Adverse life experiences increase the risk of health problems. Little is known about General Practitioners’ (GPs') thoughts, clinical concepts, and work patterns related to eliciting, including, or excluding their patients’ stories of painful and adverse life experiences. We wanted to explore GPs’ perceptions of the medical relevance of stories of painful and adverse life experiences, and to focus on what hinders or facilitates working with such stories.Eighteen Norwegian GPs participated in three focus group interviews. The interviews were analysed using reflexive thematic analysis.confident-accepting stance, and an ambivalent-conditional stance. GPs encountered barriers to exploring such stories: scepticism on behalf of the medical discipline; scepticism on behalf of the patients; and, uncertainty regarding how to address stories of painful and adverse experiences in consultations. Work with painful stories was best facilitated when GPs manifested personal openness and prepared availability, within the context of a doctor-patient relationship based on trust.The participating GPs’ views on the clinical relevance of patients’ painful and adverse experiences varied considerably. Our analysis revealed two distinct stances: a Clearer processes for handling biographical information and life experiences that affect patients’ health are needed to facilitate the work of primary care physicians. Competent listening may be particularly important in primary health care, where General Practitioners (GPs) encounter self-selected patients with a wide range of health problems. By listening carefully to the patient, the GP can gather accurate, relevant, and useful clinical information, supporting a shared interpretation or diagnosis on which to base a treatment plan or further action Launer, . Howeverembodiment to accommodate knowledge about the interface between experience and biology. Evidence pertaining to these perspectives has continued to accumulate, supported by increasingly sophisticated methodologies ranging from neuroimaging to epigenetics  affect health outcomes (biology)—for better and for worse. This subjective turn  theoretical foundation for General Practice/Family Medicine as distinguishable from other medical disciplines  has dominated the medical discourse, with patient-centred communication remaining a useful communication tool. The call for more genuinely holistic, humane, person-centred medicine (or care) has, however, re-emerged in various milieus and ignited debate Charon, .2.2.1.critical realist ontology in which reality is defined as something that exists “out there” while “access to it is always mediated by socio-cultural meanings” . All interview audio was recorded and transcribed, verbatim, by MR, who was also responsible for making field/reflection notes after each session.complementary interactions, those exchanges in which participants supported and enhanced each other’s views and experiences, and to as argumentative interactions, exchanges in which participants questioned one another or openly expressed disagreement  and described the study. No formal application was required by them, nor by the Norwegian Centre for Research Data (NSD), with whom we also consulted. Written consent to participate in the interviews/analyses was obtained from all focus group participants. The focus group audio recordings and transcripts have been secured in accordance with Norwegian research regulations.3.confident-accepting stance. GPs taking this stance were found in all three groups, often among those with the most clinical experience. They were few in number, however. For a variety of reasons, the majority of the participants, both novel and experienced GPs, took the second position, characterized by an ambivalentand only conditional acceptance of addressing patients’ stories of painful and adverse experiences. They expressed concerns related to questions regarding the medical relevance of such stories, as well as to whether GPs should be addressing them at all.Our analysis of the three GP focus group interviews revealed two main stances regarding the medical relevance of patients’ stories of painful and adverse experiences. The first position was characterized by explicit acknowledgement of the medical relevance of such stories. We term this the confident-accepting, and ambivalent-conditional—were not sharply demarcated but were rather the poles of a continuum. During parts of the discussion, several of the GPs’ views oscillated between the stances. However, one or two of the more experienced GPs in each focus group maintained a confident-accepting stance throughout the entire discussion.These two positions—In addition to revealing these two stances regarding GPs’ relationship to patients’ stories of painful and adverse experiences in their clinical practices, our analysis identified factors hindering or facilitating their relating to such stories. As barriers, we identified scepticism on behalf of the medical discipline and on behalf of the patients. Many GPs wondered whether work with patients’ stories of painful and adverse experiences belongs within the scope of General Practice. Most participants were under the impression that many patients do not want to tell their GPs such stories; some seemed to imply that GPs might feel at a loss when faced with patients` painful stories.On the other hand, certain qualities of the GP as a person were likely to facilitate the doctors in addressing relevant stories, including the GP being willing and able to allocate sufficient time to listen, within a context of a doctor-patient relationship based on trust.3.1.As outlined above, some GPs in all three focus groups immediately took, and maintained, a confident-accepting stance in relation to working with patients’ stories of pain and adversity.These confident-accepting GPs often validated the relevance of the vignette by recounting similar stories from their own practices, as one of them said in response to the opening vignette: “I know a lot of Annas.” (GP F)‘that German kid’ and she suffers from asthma and fibromyalgia, too. (GP Q)I have a patient in my practice who’s in an almost identical situation – she was also called In the discussions that followed, these GPs seemed to take the biography/biology interconnectedness as a given and rarely referred to scientific studies or theoretical frameworks to support their view. Their responses seemed primarily experience-based and case-oriented; they included types of adversity extending beyond the explicit, categorizable events or trauma typically discussed in the medical literature. For instance, they would agree that having a “longstanding lack of feeling safe and protected” would generally increase people’s susceptibility to disease. The confident-accepting GPs hardly distinguished between health problems that are classified conventionally into categories of somatic vs. psychiatric, or medically acknowledged vs. medically unexplained. For instance, GP Q associated a patient’s childhood history of being severely bullied and socially excluded with both muscular pain and lung disease in adult life:language metaphors. GP J referred to “good ballast” to explain how growing up in a safe and supportive environment tends to make people resilient. GP L referred to adverse life experiences as the patient’s “backpack” and that the GP might help the person “re-pack”. GP F stated that her most important role was to listen to patients’ stories, even repeatedly, so that they could “air themselves out”. Secondly, she should serve a supportive role for the patient, as a metaphorical “walking stick”. Unresolved ethical and practical issues restrain health professionals from entering stories of painful or adverse experiences into patients’ medical records, yet GPs often remembered them. One GP referred to this undocumented knowledge as “the shadow files”.To explain how they reasoned and worked, some of the confident-accepting GPs turned to everyday ‘ripened’. (GP L)We have to be a bit careful. People are so different. Some are interested in learning about the causes of their ailments – others aren’t. So, I think of it as an issue of autonomy. The patient has to be the one who’s in charge here. The GP can ask some questions, and sometimes the answer won’t come until a later visit, after the patient has given it some thought – after it has sort of The consultation style of the confident-accepting GPs typically involved thinking through and applying a flexible strategy when it seemed that the patient’s painful story