Physician challenges in communicating bad news.

Communicating bad news is never easy and for physicians these interactions may be a significant source of stress. To examine the characteristics that make delivering of bad news stressful, two studies were conducted. In the first study, 37 physicians generated 192 responses describing the characteristics that influence how difficult it is to break bad news. After sorting the responses in terms of common themes, six categories were identified: Physician, Patient, Institutional, Illness, Relationship, and Mishap. In Study 2, 115 physicians rated the degree of stress associated with each factor. Using principle component and reliability analyses, empirical support was found for six categories. A higher-order factor analysis suggested the existence of one over-arching factor. Items in the Mishap category were rated on average as the most stressful. Stress scores were largely unrelated to years in practice, experience delivering bad news or training.

First Report of Tobacco streak virus on Dahlia in the Czech Republic.

Dahlia is an important ornamental crop in the Czech Republic where they have been grown for more than 150 years. New dahlia cultivars have been selected by Czech plant breeders. Virus diseases, including mosaic and stunt caused mostly by Dahlia mosaic virus, have been a problem. From 2003 to 2005, color breaking was observed in several dahlia cultivars of foreign and Czech origin. White stripes in blossoms were most frequently expressed in the second half of the flowering season. No symptoms are visible in flowers of white and yellow cultivars. It was difficult to characterize symptoms on leaves because most cultivars were infected simultaneously by Dahlia mosaic virus. Sap inoculations of Chenopodium quinoa produced local lesions after 5 to 7 days, followed by systemic chlorosis, necrosis of younger leaves, and death of the shoot apex, indicating possible Tobacco streak virus (TSV) infection (2). Spherical particles (25 to 30 nm) were observed in leaf-dip preparations of samples from experimentally infected C. quinoa plants and analyzed by using transmission electron microscopy. These particles became decorated when using immunoelectron microscopy with TSV IgG (Bioreba, Reinach, Switzerland and Neogen, Ayrshire, Scotland). Samples of 80 dahlia cultivars were tested for TSV infection by ELISA using commercially available kits (Bioreba and Neogen). Most of the samples were grown in a collection of dahlia cultivars of Czech and foreign origin and some were obtained from growers in the Czech Republic. Fifty six dahlia cultivars were shown to be TSV infected. ELISA also indicated a higher concentration of the virus in flowers. The identity of the virus isolated from symptomatic plants was confirmed by reverse transcription (RT)-PCR using total RNA extraction from symptomatic plants. RT-PCR (4), using a primer pair (1) derived from the coat protein gene sequence of TSV (3), was followed by electrophoresis on 1.0% agarose gels. Products of the predicted size (approximately 700 bp) were found in naturally infected dahlia plants (n = 10), systemically infected host plants C. quinoa (n = 10), and symptomatic Nicotina megalosiphon (n = 10) that scored as TSV positive by ELISA. No bands of this size were seen in negative controls. To our knowledge, this is the first detection of TSV in the Czech Republic. References: (1) A. I. Bhat et al. Arch. Virol. 147:651, 2002. (2) A. A. Brunt Plant Pathol. 17:119, 1968. (3) B. J. C. Cornelissen et al. Nucleic Acids Res.12:2427, 1984. (4) S. S. Pappu et al. J. Virol. Methods 4:9, 1993.

PET/CT in giant cell arteritis: High 18F-FDG uptake in the temporal, occipital and vertebral arteries.

18F-FDG PET/CT imaging is useful in patients with fever of unknown origin and can detect giant cell arteritis in extracranial large arteries. However, it is usually assumed that temporal arteries cannot be visualized with a PET/CT scanner due to their small diameter. Three patients with clinical symptoms of temporal arteritis were examined using a standard whole body PET/CT protocol (skull base - mid thighs) followed by a head PET/CT scan using the brain protocol. High 18F-FDG uptake in the aorta and some arterial branches were detected in all 3 patients with the whole body protocol. Using the brain protocol, head imaging led to detection of high 18F-FDG uptake in temporal arteries as well as in their branches (3 patients), in occipital arteries (2 patients) and also in vertebral arteries (3 patients).

