Sm Lindqvist

Dynamic and differential regulation of NKCC1 by calcium and cAMP in the native human colonic epithelium

The capacity of the intestine to secrete fluid is dependent on the basolateral Na+–K+–2Cl− co‐transporter (NKCC1). Given that cAMP and Ca2+ signals promote sustained and transient episodes of fluid secretion, respectively, this study investigated the differential regulation of functional NKCC1 membrane expression in the native human colonic epithelium. Tissue sections and colonic crypts were obtained from sigmoid rectal biopsy tissue samples. Cellular location of NKCC1, Na+–K+‐ATPase, M3 muscarinic acetylcholine receptor (M3AChR) and lysosomes was examined by immunolabelling techniques. NKCC1 activity (i.e. bumetanide‐sensitive uptake), intracellular Ca2+ and cell volume were assessed by 2′,7′‐bis(2‐carboxyethyl)‐5‐(and‐6)‐carboxyfluorescein (BCECF), Fura‐2 and differential interference contrast/calcein imaging. Unstimulated NKCC1 was expressed on basolateral membranes and exhibited a topological expression gradient, predominant at the crypt base. Cholinergic Ca2+ signals initiated at the crypt base and spread along the crypt axis. In response, NKCC1 underwent a Ca2+‐dependent 4 h cycle of recruitment to basolateral membranes, activation, internalization, degradation and re‐expression. Internalization was prevented by the epidermal growth factor receptor kinase inhibitor tyrphostin‐AG1478, and re‐expression was prohibited by the protein synthesis inhibitor cylcoheximide; the lysosome inhibitor chloroquine promoted accumulation of NKCC1 vesicles. NKCC1 internalization and re‐expression were accompanied by secretory volume decrease and bumetanide‐sensitive regulatory volume increase, respectively. In contrast, forskolin (i.e. cAMP elevation)‐stimulated NKCC1 activity was sustained, and membrane expression and cell volume remained constant. Co‐stimulation with forskolin and acetylcholine promoted dramatic recruitment of NKCC1 to basolateral membranes and prolonged the cycle of co‐transporter activation, internalization and re‐expression. In conclusion, persistent NKCC1 activation by cAMP is constrained by a Ca2+‐dependent cycle of co‐transporter internalization, degradation and re‐expression; this is a novel mechanism to limit intestinal fluid loss.

Acetylcholine-induced calcium signaling along the rat colonic crypt axis

BACKGROUND & AIMS Acetylcholine-induced calcium signaling dynamics have been described in cell monolayers derived from colonic mucosa, but not in intact colonic crypts. The aim of this study was to characterize the spatiotemporal characteristics of calcium signaling induced by acetylcholine in isolated intact rat colonic crypts and to identify the muscarinic receptor subtype coupled to this signaling pathway. METHODS Isolated crypts from the distal colon of male Wistar rats were loaded with the calcium-sensitive dye Fura-2 and imaged with a charge-coupled device video camera. RESULTS Acetylcholine mobilized intracellular calcium with an EC50 of 3.9 micromol/L. The response was initiated at the base of the crypt and progressed toward the surface. The velocity of propagation was dose dependent. Addition of muscarinic antagonists inhibited the response (pKb values calculated for pirenzepine and 4-DAMP, 6.08 and 8.65, respectively). Microperfusion of acetylcholine initiated a calcium signal throughout the lower half of the crypt. Microinjection of inositol 1,4,5-triphosphate induced a propagation of a calcium signal along the crypt axis. Heptanol inhibited the velocity of acetylcholine-induced wave propagation by 33%. CONCLUSIONS M3 muscarinic receptors are coupled to the mobilization of calcium from intracellular stores of intact, isolated rat colonic crypts. Intercellular communication potentiates the propagation of the acetylcholine-induced calcium signal along the crypt axis.

Facilitator training for educators involved in interprofessional learning

The provision of interprofessional education (IPE) within undergraduate healthcare programmes is now widespread, and a selection of approaches can be found in the literature. Although no optimal method of delivering IPE has been identified, some key elements, such as effective facilitation, are acknowledged to be a crucial part of successful IPE. However, to date, limited guidance is available on how to prepare facilitators involved in interprofessional learning (IPL). This paper aims to contribute towards bridging this gap by describing a facilitator training programme (FTP) for IPL facilitators in a Higher Education setting. The FTP comprises eight components relating to: objectives, context, role and skills, small group work, group dynamics, resources, support and evaluation. These components are designed to accommodate trainees with different learning styles (activists, pragmatists, theorists and reflectors) using training methods underpinned by adult learning theory and contact hypothesis. A description of the facilitator training is provided within this paper to illustrate how these eight components can be utilised by educators, to apply to their own IPE intervention and customising training to suit their own specific need.

