Early Specialist Research Articles

Stakes of Assessments in Residency: Influence on Previous and Current Self-Regulated Learning and Co-Regulated Learning in Early Career Specialists.

Assessments drive learning but the influence of the stakes of the assessments on self-regulated (SRL) during and after residency are unknown. As early career specialists (ECS) must continue learning independently, the answer to this is important as it may inform future assessments with the potential to promote life-long learning after graduation. We utilized constructivist grounded theory to explore the perspectives of eighteen ECS on the influence of stakes of assessments within residency on their SRL during training and in current practice. We conducted semi-structured interviews. We initially set out to examine the influence of the stakes of assessments on SRL during residency and after graduation. However, it was apparent that learners increasingly engaged with others in co-regulated learning (CRL) as the perceived stakes of the assessments increased. The individual learner's SRL was embedded in CRL in preparation for the various assessments in residency. For low-stakes assessments, the learner engaged in less CRL, taking less cues from others. As stakes increased, the learner engaged in more CRL with peers with similar intellectual level and supervisors to prepare for these assessments. SRL and CRL influenced by assessments in residency had a knock-on effect in clinical practice as ECS in: 1) developing clinical reasoning, 2) improving doctor-patient communication and negotiation skills, and 3) self-reflections and seeking feedback to deal with expectations of self or others. Our study supported that the stakes of assessments within residency reinforced SRL and CRL during residency with a continued effect on learning as ECS.

Supporting service children in early years education

In the last of this three-part series, Debra Barton, early years specialist lead for the Ministry of Defence (MOD) Armed Forces Families & Safeguarding (AFFS) team, gives an overview of the challenges service families face when trying to access childcare, and how early childhood education and childcare providers can help with this process. Barton also shares ideas of how providers can reflect on and improve their offering to young service children.

Effects of Specialist Palliative Care for Patients Undergoing Major Abdominal Surgery for Cancer

Specialist palliative care benefits patients undergoing medical treatment of cancer; however, data are lacking on whether patients undergoing surgery for cancer similarly benefit from specialist palliative care. To determine the effect of a specialist palliative care intervention on patients undergoing surgery for cure or durable control of cancer. This was a single-center randomized clinical trial conducted from March 1, 2018, to October 28, 2021. Patients scheduled for specified intra-abdominal cancer operations were recruited from an academic urban referral center in the Southeastern US. Preoperative consultation with palliative care specialists and postoperative inpatient and outpatient palliative care follow-up for 90 days. The prespecified primary end point was physical and functional quality of life (QoL) at postoperative day (POD) 90, measured by the Functional Assessment of Cancer Therapy-General (FACT-G) Trial Outcome Index (TOI), which is scored on a range of 0 to 56 with higher scores representing higher physical and functional QoL. Prespecified secondary end points included overall QoL at POD 90 measured by FACT-G, days alive at home until POD 90, and 1-year overall survival. Multivariable proportional odds logistic regression and Cox proportional hazards regression models were used to test the hypothesis that the intervention improved each of these end points relative to usual care in an intention-to-treat analysis. A total of 235 eligible patients (median [IQR] age, 65.0 [56.8-71.1] years; 141 male [60.0%]) were randomly assigned to the intervention or usual care group in a 1:1 ratio. Specialist palliative care was received by 114 patients (97%) in the intervention group and 1 patient (1%) in the usual care group. Adjusted median scores on the FACT-G TOI measure of physical and functional QoL did not differ between groups (intervention score, 46.77; 95% CI, 44.18-49.04; usual care score, 46.23; 95% CI, 43.08-48.14; P = .46). Intervention vs usual care group odds ratio (OR) was 1.17 (95% CI, 0.77-1.80). Palliative care did not improve overall QoL measured by the FACT-G score (intervention vs usual care OR, 1.09; 95% CI, 0.75-1.58), days alive at home (OR, 0.87; 95% CI, 0.69-1.11), or 1-year overall survival (hazard ratio, 0.97; 95% CI, 0.50-1.88). This randomized clinical trial showed no evidence that early specialist palliative care improves the QoL of patients undergoing nonpalliative cancer operations. ClinicalTrials.gov Identifier: NCT03436290.

Buruli ulcer - A neglected tropical disease in the Barwon region of Victoria, Australia: An emerging public health threat with local and national ramifications.

