PEGASUS: the Design of an Intervention to Facilitate Shared Decision-making in Breast Reconstruction

Studies have found varying levels of satisfaction after breast reconstruction surgery with a substantial group of patients reporting some level of regret about their decision. The variable outcomes reported by women undergoing breast reconstruction surgery suggest a role for improved pre-operative communication and shared decision-making (SDM) between patient and health professional. Pragmatic approaches such as decision aids have been evaluated, but the aim of the Patient Expectations and Goals Assisting Shared Understanding of Surgery (PEGASUS) intervention is to facilitate closer interaction between the patient and clinical team. PEGASUS is a standardised two-stage process, in which patients' goals are first elicited, ranked in importance and recorded before being used to frame discussion and decision-making with the surgeon managing care. Following the Medical Research Council (MRC) model, feasibility and acceptability studies have already been reported and a 4-year multicentre randomised controlled trial of 180 participants is underway, (completion 2020). This paper therefore focuses on the design of the intervention itself, in line with recent advice that interventions, in comparison with evaluations, commonly lack a theoretical base and are often under reported. We report a retrospective application of the Capability, Opportunity, Motivation-Behaviour (COM-B) model to provide explicit detail of each step in the intervention design. This is intended to facilitate replication by other clinicians and to provide systematic guidance for others wishing to develop PEGASUS as a strategy for implementing SDM in other clinical populations. Trial Registration: ISRCTN 18000391 (DOI 10.1186/ISRCTN18000391) 27/01/2016.

Oncoplastic breast surgery: A guide to good practice

Oncoplastic Breast Surgery has become standard of care in the management of Breast Cancer patients. These guidelines written by an Expert Advisory Group; convened by the Association of Breast Surgery (ABS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), are designed to provide all members of the breast cancer multidisciplinary team (MDT) with guidance on the best breast surgical oncoplastic and reconstructive practice at each stage of a patient's journey, based on current evidence. It is hoped they will also be of benefit to the wide range of professionals and service commissioners who are involved in this area of clinical practice.

The nature and importance of women's goals for immediate and delayed breast reconstruction

OBJECTIVES

Increasingly, women undergo breast reconstruction (BR) surgery to restore health-related and psychosocial quality of life after mastectomy. Most research focuses on BR outcomes rather than women's pre-surgical expectations of, and goals for, immediate (IBR) or delayed (DBR) procedures, yet such information could support women's decision-making. This study aimed to investigate women's BR goals, whether they differed according surgery timing (IBR or DBR), and the importance women placed on them.

METHODS

Seventy-six women considering DBR (n = 50) or IBR (n = 26) at a UK hospital were encouraged to clarify their BR goals and rate the importance of achieving each one. Content analysis categorised and counted the frequency of the goals they reported.

RESULTS

Fifteen goal categories (7 surgical, e.g. scarring; 8 psychosocial/lifestyle, e.g. feeling feminine) were identified. Many (e.g. scarring, intimacy) were reported by a similar percentage of women in each surgical group, however, differences were identified (e.g. breast sensation was not mentioned by women considering IBR). Women reported more psychosocial (n = 206) than surgical goals (n = 160). Further, an independent t-tests revealed that women in both groups placed significantly more importance on the psychosocial (M = 9.4) than surgical goals (M = 8.5).

CONCLUSIONS

This study highlights the variety of goals women have for BR, the importance they attach to them, and differences and similarities between those seeking IBR and DBR. Future research should consider whether BR goals are met, how goal achievement influences satisfaction with outcome over time and how best to incorporate goals into pre-surgical treatment decision-making.

SAT0615-HPR FACTORS ASSOCIATED WITH PATIENT ACTIVATION IN PEOPLE WITH RHEUMATIC CONDITIONS

Background:

Patient activation describes the skills, abilities and confidence someone uses to actively manage their health. Patient activation abilities in rheumatology are unclear, and there is little knowledge about factors that explain variation in patient activation. Therefore, understanding these factors can contribute to the development of appropriate, rheumatology-specific interventions targeting activation. The Patient Activation Measure (PAM) captures patient activation and provides people with both a score and a level to describe how able they are to actively manage their health.

Objectives:

To explore longitudinal changes to patient activation (measured using the PAM) (Hibbardet al., 2005), and the PAM’s associations with related constructs (including self-efficacy, health literacy and health beliefs) in a sample of participants with inflammatory arthritis.

