The Partial Mediator Role of Satisficing Decision-Making Style Between Trait Emotional Intelligence and Compassion Fatigue in Healthcare Professionals

Background: Compassion fatigue (CF) represents a relevant issue for healthcare professionals. Currently, it is still unclear which psychological mechanism might lead to CF and which might protect workers from that. Decision-making styles, as well as emotional intelligence, might partially account for the presence of CF. Specifically, we hypothesized that a satisficing decision-making style would mediate the relationship between emotional intelligence and CF.Methods: A cross-sectional online survey was conducted on physicians and nurses from Italian Medical Departments. Three self-reported questionnaires were administered to collect data in accordance with our aims. A mediation model with Structural Equation Modeling on the relationship between trait emotional intelligence (TEI) and CF through the maximizing decision-making style was performed.Results: We found a significant relationship between TEI and CF (β = -0.28, SE = 0.04, p < .001). The maximizing style partially mediated this relationship (β = -0.04, SE = 0.01, p < .001). Moreover, negative relationships were found between sex (male), working hours, sleep quality, and CF. Conversely, a positive relationship between age and CF was demonstrated.Conclusions: Being emotionally intelligent resulted as a protective factor for developing CF, while the decision-making styles shaped the risk of developing CF.

Support for Chronic Pain Management for Breast Cancer Survivors Through Novel Digital Health Ecosystems: Pilot Usability Study of the PainRELife Mobile App

BACKGROUND

Chronic pain is one of the most common and critical long-term effects of breast cancer. Digital health technologies enhance the management of chronic pain by monitoring physical and psychological health status and supporting pain self-management and patient treatment decisions throughout the clinical pathway.

OBJECTIVE

This pilot study aims to evaluate patients' experiences, including usability, with a novel digital integrated health ecosystem for chronic pain named PainRELife. The sample included patients with breast cancer during survivorship. The PainRELife ecosystem comprises a cloud technology platform interconnected with electronic health records and patients' devices to gather integrated health care data.

METHODS

We enrolled 25 patients with breast cancer (mean age 47.12 years) experiencing pain. They were instructed to use the PainRELife mobile app for 3 months consecutively. The Mobile Application Rating Scale (MARS) was used to evaluate usability. Furthermore, pain self-efficacy and participation in treatment decisions were evaluated. The study received ethical approval (R1597/21-IEO 1701) from the Ethical Committee of the European Institute of Oncology.

RESULTS

The MARS subscale scores were medium to high (range: 3.31-4.18), and the total app quality score was 3.90. Patients with breast cancer reported reduced pain intensity at 3 months, from a mean of 5 at T0 to a mean of 3.72 at T2 (P=.04). The total number of times the app was accessed was positively correlated with pain intensity at 3 months (P=.03). The engagement (P=.03), information (P=.04), and subjective quality (P=.007) subscales were positively correlated with shared decision-making. Furthermore, participants with a lower pain self-efficacy at T2 (mean 40.83) used the mobile app more than participants with a higher pain self-efficacy (mean 48.46; P=.057).

CONCLUSIONS

The data collected in this study highlight that digital health technologies, when developed using a patient-driven approach, might be valuable tools for increasing participation in clinical care by patients with breast cancer, permitting them to achieve a series of key clinical outcomes and improving quality of life. Digital integrated health ecosystems might be important tools for improving ongoing monitoring of physical status, psychological burden, and socioeconomic issues during the cancer survivorship trajectory.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/41216.

Cancer Pain Experience Through the Lens of Patients and Caregivers: Mixed Methods Social Media Study

BACKGROUND

Cancer pain represents a challenge for cancer patients and their family members. Despite progression in pain management, pain is still underreported and undertreated, and there is limited information on the related needs that patients and caregivers may have. Online platforms represent a fundamental tool for research to reveal the unmet needs of these users and their emotions outside the medical setting.

OBJECTIVE

This study aimed to (1) reveal the unmet needs of both patients and caregivers and (2) detect the emotional activation associated with cancer pain by analyzing the textual patterns of both users.

METHODS

A descriptive and quantitative analysis of qualitative data was performed in RStudio v.2022.02.3 (RStudio Team). We analyzed 679 posts (161 from caregivers and 518 from patients) published over 10 years on the "cancer" subreddit of Reddit to identify unmet needs and emotions related to cancer pain. Hierarchical clustering, and emotion and sentiment analysis were conducted.

