Termination of pregnancy among teenagers - why more surgical terminations?

Introduction: In 2012, a study by K. Chatziioannidou and S-C. Renteria showed that teenagers chose to undergo a surgical termination of pregnancy (TOP) more often than a medical TOP (mifepristone followed by misoprostol) when they decided to terminate a pregnancy. It also showed that the teenagers' choice for a medical versus surgical method is inversely proportional to the adults' choice although the efficiency of the medical method showed even better results for teenagers than for adults. According to the hypothesis made, the reasons for this choice might be influenced by the following facts: (i) the belated call to make an appointment, the medical procedure not being available after 9 weeks of gestation; (ii) the imperative request for confidentiality; (iii) the beliefs and subjective appreciation of the medical staff. Objectives: The aim of this retrospective and qualitative study is to analyse the reasons why, in case of a TOP, teenagers chose the surgical method more often than their adult counterparts. Material: (i) All teenagers who were admitted for an abortive procedure during 2011 in the in- or outpatient ward. (ii) The professional team (midwives and sexual and reproductive counsellors) in charge in the case of a TOP request. Methods: The information about the patient's history and the biopsycho- social data was retrieved from the patient files filled out by midwives and sexual and reproductive health counsellors during the first appointment for a TOP request or during its process. The professionals' appreciation was evaluated by means of a semi-structured questionnaire. Results: Concerning the choice of the method for a pregnancy termination, the results of our research show that: (i) Out of 47 teenagers, 27 chose the surgical method and 17 the medical method. (ii) Three had a second trimester abortion (which includes use of the medical method). (iii) Fifteen teenagers out of the 27 who chose a surgical method consulted between the 9th and 14th weeks of amenorrhoea and therefore did not have any other choice. The reasons for their 'late arrival' will be explained in detail. The 12 teenagers who arrived before the 8th week of amenorrhoea and chose to undertake abortion by suction & curettage under general anaesthesia did it for the following reasons: (i) Four were afraid of bleeding and pain. (ii) Five thought that the organisation of the surgical procedure was easier. (iii) Two did not trust the abortion pill. (iv) One was taken to her mother's gynaecologist where she had a D&C. Confidentiality was requested nine times out of 27 when choosing the surgical method, and six times out of 17 when choosing the medical method. Therefore, although confidentiality concerns a third of the teenagers' pregnancy termination requests, it does not seem to be a significant element for the choice of the method. As for the subjective appreciation of the professionals, the first results of the discussions seem to show that teenagers were reluctant or resistant towards the medical method. Conclusion: This study shows that the reasons why teenagers still prefer the use of the surgical over the medical method compared to adults, seem to include the late request for an appointment, fear of pain and bleeding and organisational issues. Confidentiality does not seem to greatly influence the teenagers' choice. Nonetheless, medical professionals seem to favour the suction curettage procedure performed under anesthesia because they associate young age with vulnerability and psychological frailty and consequently diminished ability to cope with pain and emotional distress during the medical procedures.

High prevalence of anorectal chlamydial infection in HIV-infected men who have sex with men in Switzerland.

Human immunodeficiency virus (HIV)-infected men who have sex with men (MSM) were enrolled in an anorectal Chlamydia trachomatis screening study. Anorectal Chlamydia DNA was detected in 16 (10.9%) of 147 men, mainly among asymptomatic patients and patients having >20 sexual partners. These results support routine anorectal Chlamydia screening in HIV-infected MSM who report unprotected anal intercourse.

Five-year monitoring of a gay-friendly voluntary counselling and testing facility in Switzerland: who got tested and why?

