International validation of the European Organisation for Research and Treatment of Cancer QLQ-BRECON23 quality-of-life questionnaire for women undergoing breast reconstruction.

BACKGROUND: The aim was to carry out phase 4 international field-testing of the European Organisation for Research and Treatment of Cancer (EORTC) breast reconstruction (BRECON) module. The primary objective was finalization of its scale structure. Secondary objectives were evaluation of its reliability, validity, responsiveness, acceptability and interpretability in patients with breast cancer undergoing mastectomy and reconstruction. METHODS: The EORTC module development guidelines were followed. Patients were recruited from 28 centres in seven countries. A prospective cohort completed the QLQ-BRECON15 before mastectomy and the QLQ-BRECON24 at 4-8 months after reconstruction. The cross-sectional cohort completed the QLQ-BRECON24 at 1-5 years after reconstruction, and repeated this 2-8 weeks later (test-retest reliability). All participants completed debriefing questionnaires. RESULTS: A total of 438 patients were recruited, 234 in the prospective cohort and 204 in the cross-sectional cohort. A total of 414 reconstructions were immediate, with a comparable number of implants (176) and donor-site flaps (166). Control groups comprised patients who underwent two-stage implant procedures (72, 75 per cent) or delayed reconstruction (24, 25 per cent). Psychometric scale validity was supported by moderate to high item-own scale and item-total correlations (over 0·5). Questionnaire validity was confirmed by good scale-to-sample targeting, and computable scale scores exceeding 50 per cent, except nipple cosmesis (over 40 per cent). In known-group comparisons, QLQ-BRECON24 scales and items differentiated between patient groups defined by clinical criteria, such as type and timing of reconstruction, postmastectomy radiotherapy and surgical complications, with moderate effect sizes. Prospectively, sexuality and surgical side-effects scales showed significant responsiveness over time (P < 0·001). Scale reliability was supported by high Cronbach's α coefficients (over 0·7) and test-retest (intraclass correlation more than 0·8). One item (finding a well fitting bra) was excluded based on high floor/ceiling effects, poor test-retest and weak correlations in factor analysis (below 0·3), thus generating the QLQ-BRECON23 questionnaire. CONCLUSION: The QLQ-BRECON23 is an internationally validated tool to be used alongside the EORTC QLQ-C30 (cancer) and QLQ-BR23 (breast cancer) questionnaires for evaluating quality of life and satisfaction after breast reconstruction.

Cancer patients' wish for psychological support during outpatient radiation therapy : Findings from a psychooncological monitoring program in clinical routine.

BACKGROUND: Cancer patients frequently suffer from physical and psychosocial impairments due to their disease and its treatment. Psychooncology (PO) can help to cope with stress resulting from outpatient radiotherapy (RT) treatment. There are currently few data regarding patients' wishes for PO support. The aim of this study was to investigate the number of patients with a wish for PO, treatment paths, and predictors of the wish for PO among cancer patients at the beginning of RT. METHODS: The results of routine psychological stress screening (Hornheide screening instrument; cut-off  ≥ 4) of 944 cancer patients between 2015 and 2017 were analyzed in a retrospective cross-sectional study. Predictors for a wish for PO support were identified by stepwise binary logistic regression, in which sociodemographic and treatment data were included in addition to the screening items. RESULTS: Around 20% of patients had above-average stress levels and 13% expressed a wish for PO support (participation rate was approximately 55%). Low emotional wellbeing (OR = 11.3) and lack of social support (OR = 9.4) were strong predictors for this treatment wish. Among patients with pancreatic cancer, head and neck tumors, and hematologic disease, there was a substantial difference between the degree of psychological stress and the wish for treatment. Patients with urological (23.5%) and lung tumors (20.9%) most frequently expressed a wish for PO support. CONCLUSION: Patient-reported psychosocial problems were better predictors of a wish for PO support than sociodemographic or clinical data. Stress screening should thus be implemented in clinical routine.

Evaluation of electronic patient-reported outcome assessment with cancer patients in the hospital and at home.

