Long-term Complaints Research Articles

Austrian experiences with redo antireflux surgery

From 1996, the entire number of fundoplications performed in Austria increased dramatically, favoring the laparoscopic technique. Despite good results, some patients experience failure of antireflux surgery and therefore require redo surgery if medical therapy fails to control symptoms. The aim of the study was to describe the refundoplication policy in Austria with evaluation of the postoperative results. A questionnaire was sent to all Austrian surgical departments at the beginning of 2003 with questions about redo fundoplications (number, techniques, intraoperative complications, history, migration of patients, preoperative workup, mortality, and postoperative long-term complaints). It also included questions about primary fundoplications (number, technique, postoperative symptoms). Out of 4,504 primary fundoplications performed in Austria since 1990, 3,952 have been carried out laparoscopically. In a median of 31 months after the primary operation, 225 refundoplications have been performed, laparoscopically in the majority of patients. The Nissen and the partial posterior fundoplication were the preferred techniques. The conversion rate in these was 10.8%, mainly because of adhesions and lacerations of the spleen, the stomach, and the esophagus. The mortality rate after primary fundoplications was 0.04%, whereas the rate after refundoplications was 0.4%, all resulting from an open approach. Laparoscopic refundoplications are widely accepted as a treatment option after failed primary antireflux surgery in Austria. However, the conversion rate is 6 times higher and the mortality rate is 10 times higher than for primary antireflux surgery. Therefore, redo fundoplications should be performed only in departments with large experience.

5:52 128. A prospective randomized double blind study evaluating the efficacy of postoperative continuous local anesthetic infusion at the iliac crest bone graft site after spinal arthrodesis

BACKGROUND CONTEXT: Harvesting iliac crest bone has been shown to be a source of pain and morbidity. Long-term patient complaints may be more closely associated with the procurement of the iliac crest bone graft (ICBG) rather than the primary surgical site.

PATTERNS OF LONG-TERM PHYSICAL SYMPTOMS AFTER DISASTER WORK

ISEE-291 Purpose: In 1992 a Boeing 747 cargo aircraft crashed into two apartment buildings in a densely populated suburb. Forty-three people were killed and many more were injured. In the following years rumours and questions arose about the cause of the accident, the contents of the cargo and possible acute and future health risks. Meanwhile, people affected by this air disaster expressed health complaints. In 2000, a controlled epidemiological study set out to investigate long-term health complaints and indicators of exposure among occupationally involved subjects. As part of this study, the present paper addresses patterns of health complaints. The main hypothesis is that occupational involvement and exposure to a variety of potentially toxic materials during this stressful event, combined with public debate and extensive media-coverage, may have led to a pattern of medically unexplained symptoms that differs from that reported in non-involved colleagues. Methods: In this cohort study a comparison is made between fire fighters (n=334), police officers (n=834) and accident and investigation workers (n=399) who were occupationally involved in this air disaster and reference groups of colleagues who were not involved in this air disaster (n=194, n=634, and n=104, respectively). The overall response rate was 70%. Data collection took place from January 2000 to March 2002, and included questionnaires on occupational involvement, various types of current health complaints and health-related background information. Results: Preliminary results indicate that occupationally involved workers report considerably more health complaints of various kinds than the respective reference groups. Further analyses on symptom patterns will be presented at the conference.

Femoral nail removal should be restricted in asymptomatic patients.

Femoral nail removal has been suggested as a routine procedure for symptomatic and asymptomatic patients. The aim of this study was to evaluate whether asymptomatic patients have long-term complaints after femoral nail removal. Additionally, factors that might extend operation time and effect soft tissue healing negatively were analyzed. A retrospective study on the removal of 164 femoral nails after fracture consolidation was done. A review of the patient charts and radiographs was done. Neither the interval between nail implantation and nail removal or the use of an end-cap significantly influenced the operation time. The surgeon's qualification and nail depth were the only variables that influenced operation time. Neither operation time, nail depth, surgeon's qualification, nor the grade of heterotopic ossification significantly influenced the incidence of wound healing problems. One hundred nine patients (73%) were available for the followup interview. Preoperatively, 58 patients (53%) had local complaints. Of these 58 patients, 78% reported improvement and 7% reported an aggravation of their local complaints. Of the 51 patients who were asymptomatic before surgery, 20% reported long-term complaints at followup. Only symptomatic patients should be considered for femoral nail removal.

Uvulopalatoplasty (UP2): a modified technique for selected patients.

