AB1583-PARE QUALITATIVE INTERVIEWS OF SYMPTOMS, IMPACTS AND SELECTED PROMIS SHORT FORMS: A STUDY IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background

Axial spondyloarthritis (axSpA) is characterised by inflammation of the sacroiliac joints and spine. Sleep disturbance, pain and fatigue are reported in the literature to be key symptoms and impacts of axSpA. Three customised Patient-Reported Outcomes Measurement Information System (PROMIS) Short Forms (Sleep Disturbance, Pain Interference and Fatigue), previously developed for use in rheumatoid arthritis, have been proposed for use in patients with axSpA to assess the key concepts.

Objectives

To conduct in-depth qualitative interviews to further understand the patient experience of axSpA and evaluate the content validity of the three PROMIS Short Forms to support their use as endpoints in axSpA clinical trials.

Methods

A non-interventional, cross-sectional qualitative (concept elicitation [CE] and cognitive debriefing [CD]) study was conducted in 28 adult patients with diagnosed axSpA, including radiographic axSpA (r-axSpA), also known as ankylosing spondylitis (AS, n=12), and non-radiographic axSpA (nr-axSpA, n=16). Patients took part in 90-minute telephone interviews. A semi-structured interview guide was used to assist discussions. The CE section used broad, open-ended questions to elicit information about symptoms and impact experienced by patients. The CD section involved a ‘think-aloud’ exercise in which patients read out each instruction, item and response option for the three PROMIS Short Forms and shared their feedback. Patients were also asked detailed questions about the relevance of the items, response options and recall period. Verbatim interview transcripts were subject to thematic and content analysis.

Results

Patients were from the United States (n=20) and Germany (n=8), mean age was 52.8 years, and 57% (n=16) were male; mean time since diagnosis of axSpA was 9.5 years (range 0.3–31.3 years). The CE section identified 12 distinct signs and symptoms that characterised patients’ experience of axSpA: pain, sleep problems, fatigue/tiredness, stiffness, swelling, vision/eye issues, restricted body movements, headache/migraine, spasms, change in posture/stature, balance/coordination problems and numbness. Pain, sleep problems and fatigue/tiredness were all reported to be experienced by ≥90% of patients, occurring simultaneously and exacerbating one another. 78% (n=21/27) of patients reported pain to be the most bothersome symptom, and 88% (n=23/26) described it as the symptom they would most like treatment to improve. Patients reported axSpA to impact their lives across six health-related quality of life (HRQoL) domains: physical functioning (100%), emotional wellbeing (89%), work/volunteering (79%), social functioning (75%), activities of daily living (61%) and cognitive functioning (54%). Impacts were most frequently described as being associated with pain, stiffness and fatigue. The experiences of symptoms and impacts were consistent between the AS and nr-axSpA patients. CD showed all three PROMIS instruments are conceptually comprehensive and well understood by patients with axSpA. No patients reported misunderstanding of instructions and/or items of the sleep disturbance instrument, and only one and four items had a small number of instances of misunderstanding for the fatigue and pain interference instruments, respectively. Across each instrument, all items were relevant to at least half of patients, and almost all patients reported the instruments to be appropriate for measuring their experience of sleep problems, pain and fatigue due to axSpA. Both AS and nr-axSpA patients confirmed the three PROMIS Short Forms to be relevant and appropriate for assessing their disease experience.

Conclusion

Pain, sleep problems and fatigue are pivotal symptoms of axSpA and associated with HRQoL impacts. Interpretability and content validity of the PROMIS customised Short Forms have been confirmed, with each deemed to adequately assess key impacts associated with axSpA, making them suitable for use in clinical trials of patients with axSpA.

Funding: GSK [209770]

Acknowledgements

Medical writing support was provided by Tony Reardon, of of Aura, a division of Spirit Medical Communications Group Limited (Manchester, UK), and was funded by GlaxoSmithKline.

