Four ways blue foods can help achieve food system ambitions across nations.

Blue foods, sourced in aquatic environments, are important for the economies, livelihoods, nutritional security and cultures of people in many nations. They are often nutrient rich1, generate lower emissions and impacts on land and water than many terrestrial meats2, and contribute to the health3, wellbeing and livelihoods of many rural communities4. The Blue Food Assessment recently evaluated nutritional, environmental, economic and justice dimensions of blue foods globally. Here we integrate these findings and translate them into four policy objectives to help realize the contributions that blue foods can make to national food systems around the world: ensuring supplies of critical nutrients, providing healthy alternatives to terrestrial meat, reducing dietary environmental footprints and safeguarding blue food contributions to nutrition, just economies and livelihoods under a changing climate. To account for how context-specific environmental, socio-economic and cultural aspects affect this contribution, we assess the relevance of each policy objective for individual countries, and examine associated co-benefits and trade-offs at national and international scales. We find that in many African and South American nations, facilitating consumption of culturally relevant blue food, especially among nutritionally vulnerable population segments, could address vitamin B12 and omega-3 deficiencies. Meanwhile, in many global North nations, cardiovascular disease rates and large greenhouse gas footprints from ruminant meat intake could be lowered through moderate consumption of seafood with low environmental impact. The analytical framework we provide also identifies countries with high future risk, for whom climate adaptation of blue food systems will be particularly important. Overall the framework helps decision makers to assess the blue food policy objectives most relevant to their geographies, and to compare and contrast the benefits and trade-offs associated with pursuing these objectives.

Impact of dairy fat manipulation on endothelial function and lipid regulation in human aortic endothelial cells exposed to human plasma samples: an in vitro investigation from the RESET study.

PURPOSE: Longer-term intake of fatty acid (FA)-modified dairy products (SFA-reduced, MUFA-enriched) was reported to attenuate postprandial endothelial function in humans, relative to conventional (control) dairy. Thus, we performed an in vitro study in human aortic endothelial cells (HAEC) to investigate mechanisms underlying the effects observed in vivo. METHODS: This sub-study was conducted within the framework of the RESET study, a 12-week randomised controlled crossover trial with FA-modified and control dairy diets. HAEC were incubated for 24 h with post-intervention plasma samples from eleven adults (age: 57.5 ± 6.0 years; BMI: 25.7 ± 2.7 kg/m2) at moderate cardiovascular disease risk following representative sequential mixed meals. Markers of endothelial function and lipid regulation were assessed. RESULTS: Relative to control, HAEC incubation with plasma following the FA-modified treatment increased postprandial NOx production (P-interaction = 0.019), yet up-regulated relative E-selectin mRNA gene expression (P-interaction = 0.011). There was no impact on other genes measured. CONCLUSION: Incubation of HAEC with human plasma collected after longer-term dairy fat manipulation had a beneficial impact on postprandial NOx production. Further ex vivo research is needed to understand the impact of partial replacement of SFA with unsaturated fatty acids in dairy foods on pathways involved in endothelial function.

Timing and magnitude of climate-driven range shifts in transboundary fish stocks challenge their management.

Climate change is shifting the distribution of shared fish stocks between neighboring countries' Exclusive Economic Zones (EEZs) and the high seas. The timescale of these transboundary shifts determines how climate change will affect international fisheries governance. Here, we explore this timescale by coupling a large ensemble simulation of an Earth system model under a high emission climate change scenario to a dynamic population model. We show that by 2030, 23% of transboundary stocks will have shifted and 78% of the world's EEZs will have experienced at least one shifting stock. By the end of this century, projections show a total of 45% of stocks shifting globally and 81% of EEZs waters with at least one shifting stock. The magnitude of such shifts is reflected in changes in catch proportion between EEZs sharing a transboundary stock. By 2030, global EEZs are projected to experience an average change of 59% in catch proportion of transboundary stocks. Many countries that are highly dependent on fisheries for livelihood and food security emerge as hotspots for transboundary shifts. These hotspots are characterized by early shifts in the distribution of an important number of transboundary stocks. Existing international fisheries agreements need to be assessed for their capacity to address the social-ecological implications of climate-change-driven transboundary shifts. Some of these agreements will need to be adjusted to limit potential conflict between the parties of interest. Meanwhile, new agreements will need to be anticipatory and consider these concerns and their associated uncertainties to be resilient to global change.

