Patients' expectations and satisfaction with total hip arthroplasty

Although there have been many studies focusing on the increasingly important assessment of patients' satisfaction, few studies have specifically addressed this tissue for total hip arthroplasty (THA). The goals of this study were to measure patients' satisfaction with THA and to evaluate the relationships of expectations and outcome to patients' satisfaction. A total of 180 patients were surveyed 2 to 3 years after THA about their experiences with THA. Patients cited 45 different expectations, which were grouped into five categories reflecting improvement in pain, walking, psychological state, essential activities, and nonessential activities. Overall, 89% of patients were satisfied with the results of surgery. Lower rates of satisfaction were found in patients who had a better preoperative condition (as measured by the surgeons with The Hospital for Special Surgery Hip Scale), in patients who expected improvement in nonessential activities, and in patients who reported worse postoperative condition (as measured by self-assessment with the Hip Rating Questionnaire and the Medical Outcomes Study Short-form General Health Survey). Patients were also asked how they came to THA. Nearly 50% of patients were first referred to an orthopaedist by family or friends or based on their own knowledge. Seventy-four percent either had subsequently referred others for THA or would have done so if they knew someone with hip pain. This study demonstrates that satisfaction with THA is a complex phenomenon, affected by expectations, outcome, and what patients know about the procedure from their community network. A better understanding of THA satisfaction will enable better future selection of patients and an additional dimension of outcome, both of which are important to patients and payers.

A self-administered questionnaire for assessment of symptoms and function of the shoulder

A self-administered questionnaire was designed to assess the severity of symptoms related to and the functional status of the shoulder. It includes domains of global assessment, pain, daily activities, recreational and athletic activities, work, satisfaction, and areas for improvement. Each domain is graded separately and is weighted to arrive at the total score. The over-all scale and each domain were prospectively tested for validity, reliability, and responsiveness to clinical change. One hundred patients who were seen for evaluation of the shoulder were enrolled in the study. The validity of the scale was demonstrated by moderate-to-high correlation of the domains and individual questions of the Shoulder Rating Questionnaire with those of the Arthritis Impact Measurement Scales 2. Validity was supported further by significant correlation of the scores in each domain with the level of satisfaction in that domain and by significantly lower scores in domains that patients selected as areas important for improvement. The over-all scale and each domain were internally consistent (Cronbach alpha, 0.71 to 0.90). Reproducibility was evaluated by repeated administration of the questionnaire after a mean of three days to forty patients whose condition was clinically stable. Reproducibility of the over-all questionnaire and individual domains was excellent (Spearman-Brown index, 0.94 to 0.98). Individual questions were reproducible, with a weighted kappa value of more than 0.7 for each. Responsiveness was evaluated by comparison of the preoperative and postoperative scores of thirty patients who had a satisfactory result one year after an operation on the shoulder. The over-all Shoulder Rating Questionnaire and each domain were responsive to clinical change as demonstrated by favorable standardized response means (range, 1.1 to 1.9) and indices of responsiveness (range, 1.1 to 2.0). Similar analysis performed for individual diagnostic groups supported the validity, reliability, and responsiveness of the questionnaire in each group. The self-administered shoulder questionnaire was found to be valid, reliable, and responsive to clinical change. These qualities should make it a useful instrument for the prospective assessment of the outcome of treatment of disorders related to the shoulder.

Fc gamma RIIA alleles are heritable risk factors for lupus nephritis in African Americans

Allelic variants of Fc gamma R confer distinct phagocytic capacities providing a mechanism for heritable susceptibility to immune complex disease. Human Fc gamma RIIa has two codominantly expressed alleles, R131 and H131, which differ substantially in their ability to ligate human IgG2. The Fc gamma RIIa-H131 is the only human Fc gamma R which recognizes IgG2 efficiently and optimal IgG2 handling occurs only in the homozygous state. Therefore, since immune complex clearance is essential in SLE, we hypothesized that Fc gamma RIIA genes are important disease susceptibility factors for SLE, particularly lupus nephritis. In a two-stage cross-sectional study, we compared the distribution of Fc gamma RIIA alleles in African Americans with SLE to that in African American non-SLE controls. A pilot study of 43 SLE patients and 39 controls demonstrated a skewed distribution of Fc gamma RIIA alleles, with only 9% of SLE patients homozygous for Fc gamma RIIa-H131 compared with 36% of controls (odds ratio, 0.18; 95% CI, 0.05-0.69, P = 0.009). This was confirmed with a multicenter study of 214 SLE patients and 100 non-SLE controls. The altered distribution of Fc gamma RIIA alleles was most striking in lupus nephritis. Trend analysis of the genotype distribution showed a highly significant decrease in Fc gamma RIIA-H131 as the likelihood for lupus nephritis increased (P = 0.0004) consistent with a protective effect of the Fc gamma RIIA-H131 gene. The skewing in the distribution of Fc gamma RIIA alleles identifies this gene as a risk factor with pathophysiologic importance for the SLE diathesis in African Americans.

