**Abstract**

Moyamoya disease is a rare cerebrovascular disease most prevalent in East Asian Countries. Thanks to the new diagnostic capabilities, the number of cases discovered has been rising steadily in the latest years, including many asymptomatic patients. But asymptomatic from the clinical point of view does not necessarily mean that there are no subjacent problems and that there will be no disease progression. Indeed, many patients harbour cognitive decline long before they start with clinical or even radiological manifestations. The only effective treatment is surgical revascularization, with all its possibilities: direct, indirect, and combined. While direct techniques are more useful in adult moyamoya patients, children seem to benefit most from indirect techniques. Additionally, indirect or combined procedures can be used as salvage procedures in case of unsatisfactory outcomes. Thus, many surgeons posit that surgical treatment should be considered in moyamoya patients, even if asymptomatic, particularly in the paediatric age group.

**Keywords:** moyamoya disease, surgical revascularization, bypass surgery, asymptomatic moyamoya disease, cerebral revascularization, treatments modalities


Although more than 85% of the ingested sucralose contacts the colonic microbiota, between 94% and 99% of this LNCS is recovered in the feces without any structural change, thus indicating little or no metabolism by the gut microbiota [10]. Thus, sucralose does not appear to be a substrate for the colonic microbiota [16]. Nevertheless, considering the practically null microbial metabolism of sucralose, we must be cautious when interpreting the results of studies that indicate an alteration of the intestinal microbiota after sucralose consumption [17]. In those cases, it will be worth investigating whether pure sucralose or a commercial formulation was used in the research, since these formulations usually contain around 1% of sucralose and 99% of the carriers maltodextrins [16].

On the other hand, it has been shown that sucralose promotes inflammation in a mouse model of human Crohn's disease-like ileitis as well as dysbiosis of the gut microbiota [34]. Furthermore, sucralose causes a decrease in the number of Firmicutes species [35]. This result is the opposite to that reporter by Olivier-Van Stichelen et al., who found that Firmicutes doubled, including the Clostridiales families Lachnospiraceae and Ruminococcaceae (e.g., Oscillospira), in mice's pups [27]. Wang et al. observed an increase of Firmicutes and a tendency to decrease for Bacteroidetes [28]. These authors did not observe changes in Actinobacteria and Proteobacteria phyla in mice fed with a chow diet, but they reported a synergistic effect when sucralose was provided in the context of a high-fat diet. On the other hand, a chow diet might cause a significant increase in *Bifidobacterium* [28]. A study carried out in humans examined the short-term effect of sucralose consumption on glucose homeostasis and gut microbiome in healthy male volunteers. The authors concluded that no changes occurred in the gut microbiome due to sucralose intake [36]. In contrast, another study shows an increase in the abundance of pro-inflammatory bacteria like *Turicibacter*, which was associated with hepatic inflammation, after sucralose administration [37].

Splenda administration in mice was associated with a high presence of Bacteroidetes, an enhanced overgrowth of *E. coli*, and the expansion of Proteobacteria [38]. The effect of sucralose was analyzed in fecal samples from 13 healthy volunteers. The authors found increased abundances of *Escherichia*, *Shigella,* and *Bilophila.* With regard to SCFA, increased production of valeric acid was observed [19].

A recent publication evaluated the short-term effect of sucralose consumption on glycemic control and its interaction with the intestinal microbiota (comparison before/after the intervention by 16S rRNA sequencing) in healthy subjects. This study concluded that consumption of high doses of sucralose (75% of the ADI) for 7 days did not alter glycemic control, insulin resistance, or intestinal microbiome at the phylum level [36].

Although previous human studies showed similar results concerning glycemic control (glycosylated hemoglobin, fasting blood glucose, C-peptide), both in diabetic [39] and in non-diabetic populations [40], this is the first time that a randomized, controlled, double-blind study concomitantly evaluated the composition of the intestinal microbiome in healthy subjects, thus providing a better level of evidence in comparison to other earlier published trials.

#### 2.1.5. Saccharin

After intake, more than 85% of saccharin is absorbed as an intact molecule, since it does not undergo gastrointestinal metabolism. Once absorbed, it binds to plasma proteins and is distributed throughout the body. Finally, it is eliminated by urine through active tubular transport [10,41,42]. The small percentage of non-absorbed saccharin is excreted into the feces, indicating that high concentrations of this LNCS could lead to changes in the composition of the intestinal microbial population [16]. It is important to highlight that one of the main studies that reported an alteration of the intestinal

microbiota with the consumption of saccharin [17] was carried out by administering the full ADI of saccharin, which does not correspond to what happens with habitual human consumption.

In an in vitro model study, saccharin produced an increase in *Bifidobacterium*. Not only saccharin but also sucralose caused a decrease in the number of Firmicutes species, directly correlated with the SCFA level [30].

Some herbicides, which are considered nowadays safe, can change the gut microbiota of animals in the early stages of embryonic development. Indeed, exposure to glyphosate and glyphosate in combination with saccharin contributes to the broader reproduction of pathogenic bacteria such as *Klebsiella*, *Citrobacter*, *Enterobacter,* and *Pseudomonas* [43]. On the other hand, studies show that saccharin administration can also disrupt monolayer integrity and alter paracellular permeability in a Caco-2 cell monolayer model [44].

Overall, saccharin administration also promotes Bacteroidetes, Turicibacter, and Clostridiales and reduces Firmicutes abundances. The Turicibacter bacteria increases have been related to a pro-inflammatory effect of saccharin [37].

The effect of a mixture of fiber–prebiotics and saccharin–eugenol has been evaluated in dogs. Four diets were prepared: control diet, containing 5% of cellulose; diet containing a 5% fiber and prebiotic blend; diet containing 0.02% of saccharin (sweetener SUCRAM) and eugenol and 5% of a fiber and prebiotic blend plus 0.02% of saccharin and eugenol. The use of saccharine did not affect species richness measured by alpha-diversity or alter the proportions of bacterial phyla. No changes were observed in fecal microbial communities [45]. More studies are needed to confirm these saccharin effects using different concentrations and animal models.

#### 2.1.6. Steviol Glycosides

Steviol glycosides can be extracted from the leaves of *Stevia rebaudiana*. They all have a central steviol structure, conjugated with different sugar residues, such as stevioside and rebaudioside A, which all are steviol glycosides. Steviol glycosides are hydrolyzed neither by enzymes nor by the acid present in the upper gastrointestinal tract [46]. Therefore, they pass through the upper portion of the gastrointestinal tract without being absorbed and enter the colon as intact molecules [47]. In the colon, bacteria of the Bacteroidacea family eliminate the sugar residues that are conjugated to steviol [47,48]. While these sugar residues may represent a source of energy for the microbiota [49], it is worth noting that the energy contribution is negligible, given the low total daily intake of steviol glycosides [50]. The resulting steviol is not a substrate for the intestinal microbiota, since it is resistant to bacterial degradation [48]. Hence, steviol is completely absorbed and reaches the liver where it is conjugated with glucuronic acid. Steviol glucuronide is mainly excreted in the urine in humans [51,52].

While steviol glycosides interact with the colonic microbiota, there are no reports indicating that these compounds could affect bacteria negatively [30]. A recent study showed that steviol incubation in the GIS1–phase 2 system, an in vitro system that simulates the human intestinal microbial ecosystem, reduced the ammonium level and *Bifidobacterium* and exerted a negative influence on the fermentative profile, resulting in higher pH and SCFA ratio [30].

*S. rebaudiana* is another natural steviol glycoside 250 times sweeter than sucrose [53]. In Europe, only the purified steviol glycosides are approved for use in food, and the ADI of 4 mg kg−1 of body weight per day is safe (EU Regulation (EU) 1129/2011) [1,7,54]. Another study recently reported that a low dose of stevia rebaudioside A alters gut microbiota composition and reduces nucleus accumbens tyrosine hydroxylase and dopamine transporter mRNA levels in rebaudioside A-supplemented rats. Nonetheless, the oligofructose-enriched inulin prebiotic, in the presence or absence of rebaudioside A, reduced fat mass, food intake, gut permeability, and cecal SCFA concentration. However, only stevia rebaudioside A increased SCFAs acetate and valerate, which are positively correlated with fat mass and total weight. Hence, stevia rebaudioside A seems to decrease the "healthy" status of the gut microbiota [55].

Chronic stevia consumption has effects on gut microbiota and immunity in the small intestine of young mice. In 21-day-old mice treated with sucrose, Splenda, and stevia, mice preferred the consumption of Splenda and stevia. Besides, those mice showed an increase in CD3+ lymphocytes in Peyer's patches, but only stevia induced an increase in the lamina propria. Both Splenda and stevia elevated leptin, C-peptide, IL-6, and IL-17 and decreased resistin. Stevia modified the predominantly genera *Bacillus* such as *Bacillus aerius*, *Bacillus circulans*, *Bacillus licheniformis*, and *Bacillus safensis*, although the authors observed effects on *Streptococcus saliviloxodontae*, *Oceanobacillus sojae*, and *Staphylococcus lugdunensis*. Even though the results of this study are significant, they have some limitations. The modifications observed in the immune system of the mucous membranes and in the microbiota of the small intestine in young mice after weaning depend on age and diet. This study used culture media and not metagenomic approaches, and some results might be related to some carriers present in the evaluated products, such as maltodextrins [56].

Recently, by testing stevia glycosides and erythritol, which are often combined in food preparation to minimize changes in the organoleptic profile, in an in vivo *Cebus apella* model, changes in bacteria growth and gut microbial structure and diversity have been observed [57]. Overall, stevia seems to modify the gut microbiota; however, further studies are needed to clarify its specific effects.

Although different changes in the intestinal microbiota have been described in relation to the influence of sweeteners on the immune system, the wide use of aspartame, ace-K, cyclamate, sucralose, saccharin and steviol glycosides makes it necessary to carry out other analyses to complete the picture of the influence that these sweeteners have on the intestinal microbiota.

