Dynamic ctDNA Mutational Complexity in Patients with Melanoma Receiving Immunotherapy

BACKGROUND

Circulating tumour DNA (ctDNA) analysis promises to improve the clinical care of people with cancer, address health inequities and guide translational research. This observational cohort study used ctDNA to follow 29 patients with advanced-stage cutaneous melanoma through multiple cycles of immunotherapy.

METHOD

A melanoma-specific ctDNA next-generation sequencing (NGS) panel, droplet digital polymerase chain reaction (ddPCR) and mass spectrometry analysis were used to identify ctDNA mutations in longitudinal blood plasma samples from Aotearoa New Zealand (NZ) patients receiving immunotherapy for melanoma. These technologies were used in conjunction to identify the breadth and complexity of tumour genomic information that ctDNA analysis can reliably report.

RESULTS

During the course of immunotherapy treatment, a high level of dynamic mutational complexity was identified in blood plasma, including multiple BRAF mutations in the same patient, clinically relevant BRAF mutations emerging through therapy and co-occurring sub-clonal BRAF and NRAS mutations. The technical validity of this ctDNA analysis was supported by high sample analysis-reanalysis concordance, as well as concordance between different ctDNA measurement technologies. In addition, we observed > 90% concordance in the detection of ctDNA when using cell-stabilising collection tubes followed by 7-day delayed processing, compared with standard EDTA blood collection protocols with rapid processing. We also found that the undetectability of ctDNA at a proportion of treatment cycles was associated with durable clinical benefit (DCB).

CONCLUSION

We found that multiple ctDNA processing and analysis methods consistently identified complex longitudinal patterns of clinically relevant mutations, adding support for expanded clinical trials of this technology in a variety of oncology settings.

Virtual lesion clinic - Evaluation of a teledermatology triage system for referrals for suspected melanoma

INTRODUCTION

The Virtual Lesion Clinic (VLC) of Waitematā District Health Board (WDHB) improves melanoma assessment and treatment using teledermatology. The VLC is reserved for pigmented lesions referred as suspected melanoma from primary care but indeterminate at the initial triage.

OBJECTIVES

To assess the efficacy of the VLC diagnosis of melanoma.

METHODS

A retrospective audit of suspected melanoma referrals (1 January 2012 to 31 December 2016) was conducted. Lesions were referred to the VLC if diagnostic uncertainty remained at the initial triage. VLC patients attended MoleMap imaging centres, a dermatologist reviewed history and images remotely and suggested a diagnosis and management plan. Post VLC provisional diagnosis of melanoma, all lesions subsequently excised were reviewed. A positive predictive value (PPV) was calculated using concordance between VLC diagnosis of melanoma and histopathological diagnosis of melanoma. Number needed to excise (NNE) for melanoma was derived, as well as an invasive to in-situ melanoma ratio (IM:MIS) and false negative rate (FNR).

RESULTS

The VLC received 1874 referrals for 3546 lesions during the 5-year study period. Six hundred and seventy-nine lesions were recommended excision/biopsy or specialist face-to-face assessment, and 504 lesions were subsequently excised. The PPV was 62%, NNE 1.62 and IM:MIS 0.76 for lesions suspected to be melanoma at VLC assessment. The VLC had a melanoma-specific FNR of 7%.

CONCLUSIONS

The VLC is effective in early diagnosis of melanoma with a high positive predictive value, low number needed to excise and low false negative rate amongst lesions referred as suspected melanoma.

Postmodernism for healthcare workers in 13 easy steps

Despite a growing literature on postmodernism in nursing and other healthcare disciplines, it continues to be dogged by mistrust, misunderstanding and outright hostility. Presenting the philosophy of postmodernism is a particularly difficult task, and most attempts fall into one of two traps: either the writer is a well-read and committed postmodernist in which case the writing tends to make too many assumptions about the background knowledge of the reader; or else the writer has only a passing knowledge of 'popular' postmodernism, in which case the writing often falls back on over-simplistic concepts which do not do justice to the issues and which are often completely misconceived. The problem is further compounded by the difficulty of writing about one discourse (I am using the word in its postmodern sense-all such 'jargon' is explained in the paper) from within a different and potentially hostile one. For the postmodernists, rational debate with their modernist colleagues is all but impossible, since (as we shall see) the logic and language of the dominant discourse of modernism rules out and refuses to acknowledge that of postmodernism (and vice versa). Postmodern texts therefore rely less on rational argument than on persuasive narrative and a deliberate subversion of many of the usual practices of writing. This introduction to postmodernism for healthcare workers attempts to straddle the two discourses in both its form and its content, and offers a mixture of argument, example and speculation.

