RESUMEN
This study assessed long-term psychosocial sequelae of young adult pediatric burn survivors. Subjects were 101 young adults (43 females and 58 males) between the ages of 18 and 28 years who were at least 2 years (average, 14 years) postburn at least 30% TBSA (mean = 54 +/- 20%). Educational status was 25% high school dropouts, 28% high school graduation only, 32% some college, and 5% completed college. Seventy-seven percent either worked or attended school; 28% had had a long-term partner. When assessed by Achenbach's Young Adult Self-Report (YASR) scale and compared with its published reference group, the males reported differences only in the somatic complaints, but the females endorsed significantly more externalizing and total problems, specifically withdrawn behaviors, somatic complaints, thought problems, aggressive behavior, and delinquent behavior. Despite these problems suffered by some female pediatric burn survivors, the overall outcome revealed that most pediatric burn survivors are making the transition into adulthood with minimal unexpected difficulty.
Asunto(s)
Adaptación Psicológica , Trastornos de Adaptación/epidemiología , Quemaduras/psicología , Adulto , Conducta , Superficie Corporal , Quemaduras/complicaciones , Estudios de Casos y Controles , Niño , Evaluación de la Discapacidad , Empleo , Femenino , Estudios de Seguimiento , Humanos , Masculino , Factores Socioeconómicos , Factores de TiempoRESUMEN
Anxiety is an affective response commonly experienced by persons after emotional and physical trauma, as well as associated with aversive medical treatments. The scientific information related to the conceptualization, assessment, and treatment of anxiety is limited. In order to develop a pilot protocol for anxiety management, nursing directors at 64 burn centers were surveyed. At 89% of the centers, anxiety measures were not used. Most of the teams assess informally through observation of patient (n=21), dialogue with patient (n=12), or both observation and dialogue with patient (n=15). Assessors of anxiety range in breadth from nurse only to the entire burn team, including pastoral care representatives and family. The class of medication most frequently endorsed in treating anxiety is the benzodiazipine, most often lorazepam (Ativan). A number of non-pharmacologic techniques are used to manage anxiety, e.g., muscle relaxation, breathing, imagery. Consideration should be given to assessing anxiety systematically, so knowledge can be gleaned and applied to conceptualization of symptom presentation and application of treatment resources.
Asunto(s)
Ansiedad/diagnóstico , Ansiedad/terapia , Quemaduras/psicología , Adulto , Ansiedad/etiología , Niño , Humanos , Pautas de la Práctica en Medicina , Encuestas y CuestionariosRESUMEN
Advances in medical management have dramatically decreased the mortality of children with massive burn injuries, which raises many questions about the expected quality of life for these young survivors. In this article, we address this issue by examining the functional and psychological adaptation of 41 young survivors with 88% mean total body surface area (TBSA) burns and 85% mean third degree TBSA burns. Patient scores were compared with normative data on standardized psychological measures of adjustment and on performance of age appropriate activities of daily living (ADL) skills. Thirty-three of the 41 patients (80%) were independent in basic ADL skills. Eighty-six percent of the patients who were aged 10 years and older were independent in advanced ADL skills. Patients with amputated fingers were significantly more dependent in ADL skills than those without amputations (P < .05). Mean psychosocial adjustment scores were within normal limits and were not significantly related to functional independence in ADL skills.
Asunto(s)
Actividades Cotidianas , Adaptación Psicológica , Quemaduras/rehabilitación , Niños con Discapacidad/psicología , Calidad de Vida , Amputación Quirúrgica , Quemaduras/psicología , Niño , Preescolar , Femenino , Dedos , Estudios de Seguimiento , Humanos , Lactante , Recién Nacido , Masculino , Salud Mental , Índice de Severidad de la EnfermedadRESUMEN
Very little information has been published about 2- and 3-year-old children who have experienced major burns. This study used a standardized instrument to measure the behavioral adjustment of these young burn survivors, and the results were compared with those of a nonclinical normative sample. Thirty-three pediatric burn survivors with 50%+/-28% total body surface area burns were evaluated 1.2+/-0.7 years postburn. Parental observations were assessed with the use of the Child Behavior Checklist for 2- and 3-Year-Olds, a 99-item standardized checklist designed to identify behavior problems. Forty of the questions are specific to 2- and 3-year-olds, and the scores of male and female children are not differentiated. The raw scores of the children with burns were statistically compared with the reported normative sample for this version of the Child Behavior Checklist. Pediatric burn survivors in this sample exhibited significantly more internalizing behaviors than the children in the normative group. Parents reported children who had been burned to be more depressed and to have more somatic complaints and sleep problems. Determining the relationship of behavior problems to posttrauma sequelae and preburn environmental factors would assist with the establishment of appropriate psychosocial interventions.
