[Waiting times in breast disease clinics and psychological well-being: speedy care is better care]

OBJECTIVE

To examine the effect of diagnostic speed and the waiting time before surgery on the psychological well-being of patients in breast disease clinics.

DESIGN

Prospective cohort study

METHOD

Women with suspected breast cancer completed questionnaires about their psychological well-being before the first outpatient clinic visit (time T1: with malignancy (n = 149); without malignancy (n = 515)), shortly after diagnosis (T2: n = 96 and n = 432, respectively) and 2-3 months later (T3: with malignancy (n = 139)). Two months after the end of treatment (T4: with malignancy (n = 202)), women with breast cancer indicated which period they considered most stressful in retrospect. Diagnostic speed and the waiting time before surgery were categorized and the relation with well-being was examined. Analyses were controlled for age and cancer stage.

RESULTS

Although the period before diagnosis was experienced as stressful, diagnostic speed did not affect emotional well-being after a breast cancer diagnosis. However, a diagnosis that took a long time (> 2 weeks) did affect the emotional well-being of women who were not diagnosed with breast cancer. These women were worried and distressed for a longer period of time after diagnosis than women who received the favourable news sooner. The length of the waiting time before surgery did not affect the emotional well-being of patients thereafter: women who had surgery within two weeks were not worse or better off than women who had to wait longer. Yet, patients' emotional well-being did improve considerably after surgery, which indicates that short waiting times might shorten a period of psychological distress.

CONCLUSION

The results support a speedy diagnosis and surgery. There was no support for short waiting times having a negative psychological effect.

Socioeconomic status and the course of quality of life in older patients with coronary heart disease

Background

Previous research suggests that socioeconomic status (SES) might be related to the course of quality of life (QoL) in coronary heart disease (CHD) patients. The authors sought to determine whether there are differences in the course of QoL before and after the incidence of CHD among older persons of differing SES.

Method

Two hundred two CHD patients were followed up longitudinally using a community-based survey. Data on patients’ QoL were collected before the diagnosis and at three follow-up assessments.

Results

High SES patients reported better outcomes at the premorbid assessment with fewer depressive feelings and better physical functioning. In physical functioning, similar results were repeated 6 and 12 months after the diagnosis. Additionally, high SES patients showed better role and social functioning 1 year after CHD. A multivariate analysis of variance revealed differential longitudinal pathways in relation to SES in role, social, and physical functioning.

Conclusion

CHD modulates premorbid differences in depressive feelings. Conversely, high SES leads to better outcomes in all functional domains in the long-term after diagnosis. Postmorbid differences in physical functioning are not directly related to CHD, but rather the reestablishment of a premorbid situation. In contrast, socioeconomic inequalities in social and role functioning are a direct response to the impact of the disease.

The mediating role of perceived control on the relationship between socioeconomic status and functional changes in older patients with coronary heart disease

Using a prospective design, this study examines the mediating effect of perceived control in explaining the predictive role of socioeconomic status (SES) in long-term changes in functional status as a consequence of the occurrence of coronary heart disease (CHD). We followed 221 older CHD patients by using a community-based survey. We collected data on patients' functional status before the onset of disease and 1 year after the diagnosis. Multiple linear regressions show that SES predicts functional changes only in relation to physical functioning. Furthermore, self-efficacy, but not mastery, mediates the predictive role of SES in changes in physical functioning in CHD patients. Self-efficacy is the only aspect of control that mediates the relation between SES and changes in physical functioning. Our findings provide a basis for future interventions in disadvantaged groups of older persons and new theoretical models of recovery processes.

Depressive symptoms as predictors of mortality in patients with COPD

OBJECTIVE

Prognostic studies of mortality in patients with COPD have mostly focused on physiologic variables, with little attention to depressive symptoms. This stands in sharp contrast to the attention that depressive symptoms have been given in the outcomes of patients with other chronic health conditions. The present study investigated the independent association of depressive symptoms in stable patients with COPD with all-cause mortality.

