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1.  Relations between Posttraumatic Stress and Posttraumatic Growth in Long-Term Survivors of Childhood Cancer: A Report from the Childhood Cancer Survivor Study 
Contemporary models of trauma suggest that posttraumatic stress and growth should be related, and that symptoms of stress resulting from a perceived trauma (e.g. childhood cancer) are prerequisite for posttraumatic growth to occur. However, empirical data regarding the relationship of posttraumatic stress and growth have been equivocal. The purpose of this study is to examine the relationship between posttraumatic stress symptoms (PTSS) and posttraumatic growth (PTG) among adult survivors of childhood cancer.
Survey methods were utilized to collect data from 6162 survivors participating in the Childhood Cancer Survivor Study (CCSS). Non-parametric correlation was examined pair-wise between PTG and PTSS using Spearman’s correlation coefficient with 95% confidence intervals, with non-linear canonical correlation analysis being conducted to examine relationships between subscales. A multivariable partial proportional odds model was also fit for PTG Total quartiles focusing on associations with PTSS Total quartiles while adjusting for sociodemographic and medical variables.
Examination of unadjusted PTSS and PTG total scores revealed a Spearman correlation of 0.11 (p<0.001), with coefficients ranging from 0.03 to 0.17 between total and subscale scores. The non-linear canonical correlation analyses resulted in two Dimensions with Eigenvalues of 0.15 and 0.14, resulting in a fit value of 0.30 and evidence that little variability in the data (15%) was explained by the weighted combinations of the variables.
Although statistically significant, these results do not indicate a robust relationship between PTSS and PTG among adult survivors of childhood cancer. Theories suggesting that PTSS is a prerequisite for PTG should be reconsidered.
PMCID: PMC4158696  PMID: 24799000
3.  Relationship between medical student perceptions of mistreatment and mistreatment sensitivity 
Medical teacher  2012;35(3):e998-1002.
National statistics reveal that efforts to reduce medical student mistreatment have been largely ineffective. Some hypothesize that as supervisors gain skills in professionalism, medical students become more sensitive.
The purpose of this study was to determine if medical student perceptions of mistreatment are correlated with mistreatment sensitivity.
At the end of their third year, 175 medical students completed an Abuse Sensitivity Questionnaire, focused on student assessment of hypothetical scenarios which might be perceived as abusive, and the annual Well-Being Survey, which includes measurement of incident rates of mistreatment. It was hypothesized that those students who identified the scenarios as abusive would also be more likely to perceive that they had been mistreated.
Student perceptions of mistreatment were not statistically correlated with individual’s responses to the scenarios or to a statistically derived abuse sensitivity variable. There were no differences in abuse sensitivity by student age or ethnicity. Women were more likely than men to consider it “harsh” to be called incompetent during rounds (p <0.0005).
This study provides preliminary evidence that challenges the hypothesis that medical students who perceive mistreatment by their superiors are simply more sensitive.
PMCID: PMC4399964  PMID: 23102103
4.  Integrating Case Topics in Medical School Curriculum to Enhance Multiple Skill Learning: Using Fetal Alcohol Spectrum Disorders as an Exemplary Case 
This article describes the use of fetal alcohol spectrum disorders (FASDs) as a theme to connect the learning of basic neurosciences with clinical applications across the age span within a systems-based, integrated curricular structure that emphasizes problem-based learning.
In collaboration with the Centers for Disease Control and Prevention (CDC) and the National Organization on Fetal Alcohol Syndrome, the Western Regional Training Center for Fetal Alcohol Exposure at UCLA developed and integrated educational materials on FASDs into the curriculum for first-year medical students.
Quantitative and qualitative evaluations suggested materials were effective in enhancing student knowledge and skills related to FASDs, as well as embryology, brain development, substance abuse, developmental psychopathology, and medical ethics.
The use of a unifying theme integrating basic science and clinical information and skills is effective for medical student training in the prevention and treatment of common medical problems.
PMCID: PMC4380512  PMID: 19398629
5.  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.
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.
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).
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.
PMCID: PMC3098501  PMID: 20435702
childhood cancer; young adult
6.  Psychiatric Issues in Pediatric Organ Transplantation 
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.
PMCID: PMC2873967  PMID: 20478500
child; adolescent; transplant; psychiatric
8.  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.
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.
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.
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.
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.
PMCID: PMC3697081  PMID: 21425388
Psychosocial; childhood cancer; trauma; event centrality; survivors
9.  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.
PMCID: PMC1351002  PMID: 15797313
Posttraumatic stress disorder; Stress; Women; Laboratory challenge; Natural killer
10.  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 1-10 (10)