with subsequent lifetime steroid replacement, but unilateral adrenalectomy has been recently proposed to reduce the secreting tissue. This prospective study was designed to evaluate the long-term results of unilateral adrenalectomy in AIMAH concerning the main laboratory and clinical abnormalities and the patient's quality of life. Seven consecutive patients with confirmed AIMAH underwent unilateral adrenalectomy of the largest gland. ACTH and cortisol levels, arterial blood pressure (BP), glycometabolic parameters, and patient's subjective perception of health-related quality of life (by the SF-36 questionnaire) were measured preoperatively and postoperatively. No surgery-related morbidity occurred. One patient with a large contralateral adrenal enlargement required a completion adrenalectomy after 7 months because of persistent hypercortisolism. At a median follow-up of 53 (range, 27-68) months, the remaining six patients were cured, because serum and urinary free cortisol levels significantly decreased and ACTH increased, thus regaining the normal range. Both systolic and diastolic BP levels significantly reduced: 50% of patients definitively became normotensive, and the remaining patients reduced the need for antihypertensive treatment; 40% of patients suffering from preoperative diabetes were cured, whereas 40% reduced the need for hypoglycemizing drug. SF-36 evaluation of the health-related quality of life confirmed a significant amelioration. Unilateral adrenalectomy of the largest gland can be an effective and safe treatment for AIMAH in case of asymmetric involvement. It may achieve long-term remission of Cushing's syndrome and improve BP values, glycemic control, and patient's quality of life.

The Need for Rigid Cystoscopy and Resection of Tumour (TURBT)

Whilst we agree that coughing may lower the patient's subjective perception of pain, we are unsure whether this technique would improve the diagnostic yield of muscle invasive bladder carcinoma identified by biopsy. Flexible cystoscopy is good in diagnosis and biopsy of superficial dieases of the bladder in trained hands1 but is not reliable in identifying muscle invasive bladder carcinoma as this requires resection of the tumour together with the underlying lamina propria (i.e. for diagnosis of T1b tumours) or detrusor muscle to stage the tumour accurately. It has also been long known that the main risk associated with bladder biopsy is that of bladder perforation.2 The incidence of asymptomatic bladder perforation following routine bladder operation for investigation of bladder tumour can be as high as 58.3%.3 We feel that with the technique described by De'ath and Kayes, one may lose the preciseness of controlling the depth of biopsy which may result in inadvertent perforation of the bladder. A formal rigid cystoscopy and resection of tumour (TURBT) should, therefore, be organised if suspicion of muscle invasion arises during flexible cystoscopy.

Perception of night‐time sleep by surgical patients in an intensive care unit

The night-time sleep of patients hospitalized in intensive care is a very important feature within the health or disease process, as it has a direct repercussion on their adequate recovery. (1) To describe how surgical patients perceive their sleep in the intensive care unit; (2) to compare the subjective perception of patients with the nursing records and analyse these for the degree of agreement. Descriptive research. One hundred and four surgical patients were recruited to the study. Patients completed the Richards-Campbell Sleep Questionnaire, a five-item visual analogue scale, to subjectively measure their perceived level of sleep (range 0-100 mm). The observation of patient sleep by nurses, demographic data, nursing care during the night and use of specific pharmacological treatments were also collected from the nursing records. The total mean score of sleep on the first post-operative night was 51.42 mm, 28% of patients had a good sleep, 46% a regular sleep and 26% a bad sleep. The sleep profile of these patients has been characterized by the patients having a light sleep, with frequent awakening and generally little difficulty to go back to sleep after the awakenings. The agreement between the nurses' perceptions of patients' sleep and the patients' perception of their sleep was tested by means of one-factor analysis of variance (p < 0.05) with a variation coefficient of 36.88%, which indicates that relative agreement was obtained. From analysing every nurse-patient perception, we obtained 44% of total agreement and 56% of disagreement. When discrepancy was found, the nurse generally overestimated the patients' perception. Surgical patients' perceptions of their sleep in the ICU suggest that this is inadequate. Nurses' perceptions of patients' sleep partially coincides with the latter's perception, but we have also found that the former frequently overestimate patients' sleep.