ABSTRACT: BACKGROUND: An increase in new HIV cases among men who have sex with men (MSM) has been reported in Switzerland since 2001. A rapid result HIV testing for MSM through voluntary counselling and testing (VCT) facility ("Checkpoint") was opened in Geneva in 2005. This gay-friendly facility, the first to open in Switzerland, provides testing for sexually transmitted infections (STI) and rapid result HIV testing and counselling. Our objective was to analyze Checkpoint's activity over its first five years of activity and its ability to attract at-risk MSM. METHODS: We used routine data collected anonymously about the facility activity (number of clients, number of tests, and test results) and about the characteristics of the clientele (sociodemographic data, sexual risk behaviour, and reasons for testing) from 2005 to 2009. RESULTS: The yearly number of HIV tests performed increased from 249 in 2005 to 561 in 2009. The annual proportion of positive tests among tests performed varied between 2% and 3%. Among MSM clients, the median annual number of anal intercourse (AI) partners was three. Roughly 30% of all MSM clients had at least one unprotected anal intercourse (UAI) experience in the previous 12 months with a partner of different/unknown HIV status.The main reason for testing in 2007, 2008, and 2009 was "sexual risk exposure" (~40%), followed by "routine" testing (~30%) and "condom stopping in the beginning of a new steady relationship" (~10%). Clients who came to the facility after a sexual risk exposure, compared to clients who came for "routine testing" or "condom stopping" reasons, had the highest number of AI partners in the previous 12 months, were more likely to have had UAI with a partner of different/unknown HIV status in the previous 12 months (respectively 57.3%, 12.5%, 23.5%), more likely to have had an STI diagnosed in the past (41.6%, 32.2%, 22.9%), and more likely to report recent feelings of sadness or depression (42.6%; 32.8%, 18.5%). CONCLUSION: Many of Checkpoint's clients reported elevated sexual risk exposure and risk factors, and the annual proportion of new HIV cases in the facility is stable. This VCT facility attracts the intended population and appears to be a useful tool contributing to the fight against the HIV epidemic among MSM in Switzerland.

Cystic lymphangioma of the adrenal gland: report of a case and review of the literature.

BACKGROUND: Cystic lymphangioma is a rare tumor of the lymphatic vessels that occurs more frequently in women. Location of this pathology can be diverse but most commonly occurs in the neck or axilla. Cystic lymphangioma originating from the adrenal tissue represents a very rare entity. CASE PRESENTATION: We report here the case of a 38-year-old woman who was diagnosed with a cystic retroperitoneal mass. After further investigations, the patient was suspected to have a left adrenal cystic lymphangioma. She underwent successful open left adrenalectomy as curative treatment, and the diagnosis of cystic lymphangioma of the left adrenal gland was confirmed at histology. The postoperative course was uneventful. CONCLUSION: This case report and review of the literature bring new insights into the diagnostic difficulty and management of cystic lymphangioma of the adrenal gland.

Hoitoketjun kustannukset perusterveydenhuollosta erikoissairaanhoitoon: Case Lappeenranta ja Imatra

Työn tavoitteena oli selvittää perusterveydenhuollon ja erikoissairaanhoidon välillä kulkevien lappeenrantalaisten (34 potilasta) ja imatralaisten (20 potilasta) hoitoketjun kustannukset ja hoitoajat, sekä analysoida niitä. Kustannusten ja hoitoketjun läpimenoaikojen esittämisessä käytettiin kustannuskertymäajattelua. Tutkimuksessa tutkittiin prosessien ohjauksen ja toiminnanohjauksen teoriaa sekä terveydenhuollossa että teollisuudessa, ja kustannuslaskennan perusteita. Huomattiin, että erityisesti lean -ajattelua voidaan käyttää myös terveydenhuollossa ja hoitoketjuja tarkasteltaessa. Empiirisessä osuudessa tarkasteltiin Lappeenrannan ja Imatran tutkittavien kolmen potilasryhmän kustannuksia ja hoitoaikoja kustannuskertymäkäyrien avulla. Tarkastelussa olivat kaupunkien ja potilasryhmien maksimi-, minimi- ja mediaanikustannuspotilaan hoitoketjun kustannukset ja läpimenoajat. Keskeisenä tuloksena havaittiin, että perusterveydenhuollon osuus kustannuksista oli suuri etenkin potilailla, joilla oli pitkä läpimenoaika hoitoketjussa, sillä hoitoaika painottui tällöin terveyskeskussairaalaan. Hyvin lyhyen läpimenoajan potilailla taas erikoissairaanhoidon osuus kustannuksista oli suurempi, mutta tällaiset potilaat olivat lähinnä minimi-, tai korkeintaan mediaanikustannuspotilaita. Päiväkohtainen kustannus havaittiin erikoissairaanhoidossa korkeammaksi, mutta perusterveydenhuollon terveyskeskussairaalahoito nousi maksimikustannuspotilailla aina selvästi suurimmaksi kustannuksen aiheuttajaksi. Havaittiin myös, että potilaiden lyhyt keskussairaalahoito ei takaa alentuneita hoitoketjun kokonaiskustannuksia. Työssä havaittiin, että perusterveydenhuollon toimivuus on koko terveydenhuollon toimivuuden ja tuottavuuden selkäranka. Erityisesti keskeisiä osia, mihin tulee kiinnittää huomiota hoitoketjussa, ovat potilaan sijoittaminen oikeinkeskussairaalahoitoon tultaessa ja sieltä lähdettäessä. Muun muassa näillä tavoilla voidaan karsia potilaiden ylipitkiä hoitojaksoja perusterveydenhuollossa tai potilaan jäämistä kiertämään hoitoketjuun.

