Prospective Validation of an Ex Vivo, Patient-Derived 3D Spheroid Model for Response Predictions in Newly Diagnosed Ovarian Cancer

Although 70–80% of newly diagnosed ovarian cancer patients respond to first-line therapy, almost all relapse and five-year survival remains below 50%. One strategy to increase five-year survival is prolonging time to relapse by improving first-line therapy response. However, no biomarker today can accurately predict individual response to therapy. In this study, we present analytical and prospective clinical validation of a new test that utilizes primary patient tissue in 3D cell culture to make patient-specific response predictions prior to initiation of treatment in the clinic. Test results were generated within seven days of tissue receipt from newly diagnosed ovarian cancer patients obtained at standard surgical debulking or laparoscopic biopsy. Patients were followed for clinical response to chemotherapy. In a study population of 44, the 32 test-predicted Responders had a clinical response rate of 100% across both adjuvant and neoadjuvant treated populations with an overall prediction accuracy of 89% (39 of 44, p < 0.0001). The test also functioned as a prognostic readout with test-predicted Responders having a significantly increased progression-free survival compared to test-predicted Non-Responders, p = 0.01. This correlative accuracy establishes the test’s potential to benefit ovarian cancer patients through accurate prediction of patient-specific response before treatment.

Abstract B201: Drug response profiling, redox ratio, and biomarker analysis in an in vitro 3D tri-culture model of breast cancer

Approximately 1 in 8 women will develop breast cancer in their lifetime, and many require a combination of debilitating surgery, chemotherapy or radiation for long term survival. Histologic evaluation of biomarkers such as estrogen receptor and Her2 often dictate treatment regimens. However, despite high initial response rates, relapses are common, and choosing the right therapy for each patient remains challenging. In vitro 3D models of breast cancer that maintain biologic features and more closely resemble clinical disease than 2D models are a promising option for pre-determining the best, most effective therapies for patients. Utilizing both immortalized cell lines and patient-derived xenografts (PDX) lines, we have developed a complex 3D model of breast cancer that combines cancer cells, fibroblasts, and adipocytes in a 3D matrix under perfusion culture (3D microtumors). We have examined these microtumors for metabolism as measured by redox ratio, biomarker expression, and drug response. Using multiphoton microscopy, we have been able to not only live image our 3D microtumors in a non-destructive manner, but also to develop a profile of their redox ratio based upon the autofluorescence of NADH and FAD. Tumor cells often switch from oxidative phosphorylation to aerobic glycolysis for ATP generation (Warburg effect) and previous data examining redox ratios in 2D breast cancer cells have shown that the ratio of NADH to FAD is higher in HER2+ cell lines compared to ER+ cell lines indicating that HER2+ cells utilize aerobic glycolysis more than ER+ cell lines. While we have been able to replicate that data using cell lines in 2D culture, all of our 3D microtumors have indicated a different redox ratio where triple negative breast cancers have the highest redox ratio and ER+ and HER2+ microtumors have similar but lower redox ratios. Cell line and PDX-derived microtumors were used to compare soluble factors secreted across 3D static and 3D perfusion and we have found that both 3D culture, perfusion and higher redox ratios are associated with increased cancer associated biomarker secretion. Furthermore, relative increases or decreases of biomarkers in 3D allowed for the identification of unique secretome signatures according to breast subtype, but these signatures varied between cell lines and PDX-derived microtumors. 3D Microtumors from cell lines better identified tamoxifen and cisplatin as active agents against ER+ and TNBC tumor cells as compared to 2D. Whereas drug response using PDX was not feasible due to poor adaptation to 2D conditions, we were able to assess drug response using both redox ratio and resazurin reduction using our 3D microtumors derived from PDX and have verified molecular subtype-dependent drug responses. By combining drug response profiling with redox ratio and biomarker analysis we have developed a profile of these 3D microtumors that correlates to the molecular subtype of breast cancer cells. This work demonstrates the potential utility of label-free, non-destructive MPM analysis of complex 3D microtumors for early and continuous drug response assessment. Future work is focusing on correlating drug responses to clinical response in microtumors derived from primary human breast tumors.

