Cognitive apprenticeship in clinical practice; Can it be extended to postgraduate psychiatry training programmes?

Introduction: Postgraduate psychiatry training occurs in the workplace or situated learning settings. The Cognitive Apprenticeship Model [CAM] was introduced as an instructional model for situated learning. While undergraduate medical students' experience of the model has been tested, to our knowledge there has been no such reports from postgraduate psychiatry training. Methods: We surveyed 134 Oxford Deanery psychiatry trainees recruited between 2005 and 2013 through an online questionnaire. Respondents identified which CAM components [scaffolding, modelling coaching, articulation, reflection exploration] were the best aspects, and most needing improvement, in their clinical training. Results: Of 57 respondents, 80% were satisfied with and enjoyed [90%] their training. They recognised all individual CAM components; modelling and coaching were identified as the best methods. Exploration was identified as the one most in need of improvement. The behavioural [modelling, coaching and scaffolding] rather than the cognitive methods were identified as the best aspects of their training [54 v 35%, p < 0.001]. Conclusions: The results extend findings from undergraduate students in suggesting that the CAM is a useful model for training strategies. Greater awareness of the cognitive components may be needed. The training methods could be included as indicators of training quality in national quality assurance surveys

Determinants of Depressive Symptoms at 1 Year Following ICU Discharge in Survivors of $ 7 Days of Mechanical Ventilation : Results From the RECOVER Program, a Secondary Analysis of a Prospective Multicenter Cohort Study

Abstract : Background: Moderate to severe depressive symptoms occur in up to one-third of patients at 1 year following ICU discharge, negatively affecting patient outcomes. This study evaluated patient and caregiver factors associated with the development of these symptoms. Methods: This study used the Rehabilitation and Recovery in Patients after Critical Illness and Their Family Caregivers (RECOVER) Program (Phase 1) cohort of 391 patients from 10 medical/surgical university-affiliated ICUs across Canada. We determined the association between patient depressive symptoms (captured by using the Beck Depression Inventory II [BDI-II]), patient characteristics (age, sex, socioeconomic status, Charlson score, and ICU length of stay [LOS]), functional independence measure (FIM) motor subscale score, and caregiver characteristics (Caregiver Assistance Scale and Center for Epidemiologic Studies-Depression Scale) by using linear mixed models at time points 3, 6, and 12 months. Results: BDI-II data were available for 246 patients. Median age at ICU admission was 56 years (interquartile range, 45-65 years), 143 (58%) were male, and median ICU LOS was 19 days (interquartile range, 13-32 days). During the 12-month follow-up, 67 of 246 (27.2%) patients had a BDI-II score ≥ 20, indicating moderate to severe depressive symptoms. Mixed models showed worse depressive symptoms in patients with lower FIM motor subscale scores (1.1 BDI-II points per 10 FIM points), lower income status (by 3.7 BDI-II points; P = .007), and incomplete secondary education (by 3.8 BDI-II points; P = .009); a curvilinear relation with age (P = .001) was also reported, with highest BDI-II at ages 45 to 50 years. No associations were found between patient BDI-II and comorbidities (P = .92), sex (P = .25), ICU LOS (P = .51), or caregiver variables (Caregiver Assistance Scale [P = .28] and Center for Epidemiologic Studies Depression Scale [P = .74]). Conclusions: Increased functional dependence, lower income, and lower education are associated with increased severity of post-ICU depressive symptoms, whereas age has a curvilinear relation with symptom severity. Knowledge of risk factors may inform surveillance and targeted mental health follow-up. Early mobilization and rehabilitation aiming to improve function may serve to modify mood disorders

Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

BackgroundAnterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.MethodsWe did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.FindingsBetween Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.InterpretationSurgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management

Collateral sensitivity to cisplatin in KB-8-5-11 drug-resistant cancer cells

BACKGROUND: KB-8-5-11 cells are a drug-resistant cervical cell model that overexpresses ABCB1 (P-glycoprotein). KB-8-5-11 has become sensitive to non-ABCB1 substrate cisplatin. Understanding the mechanism of collateral sensitivity to cisplatin may lead to biomarker discovery for platinum sensitivity in patients with cancer. MATERIALS AND METHODS: A Taqman low-density array was used to characterize the expression of 380 genes previously associated with chemoresistance. Identified pathways were further analyzed using cytotoxicity assays, metabolomics and western blots. RESULTS: KB-8-5-11 cells were sensitive to CuSO4 and the glutathione inhibitor buthionine sulphoximine. Expression of ATPase, Cu(2+) transporting alpha (ATP7A) and ATP7B were decreased at the protein and gene levels respectively in KB-8-5-11. KB-8-5-11 had decreased gene expression of glutathione S-transferase pi 1 (GSTP1), GSTA4 and GSTK1. Cisplatin treatment significantly lowered total cellular glutathione in parental KB-3-1 cells. Glutathione also tended to be lower in KB-8-5-11 cells compared to KB-3-1 cells. CONCLUSION: KB-8-5-11 cells have alterations in their copper transporters and glutathione metabolism, contributing to their cisplatin-sensitive phenotype

