Vaginal leiomyoma in a goat expressing the nuclear progesterone receptor (PGR): a case report.

BACKGROUND: The risk of developing tumorous diseases in the genital tract also increases with age in animals. One of the classified tumor types is genital leiomyoma. Presently, our understanding of the pathogenesis of this tumor in goats is, however, limited. This accounts also for the information regarding the presence of steroid hormone receptors and, thus, possible responsiveness to circulating steroids. CASE PRESENTATION: This study describes the case of a vaginal tumor in a seven-year-old Anglo-Nubian goat. The goat was presented due to blood mixed vaginal discharge. Per vaginal examination a singular pedunculated mass in the dorsum of the vagina measuring approximately 3 cm x 4 cm x 4 cm was revealed. After administering epidural anesthesia, the mass was removed electrothermally. There were no postoperative complications. The histopathological examination identified the mass as a leiomyoma. The immunohistochemical examination revealed the presence of the nuclear progesterone receptor (PGR) in the tumor tissue. One year after the surgery, during the follow-up examination, the goat was in good overall health, and the owners had not observed any recurrence of vaginal discharge. CONCLUSIONS: When observing vaginal discharge in goats, it is important to consider the possibility of genital tract tumors. These tumors may express sex steroid receptors. In the future, it is worth considering the investigation of potential approaches for preventing tumorigenesis or treating the tumor, such as castration or the administration of antiprogestogens.

MFSD2A frameshift variant in Kerry Hill sheep with microcephaly.

Microcephaly is a rare neurodevelopmental disorder characterized by reduced skull circumference and brain volume that occurs sporadically in farm animals. We investigated an early-onset neurodegenerative disorder observed in seven lambs of purebred Kerry Hill sheep. Clinical signs included inability to stand or severe ataxia, convulsions, and early death. Diagnostic imaging and brain necropsy confirmed microcephaly. The pedigree of the lambs suggested monogenic autosomal recessive inheritance. We sequenced the genome of one affected lamb, and comparison with 115 control genomes revealed a single private protein-changing variant. This frameshift variant, MFSD2A: c.285dupA, p.(Asp96fs*9), represents a 1-bp duplication predicted to truncate 80% of the open reading frame. MFSD2A is a transmembrane protein that is essential for maintaining blood-brain barrier homeostasis and plays a key role in regulating brain lipogenesis. Human MFSD2A pathogenic variants are associated with a neurodevelopmental disorder with progressive microcephaly, spasticity, and brain imaging abnormalities (NEDMISBA, OMIM 616486). Here we present evidence for the occurrence of a recessively inherited form of microcephaly in sheep due to a loss-of-function variant in MFSD2A (OMIA 002371-9940). To the best of our knowledge, this is the first report of a spontaneous MFSD2A variant in domestic animals.

Handle with Care: Transformative Learning as Pedagogy in an Under-Resourced Health Care Context.

Issue: A significant component of health professions education is focussed on students' exposure to the social determinants of health and the challenges that patients within the health care system face. An appropriate way to provide such exposure is through distributed clinical training. This usually entails students training in smaller groups along the continuum of care, away from tertiary academic hospitals. This also means students are away from their existing academic and social support systems. It is evident that knowledge and clinical skills alone are not sufficient to prepare students, they also need to be taught to critically reflect on how their own values and attitudes traverse their knowledge and skills to influence their practice as healthcare professionals. This process of critical reflection should aim to provide a transformative learning experience for students and requires active facilitation. In under-resourced health care contexts where clinicians responsible for student training are facing high patient load, lack of resources, inequitable health care services and high levels of burn-out, the facilitation of student learning may be compromised. Evidence: Clinical learning opportunities that are considered transformative, frequently challenge students' sense of self and sense of belonging. This experience can have detrimental effects if the processes of transformative learning pedagogy are not adequately facilitated. The provision of support staff, lecturers and clinical facilitators on the distributed training platform is challenged by the remote nature of some of the sites and the cost of recruiting and capacitating additional on-site staff. The potential for what has been termed "transformative trauma" and the subsequent halted transformative learning experience, has ethical implications in terms of student wellness and the educational responsibility institutions carry. Implications: The authors suggest considerations in facilitating an ethical transformative learning process. These include making the transformative learning pedagogy explicit to students and clinical facilitators and using the 'brave spaces' framework to help students with individuation and provide them with the tools to understand how emotion influences behavior. Strategies to improve relationship development and communities of support, as well as ideas for faculty development are offered.

