Snakes and ladders: An integrative literature review of refugee doctors' workforce integration needs.

INTRODUCTION: Healthcare systems worldwide are facing a workforce crisis; meanwhile, refugee doctors throughout the world face difficulties in accessing work. The aims of this review were to explore the integration needs of refugee doctors into host healthcare systems from the refugee perspective, synthesise the literature to construct a theory of refugee doctor integration needs and explore how these needs are met or challenged on the pathway to full integration. METHODS: In this integrative literature review, 11 databases and eight grey literature sources were searched by combining terms for refugee doctor and social integration and limiting to research published in or after 2003. Data were extracted, and quality scoring was completed independently by two researchers. This study utilised template analysis to perform a qualitative synthesis of the data. The multidimensional template included a pre-defined template based on a theoretical framework and a concurrent fully inductive template. RESULTS: Twenty-two papers were included, incorporating the views of 339 doctors from 30 different home countries and 10 different host countries. The resultant theory included 'foundations' (rights and responsibilities) and three pillars. The 'learning' pillar included required knowledge and skills acquisition. The 'being' pillar encompassed necessary identity work. The 'connecting' pillar comprised social connections, which impacted all other domains. The random and non-linear path to integration faced by refugee doctors was also presented as a serious game. DISCUSSION: This study produced a theory exploring refugee doctors' integration needs and how these are met or challenged. Medical educators developing courses for refugee doctors should attend not only to knowledge and skills acquisition but also social connections, identity work and rights and responsibilities. The theory highlights the central importance of social connections. Medical educators can therefore have a transformative impact on refugee doctors' integration. This may also contribute to society by helping to alleviate the workforce crisis.

The development of a marker system for Pharmacists' Behavioural Skills.

OBJECTIVES: Pharmacists increasingly require complex behavioural skills to fulfil enhanced roles within healthcare teams. Behavioural marker systems are used to assess behavioural (or non-technical) skills during immersive simulation. This study aimed to develop a marker system for pharmacists' behavioural skills in patient-focussed care scenarios, and to investigate its content validity. METHODS: Literature describing existing marker systems and the requisite behavioural skills of pharmacists were presented to two expert panels, alongside video examples of pharmacists in patient-focussed care simulations. The expert panels used this information to develop a new behavioural marker system. A third expert panel assessed the content validity, and the item- and scale-content validity indices were calculated. KEY FINDINGS: The resulting tool contains four categories, each with three or four skill elements: situation awareness (gathering information; recognising and understanding information; anticipating, preparing and planning), decision-making and prioritisation (identifying options; prioritising; dealing with uncertainty; implementing or reviewing decisions), collaborative working (involving the patient; information sharing; leadership or followership), self-awareness (role awareness; speaking up; escalating care; coping with stress). The scale-content validity index was 0.95 (ideal) and the only item below the acceptable cut-off was 'leadership or followership' (0.7). CONCLUSIONS: This tool is the first marker system designed to assess the behavioural skills of pharmacists in patient-focussed care scenarios. There is evidence of good content validity. It is hoped that once validated, the Pharmacists' Behavioural Skills marker system will enable pharmacy educators to provide individualised and meaningful feedback on simulation participants' behavioural skills.

Investigating how interprofessional simulation influences tolerance of ambiguity.

INTRODUCTION: Decision making in clinical practice is only possible if we are able to understand the limits of our own knowledge and manage the associated uncertainty. Tolerance of ambiguity is therefore an important attribute for trainee pharmacists and medical students to develop. This study aimed to explore the impact of an interprofessional simulation on the tolerance of ambiguity of trainee pharmacists and medical students. METHODS: Trainee pharmacists and final year medical students participated in interprofessional simulation in two regions of Scotland. Participants completed pre- and post-session tolerance of ambiguity questionnaires. Analysis included differences between the pre-session scores of the two groups; the trainee pharmacists' pre- and post-session scores; and the medical students' pre- and post-session scores. RESULTS: A total of 15 trainee pharmacists and 15 medical students participated. Baseline tolerance of ambiguity was slightly higher in medical students than trainee pharmacists (56.9 vs. 52.6), but the study was insufficiently powered to detect whether this was a true difference (P = .21). Trainee pharmacists showed a statistically significant increase in self-reported tolerance of ambiguity (52.6 to 60.8, P = .004), but medical students did not (56.9 to 63.8, P = .04). CONCLUSIONS: Trainee pharmacists' tolerance of ambiguity was improved following participation in an interprofessional simulation. Further research could establish whether the improvements differ between professional groups, and explore the reasons why tolerance of ambiguity may be affected by interprofessional simulation.