Disclosure of Interests

Amy Findley Grant/research support from: employee of Adelphi Values, who received fees from GlaxoSmithKline for the conduct of this study, Jessica Middlehurst Grant/research support from: employee of Adelphi Values, who received fees from GlaxoSmithKline for the conduct of this study, Chloe Howse Grant/research support from: employee of Adelphi Values, who received fees from GlaxoSmithKline for the conduct of this study, Molly Clifford Grant/research support from: employee of Adelphi Values, who received fees from GlaxoSmithKline for the conduct of this study, William Neill Grant/research support from: employee of Adelphi Values, who received fees from GlaxoSmithKline for the conduct of this study, Sophi Tatlock Grant/research support from: employee of Adelphi Values, who received fees from GlaxoSmithKline for the conduct of this study, Wen-Hung Chen Shareholder of: GlaxoSmithKline, Employee of: GlaxoSmithKline

, Marguerite Bracher Shareholder of: GlaxoSmithKline, Employee of: GlaxoSmithKline, Dharm Patel Shareholder of: GlaxoSmithKline, Employee of: GlaxoSmithKline

The impact of sarcopenia on outcomes in patients with inflammatory bowel disease undergoing colorectal surgery

INTRODUCTION

Sarcopenia is an independent predictor of poor post-operative outcomes following major surgery. Inflammatory bowel disease (IBD) consists of Crohn's disease (CD) and ulcerative colitis (UC), which are chronic inflammatory conditions involving the gastrointestinal system. Evidence demonstrates that up to 60% of patients with IBD have sarcopenia. Despite advances in medical management, more than 15% of patients with UC and 80% with CD eventually require surgical intervention. The primary aim of the study was to assess the impact of sarcopenia on post-operative anastomotic leak rates.

METHODS

A retrospective cohort study of patients at Royal Perth Hospital who underwent major abdominal surgery for management of IBD between January 2010 and December 2020 was performed. Sarcopenia was assessed according to the skeletal muscle index at the level of the third lumbar vertebrae using the cut off 52.4 and 38.5 cm² /m² for men and women, respectively.

RESULTS

A total of 147 patients were included. The prevalence of sarcopenia within the study population was 36.1%. Patients with sarcopenia were significantly taller (P = 0.025) and were more likely to be on pre-operative steroid medications (P = 0.045). There was no difference in the remaining baseline characteristics between sarcopenic and non-sarcopenic patients. Patients with sarcopenia were more likely to develop a post-operative anastomotic leak (OR:11.303, 95% CI, 1.53-83.51, P = 0.017), grade IV complications (OR:6.79, 95%CI:1.1-43.6, P = 0.044) and require total parenteral nutrition (TPN) (OR:3.212, 95% CI:1.3-8.1, P = 0.013).

CONCLUSIONS

Sarcopenia significantly increases the risk of major post-operative complications for patients with IBD undergoing colorectal surgery.

Evaluation of Novel Process Indicators for Rapid Monitoring of Hydrogen Peroxide Decontamination Processes