#### *2.2. E*ff*ects of Nutritive Low-Calorie Sweeteners on the Gut Microbiota*

#### 2.2.1. Polyols

Polyols are a group of compounds used in an increasingly wide variety of commercial foods as additives. They are quite stable at high temperatures and various pH and do not interfere in Maillard reactions, conferring organoleptic characteristics to the foods. Polyols are naturally present in fruits, vegetables, and mushrooms and are used to produce food without added sugar, reducing the sugar content in recipes. In addition, polyols are non-cariogenic, do not induce salivation, and do not interfere with insulin and glucose levels in the blood. Nevertheless, the excessive consumption of polyols causes gastrointestinal symptoms and laxative effects, which can be even worse in patients with IBS. As we described previously, the FDA, the Codex Alimentarius, and the EFSA have approved eight different polyols, i.e., erythritol, hydrogenated starch hydrolysates, isomalt, lactitol, maltitol, mannitol, sorbitol, and xylitol, for use as bulk sweeteners in human foods [1,58]. Indeed, in September 2019, EFSA launched an open consultation on the "Protocol for the assessment of hazard identification and characterization of the sweeteners", which will be used for the evaluation of the safety of sweeteners under the re-evaluation program of food additives. The evaluation should be completed by the end of 2020 [59].

#### 2.2.2. Erythritol

Erythritol (E-968) is a four-carbon sugar alcohol that has a fast absorption through the small intestine with a very low metabolization and it is over 90% excreted unchanged in the urine [58]. Furthermore, an unabsorbed part (~10%) is fermented in the large intestine by the colonic microbiota, which consequently rarely leads to gas production [60]. Hence, the limited amount of erythritol that reaches the colon could be the explanation of the lack of evidence of effects of erythritol on the gut microbiota in humans, based on clinical trials as we previously reported [1]. Nevertheless, a recent in vitro study demonstrated that low doses of erythritol (25 μg mL−1, 50 μg mL−1, and 100 μg mL−1) did not exert any effect on the growth of *Escherichia*, *Enterococcus*, *Lactobacillus*, *Ruminococcus* and Bacteroides in the human gut microbiota. Moreover, erythritol doses did not disrupt alpha and beta diversities or the composition of the human gut microbial community [57]. In contrast, butyric and pentanoic acids were increased significantly after erythritol consumption, indicating that this polyol

may be able to affect the function of the human gut microbiota. Indeed, the authors reported that this change in SCFAs production was due to the 10% of erythritol that reaches the human colon [57].

#### 2.2.3. Isomalt

Hydrogenated isomalt, isomaltitol (E-953), is not absorbed by the small intestine and is easily fermented in the colon by the microbiota [61]. This fermented fraction of ingested isomalt is approximately 90% [62]. Therefore, itis expected thatisomaltis capable of altering the bacterial population. Isomalt has been proposed as a prebiotic carbohydrate that might contribute to a healthy luminal colonic mucosal environment, with bifidogenic properties and high butyrate production [63]. Accordingly, besides evidence reported in Ruiz-Ojeda et al., 2019 [1], a recent study based on the administration of buckwheat honey to human gut microbes cultures reported that the principal constituents of buckwheat honey are oligosaccharides with a low degree of polymerization, including isomalt and isomaltotriose, which may serve as food to promote the growth of indigenous intestinal probiotics such as *Bifidobacterium* [64]. In addition, an increase in the abundance of *Escherichia*/*Shigella* and *Streptococcus* was also reported, while the alpha diversity, as well as the abundance of *Prevotella*, *Faecalibacterium*, and *Lachnospiraceae incertae sedis*, were decreased, thus fostering a reduction of pathogenic bacteria in the gut tract [64]. However, this might be also explained by the polyphenols composition of the buckwheat honey studied, since polyphenols also markedly affect the gut microbiota [64]. Indeed, the authors concluded that phenolic compounds and oligosaccharides in buckwheat honey appear to synergistically impact human intestinal microbes to enhance the growth of probiotics. More efforts, especially in vivo, are required to elucidate the possible specific impact of isomalt on the gut microbiota.

#### 2.2.4. Lactitol

Lactitol (E-966) is a disaccharide normally not absorbed in the small intestine [65] that therefore reaches the lower gut where it is fermented, producing both gases and SCFA [66]. Lactitol mitigates pathogenic translocation in the small intestine by the reduction of permeability and stimulates the growth of bifidobacteria and lactobacilli [67]. Thus, similarly to isomalt, lactitol could act as a prebiotic, enhancing the composition of the intestinal microbiota, even when consumed at low doses as a sweetener, normally 10 grams [68]. Nevertheless, it is important to highlight that lactitol, due to its limited sweetening power, is usually used in combination with other intense sweeteners [69] or a set of prebiotics [70], and this could disturb the results concerning its effect on the intestinal microbiota. Furthermore, it has also been studied as a synbiotic product along with *Lactobacillus acidophilus* NCFM and jointly promoted beneficial changes since it led to a decrease in the abundance of the *Blautia coccoides*–*Eubacterium rectale* bacterial group and *Clostridium* cluster XIVab counts in the elderly population [71]. Since 2018, two studies were identified regarding lactitol and the gut microbiota. One trial was based on the administration of probiotics, synbiotics, probiotics together with lactitol, or only lactitol to mice with acute colitis. The authors found that the lactitol group showed higher levels of *Akkermansia* compared with the control, probiotic (*Bifidobacterium* and *Lactobacillus*), and synbiotic (probiotics and inulin) groups. It is worth highlighting this work, since *Akkermansia* seems to ameliorate the inflammatory response and insulin resistance in obese and diabetic patients [72], protecting the intestinal epithelial cells and enhancing the mucosal barrier function [73]. As the genome of *Akkermansia* was proved to be able to encode a wide variety of secretory proteins such as glycohydrolyzases [74], the authors speculated that *Akkermansia* might be able to decompose lactitol and promote its own proliferation [75]. Furthermore, the supplementation of probiotics and prebiotics, including lactitol, induced an increment of the proportion of helpful bacteria and regulated the balance of the intestinal microbiota [75]. For instance, the abundance of *Bifidobacterium* was increased in all the experimental groups in comparison with the control. However, the observed effect might not be exerted by lactitol itself [75]. Another study was performed in Korean adults to evaluate the efficacy of supplementation with the prebiotic UG1601 (based on inulin (61.5%), lactitol (34.6%), and an aloe vera gel (3.9%)) for 4 weeks to alleviate the symptoms of constipation associated with the gut microbiota [70]. Here, the clinical trial showed that the prebiotic UG1601 in patients with mild constipation resulted in decreased serum concentrations of the bacterial endotoxin lipopolysaccharide and its receptor CD 14. Additionally, it increased the abundance of *Roseburia hominis*, a major butyrate producer, which could be related to the observed reduction of the levels of these endotoxemia markers [70]. In summary, lactitol along with other compounds, may induce changes in the gut microbiota, but further studies are needed to demonstrate whether lactitol itself triggers an effect on the gut microbiota.

#### 2.2.5. Maltitol

Maltitol (E-965) is obtained through the hydrolysis, reduction, and hydrogenation of starch. This polyol has a very slow absorption rate, being fermented in the colon. Thus, as we previously mentioned, it is expected that maltitol is susceptible fermentation by the gut microbiota [1]. To date, only one clinical trial has been reported which studied the effect of maltitol present in experimental chocolate on the gut microbiota. The authors concluded that both maltitol and polydextrose, as well as maltitol alone, increased the amount of fecal bifidobacteria, lactobacilli, and SCFA compared with the control chocolate [26]. Besides evidence reported by Ruiz-Ojeda et al., 2019 [1], there are no additional studies. Although maltitol could be a good alternative with high sweetening capacity (~90%), safe, and non-cariogenic, data to determine the specific effects of maltitol on the gut microbiota are not still sufficient.

#### 2.2.6. Sorbitol

Sorbitol or D-glucitol (E-420) is partially absorbed in the upper gastrointestinal tract, where it undergoes digestion, while the non-absorbed portion is extensively fermented to SCFA and gases by the colonic microbiota [62]. Consumers can suffer slight gastrointestinal symptoms, such as flatulence or bloating, or more severe symptoms when it is ingested at high doses as 20 g d−1 [76]. Overall, studies on this isomeric polyol and its effect on the gastrointestinal tract are mostly focused on the symptomatology induced by sorbitol than on its possible capacity to alter the gut microbiota. Since the 1930s, it is known that sorbitol can be fermented by bacteria like *E. coli*, *Lactobacillus* spp., and *Streptococcus* spp. [77] which are present in our intestinal microbiota. However, so far, there has been no thorough study and there is not enough evidence to define the specific effects of sorbitol on the gut microbiota.

#### 2.2.7. Mannitol

Mannitol (E-421) is an isomer of sorbitol, and both are listed as hydrogenated monosaccharides. Approximately, 75% of ingested mannitol reaches the large intestine [78]. The intestinal bacteria metabolize D-mannitol to butyrate and propionate in animal models. Indeed, D-mannitol has been suggested as a prebiotic, due to its stimulation of colonic butyrate and propionate production [79]. Although no data are available so far about the effects of mannitol on the gut microbiota, its role as a substrate reflects an interaction between this polyol and the intestinal microbiota that should be studied more deeply.

#### 2.2.8. Xylitol

Xylitol (E-967) is a five-carbon polyol obtained from the hydrogenation of D-xylose, called wood sugar or birch sugar. Xylitol can be directly metabolized mainly in the liver, remaining unchanged in the gastrointestinal tract [80]. Furthermore, only a certain proportion of the ingested xylitol is absorbed slowly from the intestinal lumen and fermented by the intestinal microbiota. Besides minor amounts of gases such as H2, CH4, and CO2, the end products of the bacterial metabolism of xylitol are mainly SCFA, (i.e., acetate, propionate, and butyrate). Xylitol might cause osmotic diarrhea when the amounts consumed are too high [81]. Hence, it is expected that this polyol is capable of altering the intestinal microbiota. Interesting results were reported, as previously mentioned, in our recent review [1], but further studies were not reported since then.