Patients' perceptions of receiving bad news about cancer.

PURPOSE: The purpose of this investigation was to document patients' recollections about what transpired during bad news interactions between physicians and themselves. PATIENTS AND METHODS: One hundred twenty cancer patients provided information about the most recent time they received bad cancer-specific news. Using a series of descriptive statements, patients reported on what the physician did while communicating the bad news. Patients also indicated the extent to which they were satisfied with the transaction and whether they believed that the interaction had any long-lasting impact on their adjustment or on their subsequent interactions with the physician who delivered the news. RESULTS: Overall, patients reported having similar experiences, with most physicians behaving in ways that were consistent with advice published in the medical literature. Satisfaction with the bad news transaction was high. Younger patients and women found the transaction to be more stressful, and older patients believed that the transaction was less important for subsequent interactions with the physician. Logistic regression analyses indicated that satisfaction with the transaction was uniquely predicted by factors related to the environment, to what the physician said, and to how the physician said it. CONCLUSION: Despite high levels of self-reported satisfaction by patients, some factors differentiated the most satisfied patients from patients who were less satisfied. The findings suggest that special attention should be given to making the environment comfortable, taking plenty of time with the patient, and attempting to empathize with the patient's experiences.

Complete nucleotide sequence and molecular probing of potato virus S genome.

Complete genomes of three isolates of Potato virus S (PVS) were cloned and sequenced. The PVS ORF-1 was characterized for the first time. It encodes a putative replication protein (RPT) that shares the highest homology (about 52%) with that of Blueberry scorch virus (BlScV). ORF-1 motifs, characteristic for carlaviruses were found for methyltransferase (MTR), helicase (HEL) and RNA-dependent RNA polymerase (RdRp). The complete sequence of PVS genome enabled to develop an immunocapture RT-PCR probing of the PVS genome. Using this system, the sequence variability of 11 genome zones was examined for 34 PVS isolates including 15 PVS-CS variants that caused a systemic infection in Chenopodium quinoa. A broad variability between PVS isolates and diverse sequence variants was found. cDNA fragments covering the coat protein (CP) leader and CP-coding region (approx. 420 bp) were pooled for PVS-O and Chenopodium-systemic PVS isolates (PVS-CS) and corresponding cDNA libraries were screened for sequence variants. Both cDNA pools differred mainly in the 5'-end of the CP gene. Methionine at the position 17 in combination with serine at the position 34 were frequently associated with the CS character of PVS. In general, hydrophobic and polar amino acids were characteristic for the positions 17 and 34, respectively in PVS-CS isolates. Genome probing and evolutionary distances suggested that the PVS-CS isolates analyzed were close to the ordinary European isolates of ordinary strain of PVS (PVS-O) but distant to the original Andean strain of PVS (PVS-A).

Lorazepam as an adjunct to opioid analgesics in the treatment of burn pain.

Benzodiazepines are commonly used to supplement opioid analgesics in treating procedural pain during the treatment of major burn injuries. To date, no study has investigated whether benzodiazepines actually have an analgesic or anxiolytic effect in such circumstances. Seventy-nine patients admitted to a major regional burn center were randomly assigned to groups that received 1 mg of lorazepam or a placebo in addition to their standard opioid analgesics. A strong analgesic effect of lorazepam was not observed when treatment groups were compared independent of their baseline pain ratings. However when patients who had high baseline pain were compared, lorazepam resulted in a significant reduction in pain ratings (adjusted post-treatment VAS mean score = 54.28; adjusted control VAS mean score = 69.06). Trait anxiety did not predict those patients who had an analgesic effect with lorazepam, but state anxiety did prove to be a covariate with visual analogue score decreases in pain reports.

Baseline pain as a moderator of hypnotic analgesia for burn injury treatment.