Methods:

A postal survey was administered at two time points that were nine months apart. This survey captured the PAM and a range of clinical, demographic and psychosocial variables in a sample of rheumatology patients from 6 NHS sites in England. The measures included in the survey had been selected based on both theory and prior qualitative research and the survey pack was designed in collaboration with a patient partner. Following data collection, candidate variables for a multiple regression analysis were initially identified using univariable analysis. These variables were included in a forced entry multiple regression at each time point, and the variables that were statistically significant contributors at a 0.1 level were included in the final models. Changes to PAM scores over time were investigated using a Wilcoxon matched-pair signed rank test.

Results:

251 participants completed the first survey and 154 participants completed both full surveys. Self-efficacy, illness beliefs, health literacy and health locus of control were consistently associated with variance in PAM scores. The first three factors were also predictive of variance in PAM levels. With the 154 participants who fully completed both surveys, there was a statistically significant difference in participants’ PAM scores between the two surveys.

Conclusion:

The findings suggest factors that may be targets for interventions that aim to increase patient activation. The changes to PAM scores across the data collection period also suggest that when using the PAM as a clinical tool, healthcare professionals would benefit from incorporating regular reviews and preparations for any increases or reductions in patient activation.

References:

[1]Hibbard, J.H., Mahoney, E.R., Stockard, J. and Tusler, M. (2005) Development and testing of a short form of the patient activation measure.Health Services Research. 40 (6 I), pp. 1918–1930.

Disclosure of Interests:

Bethan Jones Speakers bureau: Honorarium for Lilly in their work with the British Society of Rheumatology for the delivery of 2 webinars due to be held on 30th January 2020., Andrew Hunt: None declared, Sarah Hewlett Grant/research support from: Received independent learning grant from Pfizer for the STRIDE project. However, the work has been completed and the grant closed, Diana Harcourt: None declared, Emma Dures Grant/research support from: Independent Learning Grant from Pfizer, combined funding for a research fellow from Celgene, Abbvie and Novartis, Paid instructor for: A fee from Novartis to deliver training to nurses.

A systematic review of patient reported outcome measures (PROMs) used in child and adolescent burn research

INTRODUCTION

Patient reported outcome measures (PROMs) can identify important information about patient needs and therapeutic progress. The aim of this review was to identify the PROMs that are being used in child and adolescent burn care and to determine the quality of such scales.

METHODS

Computerised and manual bibliographic searches of Medline, Social Sciences Index, Cinahl, Psychinfo, Psycharticles, AMED, and HAPI, were used to identify English-language articles using English-language PROMs from January 2001 to March 2013. The psychometric quality of the PROMs was assessed.

RESULTS

23 studies met the entry criteria and identified 32 different PROMs (31 generic, 1 burns-specific). Overall, the psychometric quality of the PROMs was low; only two generic scales (the Perceived Stigmatisation Questionnaire and the Social Comfort Scale) and only one burns-specific scale (the Children Burn Outcomes Questionnaire for children aged 5-18) had psychometric evidence relevant to this population.

CONCLUSIONS

The majority of PROMs did not have psychometric evidence for their use with child or adolescent burn patients. To appropriately identify the needs and treatment progress of child and adolescent burn patients, new burns-specific PROMs need to be developed and validated to reflect issues that are of importance to this population.

Abstract P4-17-03: Towards the standardisation of outcome reporting in reconstructive breast surgery: Initial results of the BRAVO (Breast Reconstruction and Valid Outcome) Study–A multicentre consensus process to develop a core outcome set for reconstructive breast surgery

Introduction: Appropriate outcome selection is essential if research is to guide decision-making for patients, professionals and policy makers. Systematic reviews evaluating the clinical, cosmetic and patient-reported outcomes of breast reconstruction, however, have demonstrated marked heterogeneity of outcome reporting such that results from individual studies cannot be compared or combined. Standardising end-points by developing and using core outcome sets - an agreed minimum set of outcomes that should be measured and reported in all research and audit studies – is one way by which outcome reporting may be improved. We therefore report the initial results of the BRAVO (Breast Reconstruction and Valid Outcomes) Study which aims to use a scientifically rigorous Delphi consensus process to develop a core outcome set for reconstructive breast surgery.

Methods: The Delphi process involves the sequential completion of questionnaires to allow stakeholder opinions to be synthesised using item responses to prioritise outcome domains.