Discursive constructions of professional identity in policy and regulatory discourse

Aim To examine and describe disciplinary discourses conducted through professional policy and regulatory documents in nursing and midwifery in Ireland. Background A key tenet of discourse theory is that group identities are constructed in public discourses and these discursively‐constructed identities become social realities. Professional identities can be extracted from both the explicit and latent content of discourse. Studies of nursing's disciplinary discourse have drawn attention to a dominant discourse that confers nursing with particular identities, which privilege the relational and affective aspects of nursing and in the process, marginalise scientific knowledge and the technical and body work of nursing. Design We used critical discourse analysis to analyse a purposive sample of nursing and midwifery regulatory and policy documents. Method We applied a four‐part, sequential approach to analysing the selected texts. This involved identifying key words, phrases and statements that indicated dominant discourses that, in turn, revealed latent beliefs and assumptions. The focus of our analysis was on how the discourses construct professional identities. Findings Our analysis indicated recurring narratives that appeared to confer nurses and midwives with three dominant identities: ‘the knowledgeable practitioner’, the ‘interpersonal practitioner’ and the ‘accountable practitioner’. The discourse also carried assumptions about the form and content of disciplinary knowledge. Conclusions Academic study of identity construction in discourse is important to disciplinary development by raising nurses’ and midwives’ consciousness, alerting them to the ways that their own discourse can shape their identities, influence public and political opinion and, in the process, shape public policy on their professions

Integrative review; identifying the evidence base for policymaking and analysis in health care

Aim The aim of this was to identify and synthesize the evidence underpinning the health policymaking process to inform the development of a health‐related policy analysis framework. Design A mixed methods review using “Best Fit” Framework synthesis. Data Sources PUBMED and CINAHL+ databases for English language papers published between March 2013 – March 2017. Review Methods Titles were screened, data abstracted and analysed by two authors at each stage. Findings from included studies were coded against six a priori categories which had been constructed through a preliminary literature review, consultation and consensus. Results Sixty‐eight papers were included. There exists empirical support for six key domains which require to be addressed in the policymaking and analysis process: (1) Context; (2) Process; (3) Content; (4) Stakeholder Consultation; (5) Implementation; and (6) Evaluation. Failure to contextualize and integrate these six domains in problem identification, policy analysis, strategy and policy development, policy enactment and policy implementation is problematic. Conclusion There is a need to test and refine the constructs linked to the policymaking cycle taking cognizance of the context where these are developed, implemented and evaluated. Impact This review makes a novel contribution to the synthesis of evidence to inform the policymaking and analysis process. Findings illuminate the complexity of policymaking, the competing pressures involved and the importance of the local, national and international context. These findings have international relevance and provide empirical support for key criteria to guide those involved in context specific policymaking and/or the analysis of existing policy

Developing a new health-related policy analysis tool: An action research cooperative inquiry approach

Aim To develop a tool for the analysis of nursing, midwifery and health‐related policy and professional guidance documents. Background Analysis tools can aid both policy evaluation and policy development. However, no framework for analysing the content of professional regulation and guidance documents among health care professionals currently exists. Method This study used an action research, cooperative inquiry design. Data were generated from two integrative literature reviews and discussions held during the cooperative inquiry meetings. Results A set of key themes to be considered in the development or evaluation of health policy or professional regulation and guidance documents were identified. These themes formed the basis of the six domains considered by the Health‐related Policy Analysis Tool (HrPAT): Context, Process, Content, Stakeholder Consultation, Implementation and Evaluation. Conclusion Use of the HrPAT can assist in policy development, evaluation and implementation, as well as providing some retrospective analytical insights into existing health policies. Implication for Nursing Management Professional regulation documents, guidelines and policy reports should be capable of being scrutinized for their content, quality and developmental process. The HrPAT can assist relevant stakeholders in the development, analysis and evaluation of such documents, including local, service‐level policies and guidelines

A protein interaction landscape of breast cancer

Cancers have been associated with a diverse array of genomic alterations. To help mechanistically understand such alterations in breast-invasive carcinoma, we applied affinity purification–mass spectrometry to delineate comprehensive biophysical interaction networks for 40 frequently altered breast cancer (BC) proteins, with and without relevant mutations, across three human breast cell lines. These networks identify cancer-specific protein-protein interactions (PPIs), interconnected and enriched for common and rare cancer mutations, that are substantially rewired by the introduction of key BC mutations. Our analysis identified BPIFA1 and SCGB2A1 as PIK3CA-interacting proteins, which repress PI3K-AKT signaling, and uncovered USP28 and UBE2N as functionally relevant interactors of BRCA1. We also show that the protein phosphatase 1 regulatory subunit spinophilin interacts with and regulates dephosphorylation of BRCA1 to promote DNA double-strand break repair. Thus, PPI landscapes provide a powerful framework for mechanistically interpreting disease genomic data and can identify valuable therapeutic targets