Elaine Jolly

A decision aid for women considering hormone therapy after menopause: decision support framework and evaluation

Although postmenopausal women are advised to consider their values when deliberating about potential benefits and risks of hormone therapy (HRT), feasible, effective methods of decision support in primary care have yet to be established. Using an explicit decision support framework, we developed a self-administered HRT decision aid and evaluated it in a before/after study of 94 women from six family practices. An audiotape guided women through an illustrated booklet including: detailed information about HRT benefits and risks tailored to a womans clinical risk, and a values clarification exercise to promote informed decision making consistent with personal values. After using the decision aid participants: had better general knowledge and more realistic personal expectations of HRT benefits and risks; and, felt more certain, informed, clear about values, and supported in decision making. Womens values elicited in the clarification exercise were 84% accurate in discriminating between decisions. Women with polarized preferences at baseline did not change their minds, but were better informed. Changes in preferences occurred in the uncertain group, with equal numbers accepting or declining HRT. Most participants found the decision aid comprehensible, acceptable in length and pace, and balanced. Decision aids are useful in preparing women for decision making about this complex, personal issue.

Randomized Trial of a Portable, Self-administered Decision Aid for Postmenopausal Women Considering Long-term Preventive Hormone Therapy

Although practice guidelines suggest that postmenopausal women learn about the benefits and nsks and consider their values when deciding about hormone therapy, the optimal decision-support method has not been established. In a randomized controlled trial, the authors compared the efficacy of a general educational pamphlet with that of a tailored decision aid. The pamphlet briefly summarized benefits, risks, and likely beneficiaries in general terms. The decision aid, delivered via booklet and audiotape, provided: detailed benefits and risks using functional terms and probabilities tailored to clinical risk; and steps for considering the issue in a womans own situation, including a value-clarification exercise. Compared with the pamphlet group, the decision-aid group had statistically significant (p < 0.05) improvements in terms of realistic personal expectations of the benefits and nsks, decisional conflict, and perceived acceptability of the intervention. Levels of general knowledge about the main benefits and nsks were comparable for the two interventions It is concluded that tailored decision aids prepare women for decision making better than do general pamphlets. Key words: decision making; choice behavior; informed consent; decision-support techniques; woman education; woman participation; health education; consumer satisfaction; hormone replacement therapy; menopause. (Med Decis Making 1998;18:295-303)

A qualitative study of physicians' perceptions of three decision aids

The study objective was to investigate physicians perceptions of three patient decision aids (DA). Semi-structured telephone interviews were conducted with 20 family physicians and 12 gynecologists about a DA for women considering long-term hormone replacement therapy; with 16 respirologists about a DA for the use of intubation and mechanical ventilation for patients with severe chronic obstructive pulmonary disease; and with 19 physicians (geriatricians, gastroenterologists, internists) about a DA for long-term placement of feeding tubes in the elderly. Participants were identified by a snowball sampling technique. The interviews were analyzed using standard qualitative methods. Most participants (81%) indicated some willingness to use the DAs. The characteristics of the DA viewed positively included it being: balanced, well organized, a useful tool, evidence-based, improves decision making process and multimedia. Some of the negative characteristics were stated as: too complex, the cost, the availability, only appropriate for certain groups of patients, and time consuming. The DAs were acceptable to most participants. Perceived positive and negative factors were similar for all DAs. Uptake of decision aids may be facilitated if physicians have an opportunity to examine and try them, and if they can have unfettered access to them for distribution purposes.

Primary thrombocythemia in pregnancy: A report of two cases

We report two cases of primary thrombocythemia diagnosed during pregnancy. One patient developed transient visual field defects. She was treated with plateletpheresis at term and delivered of a normal child by cesarean section. The second patient was not treated. Intrauterine fetal death occurred at 36 weeks gestation from multiple placental infarcts. In cases of primary thrombocythemia, we suggest close monitoring of both mother and fetus throughout pregnancy.

Spherical versus Conventional Polyvinyl Alcohol Particles for Uterine Artery Embolization

PURPOSEnTo compare the efficacy of spherical polyvinyl alcohol (PVA) particles versus conventional PVA particles for uterine artery embolization (UAE).nnnMATERIALS AND METHODSnOf 149 patients with 1-year follow-up after UAE, 96 received conventional PVA particles and 53 received spherical PVA particles. Severity of symptoms was ranked on an 11-point numeric rating scale (0-10). The changes in severity of symptoms after embolization, blood hemoglobin level, and the size of the dominant tumor depicted by ultrasonography were used to assess the efficacy of the two types of particles. The number of hysterectomies and myomectomies in each group was also recorded as evidence of UAE failure.nnnRESULTSnOn 1-year follow-up, patients treated with conventional PVA showed average numeric rating scale score improvements of 4.6 in menorrhagia, 2.9 in dysmenorrhea, 3.7 in pressure sensation, and 3.4 in urinary frequency. With spherical PVA, the average improvements were 3.0 in menorrhagia, 2.4 in dysmenorrhea, 3.1 in pressure sensation, and 2.0 in urinary frequency. Except in dysmenorrhea, all differences were significant (P < .001). With conventional PVA, there was an 8-mg/mL increase in blood hemoglobin level versus a 3-mg/mL increase with spherical PVA (P < .05). With conventional PVA, there was a 28-mm (34%) average reduction in diameter of the dominant tumor versus a 15.7-mm (19%) reduction with spherical PVA (P = .01). Eight of 96 patients (8%) treated with conventional PVA underwent hysterectomy or myomectomy during the entire length of the study, versus six of 53 patients (11%) treated with spherical PVA (P = .6). No patient underwent multiple embolizations.nnnCONCLUSIONSnIn comparison with conventional PVA particles, UAE with the use of spherical PVA particles resulted in less fibroid tumor shrinkage and less improvement in clinical symptoms.