Patients who attend a private practice vs a university outpatient clinic: how do they differ?

Although interpersonal continuity is commonly assumed to be essential for care, some patients prefer to attend a university outpatient clinic where physicians change regularly and interpersonal continuity of care is not ensured. The aim of this exploratory study was to evaluate the differences between patients attending a university outpatient clinic and patients frequenting a private practice, explore their patterns of care-seeking and their understanding of continued care. We conducted a cross-sectional study of patients attending the university medical outpatient clinic (OC) in Lausanne, Switzerland and ten randomly selected private general practices (PP). Eligible patients were >30 years, Swiss nationals or long term residents, with one or more chronic conditions and attending the same practice for >3 years. They were asked to complete a questionnaire on sociodemographic data, use of medical resources and reasons for choosing and remaining at the same practice. Semi-structured interviews were conducted with a randomly selected subset of 26 patients to further explore their preferences. 329 patient questionnaires were completed, 219 by PP and 110 by OC patients. OC patients tended to be of lower socioeconomic status than PP patients. The main reason for choosing a PP were personal recommendation, while a higher percentage of patients chose the OC because they could obtain a first appointment quickly. A higher percentage of PP patients accorded importance to physician communication skills and trust, whereas a higher percentage of OC patients favoured investigation facilities. Qualitative data suggested that although OC and PP patients reported different reasons for consulting, their expectations on the medical and relationship level were similar. Our study suggests that the two groups of patients belong to different social backgrounds, have different patterns of care-seeking and attach importance to different aspects of care continuity. However, patients' expectations and perceptions of the physician-patient relationship are similar.

Predictors of favourable outcome in first-episode patients who refuse medication: results from the FEPOS study

There are suggestions that some first-episode psychosis (FEP) patients can have favourable outcome without antipsychotic medication. However, there is very limited data regarding patients' characteristics on which the decision to propose medication free treatment could be based. FEPOS is a fi le-based study of an epidemiological sample of 704 FEP patients treated at EPPIC, Melbourne, between 1998 and 2000. Among the 661 patients where data was available, 108 consistently refused medication during the entire duration of their treatment at EPPIC. In this paper we compared, within this sub-group, patients who had a favourable outcome with those who did not. Patients were aged between 15 and 29 years (M = 21.9, SD = 3.40) and the majority were male (70.4%, n = 76). Symptomatic remission data was available on 105 patients; of these patients 41.0% (n = 41) had achieved remission. Functional remission data was available on 100 patients; of these patients 33.0% (n = 33) had achieved functional remission. Combined remission was evident in 23.0% (n = 23) of patients. Three factors were associated with symptomatic remission: better premorbid functioning (based on GAF, OR = 1.07, p = 0.006), higher number of years of education (OR = 1.43, p = 0.020), and being employed or studying at service entry (OR = 2.59, p = 0.034). Three factors were associated with functional remission: shorter duration of prodrome (OR = 0.50, p = 0.043), severity of psychopathology (CGI-S, OR = 0.51, p = 0.024), and vocational status at service entry (OR = 4.29, p = 0.003). While various aspects of pre-morbid functioning seem to correlate with the possibility of a favourable outcome in FEP patients who refuse medication, various limitations need to be taken into account in this study.

