The courage to advocate: How two professions approach public advocacy work.

BACKGROUND: While health advocacy is an established physician role, most of the educational attention to advocacy has been at the individual patient level. Public advocacy-efforts to effect change at the level of communities, populations or society-remains a poorly defined concept whose educational foundation is underdeveloped. To enrich our understanding of public advocacy, we explored how professionals in two disciplines-medicine and law-have approached its tasks and experienced its challenges. METHODS: Using constructivist grounded theory, we interviewed 18 professionals (nine physicians, eight lawyers and one qualified in both disciplines) who engage in public advocacy. We used constant comparison throughout an iterative process of data collection and analysis to develop an understanding of what it means to be a professional in the public domain. RESULTS: Public advocacy work occurs at the intersection of personal and professional identities. Lawyers perceived public advocacy as an embedded element of their professional identity, while physicians more often viewed it as outside their core professional scope. Nonetheless, professional identity influenced how both groups conducted their work. Physicians were more likely to draw on professional attitudes (e.g. their orientation towards evidence and their trusted social position), while lawyers were more likely to draw on professional skills (e.g. building an argument and litigating test cases). The work requires courage and often demands that individuals tolerate personal and professional risk. CONCLUSION: While medicine has enshrined advocacy in its competency frameworks, it is the legal profession whose practitioners more fully embrace advocacy as intrinsic to professional identity, suggesting that roles are difficult to engineer or impose. Collaboration across public-facing professions like medicine and law creates opportunities to reimagine public advocacy, to identify the skills required to do it well and to refresh educational strategies.

Trainee selection of tasks in postgraduate medical education: Is there a role for 'cherry-picking' to optimise learning?

PURPOSE: Learning is optimised when postgraduate trainees engage in clinical tasks in their zone of proximal development (ZPD). However, workplace learning environments impose additional non-learning goals and additional tasks that may lead to trainees engaging in tasks that do not fall within their ZPD. We do not fully understand how trainees select clinical tasks in the workplace learning environment. If we knew the goals and factors they consider when selecting a task, we could better equip trainees with strategies to select tasks that maximise learning. We explored how postgraduate trainees select clinical tasks using echocardiography interpretation as a model. METHODS: Canadian General Cardiology residents and Echocardiography fellows were invited to participate in semi-structured interviews. Aligning with a theory-informed study, two independent researchers used a deductive, directed content analysis approach to identify codes and themes. RESULTS: Eleven trainees from seven Canadian universities participated (PGY4 = 4, PGY5 = 3, PGY6 = 1 and echocardiography fellows = 3). Goals included learning content, fulfilling assessment criteria and contributing to clinical demands. Trainees switched between goals throughout the day, as it was too effortful for them to engage in tasks within their ZPD at all times. When trainees had sufficient mental effort available, they selected higher complexity tasks that could advance learning content. When available mental effort was low, trainees selected less complex tasks that fulfilled numerically based assessment goals or contributed to clinical demands. Trainees predominantly used perceived complexity of the echocardiogram as a factor to select tasks to achieve their desired goals. CONCLUSION: Postgraduate trainees select tasks within their ZPD that enable them to maximise learning when they perceive to have sufficient mental effort available and workplace affordances are adequate. These findings can inform individual and systemic strategies to maximise learning when selecting tasks.

Interventions for the detection, monitoring, and management of chronic non-communicable diseases in the prison population: an international systematic review.