RESULTS

The language used for describing experiences related to cancer pain and expressed needs differed between patients and caregivers. For patients (agglomerative coefficient=0.72), the large cluster labeled unmet needs included the following clusters: (1A) reported experiences, with the subclusters (a) relationship with doctors/spouse and (b) reflections on physical features; and (1B) changes observed over time, with the subclusters (a) regret and (b) progress. For caregivers (agglomerative coefficient=0.80), the main clusters were as follows: (1A) social support and (1B) reported experiences, with the subclusters (a) psychosocial challenges and (b) grief. Moreover, comparison between the 2 groups (entanglement coefficient=0.28) showed that they shared a common cluster labeled uncertainty. Regarding emotion and sentiment analysis, patients expressed a significantly higher negative sentiment than caregivers (z=-2.14; P<.001). On the contrary, caregivers expressed a higher positive sentiment compared with patients (z=-2.26; P<.001), with trust (z=-4.12; P<.001) and joy (z=-2.03; P<.001) being the most prevalent positive emotions.

CONCLUSIONS

Our study emphasized different perceptions of cancer pain in patients and caregivers. We revealed different needs and emotional activations in the 2 groups. Moreover, our study findings highlight the importance of considering caregivers in medical care. Overall, this study increases knowledge about the unmet needs and emotions of patients and caregivers, which may have important clinical implications in pain management.

The emotional side of taking part in a cancer clinical trial

BACKGROUND

Taking part in a cancer clinical trial often represents a source of psychological distress and emotional activation among patients and their caregivers. Nowadays, social media platforms provide a space for these groups to freely express and share their emotional experiences.

AIMS

We aimed to reveal the most prevalent basic and complex emotions and sentiments in the posts of the patients and caregivers contemplating clinical trials on Reddit. Additionally, we aimed to categorize the types of users and posts.

METHODS

With the use of keywords referring to clinical trials, we searched for public posts on the subreddit 'cancer'. R studio v. 4.1.2 (2021-11-01) and NRC Emotion Lexicon was used for analysis. Following the theoretical framework of Plutchik's wheel of emotions, the analysis included: 8 basic emotions (anger, fear, anticipation, trust, surprise, sadness, joy, and disgust) and 4 types of complex emotions (primary, secondary, tertiary, and opposite dyads). We utilized the package 'PyPlutchik' to visualize the emotion wheels in Python 3.10.5.

RESULTS

A total of 241 posts were included in the final database. User types (129 patients, 112 caregivers) and post types (142 expressed shared experience, 77 expressed advice, and 85 conveyed both) were identified. Both positive (N = 2557, M = .68) and negative (N = 2154, M = .57) sentiments were high. The most prevalent basic emotions were: fear (N = 1702, M = .45), sadness (N = 1494, M = .40), trust (N = 1470, M = .44), and anticipation (N = 1376, M = .37). The prevalence of complex/dyadic emotions and their interpretation is further discussed.

CONCLUSION

In this contribution, we identified and discussed prevalent emotions such as fear, sadness, optimism, hope, despair, and outrage that mirror the psychological state of users and affect the medical choices they make. The insights gained in our study contribute to the understanding of the barriers and reinforcers to participation in trials and can improve the ability of healthcare professionals to assist patients when confronted with this choice.

Eliciting empathetic drives to prosocial behavior during stressful events

In the current pandemic situation, psychological science is increasingly considered by public health policy. Empathy is mainly recognized as a crucial drive for prosocial behavior. However, this rich body of evidence still lacks visibility and implementation. Effective social programs are needed, and little is known about how to elicit empathetic drives. The paper gives first a clear foundation to the role of empathy during stressful events. It provides then a comprehensive overview of innovative interventions triggering empathic response in the public such as fiction, film, and theater. Moreover, it integrates interactive ways of sharing personal views that could elicit empathetic feelings in different people. Advances deriving from this perspective could be of significant public interest in the current and future health crises and help authorities develop innovative social programs, which should be the focus of further scientific inquiry.

