The implementation of an advanced practice radiation therapy (APRT) program in Singapore.

BACKGROUND: The exploration of Advanced Practiced Radiation Therapists (APRTs) development in Singapore started in 2011. This study aims to provide an overview of the development of the APRT roles, and to discuss the approaches used to develop and implement these roles in Singapore. MATERIALS AND METHODS: A mixed methods approach was used in the development of the APRT program. A literature review was carried out to define the APRT scope of practice and core responsibilities. A competency and assessment framework were setup to assess the core competency areas. With this framework, a structured 1-year residency training program was developed. RESULTS: The scope of practice and core responsibilities of APRTs were defined with five proposed advanced practice profiles being successfully validated. A competency framework was set up to assess the core competency domains: clinical, technical and professional competencies, research, education and leadership. A 4-point scoring system was developed for the competency assessment based on two criteria; the frequency with which RTTs would demonstrate competency, and the ability of performing the task competently. A 1-year structured APRT residency program was developed and implemented. The programme consisted of structured lectures, and clinical practice-based modules where APRT residents receive structured mentoring under a mentorship program. CONCLUSION: The APRT program in Singapore employed an evidence-based implementation process that tested the feasibility of a new practice model. Multidisciplinary involvements, mentorship and clinical training were important factors for the success of the APRT program.

Nurses' perspectives on their communication with patients in busy oncology wards: A qualitative study.

BACKGROUND: Despite an increase in emphasis on psychosocial care in cancer nursing, time constraints and nurses' lack of knowledge in skilled communication continue to be challenges. AIMS: To examine how cancer care nurses view their communication with patients and how they deal with the psychosocial needs of patients in busy wards. DESIGN: A qualitative interview study. METHODS: Focus groups and individual interviews were conducted with eleven hospital-based cancer nurses in Hong Kong from July 2, 2017 to January 2, 2018. RESULTS: A qualitative thematic analysis of the data identified three themes: 1. Intentional and unintentional psychosocial care that is secondary in focus; 2. Managing an emotionally challenged environment; 3. Mentoring and learning. CONCLUSION: Oncology settings are time-constrained, emotionally charged environments for nurses, and providing psychosocial care for patients is a secondary concern. While proactive strategies can be used to avert patient complaints, being open and attending to the individual needs of patients is equally important to avoid blocking in nurse-patient communication. Despite emotional entanglement and tensions, the positive follow-up strategies used by nurses to manage the patients' emotions and provide psychosocial care reflect good practices. Leadership and support are needed to deal with the nurses' perception that their communication training has been ineffective and their ability to manage strong emotions deficient. Communication skills, honed by making continuous opportunities to communicate available, as well as an understanding of emotional labour, need to be integrated with mindfulness in the nurses' care of themselves and their patients. Notwithstanding the importance of experience in oncology care for junior nurses, it is necessary for both junior and senior nurses to learn about and reflect upon the different forms of emotional labour if value-based care is to be provided. In addition, it is essential for junior nurses to receive continuous coaching and mentoring, and to engage in reflective learning from each clinical encounter with oncology patients.

Validation of the AJCC 8th prognostic system for breast cancer in an Asian healthcare setting.

AIMS: We aim to validate the AJCC 8th edition prognostic staging system for breast cancer in an Asian setting. METHODS: Clinico-pathologic information and cancer-specific survival (CSS) outcomes of 6287 stage I to III patients with invasive breast cancer who underwent upfront surgery at SingHealth institutions in Singapore from 2006 to 2014 were analyzed. Survival distributions for the different staging systems were estimated by the Kaplan-Meier method and compared using the log-rank tests. Multivariable Cox proportional hazards models were used, with Akaike Information Criterion (AIC) and Harrell's Concordance Index (C-index) to compare both staging systems. Among patients with positive hormone-receptor status, 84.8% received endocrine therapy. Among the cohort, 60.3% of received chemotherapy; 82.1% of node positive patients received chemotherapy and 86.0% of HER2-enriched patients in whom chemotherapy was also indicated received adjuvant HER2-targeted therapy. Ninety-seven percent of patients received anthracyclines and/or taxanes containing chemotherapy regime. RESULTS: The median follow up was 64 months. 2921 patients (46.5%) were discordant between the anatomic and prognostic systems of which 363 (5.8%) were upstaged and 2558 (40.7%) were down-staged. For all patients, stages in both the prognostic and anatomic systems were discriminating for 5-year CSS. Controlling for age, ethnicity and receipt of chemotherapy, the prognostic staging system model (AIC = 7538.87, C = 0.79) presented slightly better explanation and concordance of survival times than the anatomic staging system model (AIC = 7607.31, C = 0.77). CONCLUSION: The prognostic staging system was better than the anatomic staging system in predicting outcomes but the anatomic system remains relevant due to its ease of use.

