Fatigue and its association with sociodemographic variables among multiple sclerosis patients

Objective: To explore the relationship between fatigue, sociodemographic and clinical variables in a population of patients with multiple sclerosis (MS). Rationale: There is a need to identify empirical relationships with possible antecedents of fatigue among patients with MS. Methods: A mailed questionnaire designed to survey sociodemographic variables and the Fatigue Severity Scale (FSS) was mailed to 502 individuals from the population of patients with definite MS in the city of O slo. A total of 368 (73%) responded. C linical data were collected from the O slo C ity MS-Registry. Results: The prevalence of fatigue in this population was 60.1%. The FSS score showed a negative correlation with education (r =-0.15, P <0.01) and a positive correlation with age (r =0.20, P B-0.001) and time since disease onset (r =0.11, P B-0.05). When controlled for gender, level of education and time since disease onset, the data showed a positive relationship between fatigue and age (P B-0.001) among patients with primary progressive (PP) disease. This relationship between age and fatigue was not found among patients with relapsing-remitting/secondary progressive (RR/SP) disease. Conclusion: The negative relationship between level of formal educatio n (FE) and fatigue among individuals with RR/SP disease suggests that behavioral factors may be among the antecedents of fatigue in this patient group. In contrast to normative data from the general population, our findings revealed no differences in fatigue related to gender. Thus, this study supports the hypothesis that there are disease-specific antecedents of fatigue among patients with MS.

Mental health among people with psoriasis undergoing patient education in climate therapy

This study investigated the mental health of people with psoriasis undergoing patient education in climate therapy. A prospective design included a baseline assessment and two follow-ups after a 3-week patient education program. Participants were 254 adults. Positive mental health was measured by the mental health continuum short form (0-70), and negative mental health by the emotional distress subscale (1-4) of the health education impact questionnaire. Paired-samples t-tests were used to evaluate changes in mental health from baseline to follow-up. Multiple linear regression was used to analyse the ability of socio-demographic and clinical variables and emotional distress to predict changes in positive mental health. To predict change in negative mental health we repeated the same analysis but with a change in negative mental health as a dependent variable and positive mental health as an independent variable. The results show that positive mental health and health-related emotional distress improved significantly from before to after the intervention by 7.1 points, p < 0.001 and 0.21 points, p < 0.001) respectively. At the second follow-up, health-related emotional distress remained significantly improved compared with baseline levels by 0.11 points, p = 0.004. The longer participants had lived with psoriasis ( β = 146, p = 0.027), and the presence of co-morbid health problems (β  =  111, p = 0.051) the greater the improvement in the positive mental health immediately after the intervention. No predictors were identified for negative mental health. This study indicates that the promotion of positive mental health needs to be integrated into the climate therapy program, and sustained in their home context.

Long-term functional outcome and quality of life after restorative proctocolectomy with ileo-anal anastomosis for colitis

AIM

The study aimed to evaluate long-term health-related quality of life (HRQOL) and functional outcome in patients who had undergone restorative proctocolectomy with ileo-anal anastomosis (IPAA) for ulcerative colitis and familial adenomatous polyposis.

METHOD

A total of 156 patients who underwent IPAA during the period 1984-2003 and who still had an intact pouch were included. The HRQOL score was compared with 4152 individuals from the general Norwegian population using the SF-36 questionnaire, and function was evaluated using the Wexner Continence Grading Scale.

RESULTS

One hundred and ten (71%) patients answered the questionnaires, 60 (55%) of whom were men. All except five patients had ulcerative colitis. Median (range) age at interview was 47 (19-66) years, and time after surgery was 12 (2-22) years. The IPAA patients scored slightly, but significantly, lower in four of six SF-36 health domains than the control subjects, adjusted for age and gender. Multiple regression analysis showed frequency of nocturnal defaecation, faecal incontinence and urgency to be independent negative prognostic factors of quality of life. Frequency of defaecation was a median of 7 (3-12) bowel movements during the day and 2 (0-6) at night. The majority had some degree of faecal incontinence, median (range) Wexner score of 8 (0-17), and 40% reported urgency of defaecation necessitating alterations in lifestyle.

CONCLUSION

Patients with IPAA reported slightly lower HRQOL rates than the general population and had an inferior functional outcome.

Changes in pain, stiffness and physical function in patients with osteoarthritis waiting for hip or knee joint replacement surgery

OBJECTIVE

Little has been reported on changes in health status in patients with osteoarthritis (OA) while waiting for hip or knee replacement surgery. In this study we assessed (1) changes in self-reported pain, stiffness and physical function in patients with OA of the hip or knee, from the decision to undergo surgery to 14 days prior to surgery, and (2) the determinants of these changes.

METHODS

Among 353 baseline respondents, 170 waited >30 days for surgery, completed the Western Ontario and McMaster Universities Arthritis Index (WOMAC) before surgery and were included in the analysis of changes; 120 with OA of the hip and 50 of the knee. We analyzed changes in WOMAC scores using the paired t test and determinants of the changes using multiple linear regression.

RESULTS

Patients with OA of the hip did not change on any WOMAC scale before surgery. Knee patients deteriorated with time on the WOMAC stiffness and total scales, but not on the pain or physical function subscales. In both patient categories, higher baseline WOMAC scores were associated with smaller changes on all subscales and the total score, and female sex was associated with deterioration on the pain subscale.

CONCLUSIONS

Patients with OA of the hip reported no change in pain, stiffness or physical function while waiting for joint replacement surgery, whereas patients with OA of the knee deteriorated on the stiffness and total scales of the WOMAC. This suggests a difference in patient selection, referral pattern or disease development between the patient categories.

Anxiety, depression, and quality of life in caregivers of patients with cancer in late palliative phase

BACKGROUND

Limited research has been done on mental health and health-related quality of life (QOL) of primary caregivers (PCs) to patients staying at home with advanced cancer. This study examines anxiety, depression, and QOL in PCs of patients with cancer in the late palliative phase.

PATIENTS AND METHODS

The sample consisted of 49 PCs of women with breast cancer and 47 PCs of men with prostate cancer. QOL was rated with the Medical Outcome Study Short Form (SF-36), and mental health with the Hospital Anxiety and Depression Scale (HADS). The findings were compared with age-adjusted norm data (norm).

