A Qualitative Study of the Experiences and Factors That Led Physicians to Be Lifelong Health Advocates.

PURPOSE: Given the public's trust and the opportunities to observe and address social determinants of health, physicians are well suited to be health advocates, a key role in the CanMEDS physician competency framework. As some physicians find it difficult to fulfill this role, the authors explored the experiences and influences that led established physicians to be health advocates. METHOD: The authors used a phenomenological approach to explore this topic. From March to August 2014, they interviewed 15 established physician health advocates, using a broad definition of health advocacy-that it extends beyond individual patient advocacy to address the root causes of systemic differences in health. Interviews were audio recorded and transcribed verbatim. The transcripts were coded and the data categorized into clusters of meaning, then into themes. Data analysis was conducted iteratively, with data collection continuing until no new information was gathered. RESULTS: Participants described the factors that contributed to the development of their health advocate identity (i.e., exposure to social injustice, upbringing, schooling, specific formative experiences) and those that facilitated their engagement in health advocacy work (i.e., mentors, training, systemic and organizational supports). They also highlighted how they continue in their role as lifelong advocates (i.e., continuous learning and improvement, self-reflection and self-reflexivity, collaboration, intrinsic satisfaction in the work). CONCLUSIONS: Many factors allow physician health advocates to establish and sustain a commitment to improve the health of their patients and the broader population. Medical schools could use these findings to guide curriculum development related to teaching this physician competency.

Prostaglandin E2 modulates IL-8 expression through formation of a multiprotein enhanceosome in human colonic epithelial cells.

Gastrointestinal inflammation is mediated by the pro-inflammatory mediators interleukin-8 (IL-8) and prostaglandin E(2) (PGE(2) ). PGE(2) binding and coupling through EP2/4 receptor subtypes on colonic epithelial cells stimulates cyclic adenosine monophosphate (cAMP) and IL-8 production. Here we determined the mechanisms whereby PGE(2) regu-lates IL-8 in Caco2 colonic epithelial cells and in cells over-expressing the EP2/4 receptors (EP2S/EP4S). PGE(2) coupling through EP2 activated the transcription factor inducible cAMP early repressor (ICER), whereas coupling through EP4 receptors activated the cyclic AMP-responsive element-binding protein (CREB). Activation of CREB in Caco2/EP2S was protein kinase A (PKA) dependent, whereas in EP4S cells, activation of CREB occurred through the PKA and phosphatidylinositol 3-kinase pathways. Since ICER lacks the transactivation domain, it functions as a transcription repressor as opposed to CREB. PGE(2) coupling through EP2/4 receptors can therefore acts in an opposing manner to either decrease (EP2) or promote IL-8 expression by recruiting CREB-binding protein (CBP) (EP4), which formed a multiprotein IL-8 enhanceosome. A novel half CRE (167CRE) and a composite NFAT1-AP1-like site in the IL-8 promoter participated in binding and complex formation as confirmed by mutagenesis and expression studies. These data unravel the mechanisms by which expression of IL-8 is controlled by different signalling pathways that are activated by PGE(2) but acting through different EP receptors.

Tumor necrosis factor-α and Muc2 mucin play major roles in disease onset and progression in dextran sodium sulphate-induced colitis.

The sequential events and the inflammatory mediators that characterize disease onset and progression of ulcerative colitis (UC) are not well known. In this study, we evaluated the early pathologic events in the pathogenesis of colonic ulcers in rats treated with dextran sodium sulfate (DSS). Following a lag phase, day 5 of DSS treatment was found clinically most critical as disease activity index (DAI) exhibited an exponential rise with severe weight loss and rectal bleeding. Surprisingly, on days 1-2, colonic TNF-α expression (70-80-fold) and tissue protein (50-fold) were increased, whereas IL-1ß only increased on days 7-9 (60-90-fold). Days 3-6 of DSS treatment were characterized by a prominent down regulation in the expression of regulatory cytokines (40-fold for IL-10 and TGFß) and mucin genes (15-18 fold for Muc2 and Muc3) concomitant with depletion of goblet cell and adherent mucin. Remarkably, treatment with TNF-α neutralizing antibody markedly altered DSS injury with reduced DAI, restoration of the adherent and goblet cell mucin and IL-1ß and mucin gene expression. We conclude that early onset colitis is dependent on TNF-α that preceded depletion of adherent and goblet cell mucin prior to epithelial cell damage and these biomarkers can be used as therapeutic targets for UC.

Human trafficking: an evaluation of Canadian medical students' awareness and attitudes.

CONTEXT: Human trafficking is a human rights violation prevalent globally. Current guidelines highlight healthcare professionals' key role in responding to human trafficking, emphasizing the importance of medical education in raising awareness of trafficking. OBJECTIVE: To assess pre-clerkship medical students' awareness of human trafficking and attitudes towards learning about trafficking in the medical curriculum at Canada's largest medical school. METHODS: An anonymous, classroom-based questionnaire was designed, piloted and administered to first- and second-year medical students at one large Canadian medical school with a diverse student population. The questionnaire sought demographic data and information on students' self-perceived awareness of human trafficking and interest in learning about trafficking and other community health issues. RESULTS: 262 medical students completed the questionnaire (70.0% response). Most participants reported that they were not knowledgeable (48.5%) or only somewhat knowledgeable (45.4%) about human trafficking. 88.9% of participants were not familiar with signs and symptoms of trafficked persons. While students' responses indicated that they prioritized other social issues, a majority of participants (76.0%) thought that trafficking was important to learn about in medical school, especially identifying trafficked persons and their health needs. CONCLUSIONS: These medical students of one Canadian medical school demonstrated limited familiarity with the issue of human trafficking but largely felt that they should be taught more about this issue during their medical education. This assessment of early medical students' awareness of human trafficking is relevant to medical educators and the organizations that could develop the required educational curricula and resources.

Role of EP4 receptor and prostaglandin transporter in prostaglandin E2-induced alteration in colonic epithelial barrier integrity.

Prostaglandin E(2) (PGE(2)) is a proinflammatory lipid mediator produced in excess in inflammatory bowel disease (IBD). PGE(2) couples to and signals via four different E-prostanoid (EP) receptors, namely EP1, EP2, EP3, and EP4. In this study, we determined a role for PGE(2) and EP4 receptors in altering colonic epithelial barrier integrity. In healthy colonic mucosa, EP4 receptors were localized on apical plasma membrane of epithelial cells at the tip of mucosal folds, whereas, in patients with IBD and in rats with dextran sodium sulfate (DSS)-induced colitis, they were diffusely overexpressed throughout the mucosa. Similarly, expression of EP4 receptor was polarized in T84 colonic epithelial monolayer and mimics the normal epithelium. Apical exposure of T84 monolayer with high levels of PGE(2) decreased barrier integrity, which was abrogated by an EP4 receptor antagonist. To reveal the mechanism of vectorial transport of basally produced PGE(2) toward apical EP4 receptors, we identified prostaglandin transporters (PGT) in human colonic epithelia. PGT were least expressed on epithelial cells at the colonic mucosal folds of control subjects but overexpressed in epithelial cells of patients with IBD or animals with DSS-induced colitis. T84 monolayer also expressed PGT, which increased twofold following stimulation with TNF-α. Importantly, in T84 monolayer stimulated with TNF-α, there was a corresponding increase in the uptake and vectorial transport of (3)H-PGE(2) to the apical surface. Knockdown or pharmacological inhibition of PGT significantly decreased vectorial transport of (3)H-PGE(2). These studies unravel a mechanism whereby EP4 receptor and PGT play a role in PGE(2)-induced alteration of epithelial barrier integrity in colitis.