METHODS

The baseline characteristics of 121 COPD patients (78 men and 43 women; mean [+/- SD] age, 61.5 +/- 9.1 years; and mean FEV(1), 36.9 +/- 15.5% predicted) were collected on hospital admission to a pulmonary rehabilitation center. The data included demographic variables, body mass index (BMI), post-bronchodilator therapy FEV(1), and Wpeak (peak workload [Wpeak]). Depressive symptoms were assessed using the Beck depression inventory. The vital status was ascertained using municipal registrations. In 8.5 years of follow-up, 76 deaths occurred (mortality rate, 63%). Survival time ranged from 88 days to 8.5 years (median survival time, 5.3 years). The Cox proportional hazard model was used to quantify the association of the baseline characteristics (ie, age, sex, marital status, smoking behavior, FEV(1), BMI, Wpeak, and depressive symptoms) with mortality.

RESULTS

Depressive symptoms (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.12 to 3.33) were associated with mortality in patients with COPD, independent of other factors including male sex (OR, 1.73; 95% CI, 1.03 to 2.92), older age (OR, 1.05; 95% CI, 1.02 to 1.08), and lower Wpeak (OR, 0.98; 95% CI, 0.97 to 0.99).

CONCLUSIONS

This study provides evidence that depressive symptoms assessed in stable patients with COPD are associated with their subsequent all-cause mortality.

A prospective study on educational level and adaptation to cancer, within one year after the diagnosis, in an older population

Socio-economic status (SES) has often been associated with health disparities and mortality in cancer patients, yet systematic research into the role of SES in the course of the disease is lacking. This prospective study intends to examine the role of SES (i.e. educational level in this study) in psychological and physical adaptation to cancer. Ninety-nine cancer patients were followed from a community-based survey. Pre- and post-morbid data on patients' quality of life (QoL) were available. Adaptation was defined by looking at the level and pattern of scores on QoL scales from pre- to post-disease assessments. Results show some non-significant trends that more high-educated patients managed to adapt completely to cancer in relation to role and physical functioning when compared with low-educated participants. Furthermore, the greater part of high-educated patients who completely adapted in physical functioning achieved this result more rapidly without an initial deterioration. Unexpectedly, these differences were not significant when tested in a regression model. Hence, although there are some indications for differences in adaptation to role and physical functioning between educational groups, we did not find any evidence that proved such a relation. For the group as a whole, it is very interesting to see that based on our operationalization of adaptation, only a small percentage of patients deteriorated from pre- to post-disease assessments.

The enigma of quality of life in patients with heart failure

Current treatment goals in heart failure (HF) aim to improve both survival and quality of life (QoL) of patients. In this brief communication, we reviewed randomized controlled trials that assessed the impact of pharmacological treatment on QoL, and we discussed some methodological limitations of QoL assessment in HF. Studies that assessed QoL with a disease-specific questionnaire were included. We found that at present there is a paradox in HF treatment. Life prolonging therapies, such as angiotensin-converting-enzyme-inhibitors, and angiotensin receptor blockers improve modestly or only delay the progressive worsening of QoL in HF. Treatment with beta blockers does not affect QoL in any way. However, this neutral effect of beta blockers may also be due to some methodological limitations, such as the small number of patients included in beta blocker trials or the short duration of follow-up. Disease-specific questionnaires may also have some limitations, e.g. are not sensitive enough to detect small changes in QoL. On the other hand, therapies that significantly improve QoL in HF (e.g. inotropic agents) do not seem beneficial in relation to survival. We conclude that QoL in HF remains an open field, in which new therapies but also clarification of methodology is required. In the mean time, the use of life prolonging therapies appears as a safe measure to modestly improve or maintain QoL.