might have specific medical relevance. For example:3.2.ambivalent response to the concept that life experiences and health are interconnected, and a conditional acceptance of patients` stories of painful and adverse experiences being relevant medically and falling within the GP’s mandate to explore.This stance is characterized by an Responding to the introductory vignette, some of these GPs seemed reluctant to acknowledge any general, biomedically relevant connection between a difficult childhood and adult disease, as one exclaimed: “Generally speaking, I’m sceptical about these studies or results.” (GP R)Well, I think some of the symptoms in the story presented in the vignette could probably be due to childhood difficulties, but other diseases, like vasculitis and recurring pneumonia … I find it hard … I couldn’t say that those are the results of a difficult childhood. (GP E)These GPs had doubts as to how such childhood experiences could cause somatic diseases. GP E, for example, was sceptical about the existence of a link between stressful life events and what he referred to as “real” somatic diseases:GP E’s statement exemplifies the tendency among those taking the ambivalent-conditional stance to draw a clear line between somatic and mental diseases/disorders. While they did not link somatic diseases to experienced adversity, they frequently associated mental problems and so-called “medically unexplained physical symptoms” (MUPS) with adverse life experiences. They often referred to symptoms that might have alerted them to a history of adversity as “diffuse”, “non-specific”, and/or “subjective”, effectively placing them in a diagnostic no-man’s land, some stressing how uniquely personal and unpredictable such linkages would be. Nonetheless, while concluding that the eliciting of such stories was of limited clinical value, they seemed eager to share examples of patients who were in good health—despite considerable adversity earlier in life.conditional willingness to include patients’ stories in clinical work can be exemplified by the following exchange between two GPs taking the ambivalent-conditional stance (GP H and GP J), and one GP who held a confident-accepting stance (GP F). The three discussed allowing a patient to keep repeating what one GP perceived as, “Just the same story over and over again”. Was that a waste of time or might it be beneficial in some way?GP H: But if [the patients] keep coming [to see their GPs] just to talk about the same things, I don’t think that’s really useful.GP J: I pretty much agree. We have to look for some action that could create change. That’s what’s interesting: How to get them to stop gnawing on the same old bone all the time. Help them get onto something different. Move on.A distinct feature of the ambivalent-conditional stance was that these GPs appeared willing to work with stories of adversity if and only if the patient explicitly asked them to do so, and if they considered the patient capable of exploring and carrying out necessary life changes. Such a GP F: I do have faith in repetition […] I think many keep the same stories going, and use their regular GP as an outlet, a safety valve. But, I think we ought to limit our ambitions sometimes to serving as somebody’s crutch, so they can manage to live with their problems.The GP who generally took the confident-accepting stance responded:3.3.3.3.1.[Working with stories of painful and adverse experiences] doesn’t fit with my daily routines as a GP. Problems have to be solved then and there. (GP R)Well, I’m a GP. I’d have referred [that patient] to a specialist. (GP B)Some GPs in all three focus groups expressed uncertainty as to whether work with painful and adverse experiences fits into the scope or mandate of a busy GP’s clinical practice, irrespective of the stories’ potential medical relevance:These quotations illustrate how both time constraints and presumptions of what ought to be expected of a doctor represent obstacles to including work with patients` stories of painful and adverse experiences in their practice.Well, I don’t have many of these patients with behavioural problems or drug addiction on my list. I suppose my being so overtly structured helps me manage to avoid some types of patients. (GP K)During discussions about clinical suitability, there were participants in all three groups who indicated that it might actually be up to the GP to develop a consultation style that either encourages patients to share painful stories or discourages them from doing so. For instance, GP K described the self-protective strategy of assuming a formal and highly structured consultation style, particularly when encountering problems that might be rooted in adverse experiences:3.3.2.leave the painful stories behind. The best clinical approach, these GPs agreed, is to place the focus on the patients’ strong sides and resources. For example:Whenever patients bring up something sad, we try to stick to all the good things that have happened, to hold onto whatever is positive. (GP R)Several GPs argued that the best solution for patients with a history of painful and adverse experiences would often be to simply GPs who shared this view were also among those finding it inappropriate for the GP to take the initiative in bringing up painful stories but rather leave it up to the patient.right to confidentiality. The content of painful stories may be highly sensitive, and patients may simply not want to share them with their GP, irrespective of potential medical relevance.Some scepticism on behalf of the patients focused on the Some GPs told of patients who had rejected an invitation to explore connections between their life experiences and their presenting complaints. Such refusals, they reasoned, might indicate the patient’s lack of insight into the existence, and thus the potential impact, of such connections. Once an attempt to elicit such stories had been rejected, the GPs rarely repeated the suggestion. Those who still wished to try expressed having difficulty devising alternative ways to open the topic.3.3.3.Sometimes, even if I have the feeling that there’s something there … [that that patient has a story] that I really want to ask about, to learn about … still, I struggle to figure out how to ask. I find myself thinking, ‘No, this isn’t the right time.’ I’m afraid it might take too long, like I’m about to open a wasp’s nest. I’m afraid I might retraumatize my patient … or hurt the person’s feelings if my questions seem inappropriate, or insulting … (GP A)Despite the professional barriers described above, most GPs did acknowledge having encountered patients whose adverse life experiences they suspected were relevant to the patients’ current health problems. Several GPs reported feeling at a loss in such circumstances. As one put it:do more harm than good by encouraging patients to bring such stories to the surface, even when the person might appear ready to share them. Third, the quote above also indicates the tentative, vague way the GPs spoke as they struggled with whether, how, and when to address patient stories of pain and adversity. They made frequent use of qualifying phrases such as maybe … one might think that … it’s hard to tell if, as if grappling to find the right words.This highlights several of the obstacles some GPs mentioned facing. First, they felt uncertain about how to position themselves to ask specifically about, and relate professionally to, painful stories. Second, they worried they might takes courage to ask patients pointedly about adverse life experiences, and that a lack of courage may sometimes have kept them from asking, even when they suspected that what a patient might have endured had medical relevance. One GP shared, however, that the clinical experience in his professional role as doctor had had the opposite effect, so that it became easier to elicit stories of painful and adverse experiences:Being a doctor means you can ask about anything – if you ask respectfully, that is. And, gradually, I’ve become braver. (GP L)Several GPs said it 3.4Despite the continuum of stances in relation to patients’ narratives of painful and adverse experiences, all participating GPs shared some ideas on factors that might facilitate GPs, and others, in working with them.3.4.1.I knew that a certain [patient] really liked to take trips up to his cabin. One day, he suddenly said, ‘Well, I haven`t been up at my cabin very much this fall.’ So, I said, ‘Okay.’ And then I asked, ‘But why not?’ That question started a stream of revelations. (GP Q)The consensus reached among participants in all three focus groups was that a GPs' work with stories of adversity required a quality clinical relationship, with a solid doctor-patient relationship based on trust paving the way. Some patients seemed simply to know that they could show up for their regular doctor appointment and share their stories spontaneously, making it unnecessary for the GP to even ask. Knowing patients over time also helped GPs notice and then comment, carefully and appropriately, on changes in patients’ behaviour or habits. Quite often the patient would respond to such comments by sharing a story about a painful experience:3.4.2.[Patients] have to feel that they can trust their doctor … You [the GP] have to signal that you have time to listen, no matter what … I’ve had people come to see me about things they haven`t shared with anybody, ever. To me, that’s a clear declaration of trust. (GP J)Participants in all three focus groups considered the patients’ perception of the doctors’ personal qualities and attitudes during clinical encounters to have an impact on whether or not patients would share their painful stories. Pivotal factors included how trustworthy physicians seemed, how willing they were to listen, and, generally, how empathetic they seemed to be.My colleagues and I have sometimes noticed at the end of a certain day that several of the patients we’d seen had started crying. It`s a bit strange. I wonder if we GPs have times when we’re more empathetic, more open to people’s pain and what they struggle with, and that makes it easier for our patients to bring up whatever is burdening them. (GP D)GPs also noted that simply asking the (presumably) right questions was not always enough to encourage patients to share their inner pain. Their own timing had to be right as well. Two GPs pointed out that experiences in their own lives, the mood they might have been in on a particular day, or perhaps even non-verbal cues, might have helped alert them to medically relevant stories, and also aided patients in sharing them. As one GP put it:I believe we can all be supportive when we work with such issues. I really do. (GP R)After having listened to the group discuss which personal qualities might be valued by patients who felt the need to talk to their doctors about adverse experiences, one previously sceptical GP commented:3.4.3.You’ve simply got to have enough time. In my experience, that’s when magic happens. (GP O)Time and time management were brought up by several GPs in relation to their work with patients’ stories of adversity. There was nearly unanimous agreement about the importance of having enough time to listen, and being able to signal to the patient, verbally and/or non-verbally, that there was time available. As one GP put it, enthusiastically:Some GPs said they could sometimes organize their appointment schedules to leave extra time for when they expected it would be needed. At other times, however, they simply had to make room in the middle of a busy day for an unexpectedly lengthy consultation. GPs also noted how sensitive some patients were to the GP having spent more time than might have been necessary; some patients even apologized if their consultations had lasted longer than usual. These GPs reassured their patients that the extra time had been well spent and useful.4.4.1.Our study documents the reflections of 18 University-affiliated, GP supervisors in Norway, on what hinders or facilitates GPs’ work with patients’ stories of painful and adverse life experiences. The most striking finding was the diversity in how the GPs regard the medical relevance of working with their patients` stories of such experiences—ranging from a completely confident and proactive stance to a deeply ambivalent and conditional stance.Another notable feature was the way the GPs spoke when discussing their reflections and experiences with patients` stories: the frequency of verbal hesitations was high, as were tentative and incomplete utterances, and the use of metaphors. We connect this to a lack of role models that leaves them unfamiliar with appropriate terminology, limiting their ability to describe their experiences, interpretations, and viewpoints regarding their work with patients’ stories and narratives in a concise, confident, and professional language. Ian McWhinney describes a similar phenomenon in his paper, “The Meaning of Holistic Medicine”. He gives an account of how physicians who try to work in a holistic manner and take patients’ life experiences and lifeworld into account, struggle to explain how they work: “He finds it much easier to practice the method than to articulate it, as there is no readily available taxonomic vocabulary, as there is with the conventional school” , one of whom is an established, qualitative researcher (BPM). MR has worked as a GP in a rural area for 15 years and is also a GP tutor. LG practiced earlier as a GP and is now a Professor of Behavioural Sciences. LH has worked for decades as a GP in Denmark and is also an experienced qualitative researcher. As professionals, the authors share their recurring recognition that patients’ past and current medical problems and their stories of painful and adverse experiences are related. LG, BPM and LH have also conducted research into that subject.As moderators of the focus groups (MR and BPM), we emphasized that the group members be allowed to speak as freely as possible. Questions were open-ended, and we maintained awareness of the importance of setting aside our own preconceptions. Our field notes, which we wrote immediately after each interview, included participants’ non-verbal responses. We also described responses we found especially interesting or surprising, such as those that showed apparent ambivalence or hesitancy. We paid particular attention to such aspects of our data when analysing the material.insider perspective facilitated the rapid establishment of collegial contact with the participants and thus their ensuing discussions (Dwyer & Buckle, The author groups’ We do not know whether interviewing GPs who were not also University-affiliated tutors of medical students might have impacted our results. At the same time, other than the common denominator of being GP tutors, the focus groups were heterogenous, for example, regarding age, gender, years of experience.This would seem to indicate that our results might be transferable to other GPs. Also, our having elicited and identified an unexpected and notable diversity of viewpoints and working habits within what might well be presumed to be a resourceful subgroup of GPs, does suggest that our findings have high validity and relevance. The fact that several participants expressed uncertainty to the concept of medical relevance as early as our presentation of the opening vignette, suggests that they were not tailoring their reactions to try to please us, and that the subsequent analysis has not been unduly influenced by our own preconceptions.information power (Malterud et al., information power is sufficient.We applied principles of To ensure rigour and transparency, we consulted Braun and Clark’s twenty guiding questions to assess our thematic analysis research quality (Braun & Clarke, 5.Our study identified a wide diversity of views among GPs regarding the medical relevance of patients’ stories of pain and adversity. Many participants seemed frustrated, even bewildered, when shifting between conventional, abstract biomedical knowledge and a more holistic, person-centred approach to individual patients.It is not only inefficient but also unethical to leave it to individual doctors and patients to manoeuvre within a medical paradigm characterized not only by incomplete knowledge but also by unresolved theoretical tensions. These can render both parties deeply uncertain about what is relevant to tell, to ask, and to question (Assing Hvidt et al., As GP academics, we believe more space should be allocated for biographic information and life experiences that may affect patients’ health. In the meantime, if patients’ stories of painful and adverse experiences are to be integrated into GPs’ practices, clearer processes for handling biographical information, including the life experiences that impact on patients’ health, need to be developed. This calls for knowledge about the interconnectedness between life experiences and health to be integrated into medical curricula. Instruction and guidance in how to work with patients’ stories of painful and adverse experiences in a safe and professional manner are also imperative. Providing care that takes the whole person into consideration has been shown to increase patient satisfaction and to reduce costs (Weiner & Schwartz, Click here for additional data file.