Asunto(s)
Adaptación Psicológica , Quemaduras/psicología , Calidad de Vida , Sobrevivientes/psicología , Adolescente , Adulto , Distribución por Edad , Estudios de Casos y Controles , Preescolar , Estudios de Evaluación como Asunto , Femenino , Estudios de Seguimiento , Humanos , Puntaje de Gravedad del Traumatismo , Estudios Longitudinales , Masculino , Distribución por Sexo , Encuestas y CuestionariosRESUMEN
Although children with burn scars are reported to have positive self-concepts, social and sexual maturation can be expected to stimulate anxiety, depression and diminished self-esteem in adolescents with disfiguring scars. This study examines complex self-regard of adolescents with burn scars. The following were hypothesized: (1) adolescents with disfiguring burn scars would view themselves as less competent than unburned normative samples; (2) subjects' perceived competence would be incongruent with the importance ascribed to the domains of physical appearance and athletic competence and (3) depression/anxiety would correlate negatively with perceived competence. Subjects were 14 adolescents: 6 male and 8 female, 13-20 years old, at least 2 years post-burn injury (TBSA = 39% +/- 23%). All had scars in at least 2 of the following areas: head/face, neck, chest, hands, genitals. Each subject was administered the Harter Self Perception Profile, a standardized measure of self-competence and value in 8 domains plus a general competence measure. The subjects were also assessed for anxiety/depression by the Child Behavioral Checklist. Overall, adolescents in this sample exhibited a similar or higher degree of self-worth as compared to their peers. However, the athletic competence and physical appearance sub-domains of self-worth for the burn survivors were significantly lower as compared to the normative group. Half of the participants rated the importance of physical appearance to be higher than their level of personal competence in this area, making for distressing emotions. Mood was similar to the normative group and mood correlated significantly with self-worth.
Asunto(s)
Quemaduras/complicaciones , Cicatriz Hipertrófica/psicología , Psicología del Adolescente , Autoimagen , Adolescente , Adulto , Quemaduras/psicología , Cicatriz Hipertrófica/etiología , Estética , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Pruebas Psicológicas , Valores de Referencia , Sensibilidad y EspecificidadRESUMEN
OBJECTIVE: Pediatric burn patients often exhibit acute stress disorder (ASD) symptoms. Information on psychopharmacological treatment of ASD symptoms in children is scarce. This pilot study used a prospective, randomized, double-blind design to test whether thermally injured children suffering ASD symptoms benefit from imipramine. METHOD: Twenty-five children, aged 2 to 19 years, received either imipramine or chloral hydrate for 7 days. A structured interview (clinically useful, but validity and reliability not yet established) was used to assess the presence and frequency of ASD symptoms both before treatment and 3 times during the treatment period. RESULTS: Eleven females and 14 males participated, with a mean total burn surface area of 45% (SD = 23%) and mean age of 8 years (SD = 6). Imipramine was more effective than chloral hydrate in treating ASD symptoms (chi 2 [1, N = 25] = 5.24, p < .02). Five of 13 were positive responders to chloral hydrate (38%). Ten of 12 were positive responders to low-dose imipramine (83%). CONCLUSIONS: This pilot study suggests a place for cautious initial use of imipramine to reduce ASD symptoms in burned children. Care must be taken to minimize cardiovascular risks in an off-label application of imipramine in children, especially those receiving additional medications.