Relationship satisfaction in women: a longitudinal case-control study about the role of breast cancer, personal assertiveness, and partners' relationship-focused coping

OBJECTIVE

The aim of this study was to investigate whether a breast cancer diagnosis, personal assertiveness (i.e. frequency of assertive behaviour and tension associated with this behaviour), and partners' relationship-focused coping (i.e. active engagement and protective buffering) were sources of variation in patients' relationship satisfaction, cross-sectionally and over time.

DESIGN AND METHOD

This longitudinal case-control study assessed the two dimensions of personal assertiveness and relationship satisfaction in both women with cancer (N=72) and comparison controls (N=62). In addition, patients completed a measure assessing their partners' active engagement and protective buffering.

RESULTS

Cases (i.e. women with breast cancer) were not found to report more relationship problems than controls. Women with breast cancer who tended not to express their concerns and feelings and who experienced much tension when they did, reported relatively low marital satisfaction. Moreover, partners' protective buffering was associated with less relationship satisfaction in especially more assertive (i.e. high frequency of assertive behaviour and low tension) women with cancer, while active engagement was associated with more relationship satisfaction, regardless of the women's personal assertiveness.

DISCUSSION

The results of the present study indicate that a breast cancer diagnosis by itself may not be a risk factor for relationship problems. However, in the context of an illness such as cancer, personal assertiveness, and a partner's relationship-focused coping strategies do seem to play a role in maintaining a satisfactory relationship with one's partner.

The contribution of observational studies to the knowledge of drug effectiveness in heart failure

AIMS

Randomized controlled trials (RCTs) are the golden standard for the assessment of drug efficacy. Little is known about the add-on value of observational studies in heart failure (HF). We aimed to assess the contribution of observational studies to actual knowledge regarding the effectiveness of angiotensin-converting enzyme inhibitors (ACEI), and beta-blockers (BB) in HF.

METHODS

Observational studies that assessed the effectiveness of ACEI and BB in HF were identified by searching Medline, Embase, Cochrane Database (1990-2005) and the bibliographies of published articles. Cohort, case-control and time-series analysis studies were considered for inclusion. Studies with <100 patients and those who did not perform a multivariate analysis were excluded.

RESULTS

A total of 23 cohort studies met the inclusion criteria. Studies of ACEI and BB showed a decrease in mortality with drug use in elderly patients with a broad range of ejection fraction (EF), and in those with depressed EF. Additionally, they showed a decrease in mortality in patients with renal insufficiency. The effect of ACEI and BB in HF with preserved EF was not clear, although last evidence suggests a potential benefit. Low-dose ACEI and BB may have beneficial effects. Target doses of ACEI seemed superior to low doses, but there was no clear dose-response relationship.

CONCLUSIONS

Observational studies in HF validate the effectiveness of ACEI and BB in populations underrepresented or excluded from RCTs. Observational studies of drug effectiveness provide relevant additional information for clinical practice.

Measuring somatic symptoms with the CES-D to assess depression in cancer patients after treatment: comparison among patients with oral/oropharyngeal, gynecological, colorectal, and breast cancer

There is a high prevalence of depression after cancer treatment. In the literature, several authors have raised questions about assessing somatic symptoms to explore depression after cancer treatment. These somatic sequelae are a consequence of cancer treatment and should cause higher depression rates in cancer patients. In this study, the Somatic domain on a depression questionnaire, the Center for Epidemiologic Studies-Depression scale (CES-D) was analyzed in different cancer patients after treatment, as compared with a control group. Data from 566 cancer patients (oral/oropharyngeal, gynecological, colorectal, and breast cancer) and 255 randomly chosen comparison patients were analyzed. The total score on the CES-D domain of Somatic Retarded Activity significantly differed between the cancer and comparison groups; but the cancer groups showed both less somatic morbidity (colorectal cancer) and more somatic morbidity (oral/oropharyngeal, breast) than the comparison group. In the analyses of the CES-D with and without the Somatic domain, the prevalence of depression symptoms with the Somatic domain is lower for the cancer groups. Authors conclude that cancer patients are not a homogenous group as regards somatic sequelae. Evidence for removing Somatic items from the CES-D for patients after cancer treatment was not confirmed.