A Comprehensive Analysis of the Cancer Chronic Pain Experience: A Narrative Review

Cancer-related chronic pain (CP) represents a critical clinical issue through the disease, severely compromising the quality of life (QoL) of patients and the family environment. The current review employed a narrative method to synthesize the main results about the impact of cancer-related CP on QoL, adopting a multidimensional and threefold vision: patients, caregivers, and patient–caregiver perspective. Evidence emphasizes the importance of considering a bidirectional perspective (patient–caregiver) to understand better the pain experience throughout the cancer continuum and its consequences on QoL of patients and caregivers. Moreover, a holistic and multidimensional approach to cancer-related CP and its impact on QoL of patients and caregivers is still needed, in which the interconnection between physical, psychological, and social factors should be analyzed. Theoretical and methodological issues for orienting future social and family research initiatives were discussed.

“Usability testing of a new digital integrated health ecosystem PainRELife for the clinical man-agement of chronic pain in early breast cancer patients: Protocol for a Pilot Study” (Preprint)

BACKGROUND

Chronic pain (CP) and its management are critical issues in the care pathway of patients with breast cancer. Considering the complexity of CP experience in cancer, the international scientific community has advocated identifying cutting-edge approaches for CP management. Recent advances in the field of health technology enable the adoption of a novel approach to care management by developing integrated ecosystems and mobile health apps.

OBJECTIVE

The primary end point of this pilot study is to evaluate patients' usability experience at 3 months of a new digital and integrated technological ecosystem, PainRELife, for CP in a sample of patients with breast cancer. The PainRELife ecosystem is composed of 3 main technological assets integrated into a single digital ecosystem: Fast Healthcare Interoperability Resources-based cloud platform (Nu platform) that enables care pathway definition and data collection; a big data infrastructure connected to the Fast Healthcare Interoperability Resources server that analyzes data and implements dynamic dashboards for aggregate data visualization; and an ecosystem of personalized applications for patient-reported outcomes collection, digital delivery of interventions and tailored information, and decision support of patients and caregivers (PainRELife app).

METHODS

This is an observational, prospective pilot study. Twenty patients with early breast cancer and chronic pain will be enrolled at the European Institute of Oncology at the Division of Medical Senology and the Division of Pain Therapy and Palliative Care. Each patient will use the PainRELife mobile app for 3 months, during which data extracted from the questionnaires will be sent to the Nu Platform that health care professionals will manage. This pilot study is nested in a large-scale project named "PainRELife," which aims to develop a cloud technology platform to interoperate with institutional systems and patients' devices to collect integrated health care data. The study received approval from the Ethical Committee of the European Cancer Institute in December 2021 (number R1597/21-IEO 1701).

RESULTS

The recruitment process started in May 2022 and ended in October 2022.

CONCLUSIONS

The new integrated technological ecosystems might be considered an encouraging affordance to enhance a patient-centered approach to managing patients with cancer. This pilot study will inform about which features the health technological ecosystems should have to be used by cancer patients to manage CP.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41216.

A longitudinal application of the Actor Partner Interdependence Model extended Mediations to the health effects of dyadic support

Supportive communicative experiences within close relationships, such as dyadic support, have a protective effect on individuals’ health and emotional well-being. However, little is known about how partners interact in determining their own and others’ health or the mechanisms through which dyadic support influences physical health. We addressed those gaps by studying 1088 romantic couples from three consecutive years (T1, T2, T3; Swiss Household Panel). The study applied a data analysis strategy called Actor Partner Interdependence Model extended Mediation, which allows for mediation processes while considering the interdependence, or non-independence, of data coming from partners. Results showed that dyadic support was positively associated with perceived health over two years through the mediation of optimistic attitudes and depressive mood, both for person and partner effects. The present study demonstrates the interplay between the dyadic process and personality dispositions in maintaining good health.

A Breast Cancer Smartphone App to Navigate the Breast Cancer Journey: Mixed Methods Study

BACKGROUND

Several mobile apps have been designed for patients with a diagnosis of cancer. Unfortunately, despite the promising potential and impressive spread, their effectiveness often remains unclear. Most mobile apps are developed without any medical professional involvement and quality evidence-based assessment. Furthermore, they are often implemented in clinical care before any research is performed to confirm usability, appreciation, and clinical benefits for patients.

OBJECTIVE

We aimed to develop a new smartphone app (Centro di Senologia della Svizzera Italiana [CSSI]) specifically designed by breast care specialists and patients together to help breast cancer patients better understand and organize their journey through the diagnosis and treatment of cancer. We describe the development of the app and present assessments to evaluate its feasibility, usefulness, and capability to improve patient empowerment.