Determinants of physical activity during cancer treatment: a longitudinal exploration of psycho-cognitive variables and physician counseling.

Individuals with cancer are recommended to engage in regular physical activity (PA) even during cancer therapy. The aim of this study was to explore how patient-reported physician PA counseling influences their PA intention and behavior in addition to psycho-cognitive determinants derived from the theory of planned behavior (TPB). A longitudinal study during cancer treatment was conducted among N = 115 patients with breast, prostate, or colorectal cancer (Mage = 58.0, SD = 11.5; 55.7% female). The median time since diagnosis was 2 months, and 19.1% were diagnosed with metastases. Participants provided information on PA counseling by their physicians and on psycho-cognitive variables of the TPB at three measurement points. Additionally, they wore accelerometers for seven days at baseline and three months later. Nearly half of participants (48%) reported basic PA counseling and 30% reported in-depth PA counseling. Patients in poorer health and with lower education reported significantly less in-depth counseling. In addition to patient self-efficacy in performing PA, only in-depth physician PA counseling, but not basic physician counseling, predicted intention for PA four weeks later. Patients' PA three months after baseline was predicted by patients' PA at baseline and their intention for PA. Overall, the PA level at baseline was identified as the most important predictor of PA three months later. Nevertheless, physicians seem to have the ability to increase their cancer patients' intention for PA by in-depth counseling.

Expected increase in health competence improves over modules of an unguided internet-based cognitive-behavioural therapy for obsessive-compulsive disorder.

Internet-based cognitive-behavioural interventions (iCBT) are a valuable alternative to face-to-face psychotherapy. An unguided iCBT program has shown to be efficacious for patients with obsessive-compulsive disorder (OCD). However, the modules' mode of action is not well understood, which is the objective of the present study. Twenty-five patients with OCD who participated at the iCBT program for 8 weeks answered a questionnaire on their self-efficacy, motivation, expected increase in health competence and experiential avoidance before and after each module and were included in the present analyses. Linear mixed-effects models demonstrated that patients' expected increase in health competence improved over the course of the treatment. No within-module-specific effect was found. The iCBT program was able to improve patients' expected health competence. However, all other variables did not change. The iCBT program should be revised by focusing more strongly on the integration of the content to reduce experiential avoidance and to improve motivation.

Reviewing academic coordination on the rural distributed training platform in South Africa.

INTRODUCTION: Distributed training of students from a variety of health professions is increasing in South Africa because of the type of learning it offers and that it caters for the increasing number of students being accepted into health sciences programs. Challenges and facilitators to distributed training are well documented in the literature, and include increased distance from the academic home, human resources for health challenges, student access to support systems, and identifying learning environments to match learning outcomes. In the case of the Rural Clinical School in the Western Cape, South Africa, 'academic coordinators' were employed on site to fulfil the role of coordinating and supervising student learning and community engagement. This article explores their experiences. METHODS: A large-scale qualitative study was conducted in 2017 exploring the history and development of the Ukwanda Centre for Rural Health and the Rural Clinical School. Part of this study included semi-structured individual and focus group interviews with consenting academic coordinators exploring their experiences of developing and working on a rural distributed training platform in South Africa. Data were inductively analysed. Ethical approval and institutional permission were obtained for this study, and all participants provided consent. RESULTS: In addition to previously published challenges that clinical supervisors who are employed by the health system face, the academic coordinators reported facing challenges related to professional isolation, boundary blurring between providing student support versus acting as clinical educator, juggling multiple line managers and administrative responsibilities, navigating the new field of academia, and not having the potential for career progression. CONCLUSION: Reflecting on the needs of academic coordinators expressed in this article, we identified four conditions that may promote sustained and continuous academic coordination at rural or remote distributed training sites. These conditions are (1) living and working local; (2) having a dual role in academia and the health system; (3) having access to academic support; and (4) regular engagement with the academic home, the value of which is detailed in this article. These recommendations can be adopted to optimise and sustain academic engagement on the distributed training platform, especially in light of the current expansion of health professions training and subsequent need to attract and retain clinician-academics in remote locations.