In summary, according to the new findings reported from February 2018, erythritol, lactitol, and maltitol have shown to exert beneficial effects on the gut microbiota by themselves. Nevertheless, because of the promising effect of lactitol to enhance *Akkermansia* proliferation in mice with acute colitis, we encourage corroborating this finding by further studies in humans. Overall, the latest evidence is not still enough to establish firm conclusions in relation to how polyols influence the gut microbiota. In addition, it is necessary to highlight that some polyols could induce laxative effects, and it would be more reliable to evaluate their effects separately. Figure 1 summarizes the effects of different sweeteners on intestinal microbiota.

**Figure 1.** Schematic representation of sweeteners' effects on the gut microbiota. Abbreviations. IgA, Immunoglobulin A; N/A, not available information; SCFA, short-chain fatty acids.

#### **3. Conclusions and Future Perspectives**

The effects of sweeteners on gut microbiota composition are still in discussion. Even though there are some gaps in the evidence related to the health effects of NNS in both healthy and non-healthy populations, authorities such as FDA, EFSA, and Codex Alimentarius consider them safe and well-tolerated, as long as the appropriate ADI is not exceeded. Regarding NNS, neither aspartame nor its degradation products make contact with the colonic microbiota. In contrast, though Ace-K is absorbed and eliminated by urine and almost does not contact the colonic microbiota, surprisingly, it increases Firmicutes and depletes *A. muciniphila.* However, further research is required in order to firmly establish an effect in humans. We previously reported that saccharin and sucralose seem to change the composition of the gut microbiota. However, it is necessary to take account that only 15% of the consumed saccharin contacts the colonic microbiota, so only high doses could alter the intestinal microbiota composition. On the contrary, more than 85% of the consumed sucralose reaches the colon; therefore, sucralose could potentially either alter or change the gut microbiota composition, but it is not practically metabolized by intestinal bacteria. On the other hand, steviol glycosides directly interact with the intestinal microbiota and need bacteria for their metabolization, so they could potentially alter the bacterial population.

In summary, in the absence of biological plausibility, results indicating a possible alteration of the intestinal bacteria population after the consumption of LNCS should be explained by alternative mechanisms, such as alterations in the dietary pattern, administration of exaggerated LNCS doses, and co-administration of carriers.

**Author Contributions:** J.P.-D. and F.J.R.-O. design the work, participated in the bibliographic search, discussion, and writing of the manuscript. B.P.-V. and A.R.-R. participated in the bibliographic search, discussion, and writing of the manuscript. F.A.-M. revised the manuscript. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Acknowledgments:** Julio Plaza-Díaz is part of the "UGR Plan Propio de Investigación 2016" and the "Excellence actions: Unit of Excellence on Exercise and Health (UCEES), University of Granada". Francisco J. Ruiz-Ojeda and Belén Pastor-Villaescusa are supported by a grant to postdoctoral researchers at foreign universities and research centers from the "Fundación Alfonso Martín-Escudero", Madrid, Spain. We are grateful to Belen Vazquez-Gonzalez for assistance with the illustration service.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**

© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).


### Ancients Poets, New Preachers and the Poetry of Salvation

In cantos xxi–xxii of *Purgatorio* there are no autobiographical allusions in the narrative sense, and overt elements of direct self-representation of the poet do not appear either. Consideration of poetry through the figures of Statius and Virgil, however, has a clear value that reflects on the figure of Dante, poet of the *Commedia*. In fact, the acts of identity construction based on certain models are here intertwined with metaliterary reflection on the power and limits of poetry. Even in canto xxi, this theme is at the centre of Statius's self-representation (ll. 82–93), which is structured like Virgil's in *Inferno* i (ll. 67–75).29 Furthermore, Statius acknowledges that if he has become a poet, he owes it to the love with which he studied Virgil's *Aeneid*, which taught him everything (*Purg*., xxi. 94–99). And thanks to Virgil's poem, Statius turned away from the vice of prodigality (*Purg*., xxii. 37–45). Yet as I already mentioned, the text from Virgil that Statius cites is here profoundly transformed in meaning. Only thus does it become effective in promoting Statius's moral conversion. Finally, Virgil's poem enlightens Statius to the faith, in the passage I have already cited (*Purg*., xxii. 64–73). Statius's translation of the beginning of Virgil's fourth eclogue is substantially faithful, but the meaning that Virgil attributed to these verses was limited and reductive. Only a Christian reading, attentive to the consonance Virgil's verses found with the good news spread by the Gospel, can render these verses able to illuminate the path to salvation.

Alongside this reflection on Virgil's poetry, there is, however, another on Statius's poetry. Statius's poem, in fact, does not make his faith manifest:

> 'Or quando tu cantasti le crude armi de la doppia trestizia di Giocasta', disse 'l cantor de' buccolici carmi, 'per quello che Clïò teco lì tasta, non par che ti facesse ancor fedele la fede, sanza qual ben far non basta'. (*Purg.*, xxii. 55–60)

['Now when you sang of the cruel war that caused the double sadness of Jocasta', said the singer of the bucolic songs, 'by what Clio touches on with you there, it seems that faith, without which good works are not enough, had not yet made you faithful'.]

29 See Rossi, 'Canto XXI', pp. 324–29.

And Statius himself admits to having been a 'chiuso cristian' [secret Christian], to not having displayed his faith openly and to having actually continued to feign his adherence to paganism:

> 'E pria ch'io conducessi i Greci a' fiumi di Tebe poetando, ebb'io battesmo; ma per paura chiuso cristian fu' mi, lungamente mostrando paganesmo'. (*Purg*., xxii. 88–91)

[And before I led the Greeks to the rivers of Thebes in my poetry, I was baptized; but out of fear I was a secret Christian, for a long time feigning paganism.]

The long appendix on the poets in Limbo, Virgil's fellow sufferers, who are always engaged in talking about poetry, confirms their eternal fate of failure and absence. Just as Virgil had presented himself to Statius as someone banished 'ne l'etterno essilio' [to eternal exile], so now all the great ancient poets are condemned to Limbo, 'nel primo cerchio del carcere cieco' [in the first circle of the blind prison], also Homer and the other 'Greci che già di lauro ornar la fronte' [Greeks who once adorned their brows with laurel]:30

> 'dimmi dov'è Terrenzio nostro antico, Cecilio e Plauto e Varro, se lo sai; dimmi se son dannati, e in qual vico'. 'Costoro e Persio e io e altri assai', rispuose il duca mio, 'siam con quel Greco che le Muse lattar più ch'altri mai nel primo ringhio del carcere cieco; spesse fïate ragioniam del monte che sempre ha le nutrice nostre seco. Euripide v'è nosco e Antifonte, Simonide, Agatone e altri piùe Greci che già di lauro ornar la fronte'. (*Purg.*, xxii. 97–108)

['tell me where our ancient Terence is, Caecilius and Plautus and Varro, if you know: tell me if they are damned, and to which district'. 'They and

30 Dante expresses the desire for poetic laurels in the first canto of *Paradiso* (ll. 13–33) and then in canto xxv (ll. 1–12), in the middle of the sequence of the sphere of fixed stars. See Michelangelo Picone, 'Il tema dell'incoronazione poetica in Dante, Petrarca e Boccaccio', *L'Alighieri* 25 (2005), 5–26.

Persius, and I, and many others', replied my leader, 'are with that Greek to whom the Muses gave more milk than ever to any other, in the first circle of the blind prison; often times we speak about the mountain that forever holds our nurses. Euripides is with us and Antiphon, Simonides, Agathon, and many other Greeks who once adorned their brows with laurel'.]

Now Dante is representing himself as intent on listening to Virgil and Statius's discussion of the power, glory, and limits of poetry. He draws on these discussions for lessons that he will seek to apply to his own poetry:

> Elli givan dinanzi, e io soletto di retro, e ascoltava i lor sermoni, ch'a poetar mi davano intelletto. (*Purg*., xxii. 127–29)

[They were walking ahead, and I all by myself behind them, listening to their talk, which instructed me in writing poetry.]

But the lessons for Dante's new poetry also come from Statius's references to another activity of speech: the preaching by the messengers of the 'vera credenza' [true belief], the 'novi predicanti' [new preachers] who brought the truth of the Gospel into the world (*Purg.*, xxii. 76–81).

Cantos xxi and xxii of *Paradiso* display, in ways that are unexpected and thus particularly relevant, passages with strong metaliterary significance, important reflections on the poem, its structure, its function, its meanings. In *Paradiso* xxi we find a first confirmation of the prophetic mission assigned to Dante by Beatrice in Eden and solemnly reaffirmed by Cacciaguida in the sphere of Mars (*Par*., xvii. 124–42).31 Now, in the Heaven of Saturn, Dante the character asks the first blessed soul he encounters why he had been the one predestined by divine providence to carry out this task (ll. 76–78). But his response is that divine providence elects men, and also the blessed souls, to take on certain offices, according to an infallibly just will that no creature can fully know (ll. 82–96). And he adds that this response should be extended to all men:

31 On the prophetic dimension of the *Comedy* see Nicolò Mineo, *Profetismo e apocalittica in Dante. Strutture e temi profetico-apocalittici in Dante: dalla 'Vita nuova' alla 'Divina Commedia'* (Catania: Università di Catania, Facoltà di Lettere e Filosofia, 1968); and Robert Wilson, *Prophecies and Prophecy in Dante's 'Commedia'* (Florence: Olschki, 2007).

*'*E al mondo mortal, quando tu riedi, questo rapporta, sì che non presumma a tanto segno più mover li piedi*'*. (*Par*., xxi. 97–100)

[And when you return to the mortal world, carry this back, that it may no longer presume to move its feet toward so great a mark.]

Dante's mission is thus also to remind men of the limits of their knowledge and of the need not to presume beyond these limits, but to accept them humbly. This prophetic investiture is unexpected and therefore very significant; it confirms Cacciaguida's solemn investiture and precedes a series of investitures entrusted to the apostles most beloved by Jesus: James (*Par.*, xxv. 40–45), John (*Par.*, xxv. 127–29), and Peter (*Par.*, xxvii. 64–66).