Asunto(s)
Quemaduras/complicaciones , Imipramina/uso terapéutico , Trastornos por Estrés Postraumático/tratamiento farmacológico , Trastornos por Estrés Postraumático/etiología , Enfermedad Aguda , Adolescente , Adulto , Unidades de Quemados/estadística & datos numéricos , Distribución de Chi-Cuadrado , Niño , Preescolar , Hidrato de Cloral/uso terapéutico , Femenino , Humanos , Masculino , Proyectos Piloto , Placebos , TexasRESUMEN
A convergent postburn psychopharmacologic treatment for children for acute stress disorder (ASD) symptoms has not been established. Both the application of what has been learned through treatment of similar symptoms experienced by adults with posttraumatic stress disorder and the examination of safe treatment options for children led to the clinical decision to use imipramine for 25 pediatric patients with acute burns. The treatment histories of these patients were retrospectively reviewed to see if further exploration into the efficacy of imipramine was warranted. Eighty percent of the children experienced remission of hyperarousal symptoms (eg, trouble staying asleep, trouble falling asleep) and intrusive reexperiencing symptoms (eg, nightmares). Twelve percent of the children experienced a decrease in the frequency or intensity of ASD symptoms. Eight percent had no relief of ASD symptoms. Initial findings suggest that imipramine assists children who have postburn ASD symptoms by decreasing the hyperarousal and intrusive reexperiencing symptoms of ASD.
Asunto(s)
Antidepresivos Tricíclicos/uso terapéutico , Quemaduras/psicología , Imipramina/uso terapéutico , Trastornos por Estrés Postraumático/tratamiento farmacológico , Adulto , Niño , Femenino , Humanos , Masculino , Estudios Retrospectivos , Trastornos por Estrés Postraumático/diagnóstico , Trastornos por Estrés Postraumático/etiología , Factores de TiempoRESUMEN
It is popularly believed that disfiguring scars compromise the burned adolescent's ability to establish satisfactory dating relationships and to develop positive identities as sexually attractive people. The purpose of this study was to test that belief by obtaining information about the sexual behaviors and beliefs of adolescents who have disfiguring scars. Nineteen adolescents, ages 13 to 20 and at least 1 year postburn, completed a sexuality survey entitled What Young People Believe and Do--Revised. When compared with the available information, adolescents with disfiguring burn scars appear to have thoughts, feelings, and behaviors that are similar to those of nonburned adolescents. The severity of disfigurement as measured by numbers of affected body areas does not seem to be related to the sexual behaviors of the teenagers in this sample.
Asunto(s)
Conducta del Adolescente , Quemaduras/psicología , Cicatriz/psicología , Conducta Sexual , Sexualidad , Adolescente , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , MasculinoRESUMEN
The purpose of this study was to examine the relationship between psychosocial adjustment of the burned child and characteristics of the child's family. It hypothesized that parents who perceived their children without major behavioural problems would possess supportive family values and would, themselves, be better adjusted psychologically than those parents who perceived their children as possessing multiple behavioural problems. A stratified random sampling technique was used to select 35 (29 boys, 6 girls) paediatric burn survivors, ages 9 to 18, 1-5 years post-burn, with burn sizes ranging from 3 to 92% burn. Subjects' parents were administered the Child Behaviour Checklist (CBCL), the Family Environment Scale (FES), the Impact of Events Scale (IES), and the Beck Depression Inventory (BDI). The subjects were divided into two groups on the basis of the total problem CBCL scores. i.e. troubled (T > or = 60) or untroubled (T<60). One-way ANOVA tests revealed no significant differences between the two groups in the way parents reacted to trauma (IES) and parental depression (BDI). Significant differences (p<0.01) were revealed between the two groups on FES subscales. The parents of the untroubled group scored higher on 'Cohesion' and 'Organization' and lower on 'Conflict'. These parents also scored higher (p< or =0.05) on 'Achievement Orientation'. The results indicate that work with the family to promote cohesion. to decrease conflict, to enhance stability and to promote expectation of positive achievement must he a part of the rehabilitation of the burned child.
Asunto(s)
Adaptación Psicológica , Quemaduras/psicología , Padres/psicología , Adolescente , Adulto , Análisis de Varianza , Quemaduras/rehabilitación , Niño , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Relaciones Padres-Hijo , Escalas de Valoración Psiquiátrica , Psicología , Calidad de Vida , Ajuste Social , Apoyo Social , Sobrevivientes/psicologíaRESUMEN
OBJECTIVE: To examine the psychosocial adjustment of survivors of massive pediatric burn injuries, the change in adjustment across time, and the impact on parents. BACKGROUND: Patients/parents were assessed at regular intervals postburn using standardized tests of adjustment. Patients who could not be included in standardized longitudinal assessments were administered questionnaires by mail/telephone. METHODS: The Child Behavior Checklist, the Teacher Report Form, the Youth Self Report Form, and the Parenting Stress Index were utilized to assess adjustment. RESULTS: On all objective measures, the group of survivors and their parents were within normal limits. Adjustment neither improved nor deteriorated over time. CONCLUSION: Children who survive massive burn injuries can achieve positive psychosocial adaptation.