BACKGROUND: High rates of health inequalities and chronic non-communicable diseases exist amongst the prison population. This places people in and/or released from prison at heightened risk of multimorbidity, premature mortality, and reduced quality of life. Ensuring appropriate healthcare for people in prison to improve their health outcomes is an important aspect of social justice. This review examines the global literature on healthcare interventions to detect, monitor and manage chronic non-communicable diseases amongst the prison population and people recently released from prison. METHODS: Systematic searches of EMBASE, MEDLINE, CINAHL, Web of Science, Scopus, and the Cochrane Library were conducted and supplemented by citation searching and review of the grey literature. The literature searches attempted to identify all articles describing any healthcare intervention for adults in prison, or released from prison in the past 1 year, to detect, monitor, or manage any chronic non-communicable illness. 19,061 articles were identified, of which 1058 articles were screened by abstract and 203 articles were reviewed by full text. RESULTS: Sixty-five studies were included in the review, involving 18,311 participants from multiple countries. Most studies were quasi-experimental and/or low to moderate in quality. Numerous healthcare interventions were described in the literature including chronic disease screening, telemedicine, health education, integrated care systems, implementing specialist equipment and staff roles to manage chronic diseases in prisons, and providing enhanced primary care contact and/or support from community health workers for people recently released from prison. These interventions were associated with improvement in various measures of clinical and cost effectiveness, although comparison between different care models was not possible due to high levels of clinical heterogeneity. CONCLUSIONS: It is currently unclear which interventions are most effective at monitoring and managing chronic non-communicable diseases in prison. More research is needed to determine the most effective interventions for improving chronic disease management in prisons and how these should be implemented to ensure optimal success. Future research should examine interventions for addressing multimorbidity within prisons, since most studies tested interventions for a singular non-communicable disease.

Connected for life: How social connectedness can help prevent suicide in American Indian and Alaska Native communities.

Enhancing social support and connectedness can reduce suicide risk, yet few studies have examined this effect in American Indian and Alaska Native (AI/AN) adults. We assessed suicidal ideation and behavior, thwarted belongingness, social support, enculturation, historical trauma, and traumatic life events in 709 AI/AN adults at high risk of suicide from five AI/AN communities. Suicidal ideation was associated with thwarted belongingness and protected against by social support and engaging in AI/AN ceremonies. Among those who made lifetime suicide attempts, traumatic life events, symptoms of depression/anxiety due to historical trauma, and thwarted belongingness were linked to more attempts. More engagement in cultural practices was associated with fewer suicide attempts. Higher levels of social support were associated with more suicide attempts, an observation potentially attributable to the cross-sectional nature of the study. Interventions should focus on protective factors and context-specific interventions emphasizing community history, values, and strengths.

'For the most part it works': Exploring how authors navigate peer review feedback.

BACKGROUND: Peer review aims to provide meaningful feedback to research authors so that they may improve their work, and yet it constitutes a particularly challenging context for the exchange of feedback. We explore how research authors navigate the process of interpreting and responding to peer review feedback, in order to elaborate how feedback functions when some of the conditions thought to be necessary for it to be effective are not met. METHODS: Using constructivist grounded theory methodology, we interviewed 17 recently published health professions education researchers about their experiences with the peer review process. Data collection and analysis were concurrent and iterative. We used constant comparison to identify themes and to develop a conceptual model of how feedback functions in this setting. RESULTS: Although participants expressed faith in peer review, they acknowledged that the process was emotionally trying and raised concerns about its consistency and credibility. These potential threats were mitigated by factors including time, team support, experience and the exercise of autonomy. Additionally, the perceived engagement of reviewers and the cultural norms and expectations surrounding the process strengthened authors' willingness and capacity to respond productively. Our analysis suggests a model of feedback within which its perceived usefulness turns on the balance of threats and countermeasures. CONCLUSIONS: Feedback is a balancing act. Although threats to the productive uptake of peer review feedback abound, these threats may be neutralised by a range of countermeasures. Among these, opportunities for autonomy and cultural normalisation of both the professional responsibility to engage with feedback and the challenge of doing so may be especially influential and may have implications beyond the peer review setting.

Convergent evolution of conserved mitochondrial pathways underlies repeated adaptation to extreme environments.

Extreme environments test the limits of life; yet, some organisms thrive in harsh conditions. Extremophile lineages inspire questions about how organisms can tolerate physiochemical stressors and whether the repeated colonization of extreme environments is facilitated by predictable and repeatable evolutionary innovations. We identified the mechanistic basis underlying convergent evolution of tolerance to hydrogen sulfide (H2S)-a toxicant that impairs mitochondrial function-across evolutionarily independent lineages of a fish (Poecilia mexicana, Poeciliidae) from H2S-rich springs. Using comparative biochemical and physiological analyses, we found that mitochondrial function is maintained in the presence of H2S in sulfide spring P. mexicana but not ancestral lineages from nonsulfidic habitats due to convergent adaptations in the primary toxicity target and a major detoxification enzyme. Genome-wide local ancestry analyses indicated that convergent evolution of increased H2S tolerance in different populations is likely caused by a combination of selection on standing genetic variation and de novo mutations. On a macroevolutionary scale, H2S tolerance in 10 independent lineages of sulfide spring fishes across multiple genera of Poeciliidae is correlated with the convergent modification and expression changes in genes associated with H2S toxicity and detoxification. Our results demonstrate that the modification of highly conserved physiological pathways associated with essential mitochondrial processes mediates tolerance to physiochemical stress. In addition, the same pathways, genes, and-in some instances-codons are implicated in H2S adaptation in lineages that span 40 million years of evolution.