The questionnaire was developed from a long list of 148 outcomes generated from literature reviews and qualitative work with stakeholders. The outcomes were categorised into 34 domains in six categories (short-term complications; late complications; symptoms; psychosocial issues; practical issues and cosmesis) and each domain operationalised.

Key stakeholders were identified as patients, surgeons, specialist nurses and psychologists and participants were sampled purposively to ensure a breadth of perspectives. Each participant was sent a questionnaire and asked to prioritise the outcomes on a nine-point likert scale from 1(not important) to 9(extremely important).

The number of respondents in each group rating each outcome as not important(scores 1–3); equivocal(scores 4–6) or very important(score 7–9) were calculated for each item and compared between groups. The proportions of respondents rating each item as very important(score 7–9) was used to rank the items.

Results: 213 of the 430 questionnaires were returned(126/274 patients and 87/156 professionals) giving a response rate of 49.5%.

Patient participants had a median age of 53.4 years(range 34–76) and had undergone a full range of reconstructive procedures. The professional group included 39 breast surgeons, 20 plastic surgeons and 18 clinical nurse specialists.

There was agreement between 7 of the 10 outcomes that each group rated most highly. Items with consensus included patient-reported cosmesis, cosmetic satisfaction and early complications. Patients, but not professionals, considered generic complications such as bleeding to be important while professionals valued psychosocial issues such as self-esteem more highly than patients.

Conclusions: Patients and professionals prioritise similar outcomes, but areas of discrepancy with regard to complications and psychosocial outcomes remain. A further Delphi round asking participants to re-prioritise outcomes and a consensus meeting to ratify the final decisions will be necessary to determine a final core outcome set for reconstructive breast surgery.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-17-03.

Abstract P4-17-04: BRECONDA: Development and acceptability of an interactive decisional support tool for women considering breast reconstruction

Introduction: Women needing a mastectomy for breast cancer, or cancer prophylaxis, are faced with the difficult decision regarding whether, and how, to restore breast shape after surgery. To a large extent this decision is based on personal preferences and values. In view of limited support resources available in this context, we have developed an online interactive decision aid, BRECONDA, to assist with decision-making. BRECONDA uses a multi-media platform to provide up-to-date information about surgical choices, interactive decision sheets encouraging women to weigh-up perceived benefits and risks and identify personal values and preferences, and video recorded patient stories. Since psychological stress can hamper decision-making, BRECONDA also demonstrates videoed stress management relaxation techniques. The aim of this study was to assess the user acceptability of this intervention.

Methods: Following diagnosis, and prior to surgery, 54 women with breast cancer who were eligible for breast reconstruction following mastectomy were randomly assigned into one of two conditions: 1) Intervention group which received access to the BRECONDA program as well as a standard information booklet about breast surgery given to all such patients; and, 2) Control/Usual care group which received the standard information booklet alone. User ratings of satisfaction and reactions to BRECONDA were documented at 6-week follow-up for the Intervention group through quantitative measures and telephone interviews. Additionally, perceived decisional conflict, distress (intrusive and avoidant thoughts), knowledge and satisfaction with information at the 6-week assessment were documented for all participants. ANCOVAs were used to identify between group differences on these key variables at follow-up.

Results: Intervention participants' ratings of BRECONDA demonstrated high user acceptability, with high scores on perceived usefulness, ease of use and provision of sufficient information. Interview data indicated that Intervention participants perceived BRECONDA to be well-balanced, informative, and beneficial to the decision making process and that it helped them feel more secure in their decision and to prepare questions for their surgeon. Interactive decision sheets, patient testimonials and photo galleries were highly valued by all interviewees. At follow-up, 40% of participants had undergone immediate reconstruction, with fewer Intervention participants electing this surgery. Furthermore, Intervention participants reported lower decisional conflict compared with Usual Care participants at follow-up (p <.05). Specifically, these participants reported feeling significantly clearer about personal values for benefits and risks of reconstruction compared with those receiving Usual Care.

Conclusions: Users of the interactive online BRECONDA intervention reported high levels of user satisfaction with this innovative decisional support resource, as well as benefits in terms of experiencing less decisional conflict related to the ability to clarify the values that are personally important in the decision making context. This provides preliminary evidence for the acceptability and efficacy of this decision support intervention.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-17-04.