The goal of uvulopalatopharyngoplasty (UP3) in the treatment of obstructive sleep apnea-hypopnea syndrome (OSAHS) is to reduce obstruction by eliminating redundant tissue in three areas: the soft palate, tonsils, and pharynx. However, some OSAHS patients may present with tonsil hypertrophy and elongated soft palate without redundant pharyngeal folds. We treated this group of patients with tonsil reduction using radiofrequency coblation combined with uvulopalatoplasty (UP2) using a palatal flap technique without pharyngoplasty. Morbidity and outcome was then compared with a group of patients who underwent classic UP3. A retrospective, nonrandomized study comparing morbidity and outcomes of the modified technique (UP2) with patients who underwent standard UP3. Patients were all staged according to the previously described Friedman staging system. Those with redundant pharyngeal folds were treated with UP3 (n = 33), and those without redundant pharyngeal folds were treated with tonsil coblation and UP2 (n = 30). Charts of patients undergoing UP2 and UP3 between July 1, 2001 and July 1, 2002 were reviewed. Thirty-three consecutive patients who underwent UP3 were selected for study as well as 30 consecutive patients who underwent UP2. Pre- and postoperative quality of life questionnaires and patient questionnaires focusing on diet, pain, and return to activity were reviewed to assess subjective morbidity and elimination of symptoms. Objective measurements include preoperative and postoperative (6-18 months) polysomnography (PSG). Symptom elimination and objective PSG results were compared. There was no statistical difference in results between the UP3 group and the UP2 group. Morbidity, however, was significantly more prominent, and recovery was more prolonged, in the UP3 group. Patients undergoing UP2 had fewer pain days, less narcotic use, quicker return to solid diet, and less long-term complaints of globus sensation. UP2 with tonsil coblation offers some reduction in postoperative morbidity without affecting outcome for selected patients with OSAHS. Pain levels, however, are still very significant.

Non-surgical intervention and cost for mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury.

We examined the evidence for non-surgical interventions and for economic costs for mild traumatic brain injury patients by a systematic search of the literature and a best-evidence synthesis. After screening 38,806 abstracts, we critically reviewed 45 articles on intervention and accepted 16 (36%). We reviewed 16 articles on economic costs and accepted 7 (44%). We found some evidence that early educational information can reduce long-term complaints and that this early intervention need not be intensive. Most cost studies were performed more than a decade ago. Indirect costs are probably higher than direct costs. Studies comparing costs for routine hospitalized observation vs the use of computerized tomography scan examination for selective hospital admission indicate that the latter policy reduces costs, but comparable clinical outcome of these policies has not been demonstrated. The sparse scientific literature in these areas reflects both conceptual confusion and limited knowledge of the natural history of mild traumatic brain injury.

Long-term subjective memory function in ventricular fibrillation out-of-hospital cardiac arrest survivors resuscitated by early defibrillation

Brain injury after a cardiac arrest remains a major cause of morbidity. Programs focusing on early defibrillation have yielded improved survival of patients after hospital discharge following ventricular fibrillation (VF) out-of-hospital cardiac arrest (OHCA). Early defibrillation that promptly restores a circulating rhythm should decrease the hypoxic period and subsequent organ injury. Therefore this study was designed to determine if long-term memory complaints persist in VF OHCA survivors resuscitated in an early defibrillation program when compared with a healthy control population not experiencing cardiac arrest. All patients with an OHCA between November 1990 and January 2001 who received defibrillation by emergency medical services personnel in Olmsted County, MN, USA, were included. The memory function questionnaire (MFQ), a 64-item, 7-point Likert-scaled instrument to evaluate the perception of everyday memory functioning was sent to all survivors. The MFQ comprises four scales: general frequency of forgetting (rates general forgetting), retrospective functioning (compares current memory with past ability), seriousness of forgetting (rates how memory impairment impacts daily life), and mnemonics usage (measures adaptation). The MFQ is scaled so that high scores reflect less severe memory complaints. The comparison population comprised members of the Mayo Older Americans Normative Studies (MOANS) cohort. Quality of life was ascertained with a short form (SF)-36 survey. Seventy-nine of the 200 VF OHCA patients (40%) were discharged. Twenty-two patients have died since dismissal, with an overall average length of follow-up of 4.9+/-3.0 years. Thirty-eight (67%) of the survivors completed the MFQ. Compared with the normal, there was a significant decrease in the general frequency of forgetting score of 144.2+/-37.4 versus 168.1+/-27.3 ( P<0.001) and the seriousness of forgetting score of 84.8 +/-26.7 versus 95.2+/-19.7 (P=0.004). The retrospective function-scale scores were not significantly different ( 18.4+/-6.8 versus 18.7+/- 5.0 (P=0.74). Younger patients (lesser than 65 years of age) reported an increase in general forgetting and the seriousness of forgetting compared with older survivors. A comparison with SF-36 scores suggested an association between general forgetting and decreased vitality (P=0.03) and the seriousness of forgetting with a decreased general health (P=0.005), mental health (P=0.009), physical functioning ( P=0.02 ), and vitality ( P=0.05). In a cohort of VF OHCA patients, survivors report more memory complaints in comparison with a general healthy older population. There were more long-term-memory complaints in younger patients. Patients with higher long-term quality-of-life score have fewer memory complaints.

