Spatial distribution of soil phosphorous fractions following 1-year farrowing sows in an outdoor hog-rearing farm in Eastern Canada.

Outdoor hog-rearing operations are of interest for both producers and consumers due to high product quality, animal welfare status, and low input and potential environmental risks. However, hog manure is rich in phosphorus (P), an environmentally sensitive nutrient, and distribution of different P fractions down the soil profile in these production systems is not well understood. The objective of this study was to determine the spatial variability of soil P in different soil depth intervals following 1-year outdoor farrowing sows in a 0.5-ha paddock in cold-temperate climate of Eastern Canada. Soil samples were collected with 0-15, 15-30, and > 30 cm depth intervals (up to 60 cm or the depth that sampling was possible) in grazing/rooting, feeding, wallow, and farrowing hut areas. Soil samples were analyzed for Olsen P (Pol), organic P (PO), and total P (PT). Areas with more frequent presence of hogs showed 45-80% greater Pol concentrations, and movement of soluble PO down the soil profile was higher in these areas compared with the grazing/rooting area. The PO formed 80% of PT throughout the paddock, and the spatial distribution of PO was similar to PT in all soil depth intervals but different from Pol. Results also showed that PO concentrations in the paddock decreased at > 30 cm depth except for the feeding area. Findings of this study reveal that farrowing sow cycle in an outdoor hog-rearing farm setting can result in hot spots of P, which enhance the risk of environmental pollution.

Teaching mindfulness in medical school: where are we now and where are we going?

OBJECTIVES: Mindfulness has the potential to prevent compassion fatigue and burnout in that the doctor who is self-aware is more likely to engage in self-care activities and to manage stress better. Moreover, well doctors are better equipped to foster wellness in their patients. Teaching mindfulness in medical school is gaining momentum; we examined the literature and related websites to determine the extent to which this work is carried out with medical students and residents. METHODS: A literature search revealed that 14 medical schools teach mindfulness to medical and dental students and residents. RESULTS: A wide range of formats are used in teaching mindfulness. These include simple lectures, 1-day workshops and 8-10-week programmes in mindfulness-based stress reduction. Two medical schools stand out because they have integrated mindfulness into their curricula: the University of Rochester School of Medicine and Dentistry (USA) and Monash Medical School (Australia). Studies show that students who follow these programmes experience decreased psychological distress and an improved quality of life. CONCLUSIONS: Although the evidence points to the usefulness of teaching mindful practices, various issues remain to be considered. When is it best to teach mindfulness in the trajectory of a doctor's career? What format works best, when and for whom? How can what is learned be maintained over time? Should mindfulness training be integrated into the medical school core curriculum?

Translating theory into clinical practice: a qualitative study of clinician perspectives implementing whole person care.

Whole Person Care (WPC) is an emerging framework that emphasises the clinician's role in empowering patient healing. However, reliably translating a framework's theory into practice is a recognised challenge for clinicians. Observational studies have revealed discrepancies between a clinician's stated values in theory and how these may be implemented in practice. The aim of this qualitative study is to bridge the gap between the theory of WPC and its practical implementation by clinicians. We interviewed a diverse group of 34 clinicians attending the 2017 International Whole Person Care Congress to explore (1) their conceptions of WPC in theory as well as (2) how they monitor their practice in real time. Data were analysed using Grounded Theory Methodology. Preliminary results were presented in the form of a workshop at the 2019 International Whole Person Care Congress to validate our findings with relevant stakeholders. The results revealed a vision of WPC that highlighted themes of the clinician's way of being, seeing the person beyond the disease, and the clinician-patient relationship. Our results demonstrate that clinicians use a range of strategies to monitor their practice in real time. Mindfulness and self-awareness were frequently cited as being crucial to this ability of self-regulating their practice. This study helps establish a unifying framework of WPC based on a diverse range of clinician-reported experiences. More importantly, it sheds light on the range of strategies employed by clinicians who monitor their practice in real time. These collected insights will be of interest to any clinician interested in translating their stated values into their clinical practice more reliably.

National pilot audit of intermediate care.

The National Service Framework for Older People resulted in the widespread introduction of intermediate care (IC) services. However, although these services have shared common aims, there has been considerable diversity in their staffing, organisation and delivery. Concerns have been raised regarding the clinical governance of IC with a paucity of data to evaluate the effectiveness, quality and safety of these services. This paper presents the results of a national pilot audit of IC services focusing particularly on clinical governance issues. The results confirm these concerns and provide support for a larger scale national audit of IC services to monitor and improve care quality.

Mindful medical practice: An innovative core course to prepare medical students for clerkship.

