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PubMed1997

The management of tinnitus with or without Menière's disease.

More than 95% of tinnitus patients do not require anything but careful examination and explanation, i.e. directive counselling. The first and principal therapy consists of history taking and routine ear, nose and throat (ENT) examination, including a thorough audiometric assessment with tinnitus analysis. The best management of the patient appears to be a behavioural approach centred on the complaint, including information provision and explanation, discussion of treatment options, and an informed selection from the alternatives available.

Humans↗
PubMed1996

Role of consumer information in today's health care system.

This overview discusses articles published in this issue of the Health Care Financing Review, entitled "Consumer Information in a Changing Health Care System." The overview describes several trends promoting more active consumer participation in health decisions and how consumer information facilitates that role. Major issues in developing consumer information are presented, stressing how orientation to consumer needs and use of social marketing techniques can yield improvement. The majority of the articles published in this issue of the Review discuss different aspects of information for choice of health plan, ranging from consumer perspectives on their information needs and their comprehension of quality indicators, to methods used for providing such information, such as direct counseling and comparative health plan performance data. The article concludes with thoughts on how we will know if we succeed in developing effective consumer health information.

Community Participation↗
PubMed1999

Sexual practices in a cohort of US women with and without human immunodeficiency virus. HERS Study. HIV Epidemiology Research Study.

OBJECTIVES: To compare the frequency and pattern of sexual activities of women infected with human immunodeficiency virus (HIV) relative to uninfected women at the time of enrollment into a multisite cohort study. METHODS: The HIV Epidemiology Research Study (HERS) is a prospective study following 873 HIV-infected and 438 HIV-uninfected women. The baseline protocol included interviews about sexual practices, sociodemographic information, and drug and alcohol use, as well as clinical and laboratory studies. Multiple logistic regression models estimated differences between infected and uninfected women in relation to sexual activity and practice. RESULTS: 77% of infected women and 89% of uninfected women reported at least one sexual partner in the six months before study entry. Among sexually active women, specific practices varied little by HIV serostatus, with the exception of oral sex, which was more frequently performed and received by uninfected women. Despite the high prevalence of sexual activity, infected women were 2.5 times as likely not to have had any recent sexual partners as uninfected women (95% CI = 1.77-3.44). CONCLUSIONS: Women who decrease or altogether stop engaging in sexual partnerships may benefit from direct counseling in relation to underlying loss of sexual affection.

Adolescent↗
PubMed2002

[Ultrasound screening in pregnancy: evidence and maternity care reality].

Since 1980 maternity care in Germany has included ultrasound screening. The aim of this review is (1) to assess the benefit of ultrasound screening on the basis of randomised, controlled trials in accordance with the criteria of evidence-based medicine, (2) to examine current screening practice and the quality of German maternity care in everyday clinical practice, and (3) to indicate priorities for further screening developments. We reviewed Cochrane reviews, health technology assessment reports and relevant individual studies. The three essential effects that may be achieved by ultrasound screening include: (1) earlier detection of multiple pregnancies, (2) better dating of pregnancy and reduction in induced labour by 40%, and (3) more frequent and earlier detection of foetal malformations including the option for an abortion. Yet, early detection does not increase the rate of successful pregnancies. The effects mentioned are only incompletely achieved with standard maternity care in Germany. For example, there is no evidence for an essential reduction of the frequency with which labour is induced. Detection rates in routine preventive care are markedly lower than described for trial conditions. Only multiple pregnancies can be identified more or less completely; detecting other target diagnoses remains unsatisfactory: placenta praevia 57% (without signs of bleeding 14%), postmaturity 46%, malformations 30-40% and intrauterine growth retardation 30%. Also, high rates of false positive findings can be observed that might lead to follow-up examinations and unnecessary treatment procedures. Quality of maternity screening is low and is not subjected to substantial quality assurance. We suggest the following priority measures: (1) to improve the quality of screening by modifying the previous three-step concept with the aim of promoting accessibility of highly qualified examiners for all pregnant women, (2) to strengthen quality assurance, (3) to assist the pregnant woman with her informed decision by offering independent and non-directional counselling concerning the advantages and disadvantages of screening and (4) to focus maternity care on effective interventions according to the criteria of evidence-based medicine.

Evidence-Based Medicine↗
PubMed2003

Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression. I. Impact on maternal mood.