Truncated mammalian Notch1 activates CBF1/RBPJk-repressed genes by a mechanism resembling that of Epstein-Barr virus EBNA2

The Notch/Lin-12/Glp-1 receptor family participates in cell-cell signaling events that influence cell fate decisions. Although several Notch homologs and receptor ligands have been identified, the nuclear events involved in this pathway remain incompletely understood. A truncated form of Notch, consisting only of the intracellular domain (NotchIC), localizes to the nucleus and functions as an activated receptor. Using both an in vitro binding assay and a cotransfection assay based on the two-hybrid principle, we show that mammalian NotchIC interacts with the transcriptional repressor CBF1, which is the human homolog of Drosophila Suppressor of Hairless. Cotransfection assays using segments of mouse NotchIC and CBF1 demonstrated that the N-terminal 114-amino-acid region of mouse NotchIC contains the CBF1 interactive domain and that the cdc10/ankyrin repeats are not essential for this interaction. This result was confirmed in immunoprecipation assays in which the N-terminal 114-amino-acid segment of NotchIC, but not the ankyrin repeat region, coprecipitated with CBF1. Mouse NotchIC itself is targeted to the transcriptional repression domain (aa179 to 361) of CBF1. Furthermore, transfection assays in which mouse NotchIC was targeted through Gal4-CBF1 or through endogenous cellular CBF1 indicated that NotchIC transactivates gene expression via CBF1 tethering to DNA. Transactivation by NotchIC occurs partially through abolition of CBF1-mediated repession. This same mechanism is used by Epstein-Barr virus EBNA2. Thus, mimicry of Notch signal transduction is involved in Epstein-Barr virus-driven immortalization.

Balloon photodynamic therapy of esophageal cancer: effect of increasing balloon size

BACKGROUND AND OBJECTIVE

Photodynamic therapy is currently being used to treat various malignancies including esophageal cancer. The effect of photodynamic therapy depends upon the concentration of photosensitizing drug, light energy delivered to tissue, and the presence of oxygen in the targeted tissue. We have found that an esophageal centering balloon improves light delivery to esophageal mucosa. However, balloon pressure on esophageal mucosa could possibly reduce mucosal blood flow and oxygenation, therefore reducing the effect of photodynamic therapy. This study was conducted to investigate the effect of balloon pressure on the esophageal wall during photodynamic therapy in the canine esophageal model.

STUDY DESIGN/MATERIALS AND METHODS

Studies were performed in the canine esophagus of ten animals to investigate whether increasing the size of the centering balloon, and hence the pressure on esophageal mucosa, would alter the tissue effect of PDT. Porfimer sodium 4 mg/Kg was administered and 630 nm light was delivered via a 1 cm diffuser located in the center of a 360 degrees 2 cm windowed balloon. Mucosal light measurements were made to ascertain equivalent mucosal light dosing of approximately 25 J/cm2. Endoscopic and necropsy findings obtained following photodynamic therapy with 25 mm, 33 mm, and 35 mm balloons were compared.

RESULTS

In larger dogs (groups A and B), increasing the size of the esophageal centering balloon from a 25-33 mm size did not result in an overly tight fit nor was the increase associated with significant change in the PDT effect. In contrast, increasing the balloon size to 35 mm in smaller dogs (group C) resulted in a tight fit of the balloon in the esophagus and in significant reduction in the PDT effect on mucosal damage when mucosal equivalent light dose was administered during photodynamic therapy in the canine esophageal model.

CONCLUSION

Increasing centering balloon size resulted in reduced tissue damage when mucosal equivalent light dose was administered during photodynamic therapy in the canine esophageal model. Proper sizing of centering balloons will be necessary for balloon PDT of esophageal mucosal dysplasia or cancer in humans.