Dopamine treatment during acute hypoxia is neuroprotective in the developing sheep brain.

Dopamine is often used to treat hypotension in preterm infants; these infants are at risk of developing brain injury due to impaired autoregulation and cerebral hypoperfusion. However the effects of dopamine on the immature brain under conditions of cerebral hypoxia are not known. We hypothesized that pretreatment with dopamine would protect the immature brain from injury caused by cerebral hypoxia. Preterm fetal sheep were used to determine the effects of intravenous dopamine on hypoxia-induced brain injury. In 16 pregnant sheep at 90days of gestation (0.6 of term, term=147days) catheters were implanted aseptically into the fetal carotid artery and jugular vein; an inflatable occluder was placed loosely around the umbilical cord for later induction of fetal hypoxemia. At 5days after surgery, dopamine (10µg/kg/min, n=7 fetuses) or saline (n=9 fetuses) was infused for 74h. Two hours after commencing the dopamine/saline infusion, we induced umbilical cord occlusion (UCO) for up to 25min to produce fetal asphyxia. Fetuses were allowed to recover, and brains were collected 72h later for assessment of neuropathology. Un-operated twin fetuses were used as age-matched non-UCO controls (n=8). In UCO+saline fetuses, microglial and apoptotic cell density in the subcortical and periventricular white matter, caudate nucleus and hippocampus was greater than that in age-matched controls; oxidative stress was elevated in the subcortical and periventricular white matter and caudate nucleus compared to that in age-matched controls. In UCO+dopamine fetuses microglial density and oxidative stress in the cerebral white matter and caudate nucleus were not different to that of age-matched controls. Apoptotic cell death was decreased in the cerebral white matter of UCO+dopamine brains, relative to UCO+saline brains. We conclude that pretreatment with dopamine does not exacerbate hypoxia-induced injury in the immature brain and may be neuroprotective because it led to decreased apoptosis, oxidative stress and neuroinflammation in the cerebral white matter and decreased neuroinflammation in the caudate nucleus.

Validation of a nomogram in the prediction of local recurrence risks after conserving surgery for Asian women with ductal carcinoma in situ of the breast.

AIMS: At our centre, ductal carcinoma in situ (DCIS) was commonly treated with breast-conservation therapy (BCT). Local recurrence after BCT is a major concern. The aims of our study were to review the outcomes of DCIS treatment in our patients and to evaluate a nomogram from Memorial Sloan Kettering Cancer Centre (MSKCC) for predicting ipsilateral breast tumour recurrence (IBTR) in our Asian population. MATERIALS AND METHODS: Chart reviews of 716 patients with pure DCIS treated from 1992 to 2011 were carried out. Univariable Cox regression analyses were used to evaluate the effects of the 10 prognostic factors of the MSKCC nomogram on IBTR. We constructed a separate National Cancer Centre Singapore (NCCS) nomogram based on multivariable Cox regression via reduced model selection by applying the stopping rule of Akaike's information criterion to predict IBTR-free survival. The abilities of the NCCS nomogram and the MSKCC nomogram to predict IBTR of individual patients were evaluated with bootstrapping of 200 sets of resamples and the NCCS dataset, respectively. Harrell's c-index was calculated for each nomogram to evaluate the concordance between predicted and observed responses of individual subjects. RESULTS: Study patients were followed up for a median of 70 months. Over 95% of patients received adjuvant radiotherapy. The 5 and 10 year actuarial IBTR-free survival rates for the cohort were 95.5 and 92.6%, respectively. In the multivariate analysis, independent prognostic factors for IBTR included use of adjuvant endocrine therapy, presence of comedonecrosis and younger age at diagnosis. These factors formed the basis of the NCCS nomogram, which had a similar c-index (NCCS: 0.696; MSKCC: 0.673) compared with the MSKCC nomogram. CONCLUSION: The MSKCC nomogram was validated in an Asian population. A simpler NCCS nomogram using a different combination of fewer prognostic factors may be sufficient for the prediction of IBTR in Asians, but requires external validation to compare for relative performance.