Understanding normality: a qualitative analysis of breast cancer patients concepts of normality after mastectomy and reconstructive surgery

BACKGROUND

As survival rates increase, many people have to adjust to life after cancer. This includes adjusting to life after surgery. While previous research suggests that patients commonly strive to be 'normal' after mastectomy and reconstructive surgery, research surrounding individual perceptions of normality is lacking.

AIM

The aim of this study was to explore concepts of normality within a sample of breast cancer patients eligible for reconstructive surgery following mastectomy.

METHODS

A total of 35 semi structured interviews, with women who had undergone or were about to undergo breast reconstructive surgery following breast cancer, were analysed using thematic analysis.

RESULTS

Four main themes emerged from the data. Women referred to looking normal (appearance); being able to fulfil everyday activities (behaviour); adapting to a new normal (reconstructing normality); and not being ill (health). The importance placed on each area of normality differed between patients. Additionally, patients used different standards to anchor concepts of normality. These included individual standards, social standards and clinical standards.

DISCUSSION

The results indicate that although there are commonalities between patients' concepts of normality, it is important for health care professionals to recognise potential individual differences. This may usefully aid communication and help to manage expectations among patients considering surgical options.

'Your whole life, your whole world, it changes': partners' experiences of living with rheumatoid arthritis

OBJECTIVES

Research suggests that rheumatoid arthritis (RA) can have a negative psychosocial impact on partners, as well as patients. However, until now there has been very little in-depth qualitative research in this area. The aim of this study was to explore the experiences of partners of people with RA.

METHODS

Semi-structured interviews were conducted with a heterogeneous sample of eight partners of people with RA (six men, two women, age range 48-73 years). Transcripts were analysed thematically.

RESULTS

Five overarching themes emerged: psychological burden in partners was substantial, as they experienced frustration and distress at watching their partner suffer and tried to protect their spouse from emotional and physical distress. 'It's a restricted life': partners reported having to cut back on previously enjoyable shared activities and had difficulty making future plans. Adjusting lives: partners had to make considerable adjustments to many aspects of their lives, and had adopted practical and psychological ways to cope. 'It's a joint approach': many partners discussed adopting a joint approach to managing the RA. Met and unmet support needs varied considerably, and many partners felt that a joint approach to treatment taken by health professionals is needed, which involves and recognizes their role.

CONCLUSIONS

Partners of people with RA are vital to the patients' disease management, but the data show that many carry a substantial psychosocial burden. Healthcare professionals should be aware of this, so that couples coping with RA can be better supported.

Partner experiences of breast reconstruction post mastectomy

The aim of this small-scale, qualitative study was to explore partners' experiences of breast reconstruction after mastectomy. Interviews with 6 men, analysed using thematic analysis identified key themes of Involvement in the Decision-Making Process, Giving and Seeking Support, Opportunity to Talk, and Adapting Behaviour. Whilst most participants wanted to be involved in the decision-making process, they reported having experienced barriers to this, including difficulty in talking to others and expressing their true feelings about the surgery. Participants described difficulties with intimate contact after their partner had undergone surgery due to reactions to the appearance and feel of the reconstructed breast and a fear of hurting their partner and of reopening scars. This study highlights the need to recognise the role of the partner's involvement and of their own experiences during this time. The findings are of value to healthcare professionals, in particular specialist nurses, who work with women undergoing breast reconstruction and indicate areas where further research is needed.

Psychological distress surrounding diagnosis of malignant and nonmalignant skin lesions at a pigmented lesion clinic

This study aimed prospectively to investigate psychological distress throughout the diagnostic process in an outpatient pigmented lesion clinic (PLC). Psychological distress was measured at pre clinical diagnosis, post clinical diagnosis, pre histological diagnosis (including a benign follow-up) and post histological diagnosis stages using standard anxiety measurement scales and a study specific measure of satisfaction with care. In total 324 patients undergoing investigation of a suspicious skin lesion consented to take part out of a cohort of 463 patients who attended the PLC in a 6 month period. Using recognised cut-off scores, 27% of women on clinic arrival reported clinically high levels of anxiety, in comparison with 10% of men (p < 0.0001). Patients given an immediate benign post clinical diagnosis reported a reduction in anxiety (p < 0.0001) but patients requiring a biopsy reported elevated levels of anxiety. Approximately, 30% of these biopsy patients reported clinically high levels of anxiety both before and after diagnosis. Patients who received a post histological diagnosis of malignant melanoma also reported the pre histological stage at the clinic as more distressing than waiting for and receiving results (p < 0.01). Patient's quality of life prior to diagnosis was excellent, but emotional functioning (p < 0.05), insomnia (p<or=0.001), and global health status (p<or=0.001) deteriorated throughout the diagnostic process for those patients who were finally diagnosed as having malignant melanoma. Patients reported high levels of satisfaction with clinic attendance and treatment, regardless of diagnosis but a need for further information was identified. This study has implications for all healthcare professionals involved in the provision of care through Pigmented Lesion Clinics in UK. The diagnostic process of a suspicious lesion is evidently a 'critical' stage requiring appropriate provision of care to meet patients' psychosocial and information needs if distress is to minimised for the large numbers of patients attending a PLC each year.

