Development of an on-job mentorship programme to improve nursing experience for enhanced patient experience of compassionate care

Background

Evidence suggests improvement in nursing staff satisfaction, competence, and retention after implementation of evidence-based mentorship programmes. When guided by a framework of compassion, mentoring as a caring action can not only build healthy, transformative relationships but a similar behavior is reciprocated to patients which subsequently can drive patient experience of care. However, examples of on-job mentorship programs for nurses in low- and middle-income countries (LMIC) are limited.

Objective

The objective of the study was to develop an on-job nursing mentorship programme using a compassionate framework aimed at improving nurses’ experience and thus enhancing patient experience in a tertiary care hospital in Pakistan.

Methods

Designed as an intervention development study, it was completed between January 2018–December 2019. The programme was developed by a team composed of service and nursing leadership, director patient experience of care and a compassion specialist using a theory of change model. The package followed a series of steps, a) identification of a framework, b) creation of working group c) needs assessment and d) multiple meetings to frame the model followed by implementing the preconditions for roll-out of the programme with the frontline staff.

Results

The eventual outcome was improving the patient’s experience of compassion while the intermediate outcome was to have nurses demonstrate compassionate care. The pre-conditions were identified as: recruitment of staff with appropriate skills for pediatric care, provision of compassionate experience to the frontline nurses by addressing their specific pain points, development of competent head nurses as supervisors and creation of a compassionate culture. To ensure the pre-conditions, various interventions were planned with some implemented through the course of the study while others are in the process of being rolled out. These involved, inclusion of pediatric compassion specific module during orientation of new hires, creation of space to talk about compassionate skills with staff, provision of trainings and mentorship to create competent head nurses, and creating a culture that promoted and recognized compassionate care values.

Conclusion

The approach helped to delineate feasible pathways for an on-job compassionate mentorship programme enhancing routine supervisors' role as facilitators of compassionate care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00682-4.

Outcome of inadvertent high dose BCG administration in newborns at a tertiary care hospital, Karachi- Case series

Bacillus Calmette-Guérin (BCG) vaccine is given to newborns soon after birth. BCG vaccine overdose has been rarely reported. Here we report the outcome of newborns who accidently received high dose BCG at a tertiary care hospital, Karachi. We reviewed records of 26 newborns, who accidentally received intradermal high dose BCG, used for the treatment of urinary bladder cancers and 80 times higher dose than the BCG used for routine vaccination. The incident happened from 14-16^th April, 2016 at Aga Khan University Hospital, Karachi. Analysis was carried out using SPSS. A total of 23/26(88.5%) newborns were followed for atleast 3 months and 11/26 (42.3%) were followed for atleast one year. 13/26 (50%) were male. All 26 patients were prescribed isoniazid and rifampicin for 3 months. 3/26 (11.5%) were lost to follow-up before completion of anti-tuberculous drugs (ATT). Lesions at the BCG site were observed in 16/26 (61.5%) infants, of which 15 (93.8%) had a papule, 3 (18.8%) developed a pustule, 3 (18.8%) had skin induration and 2 (12.5%) had skin erythema. Axillary lymphadenopathy was observed in 1/26 (3.8%) patient. Coagulation was deranged in 3/26 (11.5%) of babies. Intracranial bleeding was observed in 1/26 (3.8%) case. Localized skin lesions were the most common adverse events. None of them developed clinical tuberculosis. Chemoprophylaxis for inadvertent high dose BCG administration should be given for atleast 3 months. Furthermore, vigilant follow-up, transparency and disclosure are the vital steps in the management of any medical error.

Abstract P4-15-05: The presence of one or multiple foci of microinvasion is not associated with an increased risk of local recurrence in women with ductal carcinoma in situ treated with breast conserving therapy

Background: Ductal Carcinoma in Situ (DCIS) is a non-invasive breast cancer often treated with breast-conserving surgery (BCS) with or without radiotherapy (RT). It is unclear if the presence of microinvasion (MI) (invasion ≤1mm) is associated with an increased risk of LR (DCIS or invasive) or invasive LR compared to women with pure DCIS. In addition, the impact of multiple foci (>2) of MI compared to pure DCIS is also unknown; therefore, it is unclear if some women with MI require more aggressive treatment. We evaluated the impact of the presence of MI and the number of foci of MI on the risks of any LR and invasive LR in a population of women with DCIS with and without MI treated with BCS.

