Understanding the distinct experience of rural interprofessional collaboration in developing palliative care programs

INTRODUCTION

Palliative care is one component of rural generalist practice that requires interprofessional collaboration (IPC) amongst practitioners. Previous research on developing rural palliative care has created a four-phase capacity development model that included interprofessional rural palliative care teams; however, the details of rural team dynamics had not been previously explored and defined. A growing body of literature has produced models for interprofessional collaborative practice and identified core competencies required by professionals to work within these contexts. An Ontario College of Family Physicians discussion paper identifies seven essential elements for successful IPC: responsibility and accountability, coordination, communication, cooperation, assertiveness, autonomy, and mutual trust and respect. Despite the fact that IPC may be well conceptualized in the literature, evidence to support the transferability of these elements into rural health care practice or rural palliative care practice is lacking. The purpose of this research is to bridge the knowledge gap that exists with respect to rural IPC, particularly in the context of developing rural palliative care. It examines the working operations of these teams and highlights the elements that are important to rural collaborative processes.

METHODS

For the purpose of this qualitative study, naturalistic and ethnographic research strategies were employed to understand the experience of rural IPC in the context of rural palliative care team development. Purposive sampling was used to recruit key informants as participants who were members of rural palliative care teams. The seven elements of interprofessional collaboration, as outline above, provided a preliminary analytic framework to begin exploring the data. Analysis progressed using a process of interpretive description to embrace new ideas and conceptualizations that emerged from the patterns and themes of the rural health providers' narratives. The questions of particular interest that guided this work were: What are the collaborative processes of a rural palliative care team? To what extent are the seven elements of IPC representative of rural teams' experiences? Are there any additional elements present when examining the experiences of rural teams?

RESULTS

The analysis showed that the seven identified elements of IPC were very much integrated in rural teams' collaborative practice, and thus validated the applicability of these elements in a rural context. However, all seven elements were implemented with a rural twist: the distinctiveness of the rural environment was observed in each element. In addition, another element, specific to rural context, was observed, that being the 'automatic teams' of rural practitioners - the collaboration has been established informally and almost automatically between rural practitioners.

CONCLUSIONS

This research contributes new knowledge about rural palliative care team work that can assist in implementing models for rural palliative care that apply accepted elements of collaborative practice in the rural context. Understanding the process of how rural teams form and continue to function will help further the current understanding of IPC in the context in which these professionals work.

Behavioral treatment of chronic psychogenic polydipsia with hyponatremia: a unique case of polydipsia in a primary care patient with intractable hiccups

Psychogenic polydipsia is recognized as a dangerous and potentially life threatening disorder. Few studies have focused on the treatment of polydipsia presenting in the outpatient setting. A review of the behavioral treatment literature pertaining to psychogenic polydipsia is presented. This review is followed by a case illustration of an outpatient behavioral approach to the treatment of psychogenic polydipsia in a non-psychiatric, primary car, adult, male patient suffering from intractable hiccup. An ABA single-case design was used, with sodium concentration as the dependent variable. This behavioral method appears promising in settings where restriction of fluid intake is not practical.

Mutations in CEN3 cause aberrant chromosome segregation during meiosis in Saccharomyces cerevisiae

We investigated the structural requirements of the centromere from chromosome III (CEN3) of Saccharomyces cerevisiae by analyzing the ability of chromosomes with CEN3 mutations to segregate properly during meiosis. We analyzed diploid cells in which one or both copies of chromosome III carry a mutant centromere in place of the wild-type centromere and found that some alterations in the length, base composition and primary sequence characteristics of the central A+T-rich region (CDE II) of the centromere had a significant effect on the ability of the chromosome to segregate properly through meiosis. Chromosomes containing mutations which delete a portion of CDE II showed a high rate of premature disjunction at meiosis I. Chromosomes containing point mutations in CDE I or lacking CDE I appeared to segregate properly through meiosis; however, plasmids carrying centromeres with CDE I completely deleted showed an increased frequency of segregation to nonsister spores.

Alterations in the adenine-plus-thymine-rich region of CEN3 affect centromere function in Saccharomyces cerevisiae

Centromere DNA from 11 of the 16 chromosomes of the yeast Saccharomyces cerevisiae have been analyzed and reveal three sequence elements common to each centromere, referred to as conserved centromere DNA elements (CDE). The adenine-plus-thymine (A + T)-rich central core element, CDE II, is flanked by two short conserved sequences, CDE I (8 base pairs [bp]) and CDE III (25 bp). Although no consensus sequence exists among the different CDE II regions, they do have three common features of sequence organization. First, the CDE II regions are similar in length, ranging from 78 to 86 bp measured from CDE I to the left boundary of CDE III. Second, the base composition is always greater than 90% A + T. Finally, the A and T residues in these segments are often arranged in runs of A and runs of T residues, sometimes with six or seven bases in a stretch. We constructed insertion, deletion, and replacement mutations in the CDE II region of the centromere from chromosome III, CEN3, designed to investigate the length and sequence requirements for function of the CDE II region of the centromere. We analyzed the effect of these altered centromeres on plasmid and chromosome segregation in S. cerevisiae. Our results show that increasing the length of CDE II from 84 to 154 bp causes a 100-fold increase in chromosome nondisjunction. Deletion mutations removing segments of the A + T-rich CDE II DNA also cause aberrant segregation. In some cases partial function could be restored by replacing the deleted DNA with fragments whose primary sequence or base composition is very different from that of the wild-type CDE II DNA. In addition, we found that identical mutations introduced into different positions in CDE II have very similar effects.