RESULTS

Physical QOL was significantly higher than norm in both genders, while mental QOL was significantly lower in male PCs. The level of anxiety was significantly higher than norm in both genders. No significant difference for level of depression was found in either gender, while caseness of HADS-defined depression was significantly more prevalent in female PCs compared with norm.

CONCLUSION

PCs of both genders had significantly more anxiety than norm samples. Health care personnel in contact with PCs should consider screening them for mental symptoms and QOL and, if necessary, recommend further evaluation by their doctors.

Are there more than cross-sectional relationships of social support and support networks with functional limitations and psychological distress in early rheumatoid arthritis? The European Research on Incapacitating Diseases and Social Support Longitudinal

OBJECTIVE

To investigate whether greater social support and support network are cross-sectionally associated with less functional limitations and psychological distress in patients with early rheumatoid arthritis (RA); whether this association is constant over time; and whether increases in social support or support network are associated with less functional limitations and psychological distress.

METHODS

Subjects were from the European Research on Incapacitating Diseases and Social Support cohort and had early RA. Social support, support network, functional limitations (Health Assessment Questionnaire), and psychological distress (General Health Questionnaire) were assessed annually. Variance and covariance analyses with repeated measures were performed.

RESULTS

A total of 542 subjects were assessed for 3 years. On average, patients with a greater amount of specific social support or a stronger specific support network experienced less functional limitation and less psychological distress. Changes in a given subject's functional limitations and psychological distress did not depend on his or her baseline social support or support network. Neither social support nor support network change over time.

CONCLUSION

There may be a cross-sectional link between specific social support or support network and functional limitations and psychological distress, but no longitudinal association could be evidenced.

Quality of life in patients with inflammatory bowel disease: translation, data quality, scaling assumptions, validity, reliability and sensitivity to change of the Norwegian version of IBDQ

BACKGROUND

The use of quality of life (QoL) questionnaires in clinical medicine must be based on instruments that are reliable and valid. The aim of this study was to describe the translation of the Inflammatory Bowel Disease Questionnaire (IBDQ) into Norwegian, its scaling assumptions and the psychometric properties of the translated questionnaire.

METHOD

All patients included were recruited from an ongoing epidemiological study started in 1990 (the IBSEN trial), based on the registration of undiagnosed cases of Crohn disease (CD) or ulcerative colitis (UC) in subjects permanently residing in the study area the year before registration. At the 5-year follow-up visit in the hospital, all patients between 18 and 75 years of age were invited to participate in this QoL study, and those willing were interviewed and asked to complete the two QoL questionnaires, IBDQ and SF-36, on two different occasions separated by 6 months. The IBDQ was tested for validity, reliability and responsiveness.

RESULTS

In total, 497 patients (93%) completed the IBDQ questionnaire at visit 1, and 493 (92%) completed SF-36. The mean age was 43.3 years, 48% were female. We found that the Norwegian version of the IBDQ (N-IBDQ) consists of five underlying dimensions in contrast to the four dimensions previously reported. Psychometric testing of the N-IBDQ indicates that the questionnaire is valid, reliable, has a high degree of responsiveness and that the results are comparable to those reported from other groups, even though our findings are based on a different factorial structure than the original McMaster version.

CONCLUSION

The N-IBDQ consists of five different dimensions in contrast to the four dimensions previously reported. Good item internal consistency, validity, reliability and responsiveness were demonstrated.

Genetic diversity and population history of two related seabird species based on mitochondrial DNA control region sequences

Geographical variation in two related seabird species, the razorbill (Alca torda) and common guillemot (Uria aalge), was investigated using sequence analysis of mitochondrial DNA (mtDNA) control regions. We determined the nucleotide sequence of the variable 5' segment of the control region in razorbills and common guillemots from breeding colonies across the Atlantic Ocean. The ecology and life history characteristics of razorbill and common guillemot are in many respects similar. They are both considered highly philopatric and have largely overlapping distributions in temperate and subarctic regions of the North Atlantic, yet the species were found to differ widely in the extent and spatial distribution of mtDNA variation. Moreover, the differences in genetic differentiation and diversity were in the opposite direction to that expected from a consideration of traditional classifications and current population sizes. Indices of genetic diversity were highest in razorbill and varied among colonies, as did genotype frequencies, suggestive of restrictions to gene flow. The distribution of genetic variation suggests that razorbills originated from a refugial population in the south-western Atlantic Ocean through sequential founder events and subsequent expansion in the east and north. In common guillemots, genetic diversity was low and there was a lack of geographical structure, consistent with a recent population bottleneck, expansion and gene flow. We suggest that the reduced level of genetic diversity and differentiation in the common guillemot is caused by an inherent propensity for repeated population bottlenecks and concomitantly unstable population structure related to their specialized feeding ecology.

Mitochondrial control region structure and single site heteroplasmy in the razorbill (Alca torda; Aves)

The primary structure of the Alca torda mitochondrial control region was determined and conserved structural features were identified based on sequence comparisons to other bird species. In a population survey using control region analysis, five individuals were found to possess heteroplasmic point mutations at the variable 5' end of the control region. The pattern of variable nucleotide positions among individuals was compared to the distribution of heteroplasmic sites and the heteroplasmic condition was further characterised by a cloning procedure applied to two individuals which harboured one and two heteroplasmic point mutations, respectively. These results are in support of recent evidence that single site heteroplasmy may be more common than previously thought.

Quality of life profiles in the first years of rheumatoid arthritis: results from the EURIDISS longitudinal study

OBJECTIVE

The aim of this study was to examine the quality of life (QoL) profiles of patients with early rheumatoid arthritis (RA) and to relate these to disease and impairment variables as indicated, respectively, by erythrocyte sedimentation rate (ESR) and by tender joint count (Ritchie Articular Index), fatigue, and pain.

METHODS

The present study uses part of the European Research on Incapacitating Disease and Social Support data of 573 patients with recently diagnosed RA (268 from the Netherlands, 216 from Norway, and 89 from France). A series of clinical and psychosocial data were collected on 4 (the Netherlands, France) and 3 (Norway) occasions, with 1-year intervals separating the waves of data collection.

RESULTS

Of the disease activity (ESR) and impairment variables (tender joint count, fatigue, pain), fatigue was identified as the consequence of disease that differentiated best on a series of QoL aspects such as disability, psychological well-being, social support, and "overall evaluation of health." Next came pain and tender joint count, and ESR showed by far the least differentiating ability. A principal-component analysis on the QoL measures used in this study yielded one general factor measuring "overall QoL." After rotation, two separate factors were encountered, one referring to the physical domain and the other to the psychological and social domains of QoL. Again, the QoL of RA patients experiencing much fatigue appeared to decline the most.

