Phytochemical and biological investigations on Centranthus kellereri (Stoj., Stef. & T. Georgiev) Stoj. & Stef. and C. ruber (L.) DC. and their potential as new medicinal and ornamental plants.

INTRODUCTION: Centranthus kellereri is a Bulgarian endemic plant species, found only in two locations in the world: The Balkans Mountains (Stara Planina), above the town of Vratsa, and The Pirin Mountains, above the town of Bansko, Bulgaria. Being endemic and endangered species precluded any significant research on it. The hypothesis of this study was that the populations of C. kellereri may represent genetically, phytochemically, and morphologically distinct forms and these will differentiate from C. ruber. Furthermore, C. kellereri possibly imperfect embryology may preclude its more widespread distribution under natural conditions. RESULTS: This study revealed the phytochemical profile, antioxidant activity, embryology, surface microstructural morphological traits, and genetic differences between the C. kellereri plants from the only two natural populations and compares them to the ones of the related and better-known plant C. ruber. The essential oil (EO) content in aboveground plant parts and in roots was generally low and the EO composition varied significantly as a function of plant part, year of sampling, location, and species. Methylvaleric acid was a major EO constituent in the C. kellereri EO, ranging between 60.2% and 71.7% of the total EO. The EO included monoterpenes, sequiterpenes, long-chain alkanes and fatty acids. Phytochemical analyses of plant tissue revealed the occurrence of 32 compounds that were tentatively identified as 6 simple phenolics, 18 flavonoids, 1 quinone, 1 lipid, 1 alkaloid, 2 diterpenes, and 3 triterpenes. There were differences in detected compounds between the C. kellereri plants at the two locations and between the roots and shoots in both species. The total phenols and flavonoids varied between the two species but were also dissimilar between the plants from the two populations of C. kelleri. Free radical scavenging activity, measured with ABTS and DPPH in aqueous and methanol extracts, had similar values; however, overall, C. kellereri from Vratsa showed the highest antioxidant activity while C. ruber had the lowest activity. Genetic analyses showed a clear differentiation between C. kellereri and C. ruber, and between the two populations of C. kellereri. Embryological studies revealed the peculiarities of the male and female generative spheres of the two species that were defined as being sexually reproducing. The pollen had high viability; however, the low viability of seeds demonstrated possible high sensitivity of C. kellereri to the environmental conditions, perhaps the main factor modifying and restricting the population sizes. The SEM analyses exposed differences in surface microstructural traits between the species (C. kellereri and C. ruber) but also between the two populations of C. kellereri. The observed dissimilarities in genetic makeup, micromorphological characteristics, and phytochemical composition strongly indicate that the two populations can be classified as distinct subspecies or varieties of C. kellereri; var. pirinensis and var. balkanensis. Further research is needed to introduce C. kellereri into culture and develop it as a high-value specialty crop or ornamental in order to conserve C. kellereri natural populations. C. kellereri may be utilized as a source for phytochemicals of interest and as an ornamental plant like C. ruber; however, it may have a greater environmental plasticity and adaptation as evidenced by its current locations.

Depressive disorders in Thai medical students: an exploratory study of institutional, cultural, and individual factors.

OBJECTIVES: This exploratory qualitative study conducted among Thai medical students aimed to investigate factors related to the development of medical students' depression and how these factors interact in contributing to depressive disorders. METHODS: Forty-three undergraduate medical students of the six-year Doctor of Medicine program were identified as having moderate to severe depression on an annual depression screening. From these, eighteen students agreed to participate in individual in-depth interviews. Transcriptions of the interviews were analyzed by independent reviewers using a thematic analysis approach. RESULTS: Among 43 participants screened as having moderate-to-severe depression, major depressive disorder and adjustment disorder were 9.3% and 14.0%, respectively. Reported factors related to medical students' disorders were personal vulnerabilities, medical educational administration, academic achievement, learning environment, intrinsic motivation, self-care and self-management, relationship, and community. In particular, lack of social support and relationship problems were mentioned among those with more severe and persistent symptoms. Protective factors were social support, positive relationships, a growth mindset, spiritual and mindfulness practices, and an adequate mentoring program. CONCLUSIONS: Medical students' depression and suicidal ideations are significant concerns in Thai medical education. Besides personal vulnerabilities, high expectations, the value placed on academic achievement, and relationship problems can precipitate the onset of depressive disorders, if not being properly addressed. The 4P framework of predisposing, precipitating, perpetuating, and protective factors are suggested to understand the onset and development of students' depressive disorders and to identify targets for institutional and educational intervention.