BACKGROUND: Patient-reported outcomes (PRO) provide a more comprehensive picture of patients' quality of life than do mere physicians' ratings. Electronic data collection of PRO offers several advantages and allows assessments at patients' homes as well. This study reports on patients' personal internet use, their attitudes towards electronic and web-based PRO assessment (clinic-ePRO and home-ePRO) and the feasibility of these two assessment modes. METHODS: At the Medical University of Innsbruck and Kufstein County Hospital, cancer patients who participated in clinic-ePRO/home-ePRO were asked to complete a comprehensive evaluation form on their personal internet usage, attitudes towards and the feasibility of routine clinic-ePRO/home-ePRO with the Computer-based Health Evaluation System (CHES) software. RESULTS: In total, 113 patients completed the evaluation form for clinic-ePRO (Ø 45 years, SD 14) and 45 patients for home-ePRO (Ø 58 years, SD 10; 33.1 per cent inclusion rate for this sample). Most patients expressed willingness to complete routine clinic-ePRO assessments in the future (94.7 per cent of clinic-ePRO patients and 84.4 per cent of home-ePRO patients) and to discuss their data with attending physicians (82.2 per cent, home-ePRO patients only). Overall, patients preferred the software over paper-pencil questionnaires (67.2 per cent of clinic-ePRO patients and 60 per cent of home-ePRO patients) and experienced it as easy to use. Only a few minor suggestions for improvement were made (e.g. adjustable font sizes). CONCLUSIONS: The use of clinic-ePRO/home-ePRO was in general shown to be feasible and well accepted. However, to be more inclusive in the implementation of clinic-ePRO/home-ePRO, educational programs concerning their particular benefit in oncology practice potentially could enhance patients' attitudes towards, and consequently their acceptance of and compliance with electronic PRO assessments.

[Acceptance of tinnitus: Validation of the ?Akzeptanzfragebogen bei chronischem Tinnitus' (AFCT)]. / Akzeptanz bei Tinnitus: Validierung des "Akzeptanzfragebogen bei chronischem Tinnitus" (AFCT).

BACKGROUND: Tinnitus is a widely spread symptom, which is perceived chronically by approximately 10% of the population. The vast majority of the tinnitus patients doesn´t feel impaired through the ear noise, but about 5-30% of the tinnitus patient are suffering in their everyday life. Whether severe distress is experienced cannot be explained by the quality of the ear noise itself (i. e. loudness or duration). Newer research tends to explain the difference in the experienced strain by the concept of acceptance. The aim of this study was to analyze the psychometric quality of a German Version of the "Chronic Pain Acceptance Ques-tionnaire" (CPAQ), namely the "Akzeptanzfragebogen bei chronischem Tinnitus" (AFCT) which has been adapted for tinnitus. METHODS: 97 patients with chronic tinnitus have been tested at the start of an outpatient tinnitus group therapy. The following questionnaires were used: "Akzeptanzfragebogen bei chronischem Tinnitus" (AFCT) and "Tinnitusfragebogen" (TF). The structure of the AFCT was determined by a factor analysis. The reliability was evaluated by the estimation of the internal consistency (Cronbach Alpha). RESULTS: Due to psychometric weakness and unclear factorial loadings 8 items have been removed. Out of the remaining 12 items the AFCT-12 has been developed. The AFCT-12 consists of 2 factors, which explain a variance of 54.9%. Both AFCT-12 and AFCT have a satisfactory reliability and validity. CONCLUSION: The results demonstrate that the AFCT-12 is a reliable and valid instrument to measure the acceptance of patients suffering from chronic tinnitus.

Assessment of health-related quality-of-life in patients with chronic Rhinosinusitis - Validation of the German Sino-Nasal Outcome Test-22 (German-SNOT-22).