Mycobacterium ulcerans (MU) is known to be endemic in heavily touristed coastal regions of Victoria and is the cause of Buruli ulcer (BU) disease. The incidence, severity and geographic spread of MU infection/BU disease is increasing, including metropolitan Victorian suburbs. While the specifics of disease transmission and effective prevention strategies remain uncertain, severe complications can be mitigated by health systems that provide vigilant population surveillance to underpin early recognition, early specialist involvement and definitive treatment for the individual. Current theories regarding disease transmission and 'best practice' (or best guess) prevention and mitigation measures are presented herein. Opportunities to improve the health system response to this emerging public health threat are identified. It is incumbent upon all healthcare providers, including ED clinicians, to contribute by familiarising themselves with the established and emerging areas of endemicity of MU infection and the array of BU clinical presentations.

Supporting service children in early years education

In this three-part series, Debra Barton, early years specialist Lead for the Ministry of Defence (MOD) Armed Forces Families and Safeguarding (AFFS) team, explains how practitioners and providers from the early childhood and early education sector can support service children and their families. This second article will give a further introduction to service children, explain some of the jargon military families use, and describe how attending early childhood education and childcare provision can be a protection against some of the challenges young children and their families face.

Supporting service children: Celebrating the Month of the Military Child

In this three-part series, Debra Barton, early years specialist lead for the Ministry of Defence (MOD) Armed Forces Families and Safeguarding (AFFS) team, explains who service children are, and how practitioners and providers from the early childhood and early education sector can support them and their families. This first article will look at how early childhood education and childcare providers can celebrate the Month of the Military child in April.

Early Diagnosis of Central Disorders Mimicking Horizontal Canal Cupulolithiasis

Horizontal Canal Cupulolithiasis (hc-BPPV-cu) can mimic a pathology of central origin, so a careful examination is essential to prevent misdiagnosis. Retrospective cross-sectional cohort study of 45 patients suffering from suspected hc-BPPV-cu. We recorded whether patients first presented through an ENT Emergency Department (ED) or through an Outpatient Otolaryngology Clinic (OC). We found statistically significant differences (p < 0.05) between the OC versus the ED in relation to the time between symptom onset and first assessment (79.7 vs. 3.6 days, respectively), the number of therapeutic maneuvers (one maneuver in 62.5% vs. 75.9%, and more than one in 25.1% vs. 13.7%), and multi-canal BPPV rate (43.8% vs. 3.4%). hc-BPPV-cu did not resolve in 2 patients (12.5%) from the OC and in 3 (10.3%) from de ED, all of which showed central pathology. There are no prior studies that analyze the approach to hc-BPPV-cu in the ED. The benefits of early specialist input are early identification of central positional nystagmus, a decrease in symptom duration, reduced number of therapeutic maneuvers required for symptom resolution, and lower rates of iatrogenic multi-canal BPPV. A comprehensive approach to hc-BPPV-cu in the ED allows both more effective treatment and early identification of central disorder mimics.

Exploring the Association between Individual-Level Attributes and Fidelity to a Vocational Rehabilitation Intervention within a Randomised Controlled Trial

Understanding what attributes or characteristics of those delivering interventions affect intervention fidelity and patient outcomes is important for contextualising intervention effectiveness. It may also inform implementation of interventions in future research and clinical practice. This study aimed to explore the relationships between attributes of Occupational Therapists (OTs), their faithful delivery of an early stroke specialist vocational rehabilitation intervention (ESSVR), and stroke survivor return-to-work (RTW) outcomes. Thirty-nine OTs were surveyed about their experience and knowledge of stroke and vocational rehabilitation and were trained to deliver ESSVR. ESSVR was delivered across 16 sites in England and Wales between February 2018 and November 2021. OTs received monthly mentoring to support ESSVR delivery. The amount of mentoring each OT received was recorded in OT mentoring records. Fidelity was assessed using an intervention component checklist completed using retrospective case review of one randomly selected participant per OT. Linear and logistic regression analyses explored relationships between OT attributes, fidelity, and stroke survivor RTW outcome. Fidelity scores ranged from 30.8 to 100% (Mean: 78.8%, SD: 19.2%). Only OT engagement in mentoring was significantly associated with fidelity (b = 0.29, 95% CI = 0.05-0.53, p < 0.05). Increased fidelity (OR = 1.06, 95% CI = 1.01-1.1, p = 0.01) and increasing years of stroke rehabilitation experience (OR = 1.17, 95% CI = 1.02-1.35) was significantly associated with positive stroke survivor RTW outcomes. Findings of this study suggest that mentoring OTs may increase fidelity of delivery of ESSVR, which may also be associated with positive stroke survivor return-to-work outcomes. The results also suggest that OTs with more experience of stroke rehabilitation may be able to support stroke survivors to RTW more effectively. Upskilling OTs to deliver complex interventions, such as ESSVR, in clinical trials may require mentoring support in addition to training to ensure fidelity.

