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1.  Perceived Positive Impact of Cancer Among Long-term Survivors of Childhood Cancer: a report from the Childhood Cancer Survivor Study 
Psycho-oncology  2011;21(6):630-639.
Background
Investigations examining psychosocial adjustment among childhood cancer survivors have focused primarily on negative effects and psychopathology. Emergent literature suggests the existence of positive impact or adjustment experienced after cancer, as well. The purpose of this study is to examine the distribution of Perceived Positive Impact (PPI) and its correlates in young adult survivors of childhood cancer.
Methods
6,425 survivors and 360 siblings completed a comprehensive health survey, inclusive of a modified version of the Posttraumatic Growth Inventory (PTGI) as a measure of PPI. Linear regression models were used to examine demographic, disease and treatment characteristics associated with PPI.
Results
Survivors were significantly more likely than siblings to report PPI. Endorsement of PPI was significantly greater among female and non-white survivors, and among survivors exposed to at least one intense therapy, a second malignancy or cancer recurrence. Survivors diagnosed at older ages and fewer years since diagnosis were more likely to report PPI. Income, education and marital/relationship status appeared to have varied relationships to PPI depending upon the subscale being evaluated.
Conclusions
The existence and variability of PPI in survivors in this study suggest that individual characteristics, inclusive of race, gender, cancer type, intensity of treatment, age at diagnosis and time since diagnosis, have unique and specific associations with different aspects of perceived positive outcomes of childhood cancer.
doi:10.1002/pon.1959
PMCID: PMC3697081  PMID: 21425388
Psychosocial; childhood cancer; trauma; event centrality; survivors
2.  Psychological Outcomes of Siblings of Cancer Survivors: A Report from the Childhood Cancer Survivor Study 
Psycho-oncology  2010;20(12):1259-1268.
Objective
To identify risk factors for adverse psychological outcomes among adult siblings of long-term survivors of childhood cancer.
Methods
Cross-sectional, self-report data from 3,083 adult siblings (mean age 29 years, range 18-56 years) of 5+ year survivors of childhood cancer were analyzed to assess psychological outcomes as measured by the Brief Symptom Inventory-18 (BSI-18). Sociodemographic and health data, reported by both the siblings and their matched cancer survivors were explored as risk factors for adverse sibling psychological outcomes through multivariable logistic regression.
Results
Self-reported symptoms of psychological distress, as measured by the global severity index of the BSI-18, were reported by 3.8% of the sibling sample. Less than 1.5% of siblings reported elevated scores on two or more of the subscales of the BSI-18. Risk factors for sibling depression included having a survivor brother (OR 2.22, 95% CI 1.42-3.55), and having a survivor with impaired general health (OR 2.15, 95% CI 1.18-3.78). Siblings who were younger than the survivor reported increased global psychological distress (OR 1.81, 95% CI 1.05-3.12), as did siblings of survivors reporting global psychological distress (OR 2.32, 95% CI 1.08-4.59). Siblings of sarcoma survivors reported more somatization than did siblings of leukemia survivors (OR 2.07, 95% CI 1.05-3.98).
Conclusions
These findings suggest that siblings of long-term childhood cancer survivors are psychologically healthy in general. There are, however, small subgroups of siblings at risk for long-term psychological impairment who may benefit from preventive risk-reduction strategies during childhood while their sibling with cancer is undergoing treatment.
doi:10.1002/pon.1848
PMCID: PMC3223600  PMID: 22114043
4.  Prevalence and Predictors of Posttraumatic Stress Disorder in Adult Survivors of Childhood Cancer: a report from the Childhood Cancer Survivor Study 
Pediatrics  2010;125(5):e1124-e1134.
Objective
Recent studies have found that a subset of young adult survivors of childhood cancer report posttraumatic stress symptoms in response to their diagnosis and treatment. However, it is unclear if these symptoms are associated with impairment in daily functions and/or significant distress, thereby resulting in a clinical disorder. Furthermore, it is unknown whether this disorder continues into very long-term survivorship, including the 3rd and 4th decades of life. This study hypothesized that very long-term survivors of childhood cancer would be more likely to report symptoms of posttraumatic stress disorder, with functional impairment and/or clinical distress, compared to a group of healthy siblings.
Patients and Methods
6,542 childhood cancer survivors over the age of 18 who were diagnosed between 1970 and 1986 and 368 siblings of cancer survivors completed a comprehensive demographic and health survey.