METHODS

A mixed method study with brief longitudinal quantitative data collection and subsequent qualitative semistructured interviews was designed. Twenty breast cancer patients participated in the study (mean age 51 years, SD 10 years). The usability of the app, the user experience, and empowerment were measured after 1 month. The semistructured interviews measured the utility of the app and the necessary improvements.

RESULTS

The app received good responses from the patients in terms of positive perception of the purpose of the app (7/20, 35%), organizing the cure path and being aware of the steps in cancer management (5/20, 25%), facilitating doctor-patient communication (4/20, 20%), and having detailed information about the resources offered by the hospital (2/20, 10%). Correlation and regression analyses showed that user experience increased the level of empowerment of patients (B=0.31, 95% CI 0.22-0.69; P=.009). The interviews suggested the need to constantly keep the app updated and to synchronize it with the hospital's electronic agenda, and carefully selecting the best time to offer the tool to final users was considered crucial.

CONCLUSIONS

Despite the very small number of participants in this study, the findings demonstrate the potential of the app and support a fully powered trial to evaluate the empowering effect of the mobile health app. More data will be gathered with an improved version of the app in the second phase involving a larger study sample.

Effects of Self-Mastery on Adolescent and Parental Mental Health through the Mediation of Coping Ability Applying Dyadic Analysis

Evidence demonstrated that self-mastery and coping ability predict mental health in adults and children. However, there is a lack of research analyzing the relationships between those constructs in parents and children. Self-report data from 89 dyads (adolescents’ mean of age = 14.47, SD = 0.50; parents’ mean of age = 47.24, SD = 4.54) who participated in waves 17, 18, and 19 (following T1, T2, and T3) of a nineteen-wave longitudinal study were analyzed using the Actor-Partner Interdependence Model’s extended Mediation. Results showed significant actor effects of parents’ and adolescents’ self-mastery (T1) on mental health (T3) and the mediator effect of their coping abilities in managing stress (T2). Both a higher parental education level and being a mother positively influenced adolescents’ coping ability. The mutually beneficial relationships between parents’ and adolescents’ self-mastery, coping ability, and mental health were not demonstrated. Self-mastery is a significant predictor of adolescents’ and parents’ mental health, and coping ability serves as a good mediator between them. Qualitative research may clarify reasons why partner effects in the model were found to be non-significant. Further research should re-test this model with a larger sample size during childhood, when parents provide significant behavioral models for their children—as well as in adolescence, considering the peer group—to develop guidelines for behavioral interventions.

Bullying and Substance Use in Early Adolescence: Investigating the Longitudinal and Reciprocal Effects Over 3 Years Using the Random Intercept Cross-Lagged Panel Model

Bullying and substance use among adolescents have been increasingly studied in the field of developmental psychology, but research to date has primarily investigated the cross-sectional relationship and, to a lesser extent, the long-term impact of bullying on substance use. Grounded in the General Theory of Crime, this study focused on the longitudinal reciprocal relationships between bullying and substance use (i.e., smoking and alcohol consumption) during early to mid-adolescence, which is a critical developmental phase. We aimed to investigate the hypothesis of a reinforcing downward spiral at the within-person level. Moreover, we intended to examine gender differences in the expected longitudinal relationships. Our analyses are based on self-report data for bullying and substance use collected from 1,495 adolescents (746 males; M age at T 1 = 12.42, SD = 0.58) at three waves between 2017 and 2019. We applied the random intercept cross-lagged panel model to separate within-person from between-person effects. At the between-person level, the mutual association between bullying and substance use, previously demonstrated in cross-sectional studies, was confirmed. At the within-person level, results provide evidence of a significant age-dependent change in bullying and substance use from 13 to 14 years old, where the significant increase in bullying could be attributed to females but not to males. We also found a gender-independent significant positive effect of bullying at 12 years old on substance use at 13 years, but not vice versa. Thus, the hypothesis of a reinforcing downward spiral, shown by significant positive reciprocal effects, did not find support. According to the General Theory of Crime, our findings underline that bullying can be considered a context-related factor inasmuch as it pushes adolescents to smoke and drink, which are both expressions of low levels of self-control, which need to be considered in intervention programs to effectively prevent unhealthy and risky behaviors in adolescence.