BACKGROUND: Medical students show a decline in empathy and ethical reasoning during medical school that is most marked during clerkship. We believe that part of the problem is that students do not have the skills and ways of being and relating necessary to deal effectively with the overwhelming clinical experience of clerkship. APPROACH: At McGill University in Montreal, starting in January 2015, we have taught a course on mindful medical practice that combines a clinical focus on the combination of mindfulness and congruent relating that is aimed at giving students the skills and ways of being to function effectively in clerkship. The course is taught to all medical students in groups of 20, weekly for 7 weeks, in the 6 months immediately prior to clerkship, a time when students are very open to learning the skills they need to take effective care of patients. EVALUATION: The course has been well accepted by students as evidenced by their engagement, their evaluations, and their comments in the essays that they write at the end of the course. In a follow-up session at the simulation centre one year later students remember clearly and enact what they were taught in the course. REFLECTION: The next steps will be to conduct a formal evaluation of the effect of our teaching that will involve a combination of qualitative methods to clarify the nature of the impact on our students and a quantitative assessment of the difference the course makes to students' experience and performance in clerkship.

When Are Adverse Outcome Pathways and Associated Assays "Fit for Purpose" for Regulatory Decision-Making and Management of Chemicals?

There have been increasing demands for chemical hazard and risk assessments in recent years. Chemical companies have expanded internal product stewardship initiatives, and jurisdictions have increased the regulatory requirements for the manufacture and sale of chemicals. There has also been a shift in chemical toxicity evaluations within the same time frame, with new methodologies being developed to improve chemical safety assessments for both human health and the environment. With increased needs for chemical assessments coupled with more diverse data streams from new technologies, regulators and others tasked with chemical management activities are faced with increasing workloads and more diverse types of data to consider. The Adverse Outcome Pathway (AOP) framework can be applied in different scenarios to integrate data and guide chemical assessment and management activities. In this paper, scenarios of how AOPs can be used to guide chemical management decisions during research and development, chemical registration, and subsequent regulatory activities such as prioritization and risk assessment are considered. Furthermore, specific criteria (e.g., the type and level of AOP complexity, confidence in the AOP, as well as external review and assay validation) are proposed to examine whether AOPs and associated tools are fit for purpose when applied in different contexts. Certain toxicity pathways are recommended as priority areas for AOP research and development, and the continued use of AOPs and defined approaches in regulatory activities are recommended. Furthermore, a call for increased outreach, education, and enhanced use of AOP databases is proposed to increase their utility in chemicals management. Integr Environ Assess Manag 2019;15:633-647. © 2019 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals, Inc. on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

Meeting report: risk assessment of tamiflu use under pandemic conditions.

On 3 October 2007, 40 participants with diverse expertise attended the workshop Tamiflu and the Environment: Implications of Use under Pandemic Conditions to assess the potential human health impact and environmental hazards associated with use of Tamiflu during an influenza pandemic. Based on the identification and risk-ranking of knowledge gaps, the consensus was that oseltamivir ethylester-phosphate (OE-P) and oseltamivir carboxylate (OC) were unlikely to pose an ecotoxicologic hazard to freshwater organisms. OC in river water might hasten the generation of OC-resistance in wildfowl, but this possibility seems less likely than the potential disruption that could be posed by OC and other pharmaceuticals to the operation of sewage treatment plants. The work-group members agreed on the following research priorities: a) available data on the ecotoxicology of OE-P and OC should be published; b) risk should be assessed for OC-contaminated river water generating OC-resistant viruses in wildfowl; c) sewage treatment plant functioning due to microbial inhibition by neuraminidase inhibitors and other antimicrobials used during a pandemic should be investigated; and d) realistic worst-case exposure scenarios should be developed. Additional modeling would be useful to identify localized areas within river catchments that might be prone to high pharmaceutical concentrations in sewage treatment plant effluent. Ongoing seasonal use of Tamiflu in Japan offers opportunities for researchers to assess how much OC enters and persists in the aquatic environment.

The wounding path to becoming healers: medical students' apprenticeship experiences.

BACKGROUND: This article responds to repeated calls in the literature to teach medical students how to treat the whole patient, not just the disease. It focuses on the educational experiences of medical students in a Canadian university in an effort to clarify the determinants of "caring" in medical education. METHOD: Nineteen (19) second-year medical students volunteered to keep weekly journal entries during the first five months of their medical apprenticeship. In journal entry analyses, the authors identified themes through a consensus-building coding process detailed in the work of Maykut and Morehouse (1994) and Huckin (2004). For this article, the authors focus on those themes most closely related to the students' caring experiences during their apprenticeship. RESULTS: The data highlight components of the medical system which made it difficult for students to engage in caring practices during their apprenticeship: the competing discourses of empathy and efficiency, the objectification of patients, the power of the medical hierarchy, and the institutionalized practice of wounding. CONCLUSION: The authors argue that returning medical care and students' experience to a balance of attention to curing and caring is a complex undertaking requiring a re-conceptualization of the process and goals of medical care.