Asunto(s)
Adaptación Psicológica , Quemaduras/psicología , Psicología Infantil , Sobrevivientes/psicología , Actividades Cotidianas , Adolescente , Adulto , Superficie Corporal , Quemaduras/patología , Niño , Conducta Infantil , Preescolar , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Estudios Longitudinales , Masculino , Padres/psicología , Estrés Psicológico/psicología , Encuestas y Cuestionarios , Factores de TiempoRESUMEN
Children with spina bifida, cerebral palsy, mental retardation, developmental delays, and seizure states are handicapped with sensorimotor deficits, including gait or coordination instability, temperature insensitivity, and mental simplicity. These handicaps make this distinct and unpretentious population more susceptible to lethal burns. A 30-year review was conducted in a pediatric burn center to examine the relationships between pediatric sensorimotor deficit and burn injury. Of the 4874 acute burn admissions, 66 children were identified with preexisting sensorimotor deficits. Data indicate that children with sensorimotor deficit are more prone to burn injury from both their physical impairment and poorly supervised environments. In addition to extended hospitalizations, these children bear significantly higher mortality risks. Had the special supervisions and protection required by such handicapped children been provided, 80% of the burn injuries could have been prevented. Results emphasize that the future of these special children with sensorimotor deficits relies on health care providers playing a greater role in educating parents and caregivers.
Asunto(s)
Quemaduras/epidemiología , Niños con Discapacidad , Desempeño Psicomotor , Quemaduras/etiología , Cuidadores , Parálisis Cerebral , Niño , Discapacidades del Desarrollo , Femenino , Humanos , Discapacidad Intelectual , Masculino , Mortalidad , Estudios Retrospectivos , Factores de Riesgo , Convulsiones , Disrafia EspinalRESUMEN
Statements by caregivers can be beneficial to paediatric burn patients, facilitating their psychological adaptation. However, the concerns of the burned child are not always obvious, and caregivers may flounder, not knowing how to elicit the concerns of the patient. The purpose of this paper is to examine whether universal concerns of the postburn survivor can be detected through one type of psychological assessment tool, a sentence completion task. Sixty paediatric burn survivors, ages 6-19, were administered a 30-item Incomplete Sentences measure. Five major aspects of postburn life were identified and proscribed the following descriptive labels: (1) preoccupation with health; (2) the struggle for internal acceptance; (3) reconstruction of one's life map; (4) changing relationships; and (5) redefining the world. These five dimensions of postburn life are discussed, as well as applications for each.
Asunto(s)
Adaptación Psicológica , Actitud Frente a la Salud , Quemaduras/psicología , Sobrevivientes/psicología , Adolescente , Adulto , Quemaduras/terapia , Niño , Estudios de Seguimiento , Humanos , Calidad de Vida , Ajuste Social , Encuestas y CuestionariosRESUMEN
This retrospective review evaluated the pain management of 395 acutely burned pediatric patients who were treated by a pain management protocol emphasizing acetaminophen as the initial medication to control background pain. Pain was assessed by using standardized instruments based on observations by patients, nurses, and parents. Morphine was added when scheduled acetaminophen (10-15 mg/kg/4 hr) did not control background pain. Fifty percent of the children received only acetaminophen to control background pain. Younger children and children with the smallest burns, regardless of age, were likely to be managed with acetaminophen alone. Most peak serum concentrations of acetaminophen were less than 10 micrograms/mL. When needed, children also received medication for painful procedures, anxiety, and posttraumatic stress symptoms. These additional medications were not more frequently given to children receiving only acetaminophen for background pain. These data suggest that acetaminophen is a safe, useful medication for the control of post-burn background pain in some children.