The colon-selective spasmolytic otilonium bromide inhibits muscarinic M 3 receptor-coupled calcium signals in isolated human colonic crypts

Otilonium bromide (OB) is a smooth muscle relaxant used in the treatment of irritable bowel syndrome. Otilonium bromide has been shown to interfere with the mobilization of calcium in intestinal smooth muscle, but the effects on other intestinal tissues have not been investigated. We identified the muscarinic receptor subtype coupled to calcium signals in colonic crypt derived from the human colonic epithelium and evaluated the inhibitory effects of OB. Calcium signals were monitored by fluorescence imaging of isolated human colonic crypts and Chinese hamster ovary cells stably expressing the cloned human muscarinic M3 receptor subtype (CHO‐M3). Colonic crypt receptor expression was investigated by pharmacological and immunohistochemical techniques. The secretagogue acetylcholine (ACh) stimulated calcium mobilization from intracellular calcium stores at the base of human colonic crypts with an EC50 of 14 μM. The muscarinic receptor antagonists 4‐DAMP, AF‐DX 384, pirenzepine and methroctamine inhibited the ACh‐induced calcium signal with the following respective IC50 (pKb) values: 0.78 nM (9.1), 69 nM (7.2), 128 nM (7.1), and 2510 nM (5.8). Immunohistochemical analyses of muscarinic receptor expression demonstrated the presence of M3 receptor subtype expression at the crypt‐base. Otilonium bromide inhibited the generation of ACh‐induced calcium signals in a dose dependent manner (IC50=880 nM). In CHO‐M3 cells, OB inhibited calcium signals induced by ACh, but not ATP. In addition, OB did not inhibit histamine‐induced colonic crypt calcium signals. The present studies have demonstrated that OB inhibited M3 receptor‐coupled calcium signals in human colonic crypts and CHO‐M3 cells, but not those induced by stimulation of other endogenous receptor types. We propose that the M3 receptor‐coupled calcium signalling pathway is directly targeted by OB at the level of the colonic epithelium, suggestive of an anti‐secretory action in IBS patients suffering with diarrhoea.

Caring for attitudes as a means of caring for patients – improving medical, pharmacy and nursing students’ attitudes to each other's professions by engaging them in interprofessional learning

Introduction: Negative attitudes between pharmacists, doctors and nurses can impact adversely on patients’ medicines management. A seven-week interprofessional learning (IPL) intervention was delivered to foster positive attitudes. Methods: First-year pharmacy, nursing and medical students’ attitudes were assessed using the Attitudes to Health Professionals Questionnaire before and after IPL intervention. Results: Students viewed pharmacists, doctors and nurses as more ‘caring’ after IPL. Nurses were viewed as most ‘caring’. Nursing and pharmacy students perceived doctors as least ‘caring’ before and after IPL whereas medical students viewed pharmacists as least ‘caring’. Students perceived their own profession as more ‘caring’ than others did. The three-way analysis of variance showed a significant difference between student groups (p < 0.0001), professions (p < 0.0001) and before-and-after IPL (p < 0.005). Conclusion: Findings suggest that students’ attitudes are more positive after they have worked together during seven weeks of IPL. Each student group view their own profession more positively than others. Views become more aligned after this IPL intervention. Time may be an important factor in allowing for attitudes to change. IPL can help foster positive attitudes between doctors, pharmacists and nurses, which may facilitate effective collaboration and thus enhance patients’ medicines management.

Introducing a post-registration interprofessional learning programme for healthcare teams

Introduction: Few studies have evaluated interprofessional learning (IPL) and teamworking in active clinical teams. The aim of this study was to evaluate an IPL programme offered to established clinical teams by assessing team climate before, during and after the intervention. Methods: A previously validated questionnaire, that explored team members’ views of team climate, was administered before the IPL programme, at four months following facilitated meetings, and again at eight months. Responses were analysed using one-sample and independent samples t-tests. Results: Nine teams, made up of 79 individuals, agreed to join the IPL programme. After four months, during which time the teams were supported by an educational facilitator, the overall team climate increased by 8.0% of the maximum possible score of the questionnaire (95% confidence interval = 7.4% to 8.6%). This difference was highly statistically significant (p-value <0.001) and similar increases in scores were seen in each section of the questionnaire. This significant change was sustained after a further four months when the programme continued without the support of an educational facilitator. Conclusion: An IPL programme, such as the one described in this paper, can improve team climate and raise awareness of professional roles within established clinical teams. Practice points Although there are studies that evaluate pre-registration interprofessional learing programmes, there is little research evaluating interprofessional learning programmes and teamworking in active clinical teams. Purposeful and structured facilitation of established interprofessional healthcare teams can lead to improvements in perceptions of team climate and teamworking. Further research is needed to confirm the effect of interprofessional learning on teamworking and the benefits to patient care and patient safety.

The development, outline and evaluation of the second level of an interprofessional learning programme–listening to the students

The delivery and content of interprofessional education (IPE) varies greatly. Currently there is little evidence to suggest the most effective approach. This paper describes an interprofessional learning programme offered to second year healthcare students (IPL2), which was developed together with the students. At the outset of developing IPL2, an interprofessional student planning group (supported by a facilitator) was formed. The student planning group (SPG) reported back their ideas to an IPL steering group. Student feedback forms from 2005–2006 were used for the review and further development of IPL2. Analysis of student feedback was completed using median (for the quantitative elements of the form) and content analysis (for the qualitative elements). Post-programme student feedback included suggestions such as improvements to the case scenario, issues such as the logistical problems associated with students being on placement and how to overcome this by expanding the use of a virtual learning environment. Student views have informed both the original and ongoing development of IPL2 and ensure that the IPL programme remains relevant to the students. This model of involving students in the development of IPL has proven effective and can be applied to other settings.