Psychometric properties of the Dutch version of the posttraumatic growth inventory among cancer patients

In the current study, we investigated the psychometric properties of a Dutch translation of the posttraumatic growth inventory in a heterogeneous group of cancer patients. Its original five-factor structure was maintained. The internal consistency of the total scale, as well as its subdimensions, was satisfactory. As expected, the experience of posttraumatic growth was positively related to: emotional expression about the illness, openness to experience, and feelings of innerness. Furthermore, the scale appeared to be sensitive for the demographics age and gender. The experience of posttraumatic growth was not related to negative feelings such as avoidance, anxiety, depression, and neuroticism. Our Dutch translation of the instrument appeared to be a sound measure for the experience of posttraumatic growth in cancer patients.

Does marriage protect older people from distress? The role of equity and recency of bereavement

The association between marital status and distress was examined in a largely neglected group, namely older people (65 and older; N = 1,649). In this 2-wave study, married persons were less distressed than single persons, but perceived equity within the marriage and recency of bereavement qualified these findings. Married persons who felt inequitably treated were more distressed than persons who had always been single. Married persons reported less distress than recently (= 2 years ago) widowed persons, but only equitably treated married persons reported less distress than persons widowed for more than 2 years. Increased distress between the 2 waves occurred in recently widowed persons, and there was a decrease in distress in persons who were widowed shortly before the 1st wave. No gender effects were found.

The role of distress, neuroticism and time since diagnosis in explaining support behaviors in partners of women with breast cancer: results of a longitudinal analysis

In this prospective study distress, neuroticism and time since diagnosis were investigated as determinants of spousal support behavior (i.e. protective buffering and active engagement) in a group of 92 partners of women with breast cancer. Distress and neuroticism were assessed at three months after diagnosis while protective buffering and active engagement were assessed at three, nine and 15 months after diagnosis. Results indicate small but significant decreases in protective buffering and active engagement over time. Moreover, initial distress and neuroticism were found to be strongly and positively related to protective buffering at all three measurements. In addition, less distress was associated with more active engagement in especially individuals scoring relatively low on neuroticism, but only at 3 months after diagnosis.

The concept and measurement of meaning in life in Dutch cancer patients

We investigated the psychometric properties of a Dutch translation of the Personal Meaning Profile in a heterogeneous group of cancer patients. Our study resulted in a relatively short scale consisting of 39 of the 57 original items, divided into 5 factors, labeled 'relation with God'; 'dedication to life'; 'fairness of life'; 'goal-orientedness' and 'relations with other people', which can be summed to a total score of the experience of meaning in life. The internal consistency of the total scale as well as of its sub dimensions was high. The experience of meaning in life was positively related to feelings of psychological well-being and negatively to feelings of distress. Furthermore, the experience of meaning in life was also related to trait-like characteristics as personality. Future research can investigate its appropriateness for other populations than cancer patients, and if and how the experience of meaning in life eventually changes as a result of existential threats.

Gender-specific risk factors for mortality associated with incident coronary heart disease--a prospective community-based study

BACKGROUND

Risk factors for mortality in community-residing persons developing congestive heart failure (CHF) and acute myocardial infarction (AMI) may differ for males and females.

METHOD

Persons from the Groningen Longitudinal Aging Study with incident CHF (N=274) or AMI (N=198) were identified between 1993 and 1998 and their survival status was collected in 2001. Risk factors are assessed prior to the cardiac diagnosis.

RESULTS

The 1-, 5-, 7-year survival rates were 65, 53, 50% for AMI and 74, 45, 32% for CHF. Multivariate analyses showed that male gender, high age, smoking, diabetes and low physical function were risk factors for mortality among persons with CHF. For AMI, 1 month mortality was related to high age and baseline low body mass index, while longer term mortality was related to male gender and high age. In addition, diabetes increased longer term mortality among females but not among males with AMI. Depression was not a risk factor for mortality for either condition in either gender.