Future doctors' perspectives on health professionals' responsibility regarding nutrition care and why doctors should learn about nutrition: A qualitative study.

Background: Improved dietary and nutrition behavior may help reduce the occurrence of noncommunicable diseases which have become global public health emergencies in recent times. However, doctors do not readily provide nutrition counseling to their patients. We explored medical students' perspectives on health professionals' nutrition care responsibility, and why doctors should learn about nutrition and provide nutrition care in the general practice setting. Methods: Semistructured interviews were conducted among 23 undergraduate clinical level medical students (referred to as future doctors). All interviews were recorded and transcribed verbatim with data analysis following a comparative, coding, and thematic process. Results: Future doctors were of the view that all health professionals who come into contact with patients in the general practice setting are responsible for the provision of nutrition care to patients. Next to nutritionists/dieticians, future doctors felt doctors should be more concerned with the nutrition of their patients than any other health-care professionals in the general practice setting. Reasons why doctors should be more concerned about nutrition were as follows: patients having regular contacts with the doctor; doctors being the first point of contact; patients having more trust in the doctors' advice; helping to meet the holistic approach to patient care; and the fact that nutrition plays an important role in health outcomes of the patient. Discussion: Future doctors perceived all health professionals to be responsible for nutrition care and underscored the need for doctors to learn about nutrition and to be concerned about the nutrition of their patients.

Correction to: Exploring burnout and the association with the educational climate in pediatric residents in Thailand.

Following publication of the original article.

Exploring burnout and the association with the educational climate in pediatric residents in Thailand.

BACKGROUND: This study, undertaken in Bangkok, Thailand, explored the extent to which paediatric residents in a non-Western setting experienced burnout and the potential association with factors in the medical educational climate and work-related quality of life. METHODS: An exploratory sequential mixed methods design was employed in a cross-sectional study. The initial, quantitative phase used the validated Maslach Burnout Inventory, the Postgraduate Hospital Educational Environmental Measure (PHEEM) and Work-Related Quality of Life scale (WRQoL). Regression analysis was used to identify the correlation between burnout and educational climate. Thereafter, residents in all years with high levels of burnout on subscales were interviewed individually. RESULTS: Forty-one paediatric residents completed the three questionnaires. None had high levels related to burnout in all three domains (emotional exhaustion, high level of depersonalization and perceived low personal accomplishment), seven (17%) showed high levels in two out of three domains. Emotional exhaustion and educational climate (perceptions of role autonomy, perceptions of teaching, perceptions of social support) were correlated with work-related quality of life. In the interviews, the main themes related to burnout were inappropriate tasks, teachers and teaching styles, the perception of knowledge insecurity relating to task performance, time dimensions, life crisis during training, role expectations and work allocation clarity, and facilities such as accommodation. CONCLUSIONS: The study, in a non-Western setting, demonstrated a positive relation between educational climate and work-related quality of life. To help reduce the risk of burnout, the following factors were identified: minimize unnecessary or duplicated workload, schedule time arrangements to avoid extension of regular duty hours, and clearly define role expectations. The impact of inappropriate tasks, teachers and teaching styles (including unsafe environment) on the incidence of burnout was also highlighted. Additional studies focusing on teaching styles, safe learning climate and mistreatment in a non-Western context are needed.

Why nutrition education is inadequate in the medical curriculum: a qualitative study of students' perspectives on barriers and strategies.