And canto xxii presents an equally significant metaliterary and structural intervention. This takes the form of an invocation — the third in *Paradiso*  of great structural import, since it begins a new part of the canticle, the part dedicated to the last three spheres: the Fixed Stars, the Primum Mobile, and the Empyrean. The difficulties that the poet is preparing himself to face in narrating the final part of his journey are emphasized with the invocation to the stars of the Gemini, to which he asks for the necessary virtue for this 'passo forte' [difficult pass] (*Par.*, xxii. 112–23).32

The metatextual import of *Inferno* xxi–xxii is announced from the beginning of canto xxi, when the title of the work, *comedìa*, is mentioned for the second time:

> Così di ponte in ponte, altro parlando che la mia comedìa cantar non cura, venimmo […] (*Inf*., xxi. 1–3)

[Thus we went from bridge to bridge, speaking of other things my comedy does not record.]

The title had already appeared at the end of canto xvi, 'Ma per le note / di questa comedìa, lettor ti giuro' (ll. 127–28) while in the canto of *Inferno* prior to this one, Virgil's *Aeneid* is defined as 'high tragedy' (*Inf.*, xx. 113). The Dantean and Christian *comedìa* is opposed to the Virgilian, pagan and

32 See Giuseppe Ledda, *La guerra della lingua. Ineffabilità, retorica e narrativa nella 'Commedia' di Dante* (Ravenna: Longo, 2002), pp. 154–55.

classical *tragedìa*. 33 The Christian comedy is not afraid to go down to the lowest levels of the humble style, down to the depths of vulgarity and triviality, as Dante does in the cantos of the barrators. In Christian culture in order to truly rise, one must come down, prostrate oneself, in order to then ascend to the sublime heights of Paradise.

In canto xxii, the animal similes which were present with a parodic function for the demons back in canto xxi, reappear.34 Here they refer to the damned, who are forced to remain under the boiling pitch so as not to be caught and further tormented by the demons:

> Come i dalfini, quando fanno segno a' marinar con l'arco de la schiena che s'argomentin di campar lor legno, talor così, ad alleggiar la pena, mostrav' alcun de' peccatori 'l dosso e nascondea in men che non balena. (*Inf*., xxii. 19–24)

[As dolphins do, when they signal to sailors, arching their spines, to take measures to save their ship: so from time to time, to lessen the pain, a sinner would show his back and hide it in less than a flash.]

Just as dolphins leap out of water revealing their curved backs, so the sinners' backs briefly emerge from the pitch and then immediately disappear back down. If the movement is similar, their motivations are completely different. The damned emerge in the attempt to relieve their own suffering, but this relief is fleeting and illusory.

The medieval tradition attributed the movement of dolphins to their desire to inform sailors of a storm's imminent arrival, so that they could allow enough time to reach shelter and keep the ship and themselves safe.35 Thus it is no surprise that extremely positive symbolic meanings were attributed to these animals. In Bartholomeus Anglicus's *De proprietatibus rerum*, a text that is often close to Dante's formulations, we find the gloss

33 See also Hollander, *Studies in Dante*, pp. 131–218.

34 See *Inf*., xxi. 44–45, 67–71.

35 See for instance Isidorus of Seville, *Etymologiae*, xii. vi. 11; Rabanus Maurus, *De universo*, viii. 5 (*PL* 111, 237–38); Vincent of Beauvais, *Speculum naturale*, xvii. 109; Alexander Neckham, *De naturis rerum*, ii. 27; Thomas of Cantimpré, *Liber de natura rerum*, vi. 16–17, and vii. 29; Brunetto Latini, *Tresor*, i. 134. For other references and more evidence in favour of the following interpretation, see Giuseppe Ledda, 'Un bestiario metaletterario nell'*Inferno* dantesco', *Studi danteschi* 78 (2013), 119–53 (pp. 127–33).

'Nota de sanctis', which is an index of not only their positive symbolic value, but also of their redemptive value in a strictly religious sense: the 'santi' [saints] are in fact the holy writers.36

The redemptive value of dolphins could thus be brought into dialogue with the metaliterary and metatextual reflections, which resound in these cantos with echoes brought about by the emphatic reference to 'la mia comedìa' [my comedy], placed at the beginning of the previous canto (*Inf*., xxi. 1–3), and of the autobiographical allusions to Dante's military experiences, with the recollection of the barratry conviction Dante had faced in the background. As opposed to these barrators damned in the pitch who are false dolphins, Dante is a true dolphin who — through his *Comedia* — directs Christians to safety and salvation.

The prophetic and potentially redemptive value of the poem is variously affirmed in the individual investitures; and even the first, where Beatrice commands Dante to write what he is shown in the afterlife 'in pro del mondo che mal vive' [for the good of the world that lives ill] (*Purg*., xxxii. 103), is affirmed with particular force by the investiture of Cacciaguida, who speaks of the 'vital nodrimento' [vital nourishment] (*Par*., xvii. 131) that the poem, with the alas bitter condemnation of the sins and the representation of the souls punished in the afterlife, would constitute for human sinners. In this framework, the phrase 'fanno segno / a' marinar […] / che s'argomentin di campar lor legno' [they signal to sailors to take measures to save their ship] assumes particular significance. The readers of the poem, too, are sailors, who can, thanks to these signals, 'campar lor legno' [save their ship]. It is through the image of the dolphins that the reflection on the poetry in the Twenty-Twos intertwines with the model of the holy preaching of the apostles, of their followers, of Benedict. Based on these models, Dante presents himself as a holy preacher and claims the redemptive power of the poetry of his *comedìa*.

36 Bartholomaeus Anglicus, *De proprietatibus rerum*, xiii. 26.

# Bibliography

For the default editions and translations of Dante's works, see 'Editions Followed and Abbreviations'

Accardo, Salvatore, 'Il canto xii del *Purgatorio*', *L'Alighieri* 26 (1985), 6–20.

—, 'Pier della Vigna's Metamorphosis: Iconography and History', in *Dante, Petrarch, Boccaccio: Studies in the Italian Trecento in Honor of Charles S. Singleton*, ed. by Aldo S. Bernardo and Anthony L. Pellegrini (Binghamton, NY: Medieval and Renaissance Texts and Studies, 1983), pp. 31–76.

Cavalcanti, Guido, *Rime*, ed. by Domenico De Robertis (Turin: Einaudi, 1986).

Pézard, André, *Dante sous la pluie de feu* (Paris: Vrin, 1950).

 *See* Bongo, Pietro Buondelmonte dei Buondelmenti 113 Burgwinkle, Bill 102 Busnelli, Giovanni 68

Cacciaguida 9, 29, 70, 71, 79, 80, 82, 84–87, 90–93, 96, 99–100, 101, 109–114, 127, 130–131, 136–139, 143–147, 152–153, 165–166, 230, 255–256, 258 Cahill, Courtney 39 Caius Fabricius 224 Calhoun, Alison 148 Caligiure, Teresa 157 Camozzi Pistoja, Ambrogio 3, 10, 59, 68, 71, 72, 175 Camporesi, Piero 249 Canaccini, Federico 97 Capaneus 60–61, 65–66, 69, 70, 72 Carpi, Umberto 112 Cary, Henry F. 191 Casadei, Alberto 78 Cassell, Anthony K. 18, 49, 58 Castelvetro, Lodovico 52 Catalano, Fra 224 Catiline 92, 93 Cato 65–66 Cerquiglini-Toulet, Jacqueline 148 Cestaro, Gary 102 Charlemagne 71, 153 Charles de Valois 90, 225 Chiarenza, Marguerite Mills 145 Chiavacci Leonardi, Anna Maria 18, 39, 64, 122, 130, 194, 222, 252 Chiesa, Paolo 117, 125 Chiron 7, 15, 19, 26 Ciacco 89–90, 102, 105, 108, 110 Ciadamidaro, Amelia 224 Ciampòlo 219 Cianghella 93 Cicero 92 Cincinnatus 93 Circe 57, 65, 157 Ciriatto 222 Ciro Perna 38 Clarke, K P 3, 5 Clement V 182, 186 Clymene 145–147 Coglievina, Leonella 198 Collins, Matthew 5 Conrad III, Emperor 109, 111 Constantine, Emperor 194

Conte, Pietro 38 Contini, Gianfranco 174 Corbett, George 2, 3, 32, 33, 34, 80, 101, 103, 127, 134, 151, 173, 191 Cornelia 93 Creusa 157 Crimi, Giuseppe 238, 243 Curtius, Ernst Robert 211 Cyrus, King 21 Daedalus 15, 148 Damian, St Peter 11, 12, 217–218, 230, 232–235, 239, 242, 247, 250, 251, 252 Daniel (Old Testament) 67, 69, 71 David (Old Testament) 3, 20, 23–24, 46, 47, 194, 206, 208, 209, 214 Davis, Charles T. 85, 220 De Angelis, Violetta 38 Deianira 15, 19 Del Castello, Antonio 39 De Matteis, Giuseppe 43 Desideri, Giovanella 82 De Vivo, Arturo 238, 241 Dido 148–149 Di Fonzo, Claudia 247 Dionysius of Syracuse 17 Dominic, St 7, 24–30, 33, 239, 242 Donatus 25 D'Ovidio, Francesco 180 Draghignazzo 222 Drittura 10, 161–164 Durling, Robert 33–34, 45, 52, 128, 130–135, 138, 154, 184, 194 Echo 24 Eckhardt, Caroline D. 36 Eliot, T.S. 77 Elizabeth (New Testament) 153–154, 159 Ellero, Diego 117 Empedocles 14 Eriphyle 21 Esposito, Enzo 97 Eurypylus 200 Eva. *See* Eve (Old Testament) Eve (Old Testament) 21, 31, 51–52, 63 Ezzelino da Romano 17