BACKGROUND: Psychological interventions for postnatal depression can be beneficial in the short term but their longer-term impact is unknown. AIMS: To evaluate the long-term effect on maternal mood of three psychological treatments in relation to routine primary care. METHOD: Women with post-partum depression (n=193) were assigned randomly to one of four conditions: routine primary care, non-directive counselling, cognitive-behavioural therapy or psychodynamic therapy. They were assessed immediately after the treatment phase (at 4.5 months) and at 9, 18 and 60 months post-partum. RESULTS: Compared with the control, all three treatments had a significant impact at 4.5 months on maternal mood (Edinburgh Postnatal Depression Scale, EPDS). Only psychodynamic therapy produced a rate of reduction in depression (Structured Clinical Interview for DSM-III - R) significantly superior to that of the control. The benefit of treatment was no longer apparent by 9 months post-partum. Treatment did not reduce subsequent episodes of post-partum depression. CONCLUSIONS: Psychological intervention for post-partum depression improves maternal mood (EPDS) in the short term. However, this benefit is not superior to spontaneous remission in the long term.

Adolescent↗
PubMed2003

Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression: 2. Impact on the mother-child relationship and child outcome.

BACKGROUND: Postnatal depression is associated with adverse child cognitive and socio-emotional outcome. It is not known whether psychological treatment affects the quality of the mother-child relationship and child outcome. AIMS: To evaluate the effect of three psychological treatments on the mother-child relationship and child outcome. METHOD: Women with post-partum depression (n=193) were assigned randomly to routine primary care, non-directive counselling, cognitive-behavioural therapy or psychodynamic therapy. The women and their children were assessed at 4.5, 18 and 60 months post-partum. RESULTS: Indications of a positive benefit were limited. All three treatments had a significant benefit on maternal reports of early difficulties in relationships with the infants; counselling gave better infant emotional and behaviour ratings at 18 months and more sensitive early mother-infant interactions. The treatments had no significant impact on maternal management of early infant behaviour problems, security of infant-mother attachment, infant cognitive development or any child outcome at 5 years. CONCLUSIONS: Early intervention was of short-term benefit to the mother-child relationship and infant behaviour problems. More-prolonged intervention may be needed. Health visitors could deliver this.

Adult↗
PubMed2003

Success rate of vaginal birth after cesarean delivery at Maharaj Nakorn Chiang Mai Hospital.

OBJECTIVE: To study the success rate of vaginal birth after cesarean delivery (VBAC) in pregnant women with prior cesarean scar who delivered at Maharaj Nakorn Chiang Mai Hospital. STUDY DESIGN: Prospective descriptive study. SETTING: Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand. SUBJECT: One hundred and seventy-seven pregnant women with one or two prior cesarean deliveries, who attended the antenatal clinic and delivered at Maharaj Nakorn Chiang Mai Hospital between January, 2000 and September, 2002 were recruited with written informed consents. INTERVENTION: Systematic non-directive counseling concerning VBAC compared with elective repeated cesarean delivery was given to the pregnant women. Couples freely chose their preferred route of delivery and were informed that they could change their mind at anytime. Subjects attended the high risk antenatal care clinic. Patients who requested repeated cesarean deliveries were scheduled for the operation at 38 weeks of gestation. All VBAC patients were admitted to the labor unit when in labor and were closely monitored. Labor and postpartum information was prospectively recorded. MAIN OUTCOME MEASURE: Success rate of VBAC. RESULT: Of 177 counselled women, 118 chose VBAC, 54 chose repeated cesarean and 5 could not make a decision. Thirty-three of the 177 cases were excluded, leaving 98 in the VBAC group and 46 in the repeated cesarean group. Baseline characteristics of the patients in both groups were not significantly different. Nineteen of the 98 cases were delivered by cesarean section because of obstetric indications (12/19) and changed their minds during the antenatal period (7/19). Forty-three of 79 cases had successful vaginal delivery, and 36 underwent repeated cesarean deliveries due to obstetric indications (19/36) and changed their minds during labor (17/36). The success rate of VBAC after trial of labor was 54.4 per cent (43 in 79). No uterine rupture or serious complication occurred in the present study. CONCLUSION: The attitude for VBAC was 66.7 per cent and the success rate of VBAC after trial of labor was 54.4 per cent in the present series. Several cesarean deliveries could be avoided by the VBAC policy. Unlike other previous reports, the failure rate of VBAC was rather high. This was associated with many factors such as change of mind due to labor pain.

Cesarean Section↗
PubMedDate not supplied

Smoking cessation rate 12 months after a group counseling program in Mongolia.

