"I wanted to communicate my feelings freely": a descriptive study of creative responses to enhance reflection in palliative medicine education.

BACKGROUND: The recent growth of arts and humanities in medical education shows recognition that these disciplines can facilitate a breadth of thinking and result in personal and professional growth. However creative work can be a challenge to incorporate into a busy curriculum. Offering the option of creative media as a way of reflecting is an example of how this can occur. This study aimed to examine the medical student response to being given this option to explore a visit to a patient in a hospice. METHODS: This was a mainly qualitative study. In the 2012 academic programme, the class of 86 students were given the option of using a creative medium to explore their responses to both the visit and their developing communication skills. Students were required to write an accompanying commentary if submitting the creative work option. Sixty-four percent of the class chose a creative medium e.g. poetry, visual art, narrative prose, music. These students were asked to take part in research including completing a short on-line survey and consenting for their creative work and commentaries to be further examined. The creative works were categorised by genre and the commentaries analysed using inductive thematic analysis. RESULTS: Seventeen students completed the on-line survey and fifteen consented to their work being used for this research. Thematic analysis of the student commentaries revealed the following themes: effectiveness for expressing emotion or ideas that are difficult to articulate; engaging and energising quality of the task; time for reflection; flexibility for individual learning styles and therapeutic value. CONCLUSIONS: Teaching the art of communicating at end-of-life is challenging especially when it involves patients, and teachers want to ensure students gain as much as possible from the experience. Offering the option to use creative media means that students can choose a medium for reflection that best suits them as individuals and that can enable them to benefit as much as possible from their experience.

Identifying Sources of Faecal Contamination in a Small Urban Stream Catchment: A Multiparametric Approach.

Small urban streams discharging in the proximity of bathing waters may significantly contribute to the deterioration of water quality, yet their impact may be overlooked. This study focuses on the Elm Park stream in the city of Dublin that is subject to faecal contamination by unidentified sources. The aim of the study was to identify a minimum number of "sentinel" sampling stations in an urban catchment that would provide the maximum amount of information regarding faecal pollution in the catchment. Thus, high-resolution sampling within the catchment was carried out over the course of 1 year at 11 stations. Faecal indicator bacteria were enumerated and microbial source tracking (MST) was employed to evaluate human pollution. In addition, ammonium, total oxidised nitrogen, and phosphorus levels were monitored to determine if these correlated with faecal indicator and the HF183 MST marker. In addition, the effect of severe weather events on water quality was assessed using automated sampling at one of the identified "sentinel" stations during baseflow and high flow conditions over a 24-h period. Our results show that this urban stream is at times highly contaminated by point source faecal pollution and that human faecal pollution is pervasive in the catchment. Correlations between ammonium concentrations and faecal indicator bacteria (FIB) as well as the human MST marker were observed during the study. Cluster analysis identified four "sentinel" stations that provide sufficient information on faecal pollution in the stream, thus reducing the geographical complexity of the catchment. Furthermore, ammonium levels strongly correlated with FIB and the human HF183 MST marker under high flow conditions at key "sentinel" stations. This work demonstrates the effectiveness of pairing MST, faecal indicators, and ammonium monitoring to identify "sentinel" stations that could be more rapidly assessed using real-time ammonium readouts to assess remediation efforts.

Acute stress in adolescence vs early adulthood following selective deletion of dysbindin-1A: Effects on anxiety, cognition and other schizophrenia-related phenotypes.

BACKGROUND: As exposure to stress has been linked to the onset and maintenance of psychotic illness, its pathogenesis may involve environmental stressors interacting with genetic vulnerability. AIM: To establish whether acute stress interacts with a targeted mutation of the gene encoding the neurodevelopmental factor dystrobrevin-binding protein 1 (DTNBP1), resulting in a specific loss of the isoform dysbindin-1A, to influence schizophrenia-relevant phenotypes in mice during adolescence and adulthood. METHODS: Male and female mice with a heterozygous or homozygous deletion of DTNBP1 were assessed in the open field test following acute restraint stress in adolescence (Day 35) and young adulthood (Day 60-70). Effects of acute restraint stress on memory retention in the novel object recognition test was also assessed in adulthood. Baseline corticosterone was measured in serum samples and, brain-derived neurotrophic factor (BDNF), glucocorticoid and mineralocorticoid receptor gene expression levels were measured in the hippocampus of adult mice. RESULTS: In the open field, deletion of dysbindin-1A induced hyperactivity and attenuated the action of stress to reduce hyperactivity in adolescence but not in adulthood; in females deletion of dysbindin-1A attenuated the effect of acute stress to increase anxiety-related behaviour in adolescence but not in adulthood. In the novel object recognition test, deletion of dysbindin-1A impaired memory and also revealed an increase in anxiety-related behaviour and a decrease in hippocampal BDNF gene expression in males. CONCLUSIONS: These data suggest that deletion of dysbindin-1A influences behaviours related to schizophrenia and anxiety more robustly in adolescence than in adulthood and that dysbindin-1A influences stress-related responses in a sex-dependent manner.

