Understanding students' and clinicians' experiences of informal interprofessional workplace learning: an Australian qualitative study

OBJECTIVES

While postgraduate studies have begun to shed light on informal interprofessional workplace learning, studies with preregistration learners have typically focused on formal and structured work-based learning. The current study investigated preregistration students' informal interprofessional workplace learning by exploring students' and clinicians' experiences of interprofessional student-clinician (IPSC) interactions.

DESIGN

A qualitative interview study using narrative techniques was conducted.

SETTING

Student placements across multiple clinical sites in Victoria, Australia.

PARTICIPANTS

Through maximum variation sampling, 61 participants (38 students and 23 clinicians) were recruited from six professions (medicine, midwifery, nursing, occupational therapy, paramedicine and physiotherapy).

METHODS

We conducted 12 group and 10 individual semistructured interviews. Themes were identified through framework analysis, and the similarities and differences in subthemes by participant group were interrogated.

RESULTS

Six themes relating to four research questions were identified: (1) conceptualisations of IPSC interactions; (2) context for interaction experiences; (3) the nature of interaction experiences; (4) factors contributing to positive or negative interactions; (5) positive or negative consequences of interactions and (6) suggested improvements for IPSC interactions. Seven noteworthy differences in subthemes between students and clinicians and across the professions were identified.

CONCLUSIONS

Despite the results largely supporting previous postgraduate research, the findings illustrate greater breadth and depth of understandings, experiences and suggestions for preregistration education. Educators and students are encouraged to seek opportunities for informal interprofessional learning afforded by the workplace.

Assessment and management of radiotherapy induced toxicity in older patients

Radiotherapy is an attractive treatment option for older adults, especially where surgery and chemotherapy pose too great a risk. Radiotherapy toxicity may be divided into acute/early and late effects of treatment. The latter may have limited relevance to an older patient with competing causes of mortality due to significant comorbidity. Altered fractionation regimes have been employed in numerous sites, with no significant toxicity impact. These offer greater convenience in the elderly, especially those with limited social support or in active caregiving roles. As radiotherapy toxicity is site specific, it's important to assess baseline function via Comprehensive Geriatric Assessment (CGA), and any pre-existing comorbidities that may influence toxicity. With modern radiotherapy technology and capabilities, these are less of an issue and radiotherapy is a very suitable treatment option for the older adult. When evaluating the literature on toxicity in older patients, it's important to recognise that older studies do not represent modern day radiotherapy techniques and capabilities. Advanced technology may simultaneously deliver enhanced target coverage and reduced toxicity. More research is required related to the predictive power of CGA in linking radiotherapy toxicity to frailty. What little evidence exists shows that CGA has a role in treatment of older patients with radiotherapy and that, in general, radiotherapy appears to be well tolerated in older adults. The purpose of this review is to provide a broad overview of the mechanisms of normal tissue reactions to radiotherapy and how radiation induced toxicity may affect older patients.

Concentrations of calcium and 25-hydroxycholecalciferol (vitamin D3) in plasma of wild kākāpō (Strigops habroptilus) living on two islands in New Zealand