Functional changes in Bleu d'Auvergne cheese during ripening.

The authentic characteristics of the famous Bleu d'Auvergne cheese were studied. Many parameters were analysed during the ripening of cheeses. Migrations of Na and Ca ions, associated with a pH gradient, occurred between the rind and the core. At 34 days, this cheese had a high salt content (2.87 %), contributing to 23 % of the recommended sodium intake for adults, but significant calcium (6.14 g/kg) and vitamin B12 (1.14 µg/100 g) levels. Thus, a 40 g serving contributed to 25 % of the population reference intake for Ca and 11 % of the adequate intake for B12. Proteolysis, yeast and mould counts strongly increased. Lactococcus and Streptococcus were predominant and correlated with B2 and B6 levels. Bleu d'Auvergne was characterised by salty taste, blue odour and aroma. This cheese has a noticeable B vitamins concentration, but the level of salt should be reduced to meet the nutritional guidelines, possibly by implementing alternative salting methods.

Exploring transformative learning for trainee pharmacists through interprofessional simulation: a constructivist interview study.

BACKGROUND: The expanding roles of UK pharmacists have prompted substantial changes to the initial pharmacy education and training, including increasing recognition of the value of learning alongside other professional groups in acute settings. Interprofessional immersive simulation training appears to represent a useful educational tool to meet the evolving needs of the profession, but the impact of such training on workplace behaviour and relationships has not been explored. This study aimed to explore how interprofessional simulation training facilitates transformative learning in pre-registration pharmacists. METHODS: Across three different locations in Scotland, pre-registration pharmacists were paired with medical students to participate in immersive simulation scenarios with post-scenario debriefs. Pre-registration pharmacists were individually interviewed shortly after their simulation session, using a semi-structured interview schedule based on the transformative learning framework. Transcripts were analysed using template analysis, with Mezirow's phases of perspective transformation forming the initial coding template. RESULTS: Fifteen interviews following five simulation sessions at three different sites were undertaken. Phases 1-6 of the transformative learning framework all resonated with the pre-registration pharmacists to varying degrees. Two prominent threads became evident in the data: a change in participants' perceptions of risk, and deepened understanding of their role within an acute context. These themes were woven throughout phases 2-6 of the transformative learning framework. CONCLUSIONS: Interprofessional immersive simulation training involving acute clinical scenarios has been found to be helpful for pre-registration pharmacists and can foster transformative learning. Through this powerful process, they developed new ways to see the world, themselves and their professional relationships. Positive future actions and roles were planned. As the patient-facing roles of pharmacists expand, educational practices that translate into meaningful change to workplace behaviour and relationships become increasingly important. Carefully constructed interprofessional immersive simulation training should be utilised within pharmacy education more widely.

Calcium lactate as an attractive compound to partly replace salt in blue-veined cheese.