El cambio climático está afectando la distribución de las poblaciones de fauna marina compartidas por Zonas Económicas Exclusivas (ZEEs) de países vecinos y en el alta mar. Los efectos del cambio climático en el manejo pesquero internacional estarán determinados por la escala temporal de dichos desplazamientos transfronterizos. Para determinar esa escala temporal, el presente estudio combinó un modelo dinámico poblacional, con una serie de simulaciones de un modelo del sistema terrestre, bajo un escenario de cambio climático de altas emisiones. Los resultados siguieren que para 2030, el 23% de las poblaciones transfronterizas se habrán desplazado y en el 78% de las ZEEs del mundo habrán experimentado cambios en la distribución de al menos una población transfronteriza. Para fines de este siglo, las proyecciones muestran que el 81% de las ZEEs tendrán al menos una población en movimiento y 45% de las poblaciones transfronterizas globales habrán cambiado su distribución. La magnitud de tal desplazamiento se reflejará en un cambio promedio del 59% de la proporción de captura de poblaciones transfronterizas entre ZEEs vecinas para el 2030. Muchos países que dependen de la pesca para sustento económico y seguridad alimentaria emergen como zonas críticas de cambios transfronterizos. Estas zonas se caracterizan por cambios tempranos en la distribución de un número importante de poblaciones transfronterizas. Por lo tanto, los acuerdos pesqueros internacionales deben evaluarse por su capacidad para responder a los impactos socio-ecológicos del desplazamiento de poblaciones transfronterizas debido al cambio climático. Dichos acuerdos deberán de ser ajustados para limitar los posibles conflictos entre las partes de interés y evitar amenazar la sustentabilidad del recurso. Así mismo, los nuevos acuerdos que vayan a establecerse deberán considerar los posibles cambios en la distribución de poblaciones compartidas (y la incertidumbre asociada) para anticiparse a dichos conflictos y aumentar la resiliencia frente al cambio climático.

Le changement climatique altère la distribution des stocks de poissons exploités posant de sérieux problèmes de juridiction et gestion des espèces partagées entre pays voisins, et/ou avec la haute mer. C'est en analysant l'échelle de temps de ces migrations transfrontalières que l'impact du changement climatique sur la gouvernance mondiale des pêches peut être évalué. Dans cette étude, nous explorons cette échelle de temps à l'aide d'un modèle de dynamique des populations marines exploitées couplé à des simulations dérivées d'un ensemble de modèles globaux océan-atmosphère. Les résultats montrent que d'ici 2030, pour le scénario à hautes émissions, 23% des stocks transfrontaliers auront changé de distribution et que 78% des zones économiques exclusives (ZEE) expérimenteront au moins une nouvelle espèce transfrontalière. A la fin du siècle, et pour ce même scénario, 81% des ZEE auront au moins une espèce transfrontalière et 45% des stocks transfrontaliers auront changé de distribution. La magnitude de tels changements de distribution est ici quantifiée par la variation dans la proportion de capture entre ZEE partageant ce stock transfrontalier. D'ici 2030, de tels changements entre ZEE seront de l'ordre de 59% à l'échelle globale, avec de nombreux pays dont la qualité de vie et la sécurité alimentaire dépendent de la pêche émergeant comme zones à haut risque. Ces zones se caractérisent par le déplacement précoce d'un grand nombre de stocks transfrontaliers. A la lumière de ces résultats, les traités et accords de pêche internationaux doivent être évalués pour leur capacité à répondre aux implications socio-écologiques du changement climatique et renégocier afin d'éviter tout conflit entre pays voisins. En anticipant des changements potentiels de distribution entre stocks transfrontaliers, tout nouvel accord de pêche se voudra plus résilient aux effets du changement climatique.