AIMS This preliminary study had the objectives of describing the concentrations of ionised calcium and 25-hydroxycholecalciferol (25(OH)D₃) in the blood of wild kākāpō (Strigops habroptilus) living on two islands in New Zealand, and to determine the effects of supplementary feeding on these blood parameters. METHODS Blood samples were obtained from 33 kākāpō living on two offshore islands during routine health checks in 2015. Birds on Hauturu were sampled in May (n=5) and birds on Whenua Hou were sampled in July (n=15) and November (n=26). Of the birds sampled on Whenua Hou in November, 15 received supplementary food prior to sampling. Samples were analysed for pH, and concentrations of ionised calcium, total calcium, phosphorous, total protein, albumin, globulin, uric acid and 25(OH)D₃. RESULTS Concentrations of ionised calcium did not differ between unsupplemented birds on the two islands, nor between supplemented (median 1.17 (95% CI=1.12-1.20) mmol/L) and unsupplemented (median 1.09 (95% CI=1.08-1.14) mmol/L) birds sampled in November on Whenua Hou (p>0.05), and were comparable with published normal ranges for other psittacines. Concentrations of 25(OH)D₃ did not differ between unsupplemented birds on the two islands (p>0.05), but were higher in supplemented (median 8.00 (95% CI=4.76-8.45) nmol/L) than unsupplemented (median 0.00 (95% CI=-0.16-0.48) nmol/L) birds on Whenua Hou (p<0.001). All values were much lower than published ranges for healthy psittacines. There was no difference between male and female birds on Whenua Hou for any parameter measured (p>0.05). CONCLUSIONS AND CLINICAL RELEVANCE The calcium status of the kākāpō in this study was comparable to other wild psittacines, however concentrations of 25(OH)D₃ were much lower. The concentrations of 25(OH)D₃ may be within the normal range for the species, however further data are required to confirm this. The significant increase in concentrations of 25(OH)D₃ in supplementary fed birds suggests that this food was providing more of the nutrient than the wild diet at that time of year, although the effects of this are unknown. Further investigation is required into the calcium and vitamin D₃ status of kākāpō, across a wider range of locations, seasons and ages. This would help define normal ranges for these parameters, allow interpretation in clinically abnormal individuals, and guide the refinement of supplementary foods. This information would, therefore, assist the future conservation management of this critically endangered species.

Metformin and improved treatment outcomes in radiation therapy - A review

BACKGROUND

Metformin, a primary treatment for diabetes mellitus (DM) patients, is associated with improved outcomes for diabetic cancer patients fuelling further investigation on its mechanisms of action. The radiosensitising properties of metformin are increasingly reported in pre-clinical studies. This review discusses whether metformin should be offered to radiotherapy (RT) cancer patients as a means to improve their treatment outcomes.

MATERIALS AND METHODS

A database search was conducted for articles published with metformin as the main intervention between 2010 and 2016. Three groups of RT cancer patients were analysed: diabetic patients using metformin, diabetic patients not using metformin and non-diabetic patients not using metformin. Data on survival and recurrence metrics were extracted.

RESULTS

Thirteen studies were included. Conflicting evidence exists with regards to the impact of metformin administration on recurrence and survival outcomes following radiotherapy. Three studies reported improved tumour response determined by recurrence rates while five studies did not observe differences or metformin use was not the associated reason. One study revealed inconsistent tumour response results. Metformin was reported as improving survival outcomes in 2 studies and not improving outcomes in 5 studies. 4 studies showed indefinite results.

CONCLUSION

Although metformin may improve tumour response in the non-randomized, retrospective studies analysed, it may not necessarily confer survival benefits. Future prospective and randomised trials are required to translate the positive impact of metformin documented in pre-clinical and retrospective studies into improve management of RT cancer patients.

Fibromyalgia remains a significant burden in rheumatoid arthritis patients in Australia

AIM

High rates of fibromyalgia (FM) are reported in rheumatoid arthritis (RA) patients. Advances in RA management have occurred, but information regarding current significance of FM in RA is limited. This investigation estimated the prevalence and health effects of concomitant FM in Australian RA patients.

METHODS

Participants were recruited from Australian rheumatology clinics. Subjects were assessed using the 1990 and 2011 American College of Rheumatology (ACR) FM criteria and the polysymptomatic distress score (PDS) was calculated. A medical history and a clinical examination were recorded. RA Disease Activity Score of 28 joints - erythrocyte sedimentation rate (DAS-28 ESR), and the Short Form-36 survey (SF-36) were completed.

RESULTS

Of 117 RA patients, 33.3% (n = 39) met 1990 ACR FM criteria and 41.9% (n = 49) met 2011 ACR FM criteria. RA patients with comorbid FM had worse outcomes across all domains of health as defined by the SF-36 (P < 0.05). There was correlation between both physical and mental health outcomes and the PDS (P < 0.001). RA patients with FM on average took 1.18 extra ongoing prescribed medications (P < 0.05), despite comparable RA disease activity (DAS-28: 3.09 vs. 3.27, P = NS). Comorbid central sensitivity conditions were more common in patients with FM (P < 0.001).