Geobacillus stearothermophilus spores on stainless steel discs are routinely used as biological indicators for the validation of hydrogen peroxide bio-decontamination processes. Given ongoing concerns about the reliability and response time of biological indicators, we explored the potential for an enzyme-based approach to decontamination process evaluation. Thermostable adenylate kinase enzyme was coated onto a solid support and exposed to hydrogen peroxide vapour, in parallel with standard commercial 6-log biological indicators, during a series of vapour-phase hydrogen peroxide cycles in a flexible film isolator. The exposed biological indicators were enumerated to define the degree of kill at different time intervals and the results compared to the thermostable adenylate kinase values, as determined by measuring adenosine triphosphate produced by residual active enzyme. Both biological indicators and the thermostable adenylate kinase indicators exhibited a biphasic inactivation profile during the process. There was significant variance between individual cycles, with some cycles showing complete inactivation of the biological indicators to the limit of detection of the assay, within 6 min, whereas biological indicators in some cycles were inactivated at a time greater than 12 min. The log-kill of the biological indicators at intermediate time points were plotted and compared to the fully quantifiable measurements derived from the thermostable adenylate kinase indicators at the same time points. The results demonstrated very similar inactivation profiles for the enzyme and for the biological indicators, thus it was possible to define a relationship between relative light units measurement and biological indicator kill. This indicates that it is possible to use thermostable adenylate kinase measurement as a direct measure of vapour-phase hydrogen peroxide bio-decontamination performance, expressed in terms of log reduction. Because thermostable adenylate kinase measurement can be achieved within a few minutes of vapour-phase hydrogen peroxide cycle completion, compared with a minimum of 7 days for the evaluation of biological indicator growth, this offers a potentially valuable tool for rapid vapour-phase hydrogen peroxide bio-decontamination cycle development and subsequent re-qualification.LAY ABSTRACT: Pharmaceutical product manufacture is performed in controlled cleanroom and closed chamber environments (isolators) to reduce the risk of contamination. These environments undergo regular decontamination to control microbial contamination levels, using a range of methods, one of which is to vaporize hydrogen peroxide (a chemical disinfectant) into a gas or an aerosol and disperse it throughout the environment, killing any microorganisms present. Biological indicators, which consist of a small steel coupon carrying a population of bacterial spores that are more resistant to hydrogen peroxide than are most microorganisms, are placed within the environment, and then tested for growth following treatment to ensure the process was effective. Confirmation of growth/no growth (and therefore hydrogen peroxide cycle efficacy) can take up to 7 days, which significantly increases time and cost of developing and confirming cycle efficacy. This study tests whether a new technology which uses a robust enzyme, thermostable adenylate kinase, could be used to predict biological indicator growth. The study shows this method can be used to confirm hydrogen peroxide cycle efficacy, by predicting whether the BI is killed at a specific time point or not and results are obtained in a few minutes rather than 7 days. This potentially offers significant time and cost benefits.

Intellectual abilities in tuberous sclerosis complex: risk factors and correlates from the Tuberous Sclerosis 2000 Study

BACKGROUND

Tuberous sclerosis complex (TSC) is associated with intellectual disability, but the risk pathways are poorly understood.

METHOD

The Tuberous Sclerosis 2000 Study is a prospective longitudinal study of the natural history of TSC. One hundred and twenty-five UK children age 0-16 years with TSC and born between January 2001 and December 2006 were studied. Intelligence was assessed using standardized measures at ≥2 years of age. The age of onset of epilepsy, the type of seizure disorder, the frequency and duration of seizures, as well as the response to treatment was assessed at interview and by review of medical records. The severity of epilepsy in the early years was estimated using the E-Chess score. Genetic studies identified the mutations and the number of cortical tubers was determined from brain scans.

RESULTS

TSC2 mutations were associated with significantly higher cortical tuber count than TSC1 mutations. The extent of brain involvement, as indexed by cortical tuber count, was associated with an earlier age of onset and severity of epilepsy. In turn, the severity of epilepsy was strongly associated with the degree of intellectual impairment. Structural equation modelling supported a causal pathway from genetic abnormality to cortical tuber count to epilepsy severity to intellectual outcome. Infantile spasms and status epilepticus were important contributors to seizure severity.

CONCLUSIONS

The findings support the proposition that severe, early onset epilepsy may impair intellectual development in TSC and highlight the potential importance of early, prompt and effective treatment or prevention of epilepsy in tuberous sclerosis.

Performance of TOTAL, in medical patients attending a resource-poor hospital in sub-Saharan Africa and a small Irish rural hospital

BACKGROUND

Recently a very simple, easy to remember early warning score (EWS) dubbed TOTAL has been reported. The score was derived from 309 acutely ill medical patients admitted to a Malawian hospital and awards one point for Tachypnea >30 breaths per minute, one point for Oxygen saturation <90%, two points for a Temperature <35°C, one point for Altered mental status, and one point for Loss of independence as indicated by the inability to stand or walk without help. TOTAL has an area under the receiver operator characteristic curve (AUROC) for death within 72 hours of 78%.