As mudanças climáticas vêm promovendo alterações na distribuição dos estoques de peixes compartilhados por países vizinhos, tanto nas suas Zonas Econômicas Exclusivas (ZEE) como em águas oceânicas internacionais. A escala de tempo desse deslocamento transfronteiriço vai determinar como as mudanças climáticas afetarão o manejo pesqueiro internacional. Diante disso, o presente trabalho teve por objetivo analisar essa escala de tempo, combinando um amplo conjunto de simulações de um modelo do sistema terrestre sob um cenário de mudanças climáticas de altas emissões a um modelo de dinâmica populacional. Foi observado que, para 2030, 23% dos estoques transfronteiriços terão suas distribuições alteradas e 78% das ZEEs do mundo terão experimentado deslocamentos em pelo menos um estoque transfronteiriço. No final deste século, as projeções mostram que 45% dos estoques transfronteiriços do mundo sofrerão alterações e que 81% das ZEEs apresentarão alterações em pelo menos um estoque. A magnitude de tal deslocamento será refletida por uma mudança média de 59% na proporção de capturas de estoques transfronteiriços entre ZEEs vizinhas no ano de 2030. Muitos países que são altamente dependentes da pesca para subsistência e segurança alimentar surgem como pontos críticos para mudanças transfronteiriças. Estes são caracterizados por mudanças iniciais na distribuição de um número importante de estoques transfronteiriços. Os acordos internacionais de pesca precisam ser avaliados quanto à sua capacidade de abordar as implicações sócio-ecológicas de deslocamentos transfronteiriços impulsionados pelas mudanças climáticas e ajustados para limitar um possível conflito entre as partes de interesse. Da mesma forma, novos acordos devem considerar possíveis mudanças na distribuição de populações transfronteiriças a fim de antecipar tais conflitos e construir resiliência em face das mudanças climáticas e das incertezas que as acompanha.

Projecting global mariculture production and adaptation pathways under climate change.

The sustainability of global seafood supply to meet increasing demand is facing several challenges, including increasing consumption levels due to a growing human population, fisheries resources over-exploitation and climate change. Whilst growth in seafood production from capture fisheries is limited, global mariculture production is expanding. However, climate change poses risks to the potential seafood production from mariculture. Here, we apply a global mariculture production model that accounts for changing ocean conditions, suitable marine area for farming, fishmeal and fish oil production, farmed species dietary demand, farmed fish price and global seafood demand to project mariculture production under two climate and socio-economic scenarios. We include 85 farmed marine fish and mollusc species, representing about 70% of all mariculture production in 2015. Results show positive global mariculture production changes by the mid and end of the 21st century relative to the 2000s under the SSP1-2.6 scenario with an increase of 17%±5 and 33%±6, respectively. However, under the SSP5-8.5 scenario, an increase of 8%±5 is projected, with production peaking by mid-century and declining by 16%±5 towards the end of the 21st century. More than 25% of mariculture-producing nations are projected to lose 40%-90% of their current mariculture production potential under SSP5-8.5 by mid-century. Projected impacts are mainly due to the direct ocean warming effects on farmed species and suitable marine areas, and the indirect impacts of changing availability of forage fishes supplies to produce aquafeed. Fishmeal replacement with alternative protein can lower climate impacts on a subset of finfish production. However, such adaptation measures do not apply to regions dominated by non-feed-based farming (i.e. molluscs) and regions losing substantial marine areas suitable for mariculture. Our study highlights the importance of strong mitigation efforts and the need for different climate adaptation options tailored to the diversity of mariculture systems, to support climate-resilient mariculture development.

Rebuilding fish biomass for the world's marine ecoregions under climate change.

Rebuilding overexploited marine populations is an important step to achieve the United Nations' Sustainable Development Goal 14-Life Below Water. Mitigating major human pressures is required to achieve rebuilding goals. Climate change is one such key pressure, impacting fish and invertebrate populations by changing their biomass and biogeography. Here, combining projection from a dynamic bioclimate envelope model with published estimates of status of exploited populations from a catch-based analysis, we analyze the effects of different global warming and fishing levels on biomass rebuilding for the exploited species in 226 marine ecoregions of the world. Fifty three percent (121) of the marine ecoregions have significant (at 5% level) relationship between biomass and global warming level. Without climate change and under a target fishing mortality rate relative to the level required for maximum sustainable yield of 0.75, we project biomass rebuilding of 1.7-2.7 times (interquartile range) of current (average 2014-2018) levels across marine ecoregions. When global warming level is at 1.5 and 2.6°C, respectively, such biomass rebuilding drops to 1.4-2.0 and 1.1-1.5 times of current levels, with 10% and 25% of the ecoregions showing no biomass rebuilding, respectively. Marine ecoregions where biomass rebuilding is largely impacted by climate change are in West Africa, the Indo-Pacific, the central and south Pacific, and the Eastern Tropical Pacific. Coastal communities in these ecoregions are highly dependent on fisheries for livelihoods and nutrition security. Lowering the targeted fishing level and keeping global warming below 1.5°C are projected to enable more climate-sensitive ecoregions to rebuild biomass. However, our findings also underscore the need to resolve trade-offs between climate-resilient biomass rebuilding and the high near-term demand for seafood to support the well-being of coastal communities across the tropics.