Citation Format: Tessa DesRochers, Stephen Shuford, Christina Mattingly, Terri Bruce, Matt Gevaert, David Kaplan, David Orr, Hal E. Crosswell. Drug response profiling, redox ratio, and biomarker analysis in an in vitro 3D tri-culture model of breast cancer. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr B201.

Abstract 320: Perfused 3D tri-culture breast cancer microtumors for accurate prediction of drug response

Background: Breast cancer (BC) occurs in 1 of 8 women, often requiring debilitating surgery, chemotherapy or radiation for long term survival. Histologic and molecular biomarkers are used to classify BC according to defined subtypes which dictate the choice of targeted therapy or of non-targeted cytotoxic therapy. Despite high initial response rates, relapses are common for more aggressive tumors, and choosing the right therapy for each patient remains challenging. In vitro 3D BC models maintain biologic features that more closely resemble clinical disease than 2D models. However, many 3D models do not contain multiple cell types, are maintained in static culture conditions and rely on immortalized cell lines previously propagated in 2D culture conditions. To address these issues, we developed long term, 3D heterotypic BC microtumors, which recapitulate the dynamic interaction between stromal and epithelial components, retain subtype-specific biomarkers and demonstrate clinically-relevant drug response. We further demonstrated the value of developing non-lytic, label-free in situ analysis to monitor morphology and function of complex 3D microtumors over time. Materials & Methods: Er+, Her2+ or triple negative (TNBC) cell lines (MCF7, SKBR3, MDA-MB-231) or patient derived xenograft (PDX) cells were embedded with human mammary fibroblasts and adipose cells within a hydrogel encapsulated by a silk fibroin scaffold. Microtumors were maintained at least 4 weeks under perfusion flow utilizing the 3DKUBE™ and were characterized for cell morphology and phenotype (IHC), proliferation (PrestoBlue and PicoGreen), gene expression (qRT-PCR), redox ratio (multiphoton microscopy), and biomarker secretion (xMAP® multiplex immunoassay). Drug response profiling (DRP) was performed with tamoxifen, lapatinib and cisplatin. Results: 3D microtumors successfully recapitulated the morphology of primary BC predicted by molecular subtype and gene expression. Perfusion promoted cell proliferation and impacted redox ratio, gene expression, and biomarker secretion in comparison to static culture. Relative redox ratios of 3D microtumors were significantly different from those of cell lines in 2D (p&lt;0.05). Perfusion, 3D conditions, Her2+ and TNBCs were independently associated with increased biomarker secretion, and both cell line and PDX microtumors had unique secretome signatures. PDX microtumors more accurately predicted drug response. Conclusions: Long-term, 3D heterotypic breast microtumors have unique metabolic and secretome signatures which are different than cells in 2D, and the microtumor morphology, metabolism and drug response can be monitored non-destructively in situ. Our ultimate goal is to develop these microtumors using primary human breast tumors for real time drug response profiling in the preclinical, co-clinical and clinical settings to improve outcomes for women with breast cancer.

Citation Format: Tessa M. DesRochers, Stephen Shuford, Christina Mattingly, Terri Bruce, Zhiyi Liu, Kyle Quinn, Irene Georgakoudi, David L. Kaplan, David Orr, Howland E. Crosswell. Perfused 3D tri-culture breast cancer microtumors for accurate prediction of drug response. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 320. doi:10.1158/1538-7445.AM2015-320

Abstract 318: Enhancing drug discovery and development throughput without sacrificing predictivity: ex vivo 3D drug response profiling (DRP) using patient-derived xenografts (PDX)