Cognitive impairment after transurethral resection of the prostate (TURP)

Purpose: It has been suggested that cognitive impairment may occur following transurethral resection of the prostate (TURP) operations due to the effects of anaesthesia or hyponatraemia or both. The aim of the study was to investigate whether TURP was associated with long-term memory complaints or cognitive impairment. Method: Patients who had received a TURP or transurethral resection of a bladder tumour (TURT) in the previous 10 months were sent a questionnaire on memory problems and mood. Seventy-six TURP patients and 38 TURT patients returned the completed questionnaires. A sample of each patient group (30 TURP, 29 TURT) was assessed on standardized tests of cognitive abilities. Results: There was no significant difference between the TURP and TURT patients on the Everyday Memory Questionnaire completed by themselves or by a family member (p > 0.05). On formal cognitive testing there were no significant differences between the groups, except on the overall grading of the Kendrick Assessment Scales of Cognitive Ageing, in which TURP patients performed at a significantly lower level than TURT patients. Conclusions: The results suggest that patients are no more likely to complain of memory problems following a TURP than with any other operative procedure. There was a slight difference in cognitive abilities but this did not indicate significant impairment of cognitive function.

Clinical response to amino acid-based formula in neurologically impaired children with refractory esophagitis.

Chronic gastrointestinal symptoms and histologic changes of the esophagus unresponsive to standard treatments for gastroesophageal reflux disease (GERD) may be improved by the use of elemental formulas. The aim of our study was to evaluate the efficacy of a dietary trial in neurologically impaired children unresponsive to medical and surgical therapy for GERD. Nine children (three boys and six girls; median age, 44 months; range, 13-180 months) affected by cerebral palsy associated with severe mental retardation and with long-standing history of GERD were fed the elemental formula, Neocate, for a minimum of 4 weeks. Before and after the dietary trial, each child underwent endoscopy with esophageal biopsy and a cellobiose/mannitol sugar permeability test. The diagnosis of GERD was based on the microscopic changes of the esophagus. Before the dietary trial, according to conventional histologic criteria, esophagitis was considered moderate in seven children and mild in two. Five of nine patients also had abnormal sugar permeability test results. During and after the dietary trial, seven of nine patients experienced resolution of their long-term symptom complaints. Furthermore, after the dietary trial, both endoscopic ( < 0.01) and histologic ( < 0.05) findings significantly improved. At 6-month follow-up, progressive reintroduction of individual dietary proteins, except for cow's milk protein, did not cause reappearance of the symptoms. In neurologically impaired children unresponsive to conventional antireflux treatments, a course of a highly restricted diet with an amino acid-based formula may bring an immediate and sustained, endoscopically and histologically proven improvement in long-standing gastrointestinal symptoms and esophagitis.

Long-term illness and psychosomatic complaints in children aged 2-17 years in the five Nordic countries. Comparison between 1984 and 1996.

Long-term illness and psychosomatic complaints in children aged 2-17 years in the five Nordic countries. Comparison between 1984 and 1996.

Tricky to find, hard to treat, impossible to cure

Tricky to find, hard to treat, impossible to cure

Unusual Paranasal Sinus Tumors in two Patients with Common Nasal Complaints

Common nasal complaints are managed by both the otolaryngologist and the primary care physician. We describe the cases of two patients with nasal obstruction who were referred to us for evaluation--one with severe headache and the other with profuse epistaxis. Their histories prior to referral included long-term, common rhinologic complaints of low-grade headache and mild epistaxis. Neither patient had been referred to us until their symptoms had become severe. Our examination revealed that both patients had rare paranasal sinus pathology. One patient had a fibroxanthoma of the frontal sinus, and the other had extramedullary hematopoiesis of the maxillary sinus. Fibroxanthoma of the frontal sinus is rare, and extramedullary hematopoiesis of the maxillary sinus has not been previously reported. These two unique cases serve as a reminder that long-term common rhinologic complaints can occasionally be a sign of life-threatening pathology and require a full evaluation by an otolaryngologist.