Adolescent alcohol use predicts cannabis use over a three year follow-up period.

Background: Alcohol and cannabis use frequently co-occur, which can result in problems from social and academic impairment to dependence (i.e., alcohol use disorder [AUD] and/or cannabis use disorder [CUD]). The Emergency Department (ED) is an excellent site to identify adolescents with alcohol misuse, conduct a brief intervention, and refer to treatment; however, given time constraints, alcohol use may be the only substance assessed due to its common role in unintentional injury. The current study, a secondary data analysis, assessed the relationship between adolescent alcohol and cannabis use by examining the National Institute of Alcohol Abuse and Alcoholism (NIAAA) two question screen's (2QS) ability to predict future CUD at one, two, and three years post-ED visit. Methods: At baseline, data was collected via tablet self-report surveys from medically and behaviorally stable adolescents 12-17 years old (n = 1,689) treated in 16 pediatric EDs for non-life-threatening injury, illness, or mental health condition. Follow-up surveys were completed via telephone or web-based survey. Logistic regression compared CUD diagnosis odds at one, two, or three-year follow-up between levels constituting a single-level change in baseline risk categorization on the NIAAA 2QS (nondrinker versus low-risk, low- versus moderate-risk, moderate- versus high-risk). Receiver operating characteristic curve methods examined the predictive ability of the baseline NIAAA 2QS cut points for CUD at one, two, or three-year follow-up. Results: Adolescents with low alcohol risk had significantly higher rates of CUD versus nondrinkers (OR range: 1.94-2.76, p < .0001). For low and moderate alcohol risk, there was no difference in CUD rates (OR range: 1.00-1.08). CUD rates were higher in adolescents with high alcohol risk versus moderate risk (OR range: 2.39-4.81, p < .05). Conclusions: Even low levels of baseline alcohol use are associated with risk for a later CUD. The NIAAA 2QS is an appropriate assessment measure to gauge risk for future cannabis use.

Tools to enhance nursing students' confidence and skills in medication administration.

ABSTRACT: Nursing students experience high levels of stress and anxiety, which can be evident in tasks like administering medications in the clinical setting. This article shares tools to help decrease student stress during medication administration and foster a culture of safety.

Postprandial Fatty Acid Profile, but Not Cardiometabolic Risk Markers, Is Modulated by Dairy Fat Manipulation in Adults with Moderate Cardiovascular Disease Risk: The Randomized Controlled REplacement of SaturatEd fat in dairy on Total cholesterol (RESET) Study.

BACKGROUND: Chronic consumption of dairy products with an SFA-reduced, MUFA-enriched content was shown to impact favorably on brachial artery flow-mediated dilatation (FMD). However, their acute effect on postprandial cardiometabolic risk biomarkers requires investigation. OBJECTIVE: The effects of sequential high-fat mixed meals rich in fatty acid (FA)-modified or conventional (control) dairy products on postprandial FMD (primary outcome) and systemic cardiometabolic biomarkers in adults with moderate cardiovascular risk (≥50% above the population mean) were compared. METHODS: In a randomized crossover trial, 52 participants [mean ± SEM age: 53 ± 2 y; BMI (kg/m2) 25.9 ± 0.5] consumed a high-dairy-fat breakfast (0 min; ∼50 g total fat: modified: 25 g SFAs, 20 g MUFAs; control: 32 g SFAs, 12 g MUFAs) and lunch (330 min; ∼30 g total fat; modified: 15 g SFAs, 12 g MUFAs; control: 19 g SFAs, 7 g MUFAs). Blood samples were obtained before and until 480 min after breakfast, with FMD assessed at 0, 180, 300, and 420 min. Data were analyzed by linear mixed models. RESULTS: Postprandial changes in cardiometabolic biomarkers were comparable between the different dairy meals, with the exception of a tendency for a 4% higher AUC for the %FMD response following the modified-dairy-fat meals (P = 0.075). Plasma total lipid FA analysis revealed that incremental AUC responses were 53% lower for total SFAs, 214% and 258% higher for total cis-MUFAs (predominantly cis-9 18:1), and trans-18:1, respectively, following the modified relative to the control dairy meals (all P < 0.0001). CONCLUSIONS: In adults at moderate cardiovascular risk, acute consumption of sequential high-fat meals containing FA-modified dairy products had little impact on postprandial endothelial function or systemic cardiometabolic biomarkers, but a differential effect on the plasma total lipid FA profile, relative to conventional dairy fat meals.This trial was registered at clinicaltrials.gov as NCT02089035.