Vaarinpidosta virtuaaliaikaan : Sata vuotta suomalaista tilintarkastusta

Tämän tutkimuksen aiheena on tilintarkastuksen historiallinen kehittyminen Suomessa runsaan sadan vuoden aikana. Tutkimuksen tavoitteena on analysoida osakeyhtiön tilintarkastuksen kehitystä ja yhdistää vuosisadan kehityspiirteet tilintarkastuksen kokonaiskuvaksi. Tutkittava periodi alkaa 1800-luvun lopulta ja päättyy 2000-luvun taitteeseen. Tutkimuksessa tarkastellaan suomalaista tilintarkastusinstituutiota, joka jaetaan kolmeen osaan: tilintarkastusta säätelevään normistoon (normit), tilintarkastajajärjestelmään (toimijat) ja tilintarkastuksen sisältöön (tehtävät). Tutkimuksessa tavoitellaan vastauksia kysymyksiin: mitä tarkastettiin, milloin tarkastettiin, kuka tarkasti ja miten tarkastettiin eri aikakausina? Tutkimus perustuu historialliseen lähdeaineistoon, jonka muodostavat tutkimusajanjakson lainsäädäntö, lainvalmisteluasiakirjat, viranomaisten ohjeet ja päätökset, alan järjestöjen suositukset, ammattilehtien artikkelit sekä laskentatoimen ja tilintarkastuksen ammattikirjallisuus. Metodologisesti tutkimus on teoreettinen, kvalitatiivinen historiantutkimus, jossa lähdeaineistoa käsitellään lähdekriittisesti ja osittain sisältöanalyysin keinoin. Tilintarkastusta säätelevässä normistossa keskeisiä lakeja ovat olleet osakeyhtiölaki, kirjanpitolaki ja tilintarkastuslaki. Lakisääteinen tilintarkastus alkoi vuoden 1895 osakeyhtiölaista, joka uudistui vuonna 1978 ja jälleen vuonna 1997. Kirjanpitolainsäädäntö on uudistunut viidesti: 1925 ja 1928, 1945, 1973, 1993 sekä 1997. Vuoden 1994 tilintarkastuslakiin koottiin tilintarkastuksen säädökset useista laeista. Muita normistoja ovat olleet EY:n direktiivit, Kilan ohjeet, KHT-yhdistyksen suositukset, Keskuskauppakamarin säännökset ja viimeisimpinä IAS- ja ISA-standardit. Ammattimainen tilintarkastajajärjestelmä saatiin maahamme kauppiaskokousten ansiosta. Ammattimaisena tilintarkastuksen toimijana aloitti Suomen Tilintarkastajainyhdistys vuonna 1911, ja sen toimintaa jatkoi KHT-yhdistys vuodesta 1925 alkaen. Tilintarkastajien auktorisointi siirtyi Keskuskauppakamarille vuonna 1924. HTM-tilintarkastajat ovat olleet alalla vuodesta 1950 lähtien. Kauppakamarijärjestö on toiminut hyväksyttyjen tilintarkastajien valvojana koko ammattimaisen tilintarkastustoiminnan ajan. Valtion valvontaa suorittaa VALA (Valtion tilintarkastuslautakunta). Koko tutkittavan periodin ajan auktorisoitujen tilintarkastajien rinnalla osakeyhtiöiden tarkastajina ovat toimineet myös maallikot.Tilintarkastuksen tehtäviin kuului vuoden 1895 osakeyhtiölain mukaan hallinnon ja tilien tarkastus. Myöhemmin sisältö täsmentyi tilinpäätöksen, kirjanpidon ja hallinnon tarkastukseksi. Tutkimusajanjakson alussa tilintarkastus oli manuaalista kaikkien tositteiden prikkausta ja virheiden etsimistä. Myöhemmin tarkastus muuttui pistokokeiksi. Kertatarkastuksesta siirryttiin jatkuvaan valvontatarkastukseen 1900-luvun alkupuolella. Dokumentoinnista ja työpapereista alkaa olla havaintoja 1930-luvulta lähtien. Atk-tarkastus yleistyi 1970- ja 1980-luvuilla, jolloin myös riskianalyyseihin alettiin kiinnittää huomiota. Hallinnon tarkastuksen merkitys on kasvanut kaiken aikaa. Tilintarkastuskertomukset olivat tutkimusajanjakson alussa vapaamuotoisia ja sisällöltään ilmaisurikkaita ja kuvailevia. Kertomus muuttui julkiseksi vuoden 1978 osakeyhtiölain myötä. Myöhemmin KHT-yhdistyksen vakiokertomusmallit yhdenmukaistivat ja pelkistivät raportointia. Tutkimuksen perusteella tilintarkastuksen historia voidaan jakaa kolmeen kauteen, jotka ovat tilintarkastusinstituution rakentumisen kausi (1895 - 1950), vakiintumisen kausi (1951 - 1985) ja kansainvälistymisen ja julkisuuden kausi (1986 alkaen). Tutkimusajanjakson jokaisella vuosikymmenellä keskusteltiin jatkuvasti tilintarkastajien riittävyydestä, alalle pääsyn ja tutkintojen vaikeudesta, tilintarkastajien ammattitaidon tasosta,hallinnon tarkastuksen sisällöstä, tilintarkastuskertomuksesta sekä maallikkotarkastajien asemasta. 1990-luvun keskeisimmät keskusteluaiheet olivat konsultointi, riippumattomuus, odotuskuilu sekä tilintarkastuksen taso ja laadunvalvonta. Analysoitaessa tilintarkastuksen muutoksia runsaan sadan vuoden ajalta voidaan todeta, että tilintarkastuksen ydintehtävät eivät juurikaan ole muuttuneet vuosikymmenien kuluessa. Osakeyhtiön tilintarkastus on edelleenkin laillisuustarkastusta. Sen tarkoituksena on yhä kirjanpidon, tilinpäätöksen ja hallinnon tarkastus. Tilintarkastajat valvovat osakkeenomistajien etua ja raportoivat heille tarkastuksen tuloksista. Tilintarkastuksen ulkoinen maailma sen sijaan on muuttunut vuosikymmenten saatossa. Kansainvälistyminen on lisännyt säännösten määrää, odotuksia ja vaatimuksia on nykyisin enemmän, uusi tekniikka mahdollistaa nopean tiedonkulun ja valvonta on lisääntynyt nykypäivää kohti tultaessa. Tilintarkastajan pätevyys perustuu nykyään tietotekniikan, tietojärjestelmien ja yrityksen toimialantuntemukseen. Runsaan sadan vuoden takaisen lain vaarinpitovaatimuksesta on tultu virtuaaliaikaiseen maailmaan!