Fit for practice: Project 2000 student nurses' views on how well the curriculum prepares them for clinical practice

This paper presents the findings from a small study, which compared student nurses' views on how well they felt the Project 2000 curriculum had prepared them for their first clinical placements. The views of two student nurse cohorts were obtained using a questionnaire developed for the purpose. The curriculum for the 'old' cohort allowed very little clinical time during the first 18 months and focused on academic classroom-based learning. The curriculum was subsequently restructured so that students on the 'new' curriculum experienced greater emphasis on practice and theory to practice links, and undertook their first clinical placement much earlier on in their course. Although statistical analysis of difference between the two cohorts suggests that students from the 'new' cohort felt they were better prepared, the actual differences in scores was small. The findings of this study provide only modest evidence of improvement in 'new' student nurses' views of how well they felt they had been prepared for their first placement.

The pleasure of the bottomless: postmodernism, chaos and paradigm shifts

In her paper Reconstructing Nursing: Evidence, Artistry and the Curriculum, Marks-Maran (1999) attempted to outline a new postmodern paradigm for nursing. Whilst I fully support this timely discussion of new insights into nursing theory and practice, Marks-Maran unfortunately presents a very idiosyncratic version of postmodernism which is both simplistic and, at times; inaccurate. My main concern, however, is with her assertion that postmodernism offers a new paradigm for nursing, since she misses the fundamental point that postmodernism is not a critique or replacement for the modernist paradigm, but a challenge to the very notion of paradigms. Rather than attempting to replace the modernist paradigm of nursing, then, postmodernism offers what Spivak called 'the pleasure of the bottomless' in which the perceived certainties of science are decentred and the authority by which all knowledge claims are made is questioned.

Insufficient evidence: the problems of evidence-based nursing

Evidence-based medicine was first proposed in the early 1990s as a means of integrating clinical expertise with the best evidence from research. It has recently gained a foothold in nursing, where despite calls for a broad and nursing-oriented definition of what should count as evidence, it appears to be propounding the randomized controlled trial (RCT) as the gold standard. This paper challenges the wisdom of basing nursing practice on the findings of large-scale statistical research studies, and offers a number of logical objections to the underpinning philosophy of evidence-based nursing and the randomized controlled trial. It concludes by arguing for a rethinking of what should count as evidence, and suggests a quasi-legal model based on reflection rather than research, in which evidence is employed to understand and justify practice after the event rather than being used deterministically to plan practice in advance.

Developing the role of the generic healthcare support worker: phase 1 of an action research study

This paper reports on the first phase of an action research practice development project to explore, develop and evaluate the role of the generic healthcare support worker in a high dependency rehabilitation service. The project is being jointly conducted by staff from the University of Southampton, the University of Portsmouth and the Isle of Wight Healthcare NHS Trust and phase 1 is supported by a grant from the NHS Executive (South and West). The aim of phase 1 of the project is to explore the attitudes of staff towards the implementation of the role of the generic healthcare support worker, particularly regarding the practical, professional and ethico-legal problems of the role. Professional and support staff from different parts of the service were interviewed in groups and the interviews were tape recorded, transcribed and subjected to a simple thematic analysis. Four themes emerged from the data relating to the challenge to professional boundaries, being a generic worker, outcomes for service and patients and implementing the role. As an action research project, the aim was not to produce findings that are generalizable beyond the practice areas in which they were generated, but it is nevertheless hoped that the reader might be able to apply some of the conclusions to his or her own setting.