Background: PDX have become critical elements of preclinical drug development as they better reflect the heterogeneity, molecular and histopathologic signatures of the original tumor than cell lines or genetically engineered mouse models, and their drug response profiles correlate with clinical response. While PDX models have become a powerful tool in drug discovery and development, limitations include low throughput for broad drug screening, lack of dose-response curves, high cost and progressive loss of human-derived stromal elements over serial passages, restricting utility for certain therapeutic classes. A potential mechanism to overcome the low throughput and high cost of PDX models is the incorporation of ex vivo 3D (EV3D) DRP on cells isolated from early passage PDX models. Thus, we correlated DRP results using PDX with genetic mutations and drug response of PDX tested in vivo. Materials & Methods: Cells were isolated from low-passage triple negative breast, invasive bladder, and non-small cell lung PDX tumors propagated in NSG mice and cultured as 3D spheroids. 3D spheroid cultures were exposed to 15 clinically-relevant chemotherapy and targeted agents and assayed for cell viability over a range of concentrations. Non-linear regression curves were generated and relative IC50s estimated. In vivo response with limited numbers of agents at clinically relevant concentrations (3 including controls) was assessed. Results: 3D cultures and testing were successfully established across all PDX and IC50s were successfully generated in 98% of drugs tested. EV3D DRP of PDX tumors differentiated activity of cytotoxic and targeted agents across tumors of similar histologic site of origin. Gemcitabine (IC50 = .007 versus 27 uM) and docetaxel (0.2 versus 40uM) activity was highly correlated with in vivo response in bladder and breast cancers, respectively, whereas cisplatin was equally active across all tumor types (IC50 = 3-8uM). hENT1 mRNA expression was not predictive of gemcitabine activity. EV3D DRP data correlated with PDX and clinical outcome. It identified Erlotinib as being relatively inactive (3 uM) against lung cancer PDX with an EGFR e19del, T790M mutation which correlated with the outcome seen in the PDX mouse and the clinical patient outcome in which the patient became nonresponsive to erlotinib. Trametinib was highly active against lung cancer PDX with a KRAS G12C mutation (IC50 6.7 × 10-6 versus 1.1 × 10-3) and will be used to perform efficacy studies in the KRAS mutant lung PDX model Conclusions: EV3D DRP predicts in vivo response and correlates with pathway activating mutations. EV3D DRP using PDX may represent a novel high throughput and predictive drug response platform that enables compound ranking for preclinical and clinical applications.

Citation Format: Tessa M. DesRochers, Christina Mattingly, Stephen Shuford, Matthew Gevaert, David Orr, Carol Bult, Susie Airhart, Mingshan Cheng, Minan Wang, James Keck, Howland Crosswell. Enhancing drug discovery and development throughput without sacrificing predictivity: ex vivo 3D drug response profiling (DRP) using patient-derived xenografts (PDX). [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 318. doi:10.1158/1538-7445.AM2015-318

Abstract 3935: A perfused 3D co-culture model of vemurafenib-resistant melanoma

Background: Vemurafenib(VF) is highly active against melanomas with a BRAFV600E mutation. Although remarkable clinical responses occur, progression ensues, in part due to innate resistance driven by the tumor micro-environment (TME). 2D co-culture screens have demonstrated that the cMet-HGF axis is an important mediator of TME-associated resistance. However, many aspects of the TME including cell-extracellular matrix (ECM), ligand-receptor interactions and signaling are different in 3D versus 2D cultures, thus potentially limiting the clinical utility of a 2D co-culture screen. We report our initial results of a 3D perfused co-culture model of VF-resistant melanoma as a clinically relevant screen for identifying agents and combinations to revert VF resistance. Methods: Media conditions, 3D hydrogel scaffolds and cell ratios were optimized prior to establishing 3D co-cultures. Stromal components and tumor cells were assessed for adaptation to 3D perfused conditions using the 3DKUBE™ segregated co-culture plasticware. Multi-syringe pumps achieved flow rates of 10ul/min. Analysis consisted of cell viability, dsDNA quantification, confocal imaging and immunoassays (secreted HGF and c-Met). Results: Fibroblast HGF production correlated with increasing cell numbers in 3D perfusion, but not in 2D and there was significantly more HGF produced by fibroblasts in 3D perfusion (2504 v 1639 pg/ml, p&lt;.05). Melanoma spheres maintained cell viability better in Matrigel ™ versus Matrigel:Collagen mix and retained 3D structure in perfused co-culture for 7 days. VF showed increased activity in melanoma spheroids in 3D ECM-free static cultures versus 2D monolayer (IC50 0.016uM v 15.79µM). There was a concentration-dependent response but reduced activity of VF against perfused 3D melanoma spheroids embedded in ECM, whereas there was no effect of VF against perfused melanoma spheroids in co-culture. Conclusion: V600E melanoma cells are extremely sensitive to BRAF targeting in 3D ECM free spheroids as compared with 2D monolayers. Clinical resistance is mimicked by a more complex 3D TME comprising ECM, perfusion and segregated co-culture of HGF-secreting fibroblasts in 3D. Mechanistic studies are ongoing to identify specific factors critical for VF resistance, including HGF/cMet axis interrogation. Future Direction: The ultimate goal is to establish clinically relevant 3D perfused co-culture models to identify novel agents or combinations which will overcome TME-mediated resistance to VF and other targeted agents. Future efforts are focused on incorporation of well characterized primary malignant epithelial cells with defined stromal components in the 3D perfused co-culture model in order to better identify combinations of multitargeted agents in both the preclinical(lead compound selection) and the co-clinical process (patient selection).