CONCLUSIONS

Because of the highly variable nature of RA, impairments, activities of daily living (ADL) and instrumental ADL restrictions, and psychosocial distress can vary erratically. In particular, "fatigue" as measured over a period of 2 to 3 years distinguished best among RA patients as shown by their QoL profiles. Although the physical domain was most affected, the significant effect of RA on the psychosocial domain should not be underestimated.

Speciation, introgressive hybridization and nonlinear rate of molecular evolution in flycatchers

Evolutionary history of Muscicapidae flycatchers is inferred from nuclear and mitochondrial DNA (mtDNA) sequence comparisons and population genetic analysis of nuclear and mtDNA markers. Phylogenetic reconstruction based on sequences from the two genomes yielded similar trees with respect to the order at which the species split off. However, the genetic distances fitted a nonlinear, polynomial model reflecting diminishing divergence rate of the mtDNA sequences compared to the nuclear DNA sequences. This could be explained by Haldane's rule because genetic isolation might evolve more rapidly on the mitochondrial rather than the nuclear genome in birds. This is because hybrid sterility of the heterogametic sex (females) would predate that of the homogametic sex (males), leading to sex biased introgression of nuclear genes. Analyses of present hybrid zones of pied (Ficedula hypoleuca) and collared flycatchers (F. albicollis) may indicate a slight sexual bias in rate of introgression, but the introgression rates were too low to allow proper statistical analyses. It is suggested, however, that the observed deviation from linearity can be explained by a more rapid mutational saturation of the mtDNA sequences than of the nuclear DNA sequences, as supported by analyses of third codon position transversions at two protein coding mtDNA genes. A phylogeographic scenario for the black and white flycatcher species is suggested based on interpretation of the genetic data obtained. Four species appear to have diverged from a common ancestor relatively simultaneously during the Pleistocene. After the last glaciation period, pied and collared flycatchers expanded their breeding ranges and eventually came into secondary contact in Central and Eastern Europe and on the Baltic Isles.

Compliance with drug therapy in rheumatoid arthritis. A longitudinal European study

OBJECTIVE

To delineate compliance with drug therapy in rheumatoid arthritis patients, determine specific characteristics of compliant and noncompliant patients, and look for changes in compliance over time.

PATIENTS AND METHODS

A prospective European cohort study (EURIDISS) recruited 556 patients in four countries over three years. Compliance with drug dosages and dosing times was evaluated yearly using a questionnaire.

RESULTS

Of the 556 patients, 429 (77.2%) were on drug therapy at all three evaluation time points. Use of steroids, nonsteroidal anti-inflammatory drugs, and second-line drugs varied significantly across countries. The compliance behavior was stable over time in 59.5% of them (35.7% of patients were consistently compliant and 23.8% consistently noncompliant); it was independent of disease duration and from the clinical features of the disease. Older patients and women were more likely to be compliant (odds ratios, 2.5 and 2, respectively).

CONCLUSION

Compliance with drug therapy can be measured using two simple questions. Compliance is more closely dependent on individual behavior than on responses to specific features of rheumatoid arthritis.

Drug consumption in the first years of rheumatoid arthritis in France, The Netherlands, and Norway. A longitudinal study in the early nineties

OBJECTIVE

To analyse drug consumption in the first years of rheumatoid arthritis (RA) in France, the Netherlands, and Norway, in a longitudinal study between 1991 and 1993.

PATIENTS AND METHODS

The EURIDISS cohort followed up over three years included 695 RA subjects with less than 5 years disease duration. Clinical and biological parameters, drug consumption according to ATC classification, and use of local treatment were recorded.

RESULTS

In the Netherlands consumption of second-line treatment occurred early on, and remained constant over time. In France, it was consumed by half of the subjects and decreased during follow-up (p<0.001). In Norway, 50% of the subjects were on second-line treatment at the outset. NSAIDs rather than corticoids were the most widely consumed. Patients underwent frequently local treatments with decrease frequency of infiltrations over time (p<0.001).

CONCLUSION

Second-line treatments were used in the first years of disease development, following varying sequences in the different countries.

[Need of better knowledge of genetic tests among Norwegian physicians]

BACKGROUND

New predictive genetic tests are introduced in clinical work, and this means new tasks for the physician.

MATERIAL AND METHODS

Every sixth member of the Norwegian Medical Association practising as a general practitioner, neurologist or psychiatrist (N = 732), were asked to answer a mailed, anonymous questionnaire about their attitudes to the new tasks.

RESULTS

We obtained 451 (62%) answers. There were no significant differences between the various groups in the profession. So far, 54% had no patient in their practice who had taken a predictive genetic test. About two-thirds answered that the geneticist should inform about what is known about the consequences after a test result has been given. The general practitioner wants to do the follow-up. 97% of physicians think that the test result could lead to increased distress in various ways for the tested person or his/her family. Half of the physicians would advise taking a prenatal test if one of the parents had a known risk of an inherited disease and the foetus was at risk. Only 22% are in favour of abortion if the foetus has the gene in question.

INTERPRETATION

The physicians (93%) do not think they have sufficient knowledge about predictive genetic tests to handle the information procedure on their own. They want courses in medical genetics, concise and relevant information from geneticists, and the possibility of consulting with specialists.

Discrepancies in population differentiation at microsatellites, mitochondrial DNA and plumage colour in the pied flycatcher--inferring evolutionary processes

Genetic differentiation between three populations of the pied flycatcher Ficedula hypoleuca (Norway, Czech Republic and Spain, respectively) was investigated at microsatellite loci and mitochondrial DNA (mtDNA) sequences and compared with the pattern of differentiation of male plumage colour. The Czech population lives sympatrically with the closely related collared flycatcher (F. albicollis) whereas the other two are allopatric. Allopatric populations are on average more conspicuously coloured than sympatric ones, a pattern that has been explained by sexual selection for conspicuous colour in allopatry and a character displacement on breeding plumage colour in sympatry that reduces the rate of hybridization with the collared flycatcher. The Czech population was genetically indistinguishable from the Norwegian population at microsatellite loci and mtDNA sequences. Recent isolation and/or gene flow may explain the lack of genetic differentiation. Accordingly, different selection on plumage colour in the two populations is either sufficiently strong so that gene flow has little impact on the pattern of colour variation, or differentiation of plumage colour occurred so recently that the (presumably) neutral, fast evolving markers employed here are unable to reflect the differentiation. Genetically, the Spanish population was significantly differentiated from the other populations, but the divergence was much more pronounced at mtDNA compared to microsatellites. This may reflect increased rate of differentiation by genetic drift at the mitochondrial, compared with the nuclear genome, caused by the smaller effective population size of the former genome. In accordance with this interpretation, a genetic pattern consistent with effects of small population size in the Spanish population (genetic drift and inbreeding) were also apparent at the microsatellites, namely reduced allelic diversity and heterozygous deficiency.