Asunto(s)
Acetaminofén/uso terapéutico , Analgésicos no Narcóticos/uso terapéutico , Quemaduras/complicaciones , Dolor/tratamiento farmacológico , Niño , Preescolar , Humanos , Dolor/etiología , Estudios RetrospectivosRESUMEN
Children who survive massive burn injuries are challenged by the physical sequelae of their injuries as they return to normal daily routines. The purpose of this study was to assess the impact of physical impairment on the competence of such children as they pursued their lives. It was hypothesized that children who survive burn injuries of more than 80% total body surface area would be less competent than their unburned peers, and that competence would decrease with increased physical impairment. Competence for the 19 patients was assessed by parental report using the Child Behavior Checklist and by the patient's self-report on the Youth Self-Report. Physical impairment scores were calculated from range of motion measurements of upper and lower extremities according to AMA guidelines. Competence scores for the sample were within normal ranges. Physical impairment was significantly related to competence only in the area of activity on both the Child Behavior Checklist and the Youth Self-Report.
Asunto(s)
Actividades Cotidianas , Quemaduras/complicaciones , Quemaduras/rehabilitación , Adolescente , Distribución por Edad , Quemaduras/patología , Niño , Preescolar , Estudios de Evaluación como Asunto , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Calidad de Vida , Rango del Movimiento Articular , Reproducibilidad de los Resultados , Autoevaluación (Psicología) , Distribución por SexoRESUMEN
Pediatric burn survivors are reported to present optimistic pictures of themselves; it has been suggested that their reports of high self-esteem may reflects a coping mechanism. The purpose of this study was to compare burned children's self-perceptions of competence and adequacy to normative population with the use of two standardized instruments. A random sample of 32 pediatric burn survivors was administered two standardized instruments: the Piers-Harris and the Harter Self-Perception Profiles for children and adolescents. Paired t tests revealed significantly higher self-concepts by the burned children than the nonclinical reference groups on five of the six Piers-Harris clusters and on two of the nine Harter Self-Perception Profiles domains. Also, the relationship between the children's perceived self-worth in each domain, and the importance they attributed to that domain, indicate that the burned children are satisfied with themselves in those areas they perceive as important. Results from both tests suggest that the burn survivors' report of positive self-esteem may reflect a necessary defense mechanism in the adjustment process, which should be supported by the burn team.
Asunto(s)
Adaptación Psicológica , Quemaduras , Sobrevivientes/psicología , Adolescente , Niño , Femenino , Humanos , Masculino , Valores de Referencia , Muestreo , AutoimagenRESUMEN
Life for pediatric survivors of burns appears difficult to most observers. In an assessment by use of the Child Behavior Checklist (CBCL), survivors' parents reported that approximately 30% of the children had significant problems. The Vineland Adaptive Behavior Scales were used to gather further information concerning the children's personal and social sufficiency and functioning. Thirty-four pediatric burn survivors (28 boys and 6 girls, ages 9 to 19, 1 to 5 years after burn, with burn sizes ranging from 3% to 92% total body surface area) were selected by use of a stratified random sampling technique. Ten of the 14 scales are significantly different (p < 0.05, paired t) from the reference population in the Vineland manual. The Vineland scores indicate that parents view their burned children as being less personally or socially sufficient. Subjects with significant behavior problems as measured by use of the CBCL (T score > or = 60) differed from their peers with fewer problems by having less overall adaptive behavior (p = 0.07), fewer coping skills (p = 0.06), and significantly more maladaptive behavior (p = 0.005). The Vineland adaptive behavior domains correlated positively with the CBCL total competence scores, whereas the Vineland maladaptive behavior correlated positively with the CBCL total behavior score. Although it supports previous findings that parents of burned children see them as having problems after burn, this study elaborates on and differentiates among their difficulties in adapting to their life situations. These findings not only affirm the importance of attending to parental perceptions of burned children but also identify specific areas to be targeted for psychosocial rehabilitation of burned children.