Langzeitbeschwerden nach minimal-invasiven thoraxchirurgischen Operationen und nach Thoracotomie

Minimally invasive techniques are now frequently used in general thoracic surgery. More than 30% of all minimally invasive procedures are operations in patients with spontaneous pneumothorax. Recently, it has been shown that the video-assisted approach compared to the standard anterolateral thoracotomy results in a significant reduction of the early postoperative pain. However, little is known about the influence of video-assisted surgery on long-term complaints. We analyzed the frequency and characteristics of chronic complaints in 60 patients after video-assisted operations for spontaneous pneumothorax using a standardized questionnaire. For comparison, 27 patients after anterolateral thoracotomy for benign diseases were interviewed 24 months postoperatively using the same questionnaire. After minimally invasive surgery and a median observation time of 59 months, 19 (31.7%) out of 60 patients suffered from chronic complaints. Two of them (3.3%) required daily oral pain medication. On a visual analog pain scale (ranging from 0 to 100), 17 patients described a pain intensity of < 20 and 2 (3.3%) patients > 50. After thoracotomy 14 (51.8%) out of 27 patients suffered from chronic complaints, 5 (18.5%) of them with regular use of oral pain medications. The mean pain intensity (analog scale) was 3.6 points after minimally invasive operations and 14.4 points after thoracotomy (P = 0.01). In conclusion, even after minimally invasive thoracic operations some patients suffer from chronic complaints. However, they are less frequent and of lower intensity than after thoracotomy.

Monitoring the Indoor Environment in the Czech Republic

Most of the existing studies on health effects from exposure to pollutants are limited in their scope. In an attempt at a more holistic approach the Government of the Czech Republic implemented a decree entitled ‘A System of Monitoring Environmental Impacts on Health of the Population of the Czech Republic’. A monitoring system comprising six parts was set up to provide data necessary for a national policy for health and protection of the environment. This paper describes work carried out on a cohort of kindergarten children in Brno, Hradec Králové, Ostrava and Plzeň under the subsystem of the decree: ‘health consequences and risks related to air pollution’. It was found that 20% of the children monitored had long-term respiratory complaints, which, potentially, could be associated with the quality of indoor air. There were no differences between the towns, sex or age of the children related to these health problems. The study looked at various domiciliary factors including type and structure of housing, heating system, use of gas cookers, new furniture and carpets, presence of mould, pet animals and smoking indoors. Surprisingly, in families with sick children, there were fewer pets and also fewer smokers.

Early and long-term complaints following video-assisted thoracoscopic surgery: evaluation in 173 patients.

Minimal invasive surgical techniques have gained high acceptance in thoracic surgery during the last 10 years. However, up to now, only scant information exists on chronic postoperative pain and discomfort in patients who underwent video-assisted thoracoscopy. Therefore, a retrospective study was performed with the aid of a self-reported questionnaire. Two hundred and thirteen patients (of whom 79 females) with a mean age of 48 (range 15-88) years were operated on for a total of 225 procedures. Thoracoscopy was performed for pneumothorax (n=70), pulmonary nodules (n=44), interstitial lung diseases (n=20), pleural effusion (n=20), and empyema (n=19). Various indications included therapeutic or diagnostic procedures in bullous disease, mediastinal tumors, carcinoma, inflammatory lung disease, hyperhidrosis mani and bronchiectasis. Mean drainage time was 6.0+/-4.7 days and hospital stay 8.4+/-6.6 days. One patient died on the ninth postoperative day after lobectomy for bronchial carcinoma due to cardiac failure, five patients needed a short period of reintubation due to acute respiratory failure. In two patients, thoracoscopic reoperation was necessary for closure of bronchopleural fistula. The self-reported questionnaire was returned by 173 (81%) of all patients within a mean follow-up of 18 (3-38) months. More than half of the patients (53%) reported no thoracic pain as early as 2 weeks after the procedure. At 2 weeks after the operation, 13% of patients suffered from localized pain and 31% from diffuse discomfort. Twelve percent needed pain medication regularly, and 3% occasionally. At 6 months postoperatively, three quarters of the patients had no complaints, 5% suffered from scar pain, and 20% had diffuse chest discomfort. One year after the procedure, 86% of the patients had no complaints, 9% suffered from minimal pain, and 5% from moderate pain. Two years after the procedure, 96% of the patients had no complaints at all. One hundred and twenty-five of the 140 patients (89%) working preoperatively went back to work within 2 weeks after the operation. Fifteen patients did not work between 3 and 16 weeks; 14 due to chest pain, one due to shoulder pain. Video-assisted thoracoscopy permits very early recovery with rapid reintegration into the working process. Long-term complaints after videothoracoscopy are rare.