Methods: The cohort includes all women diagnosed with pure DCIS or DCIS with MI in Ontario from 1994-2003 treated with BCS +/- RT. All cases had systematic pathology review to confirm the presence and number of foci of MI. Treatment and outcomes were ascertained through administrative databases and validated by chart review. Cox proportional hazards model was used to evaluate the impact of MI and the number of foci of MI (1 vs >2 foci) on the development of any LR and invasive LR compared to cases with pure DCIS. The 10-yr local recurrence-free survival (LRFS) and invasive LRFS rates were calculated using the Kaplan-Meier approach with differences compared using the log-rank test.

Results: The population cohort includes 2,988 women with DCIS treated by BCS (N=2,721 pure DCIS, N= 267 DCIS with MI). Median follow-up (12 years; p=.23) and median age at diagnosis (58 years; p=.17) were similar in both groups. RT was given in 58% of cases with MI and 51% of cases with pure DCIS (p=.03). Hormonal therapy was utilized in 7.1% of women with MI and 5.3% of women with pure DCIS (p=.22). LR developed in 59 (22.1%) cases with MI and 530 (19.6%) cases of pure DCIS. Women with MI were more likely to have high nuclear grade (p<.001), and larger tumor size (p<.001) compared to those without MI. On multivariable analyses adjusted for age, the presence of 1 focus of MI(HR=.92, 95% CI: .64-1.33) or ≥2 foci of MI (HR=1.26, 95% CI: .85-1.85) was not associated with an increased risk of any LR compared to cases with pure DCIS. Factors associated with any LR were age <50 years at diagnosis, RT, multifocality and high nuclear grade. The presence of 1 focus of MI (HR=.86, 95% CI: .52-1.40) or > 2 foci of MI (HR=1.45, 95% CI: .90-2.32) was also not associated with an increased risk of invasive LR compared to cases of pure DCIS. Among women treated with BCS alone, the 10 year LRFS rates were 80%, 75% and 73% for women with pure DCIS, 1 focus, >2 foci of MI (p=.10). The invasive LRFS rates were 89%, 91% and 85% (p=.26). Among women treated with BCS+RT, the 10 year LRFS rates were 87%, 88% and 80% (p=0.32) for women with pure DCIS, 1 focus or ≥2 foci of MI. The invasive LRFS rates were 93%, 90% and 86% (p=.44). There was no interaction between the presence of MI and RT.

Conclusions: Women with DCIS with one or multiple foci of microinvasion (<1mm) treated by breast conserving therapy do not have an increased risk of LR or invasive LR compared to women with pure DCIS.

Citation Format: Lalani N, Paszat L, Sutradhar R, Gu S, Fong C, Nofech-Mozes S, Hanna W, Tuck A, Youngson B, Miller N, Done SJ, Chang MC, Sengupta S, Elavathil L, Jani PA, Bonin M, Rakovitch E. The presence of one or multiple foci of microinvasion is not associated with an increased risk of local recurrence in women with ductal carcinoma in situ treated with breast conserving therapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-15-05.

Abstract P2-12-02: Is breast-conserving therapy effective in women with large ductal carcinoma in situ (DCIS) lesions? A population-based analysis

Background: Most women diagnosed with DCIS will be treated by breast-conserving surgery (BCS) with or without radiotherapy (RT). Data on outcomes following breast-conserving therapy are predominantly based on women with small (<25mm) lesions. The paucity of data on outcomes of women with larger (>40mm) DCIS lesions leads to uncertainty of the appropriateness of breast-conserving therapy for women with larger lesions. Specifically, it is unclear if women with large tumors experience higher risks of local recurrence (LR) and invasive LR after BCS+/-RT that would preclude recommendations of breast-conserving therapy. We report the outcomes and evaluate the impact of large tumor size (>40mm) on recurrence risk in a population of women with pure DCIS treated by BCS alone or with RT.