In addition to their high sodium content, cheeses are thought to induce an acid load to the body, which is associated with deleterious effects on consumers' health. Our objective was to explore the use of alkalinizing salts in partial substitution of NaCl to reduce both the sodium content and the acid-forming potential of cheese, without altering its sensory properties. Blue-veined cheeses were produced under industrial conditions, using brine salting followed by dry salting with a 4:1 (wt/wt) mixture of calcium lactate:NaCl or calcium citrate:NaCl. Sodium chloride was used in 2 granulometries: coarse (control treatment) and fine, to obtain homogeneous mixtures with the organic salts. Cheeses were then ripened for 56 d. No major appearance defects were observed during ripening. Calcium lactate substitution decreased the Na content of the cheese core by 33%, and calcium citrate substitution increased the citrate content of the cheese core by 410%, respectively, compared with fine NaCl. This study highlighted the substantial role of salt granulometry in sodium content, with the use of the coarse salt reducing the sodium content by 21% compared with fine salt. Sensory profiles showed nonsignificant differences in bitter and salty perceptions of salt-substituted cheeses with calcium lactate and calcium citrate compared with control cheeses. The use of calcium lactate should be considered to reduce the sodium content and improve the nutritional quality of cheeses while maintaining the sensory quality of the products. Alkalinizing organic salts could replace the acidifying salts KCl or CaCl2, which are currently used in salt replacement and are not recommended for consumers with renal disease. The method described here should be considered by cheese-making producers to improve the nutritional quality of cheese. Additional nutritional optimization strategies are suggested.

Draining and salting as responsible key steps in the generation of the acid-forming potential of cheese: Application to a soft blue-veined cheese.

A disregarded nutritional feature of cheeses is their high acid-forming potential when ingested, which is associated with deleterious effects on consumers' health. This work aimed to characterize the acid-forming potential of a blue-veined cheese during manufacturing to identify the main steps of the process involved in this phenomenon. Sampling was performed on 3 batches at 10 steps of the cheese-making process: reception of raw milk, pasteurization, maturation of milk, coagulation, stirring, draining of the curds, and 4 ripening stages: 21, 28, 42, and 56d. The acid-forming potential of each sample was evaluated by (1) the calculation of the potential renal acid load (PRAL) index (considering protein, Cl, P, Na, K, Mg, and Ca contents), and (2) its organic anion content (lactate and citrate), considered as alkalinizing elements. Draining and salting were identified as the main steps responsible for generation of the acid-forming potential of cheese. The draining process induced an increase in the PRAL index from 1.2mEq/100g in milk to 10.4mEq/100g in drained curds due to the increase in dry matter and the loss of alkaline minerals into the whey. The increase in PRAL value (20.3mEq/100g at d 56) following salting resulted from an imbalance between the strong acidogenic elements (Cl, P, and proteins) and the main alkalinizing ones (Na and Ca). Particularly, Cl had a major effect on the PRAL value. Regarding organic anions, draining induced a loss of 93% of the citrate content in initial milk. The lactate content increased as fermentation occurred (1,297.9mg/100g in drained curds), and then decreased during ripening (519.3mg/100g at d 56). This lactate level probably helps moderate the acidifying potential of end products. Technological strategies aimed at limiting the acid-forming potential of cheeses are proposed and deserve further research to evaluate their nutritional relevance.

Exploratory study of acid-forming potential of commercial cheeses: impact of cheese type.

Due to their composition, cheeses are suspected to induce an acid load to the body. To better understand this nutritional feature, the acid-forming potential of five cheeses from different cheese-making technologies and two milk was evaluated on the basis of their potential renal acid load (PRAL) index (considering protein, P, Cl, Na, K, Mg and Ca contents) and organic anions contents. PRAL index ranged from -0.8 mEq/100 g edible portion for fresh cheese to 25.3 mEq/100 g for hard cheese Cantal and 28 mEq/100 g for blue-veined cheese Fourme d'Ambert. PRAL values were greatly subjected to interbatch fluctuations. This work emphasized a great imbalance between acidifying elements of PRAL calculation (Cl, P and proteins elements) and alkalinizing ones (Na and Ca). Particularly, Cl followed by P elements had a strong impact on the PRAL value. Hard cheeses were rich in lactate, thus, might be less acidifying than suspected by their PRAL values only.

The impact of raw materials and baking conditions on Maillard reaction products, thiamine, folate, phytic acid and minerals in white bread.