Transformative learning through participation: experiences at a rural clinical training site in South Africa.

BACKGROUND: Distributed training has been cited as an opportunity that offers transformative learning experiences in preparing a future workforce to address local needs. For this reason, rural and longitudinal placements are increasingly being adopted by medical schools across the world. Place, participation and person are considered integral in the process of transformation of medical students into responsive graduates on the distributed platform. This article aims to explore the experiences and perceptions of student learning on a rural training platform in South Africa while considering the interrelation between person, place and participation as a process of transformation to becoming a health care professional. The research forms part of a 5-year longitudinal case study, initiated in 2019 to explore a university-rural hospital collaboration on students, staff and the local health care system. METHODS: Data was collected using interviews and surveys from 63 purposively selected and consenting participants between January and November of 2019. All qualitative data were inductively analysed using an interpretivist approach to thematic analysis for the purposes of this article. All quantitative data was analysed descriptively using Microsoft Excel. Ethics and permission for this research was granted by the Stellenbosch University Human Research Ethics Committee, the Undergraduate Students Programme Committee and the Northern Cape Department of Health, South Africa. FINDINGS: Four themes, namely: authenticity of context; participation in a community of practice and social activities; supervision and reflection; and distance support were extracted from the data. These findings contribute to the theory of transformative learning on the distributed platform by expanding on the interrelationship of person, place and participation, specifically as it relates to participation within various communities and practices. The value of active participation in reflection and supervision, distance academic support and social support systems are explored. CONCLUSIONS: The three dimensions and interrelationship of person, place and participation in the process of transformative learning on the rural training platform can be further unpacked by exploring the types of participation that have facilitated student learning in this research context. Participation in interprofessional teams; supervision, reflection and distance support appear to be the most crucial elements during this transformative learning process.

Microglial CD74 Expression Is Regulated by TGFß Signaling.

Microglia play important roles during physiological and pathological situations in the CNS. Several reports have described the expression of Cd74 in disease-associated and aged microglia. Here, we demonstrated that TGFß1 controled the expression of Cd74 in microglia in vitro and in vivo. Using BV2 cells, primary microglia cultures as well as Cx3cr1CreERT2:R26-YFP:Tgfbr2fl/fl in combination with qPCR, flow cytometry, and immunohistochemistry, we were able to provide evidence that TGFß1 inhibited LPS-induced upregulation of Cd74 in microglia. Interestingly, TGFß1 alone was able to mediate downregulation of CD74 in vitro. Moreover, silencing of TGFß signaling in vivo resulted in marked upregulation of CD74, further underlining the importance of microglial TGFß signaling during regulation of microglia activation. Taken together, our data indicated that CD74 is a marker for activated microglia and further demonstrated that microglial TGFß signaling is important for regulation of Cd74 expression during microglia activation.

Preventive effect of sensorimotor exercise and resistance training on chemotherapy-induced peripheral neuropathy: a randomised-controlled trial.