Neglecting the care of people with schizophrenia: here we go again.

Specialist early intervention teams consider clinician-patient engagement and continuity of care to be a driving philosophy behind the treatment they provide to people who have developed schizophrenia or a related psychotic illness. In almost all countries where this service model has been implemented there is a dearth of available data about what is happening to patients following time-limited treatment. Information on discharge pathways in England indicates that some early intervention specialists are discharging most of their patients from all psychiatric services after only 2 or 3 years of input. Some ex-patients will be living in a state of torment and neglect due to an untreated psychosis. In the UK, general practitioners should refuse to accept these discharge pathways for patients with insight-impairing mental illnesses.

Utilization of Ophthalmic Management in Patients with Head-and-Neck Trauma Secondary to Firearms.

This retrospective cohort study presents the epidemiology of severe firearm-related ophthalmic injury and the level of ophthalmology involvement in the multidisciplinary management of head-and-neck gunshot injuries. A retrospective study identified 207 patients with firearm-related injuries involving the head and neck treated at an Academic Tertiary Care Institution from 2010 to 2020. Ophthalmology consulted on 29% of patients with head-and-neck firearm injuries. At least one of the services managing facial trauma (plastic surgery and otolaryngology) consulted on 71.5% of cases (P < 0.001). Of patients evaluated by ophthalmology, 93.3% survived to discharge; 78.2% of patients who were not evaluated survived to discharge (P = 0.009). Ophthalmology consulted on all patients with open globe injury (10.6%) (P < 0.001), all of which were evaluated by the facial trauma service (P = 0.002), 77.3% by otolaryngology (P = 0.42), 50% by neurosurgery, 36.4% by plastic surgery, 13.6% by orthopedic surgery, and 4.5% by vascular surgery. Ophthalmology consulted on 76.5% of patients with orbital fracture (32.9%) (P < 0.001); 83.8% were evaluated by the facial trauma service (P = 0.006), 69.1% by otolaryngology (P = 0.014), 54.4% by neurosurgery, 27.9% by plastic surgery, 10.3% by orthopedic surgery, and 2.9% by vascular surgery. For patients with orbital fractures, 92.3% survived when ophthalmology was consulted (P = 0.698); 43.8% survived when not consulted (P = 0.001). Firearm-related injuries of the head and neck frequently involve ocular and orbital structures, often causing serious vision-threatening injuries. Multispecialty management is common and early ophthalmology specialist evaluation and co-management are indicated to best identify ophthalmic injuries.

Long term quality of life outcomes following surgical resection alone for benign paediatric intracranial tumours

Survivors of paediatric intracranial tumours are at increased risk of psychosocial, neuro-developmental, and functional impairment. This study aimed to evaluate long-term health-related quality-of-life (HRQOL) outcomes in patients with benign paediatric brain tumours treated curatively with surgical resection alone. This was a cross-sectional study of patients with benign paediatric intracranial tumours managed with surgery alone between 2000 and 2015. Eligible patients with a minimum of 5-years follow-up after surgery were identified. Validated health-related quality of life (HRQOL) questionnaires were administered: SF-36, QLQ-BN20, QLQ-C30 and PedsQL™. Twenty-three patients participated (median age at surgery 13years; range 1-18; 12 male). The most common diagnosis was pilocytic astrocytoma (n = 15). Median time from surgery to participation was 11years(range 6-19). Fourteen patients achieved A-level qualifications and two obtained an undergraduate degree. Twelve patients were employed, eight were studying and three were unemployed or volunteering. HRQOL outcomes demonstrated significant limitation from social functioning (p = 0.03) and cognitive functioning (p = 0.023) compared to the general population. Patients also experienced higher rates of loss of appetite (p = 0.009) and nausea and vomiting (p = 0.031). Ten patients were under transitional teenager and young-adult (TYA) clinic follow-up. TYA patients achieved higher levels of education (p = 0.014), were more likely to hold a driver's license (p = 0.041) compared to patients not followed-up through these services. Childhood brain-tumour survivors have a greater risk of developing psychological, neuro-cognitive and physical impairment. Early comprehensive assessment, specialist healthcare and TYA services are vital to support these patients.

