Social connections and social identity as a basis for learning and support: Experiences of medical students with minoritised and non-minoritised ethnic identities.

BACKGROUND: Social connections between medical students provide a key basis for learning and support. These connections, and associated social identity, may be patterned by ethnicity, and students often perform similarly academically to those they connect with. The mechanisms that underpin the formation of these connections and the role that they play are not fully understood. This study explored how medical students connect with each other, and the potential impact of this on their academic attainment and well-being, with a focus on students with minoritised ethnic identities. METHODS: A mixed methods study combining (1) a survey to establish the number and strength of connections formed by Years 1 and 2 medical students with both minoritised and non-minoritised ethnicities and (2) semi-structured interviews to understand how connections were formed, whether this was shaped by ethnicity and the role of connections in supporting students with their learning and well-being. RESULTS: One hundred fifty-one students (15.5% response rate) completed the survey. Students connected regularly with three to four peers with the goal of supporting learning and 71.9% of students reported a sense of social identification with this group. There was no statistical difference between ethnically minoritised and White students on either of these measures (t = 0.1, p = 0.92, χ2 = 2.9, p = 0.56). Interviews with 19 students found that social connections were shaped by perceptions of their self-identity and the need to find 'equilibrium' by forming relationships with compatible others. The education environment, including its ethnic diversity, impacted on the opportunities to make connections. Students who were ethnically minoritised reported encountering challenges, especially in the clinical environment, and described the burden of these for them. DISCUSSION: Curriculum designers should consider the time and space that is afforded to student interaction during course development, as finding compatible others with whom students can socially connect is important to balancing well-being with academic performance.

Ottawa 2020 consensus statement for programmatic assessment - 1. Agreement on the principles.

INTRODUCTION: In the Ottawa 2018 Consensus framework for good assessment, a set of criteria was presented for systems of assessment. Currently, programmatic assessment is being established in an increasing number of programmes. In this Ottawa 2020 consensus statement for programmatic assessment insights from practice and research are used to define the principles of programmatic assessment. METHODS: For fifteen programmes in health professions education affiliated with members of an expert group (n = 20), an inventory was completed for the perceived components, rationale, and importance of a programmatic assessment design. Input from attendees of a programmatic assessment workshop and symposium at the 2020 Ottawa conference was included. The outcome is discussed in concurrence with current theory and research. RESULTS AND DISCUSSION: Twelve principles are presented that are considered as important and recognisable facets of programmatic assessment. Overall these principles were used in the curriculum and assessment design, albeit with a range of approaches and rigor, suggesting that programmatic assessment is an achievable education and assessment model, embedded both in practice and research. Knowledge on and sharing how programmatic assessment is being operationalized may help support educators charting their own implementation journey of programmatic assessment in their respective programmes.

Ottawa 2020 consensus statements for programmatic assessment - 2. Implementation and practice.

INTRODUCTION: Programmatic assessment is a longitudinal, developmental approach that fosters and harnesses the learning function of assessment. Yet the implementation, a critical step to translate theory into practice, can be challenging. As part of the Ottawa 2020 consensus statement on programmatic assessment, we sought to provide descriptions of the implementation of the 12 principles of programmatic assessment and to gain insight into enablers and barriers across different institutions and contexts. METHODS: After the 2020 Ottawa conference, we surveyed 15 Health Profession Education programmes from six different countries about the implementation of the 12 principles of programmatic assessment. Survey responses were analysed using a deductive thematic analysis. RESULTS AND DISCUSSION: A wide range of implementations were reported although the principles remained, for the most part, faithful to the original enunciation and rationale. Enablers included strong leadership support, ongoing faculty development, providing students with clear expectations about assessment, simultaneous curriculum renewal and organisational commitment to change. Most barriers were related to the need for a paradigm shift in the culture of assessment. Descriptions of implementations in relation to the theoretical principles, across multiple educational contexts, coupled with explanations of enablers and barriers, provided new insights and a clearer understanding of the strategic and operational considerations in the implementation of programmatic assessment. Future research is needed to further explore how contextual and cultural factors affect implementation.

Common variation in the beta-carotene 15,15'-monooxygenase 1 gene affects circulating levels of carotenoids: a genome-wide association study.

