Why We Need a Community of Practice for Dietitians Working in Indigenous Health

This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for self-archiving. © 2015 Dietitians Association of AustraliaThe current burden of disease in Indigenous Australians, compared with non‐Indigenous Australians, is well documented.1, 2 Indigenous people experience disproportionate rates of conditions including type 2 diabetes, cardiovascular disease and renal disease.1 Factors that contribute to this health gap include historical, political and socioeconomic marginalisation and negative assumptions about Indigenous peoples, which can result in intergenerational discriminatory practices that have a profound effect on health and wellbeing.3 Nutrition is an important part of the prevention and management of many of these health issues including overweight and obesity4 and diabetes.5 National policy has recognised the vital role of the nutrition workforce in preventing and managing there conditions.6 Therefore, dietitians play an important role in working with Indigenous communities. However, there is a lack of evidence about how best to support dietitians working in the Indigenous health sector. There is evidence that dietitians face challenges working in Indigenous health.7 Anecdotal evidence suggests that these individuals experience professional isolation, are often sole practitioners, find it difficult to debrief in their workplace and with dietetic colleagues, are often in the minority due to the lack of nutrition‐specific positions in Indigenous nutrition and are at high risk of burnout. This is particularly the case for dietitians working in rural and remote areas, who often work with Indigenous people due to the higher proportion of Indigenous people living outside capital cities compared with the entire Australian population.8, 9 Support networks have been identified as one factor that contribute to dietitians' decisions to begin and continue working in rural and remote locations.10 Mentoring may offer promise.11 A disincentive for dietitians to work in rural communities has been identified to be limited professional development opportunities,12 highlighting the importance of offering professional development to those working in Indigenous health and rural health. One way to address this is a peer mentoring approach known as Community of Practice (CoP). A CoP is a group of people who come together to share resources and create new knowledge to advance a topic of professional practice.13 A CoP has been shown to be an effective workforce capacity‐building intervention, particularly in novice workforces characterised by professional isolation and split function roles, including public health nutritionists.14, 15 Building on evidence of the CoP model for public health nutritionists and nutritionists working with Indigenous stores16 and recognising the anecdotal challenges faced by dietitians working in Indigenous health, a CoP approach may offer an effective workforce development strategy to strengthen the capacity of dietitians working in Indigenous health across Australia. A pilot CoP for dietitians working in Indigenous health was run from May 2013 to May 2014. Six participants met every six weeks through Skype and the discussion was guided by a peer facilitator, also part of the peer mentoring approach. The objectives of the CoP were To assist dietitians working in Indigenous health to feel more supported in their workplace, reduce professional isolation and increase retention. To support dietitians working in Indigenous health. To build the competence (skill, knowledge and attitudes) of dietitians working in Indigenous health through the CoP using performance criteria developed by the Australian Government,17 which has been used previously in a similar setting.18 The aim of this pilot study was to determine to what extent these objectives were achieved. Preliminary data to assist in answering the evaluation questions from the six participants in this pilot suggests that CoP has increased participants' self‐rated confidence in the following areas (median score reported minimum score 1 maximum 5): Negotiate strategies to effectively accommodate cultural differences in the workplace (increased from 2.5 (pre‐CoP) to 4 (post‐CoP)) Acknowledge and respect the impact of events and issues in Aboriginal history during service delivery (increased from 3 (pre‐CoP) to 4 (post‐CoP)) Demonstrate knowledge of and respect for the diversity of culture, skin and language groups, family structures, art and religion in Indigenous cultures as part of service delivery (increased from 3 (pre‐CoP) to 4 (post‐CoP)) Identify ineffective communication strategies and remodel them to support delivery of health services (increased from 3 (pre‐CoP) to 4 (post‐CoP)) Take responsibility for revisiting strategies to assist in the resolution of any difficulties, differences or misunderstandings that may occur (increased from 3 (pre‐CoP) to 4 (post‐CoP)) In‐depth interviews were also conducted with the six participants providing positive feedback about the usefulness of the CoP to participants. A second CoP commenced in May 2014 and will conclude in May 2015. This will add data to the evaluation story initiated by the pilot and more fully explore whether the objectives have been achieved through more detailed analysis of in‐depth interviews from a larger sample of participants. Indigenous health is a challenging area in which to work. There is a lack of evidence about the best way to support dietitians to work in this area and there is a need to develop evidence about the suitability of support mechanisms. This project will contribute to evidence about effectiveness of a CoP approach and will help to determine best ways to support and build the competence of dietitians working in Indigenous health

Supporting dietitians to work in Aboriginal health: Qualitative evaluation of a Community of Practice mentoring circle