BACKGROUND: Chemotherapy-induced peripheral neuropathy (CIPN) is a common, unpleasant and usually long-lasting side effect of neurotoxic chemotherapeutic agents. This study aimed to investigate the preventive potential of sensorimotor- (SMT) and resistance training (RT) on CIPN. METHODS: Patients (N = 170) were randomised to SMT, RT or usual care (UC). Both exercise groups trained 3×/week for a total of 105 min/week during neurotoxic chemotherapy (mean length: 20 weeks). Before and 3 weeks after neurotoxic chemotherapy, CIPN signs/symptoms were assessed via Total Neuropathy Score (TNSr; primary endpoint) and EORTC QLQ-CIPN15 questionnaire. In addition, balance (centre of pressure), muscle strength (isokinetic), quality of life (QoL, EORTC QLQ-C30) and relative chemotherapy dose intensity (RDI) were investigated. The follow-up period covered 6 months after the end of chemotherapy. RESULTS: Intention-to-treat analyses (N = 159) revealed no differences regarding CIPN signs/symptoms. Exploratory per-protocol analyses (minimum training attendance rate 67%; N = 89) indicated that subjectively perceived sensory symptoms in the feet increased less during chemotherapy in the adherent exercisers (pooled group: SMT+RT) than in the UC group (-8.3 points (-16.1 to -0.4); P = 0.039, ES = 1.27). Furthermore, adherent exercisers received a higher RDI (96.6 ± 4.8 vs. 92.2 ± 9.4; P = 0.045), showed a better course of muscular strength (+20.8 Nm (11.2-30.4); P < 0.001, ES = 0.57) and QoL (+12.9 points (3.9-21.8); P = 0.005, ES = 0.64). During follow-up, CIPN signs/symptoms persisted in all groups. CONCLUSIONS: This study demonstrates that SMT and/or RT alleviate subjectively perceived sensory CIPN symptoms in the feet and other clinically relevant cancer therapy-related outcomes, if an appropriate training stimulus is achieved. CLINICAL TRIAL REGISTRATION: NCT02871284.

Acute stress leaves fear generalization in healthy individuals intact.

Because threatening situations often occur in a similar manner, the generalization of fear to similar situations is adaptive and can avoid harm to the organism. However, the overgeneralization of fear to harmless stimuli is maladaptive and assumed to contribute to anxiety disorders. Thus, elucidating factors that may modulate fear (over)generalization is important. Based on the known effects of acute stress on learning, which are at least partly due to noradrenergic arousal, we investigated whether stress may promote fear overgeneralization and whether we could counteract this effect by reducing noradrenergic arousal. In a placebo-controlled, double-blind, between-subjects design, 120 healthy participants underwent a fear-conditioning procedure on Day 1. Approximately 24 hours later, participants received orally either a placebo or the beta-adrenergic receptor antagonist propranolol and were exposed to a stress or control manipulation before they completed a test of fear generalization. Skin conductance responses as well as explicit rating data showed a successful acquisition of conditioned fear on Day 1 and a pronounced fear generalization 24 hours later. Although physiological data confirmed the successful stress manipulation and reduction of noradrenergic arousal, the extent of fear generalization remained unaffected by stress and propranolol. The absence of a stress effect on fear generalization was confirmed by a second study and a Bayesian analysis across both data sets. Our findings suggest that acute stress leaves fear generalization processes intact, at least in a sample of healthy, young individuals.

Keeping the shoot above water - submergence triggers antithetical growth responses in stems and petioles of watercress (Nasturtium officinale).

The molecular mechanisms controlling underwater elongation are based extensively on studies on internode elongation in the monocot rice (Oryza sativa) and petiole elongation in Rumex rosette species. Here, we characterize underwater growth in the dicot Nasturtium officinale (watercress), a wild species of the Brassicaceae family, in which submergence enhances stem elongation and suppresses petiole growth. We used a genome-wide transcriptome analysis to identify the molecular mechanisms underlying the observed antithetical growth responses. Though submergence caused a substantial reconfiguration of the petiole and stem transcriptome, only little qualitative differences were observed between both tissues. A core submergence response included hormonal regulation and metabolic readjustment for energy conservation, whereas tissue-specific responses were associated with defense, photosynthesis, and cell wall polysaccharides. Transcriptomic and physiological characterization suggested that the established ethylene, abscisic acid (ABA), and GA growth regulatory module for underwater elongation could not fully explain underwater growth in watercress. Petiole growth suppression is likely attributed to a cell cycle arrest. Underwater stem elongation is driven by an early decline in ABA and is not primarily mediated by ethylene or GA. An enhanced stem elongation observed in the night period was not linked to hypoxia and suggests an involvement of circadian regulation.

Two Brassica napus cultivars differ in gene expression, but not in their response to submergence.