Fachard, Denis 101 Fairclough, H. Rushton 166, 246 Farinata 80, 82, 104, 106, 109, 124 Fasani, Remo 39 Fazio dei Morubaldini da Signa 111 Federico II di Svevia 45 Federzoni, Giovanni 40 Fenzi, Enrico 78 Ferrante, Joan 102, 126, 160 Ferretti, Giovanni 79 Ferrucci, Franco 140, 141 Ferzoco, George 3, 4, 127 Fischer, Bonifatius 34 Fortuna, Sara 102, 112, 122 Fosca, Nicola 195 Foster, Kenelm 35, 38, 181, 182 Fradenburg, Louise 102 Francesca da Rimini 143 Francesco da Barberino 182 Francesco da Buti 58, 165, 177 Francesco De Nicola 40 Francesco De Sanctis 38 Francis, St 7, 24–29, 201, 239, 242–244 Frate Gomita 243, 244 Freccero, Carla 102 Freccero, John 5, 55, 87 Frederick I 152 Frederick II 45 Friis-Jensen, Karsten 179 Fulcieri da Calboli 72 Fulton, Rachel 114 Fumagalli, Edoardo 224, 230, 232 Gabriel (Angel) 63, 153–154 Gentili, Sonia 195, 197, 213 Gerard, Abbot of San Zeno 152 Geryon 101, 108, 127–129, 131–132, 134–137, 139–146, 149, 151 Getto, Giovanni 38, 39, 194, 220 Ghisalberti 25 Ghisolabella Caccianemico 152 Gianferrari, Filippo 5, 6 Giannantonio, Pompeo 18, 19, 38, 39, 61, 197, 252 Gilson, Simon 101, 103, 107, 124, 127, 134, 195, 197, 198, 240

Giunta, Claudio 208, 243 Godfrey de Bouillon 71, 153 Goffis, Cesare Federico 19 Gorni, Guglielmo 198, 208, 243 Graffiacane 222 Gragnolati, Manuele 5, 8–9, 61, 63, 74, 102, 122 Grazzini, Stefano 177 Greenblatt, Stephen J. 154 Gregory I 242 Grimaldi, M. 195 Gryson, Roger 34 Guglielmo Borsiere 106, 107 Guido Cavalcanti 23, 60 Guido da Pisa 67, 177 Guido del Duca 23, 59, 60, 63, 64, 72, 86, 91, 105, 115, 177, 189, 200 Guido Guinizelli 23 Guiscard, Robert 71, 153 Guittone d'Arezzo 143 Güntert, Georges 38, 39, 43, 58, 61, 65, 68, 74, 101, 133, 186, 194, 195, 238, 239 Guthmüller, Bodo 65 Guy de Montfort 15, 18, 22 Hajdú, Istvan 178 Hartley, Sue 136 Hawkins, Peter S. 195, 203, 217, 232, 239 Heck, Christian 247 Heliodorus 206 Henry of Cornwall 15, 22 Hercules 6, 15, 19 Herse 157 Herzman, Ronald 182 Hezekiah, King 194 Hippolytus 131, 139 Hollander, Jean 104, 128–130 Hollander, Robert 82, 84, 104, 128–130, 132, 133, 138, 141, 144, 147, 148, 161, 179, 194, 198, 212, 213, 238, 241, 252, 257 Holmes, Olivia 161–164 Holofernes 21, 160

Holsinger, Bruce 102, 106, 114 Honess, Claire E. 3, 96, 102, 122, 126, 144 Hopkins, Darren 148, 154, 164, 182 Hopper, Vincent Foster 35–37 Horace 173–180, 187 Hugh Capet 25, 36–37, 194, 204–207 Hugh of St Victor 25, 36–37 Hypsipyle 152, 157–158, 160 Iannucci, Amilcare 33, 121, 201, 206, 241 Icarus 129, 138, 139, 145, 147, 148 Invernizzi, Simone 38, 238 Iris 28, 160, 167 Isidore of Seville 37, 97, 257 Ixion 19 Jacob (Old Testament) 232, 247 Jacoff, Rachel 5, 55, 87, 109, 130, 148, 155, 190, 204 Jacopo da Santo Andrea 42 Jacopo della Lana 45–49, 67, 71 James, St 1, 256 Jason (myth) 143, 152, 157–158 Jerman, James 156 Jerome, St 191 Jesus Christ 2, 6, 7, 8, 14, 16–19, 22–30, 36, 46, 51, 58, 62–63, 66, 68, 69, 70, 73, 75, 84, 98, 128, 189, 209, 225–228, 230, 231, 234, 236, 241, 242–243, 243 Jiroušková, L. 199 Joachim of Fiore 24, 25, 29 John of Garland 65, 179 Johnson, Ian 79 John, St 181, 234–235, 256 John the Baptist, St 2, 159, 248–249 Joseph (New Testament) 83, 88–89, 95 Joseph (Old Testament) 2 Joshua (Old Testament) 153, 165, 206 Jove 60, 65 Judas 225–226 Judas Maccabeus 153, 167 Judith 21, 160 Julius Caesar 153, 158, 159, 167 Juno 19, 28, 167

Jupiter 11, 146, 152, 164, 194, 208, 210–211, 230 Juvenal 175, 177, 191 Kablitz, Andreas 39 Kay, Richard 7, 32–34, 82 Kay, Tristan 4, 7, 9, 101, 102, 145, 155 Keen, Catherine 3, 4, 7–8, 102, 109, 110, 112, 114, 122, 125 Keller, Otto 179 Kilgour, Margaret 121 Kirkham, Victoria 155, 161 Kirkpatrick, Robin 3, 64, 173, 214 Kleinhenz, Christopher 2, 94 Küpper, Joachim 148 Lacaita, G. F. 34 Lady Justice. *See* Drittura Lady Wisdom. *See* Sapientia Landoni, Elena 43, 239, 242 Lano da Siena 42 Lano del Topo 40 Lansing, Richard H. 108 Lapo Saltarello 93 Latini, Brunetto 79–80, 81–82, 86–87, 89–93, 96, 99, 104–106, 108–110, 124, 128, 130, 138, 233, 257 Latinus, King 167 Latona 21 Lavinia 166–167 Ledda, Giuseppe 5, 11–12, 27, 29, 41, 201, 239, 243, 252, 256, 257 Leone, Anne 10–11 Logan, John 9, 131, 133–134 Lombardi, Elena 101, 102, 110, 120, 121, 136 Lombardo, Marco 61, 83, 115–117, 119–125, 182, 195, 238, 240 Lonergan, Corinna Salvadori 3, 11 Lucan 65, 153, 159, 167, 213 Lucchesi, Valerio 214 Lucifer 21, 53 Lucilius 175, 177, 187 Luke, St 226, 234 Lundbom, Jack R. 204 Lund-Mead, Carolynn 201, 206

Maeon 198 Magnus, Alberto 65 Malacoda 11, 222–224, 228, 237 Malato, Enrico 38, 39, 60, 78, 195, 238, 239 Malavasi, Massimiliano 60, 61, 66, 67, 68, 72 Mandelbaum, Allen 38, 39, 60, 83, 194 Manto 80, 155, 200, 213–214 Maraldi, Elisa 252 Maramauro, Guglielmo 53 Marchese Obizzo II da Este 152 Marchesi, Simone 5, 8, 9, 79, 82, 94 Marenbon, John 209 Martelli, Mario 224 Marti, Mario 61, 68, 195 Martinez, Ronald 33–34, 45, 52, 128, 130–135, 138, 154, 184, 194, 204, 246 Mary Magdalen 227 Matthew of Acquasparta 25 Matthew, St 234 Mazzamuto, Pietro 18 Mazzotta, Giuseppe 58, 65, 68, 239 Mazzucchi, Andrea 38, 39, 60, 195, 238, 239 McLaughlin, Martin 145 Medea 152, 157–158 Melampus 198 Mercury 157 Michael Scot 200 Migne, Jacques-Paul 36, 37 Mihm, Madelyn Timmel 182 Milligan, Gerry 102 Mineo, Niccolò 255 Minerva 21, 136, 157, 164, 164–167 Minnis, Alastair 35 Minotaur, the 6, 14–17, 27 Mocan, Mira 239 Moevs, Christian 4, 6–7, 83 Montaigne 35 Montorfano, Tommaso 39, 61, 195, 239 Moses (Old Testament) 67, 165 Muresu, Gabriele 38, 40, 49, 58, 61, 64, 73, 74 Musa, Mark 84 Musumarra, Carmelo 39, 40

Najemy, John 109, 112 Nardello, Chiara 177 Nathan (Old Testament) 21, 25 Nebuchadnezzar 67, 69, 71–72 Neckham, Alexander 257 Nessus 15, 19, 44 Nicholas III 180, 182, 184 Nimrod 21, 23 Niobe 21 Noah (Old Testament) 67 Nocita, Teresa 38 Nolan, David 38 Nowlan, Joanna M. Sciortino 26 Obizzo d'Este 17 Oderisi da Gubbio 20, 22–23 Oldcorn, Anthony 38, 39, 60, 83, 194 Ovid 65–66, 68–69, 87, 130, 143, 145, 147–148, 157, 164, 213 Padoan, Giorgio 78, 200, 213 Panicara, Vittoria 238 Parodi, Ernesto 194, 212 Parsons, Ben 175 Pasiphaë 14–15, 27 Pasquini, Emilio 124 Patterson, Jeanette 148 Paul, St 8, 29, 37, 63, 69, 96, 97, 199, 206, 234, 243 Paulus. *See* Paul, St Pearce, Spencer 224 Peck, Russell 36–37 Pellegrini, Anthony 49, 145 Perrus, Claude 238 Persius 175, 177, 255 Pertile, Lino 78, 102, 108, 141, 238 Peter, St 1, 2, 24, 49, 86, 96–97, 185, 195, 227, 234–235, 244, 256 Petrarch 46, 49, 145 Petrie, Jennifer 26 Petrocchi, Giorgio 38, 104, 203 Pézard, Andre 82, 85 Phaeton 129, 131, 138–139, 145–149 Philomela 136, 137 Pholus 15, 19 Piccardi, Andrea 177

Picone, Michelangelo 25, 38, 39, 43, 58, 65, 74, 101, 109, 133, 145, 186, 194, 195, 238, 239, 241, 246, 254 Pier della Vigna 33, 38, 40–41, 42, 45, 47–51, 138 Pier Pettinaio 38 Pierson, Sandra 160 Pietro.

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Cover image: The mosaic ceiling of the Bapti stery of San Giovanni in Florence. Photo by Matt hias Kabel. Cover design by Heidi Coburn.

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**1. Introduction**

Engineering material failure is an important concept engineers and designers look upon, material strength, if enhanced will give more durability and a quality product. Materials mostly fail due to loading (static, cyclic, fatigue) and avoiding failure through fracture is one of the key point we look upon. A fracture occurs when a body splits into two or more parts in response to a static stress applied at a temperature lower than the melting point of the material. There are two stages to a fracture: the crack starts, and then it spreads. There are two distinct fracture types which are brittle and ductile that varies according to the stress distribution in the member during loading.