CLINICAL RESPONSE TO AMINO ACID-BASED ENTERAL FORMULA IN NEUROLOGICALLY IMPAIRED CHILDREN WITH REFRACTORY ESOPHAGITIS

68 Recent results indicate that chronic gastrointestinal symptoms and histological changes of gastroesophageal reflux disease (GERD) unresponsive to standard treatments can be improved by the use of elemental formulas. GERD is common in neurologically impaired children (NIC), and the disorder is notoriously resistant to both medical and surgical treatments in this subject group. Because of prior observations in normally developed children, this investigation was designed to determine the efficacy of a dietary trial with an elemental formula on GERD in NIC who had not responded to medical and/or surgical therapy. Eight children (mean age ±SD: 53.7 ±40.9 months; 6 females) affected by cerebral palsy and having severe mental retardation were studied. Each had a long-standing history of GERD that had persisted despite standard antireflux therapies, including omeprazole in all and Nissen fundoplication in 3. The diagnosis of GERD was based on presence of typical microscopic changes of the esophageal mucosa. Subjects were fed the amino acid-based elemental formula Neocate (Nutricia) by mouth or by nasogastric tube for a minimum of 4 weeks while prior stable treatments for reflux disease were continued. Each child underwent endoscopy with esophageal biopsies and a cellobiose/mannitol sugar permeability test before and after the dietary trial. Symptomatology, endoscopy, and histology were graded using scales reflecting increasing severity with increasing grade; histology was graded by an observer who was blinded to the endoscopic findings. RESULTS: Using conventional histological criteria, esophagitis was considered moderate in 7 and mild in 1 at the beginning of the dietary trial. Five (62.5%) of the 8 patients also had an abnormal sugar permeability test, but none had an allergy history or positive skin testing to food antigens. By the end of the dietary trial, 7 of the 8 patients (87.5%) became free of their long-term complaints (regurgitation and/or vomiting, abdominal pain, chronic pulmonary aspiration). Furthermore, both endoscopic and histological findings of GERD significantly improved (p<0.01 and p<0.05, respectively using Fisher's exact test). Nevertheless, no significant changes were found in the number of esophageal mucosal eosinophils and mast-cells. After the trial, the permeability sugar test normalized in 3 of the 5 (60%) with initially abnormal studies. CONCLUSIONS: A course of a highly restricted diet with an amino acid-based formula may reverse long-standing upper gastrointestinal symptoms and resolve esophagitis in NIC who are unresponsive to conventional antireflux treatment. The mechanisms responsible for symptom and histological improvement remain uncertain, but they are not necessarily immunologic in nature. Disclosure: The authors have no financial interest in the described products.

Patient characteristics and practice patterns of physicians using homeopathy.

The use of homeopathy is growing in the United States, but little is known about practice patterns of physicians using homeopathy and the patients who seek homeopathic care. Data for consecutive patient visits to 27 doctors of medicine and doctors of osteopathy using homeopathy in 1992 were collected and compared with the National Ambulatory Medical Care Survey of 1990. Patients seen by the homeopathic physicians were younger, more affluent, and more likely to present with long-term complaints. Physicians using homeopathic medicine surveyed spent more time with their patients, ordered fewer tests, and prescribed fewer pharmaceutical medications than physicians practicing conventional medicine. While definite conclusions cannot be made based on this survey, we have documented that the use of diagnostic testing and conventional medications by physicians who use homeopathy to treat common chronic conditions is well below that of conventional primary care physicians. These findings, if associated with comparable clinical outcomes, suggest a potential for substantial cost savings. Further studies documenting outcomes, cost benefits, physician decision-making, and patient satisfaction will be required to further explore this subject.