Mongolia is one of the top ten countries with the highest smoking rates of men and women combined, so that tobacco control, especially creating effective smoking cessation programs, is essential issue of the government. The present study aimed to assess an effectiveness of a free group counseling program by trained medical doctors and health educators based on "5A" (Ask, Assess, Advise, Assist, and Arrange) with 12 months follow-up in 2002 and 2003. Participants were 517 smokers with an intention to quit smoking in three big cities (Ulaanbaatar, Darkhan, and Erdenet). We found that 65.0% of them were not smokers 12 months after the program. The cessation rate was significantly higher in 2003 than in 2002, indicating that the effectiveness of the program had improved over time. Group counseling based on the "5A" approach by medical doctors and health educators seems effective for smokers with an intention to quit smoking. The present approach may be more appropriate in Mongolian conditions than nicotine replacement therapy.

Adolescent↗
PubMed1987

Ethical aspects of prenatal diagnosis: views of U.S. medical geneticists.

This article presents data from a study of 295 qualified medical geneticists in the United States. The study's objective was to determine the degree of consensus and variation among practicing medical geneticists about the major ethical problems of prenatal diagnosis. Based on the data presented, the argument has been made that most medical geneticists share a dominant moral approach on three major problems: abortion choices, controversial indications for fetal diagnosis, and problems in disclosure of ambiguous or disputed results. Ethical problems in selective termination in high-risk twin and multiple pregnancies need more study. A preliminary evaluation of the strengths and weaknesses of prevailing standards in prenatal diagnosis was also made. Three weaknesses were noted: neglect of the demands for fairness in access to and distribution of prenatal diagnosis in the United States, unpreparedness for society's growing concerns about developing trends in human genetics, and need for changes in non-directive counseling in order to appreciate the complexities that will accompany the introduction of proven new treatments for genetic disorders.

Attitude of Health Personnel↗
PubMed1993

Tay-Sachs disease--carrier screening, prenatal diagnosis, and the molecular era. An international perspective, 1970 to 1993. The International TSD Data Collection Network.

OBJECTIVES: To provide an update of the international experience with carrier screening and prenatal diagnosis for Tay-Sachs disease (TSD), to assess the impact of these efforts, and to review the recent developments in DNA technology with application to TSD carrier detection and screening. DESIGN: Through the International TSD Testing, Quality Control, and Data Collection Center, all testing centers in the world were surveyed annually to assess overall experience with carrier testing and prenatal diagnosis. Quality control and laboratory surveillance of testing centers were performed through an annual assessment, using samples provided by the center. SETTING: Tay-Sachs disease testing centers around the world. PARTICIPANTS: Nearly 1 million young adults from both Jewish and non-Jewish populations. INTERVENTION: Gene product screening (enzyme testing) and DNA-based mutation analysis (in some populations). MAIN OUTCOME MEASURE: Impact of screening program on disease incidence. RESULTS: Data from all centers in the international TSD network on experience with TSD carrier testing and prenatal diagnosis since 1974 indicated that more than 36,000 heterozygotes were identified and 1056 couples found to be at risk for TSD in their offspring. A total of 2416 pregnancies at increased risk for TSD were monitored by amniocentesis or chorionic villus sampling. A dramatic decrease in the incidence of TSD in the Jewish populations was demonstrated. With both serum and leukocyte proficiency testing, there have been only 16 instances (of 845 cumulative laboratory evaluations) of one or more errors reported by a laboratory since 1983 resulting in nonaccreditation. CONCLUSIONS: This analysis represents a prototypic effort in coordinating adult education, carrier testing, and genetic counseling directed toward prospective prevention of a uniformly fatal childhood disease and demonstrates that such an effort can dramatically affect disease incidence.

Clinical Enzyme Tests↗
PubMed1996

Neurophysiological approach to tinnitus patients.

The principal postulate of the neurophysiological model of tinnitus is that all levels of the auditory pathways and several nonauditory systems play essential roles in each case of tinnitus, stressing the dominance of nonauditory systems in determining the level of tinnitus annoyance. Thus it has been proposed to treat tinnitus by inducing and facilitating habituation to the tinnitus signal. The goal is to reach the stage at which, although patients may perceive tinnitus as unchanged when they focus on it, they are otherwise not aware of tinnitus. Furthermore, even when perceived, tinnitus does not evoke annoyance. Habituation is achieved by directive counseling combined with low-level, broad-band noise generated by wearable generators, and environmental sounds, according to a specific protocol. For habituation to occur, it is imperative to avoid masking tinnitus by these sounds. Since 1991, > 500 tinnitus patients have been seen in our center. About 40% exhibited hyperacusis to varying degrees. A survey of > 100 patients revealed > 80% of significant improvement in groups of patients treated with the full protocol involving counseling and the use of noise generators. Notably, in patients who received counseling only, the success rate was < 20%. The improvement in hyperacusis was observed in approximately 90% of treated patients.