Taste changes are the third most common bothersome symptom during treatment in children with cancer. However, it is still unclear what the essence of these taste changes are, to what degree concomitant changes in sense of smell qualify this bothersome treatment symptom and how much of an impact these changes have on the life of children with cancer. The aim of this study was to explore characteristics of both taste and smell changes and to gain insight into the impact of these changes in children with cancer receiving chemotherapy.Semi-structured interviews were performed until data saturation was achieved in each age group . This resulted in an in-depth description of taste and smell changes, including its impact on the life of 27 children with various cancer types receiving chemotherapy. Thematic analysis of interview data was performed.Interview data could be grouped into three main themes, namely changes in (1) taste, (2) smell, and (3) eating behavior. As expected, most children reported experiencing taste and smell changes just after start of treatment, but changes varied greatly between children; that is, some reported changes in intensity (increased or decreased), whereas others reported different perceptions or preferences (from sweet to savory). Taste and smell changes (regardless of direction) negatively impacted quality of life, with these changes commonly described as “disappointing” or “frustrating.” Interestingly, particular chemotherapeutic agents were frequently mentioned regarding taste and smell changes, prompting sensory-specific coping strategies. Children's eating behavior changed in terms of alterations in food liking and appetite, sometimes due to chemosensory changes, but children also mentioned specific medication or hospital food being responsible for their altered eating behavior.Both taste and smell changes are common in children with cancer. The essence of these changes varies widely, but taste and smell changes are generally considered bothersome treatment symptoms. Ways to cope with taste or smell changes specifically were described by the children warranting further research and offering the opportunity for enhancing patient-centered care. Children with cancer receiving chemotherapy often experience bothersome symptoms, such as nausea and pain. Taste changes have been found to be the third most common bothersome symptom during treatment, reported by 60.3% of the children . SeveralWhen exploring chemotherapy-induced chemosensory changes in adult cancer patients, a systematic review suggests that there is insufficient evidence that chemotherapy influences taste in a uniform manner when focusing on sensitivity and intensity of taste qualities . HoweverIt should be noted that taste and smell changes associated with anti-cancer treatments (notably chemotherapy) affect food intake and nutritional status in adult patients , 12. In This is a qualitative study to explore experiences with and the impact of taste and smell changes in children with cancer undergoing chemotherapy, using semi-structured interviews. Interviews were held between January and September 2021.This study was performed at the Princess Máxima Center for Pediatric Oncology in Utrecht, the Netherlands. All children newly diagnosed with cancer, consecutively admitted to the Princess Máxima Center, were asked to participate in a prospective cohort study called SENSORY-2, including several quantitative measurements of taste and smell function during treatment. Children in the SENSORY-2 study needed to be between 6 and 17 years old, diagnosed with a hematological, solid, or brain malignancy, and currently treated with chemotherapy.As quantitative measurements alone do not inform us on all aspects concerning children's chemosensory disturbances, all children within SENSORY-2 were invited to participate in the current study comprising a semi-structured interview. At the time of the interview, these children had already undergone chemotherapy for at least 3 months so that they were sufficiently able to talk about their potential experiences with taste and smell changes. Children were not purposefully selected on reporting changes in taste and smell function (convenience sampling) and interviews were held with the children who were first enrolled in SENSORY-2 (pending data saturation).MB carried out the semi-structured interviews. We planned to enroll at least 10 children in each age group . After interviewing ~20 participants, we decided that data saturation was achieved if no new information was obtained from the three subsequent interviews in each age group, resulting in a total of 27 interviewees. Interviews were held during (day) admission at the Princess Máxima Center and lasted between 10 and 27 min. During the interviews, children were often accompanied by a parent who was allowed to participate in the conversation, preferably at the end of the interview to make any additions. The interview guide was developed in collaboration with a pediatric oncologist, nutritional scientist/dietitian, health scientist, representative of the patient organization, and two psychologists and was based on key topics from literature and experiences from a previous study . InterviThe youngest children (6–12 years) were invited to use the ‘write and draw technique' . School-Data were analyzed using thematic analysis, a qualitative method for identifying, analyzing and reporting themes , 17. TheThe team had regular discussions throughout the duration of the project. Further, MB presented findings and tentative conclusions for further discussion with other experts at a research meeting. These discussions were conducted with the intent to avoid that our conclusions being particular to the perspective of just one researcher. However, it should be noted that several members of the team  have previously investigated taste and smell changes in children with cancer, which may have influenced the interviewing and coding of the data.All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Medical Ethics Review Committee of the University Medical Center Utrecht (UMCU), the Netherlands, approved this study as subpart of the SENSORY-2 study (METC N19.809). Written informed consent was obtained from the parents, and from children ≥12 years. A 15-point checklist of criteria for good thematic analysis was used for reporting and writing .n = 20, 74.1%), whereas only one girl did not report any changes in taste or smell perception. When focusing on taste and smell separately, it can be noticed that taste changes  and smell changes  are frequently reported since the start of treatment.Twenty-seven children with cancer were included in this study. Participant demographics and clinical characteristics can be found in nature, timing, association, impact, and coping. Data regarding altered eating behavior was grouped into two sub-themes: food liking and appetite  changes in taste; (2) changes in smell, and (3) altered eating behavior. In discussing changes in taste and smell, interview data could be grouped into five sub-themes: appetite . Each thTo understand how children describe possible taste changes, we first asked them about their definition of taste. This was described in a uniform way, namely: how something (food or drink) tastes, how strong it tastes, and whether it is tasty or not.Then we continued the conversation about taste changes during chemotherapy. Children described a variety of taste changes, most often expressed by alterations in intensity, quality, preferences, or the presence of a bad taste. Taste perception in terms of intensity could be either increased or decreased:Everything tastes much stronger” “My taste was then completely gone, I couldn't taste anything” “Children also mentioned that some foods tasted very different  than before chemotherapy or than they were used to. Others experienced a bad taste in their mouth:Sometimes it has a completely different flavor, for example my father always makes soup on Sundays and suddenly the zucchini soup tasted like chicken soup or something. Not really a recognizable soup” “I often have a very bad taste in my mouth the whole day long and it doesn't matter what I eat or drink, that taste just stays the whole time” “A majority of the children noticed a change in their taste preference, with sweet being