Bartonella species as a cause of culture-negative endocarditis in South Africa.

Previous reports have highlighted the high prevalence of blood culture negative endocarditis (BCNE) in South Africa. The Tygerberg Endocarditis Cohort (TEC) study is an ongoing prospective cohort study of patients with confirmed or suspected IE presenting to Tygerberg Academic Hospital, Cape Town, South Africa. Current analysis includes patients that presented between November 2019 and August 2020. Forty four (44) patients have been included in this ongoing study. Fourteen of the 44 patients (31.8%) had BCNE. Further analysis of the patients with BCNE identified Bartonella species as the most common causative organism (n=6; 43%). Other causes included Mycoplasma species (n=2). No cause could be identified in 4 of the 44 patients (9%). Bartonella quintana was identified with PCR of valvular tissue as the causative organism in 4 of the 5 patients that underwent urgent surgery. The patients with Bartonella IE (n=6) had an average age of 39 years with equal gender distribution. The common clinical features were clubbing (n=5; 83%), anemia (n=4; 66.6%), haematuria (n=3; 50%), acute on chronic severe regurgitant lesion (n=3; 50%) and acute severe regurgitant lesion (n=2; 33.3%).The aortic valve was involved in 5 of 6 patients. During a mean follow-up period of 251 days after diagnosis, no major adverse events occurred. Bartonella-associated IE is an important cause of BCNE in the Western Cape of South Africa. Imaging findings (in patients with BCNE) of significant valvular destruction with large vegetations on the aortic valve not affected by congenital or rheumatic valve disease should raise the suspicion of Bartonella-associated IE.

Projecting global mariculture diversity under climate change.

Previous studies have focused on changes in the geographical distribution of terrestrial biomes and species targeted by marine capture fisheries due to climate change impacts. Given mariculture's substantial contribution to global seafood production and its growing significance in recent decades, it is essential to evaluate the effects of climate change on mariculture and their socio-economic consequences. Here, we projected climate change impacts on the marine aquaculture diversity for 85 of the currently most commonly farmed fish and invertebrate species in the world's coastal and/or open ocean areas. Results of ensemble projections from three Earth system models and three species distribution models show that climate change may lead to a substantial redistribution of mariculture species richness potential, with an average of 10%-40% decline in the number of species being potentially suitable to be farmed in tropical to subtropical regions. In contrast, mariculture species richness potential is projected to increase by about 40% at higher latitudes under the 'no mitigation policy' scenario (RCP 8.5) by the mid-21st century. In Exclusive Economic Zones where mariculture is currently undertaken, we projected an average future decline of 1.3% and 5% in mariculture species richness potential under RCP 2.6 ('strong mitigation') and RCP 8.5 scenarios, respectively, by the 2050s relative to the 2000s. Our findings highlight the opportunities and challenges for climate adaptation in the mariculture sector through the redistribution of farmed species and expansion of mariculture locations. Our results can help inform adaptation planning and governance mechanisms to minimize local environmental impacts and potential conflicts with other marine and coastal sectors in the future.

A Call to Restore Your Calling: Self-care of the Emergency Physician in the Face of Life-Changing Stress: Part 6 of 6: Trainee Burnout.