**3. Discussion**

We live in the age of modern information technology. Therefore, it should be fully assumed that we will work with accurate, correct, up-to-date data, which is stored

*Impact of Digital Vehicle Identification Errors on Critical Information Systems DOI: http://dx.doi.org/10.5772/intechopen.107888*

#### **Table 1.**

*Summary of basic VIN statuses identified during the correctness analysis.*

in information systems for various purposes—production, administrative, control, public transparency and efficiency, health and property protection, security, etc. It should also be assumed that data processing, including its acquisition (primary entry) into information systems in the public administration, will be supported by automated processes and modern technological means, which are already in common use in our everyday practice.

However, this is not the case in practice in the performance of state agencies (registers) working mainly with motor vehicles. There are objective and subjective reasons for this. The issue of vehicle registration as such is very specific in that there are a number of diverse manufacturers creating completely new products and global standardization in some areas (also related to registration practice) is not sufficiently flexible and at the same time not consistently observed. On the one hand, there is technological, major globalization in terms of technical or consumer aspects; on the other hand, the relevant legislation or standardization is also intended to be global (or at least pan-European), but its implementation is delayed by many years due to the adoption and implementation of European directives and regulations in national legislation.

In practice, the basic purposes of any systematic creation of various records and registers are often forgotten. In the past, every object entered into information systems was usually physically checked to ensure the quality of the information, especially key identifiers and other important characteristics.

The current registration processes, specifically in the case of motor vehicles, are only a "paper" matter as they are formally separated from each other. Vehicle registration is based only on the documents submitted, and there is a relatively large margin for error or even deliberate manipulation. In other words, one cannot, for example, technologically read the VIN by optically scanning its physical stamping from the vehicle body, read the VIN digitally from the vehicle control units, or scan the barcode. In the registration process, the vehicle is not physically present at the place of registration. This issue can theoretically be solved by carrying out quality technical inspections and vehicle originality checks that physically take place elsewhere and at different times. Unfortunately, even here the potential of optoelectronic or electronic (digital) technologies that are naturally available cannot be effectively used, because there is no standardized support for the uniform use of barcode or other technologies for recording VINs on vehicles, reading digital VINs from vehicles by manufacturers [31]. Not everyone uses barcodes or QR codes. There is no uniform device for reading (extracting) digital VINs from vehicle control units today that is capable of reading these values in general from all models that are at least simultaneously produced. For every manufacturer (manufacturing concern), it is necessary to have its proprietary technology available, which is not possible in independent inspection practice.

The basic research results obtained, presented in **Tables 1**–**3**, correspond to the practice of manual data acquisition and, at the same time, the lack of understanding of the seriousness of the vehicle identification issue in the design of the information system. The analysis shows that within the VIN item, 8.79 % percent of records do not

#### **Table 2.**

*Overview of error types in the VIN identifier. Decoded – the VIN identifier is error-free (91.21 % overall); Err – 8.79 % of VINs in the database are erroneous. Err – decoding errors.*

*Impact of Digital Vehicle Identification Errors on Critical Information Systems DOI: http://dx.doi.org/10.5772/intechopen.107888*

#### **Table 3.**

*Example of typical erroneous VIN entries. Users either write completely different information values into the database, unrelated to the VIN, or they copy only the first or last parts of the VIN.*

correspond to ISO standards imposed on this identifier. In other words, the error rate for the key identifier VIN is almost 9 %; i.e., one in 11 vehicles is problematic in terms of its unambiguous identification.

A closer analysis reveals that 5.48 % (4.15 + 0.04 + 1.29; see **Table 3**) of all the VINs are incorrect. This is due to the incorrect identifier length (different from the 17 standard characters) and the use of prohibited characters O, Q, and I. These characters must not be used in the VIN structure in order to avoid optical confusion of character pairs such as 0-O, 0-Q, I-J, and I-1, because then the object of interest cannot be found correctly in the search. The analysis also shows (see **Table 3**) that, in practice, data is entered in the VIN entry, items which have a completely different predictive value and certainly do not belong in the VIN entry. Clerks enter various official numbers and file marks. In numerous cases, this includes shortening (front or back) the VIN, usually to only 6–8 positions, because the official thinks that this sequence (reminiscent of the pre-1986 body serial number entries) is sufficient to identify a vehicle. This issue is trivially solvable at the level of information system design because it is sufficient to check the length of the VIN identifier for 17 positions and for the forbidden characters O, Q, and J. Records that do not meet these criteria must be brought to the attention of the information system operator, and such records must not normally be entered into the computer database. This type of error is of an objective nature (incorrect design of the functionality of the information system) and can be corrected retrospectively at minimal cost so that further errors do not occur.

The analysis also shows that an additional 3.31 % of all the VINs are erroneous, and the errors are due to human factors [32–34], in particular fatigue, inattention of an unintentional nature and possible fraudulent behavior [35] to change the vehicle identity [36]. A single character of the 17-digit VIN can be mistyped or misspelled, and a new "artificial" or fictitious VIN is created, which either does not formally exist or belongs to a completely different vehicle. These errors can only be eliminated by using the check digit mechanism in the VIN and/or by checking the inserted VIN

using so-called VINdecoders which check the VIN structure. As such, the VIN check digit mechanism only works in full if vehicle manufacturers in a given country are legally obliged to have this mechanism built into the vehicles they sell. An example is the USA. In Europe and other continents, there it is then necessary to use suitable VINdecoders that operate in real time.


**Abstract**

Social Work placement can be the stimulating experience hoped for or the dreaded experience gained. Professional training values, whether these are influenced by globalization and/or indigenization are principled on the sharing of ideas and debates based on a multi-disciplinary integrated narrative approach. By presenting actual 'lived experiences' in the form of aural and video podcasts and linking these with research and theory, in our eBook Project, students, field supervisors and tutors were helped to explore for example, the use of language, supervision, reflective practice. This made the learning experience more modern, interesting and easily accessible for reviewing anytime anywhere. In practice placement, the understanding is not only what is learned but how it is learned. This Irish wraparound innovation regarding the inclusion of live recordings for teaching and learning brought together a shared focused and a thoughtful and inventive approach to the fundamental work related experience.

**Keywords:** E-learning, podcasts, social work, fieldwork practicum, practice teachers, tutors, social work students, fieldwork practice, fieldwork educators.

### **1. Introduction**

A trainee sailor gets into a boat and the instructing Captain says "Away you go now. Take the boat out beyond the harbor and watch out for the rocks". The trainee gathers up all the knowledge they have acquired from their course and steers the boat out. There is so much to think about, there is too much to remember. This is not a simulation or a role play, this is real. Beyond the water-break it looks like a storm is moving in, what next, what is the best course of action, who can I ask for help?

Moving into fluid placement from the shore of academic knowledge is like the first time the trainee sailor sets sail in a boat. It is real, it is immediate and it can be exhilarating or scary.

The area of Fieldwork placement as an integral part of social work training has been well documented in research literature over the past 10 years (see [1–6]). All agree it is an essential and worthwhile experience in addition to a learning platform for students. It is where theory to practice is most relevant and the contextualization of academic knowledge is progressed.

In the history of social work education, there has always been a practical as well as a theoretical component to education and training. In reality the lines around the ambitious principles of placement can become blurred due to inattention by universities, inadequate pre-placement training for students and practice teachers, as well as unrealistic expectations. Furthermore limited availability of placements and the 'mis-fit' of understanding on why placement sites and placement supervisors need to work in tandem with educational establishments disrupt securing the best professionally trained social workers of tomorrow.

#### **1.1 Globalization and indigenization**

One of the greatest challenges within the concept of a global framework for social work is the inter-country, inter-cultural debate, involving interchanges and influences. The word indigenization in this context looks at taking research and empirical practice wisdom, re-positioning it and using it to form a scaffold for a developing profession. Growing professional identity in the context of economic policies, socio-cultural backgrounds and political regimes as in the studies of China [7–9] the Asian-Pacific [10] and Africa [11], fuels the debate on what is possible or impossible in changing environments.

In the developing world of social work education, much is written about modules, patterns and focus [12–14]. Indeed, we strive to have a better understanding of the social, cultural and environmental costs of a hyper-connected and layered world. This brings with it the need to offer academically robust social work education that encompasses important paradigms for practice. This is a framework rather than a constitution. Paradigms can 'ask questions, pose challenges and be adapted and developed for specific times, spaces and places' [15]. McGregor argues that for social work in the twenty-first century these paradigms need to challenge the dominant position of English/European-based texts and approaches. The aspiration is to develop more informed all-encompassing practices in addition to the best established texts while including specific and cultural knowledge [16, 17]. The aim is to look for a modern paradigm framework taking into consideration balance between a general frame of reference and one that is adaptable to the context of time, space and place [18].

It is interesting that much of the debate around indigenization comes from a West into East position and may or may not have to do with the perceived economic wealth of either region. However, in these changing times of limited resources all countries both rich and poor may have something to offer each other in the debate on establishing and using limited resources and the building of professionalism and education within the realm of social work.

The globalization of social work is seen as the process of International integration influenced by an interchange of world views. Social workers and social work courses around the world continually see local and wider world links within their training/educational courses, own work profiles and more specifically within their own practice case work. Economic situations, tribal and religious wars, health scares, and political regimes, can all contribute to unhealthy, unstable communities. The aim for a healthier society is to achieve sustainable, collaborative outcomes which, influenced by the skills of social work professionalism, creates a variety of multi-faceted, pragmatic solutions to highly complex problems, both individual and social [19, 20]. Further studies on global agendas and international social work are covered in Jones and Truell [21], Doel et al. [22] and Russell et al. [23]. British social work academic Lisa Dominelli also turns her attention to globalization and professional practices (see [24]) informing the more recent publication of 'Global social work in a Political context: Radical Perspectives' by Ferguson et al. [25]. For further

**97**

identity respected by all.