[To fill the gap between theory and practice: a model of clinical nursing]

Despite the efforts of nursing theorists, educationalists and practitioners, the theory-practice gap continues to defy resolution. This paper argues that only by reconsidering the relation between theory and practice can the gap be closed. Drawing upon ideas from teaching and other practice-based disciplines, including nursing, the article suggests that the current model of viewing theory as informing and controlling practice should give way to a mutually enhancing model in which theory is derived from practice, and in turn influences future practice. This coming together of theory and practice is referred to as nursing praxis, and suggests that informal theory should be unique to each individual encounter with each patient. The clinical nurse is thus not only a practitioner, but a theorist and researcher, who responds to patients not according to some grand, inflexible theory, but by the process of reflection-in-action, drawing upon their expertise and a repertoire of past experiences and encounters.

The theory-practice gap in nursing: from research-based practice to practitioner-based research

The aim of nursing research is generally agreed to be the generation of knowledge, and whilst this is a relevant aim in theory-based disciplines such as sociology, the primary concern of nursing is with practice. Using examples drawn mainly from the field of mental health, it will be argued in this paper that the application of generalizable, research-based knowledge to individual, unique, person-centred practice, the so-called 'research-based practice' advocated by the Department of Health, is one of the main causes of the theory-practice gap. It will be further suggested that nursing requires a paradigm of clinical research which focuses on the individual therapeutic encounter in order to complement the existing sociological paradigm of theoretical research which is best suited to the generation of generalizable knowledge and theory. The paper will conclude by suggesting that such a clinically based research paradigm must not only focus on the individual nurse-patient relationship, but that it must be carried out by the nurse herself. Clinical research, if it is to make a difference to practice, must therefore be practitioner-based research.

Writing ourselves: creating knowledge in a postmodern world

In an attempt to encourage nurses and academics to write, there have been some recent journal papers that outline rules and guidelines for successful publication. This paper attempts to tackle the 'why' of writing rather than the 'how', and argues that writing is more than merely the representation of speech. Rather, writing is a creative act in which knowledge is produced as part of the process of writing itself, and at this level we might talk not merely of writing, but of writing. It is further argued that whereas the verb 'to write' always has an object (we write a book or an essay), the verb 'to write' is intransitive; it has no object. We do not write a paper, we merely write. We might, of course, choose to publish our writing, but it is done as an afterthought; we write for discovery, not for presentation. The act of writing is then compared to the act of teaching, and it is concluded that in order to teach, we must also write. Finally, this paper is offered as an example of writing (not an exemplar--there are as many ways to write as there are writers), and attempts to pull together material from a variety of sources including sociology, psychology, philosophy and literature as an act of discovery, of creating what I know about writing as I write.

Science, abduction and the fuzzy nurse: an exploration of expertise

Benner's work on expertise in nursing drew heavily on the writing of Dreyfus and Dreyfus in the field of computing. Dreyfus and Dreyfus argued that the continued failure of computer programmers to create an 'expert system', a program which could replicate the way that a human expert thinks, implied that experts do not think in a rational, analytic way. Dreyfus and Dreyfus therefore concluded that expertise is an intuitive process, and that 'the expert is simply not following any rules! He is ... recognising thousands of special cases'. Applied to nursing, this model of expertise has a number of profound implications for practice and education, and has been criticised for being elitist and deliberately obscure. This paper examines some recent innovations in computer logic, and argues that nursing can learn from a new breed of 'fuzzy' computer programmes which appear to be able not only to perform better than experts, but to verbalize their decision-making processes. By beginning to understand how experts think, it might be possible to develop expertise in a more controlled and logical way, thereby improving the practice of nursing.

The development and evaluation of the role of an advanced nurse practitioner in dementia--an action research project

This action research project developed a new role of Advanced Nurse Practitioner (ANP) in dementia from first principles in response to the needs and requirements of the healthcare professionals already working in the service. In Phase 1 of the project, 42 workers were interviewed to determine their needs, hopes and fears of the role, from which a preliminary job description was constructed. In Phase 2, this role was implemented and continuously modified through regular reflective interviews with the ANP, resulting in some major changes to the original job description. In the final phase, the impact of the role was evaluated through interviews with patients who had used the new service, and questionnaires to the healthcare workers interviewed in Phase 1. The role that emerged from the project was therefore grounded in practice and proved to be an attractive proposition to the local healthcare trust.