Recovery from alcohol among urban Alaska Native and American Indian people.

Alaska Native and American Indian (ANAI) people experience dramatic alcohol-related health disparities compared to the general US population. Although the majority of ANAI people reside in urban settings (>70%), data are sparse on alcohol abstinence among urban ANAI people with alcohol use disorder (AUD). We conducted a qualitative study using a phenomenological approach to examine the experiences of 20 urban ANAI adults recovering from AUD. Participants' narratives had their own unique dimensions but shared a clear, interrelated trajectory of pre-alcohol recovery, a turning point, and ongoing alcohol recovery. All participants reported a combination of external and internal motivation to stop using alcohol.

Best Practices for Conducting Clinical Trials With Indigenous Children in the United States.

We provide guidance for conducting clinical trials with Indigenous children in the United States. We drew on extant literature and our experience to describe 3 best practices for the ethical and effective conduct of clinical trials with Indigenous children. Case examples of pediatric research conducted with American Indian, Alaska Native, and Native Hawaiian communities are provided to illustrate these practices. Ethical and effective clinical trials with Indigenous children require early and sustained community engagement, building capacity for Indigenous research, and supporting community oversight and ownership of research. Effective engagement requires equity, trust, shared interests, and mutual benefit among partners over time. Capacity building should prioritize developing Indigenous researchers. Supporting community oversight and ownership of research means that investigators should plan for data-sharing agreements, return or destruction of data, and multiple regulatory approvals. Indigenous children must be included in clinical trials to reduce health disparities and improve health outcomes in these pediatric populations. Establishment of the Environmental Influences on Child Health Outcomes Institutional Development Award States Pediatric Clinical Trials Network (ECHO ISPCTN) in 2016 creates a unique and timely opportunity to increase Indigenous children's participation in state-of-the-art clinical trials.

A scoping review of approaches for measuring 'interdependent' collaborative performances.

INTRODUCTION: Individual assessment disregards the team aspect of clinical work. Team assessment collapses the individual into the group. Neither is sufficient for medical education, where measures need to attend to the individual while also accounting for interactions with others. Valid and reliable measures of interdependence are critical within medical education given the collaborative manner in which patient care is provided. Medical education currently lacks a consistent approach to measuring the performance between individuals working together as part of larger healthcare team. This review's objective was to identify existing approaches to measuring this interdependence. METHODS: Following Arksey & O'Malley's methodology, we conducted a scoping review in 2018 and updated it to 2020. A search strategy involving five databases located >12 000 citations. At least two reviewers independently screened titles and abstracts, screened full texts (n = 161) and performed data extraction on twenty-seven included articles. Interviews were also conducted with key informants to check if any literature was missing and assess that our interpretations made sense. RESULTS: Eighteen of the twenty-seven articles were empirical; nine conceptual with an empirical illustration. Eighteen were quantitative; nine used mixed methods. The articles spanned five disciplines and various application contexts, from online learning to sports performance. Only two of the included articles were from the field of Medical Education. The articles conceptualised interdependence of a group, using theoretical constructs such as collaboration synergy; of a network, using constructs such as degree centrality; and of a dyad, using constructs such as synchrony. Both descriptive (eg social network analysis) and inferential (eg multi-level modelling) approaches were described. CONCLUSION: Efforts to measure interdependence are scarce and scattered across disciplines. Multiple theoretical concepts and inconsistent terminology may be limiting programmatic work. This review motivates the need for further study of measurement techniques, particularly those combining multiple approaches, to capture interdependence in medical education.

Involving an individual with lived-experience in a co-analysis of qualitative data.