CONCLUSION

FM continues to demonstrate a high prevalence in a population of RA patients. RA patients with FM have more symptoms of other chronic sensitivity syndromes in addition to FM. They have a lower quality of life outcome and higher medication use. This has important clinical implications in terms of diagnosis, response to therapy, prescribing choices and clinical outcomes.

Dose Sparing Potential of Deep Inspiration Breath-hold Technique for Left Breast Cancer Radiotherapy Organs-at-risk

BACKGROUND/AIM

To assess if deep inspiration breath-hold (DIBH) technique achieved dose sparing for organs-at-risk in left breast radiotherapy patients in order to reduce long-term complications.

PATIENTS AND METHODS

DIBH and Free-breathing (FB) as a control, CT planning scans obtained for 28 left breast/chest wall (+/- supraclavicular field) patients treated January 2008-December 2013 were retrospectively re-contoured and re-planned. Organs-at-risk examined: lungs, left lung, heart and left anterior descending coronary artery (LADCA). Quantitative statistical analysis of plan dose differences was performed.

RESULTS

Lung dose was not affected by DIBH. Heart D_max reduced by 34.5% (FB=41.81Gy, SD=3.963Gy vs. DIBH=27.39Gy, SD=12.393Gy, p<0.000004). Heart D_mean reduced by 32.6% (FB=1.817Gy, SD=0.627Gy vs. DIBH=1.224Gy, SD=0.344Gy, p=0.00000083067. LADCA D_max reduced by 47.8% (DIBH mean=15.56Gy, SD=10.62Gy vs. FB mean=29.82Gy, SD=10.05Gy, p=0.000031, and LADCA D_mean by 52% (DIBH mean=5.23Gy, SD=1.94Gy vs. FB mean=10.88Gy, SD=3.95Gy p=0.000000036027. Amplitude depths were not correlated with dose reductions.

CONCLUSION

DIBH significantly reduces heart and LADCA dose. Further research is required to evaluate potential long-term implications for patients treated DIBH.

ESTRO ACROP guidelines for positioning, immobilisation and position verification of head and neck patients for radiation therapists

Background and purpose

Over the last decade, the management of locally advanced head and neck cancers (HNCs) has seen a substantial increase in the use of chemoradiation. These guidelines have been developed to assist Radiation TherapisTs (RTTs) in positioning, immobilisation and position verification for head and neck cancer patients.

Materials and methods

A critical review of the literature was undertaken by the writing committee.

Based on the literature review, a survey was developed to ascertain the current positioning, immobilisation and position verification methods for head and neck radiation therapy across Europe. The survey was translated into Italian, German, Greek, Portuguese, Russian, Croatian, French and Spanish.

Guidelines were subsequently developed by the writing committee.

Results

Results from the survey indicated that a wide variety of treatment practices and treatment verification protocols are in operation for head and neck cancer patients across Europe currently.

The guidelines developed are based on the experience and expertise of the writing committee, remaining cognisant of the variations in imaging and immobilisation techniques used currently in Europe.

Conclusions

These guidelines have been developed to provide RTTs with guidance on positioning, immobilisation and position verification of HNC patients. The guidelines will also provide RTTs with the means to critically reflect on their own daily clinical practice with this patient group.

Perspectives on medical education in radiation oncology and the role of the ESTRO School

Radiation oncology is a medical specialty not just delivering ionizing radiation to cancer patients but also participating as an important partner in the care of the patient from diagnosis to cure, follow up or end of life. The specialty is rapidly evolving in a multi- and interdisciplinary setting as multimodality treatment is becoming frequent. This requires that the medical undergraduate and postgraduate training evolve to these changes. The ESTRO School has for more than 30 years offered postgraduate training courses in and outside Europe and strives to develop its services to accommodate the educational needs of a specialty in constant development. Some of these developments are described in the present paper.