Whereas our last article focused on burnout in practicing pediatric emergency medicine (PEM) physicians, this article centers on burnout in PEM fellows. Our discussion is based solely on trainee burnout literature. As graduates of pediatrics or emergency medicine residencies, PEM fellows are charged with achieving attending-level clinical expertise while continuing to cope with trainee challenges, such as limited practice autonomy, low pay, financial debt, and uncertain future employment. In this article, we discuss PEM fellow burnout and review risk and protective factors, presentation, and evidence-based interventions to mitigate it. In the absence of PEM fellow-specific literature, we share pediatrics and emergency medicine residency data.This article is dedicated to the trainees we have lost to suicide. We miss you.

A Call to Restore Your Calling: Self-Care of the Emergency Physician in the Face of Life-Changing Stress: Part 5 of 6: Physician Burnout.

This fifth article in our series focuses on burnout in practicing pediatric emergency medicine physicians. As opposed to a general review of burnout, we address understudied and undervalued risk factors, drivers, and individual- and organizational-level solutions applicable to the emergency medicine workplace.Conflicting studies impact our understanding of the prevalence of burnout in our field and the role of depression. This article's story is anonymously submitted and leads us to our discussion of the heightened risk of burnout in underrepresented physicians, those who identify themselves as women, as belonging to a racial, ethnic, gender and/or sexual minority group, and/or as having a physical and/or sensory disability.Thus far, our articles have described coping tools for individuals and health care organizations to prevent and/or mitigate the untoward effects of life-changing stressors on a pediatric emergency physician's life. They include staying healthy and active, cultivating outside interests, and nurturing relationships with peers, friends, and family. We have shared the techniques and benefits of constructive engagement when one is faced with challenging events or individuals. We have underscored the value of peer support, support groups, emotional debriefing, and engaging with outside organizations able to address specific stressors. We have introduced the practice of political engagement as a way of addressing systems-level pressures. Throughout this series, we have emphasized the need to ask for help from family, friends, peers, primary care providers, and mental health professionals. This article describes the benefits of Employee Assistance Programs, Physician Wellness Programs, positive psychology, and grounding behaviors as self-care strategies.

Screening for Adolescent Alcohol Use in the Emergency Department: What Does It Tell Us About Cannabis, Tobacco, and Other Drug Use?

BACKGROUND: The pediatric emergency department (PED) represents an opportune time for alcohol and drug screening. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends a two-question alcohol screen for adolescents as a predictor of alcohol and drug misuse. OBJECTIVE: A multi-site PED study was conducted to determine the association between the NIAAA two-question alcohol screen and adolescent cannabis use disorders (CUD), cigarette smoking, and lifetime use of other drugs. METHODS: Participants included 12-17-year olds (n = 4834) treated in one of 16 participating PEDs. An assessment battery, including the NIAAA two-question screen and other measures of alcohol, tobacco and drug use, was self-administered on a tablet computer. RESULTS: A diagnosis of CUD, lifetime tobacco use or lifetime drug use was predicted by any self-reported alcohol use in the past year, which indicates a classification of moderate risk for middle school ages and low risk for high school ages on the NIAAA two-question screen. Drinking was most strongly predictive of a CUD, somewhat weaker for lifetime tobacco use, and weakest for lifetime drug use. This same pattern held for high school and middle school students and was stronger for high school students over middle school students for all three categories. This association was also found across gender, ethnicity and race. The association was strongest for CUD for high school students, sensitivity 81.7% (95% CI, 77.0, 86.5) and specificity 70.4% (95% CI, 68.6, 72.1). Conclusions/Importance: A single question about past year alcohol use can provide valuable information about other substance use, particularly marijuana.

A Call to Restore Your Calling: Self-Care of the Emergency Physician in the Face of Life-Changing Stress-Part 4 of 6: Physician Helplessness and Moral Injury.

Many aspects of our health care system in the United States can lead to physicians feeling helpless-an inability to save a dying child, an inability to protect an immunocompromised child from a vaccine-preventable illness because of waning herd immunity, and a burdensome new electronic medical record system that your employer insists you must use. The cumulative effect of these experiences can lead to moral distress and ultimately moral injury. We discuss helplessness, moral distress, and moral injury in the setting of today's practice of emergency medicine and provide concrete recommendations to help providers cope with their own reactions to distressing clinical situations.

A Call to Restore Your Calling: Self-Care of the Emergency Physician in the Face of Life-Changing Stress-Part 3 of 6: Physician Illness and Impairment.

