Breaking bad news: Awareness and practice of the SPIKES protocol among general surgery residents at a tertiary care institute in northern India.

Background In general surgery, a clinician is commonly required to break bad news. However, training in communication is not a part of the formal curriculum either in medical school or in surgical residency and there is a paucity of data on awareness of the SPIKES (Setting up the interview, Perception, Invitation, Knowledge sharing, Emotion, Strategy and Summary) protocol among practising surgeons and residents in India. Methods We did a cross-sectional study in the Department of General Surgery at our institution. Junior residents were invited to take part in a one-on-one interview. Descriptive statistics were used to describe the findings of the study. Comparison for categorical data was done using Fisher exact test or chi-square test (whichever was applicable). Results A total of 82 residents with mean (SD) age of 27 (2.5) years (range 23-37 years) participated in the study. Only 31 (37.8%) had ever received training for breaking bad news, though 80 (97.6%) had broken bad news at least once. Twenty-one (26.3%) participants had a bad experience while breaking bad news. Seventy-seven (93.9%) participants felt the need for training in breaking bad news and 76 of them were willing to attend the same. Although the complete SPIKES protocol was followed only by 25 (31.3%) residents, 46 (56.1%) felt that it was practically possible to follow the SPIKES protocol. Conclusion Resident doctors in general surgery face situations of breaking bad news and adherence to the SPIKES protocol is poor. Formal training at every level may enhance their communication skills and enable better healthcare delivery.

Identification of a constitutively active variant of LuxO that affects production of HA/protease and biofilm development in a non-O1, non-O139 Vibrio cholerae O110.

Pathogenesis of Vibrio cholerae depends on the concerted action of numerous virulence factors that includes a secreted hemagglutinin (HA) protease. Recent studies have evidenced that the expression of these virulence factors as well as the genes responsible for biofilm development is subject to control by quorum sensing in this organism. At low cell density, LuxO, the pivotal regulator of quorum-sensing circuit, has been shown to be phosphorylated at aspartate-47. Working in concert with sigma-54, LuxO-P activates the downstream repressor, which turned out to be four sRNAs [Lenz, D.H., Mok, K.C., Lilley, B.N., Kulkarni, R.V., Wingreen, N.S., Bassler, B.L., 2004. The small RNA chaperone Hfq and multiple small RNAs control quorum sensing in Vibrio harveyi and Vibrio cholerae. Cell 118, 69-82]. Subsequently, these sRNAs form complex with sRNA chaperone, Hfq. The Hfq-sRNA complex causes the destabilization of hapR mRNA transcript. HapR is a positive regulator of hapA that encodes HA/protease. At high cell density, dephosphorylation of LuxO impairs its function to activate the expression of sRNA, which in turn promotes HapR expression and causes protease production. It has been demonstrated that conversion of aspartate to glutamate (D47E) renders the LuxO molecule active without being phosphorylated. This variant of LuxO is referred as constitutively active LuxO or con-LuxO [Freeman, J.A., Bassler, B.L., 1999. A genetic analysis of the function of LuxO, a two-component response regulator involved in quorum sensing in Vibrio harveyi. Mol Microbiol 31, 665-677]. Other than D47E, mutation at L104Q also develops con-LuxO [Vance, R.E., Zhu, J., Mekalanos, J.J., 2003. A constitutively active variant of the quorum-sensing regulator LuxO affects protease production and biofilm formation in Vibrio cholerae. Infect. Immun. 71, 2571-2576]. The purpose of this study was to investigate the cause of protease negative phenotype of a non-O1, non-O139 strain of V. cholerae O110. In the process of exploring the nature of the phenotype, a constitutively active variant of LuxO molecule was characterized which represses protease production and enhances biofilm formation by this strain. Unlike luxU, disruption of luxO restored the protease production, which showed the constitutively active nature of LuxO protein in this strain.