Association of NOD2 with Crohn's disease in a homogenous Irish population.

Linkage of IBD to the pericentromeric region of chromosome 16 has been widely confirmed by analyses of multiple populations. The NOD2 gene is located in the peak region of linkage on chromosome 16 and thought to be involved in the activation of nuclear factor (NF) kappaB in response to bacterial components. Mutations in the NOD2 gene are found to be strongly associated with susceptibility to Crohn's disease (CD). A total of 65 Irish CD families were genotyped to determine if NOD2 mutations conferred susceptibility to CD and the prevalence of these mutations in sporadic and familial forms of the disease. The Irish population is relatively homogenous and thus may provide advantages in genetic studies of complex diseases. We confirmed the IBD1 locus as a susceptibility locus for IBD within the Irish population by linkage analysis followed by linkage disequilibrium studies. No significant evidence of linkage was observed to the previously identified regions on chromosomes 1, 12 and 14. In all, 131 CD affected families were then genotyped for seven of the previously published NOD2 single-nucleotide polymorphisms (SNPs). Allelic transmission distortion was investigated using the pedigree disequilibrium test (PDT). SNP13 (3020insC) was found to be associated with CD (P=0.0186). Patients who possessed a rare allele of SNP8, 12 or 13 presented earlier when compared to patients without rare variants (mean age, 20.1 vs 24 years, P=0.011) and the rare allele of SNP13 was observed to be predominantly linked to ileal disease (P=0.02). This report confirms the importance of NOD2 as a susceptibility gene for CD within the Irish population.

Celiac disease and the transition from childhood to adulthood: a 28-year follow-up.

OBJECTIVES: Follow-up of celiac disease diagnosed in childhood is variable or nonexistent after transition to adulthood. Outcome, continuity of care, and adherence to a gluten-free diet are poorly documented. We report a 28-yr follow-up of 50 adults in whom the original childhood diagnosis could be confirmed. METHODS: Original pediatric charts were reviewed, and subjects were invited to undergo dietary evaluation, measurement of bone mineral density, and quality-of-life assessment. The mean duration of celiac was 28.5 yr, median 28.7 yr (range 22-45 yr). The mean and median age of the group was 35 yr. RESULTS: Only 22% of patients were enrolled in an adult gastroenterology clinic. Fifty percent were fully compliant with a gluten-free diet; 18% were partially compliant; and 32% were not adhering to diet. The main motivating factor for dietary compliance was avoidance of symptoms rather than avoidance of complications. Eighty-six percent of the females and 21% of the males had iron deficiency. Bone mineral density was subnormal in 32%; 28.9% were osteopenic and 2.6% were osteoporotic. Quality-of-life scores were normal. CONCLUSIONS: Most patients diagnosed with celiac in childhood receive no medical or dietary supervision after transition to adulthood. One-third are not compliant with diet; the primary motivating factor for those who do comply is avoidance of symptoms rather than fear of complications. The prevalence of preventable and treatable disorders in these young adults highlights a failure of health services after transition from pediatric to adult health care.

Celiac disease and irritable bowel-type symptoms.

OBJECTIVES: Previous reports have linked irritable bowel syndrome (IBS) etiologically with various forms of mucosal inflammation, including infectious enterocolitides and inflammatory bowel disease. The mechanism is uncertain but may involve sensitization by inflammatory mediators. The enteropathy of celiac disease has theoretical advantages as a study model because it can be controlled with dietary gluten exclusion; however, whether it also predisposes to functional bowel disorders is unclear. Therefore, we assessed the prevalence of IBS-type symptoms in adult celiac patients and correlated this with dietary compliance with gluten exclusion. METHODS: Adult patients (n = 150; 106 women and 44 men) with confirmed celiac disease were randomly selected from a computerized database of >350 patients, and were asked to complete a bowel questionnaire and the Short Form 36 Health Survey (SF-36). The control group (n = 162; 133 women and 29 men) had no history of celiac disease and had similar mean age and sex profile. RESULTS: Of 150 celiac patients reviewed, 30 of 150 (20%) fulfilled the Rome criteria compared with eight of 162 (5%) ontrols. Of the celiac patients 10 of 46 (22%) had partial or no compliance with a gluten-free diet, whereas 20 of 104 patients (19%) adhered to the diet; this difference did not achieve statistical significance. Celiac patients with IBS-type symptoms had a markedly lower quality of life than those without, all eight domains being impaired to a clinically significant extent. Dietary gluten exclusion improved QOL in four of eight scales measured. CONCLUSIONS: The hypothesis that mucosal inflammation in celiac disease may have a sensitizing effect or may predispose to IBS-type symptoms is supported by these results. Failure to attain optimal subjective well-being is common in celiac patients, particularly in those with coexisting IBS. Compliance with a gluten-free diet confers some benefit.