The profile of general practitioners (GPs) who publish in selected family practice journals

Background: Providing support for research is one of the key issues in the ongoing attempts to improve Primary Care. However, when patient care takes up a significant part of a GP's time, conducting research is difficult. In this study we examine the working conditions and profile of GPs who publish in three leading medical journals and propose possible remedial policy actions. Findings: The authors of all articles published in 2006 and 2007 in three international Family Medicine journals - Annals of Family Medicine, Family Practice, and Journal of Family Practice - were contacted by E-mail. They were asked to complete a questionnaire investigating the following variables: availability of specific time for research, time devoted to research, number of patients attended, and university affiliation. Only GPs were included in the study. Three hundred and ten relevant articles published between 2006 and 2007 were identified and the authors contacted using a survey tool. 124 researchers responded to our questionnaire; 45% of respondents who were not GPs were excluded. On average GPs spent 2.52 days per week and 6.9 hours per day on patient care, seeing 45 patients per week. Seventy-five per cent of GPs had specific time assigned to research, on average 13 hours per week; 79% were affiliated to a university and 69% held teaching positions. Conclusions: Most GPs who publish original articles in leading journals have time specifically assigned to research as part of their normal working schedule. They see a relatively small number of patients. Improving the working conditions of family physicians who intend to investigate is likely to lead to better research results.

Reporting of methodologic information on trial registries for quality assessment: a study of trial records retrieved from the WHO search portal