Contemporary updates on ventricular arrhythmias: from mechanisms to management.

Ventricular arrhythmias (VAs) are a group of heart rhythm disorders that can be life-threatening and cause significant morbidity. VA in the presence of structural heart disease (SHD) has distinct prognostic implications and requires a comprehensive and multifaceted approach for investigation and management. Early specialist referral should be considered for all patients with VA. Particular urgency is recommended in patients with syncope, nonsustained/sustained VA on Holter monitor and SHD on cardiac imaging because ofthe heightened risk of sudden cardiac death. Comprehensive phenotyping is recommended for most patients with VA, encompassing noninvasive cardiac functional testing, multimodality imaging and genetic testing in select circumstances. Management of idiopathic VA is guided heavily by symptom burden and the presence of ventricular systolic impairment. In SHD, guideline-directed heart failure therapy and device implantation are critical considerations. Whilst commonly used and well-established, antiarrhythmic drugs can be hampered by toxicity and failure of adequate arrhythmia control. Catheter ablation is increasingly being considered a feasible first-line alternative to medical therapy, where outcomes are influenced by disease aetiology and scar burden in SHD. Catheter ablation is associated with reduced arrhythmia recurrence and burden and improved quality of life at follow-up.

Results from phase one of an early intervention vocational rehabilitation trial for people with spinal cord injury conducted in Queensland, Australia

BACKGROUND: The Back2Work Early Intervention Vocational Rehabilitation (EIVR) program was developed in response to the low employment rate of people with spinal cord injuries (SCI) and their lack of access to early, specialised vocational rehabilitation (VR). The program has been delivered by qualified rehabilitation counsellors to hospital patients with newly acquired SCI since 2016. OBJECTIVE: The objective of the study was to evaluate the effectiveness and consumer perspective of the Back2Work EIVR program. METHODS: The program was evaluated using a mixed-methods, longitudinal, prospective design. RESULTS: Data analysis revealed a return to work rate (RTW) of 43% by 12 months post-discharge. Qualitative data indicated positive participant experiences with the program, emphasising the hopefulness brought about by early vocational support. CONCLUSIONS: The Back2Work program has a positive impact on participants’ RTW outcomes, through the provision of early specialist vocational rehabilitation interventions. This includes building a positive culture around RTW after SCI and engagement with employers to maximise the likelihood of timely and sustainable re-employment. The RTW outcomes and emergent themes will help inform service development in the field of early vocational rehabilitation after SCI.

THE BEAST IN THE BEAUTY BOX

THE BEAST IN THE BEAUTY BOX

Long Term Quality of Life Outcomes Following Surgical Resection Alone for Benign Paediatric Intracranial Tumours

Abstract AIMS Survivors of paediatric intracranial malignancies are at increased risk of psychosocial, neuro-developmental and functional impairment, important measures of patients’ well-being. This study aimed to evaluate long-term quality of life outcomes (QOL) in patients with benign paediatric brain tumours treated curatively with surgical resection alone. METHOD Cross-sectional cohort study of benign paediatric intracranial tumours managed with surgery alone between 2000-2015. Validated QOL questionnaires were administered: SF-36, QLQ-BN20, QLQ-C30 and PedsQLTM. RESULTS Twenty-three patients participated (median age at surgery 13 years; range 1-18), twelve were male. The most common diagnosis was pilocytic astrocytoma (n=15). Median time from surgery to participation was 11 years (range 6-19). Fourteen patients achieved A-level qualifications and two obtained an undergraduate degree. Twelve patients were employed, eight were studying and three were unemployed or volunteering. Twelve patients were currently driving. QOL outcomes demonstrated significant limitation from social functioning (p=0.03) and cognitive functioning (p=0.023) compared to the general population norms. Patients also experienced increased loss of appetite (p=0.009) and symptoms of nausea and vomiting (p=0.031). Ten patients were under transitional teenager and young-adult (TYA) clinic follow-up. TYA patients achieved higher levels of education (p=0.014), were more likely to hold a driver’s license (p=0.041) and had improved physical functioning (p=0.005) compared to patients not transitioned through these services. CONCLUSION Childhood brain-tumour survivors are particularly vulnerable and at greater risk of developing psychological, neuro-cognitive, socialisation and physical development challenges. Early identification, comprehensive assessment and specialist TYA cancer healthcare input are vital to support these patients and improve their quality of life.