The course of rheumatoid arthritis and predictors of psychological, physical and radiographic outcome after 5 years of follow-up

OBJECTIVE

: To examine the course of RA over 5 yr and identify predictors of psychological, physical and radiographic outcome.

PATIENTS AND METHODS

Out of 238 patients with rheumatoid arthritis of no more than 4 (mean 2.2) yr duration, 182 (76%) completed a clinical examination with follow-up at 1, 2, and 5 yr. The course of the disease was assessed by measures of psychological and physical health status, disease process and radiographic damage.

RESULTS

: Over 5 yr we observed at a group level a stable disease course for measures of disease process, psychological and physical health status. Radiographic damage progressed. Health status and radiographic damage after 5 yr were predicted by the baseline measures for the respective outcome. Physical function was also predicted by age and by psychological status when the physical dimension of the Arthritis Impact Measurement Scales was chosen as outcome variable. Erythrocyte sedimentation rate and presence of rheumatoid factor predicted radiographic progression.

CONCLUSIONS

: The 5 yr course of RA was characterized by preserved health status measures and clinically preserved disease process measures, whereas joint damage progressed steadily. Outcomes after 5 yr can be predicted partly by certain measures at baseline.

Inventory of interpersonal problems: a three-dimensional balanced and scalable 48-item version

Interpersonal relating has been a focus of attention in psychiatry for decades. To address this domain, a self-rating scale, the Inventory of Interpersonal Problems (IIP; Horowitz, Rosenberg, Baer, Ureño, & Villaseñor, 1988), was developed. Analysis of the psychometric properties of IIP presented in this article was performed by principal component analysis (PCA) for the purpose of obtaining subscales with a balanced, bipolar dimensionality. The model was validated by the resulting dimensions' ability to discriminate among different categories of personality disorders (PDs). The problem of a General Complaint factor affecting PCAs of questionnaires such as the IIP is discussed thoroughly, and ways of avoiding the problem are outlined. We present a three-dimensional structure of the IIP with both theoretically appealing and statistically robust dimensions of Assertiveness, Sociability, and Interpersonal Sensitivity based on 48 (out of 127) items. Balanced, additive indexes using the subset of 48 items appeared psychometrically sound by showing much lower correlations internally and less confounding from the General Complaint factor than extant indexes derived from the IIP. External validity seemed to be bolstered by all subscales' discriminating significantly between different PDs versus no PDs, on both cluster and single diagnosis levels. Our analysis seemed to substantiate the reliability (scalability) of three dimensions of the IIP tapping different areas of the interpersonal relational field.

Social network size of female patients with rheumatoid arthritis compared to healthy controls

To estimate how rheumatoid arthritis (RA), the disease duration, and level of physical disability, influence the total size of patients' social network and the size of different subsets. Two hundred sixty four female patients (mean age 57 yrs) with RA of more than 6 yrs duration (mean 20 yrs) were compared to 61 healthy controls matched for sex, age, and residential area. Network size was measured by Social Network Delineation Questionnaire (SNDQ), physical disability by Health Assessment Questionnaire (HAQ). RA patients had a significantly smaller total network compared to the healthy controls (RA: 15.8 persons;

CONTROLS

18.1), mostly due to a significant difference in the subset of important others in favour of the controls (RA: 1.1;

CONTROLS

2.3). There were no significant differences regarding the network size of family, friends, and neighbours. The same results remained after statistical control for sociodemographic variables. Neither disease duration nor physical disability had any significant association with network size. The interaction analysis did, however, show that non-working patients with long disease duration (> 15 yrs) had fewer important others than occupationally active patients. Furthermore, a high degree of physical disability was related to a smaller number of friends for patients > 57 yrs than for equally disabled patients below this age. Most patients with RA seem to maintain contact with the family network-members, despite the challenges connected with chronic disease.

Compliance to drug treatment of patients with rheumatoid arthritis: a 3 year longitudinal study

OBJECTIVE

Patient compliance is considered necessary for the success of drug treatment in chronic diseases. We document compliance with drug treatment and the factors affecting it in a cohort of patients with rheumatoid arthritis (RA).

METHODS

A prospective cohort study of 556 patients with RA followed for 3 years in 4 counties: Oslo, Norway; Groningen, The Netherlands; and Nancy and Reims, France. Compliance to treatment was assessed annually by interview in terms of adherence to the dose and timing of the prescribed drug regimen.

RESULTS

Of the 556 subjects, 429 (77.2%) were taking medication for RA throughout the observation period. Consistent behavior was recorded in 59.5% of cases: 35.7% were consistently compliant, and 23.8% consistently noncompliant. Factors significantly associated with good compliance were older age (p = 0.00), female sex (p = 0.03), decreased disability (p = 0.04), very satisfactory contacts with health care professionals (p = 0.03), and more personal knowledge about the disease and its treatment (p = 0.03).

CONCLUSION

This longitudinal study identified compliance behavior as consistent over time in 60% of patients, determined by quality of contact with professionals and the amount of patient information available.

The norwegian version of the psoriasis disability index--a validation and reliability study

OBJECTIVE

The aim of this study was to translate the Psoriasis Disability Index (PDI) into Norwegian and validate it in a Norwegian setting. The PDI is a measure that was developed to assess the impact of psoriasis on the patient's life.

METHODS

Two hundred and eighty-two patients with psoriasis were included in the study (80% outpatients, and 20% hospitalized).