BACKGROUND: The provision of nutrition care by doctors is important in promoting healthy dietary habits, and such interventions can lead to reductions in disease morbidity, mortality, and medical costs. However, medical students and doctors report inadequate nutrition education and preparedness during their training at school. Previous studies investigating the inadequacy of nutrition education have not sufficiently evaluated the perspectives of students. In this study, students' perspectives on doctors' role in nutrition care, perceived barriers, and strategies to improve nutrition educational experiences are explored. METHODS: A total of 23 undergraduate clinical level medical students at the 5th to final year in the School of Medicine and Health Sciences of the University for Development Studies in Ghana were purposefully selected to participate in semi-structured individual interviews. Students expressed their opinions and experiences regarding the inadequacy of nutrition education in the curriculum. Each interview was audio-recorded and later transcribed verbatim. Using the constant comparison method, key themes were identified from the data and analysis was done simultaneously with data collection. RESULTS: Students opined that doctors have an important role to play in providing nutrition care to their patients. However, they felt their nutrition education was inadequate due to lack of priority for nutrition education, lack of faculty to provide nutrition education, poor application of nutrition science to clinical practice and poor collaboration with nutrition professionals. Students opined that their nutrition educational experiences will be improved if the following strategies were implemented: adoption of innovative teaching and learning strategies, early and comprehensive incorporation of nutrition as a theme throughout the curriculum, increasing awareness on the importance of nutrition education, reviewing and revision of the curriculum to incorporate nutrition, and involving nutrition/dietician specialists in medical education. CONCLUSION: Though students considered nutrition care as an important role for doctors they felt incapacitated by non-prioritisation of nutrition education, lack of faculty for teaching of nutrition education, poor application of nutrition science and poor collaboration with nutrition professionals. Incorporation of nutrition as a theme in medical education, improving collaboration, advocacy and creating enabling environments for nutrition education could address some of the barriers to nutrition education.

Prevalence of Diabetic Retinopathy in Urban Slums: The Aditya Jyot Diabetic Retinopathy in Urban Mumbai Slums Study-Report 2.

OBJECTIVES: The aims of the study were to estimate the prevalence of diabetic retinopathy (DR) and enumerate history-based risk factors in the urban slums of Western India. METHODS: The population-based study was conducted in seven wards of Mumbai urban slums, where we screened 6569 subjects of ≥ 40 years age, with a response rate of 98.4%, for type 2 diabetes mellitus (T2DM) based on American Diabetes Association criteria. All subjects with T2DM underwent dilated 30° seven-field stereo-fundus-photography for DR severity grading based on modified Airlie House classification. A multivariate logistic regression model was used to assess the correlation of DR with the history-based risk factors. RESULTS: The prevalence of DR in the general population of Mumbai urban slums was 1.41% (95% CI 0.59-2.23) and in the T2DM population it was 15.37% (95% CI 8.87-21.87). The positive associations with DR were the longer duration of DM (≥ 11 years: OR, 12.77; 95% CI 2.93-55.61) and male gender (OR, 2.05; 95% CI 1.08-3.89); increasing severity of retinopathy was also significantly associated with longer duration of DM (p < 0.001). However, history of hypertension, family history of DM, consanguineous marriage and migration status were not associated with DR in the study population. CONCLUSIONS: The prevalence of DR in the general population and T2DM subjects were 1.41% and 15.37% respectively in Mumbai urban slums. Duration of DM and male gender were significantly associated with DR. The slums in Western India show the trends of urban lifestyle influences similar to the rest of urban India.

Master of Public Health programmes in South Africa: issues and challenges.

BACKGROUND: The demand for highly skilled public health personnel in low- and middle-income countries has been recognised globally. In South Africa, the need to train more public health professionals has been acknowledged. The Human Resource for Health (HRH) Strategy for South Africa includes the establishment of public health units at district and provincial levels. Programmes such as Master of Public Health (MPH) programmes are viewed as essential contributors in equipping health practitioners with adequate public health skills to meet the demands of the health care system. All MPH programmes have been instituted independently; there is no systematic information or comparison of programmes and requirements across institutions. This study aims to establish a baseline on MPH programmes in South Africa in terms of programme characteristics, curriculum, teaching workforce and graduate output. METHODS: A mixed method design was implemented. A document analysis and cross-sectional descriptive survey, comprising both quantitative and qualitative data collection, by means of questionnaires, of all MPH programmes active in 2014 was conducted. The MPH programme coordinators of the 10 active programmes were invited to participate in the study via email. Numeric data were summarized in frequency distribution tables. Non-numeric data was captured, collated into one file and thematically analysed. RESULTS: A total of eight MPH programmes responded to the questionnaire. Most programmes are affiliated to medical schools and provide a wide range of specialisations. The MPH programmes are run by individual universities and tend to have their own quality assurance, validation and assessment procedures with minimal external scrutiny. National core competencies for MPH programmes have not been determined. All programmes are battling to provide an appropriate supply of well-trained public health professionals as a result of drop-out, low throughput and delayed time to completion. CONCLUSION: The MPH programmes have consistently graduated MPH candidates, although the numbers differ by institution. The increasing number of enrolments coupled by insufficient teaching personnel and low graduate output are key challenges impacting on the production of public health professionals. Collaboration amongst the MPH programmes, standardization, quality assurance and benchmarking needs considerable attention.