Psychological aspects of breast reconstruction: a review of the literature

AIM

This paper critically examines the research literature relating to the psychological aspects of breast reconstruction. Particular attention is given to the role of specialist breast care nurses in supporting women faced with the decision of whether or not to opt for reconstructive surgery.

BACKGROUND

Breast reconstruction is intended to offer psychological benefits (e.g. improvements to quality of life, body image, anxiety and depression) to women treated by mastectomy following diagnosis of breast cancer.

METHODS

A literature search was carried out on the PSYCHINFO, MEDLINE and CINAHL databases using the terms "breast reconstruction", "mastectomy", "reconstructive surgery", "breast surgery", "breast implants", "transverse rectus adominis myocutaneous (TRAM) flap" and "Lat-dorsi". Further relevant articles were identified from the reference lists of papers detected by this literature search. Finally, proceedings of recent psychological and surgical meetings were scrutinized to identify any conference papers on this topic.

FINDINGS

A thorough search of the existing literature revealed a lack of theoretically based studies examining breast reconstruction in terms of relevant psychological constructs, especially in relation to coping and decision-making. This review highlights the methodological flaws with much of the existing research in this area, in particular the reliance upon retrospective designs and the inappropriate use of randomised controlled trials. Suggestions are given for further research in this topical area.

CONCLUSIONS

Existing research into the psychological aspects of breast reconstruction is limited and not sufficiently conclusive to inform changes to policy and the provision of care. More methodologically rigorous research is needed.

Factors implicated in the decision whether or not to join the tamoxifen trial in women at high familial risk of breast cancer

Why, given similar medical circumstances-high familial risk of breast cancer-will some women elect to join a trial of drugs designed to reduce that risk but others choose not to take part? The aim of this study was to identify measurable differences between women who elect to join a placebo-controlled, double-blind randomised trial of the drug tamoxifen and women who elect not to join. One hundred and six women attending a breast care clinic completed questionnaires covering demographic details, health locus of control, perception of risk and adequacy of medical communication. All were eligible for inclusion in the tamoxifen trial. Only half (n=53) of the sample elected to join, the other half (n=53) declined. Those who declined the trial were significantly more aware of lifestyle factors thought to influence the development of cancers-diet, exercise and oestrogen-prolonging activities (p<0.001), and they also appeared to find the information given by the hospital about tamoxifen harder to understand than did the group who had joined the trial (p=0.01). They could think of significantly fewer positive reasons for joining (p<0.001) and were significantly younger (p=0.001). Participants in both groups significantly overestimated the relative risks of breast cancer. The average estimation of risk for women aged 30 with a family history of breast cancer was 22 times higher than that given by their consultant. This gives rise to considerable concerns about the information underpinning informed consent.

Specialist nurse counsellor interventions at the time of diagnosis of breast cancer: comparing 'advocacy' with a conventional approach

Over recent years, specialist breast care nurses have become increasingly recognized as core members of any breast care team within the UK. Part of the role is to support patients at the highly stressful stage of receiving a diagnosis. This paper describes an 'advocacy' style of nurse counsellor intervention which aims to improve patients' preparation for, and involvement in, the diagnostic consultation and provides a framework for future counselling support. One hundred and three women undergoing surgery following diagnosis of breast cancer or a benign breast lump were supported using either this advocacy intervention or a more conventional model of care. The aim was to identify the most effective and appropriate method of intervening at this important stage. Assessment took place before surgery, with 2-week and 6-month follow-ups, and included the Hospital Anxiety and Depression Scale, Rotterdam Symptom Check List and semi-structured interviews addressing perceived quality of care, involvement in decision-making and psycho-social functioning. Whilst the results of many measures were similar for women in the two intervention groups, qualitative data support the implementation of the advocacy method by the breast care nurse.