Sixty-one patients hospitalized for severe burns were randomly assigned to conditions in which they received either hypnosis or a control condition in which they received attention, information, and brief relaxation instructions from a psychologist. The posttreatment pain scores of the 2 groups did not differ significantly when all patients were considered. However, when a subset of patients who reported high levels of baseline pain were examined, it was found that patients in the hypnosis group reported less posttreatment pain than did patients in the control group. The findings are used to replicate earlier studies of burn pain hypnoanalgesia, explain discrepancies in the literature, and highlight the potential importance of motivation with this population.

Pain, coping, and adjustment in patients with burns: preliminary findings from a prospective study.

We prospectively examined the associations between procedural pain during hospitalization and coping and adjustment 1 month postdischarge in 43 patients treated at a major regional burn center for burns extensive enough to require at least 5 days of daily wound debridement procedures. Both patients and nurses provided ratings of patient pain, which were summarized and aggregated across a 5-day period. Results indicated that those subjects with higher pain scores also reported poorer adjustment as measured by scores on the Brief Symptoms Inventory and the Sickness Impact Profile. Moreover, these associations remained significant after partialling out the effects of preburn adjustment. Hierarchical regression analyses revealed evidence that seeking social support had a moderating effect on the association between pain and scores on a measure of posttraumatic stress disorder.

Conjunctive moderator variables in vulnerability and resiliency research: life stress, social support and coping skills, and adolescent sport injuries.

In life event research relating to vulnerability and resilience factors, single moderator variables have typically been the focus of study. Little is known about the ways in which moderator variables may interact with one another to increase vulnerability or resilience. We propose a distinction between conjunctive moderation, in which multiple moderators must co-occur in a specific combination or pattern to maximize a relation between a predictor and an outcome variable, and disjunctive moderation, in which any one of a number of moderators maximizes the predictor-criterion relation. Our results indicate that social support and psychological coping skills are statistically independent psychosocial resources and that they operate in a conjunctive manner to influence the relation between life stress and subsequent athletic injury in adolescents. Only athletes low in both coping skills and social support exhibited a significant stress-injury relation, and in that vulnerable subgroup, negative major life events accounted for up to 30% of the injury variance. Methodological considerations in the assessment of conjunctive moderator effects are discussed.

Sensation seeking, stress, and adolescent injuries: a test of stress-buffering, risk-taking, and coping skills hypotheses.

The potential stress-buffering effects of sensation seeking were assessed in a prospective study involving high school athletes. A significant positive relation between major negative sport-specific life events and subsequent injury time-loss occurred only for athletes low in sensation seeking. No evidence was obtained for a competing hypothesis that high sensation seeking would constitute an injury vulnerability factor by increasing risk-taking behaviors. Although low sensation seekers reported poorer stress management coping skills, there was no evidence that differences in coping efficacy mediated the injury vulnerability difference. Results indicate that sensation seeking is a stress-resiliency factor and suggest the utility of assessing relations between life stressors and outcomes that occur within the same environmental context.

Facilitating and debilitating trait anxiety, situational anxiety, and coping with an anticipated stressor: a process analysis.

Participants completed anxiety and coping diaries during 10 periods that began 7 days before an academic stressor and continued through the evening after the stressor. Profile analysis was used to examine the anxiety and coping processes in relation to 2 trait anxiety grouping variables: debilitating and facilitating test anxiety (D-TA and F-TA). Anxiety and coping changed over time, and high and low levels of D-TA and F-TA were associated with different daily patterns of anxiety and coping. Participants with a debilitative, as opposed to facilitative, trait anxiety style had lower examination scores, higher anxiety, and less problem-solving coping. Covarying F-TA, high D-TA was associated with a pattern of higher levels of tension, worry, distraction, and avoidant coping, as well as lower levels of proactive coping. Covarying D-TA, high F-TA was associated with higher levels of tension (but not worry or distraction), support seeking, proactive and problem-solving coping.