Low plasma levels of carotenoids and tocopherols are associated with increased risk of chronic disease and disability. Because dietary intake of these lipid-soluble antioxidant vitamins is only poorly correlated with plasma levels, we hypothesized that circulating carotenoids (vitamin A-related compounds) and tocopherols (vitamin E-related compounds) are affected by common genetic variation. By conducting a genome-wide association study in a sample of Italians (n = 1190), we identified novel common variants associated with circulating carotenoid levels and known lipid variants associated with alpha-tocopherol levels. Effects were replicated in the Women's Health and Aging Study (n = 615) and in the alpha-Tocopherol, beta-Carotene Cancer Prevention (ATBC) study (n = 2136). In meta-analyses including all three studies, the G allele at rs6564851, near the beta-carotene 15,15'-monooxygenase 1 (BCMO1) gene, was associated with higher beta-carotene (p = 1.6 x 10(-24)) and alpha-carotene (p = 0.0001) levels and lower lycopene (0.003), zeaxanthin (p = 1.3 x 10(-5)), and lutein (p = 7.3 x 10(-15)) levels, with effect sizes ranging from 0.10-0.28 SDs per allele. Interestingly, this genetic variant had no significant effect on plasma retinol (p > 0.05). The SNP rs12272004, in linkage disequilibrium with the S19W variant in the APOA5 gene, was associated with alpha-tocopherol (meta-analysis p = 7.8 x 10(-10)) levels, and this association was substantially weaker when we adjusted for triglyceride levels (p = 0.002). Our findings might shed light on the controversial relationship between lipid-soluble anti-oxidant nutrients and human health.

Common health predictors of early retirement: findings from the English Longitudinal Study of Ageing.

BACKGROUND: facing the costs of population ageing, many governments aim to keep older people in employment for longer. Summary health measures predict early retirement, but more specific symptoms and conditions need to be identified to guide efforts to delay retirement. OBJECTIVE: to identify common symptoms and conditions that predict early work exit, at the population level. DESIGN: cohort study of community dwelling respondents to the English Longitudinal Study of Ageing. SETTING AND PARTICIPANTS: a total of 1,693 workers aged 50 and over at baseline who were younger than the contemporaneous retirement age (60 for women, 65 for men) at 4-year follow-up. RESULTS: a total of 308 (18.2%) individuals moved out of employment during the follow-up period. Advancing age, female gender, partner retirement, greater pension wealth, high alcohol consumption and fair or poor self-rated health were all associated with work exit. Accounting for these factors, reported difficulty walking a quarter mile was predictive of early work exit (odds ratio (OR) = 2.23; 95% confidence interval (CI) 1.42-3.52), especially where symptoms included lower limb pain and/or shortness of breath. Symptomatic depression (measured by Centre for Epidemiological Studies Depression scale) was also predictive of early work exit (OR = 1.52, CI 1.07, 2.18). About 50.8% of early retirees reported one or more of these specific health symptoms (depression, general pain, mobility limitations and leg pain when walking). CONCLUSION: older workers who report depressive symptoms or impaired physical mobility, especially with lower limb pain and shortness of breath, are at increased risk of early transition out of work. Health interventions targeting these conditions may enable older workers to remain in the labour force.

A genome-wide association study identifies protein quantitative trait loci (pQTLs).