*Irish Field Education/Social Work Placement: The Making of Multi-Touch eBooks...*

reading, Gray and Webb [26] critique world norms in social work suggesting that certain adopted approaches can undermine traditional expertise and working behaviors, these in turn then work against the proficiency of professional judgment. Here we have our boat analogy again. We can move from narrow inlets to expansive seas. We can take the knowledge, values and skills we learn in one area and see how they transpose and develop in another area. Social work practice can begin as one entity and develop as another. It can be heavily influenced by specific influences, be that country or culture. In an Irish context this can be seen by the previously mentioned research work of Skehill [27, 28] and the more recent publication of 'Social Work in Ireland: Changes and Continuities' edited by Christy et al*.* [29]. This brings about a continuous debate on professional social work, oscillating between past, present and future desirable positions. These discourses on social work professional identity in a world context are at times framed as a West informing the East debate. It is suggested that the end point needs to be an open exchange of views taking in traditions, cultures, the role of policy makers, coupled with the desire for an efficient and effective professionally-run service for the vulnerable in society. This should be regardless of where that society is geographically located. The International Federation of Social Work [30] began a process in 2004 to develop a clearer professional leadership in response to the evidence of worldwide low morale and loss of confidence felt by some social work practitioners. In particular the areas of education, social work practice and sustainable social development were investigated. This culminated in a policy statement titled 'Globalization and the Environment'. The statement makes practical suggestions about how social workers, in partnership with local people and communities, can work to promote the positives of global interaction and minimize harm [30]. The optimum vehicle for a social work service is a proficient individual and family social work delivery system, one that is sustainable and where workers are respected and recognized. Foucault [31] called this a 'power to govern' where in order for social work to exist there has to be a heightened knowledge where attributes are accorded to the social worker in having space and authority to arbitrate and manage within their domain. There is an obvious challenge here within the debate of globalization and social work where the make-up, functions and designation of the term 'social worker' and the duties performed - vary throughout the world. Researchers Bain and Evans [32] and Frost [33] pose the question 'Is there a European social work identity?' If we uphold and teach the values of self-realization and social determination then why would we want professional identity to be homogenized? The possible solution is to recognize the good parts, the best constituent elements of a model for identity and in addition recognize best local practice and couple this with agency support and endorsement. Indeed the research of Gray [9, 13] encapsulates the sensible approach of recognizing in social work education the elements of 'culture, economics, politics and social realities.' Interlacing these with the essential elements of fieldwork placement; professionally trained placement supervisors, a variety of placement sites, essential University support and a consideration of time, place and culture, may anticipate a more integrated outcome. This expects a Governmental policy and educational delivery partnership, together with professional organizations across borders and across countries to establish a profession and professional

In the 2019 study by Rasell et al. of a two-year multiethnic social work program,

with an approximate intake of 17 students per cohort, interconnected with five International Universities [23], the most interesting aspect of this research suggested that '*The 'international' acts as a frame of reference for studies rather than a particular body of knowledge and skills to be transmitted to students*' (p.14). In all, this seems a fair goal but its delivery may prove more challenging. The debate around

*DOI: http://dx.doi.org/10.5772/intechopen.89391*

#### *Irish Field Education/Social Work Placement: The Making of Multi-Touch eBooks... DOI: http://dx.doi.org/10.5772/intechopen.89391*

reading, Gray and Webb [26] critique world norms in social work suggesting that certain adopted approaches can undermine traditional expertise and working behaviors, these in turn then work against the proficiency of professional judgment.

Here we have our boat analogy again. We can move from narrow inlets to expansive seas. We can take the knowledge, values and skills we learn in one area and see how they transpose and develop in another area. Social work practice can begin as one entity and develop as another. It can be heavily influenced by specific influences, be that country or culture. In an Irish context this can be seen by the previously mentioned research work of Skehill [27, 28] and the more recent publication of 'Social Work in Ireland: Changes and Continuities' edited by Christy et al*.* [29]. This brings about a continuous debate on professional social work, oscillating between past, present and future desirable positions. These discourses on social work professional identity in a world context are at times framed as a West informing the East debate. It is suggested that the end point needs to be an open exchange of views taking in traditions, cultures, the role of policy makers, coupled with the desire for an efficient and effective professionally-run service for the vulnerable in society. This should be regardless of where that society is geographically located.

The International Federation of Social Work [30] began a process in 2004 to develop a clearer professional leadership in response to the evidence of worldwide low morale and loss of confidence felt by some social work practitioners. In particular the areas of education, social work practice and sustainable social development were investigated. This culminated in a policy statement titled 'Globalization and the Environment'. The statement makes practical suggestions about how social workers, in partnership with local people and communities, can work to promote the positives of global interaction and minimize harm [30]. The optimum vehicle for a social work service is a proficient individual and family social work delivery system, one that is sustainable and where workers are respected and recognized. Foucault [31] called this a 'power to govern' where in order for social work to exist there has to be a heightened knowledge where attributes are accorded to the social worker in having space and authority to arbitrate and manage within their domain.

There is an obvious challenge here within the debate of globalization and social work where the make-up, functions and designation of the term 'social worker' and the duties performed - vary throughout the world. Researchers Bain and Evans [32] and Frost [33] pose the question 'Is there a European social work identity?' If we uphold and teach the values of self-realization and social determination then why would we want professional identity to be homogenized? The possible solution is to recognize the good parts, the best constituent elements of a model for identity and in addition recognize best local practice and couple this with agency support and endorsement. Indeed the research of Gray [9, 13] encapsulates the sensible approach of recognizing in social work education the elements of 'culture, economics, politics and social realities.' Interlacing these with the essential elements of fieldwork placement; professionally trained placement supervisors, a variety of placement sites, essential University support and a consideration of time, place and culture, may anticipate a more integrated outcome. This expects a Governmental policy and educational delivery partnership, together with professional organizations across borders and across countries to establish a profession and professional identity respected by all.

In the 2019 study by Rasell et al. of a two-year multiethnic social work program, with an approximate intake of 17 students per cohort, interconnected with five International Universities [23], the most interesting aspect of this research suggested that '*The 'international' acts as a frame of reference for studies rather than a particular body of knowledge and skills to be transmitted to students*' (p.14). In all, this seems a fair goal but its delivery may prove more challenging. The debate around

*Global Social Work - Cutting Edge Issues and Critical Reflections*

best professionally trained social workers of tomorrow.

**1.1 Globalization and indigenization**

impossible in changing environments.

time, space and place [18].

education within the realm of social work.

In the history of social work education, there has always been a practical as well as a theoretical component to education and training. In reality the lines around the ambitious principles of placement can become blurred due to inattention by universities, inadequate pre-placement training for students and practice teachers, as well as unrealistic expectations. Furthermore limited availability of placements and the 'mis-fit' of understanding on why placement sites and placement supervisors need to work in tandem with educational establishments disrupt securing the

One of the greatest challenges within the concept of a global framework for social work is the inter-country, inter-cultural debate, involving interchanges and influences. The word indigenization in this context looks at taking research and empirical practice wisdom, re-positioning it and using it to form a scaffold for a developing profession. Growing professional identity in the context of economic policies, socio-cultural backgrounds and political regimes as in the studies of China [7–9] the Asian-Pacific [10] and Africa [11], fuels the debate on what is possible or

In the developing world of social work education, much is written about modules, patterns and focus [12–14]. Indeed, we strive to have a better understanding of the social, cultural and environmental costs of a hyper-connected and layered world. This brings with it the need to offer academically robust social work education that encompasses important paradigms for practice. This is a framework rather than a constitution. Paradigms can 'ask questions, pose challenges and be adapted and developed for specific times, spaces and places' [15]. McGregor argues that for social work in the twenty-first century these paradigms need to challenge the dominant position of English/European-based texts and approaches. The aspiration is to develop more informed all-encompassing practices in addition to the best established texts while including specific and cultural knowledge [16, 17]. The aim is to look for a modern paradigm framework taking into consideration balance between a general frame of reference and one that is adaptable to the context of

It is interesting that much of the debate around indigenization comes from a West into East position and may or may not have to do with the perceived economic wealth of either region. However, in these changing times of limited resources all countries both rich and poor may have something to offer each other in the debate on establishing and using limited resources and the building of professionalism and

The globalization of social work is seen as the process of International integration influenced by an interchange of world views. Social workers and social work courses around the world continually see local and wider world links within their training/educational courses, own work profiles and more specifically within their own practice case work. Economic situations, tribal and religious wars, health scares, and political regimes, can all contribute to unhealthy, unstable communities. The aim for a healthier society is to achieve sustainable, collaborative outcomes which, influenced by the skills of social work professionalism, creates a variety of multi-faceted, pragmatic solutions to highly complex problems, both individual and social [19, 20]. Further studies on global agendas and international social work are covered in Jones and Truell [21], Doel et al. [22] and Russell et al. [23]. British social work academic Lisa Dominelli also turns her attention to globalization and professional practices (see [24]) informing the more recent publication of 'Global social work in a Political context: Radical Perspectives' by Ferguson et al. [25]. For further

**96**

globalization and indigenization of social work courses transferred and transported across borders and countries will continue. The most important question is 'Will the social work course be Fit for Purpose?' Regardless of location, the answer to this question will determine and challenge the success of both the academic and practical elements of any further education.

#### **1.2 The absolute central position of placement within social work training**

How many newly-designed social work courses start with deciding the academic subjects and modules necessary for the course and not a scoping exercise to see the variety and quality of possible statutory and voluntary placements? How many courses are led by academic insistence and not practice relevance? Within the current literature on placement education there appears to be a growing concern regarding placement learning opportunities [4], staff capacity and actual desk space [34]. The time may be coming for a rethink. Think of social work training as a doughnut (a circular bun with a hole in the middle) in order to acquire the specific skills required for interaction with individuals and families, courses may need to readjust their designs. Put the academic modules in the middle of the doughnut and the placement around the outside. Currently it would appear that most social work course designs are the other way round with the emphasis and importance on the bigger circumference given over to academic modules and the practice placement filling up the middle. This does not take away from the importance of all the integral subjects such as theory, vulnerable populations, social justice etc. but it will shift the thinking into a space that might be valued more, that is, the absolute role of teaching and learning on placement. It might also offer a catalyst for critically thinking about, for example, the subject of law as it is found in the practice learning setting. Further comments on this topic will be discussed in the concluding section of this chapter.