CONCLUSION

Males with CHF or AMI have worse survival rates compared to females. Risk factors for mortality are predominantly similar for males and females, except for diabetes which is a risk factor among females, but not males with AMI.

Effectiveness of beta-blocker therapy in daily practice patients with advanced chronic heart failure; is there an effect-modification by age?

AIMS

The effects of beta-blockers in daily practice patients with advanced chronic heart failure (CHF) and a broad range of ejection fraction (EF) are not well established. We aimed to assess, first, the association between beta-blocker prescription at discharge and mortality in a cohort of patients with advanced CHF, and second, whether this association is modified by the age of the patient.

METHODS

Patients diagnosed with advanced CHF (n = 625) were prospectively followed after discharge from the Cardiology Department. The mean age was 76 years, 53% male, mean EF 42 +/- 16%. Overall, 308 (49%) patients had a beta-blocker prescribed at discharge, 140 (22%) low-dose and 168 (27%) high-dose therapy. We used multivariate Cox analysis to assess the association between beta-blocker use at discharge and mortality.

RESULTS

After a mean follow-up of 22 months, 117 (27%) patients died. Prescription of a beta-blocker was associated with a 45% relative risk reduction (hazard ratio 0.55, 95% confidence interval 0.39, 0.78). The relative risk reduction was similar with low and high doses of beta-blockers (42% and 49%). However, the relative risk reduction was higher in younger than in older patients (P = 0.006). In patients < or = 75 years old prescription of a beta-blocker was associated with 71% risk reduction, whereas in patients >75 years old it was associated with 21% risk reduction.

CONCLUSIONS

In this daily practice cohort of patients with advanced CHF, prescription of a beta-blocker was associated with significant mortality reduction. However, the beneficial effects of beta-blockers appear to be greater in younger patients.

RAte Control Efficacy in permanent atrial fibrillation: a comparison between lenient versus strict rate control in patients with and without heart failure. Background, aims, and design of RACE II

BACKGROUND

Recent studies demonstrated that rate control is an acceptable alternative for rhythm control in patients with persistent atrial fibrillation (AF). However, optimal heart rate during AF is still unknown.

OBJECTIVE

To show that in patients with permanent AF, lenient rate control is not inferior to strict rate control in terms of cardiovascular mortality, morbidity, neurohormonal activation, New York Heart Association class for heart failure, left ventricular function, left atrial size, quality of life, and costs.

METHODS

The RACE II study is a prospective multicenter trial in The Netherlands that will randomize 500 patients with permanent AF (< or = 12 months) to strict or lenient rate control. Strict rate control is defined as a mean resting heart rate < 80 beats per minute (bpm) and heart rate during minor exercise < 110 bpm. After reaching the target, a 24-hour Holter monitoring will be performed. If necessary, drug dose reduction and/or pacemaker implantation will be performed. Lenient rate control is defined as a resting heart rate < 110 bpm. Patients will be seen after 1, 2, and 3 months (for titration of rate control drugs) and yearly thereafter. We anticipate a 25% 2.5-year cardiovascular morbidity and mortality in both groups.

RESULTS

Enrollment started in January 2005 in 29 centers in The Netherlands and is expected to be concluded in June 2006. Follow-up will be at least 2 years with a maximum of 3 years.

CONCLUSION

This study should provide data how to treat patients with permanent AF.

Verapamil versus digoxin and acute versus routine serial cardioversion for the improvement of rhythm control for persistent atrial fibrillation

OBJECTIVES

The VERDICT (Verapamil Versus Digoxin and Acute Versus Routine Serial Cardioversion Trial) is a prospective, randomized study to investigate whether: 1) acutely repeated serial electrical cardioversions (ECVs) after a relapse of atrial fibrillation (AF); and 2) prevention of intracellular calcium overload by verapamil, decrease intractability of AF.