The aim of this study was to develop a white bread with improved nutrient contents and reduced levels of potentially harmful Maillard reaction products such as N(ε)-carboxymethyllysine (CML) and 5-hydroxymethylfurfural (HMF). Assays were carried out through a full factorial experimental design allowing the simultaneous analysis of four factors at two levels: (1) wheat flour extraction rates (ash content: 0.60%-0.72%), (2) leavening agents (bakers' yeast - bakers' yeast and sourdough), (3) prebaking and (4) baking conditions (different sets of time and temperature). The baking conditions affected HMF and CML as well as certain mineral contents. A reduced baking temperature along with a prolonged heat treatment was found to be favourable for reducing both the CML (up to 20%) and HMF concentrations (up to 96%). The presence of sourdough decreased the formation of CML (up to 28%), and increased the apparent amounts of calcium (up to 8%) and manganese (up to 17.5%) probably through acidification of the dough. The extraction rate of flours as well as interactions between multiple factors also affected certain mineral content. However, compounds like folate, thiamine, copper, zinc, iron and phytic acid were not affected by any of the factors studied.

Motives underlying food consumption in the Western Balkans: consumers' profiles and public health strategies.

OBJECTIVES: This study aims to identify subgroups of consumers based on the health motives underlying their food choice in Western Balkan Countries. METHODS: The survey (n = 2943) was based on the Food Choice Questionnaire (FCQ) and elicited information on socio-demographic characteristics, consumption frequency of healthy food products, nutrition knowledge and impulsiveness. Analysis of the FCQ data focused on items of "health and natural content" and "weight control" factors to identify clusters. RESULTS: The biggest group of the sample was weight control and health-concerned individuals (34 %), mainly urban women older than 50. The second group of respondents (31 %) was moderately motivated about health and weight. A third group was health concerned but paid less attention to weight control (21 %), mainly comprising men and people living with children. The last group consisted of unconcerned young men (14 %) eating less fruit and showing higher impulsiveness. CONCLUSIONS: Western Balkan consumers differ in the importance they attach to health and natural content and weight control. This insight is needed to target interventions.

Dietary protein supplementation increases peak bone mass acquisition in energy-restricted growing rats.

Peak bone mass is a major determinant of osteoporosis pathogenesis during aging. Respective influences of energy and protein supplies on skeletal growth remains unclear. We investigated the effect of a 5-mo dietary restriction on bone status in young rats randomized into six groups (n = 10 per group). Control animals were fed a diet containing a normal (13%) (C-NP) or a high-protein content (26%) (C-HP). The other groups received a 40% protein energy-restricted diet (PER-NP and PER-HP) or a 40% energy-restricted diet (ER-NP and ER-HP). High-protein intake did not modulate bone acquisition, although a metabolic acidosis was induced and calcium retention impaired. PER and ER diets were associated with a decrease in femoral bone mineral density. The compensation for protein intake in energy-restricted conditions induced a bone sparing effect. Plasma osteocalcin (OC) and urinary deoxypyridinoline (DPD) assays revealed a decreased OC/DPD ratio in restricted rats compared with C animals, which was far more reduced in PER than in ER groups. Circulating IGF-1 levels were lowered by dietary restrictions. In conclusion, both energy and protein deficiencies may contribute to impairment in peak bone mass acquisition, which may affect skeleton strength and potentially render individuals more susceptible to osteoporosis.

Influence of sourdough prefermentation, of steam cooking suppression and of decreased sucrose content during wheat flakes processing on the plasma glucose and insulin responses and satiety of healthy subjects.