RESULTS

Face and content validity were assessed as satisfactory. The PDI seems to capture issues of importance to patients. The results indicate that the PDI does not capture a unidimensional concept. A factor analysis (principal component with orthogonal rotation) resulted in three factors (physical, social, and hygienic) that were substantially different. All three factors had satisfactory internal consistency. Altogether they explained 58% of the variance. In addition, there were differing patterns of correlations with external criteria, such as dimensions of SF-36, as well as with sex, age, and education.

CONCLUSIONS

The PDI has been found to have acceptable reliability in this study. However, further validation is necessary to estimate the sensitivity to change.

Adapting the Jalowiec Coping Scale in Norwegian adult psoriasis patients

The aim of the present study was to adapt the Jalowiec Coping Scale (JCS) to accommodate adult patients with psoriasis. The sample comprised 334 patients who were treated consecutively at three dermatology departments in the eastern Norway. A total number of 273 hospitalised patients (20%) and out-patients (80%) completed the questionnaire, yielding a response rate of 82%. The study assessed the reliability and the face, content and construct validity of the Norwegian version of the JCS. In addition, researchers investigated the most frequently used/effective coping strategies, the relationships between demographic/clinical variables, self-reported physical symptoms and the use of coping strategies. The results (correlational coefficients and interitem alpha s) indicated that there was an overlap in substantive content among the original JCS subscales, due either to measurement error (bias or response style) and/or because the patients in the present study were in a demanding situation in relation to their disease, which may have activated a variety of coping strategies. A factor analysis resulted in a three-factor solution (confrontive problem-solving, normalising/optimistic and combined emotive) with satisfactory internal consistency. This factor solution comprised 31 items with an explained variance of 37% of the total pool of items. The most frequently used and effective coping strategies could be labelled as emotion-focused (optimistic/maintain control). Significant correlations were found between age, hospital setting, self-reported physical symptoms and different coping subscales. However, further studies are needed to assess the validity and reliability of the JCS among different population groups in Norway.

Coping and quality of life in patients with psoriasis

The aim of the present study was to investigate the relationship between coping dimensions and overall quality of life, disability and health status in patients' with psoriasis. Psoriasis is one of several chronic diseases which requires self-management in order to ensure an enhanced quality of life. The sample comprised 334 patients who were treated consecutively at three dermatology departments in eastern Norway. A total number of 273 patients completed the questionnaire, yielding a response rate of 82% (20% in-patients and 80% out-patients). The following questionnaires were used: The Jalowiec Coping Scale, the Psoriasis Disability Index, the Quality of Life Scale, and the SF-36. Results showed that patients who used combined emotive coping strategies reported more disability, poorer mental health and worse overall quality of life. Furthermore, patients who more frequently used normalising/optimistic coping reported higher levels of mental health. However, the variance explained by coping effort was low to moderate. Coping explained the variance in mental health and overall quality of life to a greater extent than that in physical health. Knowledge about the relationships between coping and quality of life dimensions is important with regard to the establishment and implementation of appropriate psychosocial interventions for patients with psoriasis.

The relationship between demographic and clinical variables, and quality of life aspects in patients with psoriasis

There is a strong need for health care programmes to promote functioning and quality of life in patients suffering from psoriasis. The aim of the present study is to highlight the relationships between demographic and clinical variables and disease-specific disability, health status, the perception of living with a chronic disease and the overall quality of life in patients suffering from psoriasis. A further aim is to examine the extent to which the effects of demographic and clinical variables on mental health and the overall quality of life are mediated by disability, physical health and the perception of living with psoriasis. The sample examined in this study comprised 334 patients (20% in-patients and 80% out-patients) who were treated consecutively at three dermatology departments in eastern Norway. A total of 282 patients completed the testing procedures, yielding a response rate of 85%. The following questionnaires were used: The Psoriasis Disability Index, the Sf-36 and the Quality of Life Scale. Correlation and multiple linear regression analyses were performed to address the core issue. Results show that demographic and clinical variables combine to explain variance in health status, the perception of living with psoriasis and overall quality of life. While most of the variance is explained by the clinical variables, the disease-specific disability variable seems to be an important mediating factor.

Quality of life in newly diagnosed cancer patients

The aim of this study was to examine which domains of quality of life are most strongly affected in patients with newly diagnosed cancer, and to examine if quality of life was related to gender, age, educational level, cohabitation, time since diagnosis, treatment or type of cancer in these patients. Ferrans and Powers Quality of Life Index and the Cancer Rehabilitation Evaluation System, short form, were completed by 131 newly diagnosed Norwegian adult cancer patients. The patients had different cancer diagnoses, with breast cancer being the most common type. None of them were terminally ill, and 80% had been diagnosed within the last 6 months. The patients turned out to be satisfied with their lives, especially with the family and marital domains. They were least satisfied with health, functioning and sex life. Analyses of variance and multiple regression analysis were conducted to examine the impact on quality of life of cohabiting, age, gender, educational level, cancer diagnosis, treatment and time since diagnosis. Those cohabiting had significantly higher quality of life compared with those living alone. In contrast the younger group (19-39 years) living alone had significantly lower quality of life than the older groups living alone. Although age was only significantly associated with quality of life in one sub-scale, the elderly people reported their quality of life to be better in almost all sub-scales. Time since diagnosis was not associated with quality of life, while treatment was associated with quality of life as measured by Ferrans and Powers Quality of Life Index. Gender and educational level were only associated with one or two domains in quality of life, respectively.

The meaning and significance of caseness: the Hopkins Symptom Checklist-25 and the Composite International Diagnostic Interview. II

In previous analyses of data from the present general population study we found that screening of anxiety and depression symptoms by the Hopkins Symptom Checklist-25 (HSCL-25) and diagnostic classification by the Composite International Diagnostic Interview (CIDI) identified the same amount of cases, but agreed in only half of them. In this paper we compared and validated the screening cases with the classificatory cases by the use of medication, loss of functioning and help seeking (illness indicators). We thought that the CIDI cases would have more illness indicators, because they reflected diagnoses, "true illness", in contrast to the HSCL-25, which was a more unspecific measure of distress. The HSCL-25 and the illness indicators data were collected in a stage I random individual population sample above 18 years during 1989-1991 (N = 1879, response rate 74%), the CIDI data were collected in a selected stage II, (N = 606, response rate 77%). The stage II data were weighted to represent the population sample. Screening cases by the HSCL-25 had significantly more illness indicators than diagnostic cases by the CIDI. Cases agreed upon with both instruments had the most illness indicators, cases agreed upon only by the CIDI had the least. Diagnoses give information about help eventually needed, the HSCL-25 distress measure expresses more the urgency with which it is needed. The choice between the HSCL-25 and the CIDI would depend on the aim and the resources of the study. If evaluation of needs is involved, using an instrument picking up both classification and distress would be the best choice. Given our positive experience with interviewing with the CIDI, a CIDI improved to be more sensitive to how much distress a certain diagnosis exerts on the individual would be a good choice.