The HCF repeat is an unusual proteolytic cleavage signal

The herpes simplex virus VP16-associated protein HCF is a nuclear host-cell factor that exists as a family of polypeptides encoded by a single gene. The mature HCF polypeptides are amino- and carboxy-terminal fragments of a large approximately 300-kD precursor protein that arise through cleavage at one or more centrally located sites. The sites of cleavage are the HCF repeats, highly conserved 26-amino-acid sequences repeated six times in the HCF precursor protein. The HCF repeat alone is sufficient to induce cleavage of a heterologous protein, and cleavage occurs at a defined site--PPCE/THET--within the HCF repeat. Alanine-scan mutagenesis was used to identify a large 18-amino-acid segment of the HCF repeat that is important to induce cleavage of a heterologous protein. Even though HCF is cleaved, the majority of amino- and carboxy-terminal cleavage products remain tightly, albeit noncovalently, associated. Modulation of this noncovalent association may provide a mechanism for regulating HCF activity. For example, the cleaved products of an alternative mRNA splicing variant of HCF do not remain associated.

A brief educational intervention for patients with rheumatic disease chosen to be presented in a clinic conference

Being presented in a case conference can be anxiety-provoking and intimidating for the patient. We observed that patients, at times, would show signs of apparent discomfort. A structured interview of the patient was designed to assess, address, and clarify concerns the patient might have beforehand. The patients' concerns were communicated to the staff. The structured interview was given to 31 patients before they were presented. An additional 14 patients were interviewed after the conference about their experience without the prior interview. One year later, we followed up by interviewing another 15 patients who had been selected for clinic conference cases. The structured interview revealed confusion on the patient's part about the purpose of the conference, and a desire for information about the physical setting and who would be there. Patients wanted to be introduced formally when entering the room and to be thanked when leaving, and preferred to be questioned directly about their symptoms. Of the 31 patients interviewed before the conference, 23 (74%) reported that the conference was a positive experience when questioned afterward, compared with only 9 of 14 (64%) of those who were not interviewed before the conference. The results of this study were presented to the clinic staff, and education of the patients was stressed as a primary responsibility. At the follow up, 12 of the 15 patients reported real understanding of the clinic conference purpose. The only patient who reported being uncomfortable with the clinic conference and unwilling to attend another was the only patient who reported not being informed about what the conference entailed. It can be too easy for medical staff to forget that what is routine to them is very unusual and can be very stressful to the patient.

Diminished material properties and altered bone structure in rat femora during pregnancy

Pregnancy and lactation are known to cause structural and mechanical changes in bone, but the effects of pregnancy alone have not been evaluated thoroughly. This study used radiographic measurements, torsion testing, mineral analyses, and histological evaluation to determine whether there are changes in bone material and geometric properties during pregnancy in the growing rat, as implied by earlier biochemical and histological studies. The bones of pregnant 9 to 12-week-old rats and controls that were not pregnant and were matched by age (but not weight) were evaluated at times corresponding to 5, 10, 15, and 20 days of the 23-day gestation period to address the following questions: (a) How is the growth of whole bone affected by pregnancy in the growing rat (as determined by radiographic analyses)? (b) How are the mechanical properties (structural and material) of whole bone affected by pregnancy (as assessed by torsion testing)? (c) Are there changes in the characteristics of bone mineral during pregnancy (as determined by measurement of mineral content and x-ray diffraction analyses)? and (d) Are there detectable morphological or ultrastructural differences between the bones of pregnant and control rats (as assessed by analyses based on histology and back-scattered electron imaging)? The presence of statistically significant differences in this study was determined initially on the basis of a two-factor analysis of variance. In general, significant differences were noted only at late gestation (day 20), when the bones were longer and had a greater outer radius and cortical thickness; this indicates that more growth occurred during pregnancy.(ABSTRACT TRUNCATED AT 250 WORDS)

Knowledge, beliefs, and behaviors among college women concerning the prevention of osteoporosis

OBJECTIVE

To assess the knowledge of osteoporosis risk factors among young women, their beliefs about the disease, and to what extent they practice preventive behaviors, such as adequate calcium intake and physical activity.

DESIGN

Cross-sectional survey.

SETTING/PARTICIPANTS

One hundred twenty-seven women (mean age, 19.6 years; 92% were white) enrolled in a required undergraduate health course at a midwestern state university.