less preferred and a remarkable preference for salty or savory foods:I would now rather eat something savory than something sweet, that is a really big change” “When I had chemotherapy, I leaned much more towards salty. I really liked chips, or those salty pretzels” “In general, taste changes were experienced since the start—or in the first month—of treatment:When I had chemo for the first time” “The course of these changes was relatively heterogeneous with some children describing that these changes are mainly present in the first week after a cycle of chemotherapy and then gradually normalizes, while others describing taste changes as being continuously present since the start of treatment:I think that after 1 or 2 days you already notice it and that lasts for about the first week. Then you really notice it, your tongue also feels a bit numb. Then after a week and a half you may have it [normal sense of taste] back, but then you have half a week to taste your food and then you have a new course [of chemotherapy]” “When it comes to treatment-related symptoms associated with taste changes, oral mucositis was mentioned by some of the children being responsible for their altered taste perception:My mucous membranes were completely damaged. The taste change is because of that” “In addition, specific chemotherapeutic agents (methotrexate) or chemotherapy cycles  were mentioned regarding a decreased perception of taste intensity. Furthermore, dexamethasone (a corticosteroid) was mentioned by several children in relation to changes in taste preferences:During the first two OEPA courses I experienced it [change in taste] badly. My taste was then really just gone” “That was very strange, he only wanted savory when he was on the dexa[methasone]” (mother of 6-year old boy)“Moreover, a lot of children notice a flavor or retronasal smell during saline flushing of their central venous line which was reported to be like “glue,” “medicine” or “salty”:A salty, uh yes… it's really a kind of smell that you taste in your mouth. It's really odd” “Taste changes negatively influence daily lives of most children, with these changes commonly described as “frustrating” or “disappointing”:It was extremely frustrating. I smelled yummy food everywhere, but when it ended up in my mouth, I didn't like it. It was just really annoying to go through that, it makes you not want to eat” “I really noticed that I couldn't really enjoy my food because those flavors didn't come out properly. I didn't like that at the time either” “Children tried several things to manage changes in taste. Coping strategies included adding (strong) flavors or trying (new) foods when suffering from any form of changes in taste:If we have chips, I'll have sweet chili sauce with them, and I'll dip the chips in it. That has a very strong flavor which I could taste” “I try to eat some things more often to get used to the new taste” “A bad taste in the mouth, especially when not eating, was resolved by brushing teeth, eating sweets, or drinking something:I just tried rinsing my mouth and brushing my teeth quite often, but nothing helped at that point” “When I eat lollipops, I don't taste the bad taste” “Smell changes were most often expressed by alterations in intensity, quality, or hedonics. Similar to taste, smell perception could be either increased or decreased in intensity:Well I burned a scented candle recently but that also smelled too strong” “My nose doesn't smell things far away but does smell things close to my nose” “Sometimes, smells were perceived differently compared to before chemotherapy:I remember how that perfume smelled in he past, it was always a bit sweet but now it just smells very different, a bit like sweat” “A majority of the children indicated that they perceived unpleasant smells since the start of treatment, mainly concerning food odors, body odors, and hospital odors:Dinner just stinks, but nothing else” “Your breath stinks; she never said that before” (mother of 17-year old girl)“At one point I had troubles with the smell of that disinfectant stuff. The smell was just continuously present” “Changes in smell intensity—increased or decreased—were most often noticed since the start of treatment. However, the perception of unpleasant smells, especially food odors and hospital odors, was only experienced after several visits to the hospital. From that moment on, these odors were continuously experienced as unpleasant, while, for example, a decreased smell intensity was mainly experienced in the 2 weeks after a cycle of chemotherapy and then slowly recovered:In the first two weeks, I also had a lot of smell loss. It also took a long time to come back, maybe two weeks” “At the beginning of treatment she said she didn't like it  very much, but then it wasn't so dominant. I think it started in the middle of treatment, after 6 or 7 cycles” (mother of 10-year old girl)“Although a majority of the children also experienced taste alterations besides changes in smell, these concepts were rarely linked to each other. However, nausea was often mentioned in relation to smell. On the one hand, children indicated that unpleasant odors cause nausea, but on the other hand, it was also noted that smells are poorly tolerated when you already feel nauseous:On a normal day it's okay if I smell fries or something, but on a day when I'm nauseous I think: go away” “The smell of food makes me nauseous and usually makes me vomit” “In addition to nausea, the use of corticosteroids (dexamethasone and prednisone) was mentioned a few times in relation to increased smell sensitivity or perception of body odors:What struck me is that whenever she had prednisone or dexa[methasone], if I had had coffee she would say: Gross, your breath stinks” (mother of 12-year old girl)“Moreover, a lot of children stated not liking the smell of ethanol on their central venous catheter patch, which is generally only experienced by themselves:When they change that PICC line patch, I can smell it for a few days afterwards but mommy doesn't smell it” “Odorants are frequently linked to specific experiences or locations. In this case, children with cancer described that certain smells, for example from soup or hand sanitizer, directly remind them of the hospital which is unpleasantThey often eat soup here [at the hospital], and then I smell, you know, the scent of soup. And then when I'm home and I smell tomato soup, I start to think about the hospital. It just makes me nauseous” “Changes in smell, in whatever form they appear, are mostly experienced as “irritation.” Children also describe unpleasant food and hospital odors being continuously present, which has a negative impact on their mood:It's kind of an irritation. You want to get rid of that smell. It follows you and that's not fun, it's not nice and it has to go” “It's a bit of an issue because she starts to breathe really strange and nothing helps which makes her unhappy. It makes her a bit grumpy” (mother of 10-year old girl)“Children generally described coping strategies for managing unpleasant smells, rather than solutions for a decreased or increased smell sensitivity. Coping strategies include avoiding and covering of unpleasant smells:“I often say at dinner time: give me only potatoes with Greek yogurt. I just can't tolerate the smell of other things being cooked” I usually ran upstairs around dinner time because it smells so bad but I can still smell it [food being cooked] upstairs. Then I spray deo[dorant], that suddenly smells very nice” “Children commonly described a decrease in food liking for certain foods, such as vegetables and chocolate. Sometimes, this reduction in food desire was linked to perceived changes in taste or attributed to the smell of that particular food, but this was not always clear:Well I really think: disgusting. I don't feel like that. Chocolate, yuck, no. While I normally think: oh yum, chocolate” “On the other hand, fruits and fatty snacks, such as chips, fries, and noodles, were often referred to as more desirable foods. A lot of children also explicitly stated that they prefer home-cooked meals:I started eating noodles more often” “Well, I really don't like the hospital food, I just like our own food” “Additionally, desired foods seem to fluctuate during treatment as mentioned by the following participant:Sometimes I like fruit, then candy and then, a few days later, I like something else and then candy doesn't taste good anymore” “Children noticed their appetite changed since the start of treatment, with some children experiencing