PURPOSE: The Sino-Nasal-Outcome-Test-22 (SNOT-22) represents the reference questionnaire to assess symptoms, health-related quality-of-life (HRQOL) and treatment-response in patients with chronic rhinosinusitis (CRS). The SNOT-22 has been validated for various languages, yet no validation is available for the German version. Thus, we provide a validation of the SNOT-22 for German. METHODS: In this prospective observational study 139 CRS-patients and 36 control-participants were included. CRS-patients completed the German-SNOT-22 before treatment (T0) and four (T1), twelve (T2) and 48 weeks after inclusion (T3). At T0, Mackay-Naclerio-, Lund-Mackay- and Brief-Symptom-Inventory-18 (BSI-18) scores were collected as external reference for the German-SNOT-22 and its subscales. At T1, T2, and T3 health-transition-items (HTIs) were raised to explore responsivity. Control-participants completed the German-SNOT-22 at T0. Reliability (internal consistency, item-total correlation), validity (concurrent validity, discriminatory validity) and responsiveness (distribution- and anchor-based) were explored for the German-SNOT-22. RESULTS: At T0, the mean German-SNOT-22 total-score for CRS patients was 38.0 (± 20.9) and responded to treatment (T1 = 26.3 ± 19.1; T2 = 25.8 ± 20.6; T3 = 20.5 ± 16.3). For control-participants, the mean total-score at T0 was 15.1 (±10.9). The German-SNOT-22 was reliable (excellent internal consistency α = 0.93; good overall item-total correlations r = 0.39-0.85), valid (significant correlations between Mackay-Naclerio-, Lund-Mackay- and BSI-18 scores, all r > 0.39, p < 0.01) and responsive (significant correlations between HTIs and mean change in German-SNOT-22 total-score F = 9.57, p < 0.001). CONCLUSION: The German-SNOT-22 validated here matches the original SNOT-22. It is a reliable, valid and responsive questionnaire to assess symptoms, HRQOL and treatment-response in CRS-patients. Good psychometric properties were observed.

Cancer patients' understanding of longitudinal EORTC QLQ-C30 scores presented as bar charts.

OBJECTIVE: To investigate cancer patients' understanding of graphical presentations of longitudinal EORTC QLQ-C30 scores. METHODS: We conducted semi-structured interviews with brain tumour patients participating in routine patient-reported outcome (PRO) monitoring. We assessed understanding of longitudinal quality of life (QOL) profiles, presented as bar charts objectively and with self-ratings. In addition, patients' opinions on congruency of the QOL scores with their self-perceived health status were evaluated. RESULTS: We recruited 40 brain tumour patients (57.5% female; mean age 52.7, SD 13.7). In total, 90% of patients rated the graphs as easy to understand. Accordingly, almost all questions on assessing understanding objectively were answered correctly by at least 80% of the patients. More than 95% indicated that the displayed QOL scores matched their personal perception of symptom burden and functional health in the observed period. CONCLUSION: Patients are able to understand their QOL results when presented graphically and are able to interpret important changes. Displayed QOL scores obtained with the EORTC QLQ-C30 are consistent with the patients' personal perception of physical and emotional functioning, pain and fatigue. PRACTICE IMPLICATIONS: Knowledge about patients' understanding of graphically displayed QOL results contributes to creation of optimal evidence-based feedback on the patients' present QOL and its trajectory.

Chronic pelvic pain and previous sexual abuse.

OBJECTIVE: To determine whether there is an association between history of sexual abuse and development of chronic pelvic pain. METHODS: We studied 36 women with chronic pelvic pain, 23 with chronic low back pain, and 20 healthy women with reference to experience of sexual abuse, physical violence, and emotional neglect in childhood. Semistructured interviews were used to collect data. Assessment of severity of sexual abuse was based on Russell's criteria, and emotional and physical abuse were determined according to Briere's and Adler's definitions, respectively. RESULTS: In terms of experience of sexual abuse in general, the three groups did not differ statistically significantly from each other (P =.128). However, 22% of patients with chronic pelvic pain were sexually abused before their 15th birthdays, significantly more frequently than the other two groups (chronic low back pain 0%, P =.019, pain-free control 0%, P =.028). Women with chronic pelvic pain were exposed more frequently to physical violence (38%) and suffered more emotional neglect (25%) in their childhoods than women in the pain-free control group (physical abuse 5%, P =.012; emotional abuse 0%, P =.018). With regard to physical abuse and emotional neglect, the women with chronic pelvic pain did not differ from those with chronic low back pain (physical abuse 30.4%, P =.385; emotional abuse 21.7%, P =.571). CONCLUSION: Besides physical and emotional trauma, there is a significant association between sexual victimization before age 15 years and later chronic pelvic pain.