Development and validation of a direct homologous quantitative sandwich ELISA for fathead minnow (Pimephales promelas) vitellogenin.

Vitellogenin (Vtg) is an established and sensitive endpoint for analysis of exposure to (anti-)oestrogens and their mimics in fish [Sumpter, J.P., 1995. Feminized responses in fish to environmental estrogens. Toxicol. Lett. 82, 737-742; Arukwe, A., Goksøyr, A., 2003. Eggshell and egg yolk proteins in fish: hepatic proteins for the next generation: oogenetic, population, and evolutionary implications of endocrine disruption. Comp. Hepatol. 2, 4. ]. In some instances, links have been drawn between high level induction of Vtg and adverse health effects in fish [Herman, R.L., Kincaide, H.L., 1988. Pathological effects of orally administered estradiol to rainbow trout. Aquaculture 72, 165-172; Schwaiger, J., Spieser, O.H., Bauer, C., Ferling, H., Mallow, U., Kalbfus, W., Negele, R.D., 2000. Chronic toxicity of nonylphenol and ethinyloestraiol: haematological and histopathological effects in juvenile common carp (Cyprinus carpio). Aquat. Toxicol. 51, 69-78]. The widespread use of Vtg as a biomarker has led to the development of a variety of assays to quantitatively measure Vtg concentrations in tissue samples from fish, and hence a need for a standardization of the performance criteria and validation of such assays [Goksøyr, A., Eidem, J.K., Kristiansen, S.I., Nilsen, B.M., 2003. On the need for a standardized set-up for validation studies of fish vitellogenin assays as an endpoint in endocrine disruptor testing and screening-a proposal. ]. One of the most popular test fish species for assessing chemical effects is the fathead minnow (Pimephales promelas), which is now used widely for studies into endocrine disruption [Panter, G.H., Hutchinson, T.H., Lange, R., Lye, C.M., Sumpter, J.P., Zerulla, M., Tyler, C.R., 2002. Utility of a juvenile fathead minnow screening assay for detecting (anti)estrogenic substances. Environ. Toxicol. Chem. 21, 319-326; Hutchinson, T.H., Yokota, H., Hagino, S., Ozato, K., 2003. Development of fish tests for endocrine disruptors. Pure Appl. Chem. 75, 2343-2353]. This paper describes the development and validation of a new, homologous enzyme-linked immunosorbent assay (ELISA) for quantification of Vtg in this fish species.

Professional identity formation in medical education for humanistic, resilient physicians: pedagogic strategies for bridging theory to practice.

Recent calls for an expanded perspective on medical education and training include focusing on complexities of professional identity formation (PIF). Medical educators are challenged to facilitate the active constructive, integrative developmental process of PIF within standardized and personalized and/or formal and informal curricular approaches. How can we best support the complex iterative PIF process for a humanistic, resilient health care professional? How can we effectively scaffold the necessary critical reflective learning and practice skill set for our learners to support the shaping of a professional identity?The authors present three pedagogic innovations contributing to the PIF process within undergraduate and graduate medical education (GME) at their institutions. These are (1) interactive reflective writing fostering reflective capacity, emotional awareness, and resiliency (as complexities within physician-patient interactions are explored) for personal and professional development; (2) synergistic teaching modules about mindful clinical practice and resilient responses to difficult interactions, to foster clinician resilience and enhanced well-being for effective professional functioning; and (3) strategies for effective use of a professional development e-portfolio and faculty development of reflective coaching skills in GME.These strategies as "bridges from theory to practice" embody and integrate key elements of promoting and enriching PIF, including guided reflection, the significant role of relationships (faculty and peers), mindfulness, adequate feedback, and creating collaborative learning environments. Ideally, such pedagogic innovations can make a significant contribution toward enhancing quality of care and caring with resilience for the being, relating, and doing of a humanistic health care professional.

Fragmented care and whole-person illness: Decision-making for people with chronic end-stage kidney disease.

PURPOSE: The study reported herein sought to better understand how patients with multi-morbid, chronic illness-who receive care in institutions designed for treatment of acute illness-experience and engage in health-related decisions. METHODS: In an urban Canadian teaching hospital, we studied the interactions of six hemodialysis patients and 11 of the health professionals involved in their care. For 1 year (September 2009 to September 2010), we conducted ethnographic observation and interviews of six cases each comprising one hemodialysis patient and various health professionals including medical specialists, nurses, a social worker, and a dietician. RESULTS: We found that the ubiquity and complexity of health-related decision-making in the lives of these patients suggests the need for a more holistic interpretation of health-related decision-making. DISCUSSION: We propose an interpretation of decision-making as an ongoing process of integrating illness and life; as frequently open-ended, cumulative, and relational; and as fundamentally shaped by the fragmented delivery of care for patients with multiple morbidities. CONCLUSION: Our understanding of decision-making suggests that people living with complex chronic illness need to receive care from institutions that recognize and address their multi-morbidity as a whole illness that is constantly being integrated into the life of a whole person.