Heavy rainfall causes flooding of natural ecosystems as well as farmland, negatively affecting plant performance. While the responses of the wild model organism Arabidopsis thaliana to such stress conditions is well understood, little is known about the responses of its relative, the important oil crop plant Brassica napus. For the first time, we analyzed the molecular response of Brassica napus seedlings to full submergence in a natural light-dark cycle. We used two cultivars in this study, a European hybrid cultivar and an Asian flood-tolerant cultivar. Despite their genomic differences, those genotypes showed no major differences in their responses to submergence. The molecular responses to submergence included the induction of defense- and hormone-related pathways and the repression of biosynthetic processes. Furthermore, RNAseq revealed a strong carbohydrate-starvation response under submergence in daylight, which corresponded with a fast depletion of sugars. Consequently, both B. napus cultivars exhibited a strong growth repression under water, but there was no indication of a low-oxygen response. The ability of the European hybrid cultivar to form a short-lived leaf gas film neither increased underwater net photosynthesis, underwater dark respiration nor growth during submergence. Due to the high sensitivity of both cultivars, the analysis of other cultivars or related species with higher submergence tolerance is required in order to improve flood tolerance of this crop species. One major target could be the improvement of underwater photosynthesis efficiency in order to enhance submergence survival.

Comparison of subjectively and objectively assessed sleep problems in breast cancer patients starting neoadjuvant chemotherapy.

PURPOSE: To characterize sleep problems and to compare subjective and objective assessments in breast cancer patients starting neoadjuvant chemotherapy. METHODS: Sleep characteristics of 54 breast cancer patients starting neoadjuvant chemotherapy were analyzed. Subjective sleep characteristics were assessed with the Pittsburgh Sleep Quality Index (PSQI) and objective sleep measurements with an accelerometer (ActiGraph wGT3X-BT) worn on the wrist for 7 consecutive days. RESULTS: According to the common PSQI cut-off of 8, 10 (18.87%) of the patients were poor sleepers. ActiGraph measures did not mirror this classification as values for poor, and good sleepers did not differ significantly. Overall, Bland-Altman plots illustrated higher ActiGraph values for sleep efficiency and effective sleep time and lower values for sleep latency, compared with PSQI. For total sleep time, less disagreement between both measures was observed. Actigraphy was limited in precise identification of sleep begin and sleep latency but provided supplementary information about number and minutes of awakenings during the night. CONCLUSION: Subjective and objective measurement methods differed substantially in various parameters, with limitations in both methods. A combination of both methods might be most promising. TRIAL REGISTRATION: Clinicaltrials.gov : NCT02999074.

Influence of auditory attention on sentence recognition captured by the neural phase.

The aim of this study was to investigate whether attentional influences on speech recognition are reflected in the neural phase entrained by an external modulator. Sentences were presented in 7 Hz sinusoidally modulated noise while the neural response to that modulation frequency was monitored by electroencephalogram (EEG) recordings in 21 participants. We implemented a selective attention paradigm including three different attention conditions while keeping physical stimulus parameters constant. The participants' task was either to repeat the sentence as accurately as possible (speech recognition task), to count the number of decrements implemented in modulated noise (decrement detection task), or to do both (dual task), while the EEG was recorded. Behavioural analysis revealed reduced performance in the dual task condition for decrement detection, possibly reflecting limited cognitive resources. EEG analysis revealed no significant differences in power for the 7 Hz modulation frequency, but an attention-dependent phase difference between tasks. Further phase analysis revealed a significant difference 500 ms after sentence onset between trials with correct and incorrect responses for speech recognition, indicating that speech recognition performance and the neural phase are linked via selective attention mechanisms, at least shortly after sentence onset. However, the neural phase effects identified were small and await further investigation.

Glucocorticoids, Noradrenergic Arousal, and the Control of Memory Retrieval.