A syndemic including cigarette smoking and sexual risk behaviors among a sample of MSM in Shanghai, China.

OBJECTIVES: We explored possible correlates of cigarette smoking and their associations with levels of smoking among a sample of Chinese men who have sex with men (MSM). We also explored the syndemic associations of substance use and psychosocial problems on sexual risk behaviors. METHODS: Cross-sectional data collection from 404 MSM in Shanghai, China. RESULTS: MSM exhibit a high prevalence of smoking (66.3%). Both light and heavy smoking were associated with alcohol and drug use, depression, intimate partner violence, sexual attitudes, and gay identity (though the associations for light smokers were moderate compared to those for heavy smokers). CONCLUSIONS: Our findings indicate the presence of a health syndemic among MSM, and suggest that smoking prevention and cessation and other substance abuse interventions should be integrated into efforts preventing sexual risk behaviors among MSM.

Hong Kong patients' experiences of intensive care after surgery: nurses' and patients' views.

This study was designed to explore the lived experience of patients after elective surgery when they were being cared for in a surgical intensive care unit (ICU) in the immediate post-operative period. A phenomenological approach using unstructured interviews was employed and 10 ICU nurses and 10 patients were recruited for the study. Thematic data analysis was used. Most of the nurses believed that patients had memories of their ICU stay. Two clear categories emerged from the nurses' responses: 'perceptions of the feelings experienced by the patients' and 'perceptions of what patients experienced as support'. The nurses expressed that patients had feelings related to anxiety, pain and tiredness and they were frightened by the environment and the unknown. The nurses provided support to the patients by pre-operative visits, continuous and repeated explanation, encouraging family visits and ensuring adequate pain relief and sleep. All the patients could remember at least some of what happened during their stay in ICU. The 2 main categories which emerged from patients' responses were 'feelings experienced' and 'needs during the stay'. The patients recalled the feeling of anxiety about the reason for admission and a feeling of being safe in ICU. Six patients suffered from moderate to severe pain during movement and procedures and 2 patients complained of sleeping problems. They appreciated the preoperative visit and preferred the open unit design and flexible visiting hours. The four sub-categories: pain, sleep, pre-operative visits and family visits are discussed in detail and are reviewed in the light of other studies to compare the results. Ideas for nursing interventions to help overcome these problems are outlined and recommendations for future research are presented.

Posteromedial process fractures of the talus.

In this report, we present the diagnosis and clinical outcome of four patients with fractures of the posteromedial process of the talus. In two patients, the posteromedial process fracture was missed initially, which led to painful nonunions. One patient was treated with excision of a nonunion, and the other patient with a nonunion refused further surgery. Two patients underwent ORIF through a posteromedial approach. CT scans were useful in defining the fracture in all four patients. Cast treatment was recommended for displaced fractures or fractures without significant subtalar joint involvement. ORIF was recommended for displaced fractures with significant subtalar joint involvement.

Early diagnosis of congenital dislocation of the hip.

In this prospective study, 35,550 neonates were examined shortly after birth by a team of orthopaedic surgeons. They diagnosed 775 unstable or dislocated hips in 656 babies; there were two teratological dislocations. Treatment was first with a Frejka pillow and, if this failed to give a normal hip, a Pavlik harness at three months. Early clinical examination did not identify 21 infants who were found to have subluxation or dislocation of the hip at the three-month review. The number of missed cases declined during the study, however, reflecting the increasing experience of the examiners. One case of avascular necrosis occurred in the group treated from birth and one in the late-diagnosed group. Open reduction was necessary only in the two teratological dislocations. Experienced examiners are needed for accurate clinical diagnosis; and treatment should be started before the baby is discharged from the maternity ward.

Median nerve compression, with tendon ruptures, after Colles' fracture.

A rare case of rupture of the flexor pollicis longus tendon following a Colles' fracture is described. The patient also had a ruptured flexor digitorum profundus to the index finger and compression of the median nerve of the same hand. The ruptures were noted after four weeks of plaster immobilisation. Decompression of the median nerve and corrective osteotomy was performed but no tendon repair was attempted. The patient regained good function of the hand.