Realist synthesis of educational interventions to improve nutrition care competencies and delivery by doctors and other healthcare professionals.

OBJECTIVE: To determine what, how, for whom, why, and in what circumstances educational interventions improve the delivery of nutrition care by doctors and other healthcare professionals work. DESIGN: Realist synthesis following a published protocol and reported following Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES) guidelines. A multidisciplinary team searched MEDLINE, CINAHL, ERIC, EMBASE, PsyINFO, Sociological Abstracts, Web of Science, Google Scholar and Science Direct for published and unpublished (grey) literature. The team identified studies with varied designs; appraised their ability to answer the review question; identified relationships between contexts, mechanisms and outcomes (CMOs); and entered them into a spreadsheet configured for the purpose. The final synthesis identified commonalities across CMO configurations. RESULTS: Over half of the 46 studies from which we extracted data originated from the USA. Interventions that improved the delivery of nutrition care improved skills and attitudes rather than just knowledge; provided opportunities for superiors to model nutrition care; removed barriers to nutrition care in health systems; provided participants with local, practically relevant tools and messages; and incorporated non-traditional, innovative teaching strategies. Operating in contexts where student and qualified healthcare professionals provided nutrition care in developed and developing countries, these interventions yielded health outcomes by triggering a range of mechanisms, which included feeling competent, feeling confident and comfortable, having greater self-efficacy, being less inhibited by barriers in healthcare systems and feeling that nutrition care was accepted and recognised. CONCLUSIONS: These findings show how important it is to move education for nutrition care beyond the simple acquisition of knowledge. They show how educational interventions embedded within systems of healthcare can improve patients' health by helping health students and professionals to appreciate the importance of delivering nutrition care and feel competent to deliver it.

A realist review of educational interventions to improve the delivery of nutrition care by doctors and future doctors.

BACKGROUND: Dietary interventions are considered an important aspect of clinical practice, more so in the face of the rising prevalence of obesity, diabetes and cardiovascular diseases globally. Routinely, most doctors do not provide such intervention to their patients, and several barriers, present during both training and clinical practice, have been identified. Educational interventions to improve nutrition care competencies and delivery have been implemented but with variable success, probably, due to the complex nature of such interventions. Using traditional methods only to investigate whether interventions are effective or not could not provide appropriate lessons. It is therefore pertinent to conduct a realist review that investigates how the interventions work. This realist review aims at determining what sort of educational interventions work, how, for whom, and in what circumstances, to improve the delivery of nutrition care by doctors and future doctors. METHODS/DESIGN: This realist review will be conducted according to Pawson's five practical steps for conducting a realist review: (1) clarifying the scope of the review, (2) determining the search strategy, including adopting broad inclusion/exclusion criteria and purposive snowballing techniques, (3) ensuring proper article selection and study quality assessment using multiple methods, (4) extracting and organising data through the process of note taking, annotation and conceptualization and (5) synthesising the evidence and drawing conclusions through a process of reasoning. This realist review protocol has not been registered in any database before now. DISCUSSION: Findings will be reported according to the publication criteria outlined by the realist and meta-narrative evidence synthesis (RAMESES) group.

Does community health care require different competencies from physicians and nurses?