Theory of Mind as a Mediator Between Emotional Trust Beliefs and Interpersonal Communication Competence in a Group of Young Adults

Research has provided direct and indirect evidence of associations between trust beliefs and social-perceptual theory of mind (ToM) and between social-perceptual ToM and interpersonal communication competence during childhood and adolescence. This research (a) developed a scale for evaluating trust beliefs in young Italian adults (Study 1) and (b) examined how social-perceptual ToM mediates the relationship between emotional trust beliefs and interpersonal communication competences such as assertiveness and empathy (Study 2). In Study 1, a sample of 168 university students (M = 23.3, SD = 3 months) completed the Italian Adults' Generalized Trust Beliefs (AGTB) scale and two second-order false beliefs tasks. In Study 2, 318 Italian university students (M = 22.96 years, SD = 2 months) completed the AGTB scale, the Experiences in Close Relationships-Revised questionnaire, the Reading the Mind in the Eyes Test, and items measuring assertiveness and empathy. As expected, the AGTB scale exhibited acceptable internal consistency, structural validity, and construct validity. Furthermore, path analysis confirmed the existence of the hypothesized paths between adults' emotional trust beliefs, social-perceptual ToM, assertiveness, and empathy. This study also identified the effects of gender on the other variables, but sex did not moderate the relationships between variables.

Epidemiology of pancreatic cancer in Northeastern Italy: incidence, resectability rate, hospital stay, costs and survival (1990-1992)

BACKGROUND

The incidence of pancreatic cancer and relative hospital stay and costs are not well known.

AIMS

To define the incidence, hospital stay and cost of pancreatic cancer in a well-defined area of Italy.

PATIENTS AND METHODS

Each new case of pancreatic cancer diagnosed between 1990 and 1992 among 669,703 inhabitants in the Veneto Region of Northern Italy was recorded and followed until death or for 5 years after diagnosis. Four types of hospital stay were defined. Type 1: undiagnosed pancreatic cancer; type 2: first diagnosis of pancreatic cancer, treatment excluded; type 3: main treatment; and type 4: follow-up and disease-related complications. Data were analysed for hospital stay-related procedures, costs and survival.

RESULTS

Pancreatic cancer was diagnosed in 253 patients (12.6/100,000 per year), 43 patients (17.7%) underwent surgical resection, and 93 (36.8%) palliative surgery. The mean duration of type 3 hospital stay was similar for resection, palliative and exploratory surgery. The estimated hospital cost was significantly higher for surgical resection, almost the same for palliative and exploratory surgery, and only slightly lower for medical treatment. Each patient spent a mean of 57.7 days in the hospital. The hospital mortality rate was 4.6% for surgical resection, 22.1% for palliative surgery, and 18.7% for exploratory laparotomy. Overall, the 1-, 2-, 3- and 5-year survival rates were 20.9%, 5.1%, 2.9% and 1.2%, respectively.

CONCLUSIONS

Pancreatic cancer is an expensive, almost incurable disease. Integrated treatments in specialized Centres should reduce the mortality rate and costs.

Wheat deficient in gliadins: promising tool for treatment of coeliac disease

The toxicity of two varieties of bread wheat, one poor in alpha and beta gliadins and the other poor in alpha, beta, gamma, and omega gliadins, has been tested. The peptic-tryptic digest of these wheats was assessed using coeliac mucosa in an in vitro organ culture system. A significantly lower toxicity was found in respect of bread wheat containing all gliadin fractions. These results suggest new opportunities for the treatment of coeliac disease.

Metabolism of long-chain fatty acids, alcohols and alkylglycerols in the fish parasite Paratenuisentis ambiguus (Acanthocephala)

Specific differences between the acyl composition of lipids of the helminth Paratenuisentis ambiguus and its host eel, as shown previously, prompted us to study the lipid metabolism in this intestinal fish parasite. Adults and larvae of P. ambiguus were fed various lipid precursors, e.g., fatty acids, long-chain alcohols and 1-O-alkylglycerols, which may occur as common nutrients of intestinal parasites. Incorporation of [1-14C]palmitic acid into neutral and polar lipids was found to be similar under aerobic and near-anaerobic conditions. In adult parasites maintained in culture medium supplemented with glucose, [1-14C]palmitic acid was incorporated mainly into triacylglycerols and phosphatidylcholines, whereas [1-14C]oleic acid was incorporated preferentially into triacylglycerols. In fasted adults, as well as in larvae, [1-14C]oleic acid was mainly transferred to phosphatidylcholines. Lipolytic activity was detected in adult parasites that had been incubated with radioactive trioleoylglycerol. [1-14C]Hexadecan-1-ol was oxidized in P. ambiguus at a high rate to labeled palmitic acid, which was incorporated into various lipid classes of P. ambiguus. Small but significant proportions of radioactivity from hexadecan-1-ol were incorporated into ether glycerolipids of the parasite. A more direct precursor in ether glycerolipid metabolism, i.e., rac-1-O-[1'-14C]hexadecylglycerol, was incorporated into alkyl and 1'-alkenyl moieties of choline and etha-nolamine ether-glycerophospholipids of P. ambiguus in high yield. High proportions of labeled diacylglycerols, triacylglycerols and steryl esters were detected in surface lipids as well as lipid extracts of the culture media after incubation of P. ambiguus with [1-14C]palmitic or [1-14C]oleic acids.(ABSTRACT TRUNCATED AT 250 WORDS)