METHODS

We compared the performance of the TOTAL score in 849 medical patients attending a resource poor hospital in Uganda and 2935 patients admitted to a small rural hospital in Ireland.

RESULTS

TOTAL's AUROC for death within 24 hours was the same in both hospital populations: 85.1% (95% CI 78.6 - 91.6%) for Kitovu Hospital patients and 84.7% (95% CI 77.1 - 92.2%) for Nenagh Hospital patients.

CONCLUSION

The discrimination of TOTAL is exactly the same in elderly Irish patients as it is in young African patients. The score is easy to remember, easy to calculate, and works over a broad range of patients.

Development of a biotic ligand model to predict the acute toxicity of cadmium to Daphnia pulex

The goal of this study was to develop a biotic ligand model (BLM) to predict the acute toxicity of cadmium to Daphnia pulex. Organisms were cultured in moderately soft water and standard 48h acute toxicity tests were used to determine EC50s in various water chemistries where the effects of Ca(2+), Na(+), Mg(2+), Cl(-), K(+), pH, and two sources of natural organic matter (Suwannee River and Nordic Reservoir) were evaluated. Overall, toxicity responses were consistent with the free-ion activity model and the principles inherent in the BLM. Increases in Ca(2+) resulted in higher EC50s, indicating that Cd(2+) competes with Ca(2+) for uptake at the biotic ligand. Similar cation competition effects were observed when Mg(2+) was varied but with a less pronounced protective effect relative to Ca(2+). Changes in Na(+) and K(+) concentrations had no significant effect on Cd toxicity. EC50 values did not change significantly when pH was adjusted over a range from 8.0 to 6.1. Additions of natural organic matter resulted in elevated dissolved organic carbon (DOC) concentrations that significantly reduced Cd bioavailability via complexation of Cd(2+). An existing biotic ligand model (HydroQual BLM ver 2.2.3) was tested for its ability to predict acute Cd toxicity to D. pulex. Once the BLM was adjusted for the relatively sensitivity of D. pulex the protective effects of Ca and DOC could be predicted reasonably well but other test chemistries did not match with measured EC50s. Binding constants derived from the test results (logK(CaBL) of 4.1, logK(MgBL) of 3.7, logK(HBL) of 6.1 and logK(CdBL) of 7.0) were used to develop a modified BLM for the effects of Cd on D. pulex that accounted for the moderating effect of Ca and Mg on acute toxicity but overestimated the protective effect of DOC.

Development of a biotic ligand model for the acute toxicity of zinc to Daphnia pulex in soft waters

The goal of this study was to develop a biotic ligand model (BLM) for the acute toxicity of zinc to the Daphnia pulex in soft water. In different tests Ca (as CaSO(4)), Na (as NaCl), Mg (as MgSO(4)), K (as KCl), pH (using the buffer 3-(N morpholino)-propanesulphonic acid (MOPS)) and dissolved organic carbon (DOC) were altered to determine possible effects on the 48h EC50 for Zn. Increases in waterborne Ca(2+) had a protective effect on Zn toxicity, suggesting that this ion competes with Zn and that they share a common site of biological uptake. Increased waterborne Mg(2+) also reduced Zn toxicity, but to a lesser degree compared with Ca(2+). No significant effects of other cations on EC50 for Zn were observed, indicating that the toxicity of Zn in D. pulex is not linked to Na(+) and K(+). Increasing DOC concentrations resulted in higher EC50 values for Zn due to the complexation of Zn by organic matter in solution and the resulting reduction of free Zn(2+) ion concentrations. Tests to characterize the effect of pH on Zn toxicity showed a small rise in EC50 values between pH 6.3 and 7.1 and no further change as pH was increased to 8.0. Two existing BLM implementations for acute Zn effects on D. magna were tested to determine their applicability to D. pulex in soft water. The existing models underestimated the protective effect of Ca(2+) and Mg(2+) but accurately predict the effects of DOC. A modified BLM, with revised equilibrium constants for competitive cation effects was developed. This study shows that the acute effects of Zn on D. pulex in soft water can be characterized and incorporated into a predictive BLM.