BACKGROUND: Ready-to-eat breakfast cereals (RTE-BC) are eaten more and more frequently by both adults and adolescents, but their nutritional quality is far from satisfactory: they often contained too much sugars and lead to a high glycemic index (GI) which generally contributes to a more rapid return of the feeling of hunger favouring nibbling in the morning. OBJECTIVE: To reduce the GI and to improve the nutritional quality of standard wheat flakes (SWF) by adding a sourdough prefermentation step, suppressing steam cooking and decreasing the sucrose content (MWF, modified wheat flake). METHODS: Eleven healthy male volunteers were randomly given, at three separate times, SWF, MWF, and white-wheat bread (WWB, reference food). Plasma glucose, insulin and ghrelin concentrations were measured. The feeling of hunger was evaluated using a subjective rating scale. Starch structure of SWF and MWF was characterised by scanning electron microscopy. RESULTS: GI of MWF (83 +/- 7) was 12% lower than that of SWF (94 +/- 9) at 90 min but the effect was not significant. Insulinaemic index of MWF was significantly lower than that of SWF at 90 min (78 +/- 6 vs 98 +/- 8). Hunger feelings were lower following MWF consumption and were positively correlated (r = 0.98; P < 0.05) with plasma ghrelin concentrations, for which there was no significant difference between SWF and MWF. Starch granules of SWF were fully gelatinised unlike those of MWF. CONCLUSION: Despite its relatively high GI, MWF could provide health benefits by improving the management of hunger feeling in the morning and by moderately improving insulin economy, which could be of interest for type 2 diabetic subjects. GI is not, therefore, the sole parameter reflecting the nutritional quality of cereal products.

Major phenolic compounds in olive oil modulate bone loss in an ovariectomy/inflammation experimental model.

This study was conducted to determine whether the daily consumption for 84 days of tyrosol and hydroxytyrosol, the main olive oil phenolic compounds, and olive oil mill wastewater (OMWW), a byproduct of olive oil production, rich in micronutrients, may improve bone loss in ovariectomized rats (an experimental model of postmenopausal osteoporosis) and in ovariectomized rats with granulomatosis inflammation (a model set up for senile osteoporosis). As expected, an induced chronic inflammation provoked further bone loss at total, metaphyseal, and diaphyseal sites in ovariectomized rats. Tyrosol and hydroxytyrosol prevented this osteopenia by increasing bone formation ( p < 0.05), probably because of their antioxidant properties. The two doses of OMWW extracts had the same protective effect on bone ( p < 0.05), whereas OMWW did not reverse established osteopenia. In conclusion, polyphenol consumption seems to be an interesting way to prevent bone loss.

Influence of high and low protein intakes on age-related bone loss in rats submitted to adequate or restricted energy conditions.

Low energy and protein intake has been suggested to contribute to the increased incidence of osteoporosis in the elderly. The impact of dietary protein on bone health is still a matter of debate. Therefore, we examined the effect of the modulation of protein intake under adequate or deficient energy conditions on bone status in 16-month-old male rats. The animals were randomly allocated to six groups (n = 10/group). Control animals were fed a diet providing either a normal-protein content (13%, C-NP) or a high-protein content (26%) (C-HP). The other groups received a 40% protein/energy-restricted diet (PER-NP and PER-HP) or a normal protein/energy-restricted diet (ER-NP and ER-HP). After 5 months of the experiment, protein intake (13% or 26%) did not modulate calcium retention or bone status in those rats, although a low-grade metabolic acidosis was induced with the HP diet. Both restrictions (PER and ER) decreased femoral bone mineral density and fracture load. Plasma osteocalcin and urinary deoxypyridinoline levels were lowered, suggesting a decrease in bone turnover in the PER and ER groups. Circulating insulin-like growth factor-I levels were also lowered by dietary restrictions, together with calcium retention. Adequate protein intake in the ER condition did not elicit any bone-sparing effect compared to PER rats. In conclusion, both energy and protein deficiencies may contribute to age-related bone loss. This study highlights the importance of sustaining adequate energy and protein provision to preserve skeletal integrity in the elderly.

Long-term intake of a high-protein diet with or without potassium citrate modulates acid-base metabolism, but not bone status, in male rats.