Physicians suffer from most medical conditions at the same rate as their lay peers. However, physicians' self-care is often sacrificed for patient care. This third article in our series examines physician and trainee illness and impairment. Presenteeism, physician impairment, and substance use disorder (SUD) are defined. We call attention to the potential for harm of dated cultural norms, which often fuel physicians' neglect of their own health and development of ill-advised coping skills.Although any medical condition may become a functional impairment, the primary cause of physician impairment is SUD. Alcohol and prescription opioids top the list of substances used in excess by physicians. Although SUD is less prevalent in residency, we focus on the rise of marijuana and alcohol use in emergency medicine trainees. A nonpunitive model for the prevention and treatment of SUD in residency is described.Physicians are ethically and legally mandated to report any concern for impairment to either a state physician health program or a state medical board. However, recognizing physician SUD is challenging. We describe its clinical presentation, voluntary and mandated treatment tracks, provisions for protecting reporters from civil liability, prognosis for return to practice, and prevention efforts. We underscore the need to model healthy coping strategies and assist trainees in adopting them.In closing, we offer our colleagues and trainees today's to-do list for beginning the journey of reclaiming your health. We also provide resources focused on the practical support of ill and/or impaired physicians.

A Call to Restore Your Calling: Self-care of the Emergency Physician in the Face of Life-Changing Stress-Part 1 of 6.

Few practicing emergency physicians will avoid life-changing stressors such as a medical error, personal illness, malpractice litigation, or death of a patient. Many will be unprepared for the toll they will take on their lives. Some may ultimately experience burnout, post-traumatic stress disorder, and suicidal ideation. Medical education, continuing education, and maintenance of certification programs do not teach physicians to recognize helplessness, moral distress, or maladaptive coping mechanisms in themselves. Academic physicians receive little instruction on how to teach trainees and medical students the art of thriving through life-changing stressors in their career paths. Most importantly, handling a life-changing stressor is that much more overwhelming today, as physicians struggle to meet the daily challenge of providing the best patient care in a business-modeled health care environment where profit-driven performance measures (eg, productivity tracking, patient reviews) can conflict with the quality of medical care they wish to provide.Using personal vignettes and with a focus on the emergency department setting, this 6-article series examines the impact life-changing stressors have on physicians, trainees, and medical students. The authors identify internal constraints that inhibit healthy coping and tools for individuals, training programs, and health care organizations to consider adopting, as they seek to increase physician satisfaction and retention. The reader will learn to recognize physician distress and acquire strategies for self-care and peer support. The series will highlight the concept that professional fulfillment requires ongoing attention and is a work in progress.

Methodology and Demographics of a Brief Adolescent Alcohol Screen Validation Study.

OBJECTIVE: The aim of this study was to determine the psychometric properties of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) 2-question alcohol screen within 16 Pediatric Emergency Care Applied Research Network pediatric emergency departments. This article describes the study methodology, sample characteristics, and baseline outcomes of the NIAAA 2-question screen. METHODS: Participants included 12- to 17-year-olds treated in one of the participating pediatric emergency departments across the United States. After enrollment, a criterion assessment battery including the NIAAA 2-question screen and other measures of alcohol, drug use, and risk behavior was self-administered by participants on a tablet computer. Two subsamples were derived from the sample. The first subsample was readministered the NIAAA 2-question screen 1 week after their initial visit to assess test-retest reliability. The second subsample is being reassessed at 12 and 24 months to examine predictive validity of the NIAAA 2-question screen. RESULTS: There were 4834 participants enrolled into the study who completed baseline assessments. Participants were equally distributed across sex and age. Forty-six percent of the participants identified as white, and 26% identified as black. Approximately one quarter identified as Hispanic. Using the NIAAA 2-question screen algorithm, approximately 8% were classified as low risk, 12% were classified as moderate risk, and 4% were classified as highest risk. Alcohol use was less likely to be reported by black participants, non-Hispanic participants, and those younger than 16 years. DISCUSSION: This study successfully recruited a large, demographically diverse sample to establish rates of the NIAAA screen risk categories across age, sex, ethnicity, and race within pediatric emergency departments.

Plasma phospholipid fatty acid profile confirms compliance to a novel saturated fat-reduced, monounsaturated fat-enriched dairy product intervention in adults at moderate cardiovascular risk: a randomized controlled trial.