RESULTS

One hundred fourteen (90%) of the survey respondents had heard about osteoporosis, but only 49 (43%) of the 114 had received information from either a health care provider or a school. There was a significant relationship between receiving osteoporosis information and the ability to correctly identify risk factors (P < or = .006). Only 6.7% of the women reported getting both adequate "osteoprotective" exercise per week and the recommended 1200 mg of calcium per day. Respondents believed that it was unlikely that osteoporosis would develop in them. They also expressed less responsibility and concern about osteoporosis and believed that it is less serious than other common causes of morbidity and mortality in women, such as heart disease and breast cancer (P < or = .02). There was no significant relationship between risk-factor identification and exercise habits, calcium intake, or beliefs about osteoporosis.

CONCLUSIONS

The majority of young women are not consuming the recommended daily amount of calcium and are lacking sufficient osteoprotective exercise for building healthy bone. Health care providers and educational institutions either have missed opportunities to educate young women about osteoporosis or such information has not been received and retained. Increasing levels of osteoporosis awareness may not be associated with influencing beliefs or behaviors. However, because of the importance of building an adequate bone mass in early life, our data suggest that the development and evaluation of comprehensive osteoporosis educational interventions targeted at younger women are warranted.

Mediation of Epstein-Barr virus EBNA2 transactivation by recombination signal-binding protein J kappa

The Epstein-Barr virus (EBV) transactivator protein, termed Epstein-Barr virus nuclear antigen 2 (EBNA2), plays a critical role in the regulation of latent viral transcription and in the immortalization of EBV-infected B cells. Unlike most transcription factors, EBNA2 does not bind directly to its cis-responsive DNA element but requires a cellular factor, termed C-promoter binding factor 1 (CBF1). Here, CBF1 was purified and was found to directly interact with EBNA2. CBF1 is identical to a protein thought to be involved in immunoglobulin gene rearrangement, RBPJ kappa. Contrary to previous reports, CBF1-RBPJ kappa did not bind to the recombination signal sequences but instead bound to sites in the EBV C-promoter and in the CD23 promoter.

Changes in the moment arms of the rotator cuff and deltoid muscles with abduction and rotation

The behavior of the moment arms of the rotator cuff and deltoid muscles was studied during simple and combine movements of abduction and rotation about the glenohumeral joint. This was done by experimental measurement of excursions of the muscles in an in vitro cadaver model and by use of a multiple-regression analysis to delineate the changes in the moment arms as a function of abduction and rotation. The results demonstrated the potential of some rotator cuff muscles to contribute to both abduction and rotation, the sensitivity of the abductor moment-arm lengths to internal and external rotation and of the rotator moment-arm lengths to the degree of abduction, and the capacity of the abductor moment-arm lengths of the deltoid to increase with increasing abduction. Characterization of this behavior resulted in an increased understanding of the complex role of the rotator cuff and deltoid muscles about the gleno-humeral joint and provided quantitative descriptions of functional relationships. This study demonstrates the capacity of the infraspinatus and subscapularis muscles to contribute not only to external and internal rotation, respectively, but also to elevation of the arm in the plane of the scapula, a role for which these muscles have been given little or no consideration. Furthermore, it demonstrates that the contribution of the infraspinatus to abduction is enhanced with internal rotation while that of the subscapularis is enhanced with external rotation. Thus, dysfunction of the supraspinatus muscle need not preclude good elevation of the arm, and rehabilitation to reprogram and strengthen the remaining muscles becomes an important consideration.

Strength in polymyositis and dermatomyositis: best outcome in patients treated early

OBJECTIVE

To study the influence of clinical variables on improvement in muscle strength in patients with polymyositis and dermatomyositis.

METHODS

We biomechanically examined muscle strength over the course of 2.54 years of 65 patients.

RESULTS

Disease duration before therapy was predictive of outcome. Those treated within 6 months or one year of disease onset had better outcomes than those with later treatment. In addition, among those who gained strength, degree of elevation of creatine kinase was correlated with greater gains.

CONCLUSION

Early treatment after disease onset increases the chance of a favorable response.

Lyme disease: an infectious and postinfectious syndrome

OBJECTIVE

To determine chronic morbidity and the variables that influence recovery in patients who had been treated for Lyme disease.

METHODS

Retrospective evaluation of 215 patients from Westchester County, NY, who fulfilled Centers for Disease Control case definition for Lyme disease, were anti-Borrelia antibody positive and were diagnosed and treated at least one year before our examination.