Methods: The cohort includes all women diagnosed with DCIS in Ontario from 1994-2003 treated with BCS +/- RT; 82% had pathology review. Treatment and outcomes were ascertained through administrative databases and validated by chart review. Cox proportional hazards model was used to evaluate the impact of tumor size (≤10mm,11-25mm, 26-39mm, ≥40mm) on the development of any LR (DCIS or invasive) and invasive LR. The 10 and 15-year LR-free survival (LRFS) and invasive LRFS rates were calculated using the Kaplan-Meier method with differences compared using the log-rank test.

Results: The cohort includes 3262 women with DCIS treated by BCS (N=1635 had RT). Median age at diagnosis was 59 years (IQR 50-68 years). Median follow-up was 13 years (IQR 8-15 years). Distribution of tumor size: 707 (22%) ≤10mm, 524 (16%) 11-25mm, 107 (3%) 26-39mm, 84 (3%) ≥40mm, unable to determine in 1840 (56%). Women with lesions ≥ 40mm were more likely to be ≤50 years of age at diagnosis (p=.02), have high nuclear grade (p<.001), multifocality (p<.001), and positive margins (p<.001) compared to women with smaller lesions. On multivariable analyses adjusted for age and year of diagnosis, tumor size ≥40mm was significantly associated with an increased risk of LR compared to size ≤10mm (HR=2.5, 95%CI:1.64-3.81). Other factors associated with LR were age <50 years (p<.001), omission of RT (p<.001), high nuclear grade (p=.002), and multifocality (p=.0008). Tumor size ≥40mm was not significantly associated with an increased risk of invasive LR (HR=1.68, 95%CI:.94-3.04). Women with tumour size ≥40mm treated with BCS alone had lower 10 and 15 year LRFS (53% and 41%) and invasive LRFS rates (78% and 75%) compared to women with smaller lesions. However, women with larger lesions treated with RT had significantly higher LRFS and invasive LRFS rates

Outcomes by tumour size for women with DCIS treated with BCS with or without RT  ≤10mm N=70711-25mm N=52426-39mm N=107≥40mm N=84p-valueBCS AloneLRFS (%)      10 yr85797053<0.001 15 yr81746741  Invasive LRFS (%)      10 yr928786780.03 15 yr89838375 BCS + RTLRFS (%)      10 yr928874850.01 15 yr86847079  Invasive LRFS (%)      10 yr959492910.27 15 yr90918789 

. There was a significant interaction between tumor size ≥40mm and RT (p=.02).

Conclusions: Women with DCIS lesions ≥40mm treated by BCS alone experience significantly higher risks of LR and invasive LR compared to smaller lesions but this risk can be mitigated with the addition of RT.

Citation Format: Lalani N, Paszat L, Nofech-Mozes S, Sutradhar R, Gu S, Hanna W, Fong C, Miller N, Youngson B, Done SJ, Tuck A, Chang MC, Sengupta S, Jani PA, Bonin M, Rakovitch E. Is breast-conserving therapy effective in women with large ductal carcinoma in situ (DCIS) lesions? A population-based analysis [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-12-02.

Abstract P4-15-01: Integration of clinical and pathological data with the DCIS score to predict the risk of local recurrence

Background: Prediction of local recurrence (LR) risk after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) is needed to guide decisions regarding risks and benefits of adjuvant radiotherapy (RT). We aim to determine the optimal combination of clinical and pathological characteristics with the Oncotype DCIS Score (DS) to predict individualized 10 year risks of local recurrence (LR) after BCS (with or without RT) for DCIS and develop a web-based nomogram / risk calculator.