Attitude toward alternative therapy, compliance with standard treatment, and need for emotional support in patients with melanoma.

OBJECTIVE: To examine the attitude of patients with melanoma toward alternative therapies, their compliance with standard treatment, social support received by them, and their ways of coping with illness. DESIGN: Survey in a representative sample. SETTING: University hospital; central melanoma clinic serving Tyrol region in Austria. PATIENTS: Two hundred thirty-six consecutive patients with melanoma were approached in a 3-month-period, and 215 of them participated in the study. OUTCOME MEASURES: Results of a self-developed questionnaire to record patients' interest in alternative therapies, the Hornheide Questionnaire to assess patients' distress and social support, and the Freiburg Questionnaire of Coping With Illness. RESULTS: One hundred seventeen patients (54.4%) reported interest in nonconventional therapy. Thirty (14%) patients admitted actual use of such methods. The latter group more often suffered from advanced cancer (P < .001). Compared with uninterested patients, subjects interested in alternative therapy were younger (95% confidence intervals [CI] = 41.3-46.5 vs 48.7-56.7; P < .001), showed a more active coping style (95% CIs = 3.45-3.75 vs 2.91-3.50; P = .001) and a tendency toward religiousness and search for personal meaning in the disease (95% CIs = 2.56-2.85 vs 2.17-2.64; P < or = .08). Their faith in conventional medicine and ready compliance with physicians' suggestions were not less than those of uninterested patients (95% CIs = 4.26-4.46 vs 4.35- 4.64; P = .25). However, they believed that they were receiving less emotional support from their physicians (95% CIs = 0.95-1.74 vs 0.21-0.93; P = .04) and expressed interest in getting more such support (P = .04). CONCLUSIONS: Patients with melanoma consider non-conventional therapies as supplementary to standard medical methods and as a way of avoiding passivity and coping with feelings of hopelessness. This does not lessen the need to educate patients about the lack of efficacy of unorthodox methods but stresses the importance of offering them adequate emotional support.

The impact of stressful life events on exacerbation of chronic low-back pain.

The impact of stressful life events on the development and onset of chronicity of low-back pain is not yet fully understood. Sixty-four consecutive patients with chronic low-back pain treated at the orthopedic out-patient unit of the Innsbruck University Hospital were investigated with regard to stressful life events. Patients were classified into two groups: one group consisting of patients whose pain had an organic etiology (n= 16), and another group consisting of those with pain of uncertain origin (idiopathic group, n=48). A method combining a semistructured interview with a self-assessment of the severity of stress caused by life events was employed for assessing the impact of such events on chronic low-back pain. In comparison to the patient group having organic causes of pain, the idiopathic group showed significantly more patients having at least one highly stressful event preceding the last substantial aggravation of pain (p=0.028). The latter group experienced significantly more exhaustion (p=0.016) and significantly more difficulties in active coping (p=0.011) when confronted with stressful life events. Stressful life events that arouse feelings of helplessness may contribute to the development of chronic idiopathic low-back pain. Our results emphasize the importance of investigating the subjective meaning and appraisal of stressful life events, taking into consideration both individual predisposition and psychosocial resources available to the patient. Finally, it is also important that the attending physician be aware of any life event that is particularly stressful for the patient so that psychosocial help be made available at the appropriate time.

[The influence of daily psychosocial stressors and associated emotions on the dynamic course of urine cortisol and urine neopterin in systemic lupus erythematosus: Experience taken from two "integrative single-case studies"]. / Der Einfluss von Alltagsbelastungen und assoziierten Emotionen auf den dynamischen Verlauf von Cortisol und Neopterin bei Patientinnen mit systemischem Lupus Erythematodes: Ergebnisse aus zwei "integrativen Fallstudien"