Citation Format: Chaitra Cheluvaraju, Stephen Shuford, Christina Mattingly, Teresa DesRochers, Matthew Gevaert, David E. Orr, Hal E. Crosswell. A perfused 3D co-culture model of vemurafenib-resistant melanoma. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3935. doi:10.1158/1538-7445.AM2014-3935

Characterization of a newly established human pancreatic carcinoma cell line, UK Pan-1

BACKGROUND

A highly tumorigenic cell line designated as UK Pan-1 was established in a surgically removed human pancreatic adenocarcinoma and characterized as having many of the genotypic and phenotypic alterations commonly found in pancreatic tumors.

METHODS

The cell line was characterized by its morphology, growth rate in monolayer culture and soft agar, tumorigenicity in nude mice, and chromosomal analysis. Furthermore, the status of p53, Ki-ras mutation and transforming growth factor (TGF)-/receptor expression were determined. The characteristics of UK Pan-1 were compared with those of other commonly used pancreatic carcinoma cell lines.

RESULTS

Quiescent UK Pan-1 cells could be stimulated to proliferate in growth factor free nutrient media, indicating a growth factor independent phenotype. UK Pan- 1 cells grew in soft agar and rapidly formed tumors in nude mice. This cell line possesses a mutation at codon 12 of the c-Ki-ras-2 gene that is commonly found in pancreatic carcinoma. Fluorescence in situ hybridization showed that two alleles of p53 tumor suppressor gene were present in UK Pan-1. However, sequencing analysis revealed a mutation in one allele at exon 8, codon 273 (G to A; Arg to His). Additional growth assays indicated that the cell line was insensitive to negative growth regulation induced by exogenous TGF-beta. Molecular analysis of the TGF-beta signaling pathway showed that UK Pan-1 did not express appreciable levels of the TGF-beta receptor type I, II, or III mRNAs, but did express DPC4 mRNA. Karyotype analysis revealed an 18q21 deletion indicating a possible loss of heterozygosity for DPC4, as well as other chromosomal deletions and rearrangements.

CONCLUSIONS

This study indicates that UK Pan-1 is a highly tumorigenic cell line possessing a molecularly complex pattern of mutations that may be used as a model to further the understanding of the mechanisms responsible for the development of pancreatic carcinoma.

In search of the good: narrative reasoning in clinical practice

Based on ethnographic work among North American occupational therapists, I compare two forms of everyday clinical talk. One, "chart talk," conforms to normative conceptions of clinical rationality. The second, storytelling, permeates clinical discussions but has no formal status as a vehicle for clinical reasoning. I argue that both modes of discourse provide avenues for reasoning about clinical problems. However, these discourses construct very different clinical objects and different phenomena to reason about. Further, the clinical problems created through storytelling point toward a more radically distinct conception of rationality than the one underlying biomedicine as it is formally conceived. Clinical storytelling is more usefully understood as a mode of Aristotle's "practical rationality" than the technical rationality of modern (enlightenment) conceptions of reasoning.

Metaphor and meaning in a clinical interview

This study examined the narrative features of 20 life histories gathered from psychiatric patients with the Occupational Performance History Interview. The aim was to identify how narrative features were present in the patient interview responses and to illustrate how such narrative features can be located. We found that the patients organized their interview responses with deep metaphors that served to "emplot," or give meaning to, the life story. This article illustrates how patients used the deep metaphors to both circumscribe and frame possible solutions to the problems in their lives. Deep metaphors are consistent, recurring images of a life story that give coherence to, and aid in, the interpretation of the events of that life. Moreover, we explored how metaphors can be located in patient life histories and their implications for occupational therapy.