Methods: DS (continuous, categorical risk groups low/intermediate/high) and complete clinico-pathological data (age, tumor size, nuclear grade, comedonecrosis, multifocality, margin width and receipt of breast RT) are available for 1102 cases from the Ontario population cohort of pure DCIS treated by BCS (981 cases with negative margins, 121 cases with positive margins). We examined various categorizations of discrete variables, and transformations of continuous variables, and used model selection procedures to determine the best fitting Cox proportional hazards regression model of LR according to the c-statistic, Akaike Information Criterion, and log-likelihood. We tested all two-way interactions and interactions with time. The 10-year probability of LR was calculated for each woman using the estimate of the baseline survival function and the estimate of the linear predictor, which is a function of the regression parameter estimates and specific covariate values. Model calibration will be explored by comparing observed versus predicted risk of LR, and the model's discriminative ability will be assessed by the concordance index. Model validation will be conducted via bootstrapping approaches.

Results: In the best fitting main effects full model, the adjusted hazard ratios (HR) (95% confidence intervals (CI)) for LR included: intermediate/ high risk DS vs. low risk (HR =1.96 (1.39, 2.74)), age < 50 years at diagnosis vs. age>= 50 (HR = 1.62 (1.16, 2.25)), square root of tumor size (HR/mm = 1.24 (1.11, 1.38)), comedonecrosis > 30% vs. <=30% (HR=1.53 (1.08, 2.16)), multifocality ( HR=2.01 (1.45, 2.77)), and receipt of RT ( HR=0.50 (0.37, 0.68)). There was a significant interaction between tumor size and DS but not between DS and RT. Among women with a low risk DS and age >= 50, tumor size <= 10 mm, <= 30% comedo necrosis, no multifocality, low or moderate nuclear grade and negative margins, the average predicted 10 year LR risk = 6.8% (range 6.4% - 7.6%) after treatment by BCS without RT, and 3.6% (range 3.4% - 3.8%) after BCS+RT (an absolute benefit of 3.2% from RT). Among women with intermediate/high risk DS and the same low risk clinical-pathological features, the average predicted 10 year LR risk = 19.0% (range 18.3% - 20.0%) without RT, and 9.5% (range 9.1% - 10.3%) with RT (an absolute benefit of 9.5% from RT).

Conclusion: This prediction model combines clinical and pathological features with the DS to improve estimates of local recurrence risk after BCS alone and the absolute benefit with RT, which can improve decision making in DCIS. After calibration and validation, it will be the basis of a web-based nomogram / risk calculator. It also demonstrates the importance of molecular testing for studies of the de-escalation of therapy for DCIS.

Citation Format: Paszat L, Sutradhar R, Zhou L, Lalani N, Nofech-Mozes S, Rakovitch E. Integration of clinical and pathological data with the DCIS score to predict the risk of local recurrence [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-15-01.

Prognostic effect of early treatment of paraneoplastic limbic encephalitis in a patient with small-cell lung cancer

Paraneoplastic neurologic syndrome (pns) is an uncommon manifestation of cancer and may present before any symptoms of malignant disease. This syndrome occurs in fewer than 1 of every 10,000 patients diagnosed with a malignancy. Anti-neural antibodies have been associated with pns, suggesting that this condition may reflect immune mechanisms. Depending on the region of the nervous system that has been affected, pns can have a number of manifestations. Paraneoplastic limbic encephalitis (ple) stems from involvement of the limbic system and may present with seizures and changes in mood, memory, and personality. The present report describes the case of a 55-year-old man presenting with ple in the setting of small-cell lung cancer, with subsequent improvement of his neurologic symptoms. The value of rapid diagnosis and multidisciplinary management of this syndrome are discussed.