a decreased appetite and others having an increased appetite. Particularly dexamethasone and prednisone were mentioned when it comes to an insatiable appetite and binge eating:I have the feeling that the signal between her head and tummy is just turned off” (mother of 8-year old girl)“During the first two courses I ate a lot, a lot more. But that's because of the prednisone, you're much hungrier then” “This qualitative study provided an in-depth exploration of how children with cancer experience changes in taste and smell, but also eating behavior, and the impact these changes have on their daily lives. As expected, most children reported experiencing taste and smell changes right after the start of treatment, but changes varied greatly between children; that is, some reported changes in intensity (increased or decreased), whereas others reported different perceptions or preferences. Taste and smell changes often affect the daily lives of children with cancer, with these changes commonly described as “disappointing,” “frustrating” or “annoying.” Interestingly, particular chemotherapeutic agents  were frequently mentioned regarding taste and smell changes, prompting sensory-specific coping strategies. Children's eating behavior changed in terms of alterations in food liking and appetite, sometimes due to chemosensory changes, but children also mentioned specific medication or hospital food being responsible for their altered eating behavior.In our study, taste changes were heterogeneously experienced and described by children with cancer. This is in accordance with a previous qualitative study, in which pediatric patients noted that food tasted “different” or “not right,” but could also be experienced in terms of food tasting “bland” while others experienced more extreme flavors . Like thA shift from sweet to savory foods was a common finding among children in our study. Previous qualitative reports describe a similar pattern among children with cancer undergoing chemotherapy, in which children repeatedly indicated that they avoid chocolate and candy since the start of treatment , 10, 19.A follow-up study from Loves et al. among 108 pediatric cancer patients suggested that optimizing chemotherapy-induced nausea and vomiting control, but also mucositis prevention, may reduce taste changes . ChildreIn general, extreme sensitivities to specific odorants such as perfume, cleaning solutions, food cooking, and hand sanitizer have been reported by adult cancer patients receiving cancer treatment . ChildreApplying thematic analysis as a method to explore the experiences of children with cancer undergoing chemotherapy resulted in a rich description of food-related changes and its impact on children's daily lives. This study also includes a broad range of experiences, as we did not purposefully select participants who reported smell or taste changes before. Furthermore, this is the first study that explores children's experiences with changes in smell during treatment with chemotherapy. Like taste changes, changes in smell also have a major impact on the eating experience and social lives of children with cancer, which requires more attention in the future. Moreover, a relatively large number of children participated in this study at the same time point in their treatment. However, our findings must be interpreted in the light of several study limitations. Similar to adults, children in the current study frequently confused the concepts of taste and smell. This is the result of inductive analysis where we wanted to have an open view on how children themselves describe their chemosensory disorders. However, explaining the definitions of taste and smell could have facilitated the interpretation of the results. Moreover, childhood cancer represents a heterogeneous set of diseases among children of various ages. Nevertheless, the majority of our participants were children with hematological malignancies, which may have consequences for drawing general conclusions. In addition to this qualitative study, changes in taste and smell need further investigation through quantitative measurements, including its consequences regarding nutritional status and quality of life.In conclusion, our findings show that both taste and smell changes are highly prevalent and diverse in children with cancer receiving chemotherapy, but are generally considered bothersome treatment symptoms. Ways to cope with these changes were extensively described, including adding (strong) flavors or covering unpleasant smells for taste and smell changes, respectively. Future research should explore ways to manage taste and smell changes in children with cancer undergoing chemotherapy. In the meantime, current findings can be used to improve patient-centered care.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the Medical Ethics Review Committee of the University Medical Center Utrecht (UMCU), the Netherlands. Written informed consent was obtained from the parents, and from children 12 years and under.MB conceptualized and designed the study, collected data, reviewed data, participated in interpretation of the data, drafted the initial manuscript, and revised the manuscript. MH reviewed data, participated in interpretation of the data, and helped to draft the manuscript. EH reviewed data, participated in interpretation of the data, and critically reviewed the manuscript for important intellectual content. WT participated in study design, supervised its execution, helped with interpretation of the data, and critically reviewed the manuscript for important intellectual content. RH participated in study design, supervised its execution, reviewed data, helped with interpretation of the data, and critically reviewed the manuscript for important intellectual content. All authors read and approved the final manuscript.The Laboratory of Behavioral Gastronomy was supported by the Dutch Province of Limburg. The funding organization had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript or decision to submit the manuscript for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The corrected author list appears below.In the published article, there was an error in the author list. Authors “Xiang-Bin Liu” and “Ke Pang” were erroneously missing “†, Ke Pang†, Yong-Zhong Tang* and Yuan Le*“Xiang-Bin LiuDepartment of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha, China*Correspondence:Yong-Zhong Tangtangyongzhong@csu.edu.cnYuan Leleyuanxy@csu.edu.cn†These authors have contributed equally to this work and share first authorship”The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Handling errors with household flammables, for example pan burning, may result in serious accidents, which may be caused by decreased attention or executive function.The manuals by several cities simply suggest the use of induction heating (IH) cookers. However, it requires complicated operation of buttons. Furthermore, no previous studies have examined the difficulty of IH operation in older adults.We examined 166 residents aged 75+ years in Wakuya, consisting 66 Clinical Dementia Rating (CDR) 0 , 79 CDR 0.5 (very mild dementia), and 21 CDR 1+ (dementia) participants. Based on fire accident, they were classified into “high-risk,” “low-risk,” and “safety” groups. They were asked to actually use an IH as an examination. The participants who passed all procedures were classified as “good users,” and the remaining who failed were classified as “poor users.” Their overall cognitive and executive functions were assessed using the Mini-Mental State Examination (MMSE) and Trail Making Test A and Digit Symbol (DS), respectively.The proportions of “good users” in the CDR 0, CDR 0.5, and CDR 1+ groups were 7 (10.6%), 6 (7.3%), and 0 (0%), respectively. For the CDR 0 and CDR 0.5 group, the good users had higher scores on the MMSE and DS than do the poor users.The introduction of IH is too late for “high-risk group.” Since the IH cooker requires complicated operation of buttons, they may be difficult for older residents to handle. Executive function may be examined for early detection of handling errors with household flammables. In Japan, the “New Orange Plan” promotes measures against dementia, suggesting people with dementia to remain in their own home as long as possible. For maintaining their daily life, however, people with dementia or mild cognitive impairment (MCI) face difficulties. They should appropriately manage “fire” and “water,” for ordinary domestic life, because both may likely lead to death when serious