BACKGROUND: Dairy products are a major contributor to dietary SFA. Partial replacement of milk SFA with unsaturated fatty acids (FAs) is possible through oleic-acid rich supplementation of the dairy cow diet. To assess adherence to the intervention of SFA-reduced, MUFA-enriched dairy product consumption in the RESET (REplacement of SaturatEd fat in dairy on Total cholesterol) study using 4-d weighed dietary records, in addition to plasma phospholipid FA (PL-FA) status. METHODS: In a randomised, controlled, crossover design, free-living UK participants identified as moderate risk for CVD (n = 54) were required to replace habitually consumed dairy foods (milk, cheese and butter), with study products with a FA profile typical of retail products (control) or SFA-reduced, MUFA-enriched profile (modified), for two 12-week periods, separated by an 8-week washout period. A flexible food-exchange model was used to implement each isoenergetic high-fat, high-dairy diet (38% of total energy intake (%TE) total fat): control (dietary target: 19%TE SFA; 11%TE MUFA) and modified (16%TE SFA; 14%TE MUFA). RESULTS: Following the modified diet, there was a smaller increase in SFA (17.2%TE vs. 19.1%TE; p < 0.001) and greater increase in MUFA intake (15.4%TE vs. 11.8%TE; p < 0.0001) when compared with the control. PL-FA analysis revealed lower total SFAs (p = 0.006), higher total cis-MUFAs and trans-MUFAs (both p < 0.0001) following the modified diet. CONCLUSION: The food-exchange model was successfully used to achieve RESET dietary targets by partial replacement of SFAs with MUFAs in dairy products, a finding reflected in the PL-FA profile and indicative of objective dietary compliance. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02089035 , date 05-01-2014.

Consumer acceptance of dairy products with a saturated fatty acid-reduced, monounsaturated fatty acid-enriched content.

Agriculture-based reformulation initiatives, including oleic acid-rich lipid supplementation of the dairy cow diet, provide a novel means for reducing intake of saturated fatty acids (SFA) at a population level. In a blinded manner, this study evaluated the consumer acceptance of SFA-reduced, monounsaturated fatty acid-enriched (modified) milk, Cheddar cheese, and butter when compared with control and commercially available comparative samples. The effect of providing nutritional information about the modified cheese was also evaluated. Consumers (n = 115) rated samples for overall liking (appearance, flavor, and texture) using 9-point hedonic scales. Although no significant differences were found between the milk samples, the modified cheese was liked significantly less than a regular-fat commercial alternative for overall liking and liking of specific modalities and had a lower liking of texture score compared with the control cheese. The provision of health information significantly increased the overall liking of the modified cheese compared with tasting the same sample in a blinded manner. Significant differences were evident between the butter samples for overall liking and modalities of liking; all of the samples were significantly more liked than the commercial butter and sunflower oil spread. In conclusion, this study illustrated that consumer acceptance of SFA-reduced, monounsaturated fatty acid-enriched dairy products was dependent on product type. Future research should consider how optimization of the textural properties of fatty acid-modified (and fat-reduced) cheese might enhance consumer acceptance of this product.

Near normal HbA1c with stable glucose homeostasis: the ultimate target/aim of diabetes therapy.

Achieving near normal glucose homeostasis implies that all components of dysglycemia that are present in diabetes states be eliminated. Reducing ambient/overall hyperglycemia is a pre-requisite to eliminate the risk of development and progression of diabetes complications. More controversially however, are the relative and related contributions of postprandial glucose excursions, glucose variability, hypoglycemia and the dawn phenomenon across the spectrum of dysglycemia. For instance, it is likely that the dawn phenomenon contributes to ambient hyperglycemia and that postprandial glucose excursions are at the cross road of ambient hyperglycemia and glucose variability with glucose fluctuations as causative risk factors for hypoglycemia. Proof-of-concept trials such as the ongoing FLAT-SUGAR study are necessary for gaining further insight into the possible harmful effects of some of these features such as excessive glycemic variability and glucose excursions, still considered to be of minor relevance by several diabetologists. Whether their role will be more thoroughly proven through further intervention trials with "hard" endpoints, remains to be seen. In the meantime more consideration should be given to medications aimed at concomitantly reducing ambient/overall hyperglycemia and those additional abnormal glycemic features of dysglycemia.