Background: Although randomized clinical trials (RCTs) are considered the gold standard of evidence, their reporting is often suboptimal. Trial registries have the potential to contribute important methodologic information for critical appraisal of study results. Methods and Findings: The objective of the study was to evaluate the reporting of key methodologic study characteristics in trial registries. We identified a random sample (n = 265) of actively recruiting RCTs using the World Health Organization International Clinical Trials Registry Platform (ICTRP) search portal in 2008. We assessed the reporting of relevant domains from the Cochrane Collaboration’s ‘Risk of bias’ tool and other key methodological aspects. Our primary outcomes were the proportion of registry records with adequate reporting of random sequence generation, allocation concealment, blinding, and trial outcomes. Two reviewers independently assessed each record. Weighted overall proportions in the ICTRP search portal for adequate reporting of sequence generation, allocation concealment, blinding (including and excluding open label RCT) and primary outcomes were 5.7% (95% CI 3.0–8.4%), 1.4% (0–2.8%), 41% (35–47%), 8.4% (4.1–13%), and 66% (60–72%), respectively. The proportion of adequately reported RCTs was higher for registries that used specific methodological fields for describing methods of randomization and allocation concealment compared to registries that did not. Concerning other key methodological aspects, weighted overall proportions of RCTs with adequately reported items were as follows: eligibility criteria (81%), secondary outcomes (46%), harm (5%) follow-up duration (62%), description of the interventions (53%) and sample size calculation (1%). Conclusions: Trial registries currently contain limited methodologic information about registered RCTs. In order to permit adequate critical appraisal of trial results reported in journals and registries, trial registries should consider requesting details on key RCT methods to complement journal publications. Full protocols remain the most comprehensive source of methodologic information and should be made publicly available.

Prevalence and management of cardiovascular risk factors in Portuguese living in Portugal and Portuguese who migrated to Switzerland.

BACKGROUND: Information regarding the health status of migrants compared to subjects who remain in the country of origin is scarce. We compared the levels and management of the main cardiovascular risk factors between Portuguese living in Porto (Portugal) and Portuguese migrants living in Lausanne (Switzerland). METHODS: Cross-sectional studies conducted in Porto (EPIPorto, 1999 to 2003, n = 1150) and Lausanne (CoLaus, 2003 to 2006, n = 388) among subjects aged 35-65 years. Educational level, medical history and time since migration were collected using structured questionnaires. Body mass index, blood pressure, cholesterol and glucose levels were measured using standardized procedures. RESULTS: Portuguese living in Lausanne were younger, more frequently male and had lower education than Portuguese living in Porto. After multivariate adjustment using Poisson regression, no differences were found between Portuguese living in Porto or in Lausanne: prevalence rate ratio (PRR) and (95% confidence interval) for Portuguese living in Lausanne relative to Portuguese living in Porto: 0.92 (0.71 - 1.18) for current smoking; 0.78 (0.59 - 1.04) for obesity; 0.81 (0.62 - 1.05) for abdominal obesity; 0.82 (0.64 - 1.06) for hypertension; 0.88 (0.75 - 1.04) for hypercholesterolemia and 0.92 (0.49 - 1.73) for diabetes. Treatment and control rates for hypercholesterolemia were higher among Portuguese living in Lausanne: PRR = 1.91 (1.15 - 3.19) and 3.98 (1.59 - 9.99) for treatment and control, respectively. Conversely, no differences were found regarding hypertension treatment and control rates: PRR = 0.98 (0.66 - 1.46) and 0.97 (0.49 - 1.91), respectively, and for treatment rates of diabetes: PRR = 1.51 (0.70 - 3.25). CONCLUSIONS: Portuguese living in Lausanne, Switzerland, present a similar cardiovascular risk profile but tend to be better managed regarding hypercholesterolemia than Portuguese living in Porto, Portugal.

El medievalismo fértil de Paloma Díaz-Mas

The author of this article is concerned with trying to understand why Paloma Díaz-Mas, the writer of such an excellent novel as La tierra fértil (1999), has not received much critical attention. He underlines three main reasons. First, she does not live in Madrid or Barcelona and so she is far away from the main centres of cultural power. Second, she teaches Spanish literature in the Basque Country, a political and linguistic community which significantly differs from that of many other writers. Third, she writes historical novels, which does not appear to be very fashionable in Spain these days. Moreover, Díaz-Mas is a woman writer who does not make use of the most commonly available feminine patterns, and she does not seem to offer a model easy to include in a given feminist methodology either. However, Mérida-Jiménez argues that Paloma provides an intelligent deconstruction of “male authority” through subtle rhetorical means, as well as a representation of the weakness of his “domination” in very innovative ways, such as those derived from the dialectics between history and fiction, centrality and marginality, heterosexuality and homosexuality, individual and society, dream and reason or tradition and modernity.