This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for self-archiving. © 2016 Dietitians Association of AustraliaAim This paper explores the experience of dietitians participating in a Community of Practice designed to support their work with Aboriginal communities. Methods The Community of Practice for dietitians working with Aboriginal communities ran for 12 months, starting in May 2014. Six‐weekly mentoring sessions were held using Skype, with conversation aided by a facilitator. In‐depth, semi‐structured interviews were held with all participants at the conclusion of the Community of Practice. Data were analysed using thematic analysis. Results Thirteen dietitians participated in the Community of Practice and an in‐depth, semi‐structured interview. Four key themes were identified: (i) Aboriginal health practice requires a different way of ‘knowing’, ‘being’ and ‘working’; (ii) Community of Practice is a safe place to discuss, debrief and explore ideas that are not safe elsewhere; (iii) participation in Community of Practice contributed to workforce retention in the Aboriginal health sector; and (iv) participation in Community of Practice contributed to dietitians changing their practice and feeling confident to do so. Conclusions By increasing confidence and opportunities for safe discussion, Community of Practice appears to be a useful model of Continuing Professional Development to support dietitians working in Aboriginal health

A pilot evaluation measuring the impact of a Community of Practice in Aboriginal health

© 2017 Informa UK Limited, trading as Taylor & Francis Group. This is the author accepted manuscript (post print) made available in accordance with publisher copyright policy.Effective strategies to enhance the competence of practising health professionals are limited. Communities of Practice are proposed as strategy, yet little is known about their ability to develop cultural competency and practice. This study aimed to measure the impact of a Community of Practice on the self-assessed cultural competency and change to practice of dietitians working in Aboriginal health. A mixed-method approach including a quantitative 16-item cultural-competency self-assessment tool (completed at baseline and after 12 months of participation) together with the qualitative most significant change stories were used. Quantitative and qualitative data were compared together for congruence and difference. All participants (n = 13) completed the cultural competency-self assessment and participated in the significant change story development. They reported that through networking and joint problem solving they increased competence (13 of 16 performance indicators) and qualitative described increased self-confidence for their work in Aboriginal health through improved understanding of the factors related to the impact of history, culture and utilisation of resources on service delivery, appropriate communication strategies, effective relationships and managing conflict. These findings suggests that formalised and structured Communities of Practice may be an effective workforce development strategy to influence the practice of health professionals working in Aboriginal health

Multiparametric Characterization of Intracranial Gliomas Using Dynamic [18F]FET-PET and Magnetic Resonance Spectroscopy.

Both static and dynamic O-(2-[18F]fluoroethyl)-l-tyrosine-(FET)-PET and 1H magnetic resonance spectroscopy (MRS) are useful tools for grading and prognostication in gliomas. However, little is known about the potential of multimodal imaging comprising both procedures. We therefore acquired NAA/Cr and Cho/Cr ratios in multi-voxel MRS as well as FET-PET parameters in 67 glioma patients and determined multiparametric parameter combinations. Using receiver operating characteristics, differentiation between low-grade and high-grade glioma was possible by static FET-PET (area under the curve (AUC) 0.86, p = 0.001), time-to-peak (TTP; AUC 0.79, p = 0.049), and using the Cho/Cr ratio (AUC 0.72, p = 0.039), while the multimodal analysis led to improved discrimination with an AUC of 0.97 (p = 0.001). In order to distinguish glioblastoma from non-glioblastoma, MRS (NAA/Cr ratio, AUC 0.66, p = 0.031), and dynamic FET-PET (AUC 0.88, p = 0.001) were superior to static FET imaging. The multimodal analysis increased the accuracy with an AUC of 0.97 (p < 0.001). In the survival analysis, PET parameters, but not spectroscopy, were significantly correlated with overall survival (OS, static PET p = 0.014, TTP p = 0.012), still, the multiparametric analysis, including MRS, was also useful for the prediction of OS (p = 0.002). In conclusion, FET-PET and MRS provide complementary information to better characterize gliomas before therapy, which is particularly interesting with respect to the increasing use of hybrid PET/MRI for brain tumors

Disparate Functional Responses to β-adrenergic and Ischaemic Challenge in Male and Female Hypertrophic Cardiomyocytes

Cardiac hypertrophy is the most potent cardiovascular risk factor after age, with relative mortality risk greater in women. The cognate issue of whether ischaemia coincident with hypertrophic co-morbidity has differing gender aetiology/outcome has not been addressed. We used a novel polygenic model of hypertrophy to examine male/female cellular stress responses in normal and hypertrophic cardiomyocytes.Centro de Investigaciones Cardiovasculare

Retrospective Analysis of Radiological Recurrence Patterns in Glioblastoma, Their Prognostic Value And Association to Postoperative Infarct Volume