The PaCES (Palliative Care Early and Systematic) Project: Impact of individual components of a multi-faceted intervention on early referral to specialist palliative care.

199 Background: Early referral to specialist palliative care can improve, or maintain, symptom and quality of life outcomes that matter most to patients facing life-limiting illnesses. We tested a multifaceted oncologist-facing intervention (Palliative Care Early and Systematic) in the real-world setting of a busy outpatient cancer clinic for its ability to increase the proportion of patients who receive early specialist palliative care (defined as ≥ 90 days before death). Herein, we describe how each component of the multi-faceted intervention, intended to bridge cancer, primary, and palliative care, impacted early use of specialist palliative care among advanced colorectal cancer patients. Methods: Two intervention components were implemented in Calgary, Alberta, Canada’s tertiary cancer centre from January 2019 to June 2020: 1) Adult colorectal cancer patients were referred to a community-based Clinical Nurse Specialist if they failed, or could not receive, first-line chemotherapy, or had high symptom burden (indicated by an Edmonton Symptom Assessment System Revised score ≥ 7); 2) Medical oncologists sent templated ‘Shared Care’ letters to patients’ primary care providers to improve communication, collaboration and role clarity. Results: N = 209 eligible patients died during the intervention period, of whom 57% experienced early referral to specialist palliative care. The median days from referral to death was 130 (IQR: 53-359). Of the 209, 28 (13%) saw the Clinical Nurse Specialist and received Shared Care letters, and all (100%) had early specialist palliative care referral (median 240 days, IQR: 161-359). 21/209 (10%) saw the Clinical Nurse Specialist but had no Shared Care letter. Of these 21, 76% had early specialist palliative care referral (median 197 days, IQR: 96-251). 43/209 (21%) had a Shared Care letter but no interaction with the Clinical Nurse Specialist. Of these 43, 53% had early specialist palliative care referral (median 102 days, IQR: 53-257). 117/209 (56%) did not interact with the Clinical Nurse Specialist or have a Shared Care letter. Of these 117, 45% had early specialist palliative care referral (median 86 days, IQR: 40-204). Conclusions: The Clinical Nurse Specialist was associated with the greatest increase in early specialist palliative care referral; however, the Clinical Nurse Specialist and Shared Care letters combined were associated with even greater (100%) early specialist palliative care use.

S1348 Patterns of GI Specialty Referral for Primary Care Patients With Nonalcoholic Fatty Liver Disease

Introduction: Early specialist intervention for patients with significant fibrosis from nonalcoholic fatty liver disease (NAFLD) is important in preventing related morbidity and mortality. For patients with evidence of hepatic steatosis, we aim to determine what proportion received gastroenterology (GI) referral, the reason for referral, and the severity of fibrosis between groups. Methods: This retrospective study of electronic health record data from 2012-2018 included patients with (i) radiographic reports of liver steatosis (abdominal ultrasound, CT, or MRI) and (ii) no competing, non-NAFLD chronic liver disease diagnoses. Referral to GI any time after imaging was the primary outcome. Chart review was conducted to determine if a patient was referred and the reason for the referral. Fibrosis-4 Index (FIB-4) scores were calculated and categorized by advanced fibrosis risk. Statistical analysis was performed with Student t-tests and Chi-square tests using SAS. Results: The cohort included 652 patients with a mean age of 55 (SD ± 14) years. Of included patients, 64% were female and 36% identified as Black. One in four patients received a formal diagnosis of NAFLD. FIB-4 scores were high-risk for advanced fibrosis in 12% of patients, indeterminate-risk for 31% of patients, and low-risk for 57% of patients. Overall, 46% of patients received a GI referral, with 32% of these referrals being for colonoscopy. A larger portion of referred patients (33%) received a diagnosis of NAFLD during the study period compared to those not referred (19%, p< 0.001). Of patients referred for non-colonoscopy reasons, only 15% of referral orders mentioned steatosis. When fatty liver disease was mentioned at referral, a larger proportion of patients received a formal NAFLD diagnosis compared to all other non-colonoscopy referrals (80% vs. 26%, p< 0.001). There was no difference in the proportion of high-risk FIB-4 scores between patients with and without a GI referral (p=0.95). Conclusion: Appropriate GI referral for NAFLD management remains a concern, even so NAFLD is predicted to be the leading indication for liver transplantation within the next 10 years. Our data suggests hepatic steatosis is infrequently recognized as a notable finding on abdominal imaging and did not prompt excessive GI referral. Use of FIB-4 scoring has been shown to reduce unnecessary referral and improve detection of advanced fibrosis, though FIB-4 scoring did not influence referral likelihood in this cohort.