Polymerization with the argon laser: curing time and shear bond strength

The objective of this study was to determine the efficiency of an argon laser in polymerizing a light-cured orthodontic adhesive. Metal brackets were bonded to 185 premolars, divided into 5 different protocol groups of 37 each as follows: light 40-second buccal, light 40-second lingual, laser 5-second lingual, laser 10-second lingual, and laser 15-second lingual. All bonded specimens were placed in distilled water for 30 days at 37 degrees C followed by thermal cycling for 24 hours. Brackets were detached using a shearpeel load delivered by an Instron machine. The site of bond failure was examined under 10x magnification. The difference in the shear-peel bond strength between the light 40-second buccal (13.31 MPa) and the light 40-second lingual (11.95 MPa) groups was not statistically significant. The mean shear-peel bond strengths for the laser cured groups were quite similar for the 5-, 10- and 15-second laser groups (10.86, 11.32, and 10.80 MPa). The difference in mean lingual bond strength between the light 40-second and laser 5-second groups was not statistically significant (t = 1.26; P = .212). The adhesive remnant index analysis revealed principally cohesive bond failures. An increased frequency of enamel fractures at debond was noted in the lingual light-cured and 10-second laser-cured groups, at 35.1% (13/37) and 21.6% (8/ 37), respectively. All other groups displayed enamel fractures of 16.2% (6/37). A 5-second cure using an argon laser produced bond failure loads comparable to those obtained after 40 seconds of conventional light cure, with less than half the frequency of enamel fracture at debond.

MDM2 overexpression is rare in ovarian carcinoma irrespective of TP53 mutation status

Somatic mutations in TP53 are seen in many human cancers. In addition, the protein product of the wild-type TP53 can be sequestered by the protein MDM2 (murine double minute 2). This protein is commonly overexpressed in human sarcomas and gliomas, usually as a result of gene amplification. In this study, 43 ovarian carcinomas (OCs) were analysed for aberrations in the TP53 gene by immunohistochemistry (IHC), loss of heterozygosity (LOH) or mutation analysis. The MDM2 gene and its product was studied by Southern blotting and IHC. Over 50% of the OCs studied showed mutations in TP53 by either direct sequencing (19/36, 53%), positive IHC (23,43, 53%) or both, whereas 0/32 had amplification of MDM2 and only 1/37 tumours had positive IHC using the anti-MDM2 antibody IF-2. The solitary example of positive IHC in this series was seen in a mixed müllerian tumour with sarcomatous differentiation and was not accompanied by MDM2 DNA amplification. These results support previous data showing that around 50% of OCs have mutations in TP53 and in addition, suggest that MDM2 is not amplified in OC, but the presence of sarcomatous features in mixed müllerian tumours may result in positive immunohistochemistry with IF-2.

Tissue-specific expression of a human polymorphic epithelial mucin (MUC1) in transgenic mice

The human MUC1 gene codes for the core protein of a mucin which is expressed by glandular epithelia and the carcinomas which develop from these tissues. The core protein is aberrantly glycosylated in cancers, and some antibodies show specificity in their reactions with the cancer-associated mucin, which also contains epitopes recognized by T-cells from breast and pancreatic cancer patients. For evaluating the potential use of mucin-reactive antibodies and mucin-based immunogens in cancer patients, a mouse model, expressing the MUC1 gene product PEM (polymorphic epithelial mucin) as a self antigen, would be extremely useful. To this end, we have developed transgenic mouse strains expressing the human MUC1 gene product in a tissue-specific manner. The TG4 mouse strain was established using a 40-kilobase fragment containing 4.5 kilobases of 5' and 27 kilobases of 3' flanking sequence. The TG18 strain was developed using a 10.6-kilobase SacII fragment from the 40-kilobase fragment; this fragment contained 1.6 kilobases of 5' sequence and 1.9 kilobases of 3' flanking sequence. Both strains showed tissue specificity of expression of the MUC1 gene, which was very similar to the profile of expression seen in human tissues. The antibody SM-3 is directed to a core protein epitope, which is selectively exposed in breast cancers and which shows a more restricted distribution on normal human tissues. It was established that the distribution of the SM-3 epitope of PEM in the tissues of the transgenic mice is similar to that seen in humans. The transgenic mouse strains described here should form the basis for the development of a preclinical model for the evaluation of PEM-based antigens and of antibodies directed to PEM in cancer therapy.