Glucocorticoids and noradrenaline can enhance memory consolidation but impair memory retrieval. Beyond their effects on quantitative memory performance, these major stress mediators bias the engagement of multiple memory systems toward "habitual" control during learning. However, if and how glucocorticoids and noradrenaline may also affect which memory system is recruited during recall, thereby affecting the control of retrieval, remain largely unknown. To address these questions, we trained healthy participants in a probabilistic classification learning task, which can be supported both by cognitive and habitual strategies. Approximately 24 hr later, participants received a placebo, hydrocortisone, yohimbine (an α2-adrenoceptor antagonist increasing noradrenergic stimulation), or both drugs before they completed a recall test for the probabilistic classification learning task. During training, all groups showed a practice-dependent shift toward more habitual strategies, reflecting an "automatization" of behavior. In the recall test, after a night of sleep, this automatization was even more pronounced in the placebo group, most likely due to offline consolidation processes and with beneficial effects on recall performance. Hydrocortisone or yohimbine intake abolished this further automatization, preventing the shift to a more efficient memory system and leading, in particular in the hydrocortisone group, to impaired recall performance. Our results suggest that glucocorticoids and noradrenergic stimulation may modulate the engagement of different strategies at recall and link the well-known stress hormone-induced retrieval deficit to a change in the system controlling memory retrieval.

Redundant ERF-VII Transcription Factors Bind to an Evolutionarily Conserved cis-Motif to Regulate Hypoxia-Responsive Gene Expression in Arabidopsis.

The response of Arabidopsis thaliana to low-oxygen stress (hypoxia), such as during shoot submergence or root waterlogging, includes increasing the levels of ∼50 hypoxia-responsive gene transcripts, many of which encode enzymes associated with anaerobic metabolism. Upregulation of over half of these mRNAs involves stabilization of five group VII ethylene response factor (ERF-VII) transcription factors, which are routinely degraded via the N-end rule pathway of proteolysis in an oxygen- and nitric oxide-dependent manner. Despite their importance, neither the quantitative contribution of individual ERF-VIIs nor the cis-regulatory elements they govern are well understood. Here, using single- and double-null mutants, the constitutively synthesized ERF-VIIs RELATED TO APETALA2.2 (RAP2.2) and RAP2.12 are shown to act redundantly as principle activators of hypoxia-responsive genes; constitutively expressed RAP2.3 contributes to this redundancy, whereas the hypoxia-induced HYPOXIA RESPONSIVE ERF1 (HRE1) and HRE2 play minor roles. An evolutionarily conserved 12-bp cis-regulatory motif that binds to and is sufficient for activation by RAP2.2 and RAP2.12 is identified through a comparative phylogenetic motif search, promoter dissection, yeast one-hybrid assays, and chromatin immunopurification. This motif, designated the hypoxia-responsive promoter element, is enriched in promoters of hypoxia-responsive genes in multiple species.

Factors Influencing Staff's Attitude Toward Electroconvulsive Therapy: A Comparison of New Versus Experienced Electroconvulsive Therapy Clinics.

OBJECTIVES: Despite being a highly effective treatment, electroconvulsive therapy (ECT) is still stigmatized even among professionals. The aim of this study was to identify factors associated with a positive attitude toward ECT among health care workers. METHODS: We investigated staff's attitude and their self-assessment of knowledge while introducing ECT in 3 German psychiatric clinics. Furthermore, we compared this data to that of a clinic where ECT has been applied with a long tradition. An anonymous questionnaire was answered by n = 182 employees in the ECT-introducing clinics (novices) and n = 68 employees in the clinic with a long history of ECT (experts). RESULTS: Irrespective of the clinical history, the majority of participants approved the application of ECT in their clinic. Factors associated with a positive attitude were (a) profession (physicians presented a more positive mindset about ECT than nursing staff), (b) subjective feeling of being adequately informed, and (c) having had contact to patients undergoing ECT. Interestingly, the general attitude toward ECT did not differ between subjects who reported to have seen an ECT and those who had not. CONCLUSIONS: When introducing ECT as a new treatment into a clinic, formal information should be adapted to the needs of each profession with a special emphasis on nurses. To further increase acceptance, contact to ECT-experienced patients (professionals taught by patients) might result in a more positive attitude toward ECT than participation in an ECT treatment itself.

The value of interprofessional education in identifying unaddressed primary health-care challenges in a community: a case study from South Africa.