Sterol and fatty acid composition of neutral lipids of Paratenuisentis ambiguus and its host eel

The sterol composition of free sterol and steryl ester fractions of the fish parasite Paratenuisentis ambiguus was determined. In addition, the fatty acid composition of various neutral lipid classes, i.e., wax esters, steryl esters, triacylglycerols and free fatty acids, as well as the composition of the 1-O-alkyl moieties of total ether glycerolipids of the parasite, were investigated. The results of these studies were compared with those obtained on the intestinal tract tissue of its host, the eel (Anguilla anguilla). Cholesterol is the major sterol in both P. ambiguus and A. anguilla. However, the sterols of P. ambiguus contain high proportions (> 20%) of other sterols, such as campesterol and various dehydrosterols. [e.g., 7-dehydrocholesterol and cholesta-5,22(E)-dienol]. The presence of these minor sterols agrees with the known biotransformations of exogenous sterols in various helminths. Considerable differences are found in the fatty acid composition of neutral lipid fractions, as well as the total lipid extract from the endoparasite as compared to the host tissue. In particular, eicosapentaenoic acid (20:5n-3), other polyunsaturated fatty acids, such as 20:4n-6, 22:5n-3 and 22:6n-3, as well as long-chain saturated fatty acids, such as 20:0, are generally enriched in the neutral lipid fractions of the parasite as compared to those of infected eel intestine.(ABSTRACT TRUNCATED AT 250 WORDS)

CA 50 compared with CA 19-9 as a serum tumour marker for pancreatic carcinoma

This study compared the sensitivity and specificity of CA 50 and CA 19-9 as serum tumour markers for pancreatic cancer. One hundred and seventy one subjects were evaluated: 50 healthy controls, 50 patients with pancreatic carcinoma and 71 patients with chronic pancreatitis. Eighty per cent of the pancreatic cancer patients had raised CA 19-9 serum levels and 82% had raised CA 50 serum levels. In the group of patients ith chronic pancreatitis, false positive tests occurred in 8.4% for CA 19-9 and 11.3% for CA 50. For both markers the serum level showed a severe elevation in the advanced stage of cancer disease. Despite the good sensitivity and specificity of CA 50 as a serum tumour marker for pancreatic carcinoma, no major advantage was found compared to CA 19-9. Moreover, if the CA 50 cut-off, level is raised to 85 U/ml to exclude overlap with chronic pancreatitis, sensitivity falls sharply to 46% compared with 72% for CA 19-9 when a 100 U/ml cut-off level is used.

Subclinical celiac sprue. Increasing occurrence and clues to its diagnosis

We have reviewed the clinical records of 226 consecutive adult patients with celiac sprue diagnosed in our department from 1972 to 1989. The study period has been divided into three subperiods of 6 years each (1972-1977, 1978-1983, 1984-1989). From the first to the third subperiod a significant increase in the number of new diagnoses and of the proportion of patients recognized by minor symptoms has been observed. These patients represent 50% of our series in the last 3 years of the study and 70% in 1989. Diagnosing subclinical forms of celiac sprue has significantly lowered the mean age at diagnosis and the female/male ratio. First-degree relatives of celiac patients; subjects who had a gluten-free diet for a period during childhood; patients with short stature, anemia, or amenorrhea of no obvious cause; or patients with unexplained immunological abnormalities are the groups in which most patients with subclinical celiac sprue have been found and in which potential patients should be sought. Helpful diagnostic tools include antigliadin antibody testing and the observation of absent or reduced Kerckring folds in the descending duodenum in the course of upper gastrointestinal endoscopy.