BACKGROUND: Recently competency approach in Health Professionals' Education (HPE) has become quite popular and for an effective competency based HPE, it is important to design the curriculum around the health care needs of the population to be served and on the expected roles of the health care providers. Unfortunately, in community settings roles of health providers tend to be described less clearly, particularly at the Primary Health Care (PHC) level where a multidisciplinary and appropriately prepared health team is generally lacking. Moreover, to tailor the education on community needs there is no substantial evidence on what specific requirements the providers must be prepared for. METHODS: This study has explored specific tasks of physicians and nurses employed to work in primary or secondary health care units in a context where there is a structural scarcity of community health care providers. In-depth Interviews of 11 physicians and 06 nurses working in community settings of Pakistan were conducted along with review of their job descriptions. RESULTS: At all levels of health settings, physicians' were mostly engaged with diagnosing and prescribing medical illness of patients coming to health center and nurses depending on their employer were either providing preventive health care activities, assisting physicians or occupied in day to day management of health center. Geographical location or level of health facility did not have major effect on the roles being expected or performed, however the factors that determined the roles performed by health providers were employer expectations, preparation of health providers for providing community based care, role clarity and availability of resources including health team at health facilities. CONCLUSIONS: Exploration of specific tasks of physicians and nurses working in community settings provide a useful framework to map competencies, and can help educators revisit the curricula and instructional designs accordingly. Furthermore, in community settings there are many synergies between the roles of physicians and nurses which could be simulated as learning activities; at the same time these two groups of health providers offer distinct sets of services, which must be harnessed to build effective, non-hierarchal, collaborative health teams.

Competence, commitment and opportunity: an exploration of faculty views and perceptions on community- based education.

BACKGROUND: Community-Based Education (CBE) is an instructional approach designed and carried out in a community context and environment in which not only students, but also faculty and Health Professionals' Education (HPE) institutions must be actively engaged throughout the educational experience. Despite the growing evidence of CBE being an effective approach for contemporary HPE, doubts about its successful implementation still exist. This study has explored HPE structure, policies and curriculum from the point of view of faculty members to gain understanding about the prevailing practices and to propose recommendations that nurtures and promotes CBE. METHOD: A purposive sample was drawn from three major cities of Pakistan- Karachi, Rawalpindi and Islamabad. Out of twelve HPE institutions present in these cities we selected six, which provided a sound representation of medical and nursing colleges around the country. At each institution we had two Focus Group Discussions; in addition we interviewed registrars of medical and nursing councils and two CBE experts. RESULTS: The factors effecting implementation of CBE as perceived by study participants are categorized as: preparation of faculty members; institutional commitment and enthusiasm; curricular priorities and external milieu. Within each theme, participants recurrently described structural and curricular deficiencies, and lack of commitment and appreciation for community based teaching, service and research permeating at all levels: regulatory bodies, institutional heads and faculty members. CONCLUSIONS: The factors highlighted by our study and many others suggest that CBE could not perpetuate effectively within HPE. To enhance the effectiveness of CBE approach in a way that mutually benefits local communities as well as HPE institutions and health professionals, it is important that reforms in HPE must be strategized in a holistic fashion i.e. restructuring and aligning its polices, curriculum and research priorities.

Orchestration of secretory protein folding by ER chaperones.

The endoplasmic reticulum is a major compartment of protein biogenesis in the cell, dedicated to production of secretory, membrane and organelle proteins. The secretome has distinct structural and post-translational characteristics, since folding in the ER occurs in an environment that is distinct in terms of its ionic composition, dynamics and requirements for quality control. The folding machinery in the ER therefore includes chaperones and folding enzymes that introduce, monitor and react to disulfide bonds, glycans, and fluctuations of luminal calcium. We describe the major chaperone networks in the lumen and discuss how they have distinct modes of operation that enable cells to accomplish highly efficient production of the secretome. This article is part of a Special Issue entitled: Functional and structural diversity of endoplasmic reticulum.

[The globalization of medical education]. / De globalisering van medisch onderwijs.

With reference to a recently published research article on the applicability and effectiveness of problem-based learning (PBL) in non-Western medical schools, this commentary explores the assumption that a set of shared values is the common denominator of the globalisation of medical education. The use and effectiveness of PBL are not isolated from the cultural and social structural context in which it is applied; critical differences in values and in views on education underlie what educators and students perceive to be effective locally. The globalisation of medical education is more than the import of instructional designs, and includes Western models of social organisation that require deep reflection and adaptation for success; hence, instead of spreading models for medical education across the globe, more effort should be put into the support of 'home-grown' equivalents and alternatives.