BACKGROUND: People with lived-experience of the phenomenon under investigation are seldom involved in the analysis of qualitative data, and there exists little guidance for those wishing to involve contributors at this stage of research. AIMS: To critically reflect on the process of involving people with lived-experience in a thematic analysis and to offer direction to other researchers. METHODS: An individual with lived-experience of residing in prison contributed to a co-analysis of qualitative data using thematic analysis. This paper reports on involvement at each stage of a thematic analysis and follows an established reporting checklist. RESULTS: A number of challenges and benefits were encountered in the process of co-analysing the data. These are discussed in relation to previous research and how to overcome the challenges encountered. CONCLUSIONS: The paper concludes by giving recommendations and guidance for future researchers wishing to involve people with lived-experience in qualitative data analysis.

Perceptions of alcohol misuse among Alaska native health care system stakeholders: A qualitative exploration.

Although alcohol misuse is a priority for health care systems serving Alaska Native and American Indian (ANAI) people, stakeholders' perceptions of misuse are understudied. Patients (n = 34), providers (n = 20), and leaders (n = 16) at a Tribally owned and operated health care system reported that alcohol misuse results from the interaction of factors, including colonization, structural factors, social alienation, social norms about overdrinking introduced at the time of colonizing contact, coping with emotions, and beliefs about ANAI people and alcohol. Childhood exposure to alcohol misuse leads some ANAI people to avoid alcohol altogether, shedding light on the high levels of abstinence observed in ANAI communities.

Retrospective eDNA assessment of potentially harmful algae in historical ship ballast tank and marine port sediments.

Microalgal bloom events can cause major ecosystem disturbances, devastate local marine economies, and endanger public health. Therefore, detecting and monitoring harmful microalgal taxa is essential to ensure effective risk management in waterways used for fisheries, aquaculture, recreational activity, and shipping. To fully understand the current status and future direction of algal bloom distributions, we need to know how populations and ecosystems have changed over time. This baseline knowledge is critical for predicting ecosystem responses to future anthropogenic change and will assist in the future management of coastal ecosystems. We explore a NGS metabarcoding approach to rapidly identify potentially harmful microalgal taxa in 63 historic and modern Australian marine port and ballast tank sediment samples. The results provide a record of past microalgal distribution and important baseline data that can be used to assess the efficacy of shipping guidelines, nutrient pollution mitigation, and predict the impact of climate change. Critically, eDNA surveys of archived sediments were able to detect harmful algal taxa that do not produce microscopic fossils, such as Chattonella, Heterosigma, Karlodinium, and Noctiluca. Our data suggest a potential increase in Australian harmful microalgal taxa over the past 30 years, and confirm ship ballast tanks as key dispersal vectors. These molecular mapping tools will assist in the creation of policies aimed at reducing the global increase and spread of harmful algal taxa and help prevent economic and public-health problems caused by harmful algal blooms.

The roles of plasticity and evolutionary change in shaping gene expression variation in natural populations of extremophile fish.

The notorious plasticity of gene expression responses and the complexity of environmental gradients complicate the identification of adaptive differences in gene regulation among populations. We combined transcriptome analyses in nature with common-garden and exposure experiments to establish cause-effect relationships between the presence of a physiochemical stressor and expression differences, as well as to test how evolutionary change and plasticity interact to shape gene expression variation in natural systems. We studied two evolutionarily independent population pairs of an extremophile fish (Poecilia mexicana) living in toxic, hydrogen sulphide (H2 S)-rich springs and adjacent nontoxic habitats and assessed genomewide expression patterns of wild-caught and common-garden-raised individuals exposed to different concentrations of H2 S. We found that 7.7% of genes that were differentially expressed between sulphidic and nonsulphidic ecotypes remained differentially expressed in the laboratory, indicating that sources of selection other than H2 S-or plastic responses to other environmental factors-contribute substantially to gene expression patterns observed in the wild. Concordantly differentially expressed genes in the wild and the laboratory were primarily associated with H2 S detoxification, sulphur processing and metabolic physiology. While shared, ancestral plasticity played a minor role in shaping gene expression variation observed in nature, we documented evidence for evolved population differences in the constitutive expression as well as the H2 S inducibility of candidate genes. Mechanisms underlying gene expression variation also varied substantially across the two ecotype pairs. These results provide a springboard for studying evolutionary modifications of gene regulatory mechanisms that underlie expression variation in locally adapted populations.