The WHO Framework for Action

This issue of the Journal features a number of papers related to the Framework for Action on Interprofessional Education and Collaborative Practice (World Health Organization [WHO], 2010). A report prepared for the WHO by a Study Group mainly comprising InterEd Board Members. The outcome, as the title makes plain, is a frame of reference, not a blueprint still less a roadmap; the objective is to assist policy makers in positions of influence in testing the desirability and the feasibility of a package of propositions in the context of national and international needs, priorities, resources and opportunities. The Framework is best understood as a continuation of the WHO’s longstanding commitment to improve education for health, medical and related professions through interprofessional education (IPE) (WHO, 1988). References to IPE were, however, conspicuous by their absence from WHO publications during the ensuing 20 years, despite determined efforts to promote it in ever more countries. Until that is a chance encounter in the elevator between Steven Hoffman, at that time an intern in the WHO offices in Geneva, and Jean Yan, the WHO Chief Nursing Scientist. Discussions followed, bringing in John Gilbert, then President of InterEd, as ideas took shape for a Study Group on IPE and collaborative practice. The Group, co-chaired by John Gilbert and Jean Yan, was subdivided into three teams covering IPE, collaborative practice and system level supportive structures led respectively by Professor Peter Baker from Australia, Professor Yuichi Ishikawa from Japan and Professor Dame Jill Macleod Clark from the United Kingdom. WHO officials urged the Study Group to address strategic policy makers nationally and internationally in ways that engaged with their besetting problems; especially ways in which IPE and collaborative practice could help alleviate the global workforce crisis in health care (WHO, 2006). The Study Group did indeed pin its arguments on WHO priorities, but wisely stopped short of incautious claims regarding the impact of IPE on the workforce crisis. Never has the case for interprofessional education and collaborative practice been asserted so boldly: Journal of Interprofessional Care, September 2010; 24(5): 475–478

The global emergence of IPE and collaborative care.

The publication of the World Health Organization (WHO) Technical Report ‘‘Framework for Interprofessional Education and Collaborative Care’’ (World Health Organization, 2010) marks the emergence of interprofessional concepts on the global stage of the education of health and social care professionals. It also marks a developing understanding of collaborative decision making in the care of patients and clients. Both developments come at an opportune time for educators and practitioners who are looking to work across cultural and system boundaries. The need to reduce health inequalities and to improve the health of populations remains as imperative today as it was at the time of the signing of the WHO Declaration of Alma-Ata in 1978 (World Health Organization, 1978). The increasing focus of WHO Member States on primary health care (PHC) (World Health Organization, 2008a) is seen as a means to achieve equitable, fair, affordable and efficient care. From the many approaches taken to PHC around the world, it is clear that major policy commitments will be required and that these will need to be accompanied by the active and collective involvement of stakeholders, particularly the health and social care professions, through informed and manageable implementation processes (World Health Organization, 2008b). Addressing health inequities as recently described by Dr Ramsammy in this Journal (Ramsammy, 2010), will require concerted interprofessional and multidisciplinary approaches in which each profession takes responsibility for identifying what they might bring to the table and how they might then work collaboratively to achieve common goals. Virtually all countries are faced with impending shortages in their health workforces, and the issue of the recruitment to, and retention in, remote and rural areas will remain of great concern. Through the Framework document interprofessional collaboration in education and practice has come to be seen as an innovative strategy for alleviating the crises in the global health and social care workforce (World Health Organization, 2006), and as a means for addressing health goals in primary health care and chronic disease management. The Framework outlines action items that policy makers can apply within their local health systems. Coincident with the development of the Framework, in June 2009 the WHO held a global consultation on the contribution of health professionals to the global health agenda. At this meeting representatives from more than 50 different health professional associations discussed global health challenges and synergies to foster collaborative work across professional boundaries to support primary health care; established the Health Professionals Global Network as a forum to exchange experiences and perspectives on how health professionals can contribute to the global health agenda and the implementation of primary health care; and agreed that collective action is needed to intensify our efforts to reduce health inequities. The HPGN held a further very successful Global Consultation in Journal of Interprofessional Care, September 2010; 24(5): 473–474

Promoting collaboration in emergency medicine

Collaborative practice between paramedics and medical staff is essential for ensuring the safe handover of patients. Handover of care is a critical time in the patient journey, when effective communication and collaborative practice are central to promoting patient safety and to avoiding medical error. To encourage effective collaboration between paramedic and medical students, an innovative, practice‐based simulation exercise, known as interprofessional clinical skills (ICS) was developed at the University of East Anglia, UK. Emphasising patient safety, effective handover of care and teamwork, within the context of emergency medicine, the ICS promotes collaborative practice amongst health care students through the use of high‐ and low‐fidelity simulation, human factors and values‐based practice.