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by flare-ups, the cause of which is unknown. According to new stress concepts, two "integrative single-case studies" have been conducted in order to gather evidence about whether daily stressful incidents and associated emotions interfere with the dynamics of urine cortisol and urine neopterin in SLE. Patients under study collected their urine at home, for a period of at least 50 days, on a daily basis, divided into day and night urine. Additionally, patients filled out questionnaires twice a day to determine their emotional state, life style and disease activity. Each week, patients were examined clinically and interviewed to identify the past week's stressors using the Incidents and Hassles Inventory (IHI, Brown and Harris). Statistical analysis of the serial data was performed using time-series analysis according to Box and Jenkins. In both "integrative single-case studies" we were able to demonstrate that stressful incidents predicted an increase in urine neopterin 36 hours (Case 1) to 60 hours (Case 2) later (p < 0.05). Additionally, in Case 1 the neopterin levels were highly associated with stress resulting from the weekly examinations and interviews. Furthermore, in Case 2 it turned out that depending on their predictability stressful incidents were preceded by a decrease in urine cortisol 12 hours earlier or were followed by a decrease in urine cortisol 36 hours later. And finally, emotional irritation was highly correlated with the course of urine-neopterin. In Case 2 irritation led to an increase in urine neopterin 84 hours later. There were no clinical signs of SLE during both prospective studies. In conclusion, our results validate the idea of "integrative single-case studies" as a new "bio-psycho-social" approach in psychoneuroimmunology. Further studies with SLE patients as well as with healthy probands will be necessary in order to both strengthen and generalize these results.

[Videotape preparation of patients before hip replacement surgery improves mobility after three months]. / Video-Vorbereitung bei Hüftgelenkersatz-Operation verbessert die Mobilität nach drei Monaten.

Long-term follow-up investigations of the effect of psychological preparation on postoperative physical outcome measures have very rarely been done. In this study a three-month follow-up of a previous investigation of videotape preparation before hip replacement surgery is reported. 100 patients who previously participated in a randomized controlled study received physical examination and x-ray of the hip joint three months after the operation. The mobility of the replaced hip joint was recorded as well as ossifications of the joint. Prepared patients showed a significantly higher improvement of internal rotation, rotational range of motion, and abduction, compared to the controls. The effect sizes ranged between 21% and 32% and, thus, were of clinical relevance. Prepared patients showed less ossifications (15%) that controls (22%), this difference was not significant. For the first time it could be demonstrated that psychological preparation before surgery can not only improve short-term and psychosocial outcome parameters, but also long-term physical measures. The reason for this effect remains to be investigated.

A new approach to combining clinical relevance and statistical significance for evaluation of quality of life changes in the individual patient.

OBJECTIVE: Empirical investigation of formerly proposed criteria for relevant changes of health-related quality of life (QOL) regarding their use for monitoring changes in the individual patient. Suggestion of a new criterion trying to overcome the drawbacks of former criteria. STUDY DESIGN AND SETTING: QOL data were collected longitudinally in 160 cancer patients receiving chemotherapy at an oncological outpatient unit, giving rise to a total of 975 QOL assessments. QOL was measured using the European Organization on Research and Treatment of Cancer Quality of Life Core Questionnaire. Several formerly suggested criteria of relevant change (distribution based, anchor based) were compared in terms of both prevalence and statistical significance of the resulting relevant changes. RESULTS: When considering criteria of relevant change suggested in the literature, high proportions (average: 42.3-48.3%) of reputedly relevant changes were found. The majority of these changes (average: 55.8-62.2%) were statistically insignificant. Combination of an increased threshold for clinical relevance with the concept of statistical significance resulted in a more meaningful change criterion. CONCLUSION: Formerly recommended thresholds of relevant change in QOL appear to be unduly low when focusing on the individual patient. A modified criterion is therefore suggested for this case. However, more research is needed for validation and refinement of the proposed criterion.

Convergent validity of the eating disorder inventory and the anorexia nervosa inventory for self-rating in an Austrian nonclinical population.