Predictors of diagnosis in Huntington disease

Subtle signs and symptoms of Huntington disease (HD) are often present before impairments reach a point where the neurologic disease is manifest and a diagnosis must be considered. The objective is to examine the prognostic significance of these early clinical signs and symptoms regarding time until unequivocal clinical HD diagnosis. We analyzed longitudinal data from 218 at-risk but healthy participants in the Huntington Study Group database who had either normal motor examination results or minimal soft motor signs at first observation. This group was followed periodically in HD clinics for up to 4.5 years. We used survival analysis to examine predictors of time until HD diagnosis. Diagnostic prediction was significantly improved using specific, nonredundant items from the Unified Huntington's Disease Rating Scale. When a movement disorder specialist initially had a global impression of "soft signs" present, cumulative relative risk of diagnosis was 4.68 times greater at 1.5 years of follow-up and 3.58 at 3 years. A neuropsychological test pattern with psychomotor speed 1 SD worse than a semantic knowledge measure increased cumulative risk by 1.99 times at 1.5 years and 1.81 at 3 years. Finally, reports of various subjective HD symptoms increased 3-year relative risk by 2.6 to 3.4. Findings demonstrate that neuropsychological performance and both the clinician rating and the patient subjective perception of motor difficulties contribute nonredundantly to a prediction of Huntington disease diagnosis. These findings may have implications for prognostic assessment of persons at risk and eventually assist with early interventions.

Objective versus Subjective Outcomes Assessment in Rhinology

Prior studies on the relationship between computed tomography scan findings and patient-based quality of life in chronic rhinosinusitis (CRS) have found very low correlations. Whereas surprising, similarfindings have been noted in other diseases. We performed a cross-sectional analysis of the association between objective and subjective findings in nasal septal deformity and a systematic review and synthesis of the literature on CRS and other diseases. We found no association between objective anatomic findings and subjective symptoms in nasal obstruction (R = 0.03; Kruskal-Wallis test, p = 0.97). Multiple studies in CRS and other diseases-sleep apnea, hearing loss, asthma, etc.- have found similarly low correlations between objective and subjective testing. For nasal septal deviation and CRS, the patient's subjective perception of disease severity has, at best, a very weak association with objective assessment of severity. Patient-based outcomes assessment remains important; these instruments apparently quantify an aspect of disease not detected by objective testing.

Victimization of Patients with Schizophrenia and Related Disorders

Previous research has predominately focused on patients with mental illness as the instigators, rather than the victims, of violence and criminal activity. However, patients with schizophrenia appear to experience a higher degree of victimization compared to general community samples. We aimed to establish the 1-month prevalence of violent and non-violent victimization in a sample of patients with schizophrenia spectrum disorders and to investigate the determinants of victimization. Reports of violent and non-violent victimization were recorded in 348 patients in Dandenong, an outer metropolitan suburb of Melbourne, Australia along with the subjective perception of patients as to their degree of protection from being robbed or attacked. Patients reporting victimization were compared with those who did not, across a range of clinical and psychosocial variables. 11.2% of the sample reported being the victim of non-violent crime and 4.3% the victim of violent crime in the 1-month period. 23.2% reported dissatisfaction with their protection against being attacked or robbed. The major determinant of victimization was the lack of any meaningful daily activity. Patients with schizophrenia spectrum disorders are at increased risk of victimization, both of the violent and non-violent type. Further research is required to understand the pathways through which victimization occurs and to understand whether psychosocial interventions can reduce victimization in this patient population.

Victimization of patients with schizophrenia and related disorders

Background: Previous research has predominately focused on patients with mental illness as the instigators, rather than the victims, of violence and criminal activity. However, patients with schizophrenia appear to experience a higher degree of victimization compared to general community samples. We aimed to establish the 1-month prevalence of violent and non-violent victimization in a sample of patients with schizophrenia spectrum disorders and to investigate the determinants of victimization.Method: Reports of violent and non-violent victimization were recorded in 348 patients in Dandenong, an outer metropolitan suburb of Melbourne, Australia along with the subjective perception of patients as to their degree of protection from being robbed or attacked. Patients reporting victimization were compared with those who did not, across a range of clinical and psychosocial variables.Results: 11.2% of the sample reported being the victim of non-violent crime and 4.3% the victim of violent crime in the 1-month period. 23.2% reported dissatisfaction with their protection against being attacked or robbed. The major determinant of victimization was the lack of any meaningful daily activity.Conclusions: Patients with schizophrenia spectrum disorders are at increased risk of victimization, both of the violent and non-violent type. Further research is required to understand the pathways through which victimization occurs and to understand whether psychosocial interventions can reduce victimization in this patient population.