Superior hypogastric nerve block for pain control in outpatient uterine artery embolization

PURPOSEnTo assess the efficacy of the superior hypogastric nerve block (SHNB) in permitting uterine artery embolization (UAE) to be performed as a routine outpatient procedure.nnnMATERIALS AND METHODSnOne hundred thirty-nine patients who underwent UAE in a prospective single-arm clinical trial in an academic institution underwent SHNB from an anterior abdominal approach to control acute postprocedural pain, in addition to conventional conscious sedation. They were discharged and prescribed one of two drug combinations started during the in-hospital recovery period. Regimen A included short-acting morphine tablets and indomethacin rectal suppositories and regimen B included long-acting morphine tablets for baseline pain supplemented with short-acting morphine tablets for breakthrough pain, and naproxen rectal suppositories. All patients were contacted by phone on the third and fifth postprocedural days and their peak pain experience was recorded on a scale of 0 to 10.nnnRESULTSnAll patients were able to be discharged the day of the procedure. Seven patients (5%) returned to the hospital because of pain. One was discharged after undergoing a second SHNB and four were discharged after receiving intravenous analgesics; two required longer admission for intravenous analgesia. The mean (+/-SD) peak pain score in the first 5 days after the procedure for all patients was 4.8 +/- 2.6. There was a significant difference between regimens A (mean pain score, 5.7 +/- 2.2) and B (mean pain score, 2.7 +/- 2.5; Mann-Whitney, 5.94; P < .01).nnnCONCLUSIONnThe addition of SHNB to the more conventional post-UAE pain management methodology enhances pain control, enabling the procedure to be offered with minimum pain on a routine outpatient basis.

Outpatient Uterine Artery Embolization for Symptomatic Fibroids: Short- and Long-Term Single Institution-Based Outcomes

OBJECTIVEnTo assess the short- and long-term efficacy and safety of uterine artery embolization (UAE) in the management of uterine fibroids, and to assess patient satisfaction with this procedure when performed on an outpatient basis.nnnMETHODSnOne hundred one patients who had undergone UAE for symptomatic uterine fibroids in the past five years were interviewed over the telephone, using a standard uterine fibroid symptom and quality-of-life questionnaire. The severity of post-procedural pain, occurrence of adverse reactions, complications, need for subsequent hysterectomy or myomectomy, and overall patient satisfaction were also recorded.nnnRESULTSnUAE resulted in a mean 39.1 point improvement in fibroid symptom scores and a mean rise of health-related quality of life score to 93.6, which is near normal. The mean pain score was highest (3.7/10) on the first night after the procedure. Ten patients returned to the hospital in the first 48 hours after UAE, but of these only one required admission because of sepsis. The only other major complication was spontaneous fibroid expulsion in one patient. Fourteen patients remained hypermenorrheic, 78 had regained normal or light menses, five reported spotting, and four became amenorrheic. Six patients underwent subsequent hysterectomy and one a subsequent myomectomy. Six patients found the procedure less than satisfactory.nnnCONCLUSIONnUAE is a safe, effective, and durable alternative to hysterectomy and myomectomy in women with symptomatic fibroids who wish to avoid surgery. It can be performed safely on an outpatient basis.

Ultrastructural Studies on Testicular Biopsies From Eighteen Cases of Hypospermatogenesis**Supported by Grant MA 4845 from the Medical Research Council of Canada.

An electron microscopic study was conducted on biopsies from 18 young hypospermatogenic patients. No signs of tubular blockage or germinal disorganization were found. The relationships between the different components of the germinal epithelium were comparable to those found in normal testes. Germ cells were often connected by cytoplasmic bridges and Sertoli cells by typical narrow junctions, which, in the case of very depleted tubules, were very extensive and of irregular outline owing to the interdigitations of the cells. Sertoli cells had normal cytologic characteristics and, contrary to the findings of other investigators in similar material, had apparently a normal amount of lipid droplets and microfilaments. In six cases, a large number of thick, banded collagen fibers substituted for the microfibrils usually found between the myoid cells in the tunica propia. The possible significance of these changes as a cause or as a consequence of the tubular changes is not yet clear.