Feasibility of percutaneous transabdominal portosystemic shunt creation

Evaluation of the anatomic feasibility of the percutaneous transabdominal puncture of selected portal and hepatic veins in patients with cirrhosis was performed. This approach would become the framework for an image-guided robot-assisted needle drive mechanism for use in transjugular intrahepatic portosystemic shunt (TIPS) creation. Retrospective analysis of 10 CT and 14 MRI axial abdominal studies was carried out to determine whether single simultaneous transabdominal puncture of portal and hepatic veins was possible. A necessary modification of the TIPS procedure was tested in an ex vivo porcine model under fluoroscopy. Eighteen of 24 patients (75%) had intrahepatic vascular anatomy amenable to a single transabdominal puncture. Successful catheterization of portal and hepatic veins using a modified approach for TIPS was accomplished in two ex vivo porcine livers. A suitable anatomic approach for modified TIPS is present in a majority of patients with cirrhosis. Feasibility of the technique using this anatomic approach was confirmed in two ex vivo porcine models. This study serves as an initial step in a novel technical approach to TIPS using a new anatomic approach for this procedure.

Image-guided robotic delivery system for precise placement of therapeutic agents

The effectiveness of conventional solid tumor treatment is limited by the systemic toxicity and lack of specificity of chemotherapeutic agents. Present treatment modalities are frequently insufficient to eliminate competent cancer cells without exceeding the limits of toxicity to normal tissue. The coming generation of cancer therapeutics depends on the precise targeting and sustained release of antitumor agents to overcome these limitations. We are developing an image-guided, robotic system for precise intratumoral placement of anticancer drugs and sustained release devices to advance this new treatment paradigm. The robotic system will use intraoperatively obtained computed tomographic (CT) images from a mobile CT scanner for guidance. The concept is to track patient anatomy and localize instruments using currently available optical tracking technology. Tracking will also be used to register patient anatomy with the images. The physician can then use the registered image to select an appropriate tumor target and entry location and to plan the instrument path. This path will then be transmitted to the robot, which orients and drives the instrument to the desired target under physician control. Achievement of the target is confirmed via intraoperative CT. This system will provide instrument guidance that is precise, direct, and controllable. Error due to poor target visualization and hand unsteadiness should be reduced greatly. The basic components of the system (robot, mobile CT, tracking) have been demonstrated in our laboratory, and the integration of the components is in progress. In future work, we plan to fuse preoperative PET imaging with intraoperative CT to allow functional as well as anatomic image guidance.

Inhibition of 1,2-dimethylhydrazine-induced oxidative DNA damage in rat colon mucosa by black tea complex polyphenols

The effect of black tea polyphenols on 1,2-dimethylhydrazine (DMH)-induced oxidative DNA damage in rat colon mucosa has been investigated. Fischer 344 rats were treated orally with thearubigin (TR) or theafulvin (TFu) for 10 days (40 mg/kg), injected ip with DMH (20 mg/kg) or saline and sacrificed 24 hr after DMH administration. The levels of 8-hydroxy-2'-deoxyguanosine (8-OHdG) were measured in colonic mucosa DNA and expressed as a ratio relative to 2'-deoxyguanosine (2dG). Control rat mucosa had 8-OHdG values of 1.12 +/- 0.14/10(5) dG (mean +/- SEM, n=11), whereas DMH-treated rats significantly higher values (1.52 +/- 0.14/10(5) dG, n=26, P<0.05). Pretreatment of rats with TR had significantly inhibited DMH-induced oxidative DNA damage 0.99 +/- 0.09/10(5) dG, n=10, P<0.05) and a similar, although less marked, effect was observed with TFu (1.15 +/- 0.19/10(5), n=9, P=0.06). These findings confirm that DMH causes oxidative DNA damage in the colon mucosa of rats and demonstrate that this effect is prevented by the consumption of complex polyphenols from black tea.