Beyond expertise: theory, practice and the reflexive practitioner

This paper reconsiders Benner's book From Novice to Expert, in which the expert is portrayed as a reflective practitioner who works intuitively, drawing almost unconsciously on a repertoire of context-specific paradigm cases. In the light of more recent writings on informal, practice-based theory, it is suggested that there is a sixth level beyond expertise which is characterized by mindful practice and informal theory building. At this level, the practitioner constructs informal theory out of practice, applies that theory back into practice, and reflexively modifies the theory as a result of the changed clinical situation. Seen in this way, theory and practice are two parts of the same process, and the theory-practice gap is closed.

Going to extremes: action research, grounded practice and the theory-practice gap in nursing

Action research is growing in popularity with nurse researchers, where it is often seen as a way of bridging the theory-practice gap. However, there is little agreement on exactly what is meant by the term, and most nurse researchers stop short of exploring the full potential of this methodology. This paper argues that, if taken to its logical conclusion, action research methodology goes beyond the confines of the scientific paradigm and is able to bring about improvements in practice directly without the mediation of theory. This has some important implications for how the research process is viewed, and results in a model of research which is participative, reflexive and unashamedly subjective, and which generates non-generalizable, personal knowledge directly out of practice.

An action research project to develop and evaluate the role of an advanced nurse practitioner in dementia

This paper outlines the first phase of a project to generate and evaluate the role of an advanced nurse practitioner inductively from first principles. The role was developed by interviewing a wide range of health-care professionals, careers and patients. The resulting role is responsive to perceived need at grassroots level rather than to the needs of managers with no clinical experience. Although the role might not be generalizable to other settings, the method can be applied to any role in any clinical area.

Playing at research: methodological pluralism and the creative researcher

In its quest for acceptance by the scientific community, mental health nursing research has developed an unhealthy obsession with methodological rigour. This paper draws on the work of several writers from the philosophy of social science to argue that this focus on methodology stifles individual creativity and acts as a gatekeeper to the profession which excludes many of our brightest and most creative researchers. The author proposes a new approach to doing research that facilitates the creative process by encouraging a playful approach that temporarily abandons the accepted rules and methods of the research process in favour of an 'anarchistic epistemology' and a variety of unusual and not necessarily externally validated methods. It is only at the end of the research process that valid and generalizable methods are introduced, and the author calls for journals to open a creative dialogue by being more willing to publish papers describing the early, exploratory stages of research, based on a judgement of their creativity and innovation.

Some factors associated with change in patient-centredness of student nurses during the Common Foundation Programme in Nursing

This longitudinal study examines the changes in patient-centredness of a group of student nurses during their Common Foundation Programme in Nursing, and attempts to explore some of the social, psychological and educational factors which might be associated with such change. The Patient-centredness Multi-choice Questionnaire (PMQX) was administered to a sample of 267 student nurses on commencement and completion of their Common Foundation Programme in Nursing, and significant positive as well as negative changes in PMQX scores were found, although the mean scores for the sample were unchanged. A number of factors were found to be associated with high levels of patient-centredness on commencement of the course, including marital status, age, and radicalism. Positive change in patient-centredness during the CFP was associated with a variety of variables such as class size, a student-centred climate and a tenderminded attitude. Other factors, such as psychological stability and extroversion, were associated with both increase and decrease in patient-centredness during the CFP.

Listening to students: course evaluation as action research

Course evaluation is an important but often neglected aspect of the education process, usually carried out too late and in a cursory fashion. The writer argues that evaluation should play an important part in curriculum development, and outlines a student-centred evaluation process in which the course members themselves design and implement a programme that uncovers issues that they feel are relevant and of value. Furthermore, the scheme described here is fully integrated into the curriculum, and the process of carrying out the evaluation is an important learning experience in itself. By implementing the findings and recommendations from the evaluation while the course is still in progress, students are able to reap the benefits of their own work, at the same time contributing to a living, growing, dynamic curriculum.