RESULTS

Erythema migrans had occurred in 70% of patients, neurological involvement in 29%, objective cardiac problems in 6%, arthralgia in 78% and arthritis in 41%. Patients were seen at a mean of 3.2 years after initial treatment. A history of relapse with major organ involvement had occurred in 28% and a history of reinfection in 18%. Anti-Borrelia antibodies, initially present in all patients, were still positive in 32%. At followup, 82 (38%) patients were asymptomatic and clinically active Lyme disease was found in 19 (9%). Persistent symptoms of arthralgia, arthritis, cardiac or neurologic involvement with or without fatigue were present in 114 (53%) patients. Persistent symptoms correlated with a history of major organ involvement or relapse but not the continued presence of anti-Borrelial antibodies. Thirty-five of the 114 (31%) patients with persistent symptoms had predominantly arthralgia and fatigue. Antibiotic treatment within 4 weeks of disease onset was more likely to result in complete recovery. Children did not significantly differ from adults in disease manifestations or in the frequency of relapse, reinfection or complete recovery.

CONCLUSION

Despite recognition and treatment, Lyme disease is associated with significant infectious and postinfectious sequelae.

Supraventricular tachyarrhythmias during total joint arthroplasty. Incidence and risk

Perioperative supraventricular tachyarrhythmias (AF/SVT) have been long recognized as a complication after major surgery, but little is known about the incidence after major nonthoracic surgery. One thousand two hundred ten consecutive patients undergoing total hip or knee arthroplasty were studied to determine the incidence of new onset AF/SVT. Information on preoperative medical history and laboratory tests were collected in a subset of 583 patients, and analyzed using logistic regression and linear analysis to determine risk. Ninety-four-and-one-half percent of patients received an epidural anesthetic, 4.1% had general anesthesia and 1.3% had spinal anesthesia. New onset AF/SVT was found in 38 of 1210 patients, representing an incidence of 3.1%. In the subset of 583 patients, the incidence was 4.8%. The only variables found to be independently associated with the perioperative development of AF/SVT were a history of atrial fibrillation, increasing age, left anterior hemi-block, and atrial premature depolarizations on the preoperative electrocardiogram. In those patients 60 years of age or older with one or more positive risk factors (13% of the study population), the incidence was 18.2%. In those patients less than 60 years of age with none of the identified risks, the incidence was 1.9%.

A musculoskeletal outreach screening, treatment, and education program for urban minority children

PURPOSE

A hospital-based outreach program was initiated to screen minority children in medically underserved areas of New York City for musculoskeletal diseases. We examine the number of such diseases in this population, and evaluate the program's success to facilitate referral and follow-up of children with referral conditions.

METHODS

Screenings were conducted at schools and day-care centers. Children requiring further evaluation were referred to the sponsoring hospital, a major referral center for musculoskeletal diseases. Bilingual educational strategies, transportation reimbursement, and coverage for uninsured children were used to foster participation and increase follow-up.

RESULTS

A total of 2,523 children were screened, 168 (6.7%) of whom were referred for one of 45 different musculoskeletal disorders, including scoliosis and back problems, foot problems, in- and out-toeing, knee or hip pain, and problems of joint range of motion. Sixty-seven percent of those referred had a follow-up medical consultation.

CONCLUSIONS

A substantial proportion of urban minority children have previously undiagnosed musculoskeletal disorders that, if left untreated, have the potential to lead to significant disability in later life. Targeted screening programs can be effective in identifying such disorders, and providing and opportunity for early diagnosis, treatment, and education.

The VP16 accessory protein HCF is a family of polypeptides processed from a large precursor protein

Upon lytic infection of permissive cells, the herpes simplex virus (HSV) transactivator protein VP16 associates with an accessory protein termed host cell factor (HCF). Binding to HCF activates VP16 for association with the octamer motif-binding protein Oct-1, to form a multiprotein-DNA complex responsible for activating transcription of the HSV immediate early genes. We show that HCF comprises a series of related polypeptides that range from 110 to 300 kd, all of which are encoded by a single gene. Although there is no obvious sequence similarity between HCF and other known proteins, HCF contains eight repeats of a new 26 amino acid motif. cDNAs encoding HCF predict a large open reading frame of 2035 codons. When expressed in human cells, this large open reading frame encodes both the 300 kd and smaller HCF polypeptides, indicating that the smaller polypeptides arise by processing of the 300 kd protein.

An organizational model for developing multidisciplinary clinical research in the academic medical center

OBJECTIVE

To assess the impact of a new organizational model designed to stimulate multidisciplinary clinical research.