The role of dispositional and situational factors in cognitive interference.

Two studies investigated the cross-temporal stability and cross-situational consistency of cognitive interference. In Study 1, 70 college students reported on the intrusive thoughts they experienced during 2 course examinations and a self-reflective task. In Study 2, 55 college athletes reported on intrusive thoughts following 2 course examinations and 2 regular season football games. Major findings were (a) cognitive interference showed both cross-temporal stability and cross-situational consistency, (b) it was predicted by a measure of dispositional intrusive thinking, (c) the link between cognitive interference and dispositional intrusive thinking was not accounted for by indices of depressive symptomatology and trait anxiety, and (d) the degree of cross-situational consistency of cognitive interference and the content of these intrusive thoughts were influenced by situational factors.

Physician interactions with families and caregivers after a patient's death: current practices and proposed changes.

There are little objective data concerning physician bereavement or other supportive interactions with the families and caregivers of deceased patients. We surveyed the physician staff of a large tertiary rural referral center in central Pennsylvania. We asked about current practices in attending former patients' funerals, family condolence visits, letter or phone contacts, as well as the desire of physicians to participate in these activities. The database consisted of 143 questionnaires that were returned from 286 physicians initially mailed the survey. Only 119 of the 143 had experienced patient deaths in their practices. Most of these 119 physicians did not participate in any type of planned contact with a former patient's family after the patient's death. Phone calls were used 39.6% after an inpatient death, and condolence notes were sent by about 40% of physicians. There was no correlation between these activities and number of deaths in the practice per year or if death occurred as an inpatient or outpatient. Physicians practicing at the medical center more than 10 years were more likely to contact the grieving family or caregivers. There was significant desire by the physicians to have an easy way to identify deceased patients' caregivers or loved ones, to have condolence notes available for the physicians' use, and to have bereavement service information sent to the families or caregivers.

Masking effects of social desirability response set on relations between psychosocial factors and sport injuries: a methodological note.

Social desirability has long been viewed as a potential source of error variance in self-report measures. We suggest that social desirability (whether in the form of impression management or self-deception) has the capacity to mask relations between psychosocial variables and sport-related outcome or criterion measures that are not measured by selfreport. To illustrate what can occur, we present data from a longitudinal study in which life stress and psychological coping skills were studied as predictors of behaviorally-defined athletic injuries. When data from the entire sample of 352 athletes were analyzed, virtually no injury variance was accounted for by life stress, psychological coping skills, or their interaction. In contrast, deletion from the sample of athletes with high social desirability response set scores resulted in significant predictive relations involving both life stress and coping skills, as well as a significant moderator effect for coping skills. We propose that social desirability masking effects can significantly increase the likelihood of Type II errors in sports medicine research that involves self-report measures, and that social desirability responding needs to be controlled or minimized.

Describing and predicting the nature of procedural pain after thermal injuries: implications for research.

A prerequisite for studying and treating burn-related pain is the establishment of a good understanding of the nature of burn-related pain. However, in most investigations of pain, researchers have failed to examine pain over time or to create summary scores that capture differences in the nature of the pain experiences of individual patients. For 10 consecutive days, 47 patients treated for burn injuries reported on three aspects of procedural pain: worst pain, sensory pain, and affective pain. Three summary pain scores were constructed for each pain dimension: average pain, variability in pain, and linear change in pain. The authors found considerable variability in pain reports from the same patient and from different patients. Analyses indicated that pain reports decreased over time and that patients who had more trait anxiety reported more pain. Patients with larger burn injuries tended to report more affective pain and tended to have a pattern of high and low pain reports that differed from patients with less severe burn injuries. These findings suggest that adequate assessment of burn pain must occur frequently over the course of a single day, as well as for the duration of each patient's care.

Inpatient depression in persons with burns.