Measuring disability in early juvenile rheumatoid arthritis: evaluation of a Norwegian version of the childhood Health Assessment Questionnaire

OBJECTIVE

To assess the reliability, validity, and sensitivity to change of the Norwegian version of the childhood Health Assessment Questionnaire (CHAQ) and to examine the relationship between disability, disease severity, and psychosocial factors in patients with early juvenile rheumatoid arthritis (JRA).

METHODS

Physical functioning was assessed by the CHAQ in 109 patients (median age 6.6 years, range 1.0-16.6) with JRA and a median of 4 months' (range 2-23) disease duration. Eighty-three patients were reassessed after a median of 6 months (range 3-21). Psychosocial functioning was assessed by the Child Behavior Checklist (n=39).

RESULTS

The internal consistency of the CHAQ was good (Cronbach's alpha=0.83). The test-retest and parent-patient correlations were high [intraclass correlation coefficients 0.85 (n=18) and 0.75 (n=20), respectively, p < 0.001]. The CHAQ correlated moderately with number of tender, swollen and mobility restricted joints, morning stiffness, C-reactive protein, pain, and patients' and physicians' global assessments [correlation coefficients (r) ranging from 0.55 to 0.30, p < 0.01], but weakly with erythrocyte sedimentation rate (r=0.17, NS). The CHAQ also correlated with low levels of social competence (r=-0.49, p < 0.05) and high levels of internalizing behavior problems in the patients (r=0.43, p < 0.01) and low education levels of the mothers (r=-0.31, p < 0.01). Pain (beta 0.45, p < 0.001), number of swollen joints (beta 0.31, p < 0.001), and internalizing behavior problems (beta 0.45, p < 0.01) were predictors of disability. The median CHAQ changed from 0.25 to 0.00 (p < 0.05) in the 41 patients who improved, from 0.31 to 0.85 (p < 0.05) in the 18 patients whose condition was worse, and from 0.50 to 0.59 (NS) in the 24 patients whose condition was unchanged after 6 months. The effect size of the change was small (0.28) in those who improved and moderate (0.54) in those who became worse.

CONCLUSION

The Norwegian version of the CHAQ is a reliable and valid instrument for measuring disability in children with early JRA. Pain, joint inflammation, and psychosocial factors are the most important correlates of disability and the CHAQ is sensitive to clinical change.

Nursing intervention to increase hope and quality of life in newly diagnosed cancer patients

The aim of this study was to evaluate the effect of nursing intervention on hope and quality of life in cancer patients. The sample consisted of 96 newly diagnosed Norwegian cancer patients ages 26 to 78 years, the majority of them women (71%). Breast cancer was the predominant type of cancer in this sample. The study used an experimental design in which patients were randomly allocated to three different groups. The first group was the experimental group, for which the intervention was designed to increase hope. The second group (attention control group) participated in the "Learning to Live with Cancer" program. The last group was a control group. The Nowotny Hope Scale was used to measure hope, and the Ferrans and Powers Quality of Life Index and the Cancer Rehabilitation and Evaluation Systems, short form, were used to measure quality of life. The questionnaires were completed four times: twice before, then 2 weeks and finally 6 months after the intervention. The level of hope was significantly increased (p = 0.020) for the members of the hope group just after the intervention, but not after 6 months. Despite the patients' positive evaluation of the intervention, there was no impact on quality of life.

Concordance between symptom screening and diagnostic procedure: the Hopkins Symptom Checklist-25 and the Composite International Diagnostic Interview I

The definition of case is a core issue in psychiatric epidemiology. Psychiatric symptom screening scales have been extensively used in population studies for many decades. Structured diagnostic interviews have become available during recent years to give exact diagnoses through carefully undertaken procedures. The aim of this article was to assess how well the Hopkins Symptom Checklist-25 (HSCL-25) predicted cases by the Composite International Diagnostic Interview (CIDI), and find the optimal cut-offs on the HSCL-25 for each diagnosis and gender. Characteristics of concordant and discordant cases were explored. In a Norwegian two-stage survey mental health problems were measured by the HSCL-25 and the CIDI. Only 46% of the present CIDI diagnoses were predicted by the HSCL-25. Comorbidity between CIDI diagnoses was found more than four times as often in the concordant cases (case agreed upon by both instruments) than in the discordant CIDI cases. Concordant cases had more depression and panic/generalized anxiety disorders. Neither the anxiety nor the depression subscales improved the prediction of anxiety or depression. The receiver operating characteristic (ROC) curves confirmed that the HSCL-25 gave best information about depression. Except for phobia it predicted best for men. Optimal HSCL-25 cut-off was 1.67 for men and 1.75 for women. Of the discordant HSCL-25 cases, one-third reported no symptoms in the CIDI, one-third reported symptoms in the CIDI anxiety module, and the rest had symptoms spread across the modules. With the exception of depression, the HSCL-25 was insufficient to select individuals for further investigation of diagnosis. The two instruments to a large extent identified different cases. Either the HSCL-25 is a very imperfect indicator of the chosen CIDI diagnoses, or the dimensions of mental illness measured by each of the instruments are different and clearly only partly overlapping.

Use of minor tranquilizers among Norwegian physicians. A nation-wide comparative study

The use of minor tranquilizers (hypnotics and anxiolytics) during the last month before a questionnaire was answered was studied in a postal survey of a nation-wide representative sample of Norwegian physicians (n = 1467), aged 25 to 69 years. The response rate was 73%. A total of 12.2% of the physicians had used minor tranquilizers in the past month, one third of these on a daily or weekly basis. There was no gender difference. High age, high mental distress, and working outside the hospital was identified as risk factors for drug use. Compared to a representative sample of subjects from the general population with the same age and education level, (The Nord-Trøndelag Health Survey), more male physicians than males in the comparison sample had used minor tranquilizers in the past month, also when controlled for subjective well-being. However, the physicians had used the drugs more sporadic. When self-prescription of minor tranquilizers was studied in a different sample of 1024 Norwegian physicians, it was found that 72.6% of the physicians had self-prescribed the drugs. There was no gender difference in self-prescribing.