In vitro cytolytic activity of lymphocytes from tumor-draining lymph nodes is associated with increased numbers of CD8+ cells and increased cytokine production

A murine footpad tumor model was used to determine the cytotoxic activity, tumor specificity, phenotypic profile, and cytokine production of stimulated cells from draining lymph nodes (DLN). Popliteal DLN from 5-day-old P-815 footpad tumors were stimulated with 10(-7) M phorbol 12, 13-dibutyrate +5 x 10(-7) M ionomycin for 16 hr and cultured in IL-2 (20 units/ml) for 7 or 14 days without autologous tumor. Most cells in both groups were CD3+ (93% at Day 7, 99% at Day 14); however, the percentage of CD8+ cells increased as the cell population matured in the presence of low-dose IL-2. On Day 7, the phenotypic profile was 62% CD4+ and 29% CD8+, whereas on Day 14 it was 16% CD4+ and 81% CD8+. Similarly, in vitro cytokine production increased with time in culture. After 7 days, the level of tumor necrosis factor-alpha (TNF-alpha) was 220 pg/mL and the interferon-gamma (IF-gamma) production was 150 pg/ml. At Day 14 the TNF level had increased to 500 pg/ml, and IF production had increased to 350 pg/ml. These increases in the CD8+ population and in cytokine production correlated with the increase in the percentage of target cells killed by the DLN cells. Cytolytic activity against P-815 was only 13% on Day 7 but 39% on Day 14. Neither group of effector cells (Day 7 or Day 14) had any cytolytic activity against the syngeneic tumor cell line L-1210, demonstrating the tumor specificity of the DLN cells. We describe a model for generating tumor-specific cytotoxic T-cells that have significant cytokine production, which may account for previously described in vivo activity.

Proliferation-associated nucleolar antigen P120: a prognostic marker in node-negative breast cancer

BACKGROUND

P120 is a nucleolar proliferation antigen found in rapidly dividing cells and in a variety of malignancies.

METHODS

Our purpose was to determine whether P120 expression is a prognostic factor for patients with node-negative breast cancer by testing pathologic material from 90 patients for P120 immunoreactivity, histologic grade, and estrogen receptors.

RESULTS

P120 was detected in 52 of the 90 specimens (58%). Node-negative cancer patients with tumors that did not express the P120 antigen had a significantly better overall survival rate than node-negative cancer patients with tumors that did express P120 (92% vs 69%; p = 0.035). Histologic studies indicated that 36 tumors were grade I, 28 were grade II, and 26 were grade III. The presence of P120 correlated significantly with the nuclear grade of the tumor: 73% of grade III tumors, 64% of grade II tumors, and 42% of grade I tumors stained positive for P120 (p = 0.033). The correlation between nuclear grade and overall survival rate was also significant (grade 1, 94%; grade II, 79%; grade III, 58%); (p = 0.003). No significant correlation was found between P120 expression and estrogen receptors. Multivariate analysis shows that P120 expression and histologic grade together are the strongest predictors of survival.

CONCLUSIONS

The biologic marker P120 may play an important role in determining which patients with node-negative cancer will benefit most from adjuvant therapy.

The terrible adventure of rehabilitation

Friendship with patients, caregivers are taught during their professional training, is to be avoided. Yet the capacity for friendship--to be "a person who emerges in her personhood and not simply as a professional"--may be crucial to effective therapy.

Volition as narrative: understanding motivation in chronic illness

This paper expands the current concept of volition in the Model of Human Occupation. The present version views personal causation, values, and interests as traits that determine choices to engage in occupations. Through a detailed investigation of the life histories of two persons with psychiatric disorders, this paper illustrates how volition is embedded in a personal narrative. Two features of narratively organized volition are highlighted: (a) how narrative places decisions and actions within a plot, thus giving them meaning in the context of a whole life, and (b) how the personal narrative motivates the person by serving as a context for choosing and action. Thus, the paper illustrates how persons seek to narrate their lives and live their life narratives.