Results
589 survivors (9%) and 8 siblings (2%) reported functional impairment and/or clinical distress in addition to the set of symptoms consistent with a full diagnosis of Posttraumatic Stress Disorder (PTSD). Survivors had more than a four-fold risk of PTSD compared to siblings (OR=4.14, 95%CI: 2.08-8.25). Controlling for demographic and treatment variables, increased risk of PTSD was associated with educational level of high school or less (OR=1.51, 95% CI=1.16-1.98), being unmarried (OR=1.99, 95% CI=1.58-2.50), annual income less than $20,000 (OR=1.63, 95% CI=1.21-2.20), and being unemployed (OR=2.01, 95% CI=1.62-2.51). Intensive treatment was also associated with increased risk of full PTSD (OR=1.36, 95% CI 1.06 -1.74).
Conclusions
Posttraumatic stress disorder is reported significantly more often by childhood cancer survivors than by sibling controls. Although most survivors are apparently doing well, a subset report significant impairment that may warrant targeted intervention.
doi:10.1542/peds.2009-2308
PMCID: PMC3098501  PMID: 20435702
childhood cancer; young adult
5.  Psychiatric Issues in Pediatric Organ Transplantation 
Synopsis
Solid organ transplantation has become the first line of treatment for a growing number of life-threatening pediatric illnesses. With improved survival, research into the long-term outcome of transplant recipients has become important to clinicians. Adherence to medical instructions remains a challenge, particularly in the adolescent population. New immunosuppressant approaches promise to expand organ transplantation in additional directions. Extension of transplantation into replacement of organs such as faces and hands raises complex ethical issues.
doi:10.1016/j.chc.2010.02.002
PMCID: PMC2873967  PMID: 20478500
child; adolescent; transplant; psychiatric
6.  The Knowledge, Attitudes and Usage of Complementary and Alternative Medicine of Medical Students 
The increasing use of CAM by patients has led to an increase in teaching about CAM in medical school in the US. In preparation for initiation of a new curriculum in Integrative Medicine at the David Geffen School of Medicine at UCLA a cross sectional survey was used to assess medical students': (i) familiarity, (ii) opinions, (iii) personal use and (iv) willingness to recommend specific CAM modalities, using a five point Likert scale of an established measure. A total of 263 first, second and third year medical students at UCLA completed surveys. Third year students reported less personal use of CAM and less favorable attitudes towards CAM than first year students. Since this was a cross-sectional rather than longitudinal study this may be a cohort effect. However, it may reflect the increased curricular emphasis on evidenced-based medicine, and subsequent student dependence on randomized clinical trials to influence and guide practice. This will need to be addressed in curricular efforts to incorporate Integrative Medicine.
doi:10.1093/ecam/nen075
PMCID: PMC3137293  PMID: 19073778
7.  A Framework for Developing, Implementing, and Evaluating a Cancer Survivorship Curriculum for Medical Students 
Journal of General Internal Medicine  2009;24(Suppl 2):491-494.
ABSTRACT
BACKGROUND
Cancer survivorship care is not adequately addressed in current medical school curricula.
OBJECTIVES
To develop, implement, and evaluate a modular cancer survivorship curriculum that is portable to other educational settings and is designed to provide medical students with a foundation of knowledge, attitudes, and skills related to care for cancer survivors.
PROGRAM DESCRIPTION
An expert consensus panel developed a set of learning objectives related to cancer survivorship to guide the development of educational modules, such as computer-based self-instructional modules, problem-based learning cases, videos, and clinical exercises. Course and clerkship chairs were directly involved in the development and implementation of the modules.
EVALUATION
A cohort study with a historical control group demonstrated that fourth-year medical students increased their knowledge in survivorship issues and their self-reported level of comfort in care activities compared to similar students who did not receive the survivorship curriculum.
CONCLUSIONS
Our framework resulted in a cancer survivorship curriculum that was implemented in a modular manner across the medical curriculum that improved learning and that is potentially portable to other educational settings.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-009-1024-7) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-009-1024-7
PMCID: PMC2763154  PMID: 19838856
cancer survivorship; medical education
8.  Preparedness for Caring of Cancer Survivors: a Multi-Institutional Study of Medical Students and Oncology Fellows 
Background
Despite recent advances in cancer survivorship knowledge and care, most medical schools lack a comprehensive survivorship curriculum, potentially leaving students ill-prepared for caring of survivors.
Methods
A total of 211 students and 22 oncology fellows in three institutions completed a questionnaire assessing knowledge and experience in survivorship care.
Results
Medical students and oncology fellows lack knowledge in key survivorship issues. Students were exposed to cancer survivors frequently in medical school but only half received instruction or practiced critical components of survivorship care.
Conclusions
Improvement of both undergraduate and postgraduate training in survivorship care is urgently warranted.
doi:10.1080/08858190802665260
PMCID: PMC2755519  PMID: 19259862
9.  ALLOSTATIC LOAD IN WOMEN WITH AND WITHOUT PTSD SYMPTOMS 
Psychiatry  2006;69(3):191-203.