Personality predictors of mortality in cardiac transplant candidates and recipients

OBJECTIVES

Emotional factors are generally recognized as impacting the care of end-stage heart disease and mortality following cardiac transplants. Equally important, however, are predictors of pretransplant mortality. The current study examined the utility of the Millon Behavioral Health Inventory (MBHI) as a predictor of pre- and posttransplant mortality.

METHODS

A total of 103 cardiac transplant candidates were assessed with the MBHI as part of a pretransplant evaluation that included baseline demographic variables and cardiac status. Time to transplant and mortality status at 1 and 5 years was also obtained.

RESULTS

Cluster analysis of MBHI response scores elicited two clusters characterized by high and low distress. Cluster membership predicted survival status at 1-year and 5-year follow-up, with high distress cluster patients having significantly higher mortality in both the total sample and a subgroup of patients who did receive a heart transplant.

CONCLUSIONS

These results support the value of the MBHI for assessing personality attributes that may dispose toward unfavorable outcome in heart transplant candidates. Further understanding of psychosocial contributions to illness course and outcome may enable more effective selection of treatment interventions with cardiac patients.

Scintillation proximity assay for E-, P-, and L-selectin utilizing polyacrylamide-based neoglycoconjugates as ligands

In this study, a novel scintillation proximity assay (SPA) that uses radiolabeled soluble neoglycoconjugates as synthetic alternatives to the natural E-, P-, and L-selectin counterligands was developed. The neoglycoconjugates contained sialyl LewisX or sialyl LewisA attached via a three-carbon spacer to a poly[N-(hydroxyethyl)acrylamide] backbone, thus presenting the carbohydrates in a multivalent form. Selectin-ZZ fusion proteins were immobilized on anti-rabbit IgG-coated SPA beads via a rabbit IgG bridge. The neoglycoconjugate ligands bound to all three bead-immobilized selectins, with the highest binding levels apparent with E-selectin. Saturation binding studies with E-selectin revealed a complex interaction indicative of two or more binding affinities. The response to carbohydrate inhibitors was comparable in E-selectin assays that used either the neoglycoconjugates or the tritium-labeled HL60 cells as selectin counterligands. The incorporation of tyrosine sulfate groups into the backbone of the neoglycoconjugate resulted in enhanced binding avidity to both P- and L-selectin, indicating that the sulfate-containing neoglycoconjugates are viable synthetic mimics of the natural P- and L-selectin counterligands. The use of these radiolabeled neoglycoconjugates in conjunction with SPA results in a format ideally suited for the high-throughput screening for selectin antagonists. Furthermore, this approach can potentially be used to measure other low-avidity lectin-carbohydrate interactions.

Neural control of limb coordination. I. Comparison of hatching and walking motor output patterns in normal and deafferented chicks

Previous work has shown that the neural circuits underlying the leg movements of walking and hatching coexist in post-hatching chicks (Bekoff and Kauer, 1984). In the present study, quantitative analysis of leg EMGs shows that there are some similarities, but also significant differences, in the motor output patterns of walking and hatching. This study examines the effect of removing sensory feedback from the legs on the production of the distinctive leg motor patterns. The temporal characteristics and interlimb coordination of hatching and walking are little affected. However, major changes in intralimb motor output patterns are seen when compared to records from normal chicks. These changes fall into one of 2 categories. Some parameters show similar changes in both behaviors after deafferentation (e.g., increases in flexor burst durations and cycle period). This suggests that certain features of sensory input from the legs normally modulate the hatching and walking pattern-generating circuitry in similar ways. Other parameters show convergence. That is, these aspects of the 2 intralimb motor patterns become more similar to each other after removal of sensory input. This is consistent with the hypothesis that some feature of sensory input from the legs normally modulates one set of multiuse intralimb circuitry to produce different output patterns. In general, the walking pattern becomes more like hatching after deafferentation, rather than the reverse, which suggests that the hatching pattern is a more basic one. The maintenance of some residual differences in intralimb motor patterns after leg deafferentation suggests that other sources of modulation must also be involved, or that there are some additional elements of circuitry that are called into play during the normal production of walking and hatching.