METHODS

We conducted a prospective, 3 1/2-year followup of a research training program for residents, fellows, faculty, nurses, and allied health professionals in rheumatology and orthopedic surgery. Program components included a multidisciplinary clinical research conference, a clinical research methods curriculum, consultations, a patient registry, and regular meetings of a Research Methodology Core group. Measures included participation in each program component and the number of new investigators who developed funded clinical research projects.

RESULTS

The multidisciplinary clinical research conference was attended by 369 new health professionals; 218 professionals participated in at least one of the courses; and 280 consultations were provided to 108 professionals. Thirteen new investigators developed 17 new grant proposals, of which 14 were externally funded. Investigators who successfully procured funding for new projects demonstrated significantly more participation in program components compared with those who did not (P < 0.001 overall).

CONCLUSION

Participation in the program was significantly correlated with the development of new prospective patient-based studies. We conclude that our model has the potential to foster such research in other settings.

A walking education program for patients with osteoarthritis of the knee: theory and intervention strategies

Walking is an ideal physical activity for patients with osteoarthritis because it can help to improve functional status without exacerbating pain or necessitating an increase in the use of medication. Although patient education programs designed to encourage walking have become increasingly important in the management of this condition, there is no single synthesis or other published source of theory and intervention strategies to guide the practitioner in the development of such programs. This paper describes a hospital-based patient education program designed to enhance the functional capacity of who have osteoarthritis of the knee by encouraging the adoption and maintenance of walking. The paper describes the goals, objectives, process, and impact of the program; the principal theoretical model utilized in the design of the program; and how concepts and intervention strategies from the literatures on patient compliance and patient education, exercise compliance, behavioral psychology, and relapse prevention have been operationalized and integrated in a walking program that we have evaluated for safety and efficacy.

Factors affecting deep vein thrombosis rate following total knee arthroplasty under epidural anesthesia

A retrospective review was performed of 448 consecutive patients undergoing primary, unilateral, bicondylar, and cemented total knee arthroplasty under epidural anesthesia by three surgeons to determine factors contributing to deep vein thrombosis rate. All had venography on the fourth or fifth postoperative day and received aspirin and elastic stockings as their only thromboprophylaxis. The overall deep vein thrombosis rate was 41% (2% had proximal clots). The rate of deep vein thrombosis was not related to obesity, history of heart disease, hypertension, prior malignancy, smoking, diagnosis of osteoarthritis, duration of surgery, type of local anesthetic used, or the use of postoperative epidural analgesia. The rate of deep vein thrombosis varied significantly between surgeons: one surgeon had an overall deep vein thrombosis rate of 58% (proximal thrombi, 4%) whereas the other two surgeons had a deep vein thrombosis rate of 35% (proximal clot thrombi, 1%). A number of possible mechanisms to explain the variation in deep vein thrombosis rates between surgeons are provided.

Effect of a walking program on gait characteristics in patients with osteoarthritis

This paper reports the results of a study of the gait of 102 patients with osteoarthritis of the knee. Functional status was measured by a 6-min test of walking distance; the stride characteristics associated with the walk test were assessed. Stride characteristics were measured by a Stride Analyzer. Patients were randomized to an 8-week educational and walking program (the intervention group) or to a weekly telephone survey (the control group). The intervention group patients had a 15% increase in walking distance (P < 0.0001) and increases of 9.1% in stride length at free walking speeds (P < 0.007) and 17% in stride length at fast walking speeds (P < 0.01) compared to the control group. The results of this study have shown that the walking and educational program was effective in improving gait function in patients with osteoarthritis of the knee.

Effect of counselor training on skills development and psychosocial status of volunteers with systemic lupus erythematosus

Volunteers with systemic lupus erythematosus were recruited for a telephone service to provide psychosocial support to peers. The volunteers attended an 8-week counselor training program. The aim was to evaluate the impact of the training on counselors' skill development and to record possible changes in the counselors' psychosocial status. A second group of trainees (n = 15) was used as a delayed control for the first group (n = 14). The data were analyzed using multivariate repeated measures analysis of variance. Tests chosen to monitor psychosocial status included: Arthritis Impact Measurement Scales Anxiety and Depression subscales, Arthritis Helplessness Index, Wallston General Self-Efficacy Scale, University of California at Los Angeles Loneliness Scale, Rosenberg Self-Esteem, and Campbell Personal Competence scales. Tests selected to measure skills and knowledge.