Use of auto-segmentation in the delineation of target volumes and organs at risk in head and neck

BACKGROUND

Manual delineation of structures in head and neck cancers is an extremely time-consuming and labor-intensive procedure. With centers worldwide moving towards the use of intensity-modulated radiotherapy and adaptive radiotherapy, there is a need to explore and analyze auto-segmentation (AS) software, in the search for a faster yet accurate method of structure delineation.

MATERIAL AND METHODS

A search for studies published after 2005 comparing AS and manual delineation in contouring organ at risks (OARs) and target volume for head and neck patients was conducted. The reviewed results were then categorized into arguments proposing and opposing the review title.

RESULTS

Ten studies were reviewed and derived results were assessed in terms of delineation time-saving ability and extent of delineation accuracy. The influence of other external factors (observer variability, AS strategies adopted and stage of disease) were also considered. Results were conflicting with some studies demonstrating great potential in replacing manual delineation whereas other studies illustrated otherwise. Six of 10 studies investigated time saving; the largest time saving reported being 59%. However, one study found that additional time of 15.7% was required for AS. Four studies reported AS contours to be between 'reasonably good' and 'better quality' than the clinically used contours. Remaining studies cited lack of contrast, AS strategy used and the need for physician intervention as limitations in the standardized use of AS.

DISCUSSION

The studies demonstrated significant potential of AS as a useful delineation tool in contouring target volumes and OARs in head and neck cancers. However, it is evident that AS cannot totally replace manual delineation in contouring some structures in the head and neck and cannot be used independently without human intervention. It is also emphasized that delineation studies should be conducted locally so as to evaluate the true value of AS in head and neck cancers in a specific center.

Loss of autophagy enhances MIF/macrophage migration inhibitory factor release by macrophages

MIF (macrophage migration inhibitory factor [glycosylation-inhibiting factor]) is a pro-inflammatory cytokine expressed in multiple cells types, including macrophages. MIF plays a pathogenic role in a number of inflammatory diseases and has been linked to tumor progression in some cancers. Previous work has demonstrated that loss of autophagy in macrophages enhances secretion of IL1 family cytokines. Here, we demonstrate that loss of autophagy, by pharmacological inhibition or siRNA silencing of Atg5, enhances MIF secretion by monocytes and macrophages. We further demonstrate that this is dependent on mitochondrial reactive oxygen species (ROS). Induction of autophagy with MTOR inhibitors had no effect on MIF secretion, but amino acid starvation increased secretion. This was unaffected by Atg5 siRNA but was again dependent on mitochondrial ROS. Our data demonstrate that autophagic regulation of mitochondrial ROS plays a pivotal role in the regulation of inflammatory cytokine secretion in macrophages, with potential implications for the pathogenesis of inflammatory diseases and cancers.

Dosimetric comparison of 3-dimensional conformal radiation therapy and intensity modulated radiation therapy and impact of setup errors in lower limb sarcoma radiation therapy

PURPOSE

This study compared dosimetric data between 3-dimensional conformal radiation therapy (3DCRT) and intensity modulated radiation therapy (IMRT) plans in a population of patients with lower limb sarcoma immobilized with an in-house device and quantified the impact of systematic and random errors on these techniques. The dosimetric effects of displacements on target coverage and organs at risk (OARs) were considered.

METHODS AND MATERIALS

Plans were created for 11 postoperative patients using both 3DCRT and IMRT. The techniques were compared dosimetrically. Population-based systematic and random errors were applied and the results compared with the initial plans.

RESULTS

Higher target D95, D2, D98, and D50 and the best homogeneity index resulted with IMRT compared with 3DCRT. Systematic errors increased target D2 in IMRT. Random errors decreased target homogeneity in IMRT. Maximum bone dose was higher in IMRT than in 3DCRT. Neither error type increased OAR dose for either technique.