High dietary protein intake generates endogenous acid production, which may adversely affect bone health. Alkaline potassium citrate (Kcit)(2) may contribute to the neutralization of the protein-induced metabolic acidosis. We investigated the impact of 2 levels of protein intake and Kcit supplementation on acid-base metabolism and bone status in rats. Two-month-old Wistar male rats were randomly assigned to 4 groups (n = 30 per group). Two groups received a normal-protein content (13%) (NP) or a high-protein (HP) content diet (26%) for 19 mo. The 2 other groups received identical diets supplemented with Kcit (3.60%) (NPKcit and HPKcit). Rats were pair-fed based on the ad libitum intake of the HP group. At 9, 16, and 21 mo of age, 10 rats of each group were killed. The HP diet induced a metabolic acidosis characterized by hypercalciuria, hypermagnesuria, and hypocitraturia at all ages. Kcit supplementation neutralized this effect, as evidenced by decreased urinary calcium and magnesium excretion by the HPKcit rats. Femoral bone mineral density, biomechanical properties, bone metabolism biomarkers (osteocalcin and deoxypyridinoline), and plasma insulin-like growth factor 1 levels were not affected by the different diets. Nevertheless, at 21 mo of age, calcium retention was reduced in the HP group. This study suggests that lifelong excess of dietary protein results in low-grade metabolic acidosis without affecting the skeleton, which may be protected by an adequate calcium supply.

Black Lucques olives prevented bone loss caused by ovariectomy and talc granulomatosis in rats.

This study was conducted to determine whether olive fruits, rich in micronutrients, might improve bone loss in ovariectomized (OVX) rats (an experimental model of postmenopausal osteoporosis) and in OVX rats with granulomatosis inflammation (a model of senile osteoporosis). Six-month-old Wistar female rats underwent ovariectomy and were then immediately treated orally by substituting oil in the diet by 10 g/d green Lucques olives or 6 g/d black Lucques olives for each rat for 84 days. OVX rats and sham-operated controls received the same diet with oil. Three weeks before the end of the experiment, subcutaneous inflammation was provoked by injections of sterile magnesium silicate in half the animals in each group. In OVX rats, granulomatosis inflammation, characterized by a rise in inflammatory parameters such as fibrinogen, alpha1-acid glycoprotein, spleen weight and granulocyte level, and an impairment of oxidative status (as shown by a decrease in plasma antioxidant capacity, a higher rate of isoprostane excretion) elicited a bone loss in the whole femur and in the metaphyseal areas considered on their own. Whereas green olives had no effect on osteopenia, consumption of the black variety prevented bone loss in the whole femur and at cortical sites in those oestrogen-deficient animals with talc inflammation (diaphyseal bone mineral density: black olives and inflammation 0-2323 (SE 0.0026) v. ovariectomy and inflammation 0.2117 (SE 0.0030); P=0.027). This bone-sparing effect seemed to result from an improvement in the inflammatory and oxidative status. The present data show that black olives are able to prevent bone loss in an experimental model of senile osteoporosis (oestrogen-deficient rats in which a low-grade inflammation was induced by talc injection).

Dose-response study of effect of oleuropein, an olive oil polyphenol, in an ovariectomy/inflammation experimental model of bone loss in the rat.

BACKGROUND & AIMS: This study was carried out to assess the dose-dependent bone-sparing effect of oleuropein, an olive oil phenolic compound with anti-inflammatory and anti-oxidative properties, on bone loss induced by talc granulomatosis in oestrogen-deficient rat. METHODS: Among 98 rats, 20 were sham-operated (SH) while the others (78) were ovariectomised (OVX). The SH and 26 OVX rats (controls) were given a standard diet for 100 days. The 52 remaining OVX rats were allocated to 4 groups that received oleuropein at 2.5, 5, 10 or 15 mg/kg body weight per day for 100 days. Three weeks before necropsy, an inflammation was induced by subcutaneous injections of talc in half of the SH and OVX rats and in all oleuropein-treated animals. RESULTS: Castration was associated with a decreased bone mineral density (BMD). In OVX rats, inflammation, characterised by an increase of the spleen weight and plasma fibrinogen levels, exacerbated this bone loss, as shown by values of BMD of the total femur metaphyseal and diaphyseal subregions. The 4 doses of oleuropein reduced bone loss and improved inflammatory biomarkers excepted for 5mg/kg BW. CONCLUSIONS: Every dose of oleuropein elicited protective effects on bone mass in this model of ovariectomy associated with inflammation, probably by modulating inflammatory parameters.