#### **2. The e-Book project**

To understand the fundamental importance of student placement within professional social work training, in 2015–2017 this author [35] decided to work with MSW students, practice teachers and tutors to design a 'wrap around' set of eBooks encompassing the most important aspects of teaching and learning on placement. This was to be a new multi-touch downloadable eBook experience, viewed as a series of seven eBooks which would present short videos and aural podcasts made by social work students, practice teachers, tutors, subject experts and pre-placement trainers. It would also suggest current academic subject references. Placement topics such as language, professional identity and placement expectations and beginnings were to be covered in the first eBook with assessment, supervision, feedback, home visiting, reflective practice, the failing student and placement endings all covered in subsequent eBooks. MSW students, practice teachers, tutors and pre-placement trainers were to have their say in a thoughtful, inventive approach to the fundamental fieldwork experience. It is suggested that at present, access to social work knowledge is juggled between text books, lecture-based teaching and limited digital resources. These new eBooks where to show a collective learning experience made by and for practice teachers, students and all stakeholders in fieldwork training. They would be used in conjunction with pre-placement training for the students and the in-service training for the practice teachers and Tutors. The resource would also be available online to all students throughout their 2 years MSW course for reference across both first and second year placement. It was hoped the

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*Irish Field Education/Social Work Placement: The Making of Multi-Touch eBooks...*

eBooks could shape and help the thinking process for fieldwork practice by making knowledge and discussion through video and aural podcasts, academic text and suggested references more accessible, mobile and downloadable anytime, anywhere.

The pedagogical basis for the eBooks encompassed not only that of creative teaching [36–38] but also the pedagogical importance of narrative enquiry [39, 40]. The uniqueness of the eBooks contributed to by the NUI Galway staff, students, practice teachers and tutors included in particular, the use of podcasting to produce content on specific topics such as language awareness, professional identity, cultural competence, feedback, reflective practice, the experience of failing and groupwork. The immediacy of the spoken word in sharing personal and professional opinions demonstrated the openness, validity and strength of the experiences by the contributors. The making of the eBooks at NUI Galway, gave a sense of Irish indigenous practice that now can be offered as a globally transferable resource. Dale [41] promotes this view of the benefits in education of podcasting and notes increased motivation among students in writing, improved fluency and enhanced listening skills. This is in addition to the students acquiring technical competencies and an increased awareness of the use of new media in social and professional settings, leading to reinforced learning. Indeed using podcasting as an adjunct to teaching and assessment methods in higher education has had some further exposure in the

It is an important point that using this innovative curriculum design and engaging with virtual learning technologies, this may necessitate individual and group upskilling for both educators and students. This new and forward-thinking approach to academic knowledge delivery is further investigated in the studies of Cartney [49] and Waldman and Rafferty [50] who suggest that the relevance of podcasting (in particular lecture material) may have some benefit but that the broader context to forward social work education and personal contact with students must not be belittled or ignored. By using podcasting as a creative technology to forward student learning, the authors caution us not to hold the development of the personal contact with social work students to ransom against the rush to be technologically creative [50]. The application of technology to teaching is integrated with reliable and proven educational approaches [41, 51–53], these studies build on Laurillard's [54] book which suggests the approach of a 'Conversational Framework'. Here, teaching is seen as a fluid practice which *negotiates* knowledge as opposed to a static view of *imparting* knowledge. Didactic teaching is therefore moved and shifted into a modern integrated arena which values the sharing of ideas and issue debates. The argument here is not to see the debate as one thing or another i.e. podcasting versus didactic teaching, but to incorporate new technology methods into teaching therefore giving the recipients and the deliverer a more exciting and

Information was elicited from students, practice teachers, tutors and other social work educators as to what they defined as the most important topics in the area of fieldwork placement. This was achieved with discussion groups in class and outside meetings with agency social workers. The participants on the NUI Galway Postgraduate Diploma in Practice Teaching, Supervision and Management course were also vocal in what they saw as important in the fieldwork relationship and development of the student's professional identity. Pre 2016 across a period of 2 years

*DOI: http://dx.doi.org/10.5772/intechopen.89391*

following research [42–48].

worthwhile experience.

**2.2 How the e-Books were made**

**2.1 The pedagogical reasoning for eBook education**

eBooks could shape and help the thinking process for fieldwork practice by making knowledge and discussion through video and aural podcasts, academic text and suggested references more accessible, mobile and downloadable anytime, anywhere.


**4.5.1 Clinical vignettes**

56 Prostate Cancer – Diagnostic and Therapeutic Advances

As described above, the process of becoming prostate-cancer literate unfolded along the lifedeath continuum; levels of health literacy (from low to high); levels of contact with information networks (from no contact to creation of one's own information network); and illness experiences within or outside information networks. Men's information strategies came out of the desire to preserve their moral integrity, self-image, and to maintain their social roles (as husbands, fathers, grandfathers, friends, and peer counsellors). Awareness of loss, regret, deception, and hope encouraged older men to remain in their social roles, while sharing their wisdom about how to live well1 with prostate cancer (Zanchetta, 2004). Living well with prostate cancer included creating a new body free of embarrassing conditions (e.g., urinary incontinence), a new masculinity, and a new perception of control. Living well also included redefining one's sense of successful adaptation and, most important, adopting new familial and other social roles while being aware of one's own vulnerability (Kelly, 2009). Men's experience with uncertainty throughout their prostate cancer trajectory was affected by their knowledge about the disease, the disease's stage, and the availability of informal support networks (Nanton et al., 2009). These factors may, in turn, have affected

One of older men's primary goals was to understand their illness experiences, an understanding which would enable them to tackle their other primary goal: to regain decisional power over their own bodies and destiny. Guided by hope of surviving prostate cancer, older men decided either to make their journey solitary or collective – experiences shared with family, friends, peers, and strangers. It was between these two extremes of experience with prostate cancer that construction of new social roles, even new social identities, occurred. These new roles and identities preserved the integrity of men's

Men reborn out of collective prostate-cancer journeys distinguished between sharing their own experiences and transmitting information about prostate cancer. They also discerned with which strangers to talk about their experiences of prostate cancer and with which strangers to share its private issues. In contrast, men emerging out of solitary prostatecancer journeys felt unprotected from the dehumanizing health care system and its professionals. They felt restrained in their freedom to share their cancer experiences with others and believed that silence among men about prostate cancer was natural. Despite these differences in men's preferences for living with prostate cancer, we can identify in the participants' accounts the same underlying rationale. Men's decisions about disclosing their experience with prostate cancer were explained by the intensity of their wishes, as fathers

**4.4 Contributions of this research to the practice of social and health professionals**  The research findings described in Section 4 may challenge clinicians' perception that academic education level is the only indicator of patients' ability to understand health information and that less educated patients will be unable to do so. For example,

1 Because none of the research participants was free of prostate cancer, it is beyond the scope of this section to discuss men's perspectives on being free of the disease, feeling safe, or having the disease

masculine self-images, despite suffering related to loss of sexual functioning.

and husbands as well as friends, to protect their loved ones from worry.

**4.3 Ultimate goals in constructing information strategies for becoming prostate-**

**cancer literate**

under control.

men's desire to survive prostate cancer.

Renewing Perspectives on Men's Prostate Cancer

health information.

lives in a meaningful way.

Literacy and Engagement Along the Disease Continuum 59

life. This learning experience, framed by community features, seems to be particularly critical to older individuals living with cancer, because they report decreased social and community involvement as well as shrinking social networks (Houldin & Wasserbauer, 1996). Cutilli and Bennett (2009) demonstrated that men perform worse than women on health-literacy-assessment tests, due to factors such as education, language, income, information-seeking behavior, and type of health insurance. For older men, such predictors of low performance on health literacy assessments are particularly relevant, because marital status, education, and perceived health status predict health-information seeking (Elder et al., 2010). Low literate individuals tend to have difficulty understanding health information and using the health care system. The reasons for this difficulty include (a) limited comprehension of written and verbal health information, (b) not trusting written health information and preferring to gather health information through personal communication, (c) inability to understand health terms and concepts, (d) insufficient information about the health system, and (e) feelings of shame and embarrassment in revealing their limitations (Health Canada, 1999). The paramount issue, low health literacy, seems to be related to cultural, cognitive, and social aspects of having access to, understanding, and using health information (Oldfield & Dreher, 2010). In particular, low literate individuals who have low levels of numeracy and general knowledge may have difficulty dealing with treatmentrelated information containing ratios, probabilities, or percentages. Such information, about cures, treatment complications, and/or side effects, is usually given to patients in the contexts of decision making or informed consent. Certainly, one's ability to understand complex health information can either undermine or enhance one's interest in gathering

Studies have also demonstrated that older men consider information on self-management of their diseases too superficial (Walker et al., 1998), especially because of aging-related problems such as cognitive impairment and decrease in vitality. The search for, processing of, incorporation of, and meaning attached to health information seems to be directly affected by older men's level of disease awareness (Morasso et al., 1997), which may decline with cognitive impairment. The nature of prostate cancer treatment demands that health professionals provide clinical education that responds to older men's knowledge deficits and addresses the physical and psychological problems men experience after treatment (Miaskowski, 1999). For example, men who undergo cryosurgical ablation of the prostate may face complications, such as urethrorectal fistulae, bladder-outlet-obstruction incontinence, impotence, and urinary tract infections. Radical prostatectomy may lead to anxiety, bladder spasms, pain, high risk of hemorrhage, and pulmonary embolisms. The complications surrounding external beam radiation include fatigue, diarrhea, and cystitis. Finally, hormone therapy leads to impotence, hot flashes, gynecomastia, and high risk of pathologic fractures (Giddens, 2004). The impact of such complications can affect men's self-image, and dealing with complex medical information can become challenging for older men. To become health literate, they must make sense of health information, find congruency between their past and new knowledge (Craig, 1987), and incorporate health information into their daily

Interestingly, incorporation of new knowledge about prostate cancer and other medical issues differs according to men's self-reported level of health literacy and unfolds within the

#### **Questions**