There is considerable evidence that human genetic variation influences gene expression. Genome-wide studies have revealed that mRNA levels are associated with genetic variation in or close to the gene coding for those mRNA transcripts - cis effects, and elsewhere in the genome - trans effects. The role of genetic variation in determining protein levels has not been systematically assessed. Using a genome-wide association approach we show that common genetic variation influences levels of clinically relevant proteins in human serum and plasma. We evaluated the role of 496,032 polymorphisms on levels of 42 proteins measured in 1200 fasting individuals from the population based InCHIANTI study. Proteins included insulin, several interleukins, adipokines, chemokines, and liver function markers that are implicated in many common diseases including metabolic, inflammatory, and infectious conditions. We identified eight Cis effects, including variants in or near the IL6R (p = 1.8x10(-57)), CCL4L1 (p = 3.9x10(-21)), IL18 (p = 6.8x10(-13)), LPA (p = 4.4x10(-10)), GGT1 (p = 1.5x10(-7)), SHBG (p = 3.1x10(-7)), CRP (p = 6.4x10(-6)) and IL1RN (p = 7.3x10(-6)) genes, all associated with their respective protein products with effect sizes ranging from 0.19 to 0.69 standard deviations per allele. Mechanisms implicated include altered rates of cleavage of bound to unbound soluble receptor (IL6R), altered secretion rates of different sized proteins (LPA), variation in gene copy number (CCL4L1) and altered transcription (GGT1). We identified one novel trans effect that was an association between ABO blood group and tumour necrosis factor alpha (TNF-alpha) levels (p = 6.8x10(-40)), but this finding was not present when TNF-alpha was measured using a different assay , or in a second study, suggesting an assay-specific association. Our results show that protein levels share some of the features of the genetics of gene expression. These include the presence of strong genetic effects in cis locations. The identification of protein quantitative trait loci (pQTLs) may be a powerful complementary method of improving our understanding of disease pathways.

Smoking cessation and transition into retirement: analyses from the English Longitudinal Study of Ageing.

BACKGROUND: Transitions such as retirement may represent points at which changes in health behaviour occur. OBJECTIVE: To assess whether transition into retirement is associated with increased rates of smoking cessation. DESIGN: Population-based prospective cohort study in England. SETTING AND PARTICIPANTS: One thousand seven hundred and twelve smokers aged 50 years and over, followed up for 5 to 6 years. MEASUREMENTS: Work status (working/retired) and smoking status (non-smoker/smoker) at baseline and follow-up. RESULTS: At baseline, 381 (22.2%) of our respondents had retired, 444 (25.9%) were working and remained in work at follow-up, and 167 (9.8%) transitioned from work to retirement. Seven hundred and twenty (42.1%) had some other status (e.g. unpaid work/unemployment). A total of 42.5% (95% CI 34.9-50.1) of those who retired quit smoking; for those remaining in employment this figure was 29.3% (95% CI 25.0-33.6), and for those already retired it was 30.2% (95% CI 25.5-34.9). In adjusted regression analyses, those aged 55-70 who retired were more than twice as likely (fully adjusted odds ratio 2.50 (95% CI 1.35-4.62)) to quit smoking as those who continued to work. Results were robust when those who retired for reasons of ill-health were excluded. CONCLUSIONS: Our results suggest individuals who undergo the transition into retirement are more likely to quit smoking than those who do not. Interventions should be developed to specifically target those who are retiring, or soon to retire, and those who are due to retire should be helped to incorporate smoking cessation into their retirement planning.

Baby boomers nearing retirement: the healthiest generation?

BACKGROUND: The baby-boom generation is entering retirement. Having experienced unprecedented prosperity and improved medical technology, they should be the healthiest generation ever. METHODS: We compared prevalence of disease and risk factors at ages 50-61 years in baby boomers with the preceding generation and attributed differences to period or cohort effects. Data were from the Health Survey for England (HSE) from 1994 to 2007 (n = 48,563). Logistic regression models compared health status between birth cohorts. Age-period-cohort models identified cohort and period effects separately. RESULTS: Compared to the wartime generation, the baby-boomer group was heavier (3.02 kg; 95% confidence interval [CI], 2.42-3.63; p < 0.001) and reported more diagnoses of hypertension (odds ratio [OR] = 1.48; CI, 1.27-1.72; p < 0.001), diabetes (OR = 1.71; CI, 1.37-2.12; p < 0.001), and mental illness (OR = 1.90; CI, 1.54-2.53; p < 0.001). Baby boomers reported fewer heart attacks (OR = 0.61; CI, 0.47-0.79; p < 0.001) and had lower measured blood pressures (systolic -9.51 mmHg; CI, -8.7 to -10.31; p <0.001; diastolic, -2.5 mmHg; CI, -1.99 to -3.01; p < 0.001). Higher diagnosed mental disorder prevalence was attributable to a cohort effect (prevalence for 1935-1939 cohort, 2.5%, vs.1950-1954 cohort, 4.7%), whereas changes in diagnoses of diabetes and hypertension and measured body mass index were primarily period effects. CONCLUSION: English baby boomers are moving toward retirement with improved cardiovascular health. However, the baby-boomer cohort has a higher prevalence of mental illness diagnoses and shows no improvement in self-rated health compared to the wartime birth cohort. There remains substantial scope to reduce health risks and future disability.