Worldwide severity and control of asthma in children and adults: the global asthma insights and reality surveys

BackgroundIn 1995, the Global Initiative for Asthma (GINA) guidelines recommended goals for the management of asthma, which were updated in 2002. However, there are no recent international surveys on the real management of asthma. ObjectiveThe Asthma Insights and Reality surveys are the first large-scale surveys aimed at determining international variations in the severity, control, and management of asthma in children and adults. MethodsA cross-section of households in 29 countries in North America, Europe, and Asia were surveyed to identify from the general population asthmatic patients with symptoms within the last year or who were taking current asthma medication. A standard questionnaire was administered to 7786 adults, and, through a proxy, to 3153 children with asthma. Objective and subjective patient perception of asthma control and severity were assessed, including access to medical care, health care use, missed work-school, and medication use. ResultsDespite variations at a country level, a substantial effect of asthma on patients' lives was observed, with considerable loss of schooldays and workdays. The current level of asthma control worldwide falls far short of the goals for long-term management in international guidelines. A significant proportion of patients continue to have symptoms and lifestyle restrictions and to require emergency care. The proportion of adult asthmatic patients who were current smokers was also high. However, the use of anti-inflammatory preventative medication, even in patients with severe persistent asthma, was low, ranging from 26% in Western Europe to 9% in Japan, as was the use of objective lung function testing. The correlation between self-perceived severity of asthma and objective assessment of severity on the basis of GINA criteria was consistently poor in all areas. ConclusionWe conclude that there is direct evidence for suboptimal asthma control in many patients worldwide, despite the availability of effective therapies, with long-term management falling far short of the goals set in the GINA guidelines.

An integrative approach to the management of insomnia

Over the last three decades, an evolution has occurred in our understanding of the nature of chronic insomnia, the guidelines for its identification, and the methods for its treatment. The conceptualization of insomnia is generally agreed to be contingent on the patient's subjective perception of unsatisfactory sleep quantity and/or quality, rather than on the actual amount of sleep deficit. Factors contributing to the aetiopathogenesis of chronic insomnia can be divided into three categories: predisposing, precipitating, and perpetuating. Assessment of the patient's overall clinical problem should be conducted in an individualized and integrative fashion, while special attention should be given to any psychopathology or psychological distress, which is quite common but often denied. Because of its multifaceted and variable aetiopathogenesis, chronic insomnia necessitates a multidimensional treatment plan. The treatment modalities are broadly divided into non-pharmacological ones (sleep hygiene education, cognitive-behavioural techniques, and/or psychodynamic psychotherapy) and pharmacological ones (mainly the use of benzodiazepine or non-benzodiazepine hypnotics, at the initial stages). In an integrative therapeutic approach, two or more treatment modalities are combined and their application is based on a sound patient-doctor relationship.

Stress and male fertility

In this review, empirical findings on the influence of stress on sperm parameter are presented. Although stress is not associated per se with an abnormal semen analysis, personal and situational factors may cause a decrease in sperm quality. The patient's subjective perception of stress represents an essential personal factor, whereas chronicity of stress represents a situational factor. At present, little is known about the endocrine mechanisms mediating the influence of stress on spermatogenesis. Additionally, it is not yet clear to what extent fertility is actually affected by stress-induced decrease of sperm quality. Irrespective of the effects of stress on the sperm parameters, there are other relevant behavioral effects of stress on fertility: patients infrequently seek professional help; chances to conceive may be reduced due to sexual difficulties. Patients feeling highly distressed should be offered proven interventions to reduce stress.