Asunto(s)
Adaptación Psicológica , Quemaduras/psicología , Rol del Enfermo , Ajuste Social , Actividades Cotidianas/psicología , Adolescente , Quemaduras/rehabilitación , Niño , Trastornos de la Conducta Infantil/psicología , Comunicación , Femenino , Humanos , Masculino , Grupo Paritario , Determinación de la Personalidad , SocializaciónRESUMEN
Health care providers usually except children with severe burns to have psychosocial problems due to the severity of the injuries and resulting deformities. To test the validity of that expectation, 72 children (43 boys, 29 girls) who had suffered severe burns were assessed at least 1 year after burn injury for behavior problems and competence, by use of the 1991 Achenbach questionnaires: Child Behavior Checklist (CBCL), Youth Self-Report, and Teacher Report Form. The scores on each questionnaire then were compared by use of paired t tests. Also, the scores of the patient population were compared with those of the nonreferred reference populations provided by Achenbach. Compared with the Teacher Report Form and Youth Self-Report, the CBCL revealed a statistically significant (p < 0.05) greater number of behavior problems and lower level of competence for all age groups and both sexes. Item analysis revealed in most instances excess endorsement of specific items on all scales for the patient population compared with their respective reference populations, but more items were endorsed on the CBCL. These results could be explained by increased parental sensitivity to problem behavior or decreased competence of their children after severe burns. Further studies are needed to understand the discrepancies between the CBCL and the other scales.
Asunto(s)
Adaptación Psicológica , Quemaduras/psicología , Determinación de la Personalidad/estadística & datos numéricos , Rol del Enfermo , Adolescente , Imagen Corporal , Quemaduras/rehabilitación , Niño , Trastornos de la Conducta Infantil/diagnóstico , Trastornos de la Conducta Infantil/psicología , Preescolar , Femenino , Humanos , Control Interno-Externo , Masculino , Ajuste SocialRESUMEN
Evaluation of school reentry programs are rarely reported, and statements of the value of reentry programs are usually based on anecdotal information. No known reports of empiric data support claims of positive benefit for burned children. This article reports a multifaceted effort to evaluate the effectiveness of one reentry program involving three approaches: (1) questionnaire answered by the school contact person after reentry program, (2) interviews with a random sample of patients (n = 58) and parents (n = 44) 1 to 5 years after burn, and (3) assessment of patients' behavior problems by teachers on a standardized behavior checklist comparing 10 patients who had a school reentry program involving videos to introduce them to their classmates with 10 patients who were matched for age, sex, and total body surface area burned and had no reentry program beyond phone contact. Results indicate that school reentry programs are popular with teachers and parents. This pilot effort involving empiric data failed to demonstrate a positive effect on the adjustment of the child.
Asunto(s)
Adaptación Psicológica , Quemaduras , Estudiantes/psicología , Quemaduras/psicología , Quemaduras/rehabilitación , Niño , Preescolar , Estudios de Evaluación como Asunto , Femenino , Humanos , Masculino , Instituciones Académicas , Ajuste Social , Apoyo Social , Encuestas y CuestionariosRESUMEN
School reintegration programs have been developed to enhance a positive sense of self-worth in a child who has been burned. The premise of these programs is that cognitive and affective education about children with burns will diminish the anxiety of the patient with burns, the patient's family, faculty and staff of the school, and the students. Five principles guide school reentry programs: (1) preparation begins as soon as possible; (2) planning includes the patient and family; (3) each program is individualized; (4) each patient is encouraged to return to school quickly after hospital discharge; and (5) burn team professionals remain available for consultation to the school. Reintegration programs can vary in format depending on patient and/or family need and capability of the burn team, thus allowing flexibility in assisting every child with burns make the transition from hospital patient to normal living.
Asunto(s)
Quemaduras/psicología , Instituciones Académicas , Niño , Consejo , Humanos , Relaciones Interpersonales , Psicología InfantilRESUMEN
The incidence of psychologic problems in 12 children and adolescents with severe burns was examined through four similar scales on the Children's Behavior Checklist and the Rorschach. No correlations were found for any of the pairs, which were Withdrawn-Isolation Index, Somatic Complaints-Anatomy + X-ray, Anxious/Depressed-Depression Index, and Thought Disorder-Schizophrenic Index. Discrepancies were explained as both accurate reflections of patients' personalities and function of the type of assessment instrument used to determine psychologic problems. Although the statistical power of the study is limited by the small sample size, the results suggest the lack of good objective psychologic assessment tools available to this population and the need for experienced professionals to interpret test results in light of their personal knowledge of the patient.