BACKGROUND

Rhythm control is desirable in patients suffering from symptomatic AF.

METHODS

A total of 144 patients with persistent AF were included. Seventy-four (51%) patients were randomized to the acute (within 24 h) and 70 (49%) patients to the routine serial ECVs, and 74 (51%) patients to verapamil and 70 (49%) patients to digoxin for rate control before ECV and continued during follow-up (2 x 2 factorial design). Class III antiarrhythmic drugs were used after a relapse of AF. Follow-up was 18 months.

RESULTS

At baseline, there were no significant differences between the groups, except for beta-blocker use in the verapamil versus digoxin group (38% vs. 60%, respectively, p = 0.01). At follow-up, no difference in the occurrence of permanent AF between the acute and the routine cardioversion groups was observed (32% [95% confidence intervals (CI)] 22 to 44) vs. 31% [95% CI 21 to 44], respectively, p = NS), and also no difference between the verapamil- and the digoxin-randomized patients (28% [95% CI 19 to 40] vs. 36% [95% CI 25 to 48] respectively, p = NS). Multivariate Cox regression analysis revealed that lone digoxin use was the only significant predictor of failure of rhythm control treatment (hazard ratio 2.2 [95% CI 1.1 to 4.4], p = 0.02).

CONCLUSIONS

An acute serial cardioversion strategy does not improve long-term rhythm control in comparison with a routine serial cardioversion strategy. Furthermore, verapamil has no beneficial effect in a serial cardioversion strategy.

Adjustment to cancer in the 8 years following diagnosis: A longitudinal study comparing cancer survivors with healthy individuals

This longitudinal study examined the long-term impact of a diagnosis of cancer on physical and psychological functioning, by comparing 8-year cancer survivors (n = 206) to a randomly selected sample of similar-aged references without cancer (n = 120) in the Netherlands. Comparisons were made at three fixed points in time: 3 months (T1), 15 months (T2), and 8 years (T3) after diagnosis. The results showed that, at 8 years after diagnosis, cancer survivors and references do not differ significantly in the level of depressive symptoms, anxiety, life satisfaction, self-esteem, social support, and marital satisfaction. However, survivors reported more physical symptoms, and those with a recurrence of cancer also reported more limitations in household and social activities. Most improvements in functioning were found in the year following diagnosis. Intriguingly, we found no evidence that cancer survivors experienced more positive changes in the self, relationships, or life in general than references, even though many cancer survivors attributed these changes to the cancer experience. In the discussion, we address the role of finding positive meaning in the process of adjustment to cancer.

Predictors of non-pharmacological intervention in patients with paroxysmal atrial fibrillation: Value of neuroticism

BACKGROUND

Non-pharmacological intervention is gaining increasing popularity in the treatment of patients with paroxysmal atrial fibrillation. We sought to investigate which factors play a role in the choice for non-pharmacological intervention with a particular focus on neuroticism.

METHODS

The study group comprised 73 patients with paroxysmal atrial fibrillation (mean age 55+/-13 years, 50 males). On average, patients had a 3-year-history of one symptomatic paroxysm per week lasting 2 h. The degree of neuroticism was assessed using the short scale Eysenck Personality Questionnaire.

RESULTS

During a mean follow-up period of 7.0+/-0.6 years, 20 patients (27%) underwent a non-pharmacological intervention for atrial fibrillation including His bundle ablation (n = 1), maze operation (n = 4), DDDR-pacemaker (n = 10), pulmonary vein ablation (n = 5). Multivariate regression analysis showed that age < 55 years (odds ratio 5.3, 95% CI 1.1-24.5), frequency of paroxysms of atrial fibrillation > 1 per week (odds ratio 5.9, 95% CI 1.2-28.5) and total number of anti-arrhythmic drugs (class I and III) used > 2 (odds ratio 3.4, 95% CI 1.6-6.9) were predictive of non-pharmacological intervention (all p < 0.05). In contrast, the degree of neuroticism was similar in patients who underwent non-pharmacological intervention as opposed to patients who did not undergo non-pharmacological intervention (4.5+/-3.3 vs. 4.0+/-2.9, p = NS).