Globalization and the modernization of medical education.

BACKGROUND: Worldwide, there are essential differences underpinning what educators and students perceive to be effective medical education. Yet, the world looks on for a recipe or easy formula for the globalization of medical education. AIMS: This article examines the assumptions, main beliefs, and impact of globalization on medical education as a carrier of modernity. METHODS: The article explores the cultural and social structures for the successful utilization of learning approaches within medical education. Empirical examples are problem-based learning (PBL) at two medical schools in Jamaica and the Netherlands, respectively. RESULTS: Our analysis shows that people do not just naturally work well together. Deliberate efforts to build group culture for effective and efficient collaborative practice are required. Successful PBL is predicated on effective communication skills, which are culturally defined in that they require common points of understanding of reality. Commonality in cultural practices and expectations do not exist beforehand but must be clearly and deliberately created. CONCLUSIONS: The globalization of medical education is more than the import of instructional designs. It includes Western models of social organization requiring deep reflection and adaptation to ensure its success in different environments and among different groups.

Competencies for undergraduate community-based education for the health professions--a systematic review.

BACKGROUND: Community-based education (CBE) along with competency approach is increasingly becoming popular. However, there appears to be lack of evidence on CBE competencies for undergraduate curriculum, therefore this systematic review attempted to identify and categorize CBE competencies to determine the ones used frequently. AIMS: The systematic review aimed at identifying and categorizing CBE competencies implemented in nursing and medical schools to inform all stakeholders of health professional's education. METHOD: A systematic review of electronic databases including MEDLINE, CINAHL, and ERIC and manual search of four medical education journals was carried out. Search was restricted to original research, published in English language between January 2000 and December 2009. RESULTS: Nineteen studies fulfilled the search criteria. The competencies identified were categorized under six themes: Public Health; Cultural Competence; Leadership and Management; Community Development; Research; and Generic Competencies. Moreover, a number of clinical competencies were also found to be overlapping with CBE. CONCLUSIONS: The literature on CBE competencies is limited in number and in its geographical span as most of the studies found was from developed countries; to expand the efforts to other institutions and countries, core competencies for CBE must be recognized and disseminated widely for its integration in health professionals' curriculum.

Rational decision-making about treatment and care in dementia: a contradiction in terms?

OBJECTIVE: To gain caregivers' insights into the decision-making process in dementia patients with regard to treatment and care. METHODS: Four focus group interviews (n=29). RESULTS: The decision-making process consists of three elementary components: (1) identifying an individual's needs; (2) exploring options; and (3) making a choice. The most important phase is the exploration phase as it is crucial for the acceptance of the disease. Furthermore, the decision is experienced more as an emotional choice than a rational one. It is influenced by personal preferences whereas practical aspects do not seem to play a substantial role. CONCLUSION: Several aspects make decision-making in dementia different from decision-making in the context of other chronic diseases: (1) the difficulty accepting dementia; (2) the progressive nature of dementia; (3) patient's reliance on surrogate decision-making; and (4) strong emotions. Due to these aspects, the decision-making process is very time-consuming, especially the crucial exploration phase. PRACTICE IMPLICATIONS: A more active role is required of both the caregiver and the health care professional especially in the exploration phase, enabling easier acceptance and adjustment to the disease. Acceptance is an important condition for reducing anxiety and resistance to care that may offer significant benefits in the future.

Dirofilaria immitis infection in dogs from underserved, Native American reservations in the United States.

Blood samples from 1,822 dogs residing on Native American reservations in 10 states were collected between February 2004 and August 2007. Samples were examined using a commercial enzyme-linked immunosorbent assay (ELISA) antigen capture test. All ELISA-positive samples were subsequently examined for microfilaremia. All dogs were asymptomatic for Dirofilaria immitis infection, resided outside (except for winter in the Northern latitudes), not on prophylaxis for D. immitis, and had not traveled off of the reservation. Reservations were characterized by degrees of north latitude, true prevalence of D. immitis, and a reproductive index calculated by multiplying the number of months of the year in which infective stage larvae (L(3)) could develop in 30 days or less for each reservation by the 30 yr mean annual rainfall in centimeters recorded for that community. The prevalence of heartworm was directly related to the reproductive index on each reservation.