This study assesses the convergent and divergent validity of the Eating Disorder Inventory (EDI--German version) and the Anorexia Nervosa Inventory for Self-Rating (ANIS) in a German-speaking nonclinical population. One hundred fifty-five female and 224 male Austrian medical students were surveyed. Validity was studied at a dimensional level, separately for both sexes, by correlating with conceptually related as well as distinct scales. These instruments included the General Health Questionnaire (GHQ). The intercorrelation coefficients of the EDI and the ANIS were similar to the original samples. In women, the convergent validity of the EDI and the ANIS was confirmed, especially for the subscales measuring the specific psychopathology (r = .43 to .84) and for ineffectiveness/feelings of inadequacy (r = .63). The EDI subscales Maturity Fears and Interpersonal Distrust and the ANIS subscales Obsessive-Compulsive Traits and Sexual Anxiety address traits not included in the other test and these showed divergent validity. Divergent validity of the ANIS and to a lesser degree the EDI with the GHQ was established. Both tests can be equally recommended for female subjects. In males however, the validity indices of both tests were generally lower and convergent and divergent validity was not established.

Use of complementary and alternative medicine by cancer patients is not associated with perceived distress or poor compliance with standard treatment but with active coping behavior: a survey.

BACKGROUND: Complementary and alternative medicine (CAM) is often used by cancer patients. Data on characteristics of users, concomitant psychologic disturbance, and compliance with standard treatment continue to be controversial. Use of and interest in CAM and their correlation with psychologic disturbance, ways of coping with illness, and compliance with standard treatment were examined in this study. METHODS: The authors conducted a survey in a consecutive sample of 205 cancer patients undergoing radiotherapy, using a structured questionnaire to record use of and interest in CAM, the Hospital Anxiety and Depression Scale, the Hornheide Questionnaire to assess patient distress and social support, and the Freiburg Questionnaire of Coping with Illness. RESULTS: Of the 172 participants, 24.4% (response rate, 83.9%) reported use of CAM, and 31.4% reported not having used but being interested in such methods. Logistic regression analysis including clinical, demographic, and psychologic characteristics as independent variables yielded 3 predictors of use of or interest in CAM: younger age (P = 0.004; odds ratio (OR), 0.96), progressive cancer (P = 0.064; OR, 1.47), and active coping behavior (P = 0.016; OR, 1.65). Patients interested in or using CAM did not show more psychologic disturbance, poorer social support, or less trust in medicine or compliance with radiotherapy than subjects without such interest. CONCLUSIONS: Use of CAM by cancer patients is not associated with perceived distress or poor compliance with medical treatment but with active coping behavior. Patients seem to consider CAM as supplementary to standard medical methods and one way of avoiding passivity and of coping with feelings of hopelessness.

How successful are oncologists in identifying patient distress, perceived social support, and need for psychosocial counselling?

20-40% of cancer patients show emotional distress. Psychosocial support should be offered to severely distressed patients. However, little is known about the selection of patients to whom such support should be offered. This study investigated oncologists' ability to identify such patients. In a consecutive series of 298 cancer patients undergoing radiotherapy, distress, perceived social support and desire for supportive counselling were assessed using screening instruments. Simultaneously, 8 oncologists estimated patient distress and need for psychosocial support. A complete set of data was obtained in 80.2% of cases. Concordance of the oncologists' estimation of patient distress and perceived social support with the results of the screening instruments was weak (kappa = 0.10 and kappa = 0.05). Oncologists recognized the presence of severe distress only in 11 of the 30 severely distressed patients. Correct perception of distress was lower in patients with head and neck cancer and lung cancer and in lower class patients. Oncologists' recommendations for supportive counselling did not correlate with patient distress or the amount of perceived support but rather with progressive disease and less denial behaviour. Our results underline the need for educating oncologists in order to improve their ability to identify patient distress.

Need for supportive counselling--the professionals' versus the patients' perspective. A survey in a representative sample of 236 melanoma patients.