Characterization of brimonidine metabolism with rat, rabbit, dog, monkey and human liver fractions and rabbit liver aldehyde oxidase

1. In vitro metabolism of 14C-brimonidine by the rat, rabbit, dog, monkey and human liver fractions was studied to assess any species differences. In vitro metabolism with rabbit liver aldehyde oxidase and human liver slices, and in vivo metabolism in rats were also investigated. The hepatic and urinary metabolites were characterized by liquid chromatography and mass spectrometry. 2. Up to seven, six, 11 and 14 metabolites were detected in rat liver S9 fraction, human liver S9 fraction, human liver slices and rat urine respectively. Rabbit liver aldehyde oxidase catalysed the metabolism of brimonidine to 2-oxobrimonidine and 3-oxobrimonidine, and further oxidation to the 2,3-dioxobrimonidine. Menadione inhibited the liver aldehyde oxidase-mediated oxidation. 3. Hepatic oxidation of brimonidine to 2-oxobrimonidine, 3-oxobrimonidine and 2,3-dioxobrimonidine was a major pathway in all the species studied, except the dog whose prominent metabolites were 4',5'-dehydrobrimonidine and 5-bromo-6-guanidinoquinoxaline. 4. These results indicate extensive hepatic metabolism of brimonidine and provide evidence for aldehyde oxidase involvement in brimonidine metabolism. The species differences in hepatic brimonidine metabolism are likely related to the low activity of dog liver aldehyde oxidase. The principal metabolic pathways of brimonidine are alpha(N)-oxidation to the 2,3-dioxobrimonidine, and oxidative cleavage of the imidazoline ring to 5-bromo-6-guanidinoquinoxaline.

Synthesis and evaluation of 2-[(5-methylbenz-1-ox-4-azin-6-yl)imino]imidazoline, a potent, peripherally acting alpha 2 adrenoceptor agonist

We have synthesized 2-[(5-methylbenz-1-ox-4-azin-6-yl)imidazoline, 3, a potent, peripherally acting alpha 2 adrenoceptor agonist. The agent is conveniently prepared in five steps from 2-amino-m-cresol. The agent has demonstrated good selectivity for alpha 2 adrenoceptors in binding and functional studies. When applied topically to eyes, the agent is efficacious for the reduction of intraocular pressure. The agent does not penetrate the blood-brain barrier and, as a consequence, does not lower blood pressure or induce sedation when administered topically or intravenously. We have determined the pKa and log P in water versus both octanol and dodecane of 3 and a set of related agents. The best physical parameter to explain its lack of central nervous system penetration appears to be log P measured in octanol versus water.

The antiinflammatory activity of topically applied novel calcium-channel antagonists

The antiinflammatory activities of two novel calcium-channel antagonists, AGN 190742 and AGN 190744, were evaluated in murine models of cutaneous inflammation. These 2(5H)-furanone ring compounds block both depolarization-dependent Ca2+ entry and receptor-mediated responses in GH3 cells. Topical application of AGN 190742 or AGN 190744 inhibits neutrophil infiltration and epidermal hyperplasia induced by repeated treatment of mouse skin with phorbol ester. AGN 190744 also is active in an arachidonic acid model of acute inflammation. These data suggest that topical application of calcium-channel antagonists can inhibit cutaneous inflammatory responses and that AGN 190742 and/or AGN 190744 may serve as useful pharmacological probes for examining these responses in vivo.

Role of conventional physiotherapy in cystic fibrosis

Because of the time and the emotional cost involved in performing daily conventional chest physiotherapy in patients with cystic fibrosis, a 3-year prospective study was undertaken to compare the long-term effects of postural drainage accompanied by percussion and the forced expiratory technique with the effects of the forced expiratory technique alone. Patients who performed the forced expiratory technique alone had mean annual rates of decline that were significantly different from zero for forced expiratory volume in 1 second (p less than 0.001), forced expiratory flow between 25% and 75% of vital capacity (p less than 0.001), and Shwachman clinical score (p less than 0.004). In the group performing conventional physiotherapy with percussion and postural drainage, only the mean annual rate of decline for forced expiratory flow between 25% and 75% of vital capacity was significantly different from zero (p less than 0.03), and it was significantly different from the mean rate of decline associated with the forces expiratory technique alone (p less than 0.04). We conclude that conventional chest physiotherapy should remain a standard component of therapy in cystic fibrosis.