Association of urinary bisphenol a concentration with heart disease: evidence from NHANES 2003/06.

BACKGROUND: Bisphenol A (BPA) is a high production volume chemical widely used in food and drinks packaging. Associations have previously been reported between urinary BPA concentrations and heart disease, diabetes and liver enzymes in adult participants of the National Health and Nutrition Examination Survey (NHANES) 2003/04. We aimed to estimate associations between urinary BPA concentrations and health measures in NHANES 2005/06 and in data pooled across collection years. METHODOLOGY AND FINDINGS: A cross-sectional analysis of NHANES: subjects were n = 1455 (2003/04) and n = 1493 (2005/06) adults aged 18-74 years, representative of the general adult population of the United States. Regression models were adjusted for age, sex, race/ethnicity, education, income, smoking, BMI, waist circumference, and urinary creatinine concentration. Main outcomes were reported diagnoses of heart attack, coronary heart disease, angina and diabetes and serum liver enzyme levels. Urinary BPA concentrations in 2005/06 (geometric mean 1.79 ng/ml, 95% CI: 1.64 to 1.96) were lower than in 2003/04 (2.49 ng/ml, CI: 2.20 to 2.83, difference p-value = 0.00002). Higher BPA concentrations were associated with coronary heart disease in 2005/06 (OR per z-score increase in BPA = 1.33, 95%CI: 1.01 to 1.75, p = 0.043) and in pooled data (OR = 1.42, CI: 1.17 to 1.72, p = 0.001). Associations with diabetes did not reach significance in 2005/06, but pooled estimates remained significant (OR = 1.24, CI: 1.10 to 1.40, p = 0.001). There was no overall association with gamma glutamyl transferase concentrations, but pooled associations with alkaline phosphatase and lactate dehydrogenase remained significant. CONCLUSIONS: Higher BPA exposure, reflected in higher urinary concentrations of BPA, is consistently associated with reported heart disease in the general adult population of the USA. Studies to clarify the mechanisms of these associations are urgently needed.

Association between serum perfluorooctanoic acid (PFOA) and thyroid disease in the U.S. National Health and Nutrition Examination Survey.

BACKGROUND: Perfluorooctanoic acid (PFOA, also known as C8) and perfluorooctane sulfonate (PFOS) are stable compounds with many industrial and consumer uses. Their persistence in the environment plus toxicity in animal models has raised concern over low-level chronic exposure effects on human health. OBJECTIVES: We estimated associations between serum PFOA and PFOS concentrations and thyroid disease prevalence in representative samples of the U.S. general population. METHODS: Analyses of PFOA/PFOS versus disease status in the National Health and Nutrition Examination Survey (NHANES) for 1999-2000, 2003-2004, and 2005-2006 included 3,974 adults with measured concentrations for perfluorinated chemicals. Regression models were adjusted for age, sex, race/ethnicity, education, smoking status, body mass index, and alcohol intake. RESULTS: The NHANES-weighted prevalence of reporting any thyroid disease was 16.18% (n = 292) in women and 3.06% (n = 69) in men; prevalence of current thyroid disease with related medication was 9.89% (n = 163) in women and 1.88% (n = 46) in men. In fully adjusted logistic models, women with PFOA >or= 5.7 ng/mL [fourth (highest) population quartile] were more likely to report current treated thyroid disease [odds ratio (OR) = 2.24; 95% confidence interval (CI), 1.38-3.65; p = 0.002] compared with PFOA or= 36.8 ng/mL (quartile 4) versus

Polymorphisms in LMNA and near a SERPINA gene cluster are associated with cognitive function in older people.