BACKGROUND: The aim of the study was to identify melanoma patients who suffered significant distress and were judged to be in need of supportive counselling, on the one hand, and, on the other, to investigate patient interest in such support. METHODS: Out of 236 melanoma patients, who constitute a representative sample of melanoma patients in Western Austria, 215 patients participated in the study and were assessed with regard to psychosocial distress, coping strategies, social networks and interest in receiving psychosocial support. Multiple logistic regression analyses were performed with regard to patient interest in receiving psychosocial support either from the attending oncologist or from a mental health professional. RESULTS: 65 patients (30.2%) experienced moderate and 30 patients (14.0%) severe distress, which was predominantly caused by tumour-related fears, tension and disturbance of emotional well-being. 83% of the severely distressed patients wanted psychosocial support from their oncologists, whereas only half of them were interested in additional support from a psychotherapist. In particular, patients who showed fear of tumour progression and felt that they were insufficiently informed about their disease preferred to consult their dermatologist for psychosocial support. On the other hand, patients with poor prognosis, receiving only low levels of support from their social network, and exhibiting a depressive coping style, showed interest in getting supplementary support from a psychotherapist. CONCLUSIONS: These findings underline the importance of educating oncologists with a view both to improve their communication skills and to help them identify patients making poor adjustment to illness in order to offer them appropriate emotional support.

Daily psychosocial stressors interfere with the dynamics of urine neopterin in a patient with systemic lupus erythematosus: an integrative single-case study.

OBJECTIVE: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by flare-ups, the causes of which are not known. In accordance with new concepts in stress research, this study investigated whether daily psychosocial stressors interfere with immunological processes in SLE. Because such processes are unique to each individual, single-case design using time-series analysis (Box and Jenkins) was applied. METHODS: A 40-year-old woman with SLE (last flare-up September 1995) was interviewed initially to determine major life events and difficulties (using the Life Events and Difficulties Schedule) in the previous 2 years. She was then observed for 63 days. Urine neopterin, an immunological parameter demonstrated to parallel disease activity in SLE patients, was measured in daily overnight urine. Daily incidents were identified weekly by the Incidents and Hassles Inventory and independently rated. Intervening factors, including infections, medication, and lifestyle, were controlled. RESULTS: Retrospectively, data obtained from the Life Events and Difficulties Schedule indicated that major life events and difficulties had preceded the patient's last flare-up in 1995. Although there were no clinical signs of SLE during this prospective study of 63 days, cross-correlational analyses revealed that "moderately" stressful incidents associated with higher levels of emotional irritation (lag 0: +0.271, p < .05) predicted an increase in urine neopterin the following day (lag 1: +0.441, p < .05). Moreover, a 7-day cyclicity in neopterin levels that corresponded to the weekly examinations and interviews was found. CONCLUSIONS: This study showed a causal relationship between psychosocial stressors and urine neopterin concentrations that may be related to SLE disease activity. Furthermore, the workability of an integrative approach using single-case design and time-series analysis in psychoneuroimmunology was demonstrated for the first time.

[The validity of the Hornheide questionnaire for psychosocial support in skin tumor patients: a survey in an Austrian and German outpatient population with melanoma]. / Die Validität des Hornheider Fragebogens zur psychosozialen Unterstützung bei Tumorpatienten. Eine Untersuchung an zwei repräsentativen ambulanten Stichproben von Melanompatienten.

Tumour patients are subject to different degrees of psychosocial distress depending on the course of disease, personality variables and amount of social support available. Often patients do not spontaneously talk about their distress and attending physicians fail to detect it. Therefore, it is important that the presence of distress is ascertained by specific screening instruments so that appropriate supportive measures can be instituted. The Hornheide Questionnaire (HQ) employed for investigating the need for psychosocial support in the case of patients with skin tumours and with tumours in the head and neck region represents such a specific screening instrument. The present study investigates the validity of the HQ on the basis of two representative samples from two different University Clinics for treatment and follow-ups of melanoma patients. With the help of the HQ, 215 patients at the Dermatology Out-patient Unit of the University of Innsbruck and 223 patients at the University of Freiburg were investigated with regard to their subjective experience of distress. The external constructive validity criteria were established on the basis of the Freiburg Questionnaire of Disease-Coping, the questionnaire of social support and Beck's Depression Inventory. There were significant differences between individuals in the severity of distress in different age groups and in patients in different tumour stages. The internal consistency of the HQ and its subscales proved to be satisfactory demarcation from other psychosocial dimensions and an adequate correlation with similar dimensions (depression, depressive illness coping, social support, compliance). The HQ appears to be an economical and valid screening instrument for detecting the need for psychosocial support in melanoma patients in the out-patient follow-up stage.