The relationship between psychological distress and traditional clinical variables: a 2 year prospective study of 216 patients with early rheumatoid arthritis

In this longitudinal study (12 and 24 months follow-up) of 216 patients with early rheumatoid arthritis (RA) (< or = 4 yr duration), we assessed the strength and stability of the relationship between psychological distress and traditional clinical variables examined the ability of these clinical variables to predict changes in mental distress, and explored the directionality between mental distress and the other clinical variables. Study variables were symptoms of anxiety and depression measured by the Arthritis Impact Measurement Scales, tender joint counts, erythrocyte sedimentation rate (ESR), and self-reported pain and disability. Psychological distress showed high levels of stability over time. Pain and disability were the two variables most strongly and consistently related to mental distress. High levels of disability predicted an increase in depression during the next year; otherwise, changes in psychological distress were not predicted by disease-related variables. Attempts at causal modelling of the temporal relationship between mental distress, pain and disability failed to yield consistent results.

Correlates of patients' global assessment of arthritis impact. A 2-year study of 216 patients with RA

Considering the key position of patients' global assessment in clinical practice and research, we wanted to examine the relationships between patients' global assessment and biological, functional, and mental variables, and to explore the relative contribution of these variables on patients' assessment of arthritis impact. Patients with RA of < or = 4 yrs duration were examined at baseline (n = 238) and after 12 and 24 months (n = 216). Study variables were tender joints, ESR, CRP, hand X-ray abnormalities and self-reported global arthritis impact, pain, disability, and symptoms of depression. 2-yr mean scores were computed for all variables. Strong correlations were found between patients' global assessment and pain (r = .73), depression (r = .68), disability (r = .64), and tender joints (r = .51), while ESR, CRP, and X-ray abnormalities correlated weakly with the global assessment. Using a multivariate approach, however, the relative effects of disability and tender joints were no longer statistically significant, whereas pain and depression still had significant impact on patients' global assessments.

Reliability and validity of the Norwegian version of the Nowotny Hope Scale. A nursing tool for measuring hope in cancer patients

The purpose of the present study was to assess the reliability and validity of the Norwegian version of the Nowotny Hope Scale as applied to cancer patients. The questionnaire was first translated into Norwegian following internationally accepted guidelines. The scale was tested on a sample consisting of 131 newly diagnosed cancer patients. The findings supported the internal consistency of the instrument as a whole (alpha = 0.89) and of the six subscales: confidence (alpha = 0.85), relates to others (alpha = 0.75), future is possible (alpha = 0.80), spiritual beliefs (alpha = 0.94), active involvement (alpha = 0.53) and comes from within (alpha = 0.80). Stability over time was provided by a satisfactory 3-4-week test-retest correlation (r = 0.81). The validity was confirmed by the judgement of an expert and by a principal components analysis with orthogonal rotation. The result of the factor analysis was somewhat different from the original findings in an American sample. The results obtained in this study are promising and indicate that the Nowotny Hope Scale can be used to measure hope in newly diagnosed Norwegian cancer patients.

An international study on measuring social support: interactions and satisfaction

Recently, a new instrument was developed to measure social support. It consists of two parts; the Social Support Questionnaire for Transactions (SSQT) and the Social Support Questionnaire for Satisfaction with the supportive transactions (SSQS). The SSQT measures the number of supportive interactions and has proved to have good psychometric properties. From the taxonomy that was used for the present study, it results that social support in general consists of two aspects. There are, on the one hand, actual supportive transactions and, on the other hand, the perception of being supported or the satisfaction with the social support provided. In the present study, two research questions were addressed. The first concerned the psychometric properties of the SSQS, measuring the individual's satisfaction with the supportive interactions provided. Secondly, the relative contribution of both supportive interactions (the SSQT) and the satisfaction with the support provided (the SSQS) were assessed, in explaining the level of health related quality of life outcome. The data of 744 rheumatoid arthritis (RA) patients from four different countries (116 French, 238 Norwegian, 98 Swedish and 292 Dutch patients) were used in the present study. At the entry of the study, all patients fulfilled four out of seven American Rheumatism Association (ARA) criteria and had a disease duration of 4 years or less. The results of the study indicate that the SSQS has good psychometric properties across countries. Cronbach's alpha for the emotional support scales was 0.80 or more, and for the instrumental support subscales around 0.60. The standardized regression coefficients demonstrated that, compared to supportive interactions, support satisfaction was more relevant in explaining health related quality of life measures, although it is recommended that the SSQT and SSQS be used to complement each other.

Correlates of functional disability in early rheumatoid arthritis: a cross-sectional study of 706 patients in four European countries

In this cross-sectional study of 706 European patients with rheumatoid arthritis (RA) of < or = 4 yr duration, we examined possible correlates of functional disability assessed by the Health Assessment Questionnaire. First, we examined a subsample of 237 Norwegian patients. The Ritchie index, sex, age, erythrocyte sedimentation rate (ESR) and disease duration correlated significantly with disability, whereas serum rheumatoid factor, hand X-ray changes and educational level did not. Subsequently, we cross-validated these findings in a similar sample of 469 French, Dutch and Northern Irish patients. The results supported the Ritchie index, sex, ESR and disease duration as significant correlates of disability, whereas rheumatoid factor, age and education were not significantly correlated with disability. The correlation between X-ray changes and disability could not be cross-validated. The main findings of this study are that female sex correlates significantly with disability even early in the course of RA, whereas the rheumatoid factor does not.

Identification of a new locus for autosomal dominant non-syndromic hearing impairment (DFNA7) in a large Norwegian family

Hereditary hearing impairment affects about 1 in 1000 newborns. In most cases hearing loss is non-syndromic with no other clinical features, while in other families deafness is associated with specific clinical abnormalities. Analysis of large families with non-syndromic and syndromic deafness have been used to identify genes or gene locations that cause hearing impairment. The present report describes a large Norwegian family with autosomal dominant non-syndromic, progressive high tone hearing loss with linkage to 1q21-q23. A maximum LOD score of 7.65 (theta = 0.00) was obtained with the microsatellite marker D1S196. Analysis of recombinant individuals maps the deafness gene (DFNA7) to a 22 cM region between D1S104 and D1S466. The region contains several attractive candidate genes. This report supports the idea of extensive genetic heterogeneity in hereditary hearing impairment and represents the first localization of a deafness gene in a Norwegian family.