Early specialist orthotic interventions for the lower limb in adult stroke patients: a systematic literature review

Background Stroke is a leading cause of long-term disability worldwide, estimated to affect up to 50% of stroke survivors. Many stroke survivors use orthotic splints and braces to help address difficulties with mobility and gait dysfunction both early after the stroke event and longer-term. Objectives The aim of this systematic review was to identify, synthesise and appraise the evidence on early orthotic involvement for the lower limb following stroke. Study design Systematic literature review Methods We conducted a systematic search of electronic databases including: AMED (1985 to present; CINAHL (1982 to present); EMBASE (1980 to present); MEDLINE (1949 to present); PsycINFO (1967 to present). The search took place on 18/10/2019. Included studies evaluated an early orthotic intervention designed to either promote mobility or reduce secondary complications after stroke. Articles were screened for inclusion by two independent reviewers. Results This review included six articles from one research group in the Netherlands. Methodological quality was considered good in each of the included studies. Limitations include small sample size, restricted descriptions of the intervention and short-term follow-ups. Conclusion This systematic review suggests that earlier lower limb orthotic interventions can result in improved walking speed and balance, and enhanced ability to perform activities of daily living in the early weeks post-stroke. Future research would benefit from considering wider orthotic and orthotist intervention with larger sample sizes and longer-term outcomes.

EP10.01-008 Examining Social Determinants of Health Among Newly Diagnosed Lung Cancer Patients Contacted for Early Specialist Palliative Care Consultation

Timely palliative care interventions can help to alleviate the distress people experience after diagnosis of an incurable, life-threatening cancer. However, referrals to palliative care are often late and inequities have been described across sociodemographic groups. The Palliative Care Early and Systematic (PaCES)-Automatic study was co-designed with patients and providers. It provides an automatic early palliative care intervention triggered by pre-determined clinical criteria, without the need for formal clinician referral, for automatically offering an early supportive and palliative care (SPC) consultation to all patients newly diagnosed with stage IV non-small cell lung cancer (NSCLC).

Shining the Light on You:

ObjectiveTo design and assess the effectiveness of an evidence-based intervention to improve the health and wellbeing of family child care professionals.MethodsThe early care and education (ECE) workforce, and family child care (FCC) educators in particular, face challenges to their wellbeing, mental and physical health. In addition, the demographics of the FCC workforce – disproportionately composed of low-income women of color - are associated with higher risk for chronic diseases. The Shining the Light on You program is designed to address FCC professional wellbeing in a feasible, evidence-based manner. The program includes weekly virtual sessions co-facilitated by a Board-Certified Health and Wellness Coach (HWC) and a Technical Assistance Coach (Early Childhood Specialist) and three individual coaching sessions with the HWC. HWC is built upon a foundation of behavior change theories, motivational strategies and effective communication approaches from psychology, medicine, public health and related fields. Using a mixed methods approach to gather data, participants from three initial cohorts of the program (n=33) implemented in Delaware reported improvement in health and wellbeing indicators.ResultsParticipants reported improvements in social support, physical activity and water consumption from pre- to post-program surveys. In interviews conducted with the participants following the program, participants consistently commented on the connections between all components of wellbeing and the importance of self-care.ConclusionsThis model demonstrates the potential of integrating best practices from HWC and the ECE system.