Allostatic load (AL) is the term used to describe cumulative physiological wear and tear that results from repeated efforts to adapt to stressors over time. Operationalized as a composite index of biological risk factors (e.g., blood pressure, cholesterol, glycosylated hemoglobin, and cortisol, norepinephrine and epinephrine), AL has been shown to increase with age, predict long-term morbidity and mortality among the elderly, and be associated with low parent education in a large adolescent sample. However, AL has not yet been studied in samples with putative “high stress” or posttraumatic stress disorder (PTSD). Accordingly, AL was measured in women with high acute and chronic stress: mothers of pediatric cancer survivors with and without PTSD and control mothers of health children. AL emerged in a “dose-dependent” ranking from high to low: cancer mothers meeting all criteria for PTSD, cancer mothers with no or low symptoms, and control mothers, respectively (p < .001). Effects were not altered by self-reported sleep quality or substance use (tobacco, caffeine, alcohol or drugs) and remained significant when analyzing AL without cortisol or catecholamines. Results indicate elevated AL can be detected in relatively young women with high stress histories, and particularly those with PTSD. Future prospective studies must evaluate whether this pattern represents an accelerated aging process and increased risk of disease.
doi:10.1521/psyc.2006.69.3.191
PMCID: PMC1615715  PMID: 17040172
Allostatic Load; Stress; Posttraumatic Stress Disorder
10.  Preliminary evidence for lymphocyte distribution differences at rest and after acute psychological stress in PTSD-symptomatic women☆ 
Brain, behavior, and immunity  2005;19(3):243-251.
This study investigated circulating natural killer (NK), CD4+ and CD8+ cells in response to acute psychological challenge among mothers of child cancer survivors with and without posttraumatic stress symptoms (PTSS). Control mothers of healthy children (n = 9) were compared to 17 cancer mothers with (PTSS: n = 9) and without PTSS (No PTSS: n = 7) under conditions of rest, after a generic stressor (MAT: mental arithmetic task) and a personalized stressor (script-driven trauma imagery), and after recovery from each stressor. Results indicate the PTSS group had higher percentage CD4+ and lower CD8+ levels than non-symptomatic women and blunted NK reactivity to generic challenge. Multiple regression analyses indicated PTSS effects were independent of self-reported distress. Contrary to expectations, cancer mothers without PTSS were not significantly different from controls on tonic or phasic immune outcomes. Also unlike predictions, reactivity to challenge was greatest to the non-social MAT stressor compared to the personalized challenge for all groups. Conclusions are constrained by study limitations (e.g., small sample size and potential phase order effects). Nonetheless, results are consistent with an emerging literature on PTSS-associated immune differences and further suggest these effects may be distinct from that associated with subjective distress more generally.
doi:10.1016/j.bbi.2004.08.002
PMCID: PMC1351002  PMID: 15797313
Posttraumatic stress disorder; Stress; Women; Laboratory challenge; Natural killer
11.  Laughter, Humor and Pain Perception in Children: A Pilot Study 
Although there are many clinical programs designed to bring humor into pediatric hospitals, there has been very little research with children or adolescents concerning the specific utility of humor for children undergoing stressful or painful procedures. Rx Laughter™, a non-profit organization interested in the use of humor for healing, collaborated with UCLA to collect preliminary data on a sample of 18 children aged 7–16 years. Participants watched humorous video-tapes before, during and after a standardized pain task that involved placing a hand in cold water. Pain appraisal (ratings of pain severity) and pain tolerance (submersion time) were recorded and examined in relation to humor indicators (number of laughs/smiles during each video and child ratings of how funny the video was). Whereas humor indicators were not significantly associated with pain appraisal or tolerance, the group demonstrated significantly greater pain tolerance while viewing funny videos than when viewing the videos immediately before or after the cold-water task. The results suggest that humorous distraction is useful to help children and adolescents tolerate painful procedures. Further study is indicated to explore the specific mechanism of this benefit.
doi:10.1093/ecam/nem097
PMCID: PMC2686629  PMID: 18955244
children; distraction; laughter; pain
12.  “What do we tell the children?” 
Western Journal of Medicine  2001;174(3):187-191.
PMCID: PMC1071311  PMID: 11238354
13.  Psychiatric Sequelae in Adolescent Bone Marrow Transplantation Survivors  
Survivors of life-threatening pediatric illness and their families present a number of psychotherapeutic challenges. The authors present pilot data evaluating the long-term psychiatric impact of pediatric bone marrow transplantation on 10 adolescent transplantation survivors compared with a matched control group. On a quantitative assessment of posttraumatic stress symptoms, the survivors reported a consistent but low level of symptoms. Their narratives about the experience suggest the need for ongoing mental health assessment in addition to specific interventions with families early in the treatment.
PMCID: PMC3330387  PMID: 22700211

Results 1-13 (13)