Recent studies suggested that postoperative hypoxia might trigger invasive tumor growth, resulting in diffuse/multifocal recurrence patterns. Aim of this study was to analyze distinct recurrence patterns and their association to postoperative infarct volume and outcome. 526 consecutive glioblastoma patients were analyzed, of which 129 met our inclusion criteria: initial tumor diagnosis, surgery, postoperative diffusion-weighted imaging and tumor recurrence during follow-up. Distinct patterns of contrast-enhancement at initial diagnosis and at first tumor recurrence (multifocal growth/progression, contact to dura/ventricle, ependymal spread, local/distant recurrence) were recorded by two blinded neuroradiologists. The association of radiological patterns to survival and postoperative infarct volume was analyzed by uni-/multivariate survival analyses and binary logistic regression analysis. With increasing postoperative infarct volume, patients were significantly more likely to develop multifocal recurrence, recurrence with contact to ventricle and contact to dura. Patients with multifocal recurrence (Hazard Ratio (HR) 1.99, P = 0.010) had significantly shorter OS, patients with recurrent tumor with contact to ventricle (HR 1.85, P = 0.036), ependymal spread (HR 2.97, P = 0.004) and distant recurrence (HR 1.75, P = 0.019) significantly shorter post-progression survival in multivariate analyses including well-established prognostic factors like age, Karnofsky Performance Score (KPS), therapy, extent of resection and patterns of primary tumors. Postoperative infarct volume might initiate hypoxia-mediated aggressive tumor growth resulting in multifocal and diffuse recurrence patterns and impaired survival

The glioblastoma multiforme tumor site promotes the commitment of tumor-infiltrating lymphocytes to the TH17 lineage in humans

Although glioblastoma multiforme (GBM) is not an invariably cold tumor, checkpoint inhibition has largely failed in GBM. In order to investigate T cell-intrinsic properties that contribute to the resistance of GBM to endogenous or therapeutically enhanced adaptive immune responses, we sorted CD4(+) and CD8(+) T cells from the peripheral blood, normal-appearing brain tissue, and tumor bed of nine treatment-naive patients with GBM. Bulk RNA sequencing of highly pure T cell populations from these different compartments was used to obtain deep transcriptomes of tumor-infiltrating T cells (TILs). While the transcriptome of CD8(+) TILs suggested that they were partly locked in a dysfunctional state, CD4(+) TILs showed a robust commitment to the type 17 T helper cell (T(H)17) lineage, which was corroborated by flow cytometry in four additional GBM cases. Therefore, our study illustrates that the brain tumor environment in GBM might instruct T(H)17 commitment of infiltrating T helper cells. Whether these properties of CD4(+) TILs facilitate a tumor-promoting milieu and thus could be a target for adjuvant anti-T(H)17 cell interventions needs to be further investigated

Male and female hypertrophic rat cardiac myocyte functional responses to ischemic stress and β-adrenergic challenge are different

Background: Cardiac hypertrophy is the most potent cardiovascular risk factor after age, and relative mortality risk linked with cardiac hypertrophy is greater in women. Ischemic heart disease is the most common form of cardiovascular pathology for both men and women, yet significant differences in incidence and outcomes exist between the sexes. Cardiac hypertrophy and ischemia are frequently occurring dual pathologies. Whether the cellular (cardiomyocyte) mechanisms underlying myocardial damage differ in women and men remains to be determined. In this study, utilizing an in vitro experimental approach, our goal was to examine the proposition that responses of male/female cardiomyocytes to ischemic (and adrenergic) stress may be differentially modulated by the presence of pre-existing cardiac hypertrophy. Methods: We used a novel normotensive custom-derived hypertrophic heart rat (HHR; vs control strain normal heart rat (NHR)). Cardiomyocyte morphologic and electromechanical functional studies were performed using microfluorimetric techniques involving simulated ischemia/reperfusion protocols. Results: HHR females exhibited pronounced cardiac/cardiomyocyte enlargement, equivalent to males. Under basal conditions, a lower twitch amplitude in female myocytes was prominent in normal but not in hypertrophic myocytes. The cardiomyocyte Ca2+ responses to β-adrenergic challenge differed in hypertrophic male and female cardiomyocytes, with the accentuated response in males abrogated in females - even while contractile responses were similar. In simulated ischemia, a marked and selective elevation of end-ischemia Ca2+ in normal female myocytes was completely suppressed in hypertrophic female myocytes - even though all groups demonstrated similar shifts in myocyte contractile performance. After 30 min of simulated reperfusion, the Ca2+ desensitization characterizing the male response was distinctively absent in female cardiomyocytes. Conclusions: Our data demonstrate that cardiac hypertrophy produces dramatically different basal and stress-induced pathophenotypes in female- and male-origin cardiomyocytes. The lower Ca2+ operational status characteristic of female (vs male) cardiomyocytes comprising normal hearts is not exhibited by myocytes of hypertrophic hearts. After ischemia/reperfusion, availability of activator Ca2+ is suppressed in female hypertrophic myocytes, whereas sensitivity to Ca2+ is blunted in male hypertrophic myocytes. These findings demonstrate that selective intervention strategies should be pursued to optimize post-ischemic electromechanical support for male and female hypertrophic hearts.Facultad de Ciencias MédicasCentro de Investigaciones Cardiovasculare