Towards a new model of nursing research

Nursing research is generally located within the paradigm of the social sciences, and therefore reflects the concerns and agenda of social research. In particular, nursing has become embroiled in the ongoing dispute between the advocates of qualitative and quantitative methodologies. However, it is argued in this paper that whereas the aim of social research is to develop knowledge, the aim of nursing research is primarily to advance practice. This paper offers an alternative model of nursing research which categorizes approaches to research not according to the methodology employed but on the extent to which the research process is likely to bring about change. These approaches are termed level 1, level 2 and level 3 research, where level 1 researchers are concerned with generating information for others to conceptualize and implement, while level 3 researchers see their aim as directly bringing about clinical change. Two approaches to level 3 research are suggested, and examples of projects at all three levels are examined. Finally, it is contended that only by adopting an appropriate model of research for a practice-based discipline can nursing address the real issues of relevance to nurses and patients in clinical settings.

A framework for a process-driven common foundation programme for graduates

This paper discusses some of the problems encountered in writing a shortened Common Foundation Programme in nursing for graduates, and outlines a course which takes as its starting point the particular educational needs and requirements of the student group. Thus, the first question to be addressed by the curriculum writers when designing the course was "How can we teach these students?", rather than "What can we teach them?". The resulting process-driven course is heavily influenced by the student-centred philosophy of Carl Rogers, and utilizes a variety of large- and small-group methods to facilitate the students in gradually taking responsibility for, and making decisions about, their learning needs. The paper continues with some strategies for ensuring a smooth transition from a tutor-led, syllabus-driven start to the course, to a student-led, process-driven finish for both the theoretical and clinical components, and for the assessment schedule. Finally, a student-centred approach to evaluation is briefly outlined, and the paper concludes by suggesting that the principles employed in designing and implementing this course could be successfully transferred to a wide variety of other educational settings.

Towards a theory of student-centred nurse education: overcoming the constraints of a professional curriculum

Student-centred learning is an educational philosophy which became popular during the 1960s, but which has gradually fallen from favour as the educational and political climate has changed over the years. This is particularly true of nursing, where the transition to higher education ushered in by Project 2000 has signalled a return to traditional teaching methods such as the lecture and the seminar. This paper argues that the current demands for holistic practice, professional autonomy and primary nursing can best be met by educationalists by employing a student-centred approach to learning. However, it is recognised that a radical student-centred approach will conflict with the constraints imposed on curriculum writers by a professional body, and that a modified strategy is required. The paper goes on to identify several of the more pressing constraints, and suggests some methods for overcoming these problems within a student-centred framework, while maintaining the requirements of a professional training which confers upon the students a license to practise. The paper concludes by suggesting that most problems will only be identified once courses are up and running, and that a new student-centred framework can only emerge from educational practice. Teachers and curriculum writers are therefore encouraged to come together to share ideas and experiences in order to carry forward the theory and practice of student-centred nurse education.

The Patient-Centredness Multi-Choice Questionnaire: developing an instrument for the measurement of patient-centredness in student nurses

An earlier paper by the writer reported on the construction and administration of an instrument for the measurement of therapeutic attitudes in student nurses. This paper continues that work by producing a short, appropriate and easily administered test, known as the Patient-Centredness Multi-Choice Questionnaire. The instrument was tested for validity and reliability, and was piloted on a large group of new Project 2000 students from several colleges and institutes of nursing, to produce a database for use in further studies.

The assessment of therapeutic attitudes in the psychiatric setting

Although 'attitude change' is included as one of the aims of the 1982 training syllabus for psychiatric nurses, curriculum designers are given little guidance as to what constitute desirable attitudes in the psychiatric nurse, and how those attitudes are to be assessed and evaluated. This study has three aims: to attempt to outline what might count as desirable attitudes; to propose a theoretical framework for the measurement of those attitudes; and to devise a test instrument and pilot it on three groups with differing amounts of counselling skills and experience. The outcome of the pilot study produced surprising results, leading to the tentative hypothesis that counselling training and/or experience may have a detrimental effect on so-called 'therapeutic attitudes' in the nurse.