CONCLUSIONS

On the basis of this small study, neuroticism would not appear to play an important role in the decision to perform a non-pharmacological intervention. Instead, the data indicate that younger patients with pharmacologically refractory atrial fibrillation more often undergo non-pharmacological intervention.

Evidence-based treatment and quality of life in heart failure

OBJECTIVES

To explore whether prescription of evidence-based drug therapy is associated with better quality of life (QoL) in patients with heart failure (HF).

METHODS

Patients (n = 62) were recruited in the outpatient clinic of Groningen University Hospital. Inclusion criteria were previous diagnosis of HF, age 40-80 years; ejection fraction of less than 45%, free from other serious disease (such as cancer) and psychiatric problems in the last year. QoL was assessed with the RAND 36-item health survey questionnaire, on five scales: physical functioning, mental health, social functioning, vitality and general health perception. Medication prescribed for 1 to 6 months before the QoL assessment was classified as either evidence-based treatment or under-treatment, according to the 2001 European guidelines on optimal HF treatment. The study had a cross-sectional design.

RESULTS

QoL did not differ significantly between evidence-based and under-treated patients, unadjusted or after adjustment for significant patient imbalances.

CONCLUSIONS

Conventional step-up medication approach in HF may have a positive impact on survival or morbidity, but it seems not beneficial in relation to QoL. Other interventions should be designed to improve QoL of patients with HF.

Changes in personal control as a predictor of quality of life after pulmonary rehabilitation

OBJECTIVE

Perceptions of mastery and self-efficacy may be related to better outcomes in pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD). This study examined (1) whether patients with COPD improved during a rehabilitation programme with respect to quality of life (QoL) and perceptions of self-efficacy and mastery, and (2) whether increased perceptions of mastery and self-efficacy contributed to a higher QoL after rehabilitation.

METHODS

Thirty-nine consecutive COPD patients (aged 60.5 +/- 9.0) were included from a rehabilitation centre and completed self-report questionnaires assessing symptoms, QoL, and perceptions of personal control.

RESULTS

COPD patients improved during rehabilitation in overall QoL and self-efficacy, although no significant changes were found in QoL domains and mastery. Changes in self-efficacy during rehabilitation contributed to the explanation of the social and psychological functioning QoL domains.

CONCLUSION

Even in seriously impaired COPD patients in advanced stages of illness, positive changes in self-efficacy and overall well-being can be established during rehabilitation. Changes in self-efficacy were related to a better QoL, suggesting the importance of personal control in the adjustment to COPD.

PRACTICE IMPLICATIONS

Focussing more explicitly on the enhancement of perceptions of personal control in COPD patients may be an important aim of pulmonary rehabilitation.

Psychosocial factors associated with indices of cortisol production in women with breast cancer and controls

The present study was designed to (i) explore which psychosocial factors were associated with indices representing the early morning peak, diurnal cortisol rhythm and area under the curve (AUC); (ii) examine whether the relationships between psychosocial functioning and these cortisol indices were consistent and (iii) explore whether these relationships were influenced by the clinical status of the participant. Newly diagnosed breast cancer patients (n = 85) and healthy control women (n = 59) were recruited. State and trait measures of psychosocial functioning (i.e. anxiety, depression, distress, neuroticism, extraversion, marital satisfaction and mastery) were undertaken. In addition, all participants provided four saliva samples (on waking, 30 min later, between 11 and 1 p.m., before lunch and between 8 and 10 p.m., at least 2h after evening meal) over two consecutive days to assess cortisol levels. The results highlighted the divergent nature of the four cortisol indices; revealed the presence of some significant relationships between the psychosocial measures and the cortisol indices; but highlighted inconsistencies in the relationships evident for patients and those observed for control women.