In this investigation the authors collected data regarding trait anxiety, well-being, and depression from 209 men and women who had been screened for prior psychiatric diagnosis and treated in an acute-care setting for burn injuries. Well-being was measured in reference to the month before the burn injury, whereas level of depression was self-rated by patients within 2 days of hospitalization, 5 days later, and 5 days after that. Ratings of depression were also obtained 1 month after hospital discharge. Results indicated that few patients rated their depression as severe at any point in time. Depression scores decreased significantly across the hospitalization period and were correlated with burn size, trait anxiety, and well-being. Depression ratings after discharge were significantly related to depression scores obtained at the end of the inpatient phase of the study. Although most patients did not report experiencing severe levels of depression, the stability of scores across time suggests the usefulness of early screening procedures. Catching such problems early may head off longer-term difficulties.

The 2000 Clinical Research Award. Describing and predicting distress and satisfaction with life for burn survivors.

We investigated ratings of emotional distress and satisfaction with life at discharge from the hospital and at a 6-month follow-up in a multisite sample of 295 adults hospitalized for the care of a major burn injury. Several psychosocial variables (history of alcohol abuse, marital status, and previous mental health) and some medical variables (days of intensive care, pulmonary complications, and hand burns) accounted for significant variance in the prediction of outcomes. Brief Symptom Inventory (distress) scores were higher and Satisfaction With Life Scale scores were significantly lower than those of a normative population at both measurement points. The results show the utility of biosocial models in which psychological and physical variables interact to influence adjustment and quality of life.

The 2002 Lindberg Award. PRN vs regularly scheduled opioid analgesics in pediatric burn patients.

Very little has been published on treating acute pain in children younger than the age of 3 for burns or any other trauma etiology. This study prospectively monitored the pain behavior and opioid analgesic intake of 31 pediatric burn patients (mean age = 23.71 months; SD = 15.75). Twelve of those children were randomized to conditions in which they either received opioid analgesics pro re nata (ie, as needed, pain contingent) or on a regular basis. The two groups did not show differences in demonstrable pain but, interestingly, they received equivalent does of opioid analgesics. As such, the pro re nata group was likely medicated largely on a regularly scheduled basis. For most of the remaining (nonrandomized) subjects, physicians ordered regularly scheduled opioid analgesics, suggesting that this practice has become largely institutionalized in the study setting. Information on pediatric opioid analgesic dosing and pain measurement strategies for nonverbal subjects can be derived from the findings.

Time off work and return to work rates after burns: systematic review of the literature and a large two-center series.

The literature on time off work and return to work after burns is incomplete. This study addresses this and includes a systematic literature review and two-center series. The literature was searched from 1966 through October 2000. Two-center data were collected on 363 adults employed outside of the home at injury. Data on employment, general demographics, and burn demographics were collected. The literature search found only 10 manuscripts with objective data, with a mean time off work of 10 weeks and %TBSA as the most important predictor of time off work. The mean time off work for those who returned to work by 24 months was 17 weeks and correlated with %TBSA. The probability of returning to work was reduced by a psychiatric history and extremity burns and was inversely related to %TBSA. In the two-center study, 66% and 90% of survivors had returned to work at 6 and 24 months post-burn. However, in the University of Washington subset of the data, only 37% had returned to the same job with the same employer without accommodations at 24 months, indicating that job disruption is considerable. The impact of burns on work is significant.

Rates, trends, and severity of depression after burn injuries.

It is commonly assumed that patients hospitalized for burn treatment will experience some level of depression. However, little is known about the trends in severity of depression over time. The purpose of this study was to determine the rates and severity of depression over a 2-year period. The Beck Depression Inventory was administered at 1 month (N = 151), 1 year (N = 130), and 2 years (N = 125) after discharge. At 1 month, 54% of patients showed symptoms of moderate to severe depression, and at 2 years, 43% of the patients responding still reported moderate to severe depression. The average correlation between scores over time was high. Women had higher depression scores than men at each time period. An interaction between gender and having a head or neck injury was also observed at 1 month and 1 year after discharge. Results suggest that routine outpatient screening for depression is warranted.