The association between maternal education and postneonatal mortality. Trends in Norway, 1968-1991

BACKGROUND

This study examines whether the association between maternal educational level and postneonatal death has changed over time.

METHODS

All single survivors of the neonatal period in Norway in three periods, 1968-1971, 1978-1981 and 1989-1991 were studied. There were 582 046 births and 1717 postneonatal deaths. Logistic regression analyses were applied.

RESULTS

There has been an increasing inverse relationship between maternal educational level and postneonatal mortality in recent years. There was no statistically significant association between educational level and postneonatal mortality in the late 1960s. In the second period (1978-1981) the association is statistically significant for first-born children. In the third period (1989-1991) postneonatal mortality for first-born and later-born children was associated with maternal educational level, with adjusted odds ratios of 2.5 and 2.1 respectively. The overall level of education has increased tremendously, and the proportion of women with the lowest level of education has decreased from 56.3 to 10.7% in the period under study.

CONCLUSIONS

The underlying causes of changes in the impact of educational level are hard to determine and are indicative of the complexity of using maternal educational level as an indicator of social status over time. Possible mechanisms by which certain variables may covary with educational level, and thus have an adverse effect on postneonatal mortality, are discussed. The fact that the inverse association between educational level and postneonatal mortality has increased over time should be a matter for concern. It may indicate that the growth of the welfare state has not reached all segments of the population.

Marital status as a risk factor for fetal and infant mortality

In order to study pregnancy outcome for married versus unmarried mothers when controlling statistically for maternal age, educational level, socioeconomic status and income, a total of 93,800 firstborn singleton births in 1978-1982 were examined. The unmarried mothers were younger, less well educated and had a lower socioeconomic status than the married mothers. The stillbirth, neonatal, and postneonatal mortality rates were higher among offspring of unmarried mothers. After taking sociodemographic factors into account, marital status was found to be associated with postneonatal mortality. The adjusted odds ratio for postneonatal mortality was 1.5. Our results indicate the importance of marital status as a demographic risk factor even in a welfare society. There is a need to identify specific risk behaviours associated with the life styles of unmarried mothers. Hopefully our findings will provide information that can be used for future programmes of prevention, especially for the mother and her child during the first year of life.

The impact of early rheumatoid arthritis on psychological distress. A comparison between 238 patients with RA and 116 matched controls

The objective of our study was to estimate the impact of early rheumatoid arthritis (RA) on psychological distress by comparing patients with RA and matched controls. A sample of 238 patients (age 20-70 years, mean age 52 yrs) with RA of 0 to 4 years duration (mean 2.2 yrs), was compared to 116 control persons matched to the patients with respect to sex, age, and geographic area. Data were collected through self-report questionnaires. Patients with RA rated their mental health significantly lower than the controls. Symptoms of anxiety and depression were significantly higher among arthritic patients. Twenty% of the patients had scores indicating possible psychiatric caseness compared to 6% of the controls. However, controlling for pain, disability, and fatigue, there was no significant difference in psychological distress between the patients and the controls. RA appears to have a strong impact on mental distress even early in the disease. The present study demonstrates that pain, disability, and fatigue are strongly related to the increased levels of psychological distress in RA.

Life events, psychosocial factors, and demographic variables in early rheumatoid arthritis: relations to one-year changes in functional disability

OBJECTIVE

To explore how life events, psychosocial factors, and demographic variables are related to one-year changes in disability in early rheumatoid arthritis (RA).

METHODS

A sample of 238 patients with RA of 48 mo duration or less was examined at baseline and after 12 mo (n = 227; 95%). Data on life events and psychosocial variables were collected by structured interviews, and functional disability was measured by the Health Assessment Questionnaire (HAQ). Analyses of variance and forward stepwise linear regression analyses were used as statistical procedures.

RESULTS

Mean functional disability measured by the HAQ was relatively low at baseline and remained stable during one year. Positive life events experienced during the past year were significantly related to improved physical ability, whereas female sex was significantly related to reduction in ability. Neither age, income, education, number of network members, symptoms of mental distress, nor negative life events in the past year significantly predicted one-year changes in functional limitations.

CONCLUSION

The experience of positive life events during the past year was significantly related to a reduction in disability in this prospective study of 238 patients with early RA. This finding adds to our knowledge regarding the relationship between psychosocial factors and disease progression in RA.

The EORTC core quality of life questionnaire (QLQ-C30): validity and reliability when analysed with patients treated with palliative radiotherapy

The EORTC Core Quality of Life questionnaire (EORTC QLQ-C30) is designed to measure cancer patients' physical, psychological and social functions. The questionnaire is composed of multi-item scales and single items. 247 patients completed the EORTC QLQ-C30 before palliative radiotherapy and 181 after palliative radiotherapy. The questionnaire was well accepted with a high completion rate in the present patient population consisting of advanced cancer patients with short life expectancy. In addition, the questionnaire was found to be useful to detect the effect of palliative radiotherapy over time. The scale reliability was excellent for all scales except the role functioning scale. Excellent criterion validity was found for the emotional functioning scale where it was correlated with GHQ-20. Performance of the questionnaire was improved after the second evaluation as compared with the first. The present study shows that the EORTC QLQ-C30 is found to be practical and valid in measuring quality of life in patients with advanced disease.

Diabetes mellitus and psychological well-being. Results of the Nord-Trøndelag health survey

The present study relies on questionnaire data from a diabetes and hypertension screening carried out on the entire adult population of a medium-sized Norwegian county (total number of participants = 74,977). Self-reported diabetic patients were compared with non-diabetics, and with patients with self-reported angina pectoris, previous cardiac infarction, and stroke. The psychological well-being of the known diabetic patients was found to be significantly poorer than that of those without diabetes, but better than that of those with angina and stroke. HbAl level was found to be significantly related to well-being, the low levels of HbAl (below 7.5%) scoring low on well-being and the high levels (above 15%) scoring high. Because of its special design, the present study allowed comparisons between diabetic patients undergoing treatment and newly detected patients who had not yet been treated. Treatment-related interpretations therefore could be rejected.