Psychological Predictors of Symptoms of Urinary Tract Infection and Bacteriuria in Patients Treated with Clean Intermittent Catheterization: A Prospective 7-Year Study

Objective: One of the major clinical problems in relation to clean intermittent catheterization (CIC) are symptoms of urinary tract infection (UTI) and bacteriuria. The aim of the present work was to study to what extent measures of psychological well-being, distress and neurotic personality traits in patients performing CIC could predict symptoms of UTI or bacteriuria 7 years later. Patients and Methods: Included in the study were 170 patients with a mean age of 57 years, who had used CIC for 105 months. CIC was practised due to neurogenic bladder dysfunction in two thirds of the patients, and non-neurogenic dysfunction in the remaining patients. All patients had been clinically examined 7 years prior to inclusion. Information about subjective symptoms of UTI and examination of bacteriuria in urine samples had been assessed. All subjects had also undergone repeated psychometric evaluations of psychosocial function, well-being and distress (General Health Questionnaire; GHQ-28; Spielberger State-Trait Anxiety Inventory; STAI X-1) and neuroticism (Eysenck Personality Questionnaire; EPQ-N). The results from selected assessments done 7 years earlier were used to predict reported UTI and findings of bacteriuria in urine samples in 1995. Results: Clinical UTI symptoms were reported by 35% of the patients. These patients had significantly higher GHQ-28 scores in 1988, 1989 and 1995 compared to the remaining 65%. Patients without clinical UTI during 1988/89, but with symptoms suggesting UTI in 1995, had significantly higher GHQ-28, STAI-X1 and EPQ-N scores in 1988 compared to those who did not report symptoms 7 years later. Patients with UTI during 1988/89 who were free of symptoms of UTI in 1995 had scores similar to those who were free of symptoms of UTI both in 1988/89 and in 1995. GHQ-28, STAI X-1 and EPQ-N scores in 1988/89 did not predict current bacteriuria, found in 62% of the urine samples in 1995. Conclusion: Social function, well-being and distress are significant predictors of long-term urinary tract complaints, but not of bacteriuria. This finding indicates that the aetiology of UTI complaints and of actual bacteriuria is different. Complaints of UTI may often express distress and not symptomatic infection. Physicians’ non-recognition of distress may lead to unnecessary and aggressive interventions for assumed infection such as the prescription of antibiotics. Identification and treatment of psychological distress and impaired social function should become routine in the clinical follow-up of CIC patients. Such a routine could reduce urinary tract complaints, lower the unnecessary use of antibiotics and increase the tolerability of CIC. Prospective intervention studies are needed to verify this hypothesis.

Cognitive coping and appraisal processes in the treatment of chronic headaches

The purpose of the present study was to investigate the active cognitive ingredients of change in psychological treatments for long-term chronic headache complaints. The primary questions this study addressed were: (1) Is a cognitive self-hypnosis training which explicitly attempts to change appraisal and cognitive coping processes more effective in producing these changes than a relaxation procedure, and (2) are changes in pain appraisal and cognitive coping related to changes in pain and adjustment in the short and long term? A total of 144 patients were assigned at random to a cognitive self-hypnosis (CSH) treatment or autogenic training (AT) with a duration of 7 weeks. Measures used were: Headache Index (HI), Symptom Checklist-90 (SCL-90), Coping Strategy Questionnaire (CSQ), Multidimensional Locus of Pain Control Questionnaire (MLPC) and treatment expectations. The results indicated that patients successfully changed their use of coping strategies and pain appraisals. Cognitive therapy was more effective than relaxation training in changing the use of cognitive coping strategies which were the direct targets of treatment. However, treatment effects were only related with changes in the use of coping strategies and appraisal processes to a limited extent and the mediational role of cognitive processes in pain reduction and better adjustment was inconclusive.

Spiritual healing in a general practice: Using a quality-of-life questionnaire to measure outcome

Patients were selected by their general practitioner to attend a healing clinic held at their practice. Each of the patients had long-term chronic complaints which had not responded to the usual medical approaches. A 20-minute session of healing was offered once a week, for eight weeks. Each patient completed a SF-36 Quality-of-Life questionnaire before attending the first healing session, and again after eight weeks. A total of 33 patients completed the questionnaires, with 19 completing a further questionnaire at a 6-month follow-up. The results show an improvement in all dimensions after eight weeks, which was maintained after six months. This paper suggests that, by attending a healing clinic, a selected group of patients with chronic problems improved their quality of life.