accident occurs.Only humans can use “fire” for living, such as warming and cooking. Fire is thought to be sacred since it is dangerous and could cause a “disaster.” “Small fire accidents” caused by forgetfulness in turning a gas cooking stove off or handling errors may result in pan burning and lead to serious accidents.According to the report published by the Fire and Disaster Management Agency in 2018, while the number of fire accidents generally tended to decrease annually in Japan, 21,280 building fire accidents still occurred, accounting for 50% or more of all fire accidents. The number one cause of building fire accidents was “stove,” which led to 2,963 (13.9%) accidents. Since failures in handling of fire in households may cause accidents that threaten life, body, and property, appropriate risk management is required.. We previously reported that accidents caused by the elderly who failed to handle fire, such as pan burning (hereinafter referred to as fire accidents), were related to their executive function, memory, and judgment.It was clarified that instrumental activity of daily living (IADL), including cooking, would decrease in persons with MCI or even in healthy elderly personsFire accidents may inhibit older residents from continuing to live at home. It is recommended to use electromagnetic cookers (induction heating [IH]) to reduce fire accidents because IH causes less fire accidents compared with direct fire .However, we experienced several cases, in which the elderly who were expected to operate IH cookers without fail could not learn the necessary IH operation procedures, as IH cookers require several procedures for use, compared with gas cookers. However, no previous studies have examined IH operation by the elderly.To investigate the appropriate timing and adaptation of IH introduction, we performed a standard IH operation test, general cognitive function test, and executive function test, to examine their relationships with actual situations in handling of fire in daily life among the elderly.We examined 166 residents aged 75 years or above in Wakuya, northern Japan, which consisted of 66 Clinical Dementia Rating (CDR) 0 , 79 CDR 0.5 (very mild dementia), and 21 CDR 1+ (dementia) participants (see below). The prevalence rate of dementia was approximately 13%, which was almost equivalent to the national average.. Before the interviews with the physicians, the public health nurses visited the subjects’ homes to evaluate their daily activities. Observations by family members with respect to the subjects’ lives were described in a semi-structured questionnaire. Subjects who lived alone were visited frequently by public health nurses to evaluate their daily lives. The physicians interviewed the subjects to assess episodic memory, orientation, and judgment. Finally, with reference to the information provided by the family members, the CDR for each of the subjects was determined at a joint meeting of the physicians and public health nurses. One author (KM) was certified as a CDR rater at the Washington University School of Medicine Alzheimer’s Disease Research Center Memory and Aging Project.A clinical team, composed of physicians (neurologists and a psychiatrist) and public health nurses, determined the CDR for each participant and was blinded to the cognitive test results. They used a Japanese version of the CDR scoring questionnaireFor each participant, we performed:Evaluation of the ability to operate an actual device (standard IH cooker)..General cognitive function evaluation Executive function evaluation (Digit Symbol and Trail Making Test A), as well as a questionnaire survey and interview with their families regarding actual fire handling in the households.The participants were divided into three risk groups for fire accidents based on the incidence of fire accidents during recent 2 years, such as forgetting to put out the fire , pan burning, and tatami mat burning, reported by their families, based on the “frequency of small fire accidents at home” and “the presence or absence of pan burning” in the previous 3 years, as follows :Safety group (n=98): No small fire accident and absence of pan burning.Low-risk group (n=39): 0–1 small fire accidents, in the absence of pan burning.High-risk group (n=29): one or more small fire accident(s) and the incidence of pan burning, or frequent small fire accidents.Each participant was asked to “boil the water required for cooking pot noodles as soon as possible. When the water is boiled, the kettle will sound, and then turn off the cooker.” The participants were allowed to refer to the IH cooker instruction manual. The participant could repeat the procedure after making a mistake. In addition, when a participant could not operate the cooker by themselves, the participant was allowed to refer to the instruction book prepared by our department  and then move on to the next procedure with support from the examiner. In the original manual, a large font (44 pt) was used, as the font was found in our previous report to be clear for the elderly with decreased cognitive function, and the procedures have been described briefly. For the experiment, we selected a standard type of IH cooker .The operation manual includes the following five steps. During each step, we observed a series of actions of the participants to evaluate the situations of their operation.Place a kettle on the center of the heating area.Turn on the main power supply.Start heating by pressing the heating button.Increase heat to maximum using the heat control button.When the water in the kettle has boiled, stop heating by pressing the heating button again.Based on the execution of a task to operate the IH cooker, the participants were divided into two groups as follows:Good user group .Poor user group (those who failed to operate a step).An explanation related to the study was held in public halls. After obtaining written consent from each participant, public health nurses visited the participant’s home on another day to obtain consent from family members. This study was approved by the Institutional Review Board of our university (2014-1-565).In the healthy group, 15% of the participants could operate an HI cooker, and 85% could not complete the operation by themselves . In the Although none of the group differences were significant, it was noteworthy that even in the healthy group, only 15% were able to operate the IH.The details of the impressions and ideas for improvement were obtained from 100 participants after they finished the tasks. In spite of their performance in their operation, approximately 40% of the participants answered that the cooker was easy to use, or very easy to use. From difficulty to easy, the ratios of participants selected “very difficult to use,” “difficult to use,” “easy to use,” and “very easy to use” are 5, 22, 37, and 5%, respectively. Also, 25% selected “cannot say,” and no data for 6%.Free descriptions by those selected “very difficult to use” and “difficult to use” are:It is difficult to use the cooker because there are several buttons. Single action is better.A flick of a switch would be better.A larger display would be better.All displays appear to be similar.The power supply button should be located close, next to (or just above) its display, as it is difficult to find it.It is difficult to recognize the display for turning on/off, and thus large characters indicating ON and OFF should be provided.The buttons should be located at an area other than that on the superior surface.Flat buttons are difficult to use, and conventional in-and-out buttons are better.It is better for a user to clearly feel the pushing action.There are no buttons to stop or suspend heating.The elderly cannot understand “high power.”It is difficult to find the light (red), and thus a larger light should be used.It is better that the cooker has a speaking function.I feel safe to visually confirm the heat/fire, as it is difficult to confirm whether or not the IH cooker is working.Free descriptions by those selected “easy to use” and “very easy to use” are:IH will be easy to use when I get used to it.IH seems like it will be easy to use after I learn how to use it.IH may be better to ensure safety.Since the cooker is flat, it appears to be stable.IH is good as it is easy to clean.IH is sophisticated.Our investigations showed that even in the healthy group, there were “high-risk” people. In all of the CDR groups, the high-risk group was not able to manipulate the IH cooker. In the dementia group, even the “low-risk” people were not able to manipulate the IH cooker. Furthermore, 17% of the participants in the MCI/low-risk group were able manipulate the IH cooker, compared with 40% in the healthy group. These individuals also showed higher scores on the MMSE and the executive function tests., the descriptions of fire accidents showed that the accidents were caused by a decrease in attention/executive function and the ability to predict risks in all CDR groups. If the subjects recall that they are cooking without burning a pan, even if they are distracted by something, the behavior could be based on their past memory. Also, controlling manipulation is one of the executive functions. Since the IH cooker requires complicated manipulation of the button, they may be difficult for older residents to handle. The error analysis findings suggest that IH cookers could be improved in order to be successfully manipulated by older adults.Executive function is the overall ability to control, including attention, and may be specific to risk control. As mentioned in our previous studyHousehold electric appliances increase the convenience and quality of life (QoL). With further increases in aging estimated in the future, it is expected that further technical developments will improve household electrical appliances so that the elderly who are not good at handling such appliances due to lowered cognitive and physical functions can receive the benefits.It was considered that the reason for their preference of the use of a cooking stove was that the switch system was easy for them to handle. While IH appliances are recommended for people who find it difficult to handle flammable items, the operation is complicated and not necessarily suitable for elderly. The elderly may have increased burden in learning how to use a new cooking apparatus (tool) with no direct view of the fire and no sensation of heat, because their semantic memory is different from that for conventional tools. The flat work surface, holding down of a button, and other new operational procedures may be inappropriate for the elderly. It may be desirable to construct a cooking cabinet and work surface that would enable easy understanding of ON and OFF using visual, auditory, and tactile feedback. It should be investigated whether the safety, functionality, and ease of use of such a new apparatus would be appropriate for the elderly from the viewpoint of brain function.It was suggested that the recommendation for introduction to IH cooking would be too late for the “high-risk group,” in which forgetting to put out the fire and pan burning increased. IH should be introduced as early as possible, but even in the healthy group, 85% were not able to operate an IH cooker in this study. However, one limitation of this study is that we did not evaluate the learning effect of the participants. In addition, if a user could not use the IH cooker immediately after purchase of the cooker, the user could not actually cook. In such cases, unexpected accidents could occur, as seen in past reports on fire accidents, that were caused because an elderly person had no other choice but to use an emergency portable gas stove, as the person could not use an IH cooker. To use an IH cooker, general cognitive function and executive function should be maintained. It was suggested that the operating procedures for IH would be difficult for the elderly, although such procedures appeared to be easy.


Urban Landscape (Paisaje urbano), this month’s cover image, may initially prove challenging. A kaleidoscopic assortment of wedges, semicircles, rectangles, and other shapes seems to vibrate, morph, and blur. Swaths and streaks of color compete for attention. Pedestrians in the foreground jostle and nudge one another. To the left, a woman grasps a shopping basket. On the right, several uniformed soldiers pass among the crowd. Between them, indistinct images suggest a bustling scrum of people engaged in their daily routines. A stream of equestrians and yellow horse-drawn carriages, perhaps taxis, flows across the middle of the image. The few trees, green blots perched on a hill, and some patches of pale blue sky are the only nods to the natural world. Finding a point of reference within the jumble of images that comprise the frenzied street scene sprawled acrossIt is not improbable that some viewers might also imagine the sounds and smells from this teeming thoroughfare or experience a tinge of claustrophobia from the crush of the crowd. If so, then its creator, Uruguayan artist Rafael Barradas, would have been pleased. Born in 1890 to Spanish parents in Montevideo, Uruguay, Barradas did not receive formal academic training or study art. His biography from the National Museum of Visual Arts, Uruguay, notes that Barradas learned his craft more informally, participating in gatherings with intellectuals and collaborating as an illustrator in newspapers and magazines published in Montevideo and Buenos Aires. In 1913, Barradas traveled to Europe and settled in Barcelona, Spain, where he met a number of artists and poets, including a kindred spirit, the painter Joaquín Torres-García, also from Uruguay. They “were among the preeminent Uruguayan artists to establish a vital connection with Europe’s prewar vanguards,” according to the Museum of Fine Arts, Houston, Texas, USA. The allure of futurism, cubism, and synchromism in art led Barradas and Torres-García “to propose ‘vibrationism’—essentially an art reflecting a unity of the senses—as a unique contribution to Modernist theory.”Within the European avant-garde art community of that time, art historian M. Lluïsa Faxedas Brujats explains that vibration referred to the “physical phenomenology of light and to the assumed vibration of colours,” the comparison between light and sound that lead to “all kinds of research into synaesthesia,” and a connection “between the individual and his or her environment.” Gabriel Peluffo Linari, who researches Latin American art, describes vibrationism as having a “syncretic language with a wide range of colors” that “presented a multiplicity of perspectives” and “combined elements of cubism and Italian futurism.” Urban Landscape reflects the clamorous city streets of Madrid, where Barradas had settled in 1919, with sound and motion distilled in a colorful fugue.”During this somewhat short phase of his career (by 1924 Barradas had moved on from vibrationism and was mostly painting landscapes), the artist was striving to appeal to as many senses as possible in his colorful, complex, abstract paintings. The Museum of Fine Arts, Houston, uses musical terminology to describe the syncretic elements of this work, noting, “Urban Landscape was painted more than a century ago, according to United Nations’ data, only 20% of the world's population lived in cities; in less developed countries, that percentage was around 5%. In October 2022, the World Bank estimates that “some 56% of the world’s population―4.4 billion inhabitants—live in cities.” The United Nations recently projected that by 2050, 68% of people will live in urban areas. Urbanization and the accompanying loss of natural habitat for animals have amplified the spillover of zoonoses―infections that are naturally transmissible from animals to humans―since Barradas’ lifetime. As urban populations increase, so does human contact with synanthropic wildlife, migrating birds, domestic and wild animals sold in markets, and house pets, which in turn contributes to the spread of zoonotic infections. Plus, the overcrowding of people within megacities further propagates human-to-human spread of infections that have zoonotic origins but can now spread directly among people. When Infectious disease specialist Carl-Johan Neiderud writes that “Urbanization leads to many challenges for global health and the epidemiology of infectious diseases. New megacities can be incubators for new epidemics, and zoonotic diseases can spread in a more rapid manner and become worldwide threats.” Integral to the global response to zoonotic infections is the concept of One Health, which CDC describes as “a collaborative, multisectoral, and transdisciplinary approach—working at the local, regional, national, and global levels—with the goal of achieving optimal health outcomes recognizing the interconnection between people, animals, plants, and their shared environment.” Such “a multiplicity of perspectives” from experts working in multiple disciplines and sectors can bolster public health preparedness and response for the next zoonotic pandemic.