Language impairment and comorbid vulnerabilities among young people in custody.

BACKGROUND: While the prevalence of language and communication difficulties among young people in custody is well established, holistic understanding of the complexity and co-occurrence of additional vulnerabilities among this population are rare. METHODS: Ninety-three young people in a young offenders institution in England were assessed using the Comprehensive Health Assessment Tool, the Test of Word Knowledge, and a range of additional assessments of communication, cognition, and neurodevelopmental difficulties. RESULTS: Forty-seven percent of the young people demonstrated an aspect of language skills significantly below the population average, with more than one in four identified as having impairment. Only one in four of those with an impairment had previously accessed speech and language services. Language needs were associated with difficulties with social communication and nonverbal cognition, as well as higher risk of self-harm and substance misuse. CONCLUSIONS: Earlier identification of language difficulties requires routine assessment of young people at risk of engagement in offending behavior. Where language difficulties are identified, holistic assessments of needs should be undertaken. There is a need for speech and language therapy provision within youth justice services, as well as in other services accessed by young people at risk of engagement in offending.

Incorporating Transgenerational Epigenetic Inheritance into Ecological Risk Assessment Frameworks.

Chronic exposure to environmental contaminants can induce heritable "transgenerational" modifications to organisms, potentially affecting future ecosystem health and functionality. Incorporating transgenerational epigenetic heritability into risk assessment procedures has been previously suggested. However, a critical review of existing literature yielded numerous studies claiming transgenerational impacts, with little compelling evidence. Therefore, contaminant-induced epigenetic inheritance may be less common than is reported in the literature. We identified a need for multigeneration epigenetic studies that extend beyond what could be deemed "direct exposure" to F1 and F2 gametes and also include subsequent multiple nonexposed generations to adequately evaluate transgenerational recovery times. Also, increased experimental replication is required to account for the highly variable nature of epigenetic responses and apparent irreproducibility of current studies. Further, epigenetic end points need to be correlated with observable detrimental organism changes before a need for risk management can be properly determined. We suggest that epigenetic-based contaminant studies include concentrations lower than current "EC10-20" or "Lowest Observable Effect Concentrations" for the organism's most sensitive phenotypic end point, as higher concentrations are likely already regulated. Finally, we propose a regulatory framework and optimal experimental design that enables transgenerational epigenetic effects to be assessed and incorporated into conventional ecotoxicological testing.

Light as a key driver of freshwater biofouling surface roughness in an experimental hydrocanal pipe rig.

Biofouling in canals and pipelines used for hydroelectric power generation decreases the flow capacity of conduits. A pipeline rig was designed consisting of test sections of varying substrata (PVC, painted steel) and light levels (transparent, frosted, opaque). Stalk-forming diatoms were abundant in both the frosted and transparent PVC pipes but negligible in the painted steel and opaque PVC pipes. Fungi were slightly more abundant in the painted steel pipe but equally present in all the other pipes while bacterial diversity was similar in all pipes. Photosynthetically functional biofouling (mainly diatoms) was able to develop in near darkness. Different biological fouling compositions generated differing friction factors. The highest friction factor was observed in the transparent pipe (densest diatom fouling), the lowest peak friction for the opaque PVC pipe (lowest fouling biomass), and with the painted steel pipe (high fouling biomass, but composed of fungal and bacterial crusts) being intermediate between the opaque and frosted PVC pipes.

Using Amplicon Sequencing To Characterize and Monitor Bacterial Diversity in Drinking Water Distribution Systems.