Counseling↗
PubMed1995

Ethical implications for early pregnancy of the fetus as patient: a basic ethical concept in fetal medicine.

The viable fetus is a patient. The previable fetus, including the in vitro embryo and the near-viable fetus, is a patient solely as a function of the exercise of the woman's autonomy. Directive counseling of the pregnant woman for fetal benefit is appropriate only when the fetus is a patient and must take account of the presence and severity of anomalies, extreme prematurity and beneficence-based and autonomy-based obligations to the pregnant woman.

Embryo Transfer↗
PubMed1998

Cognition and the global Malaria Eradication Programme.

When making a decision involves the analysis of complex cause-effect relationships, experts are normally consulted to describe the best options available. The global Malaria Eradication Programme relied upon the advice of a small group of experienced malariologists; their counsel directed the most ambitious endeavour in the history of the World Health Organisation. In this essay 1 week to show how that group behaved with a single purpose and ultimately grew to be greater than the sum of its parts because of the control of knowledge. Each member of this epistemic community was willing to battle against malaria as soon as possible--forsaking research, traditional tools, and risking disastrous epidemics--because they believed that residual insecticides could progressively eradicate a disease that killed millions and sapped the lives of countless more. Alternative methods were ridiculed; and the epistemic community used their individual prestige to insert the DDT gospel into the technical forums of the WHO, and the power (and money) forums of the USA. Particular knowledge structures of the post-war decade nurtured a technical solution to malaria, and we shall explore how the WHO and the epistemic community could grow within this environment so compatible to their praxes.

DDT↗
PubMed2002

The role of non-directiveness in genetic counseling.

When the complete human genome has been sequenced, everyone of us will become a potential candidate for genetic counseling and testing. Within a short period of time everyone will obtain his personal genetic passport identifying deleterious and susceptibility genes. With the availability of presymptomatic tests for late-onset disorders and the possibilities of prevention and treatment, the conflict between directiveness and nondirectiveness will dominate the counseling setting. Despite general consent on providing genetic information in a nondirective fashion to preserve value neutrality and enhance client's autonomy, there is no accepted common definition of what non-directiveness really is or ought to be. The article tries to elaborate some aspects which might be fruitful and clarifying in the complex issues involved in the black box of genetic counseling.

Communication↗
PubMed2001

Direct observation of counseling on colorectal cancer in rural primary care practices.

To better understand colorectal cancer (CRC) screening practices in primary care, medical students directly observed physician-patient encounters in 38 physician offices. CRC was discussed with 14% of patients >or=50 years of age; 87% of discussions were initiated by the physician. The rate of discussions varied among the practices from 0% to 41% of office visits. Discussions were more common for new patient visits, with younger patients, and in the 24% of offices that utilized flow sheets. The frequency of CRC discussions in physician offices varies widely. More widespread implementation of simple office systems, such as flow sheets, is needed to improve CRC screening rates.

Colorectal Neoplasms↗
PubMed2004

Determining personal care consumers' preferences for a consumer-directed cash and counseling option: survey results from Arkansas, Florida, New Jersey, and New York elders and adults with physical disabilities.

OBJECTIVE: To assess Medicaid consumers' interest in a consumer-directed cash option for personal care and other services, in lieu of agency-delivered services. DATA SOURCES/STUDY SETTING: Telephone survey data were collected from four states from April to November 1997. Postsurvey focus groups were conducted in four states in 1998. Early implementation experiences are drawn from three states from 1999 to 2002. STUDY DESIGN: Participants (N=2,140) were selected for a structured telephone survey interview from a probability-sampling frame of current Medicaid consumers in Arkansas, Florida, New Jersey, and New York. Key variables include interest in the cash option, demographic and background characteristics of consumers, as well as previous experience and training needed. Postsurvey focus groups were also conducted with current Medicaid consumers. DATA COLLECTION/EXTRACTION METHODS: Interviewers read the telephone survey from computer screens and entered responses directly into the database of the Macintosh Computer Assisted Telephone Interview software. Data were analyzed using SPSS 10.0 (http://www.spss.com) for Windows. PRINCIPAL FINDINGS: Cash option interest was positively associated with experience hiring and supervising workers, more severe levels of disability, having a live-in caregiver, living in Florida, and minority status. Age of the client was also a significant factor. CONCLUSIONS: There is significant interest in the cash option, although interest varies among subgroups of consumers. Future research should continue to evaluate interest in the cash option among different groups of consumers, as well as actual experience with the option when the Cash and Counseling Demonstration and Evaluation (CCDE) evaluation findings are completed.

Adult↗