Social and psychological problems associated with clefts: motivations for cleft palate treatment

Adolescents probably constitute a significant proportion of patient case loads for well-established cleft palate teams. Most teenagers return for periodic recall and continue to do so until they are discharged by the team. The proposition that social and psychological dissatisfactions might coalesce during adolescence and influence young people to stop treatment was examined. The modest drop-out rate argues against this contention. An alternative explanation for the low drop-out rate stresses that these patients are poorly equipped psychologically to deal with their clefts during any period of development. Maladaptation is brought into adolescence, influencing some patients to discontinue team treatment. Since most adolescents remain in treatment, it is suggested they do so because it is in their best interests or because there are no other reasonable alternatives. Adolescents who are knowledgeable about their clefts and the purpose of cleft palate teams may view treatment as a necessary and logical sequence of events designed ultimately to enhance appearance and function. For these adolescents, the goals of treatment are in keeping with existing well differentiated self-concepts and body images. It can be argued that prior good psychological adaptation to having a cleft, provides adolescents with a solid base upon which to cope effectively with the subsequent challenges of adolescence.

The meaning of concepts related to breast reconstruction

Information is presented from a psychometric study using a semantic differential to measure the meaning of concepts related to breast reconstruction. One hundred five women participated. All were experiencing breast reconstruction subsequent to mastectomy. The average woman was married, middle-aged, and had 11/2 years of education beyond high school. Results from the semantic differential demonstrated that the women viewed themselves, their bodies, and their femininity positively. They valued themselves, and their self-concepts were closer in meaning to health than to mastectomy, death, or cancer.

Group therapy for seriously disturbed boys in residential treatment

A group therapy experiment for boys aged 7 through 11 in a residential setting pointed up some key factors and techniques in this kind of intervention.

Breast reconstruction following mastectomy: II. Marital characteristics of patients seeking the procedure

Information is presented from a clinical study of 65 women and a psychometric study of 85 women. All had had mastectomies because of breast cancer and were reconstruction patients at Duke Hospital. Women seeking breast reconstruction did not exhibit characterological problems. Relatively few were in psychiatric treatment, and previous research had established the presence of positive rather than negative self-images. The marriages of women seeking this surgical procedure were positively and the women viewed their marriages as a chief source of support. Considerable satisfaction was expressed about husbands being supportive, although husbands were also viewed as poor listeners and, at times, as unable to communicate effectively. Most women were satisfied with various aspects of their sexual lives. A small percentage of the women reported problematic marriages. Various factors, related to the presence of conflict in the marriage and the ability of the husband to understand his wife, may account for the distress evidenced in these marriages. Such factors, of course, are present in any problematic marriage; it remains to be demonstrated whether these problems were caused or exacerbated by the woman's mastectomy and decision to seek breast reconstruction.

Breast reconstruction following mastectomy: I. Social characteristics of patients seeking the procedure

Information is presented from a clinical study of 65 women and a psychometric study of 85 women having breast reconstruction following mastectomy for breast cancer. The average woman was in her midforties. Less than a third of the women described themselves as fulltime housewives; most were employed outside the home. Almost all had completed high school and most had received additional education. Most of the women were married when they sought breast reconstruction. The time at which women had had their mastectomies was related to their source of information about breast reconstruction. When more than five years had elapsed between mastectomy and reconstruction, a woman most often had obtained her information from the media. Women with more recent mastectomies, though utilizing the media, obtained their information more frequently from medical sources.