Many countries rely on community health workers (CHWs) at a primary health care (PHC) level to connect individuals with needs to health professionals at health-care facilities, especially in resource-limited environments. The majority of health professionals are centrally based in facilities with little to no interaction with communities or CHWs. Stellenbosch University (South Africa), included interprofessional home visits in collaboration with CHWs as part of students' contextual PHC exposure in a rural community to identify factors impacting on the health of patients and their families. The aim of this study was to determine the impact of this interprofessional student service-learning initiative on identifying and addressing health-care challenges of households known to CHWs. Active physical, social and attitudinal factors were identified and recorded using a standardized paper case report form. Data were anonymized, captured and categorized for analysis. The frequency and proportion of each type of active problem and referral were calculated. The collaborative team identified many unaddressed health and social issues during their visits. Their exposure to communities at a PHC level offered benefits of experiential learning and provided insight into community needs, as well as offering services to enhance the current health-care system.

The collaborative care project: A practice-based approach to interprofessional education in a primary healthcare setting in South Africa.

BACKGROUND: There is global evidence that primary healthcare (PHC) leads to improved health outcomes. In the South Africa PHC model, the PHC team identifies healthcare needs through community visits. For health professional students to learn this PHC model requires an immersed, interprofessional community experience. CONTEXT: A select number of final year undergraduate health science students from Stellenbosch University, South Africa spend six weeks to one full year working at a rural clinical school with the focus on contextualised, transformative and interprofessional clinical training. OBJECTIVE: The collaborative care project is one of the opportunities aimed at exposing students to contextual interprofessional training in a resource constrained community. Students are challenged to collaboratively find potential solutions to problems patients face using local resources, with the aim of improving patient outcomes and transforming students into collaborative change agents. ACTIVITIES: Students, under the supervision of local community health workers, are tasked with conducting interprofessional home visits for discharged patients or patients identified by community members. Possible environmental, personal and health risk factors are identified and referrals made to existing community or state facilities for further management. OUTCOME: The collaborative care project has resulted in improved patient identification, accessibility to available resources and referral. Students recognise the value of contextualised collaborative clinical training to shape them as clinicians. Challenges and successes are shared to encourage more practical, community based opportunities for collaborative care. Reciprocal teaching and learning take place and students express a change in self-perception, team identity and improved role clarification. CONCLUSION: This project creates an opportunity for students and community to improve their understanding of precipitating factors to illness, which are not often considered as routine health care and to find local solutions to problems identified.

Consequences, conditions and caveats: a qualitative exploration of the influence of undergraduate health professions students at distributed clinical training sites.

BACKGROUND: Traditionally, the clinical training of health professionals has been located in central academic hospitals. This is changing. As academic institutions explore ways to produce a health workforce that meets the needs of both the health system and the communities it serves, the placement of students in these communities is becoming increasingly common. While there is a growing literature on the student experience at such distributed sites, we know less about how the presence of students influences the site itself. We therefore set out to elicit insights from key role-players at a number of distributed health service-based training sites about the contribution that students make and the influence their presence has on that site. METHODS: This interpretivist study analysed qualitative data generated during twenty-four semi-structured interviews with facility managers, clinical supervisors and other clinicians working at eight distributed sites. A sampling grid was used to select sites that proportionally represented location, level of care and mix of health professions students. Transcribed data were subjected to thematic analysis. Following an iterative process, initial analyses and code lists were discussed and compared between team members after which the data were coded systematically across the entire data set. RESULTS: The clustering and categorising of codes led to the generation of three over-arching themes: influence on the facility (culturally and materially); on patient care and community (contribution to service; improved patient outcomes); and on supervisors (enriched work experience, attitude towards teaching role). A subsequent stratified analysis of emergent events identified some consequences of taking clinical training to distributed sites. These consequences occurred when certain conditions were present. Further critical reflection pointed to a set of caveats that modulated the nature of these conditions, emphasising the complexity inherent in this context. CONCLUSIONS: The move towards training health professions students at distributed sites potentially offers many affordances for the facilities where the training takes places, for those responsible for student supervision, and for the patients and communities that these facilities serve. In establishing and maintaining relationships with the facilities, academic institutions will need to be mindful of the conditions and caveats that can influence these affordances.