Drinking water assessments use a variety of microbial, physical, and chemical indicators to evaluate water treatment efficiency and product water quality. However, these indicators do not allow the complex biological communities, which can adversely impact the performance of drinking water distribution systems (DWDSs), to be characterized. Entire bacterial communities can be studied quickly and inexpensively using targeted metagenomic amplicon sequencing. Here, amplicon sequencing of the 16S rRNA gene region was performed alongside traditional water quality measures to assess the health, quality, and efficiency of two distinct, full-scale DWDSs: (i) a linear DWDS supplied with unfiltered water subjected to basic disinfection before distribution and (ii) a complex, branching DWDS treated by a four-stage water treatment plant (WTP) prior to disinfection and distribution. In both DWDSs bacterial communities differed significantly after disinfection, demonstrating the effectiveness of both treatment regimes. However, bacterial repopulation occurred further along in the DWDSs, and some end-user samples were more similar to the source water than to the postdisinfection water. Three sample locations appeared to be nitrified, displaying elevated nitrate levels and decreased ammonia levels, and nitrifying bacterial species, such as Nitrospira, were detected. Burkholderiales were abundant in samples containing large amounts of monochloramine, indicating resistance to disinfection. Genera known to contain pathogenic and fecal-associated species were also identified in several locations. From this study, we conclude that metagenomic amplicon sequencing is an informative method to support current compliance-based methods and can be used to reveal bacterial community interactions with the chemical and physical properties of DWDSs.

Engaging stakeholders to develop a depression management decision support tool in a tribal health system.

PURPOSE: Southcentral Foundation, an Alaska Native tribal health organization, has had a depression screening program in primary care since 2001. Program monitoring identified gaps in antidepressant refills and patients' follow-up with behavioral health services. With extensive stakeholder participation, we developed an electronic, patient-centered, depression-management decision support tool (DM-DST). Quality of life and other outcomes are being assessed in a separate study; this case study reports on the multi-year stakeholder engagement process. METHODS: Data sources included interviews with patients and providers from integrated primary care teams, notes from research meetings, steering committee meetings, and consultations with tribal health system leadership, human subjects review committees, providers, and software designers, and a pilot test of the DS-DMT with patients and providers. We analyzed these sources using qualitative methods to assess the impact of stakeholder input on project processes and outcomes. RESULTS: One comprehensive, iPad-based tool was originally planned to facilitate discussions about depression management. Stakeholder input emphasized the role of family and cultural context of depression and management and improving the usability of the DM-DST. Stakeholder direction led us to split the DM-DST into: (1) a brief iPad-based tool to facilitate conversations between patients and providers during clinic visits; and (2) a complementary Web site that provides detailed information and allows patients flexibility and time to learn more about depression and share information and preferences with family and friends. CONCLUSIONS: Stakeholder input across the project substantially modified the DM-DST to ensure cultural applicability to patients and providers and facilitate integration into clinics.

Update on managing generalized anxiety disorder in older adults.

With the recent updates to the Diagnostic and Statistical Manual of Mental Disorders (5th edition; DSM-5), there are many questions on how to care for older adults with generalized anxiety disorder (GAD) and other psychiatric conditions. The current article reviews the new changes to the DSM-5 for diagnosis of GAD, discusses new anxiety assessment scales that are validated in older adults, evaluates pharmacological agents that have been studied in older adults for GAD treatment, and provides monitoring recommendations to help those who provide care to older adults experiencing GAD.

Placenta growth factor and vascular endothelial growth factor a have differential, cell-type specific patterns of expression in vascular cells.

OBJECTIVE: PLGF, a VEGF-A related protein, mediates collateral enlargement via monocytes but plays little role in capillary proliferation. In contrast, VEGF-A mediates both collateral enlargement and capillary proliferation. PLGF has been less thoroughly studied than VEGF-A, and questions remain regarding its regulation and function. Therefore, our goal was to characterize the expression of PLGF by vascular cells. We hypothesized that vascular SMC would express more PLGF than EC, since VEGF-A is primarily expressed by non-EC. METHODS: We compared PLGF and VEGF-A across eight EC and SMC lines, then knocked down PLGF and evaluated cell function. We also assessed the effect of hypoxia on PLGF expression and promoter activity. RESULTS: PLGF was most highly expressed in EC, whereas VEGF-A was most highly expressed in SMC. PLGF knockdown did not affect EC number, migration, or tube formation, but reduced monocyte migration toward EC. Monocyte migration was rescued by exogenous PLGF. Hypoxia increased PLGF protein without activating PLGF gene transcription. CONCLUSIONS: PLGF and VEGF-A have distinct patterns of expression in vascular cells. EC derived PLGF may function primarily in communication between EC and circulating cells. Hypoxia increases EC PLGF expression posttranscriptionally.