Oncology and narrative time

Oncologists encounter the uncertainty of time horizons in their patients' lives. Although American oncologists are given a cultural mandate to instill hope in the therapeutic narratives they create with patients, uncertainty leads them to expressions of time without horizons or of time with highly foreshortened horizons as they seek to create for patients an experience of immediacy rather than of chronology. The distinctiveness of the American pattern is highlighted through comparison with Japanese exemplar cases and stories of therapeutic practices in oncology. Concepts drawn from narrative analysis of temporality and the construction of the therapeutic plot are employed.

The concept of therapeutic 'emplotment'

This paper considers the narrative structure of clinical action. I argue that clinical encounters involve clinician and patient in the creation and negotiation of a plot structure within clinical time. This clinical plot gives meaning to particular therapeutic actions by placing them within a larger therapeutic story. No therapeutic plot is completely pre-ordained, however. Improvisation and revision are necessary to its creation. In making a case for the narrative construction of lived time, of narratives that are created before they are told, this paper departs from the predominant mode of narrative analysis within medical anthropology that has focused on narrative discourse. Therapeutic emplotment is concretely considered through an interpretation of a single case, a clinical interaction between an occupational therapist and a head-injured patient.

Incorporation of ethnographic methods in occupational therapy assessment

Many constructs of interest to occupational therapists can only be studied through qualitative methods. Such constructs include meaning of activity or the illness experience and the context in which these occur. The purpose of this paper is to describe how ethnographic methods used in research can be generalized and applied to clinical practice. Ethnography is compared with other qualitative research approaches and a model clinical ethnographic assessment process is described.

Coumarin (1,2-benzopyrone) enhances DR and DQ antigen expressions by peripheral blood mononuclear cells in vitro

Coumarin (1,2-benzopyrone) is a natural substance that appears to have some clinical activity against renal cell carcinoma and malignant melanoma. Preliminary evidence from in vitro and in vivo studies suggests that coumarin possesses immunomodulatory activity. It was reported previously that coumarin therapy resulted in augmented DR antigen expression by peripheral blood monocytes in cancer patients. The purpose of the present study was to examine the effects of coumarin on DR and DQ antigen expression by normal donor peripheral blood mononuclear cells in vitro. Using monoclonal antibody labeling techniques and FACS analysis, it was shown that both DR and DQ antigen expression by peripheral blood mononuclear cells were enhanced over controls after 48 hours of exposure to coumarin. While monocytes normally express these antigens, enhanced expression is consistent with an activated state. These results support the hypothesis that coumarin acts, at least in part, through immune augmentation.

What is clinical reasoning?

This paper offers a concept of clinical reasoning that differs from many of the traditional definitions of clinical reasoning in occupational therapy and the health professions in general. Here, clinical reasoning in occupational therapy is described as a largely tacit, highly imagistic, and deeply phenomenological mode of thinking. It is argued that clinical reasoning involves more than the ability to offer explicit reasons that justify clinical decisions because it is also based on tacit understanding and habitual knowledge gained through experience. Clinical reasoning also involves more than a simple application of theory, particularly theory as understood in the natural sciences, because complex clinical tasks often require that the therapist improvise a treatment approach that addresses the unique meaning of disability as it relates to a particular patient.

The narrative nature of clinical reasoning

Narrative reasoning is a central mode of clinical reasoning in occupational therapy. Therapists reason narratively when they are concerned with disability as an illness experience, that is, with how a physiological condition is affecting a person's life. In this paper, narrative reasoning is contrasted with propositional reasoning, and two kinds of narrative thinking are examined. The first is the use of narrative as a mode of speech that can be contrasted with biomedical discourse, in which disability is framed as physical pathology. The second involves the creation rather than the telling of stories. Therapists try to "emplot" therapeutic encounters with patients, that is, to help create a therapeutic story that becomes a meaningful short story in the larger life story of the patient.

Anthropology, occupational therapy, and action research

This paper describes the research process and methodology used in the American Occupational Therapy Association/American Occupational Therapy Foundation Clinical Reasoning Study. This study examined the clinical reasoning of occupational therapists through a 2-year ethnography of therapists at one hospital site. The research was innovative in several important respects. One important innovation was a combined ethnographic and action research design that involved collaboration between the research team and those therapists being studied. Therapists who were research subjects became actively involved in examining and reflecting on their own practice through group analysis of videotaped sessions with clients. One outcome of this action research component was that the study served as both a research and a staff development project.