A recent genome-wide association (GWA) study of late-onset Alzheimer's disease (LOAD) identified 15 novel single nucleotide polymorphisms (SNPs) independent of ApoE. We hypothesised that variants associated with LOAD are also associated with poor cognitive function in elderly populations. We measured additive associations between the five most strongly associated LOAD SNPs and grouped Mini Mental State Examination (MMSE) scores. Variants were genotyped in respondents (mean age 79 years) from the Oxford Healthy Ageing project (OHAP) and other sites of the MRC Cognitive Function and Ageing Study (MRC-CFAS). In adjusted ordinal logistic models, two variants were associated with poorer cognitive function: rs11622883 (OR=1.14, 95% CI: 1.01-1.28, p=0.040) and rs505058 (OR=1.29, 95% CI: 1.02-1.64, p=0.036). These SNPs are close to a SERPINA gene cluster and within LMNA, respectively. The mechanisms underlying the associations with cognitive impairment and LOAD require further elucidation, but both genes are interesting candidates for involvement in age-related cognitive impairment.

The paraoxonase (PON1) Q192R polymorphism is not associated with poor health status or depression in the ELSA or INCHIANTI studies.

BACKGROUND: The human paraoxonase (PON1) protein detoxifies certain organophosphates, and the PON1 Q192R polymorphism (rs662) affects PON1 activity. Groups with higher dose exposure to organophosphate sheep dips or first Gulf War nerve toxins reported poorer health if they had 192R, and these associations have been used to exemplify Mendelian randomization analysis. However, a reported association of 192R with depression in a population-based study of older women recently cast doubt on the specificity of the higher dose findings. We aimed to examine associations between the PON1 Q192R polymorphism and self-reported poor health and depression in two independent population-based studies. METHODS: We used logistic regression models to examine the associations in men and women aged 60-79 years from the English Longitudinal Study of Ageing (ELSA, n = 3158) and InCHIANTI (n = 761) population studies. Outcomes included the Center for Epidemiologic Studies Depression (CES-D) scale, self-rated general health status and (in ELSA only) diagnoses of depression. RESULTS: The PON1 Q192R polymorphism was not associated with self-reported poor health {meta-analysis: odds ratio (OR) = 1.01 [confidence interval (CI) 0.91-1.13], P = 0.80} or depressive symptoms in either study or in meta-analyses [CES-D: OR = 1.01 (CI 0.87-1.17), P = 0.90]. There was also no association with histories of diagnosed depression in ELSA [OR = 1.03 (CI 0.82-1.30), P = 0.80]. CONCLUSIONS: We found no evidence of an association between the PON1 Q192R polymorphism and poor general or mental health in two independent population-based studies. Neither the claimed Q192R association with depression in the general population nor its theoretical implications were supported.

The 9p21 myocardial infarction risk allele increases risk of peripheral artery disease in older people.

BACKGROUND: A common variant at chromosome 9p21 (tagged by the rs1333049 or rs10757278 single-nucleotide polymorphism) is strongly associated with myocardial infarction and major arterial aneurysms. An association with peripheral arterial disease (PAD) was also reported in a sample younger than 75 years, but this disappeared on removal of respondents with a myocardial infarction history, resulting in an odds ratio of 1.09 for PAD (P=0.075). We aimed at estimating the association of this variant with an Ankle-Brachial Index (ABI) and PAD in 3 older populations. METHODS AND RESULTS: We used data from the InCHIANTI, Baltimore Longitudinal Study of Aging, and Health, Aging, and Body Composition studies. In 2630 white individuals (mean age, 76.4 years), the C allele at rs1333049 was associated with lower mean ABI measures and with an increased prevalence of PAD. These associations remained after removal of baseline and incident myocardial infarction cases over a 6-year follow-up for both ABI (-0.017 ABI units; 95% CI, -0.03 to -0.01; P = 1.3 x 10(-4)) and PAD (per allele odds ratio, 1.29; 95% CI, 1.06 to 1.56; P = 0.012). These associations also remained after adjustment for known atherosclerosis risk factors, including diabetes mellitus, smoking, hypercholesterolemia, and hypertension. CONCLUSIONS: The C allele at rs1333049 is associated with an increased prevalence of PAD and lower mean ABI. This association was independent of the presence of diagnosed myocardial infarction and atherosclerotic risk factors in 3 older white populations.