CONCLUSIONS

IMRT could become the favored lower limb sarcoma radiation therapy technique because of superior target coverage and homogeneity. Offline imaging can adequately correct for systematic errors in these patients when an in-house immobilization device is used.

Clinical potential of boron neutron capture therapy for locally recurrent inoperable previously irradiated head and neck cancer

This review compares the safety and efficacy of boron neutron capture therapy (BNCT) in the treatment of previously irradiated, inoperable locoregional recurrent HNC patients and compares BNCT against the standard treatment of platinum-based chemotherapy. Our analysis of published clinical trials highlights efficacy of BNCT associated with mild side effects. However, the use of BNCT should be explored in stratified randomised trials.

Effect of stereotactic dosimetric end points on overall survival for Stage I non-small cell lung cancer: a critical review

Stereotactic body radiation therapy (SBRT) delivers a high biologically effective dose while minimizing toxicities to surrounding tissues. Within the scope of clinical trials and local practice, there are inconsistencies in dosimetrics used to evaluate plan quality. The purpose of this critical review was to determine if dosimetric parameters used in SBRT plans have an effect on local control (LC), overall survival (OS), and toxicities. A database of relevant trials investigating SBRT for patients with early-stage non-small cell lung cancer was compiled, and a table of dosimetric variables used was created. These parameters were compared and contrasted for LC, OS, and toxicities. Dosimetric end points appear to have no effect on OS or LC. Incidences of rib fractures correlate with a lack of dose-volume constraints (DVCs) reported. This review highlights the great disparity present in clinical trials reporting dosimetrics, DVCs, and toxicities for lung SBRT. Further evidence is required before standard DVCs guidelines can be introduced. Dosimetric end points specific to stereotactic treatment planning have been proposed but require further investigation before clinical implementation.

Expert consensus panel guidelines on geriatric assessment in oncology

Despite consensus guidelines on best practice in the care of older patients with cancer, geriatric assessment (GA) has yet to be optimally integrated into the field of oncology in most countries. There is a relative lack of consensus in the published literature as to the best approach to take, and there is a degree of uncertainty as to how integration of geriatric medicine principles might optimally predict patient outcomes. The aim of the current study was to obtain consensus on GA in oncology to inform the implementation of a geriatric oncology programme. A four-round Delphi process was employed. The Delphi method is a structured group facilitation process, using multiple iterations to gain consensus on a given topic. Consensus was reached on the optimal assessment method and interventions required for the commonly employed domains of GA. Other aspects of GA, such as screening methods and age cut-off for assessment, represented a higher degree of disagreement. The expert panel employed in this study clearly identified the criteria that should be included in a clinical geriatric oncology programme. In the absence of evidence-based guidelines, this may prove useful in the care of older cancer patients.

A guide for interprofessional case presentations

BACKGROUND

Opportunities for interprofessional learning (IPL) and the promotion of interprofessional (IP) communication at the undergraduate level are important goals of health science faculties. IPL activities with shared curriculum validity to promote full student engagement can be challenging to identify. Case presentations that focus on patient-centred learning are one type of activity that is likely to have clinical relevance to all undergraduate groups. Guiding students and facilitators on this approach using a structured framework is necessary to maximise the desired IPL outcomes.

CONTEXT

The framework was informed by two settings. Firstly, by a large metropolitan health service that provided IP clinical placements (ICPs). Six 2-week placements in aged care rehabilitation were completed by medical, nursing and allied health students Secondly, by a an inner Melbourne private hospital where weekly IP case presentations were established.

INNOVATION

The innovation was a framework developed by clinical teachers and academics across two health services to guide facilitators and students participating in an IP case presentation.

IMPLICATIONS

This framework, highlighting both strategies for success and potential pitfalls, may provide a guide to teachers wishing to establish student IP case presentations within their health service or clinical placement context. The deployment and use of this framework may then provide a basis to evaluate IP case-based presentations for formative or summative student assessment.

Video-based training improves the accuracy of seizure diagnosis

BACKGROUND AND AIM

The difficulties in differentiating epileptic seizures (ES) from psychogenic non-epileptic seizures (PNES) are well known. However, interventions to enhance diagnostic accuracy have not been well studied. We sought to evaluate the accuracy of discrimination between ES and PNES before and after targeted training among medical students.

METHODS

A teaching module incorporating videos of typical ES and PNES was used for training. Typical ES and PNES, 10 each, were shown in a random mix. The participants were asked to make a diagnosis as the baseline test, followed by a detailed discussion on videos. One month later, a 1 h lecture was delivered on the diagnosis and classification of seizures, followed by two more tests 3 and 6 months later, using a similar format, but different videos. A group of emergency medicine trainees also went through the preteaching test for comparison. We used summary receiver operating characteristic curves and area under the curve (AUC) to quantify the discriminating ability and z scores to assess the differences between AUC between different stages of training.

RESULTS

In medical students, the AUC improved significantly from 0.52 (95% CI 0.49 to 0.55) at the baseline to 0.64 (95% CI 0.59 to 0.69, p<0.001) at 3 months and 0.63 (95% CI 0.57 to 0.69, p<0.001) at 6 months. At 3 and 6 months testing, they achieved results similar to that of emergency medicine trainees (p=0.5).

CONCLUSIONS

Targeted video-based training increases the accuracy of visual discrimination of seizures short-term and medium-term.

Annexin A1: potential for glucocorticoid sparing in RA

Glucocorticoids have broad-ranging and powerful anti-inflammatory and immunomodulatory effects. Unsurprisingly, therefore, glucocorticoids are widely and persistently used to treat a large number of inflammatory diseases, including rheumatoid arthritis (RA), despite the well-described adverse effects of these drugs. Annexin A1 is a glucocorticoid-induced molecule that is known to replicate many of the described anti-inflammatory effects of glucocorticoids. In addition to the well-documented roles of this protein in neutrophil function, emerging evidence suggests that annexin A1 is involved in the modulation of T-cell function and the adaptive immune responses relevant to RA. Interest in annexin A1 was renewed after the delineation of the receptors for this protein. This breakthrough also led to advances in our understanding of anti-inflammatory annexin A1 mimetic peptides and agonistic compounds targeting these receptors, particularly those specific for the receptor N-formyl peptide receptor 2 (FPR2). Herein, we review the current knowledge of the biological activities of annexin A1 and their relevance to RA pathogenesis. We also discuss the potential of annexin A1 mimics and strategies aimed at potentiating annexin A1 signalling to become viable approaches to minimizing glucocorticoid use in RA and other inflammatory disorders.

Prior experience of interprofessional learning enhances undergraduate nursing and healthcare students' professional identity and attitudes to teamwork

BACKGROUND

How willing are today's medical, nursing and other healthcare students to undertake some of their studies as shared learning? There is a lack of evidence of students' views by discipline despite this being a priority task for higher education sectors. This study explored the views of nursing, midwifery, nursing-emergency health (paramedic), medical, physiotherapy and nutrition-dietetics students.

METHODS

Senior undergraduate students from six disciplines at one university completed the Readiness for Interprofessional Learning Scale prior to participating in interprofessional clinical learning modules.

RESULTS

For 741 students, the highest ranked response was agreement about a need for teamwork (mean 4.42 of 5 points). Nursing students held significantly more positive attitudes towards Teamwork/Collaboration, and were more positive about Professional Identity than medical students (p < .001). Midwifery and nursing-emergency-health students rejected uncertainty about Roles/Responsibilities compared with medical students (p < .001). One-third of all students who had prior experience of interprofessional learning held more positive attitudes in each of four attitude domains (p < .05).

CONCLUSION

Overall, students' attitudes towards interprofessional learning were positive and all student groups were willing to engage in learning interprofessionally. Early introduction of IPL is recommended. Further studies should explore the trajectory of students' attitudes throughout the university degree.