Studies of prognostic factors in end-stage renal disease: an epidemiological and statistical critique.

We reviewed prognostic studies for patients treated with renal replacement therapy by using an electronic database and bibliographic review for 1990 to 1998. Using the inclusion criteria of English language, adult patients, primary article, minimum 50 patients, primary focus on prognostic factors, and mortality outcome, 104 articles were identified. The 104 articles were reviewed for eight epidemiological and seven statistical criteria that addressed the scientific validity and interpretability of results. The following percentages of the 104 articles satisfied each of the eight epidemiological criteria: (1) a priori hypothesis, 6%; (2) zero time specified, 49%; (3) prognostic factors collected before zero time, 69%; (4) inception cohort, 59%; (5) control for treatment, 74%; (6) operational criteria, 82%; (7) missing variables reported, 12%; and (8) loss to follow-up reported, 42%. Summary analysis showed that 76% of studies satisfied four or fewer of the eight identified criteria. In the 77 articles (74%) that used the Cox proportional hazards model, the following percentages of articles met each of the seven statistical criteria: (1) proportional hazards verified, 26%; (2) censoring explained, 57%; (3) multivariate analysis performed, 91%; (4) significance levels given, 99%; (5) age adjusted, 95%; (6) diabetes adjusted, 66%; and (7) cardiac adjusted, 44%. Summary analysis found that 47% of the 77 studies satisfied four or fewer of the seven identified criteria. Superficially, results appear to show that when the Cox proportional hazards model was used, statistical analysis was better than the epidemiological design. However, studies we examined had serious defects in both epidemiological design and statistical analysis. The consequent validity of results for the quantification of prognostic factors is questionable.

Monoclonal antibody enzyme-linked immunosorbent assay to quantify vitellogenin for studies on environmental estrogens in the rainbow trout (Oncorhynchus mykiss).

Vitellogenin (VTG) induction has proved to be a valuable biomarker for assessing exposure to environmental estrogens in fish. The widespread use of VTG in this regard has lead to the need for standardized assays to quantify VTG, and monoclonal antibodies have the potential to help accomplish this. A VTG enzyme-linked immunosorbent assay (ELISA) was developed using a monoclonal antibody prepared against Atlantic salmon (Salmo salar) VTG (MAb BN-5) and its ability to quantify VTG in the rainbow trout (Oncorhynchus mykiss) compared with a rainbow trout vitellogenin (rt-VTG) ELISA that employed homologous polyclonal antibodies (PAb). In routine protocols, the working range of the homologous rt-PAb VTG ELISA was between 9 ng/ml and 70 ng/ml (80- 20% relative maximum binding [B/Bo]) with a 50% B/Bo of 25+/-0.9 ng/ml and inter- and intraassay variations at 50% B/Bo of 7% (n = 7) and 8% (n = 15), respectively. The working range of the MAb BN-5 VTG ELISA was between 60 ng/ml and 850 ng/ml (80-20% B/Bo) with a 50% B/Bo of 227+/-22 ng/ml and inter- and intraassay variations at 50% B/Bo of 5% (n = 10) and 9% (n = 12), respectively. In the routine protocols, detection limits for measurement of plasma VTG in rainbow trout (at 80% B/Bo; and given the requirement to dilute plasma to a minimum of 1:10 for the assays) were 90 ng/ml for the polyclonal rt-VTG assay and approximately 600 ng/ml in the monoclonal antibody assay. In juvenile female rainbow trout exposed to a series of doses of estradiol-17beta (E2) and 4-tert nonylphenol (4-NP), there were no differences in the vitellogenic responses measured in the PAb and MAb BN-5 VTG ELISAs. The monoclonal MAb BN-5 VTG ELISA is likely to be of considerable value for studies on environmental estrogens in juvenile female rainbow trout in standardized tests.

The impact of oestrogenic and androgenic contamination on marine organisms in the United Kingdom--summary of the EDMAR programme. Endocrine Disruption in the Marine Environment.

This paper summarises results of the EDMAR programme which is investigating oestrogenic and androgenic endocrine disruption in UK coastal waters. Most of the data concern fish. Four species (flounder, viviparous blenny and two sand gobies) are experiencing feminisation in industrialised estuaries. In males this includes vitellogenin (VTG) synthesis, ovotestis induction and/or feminised sexual characteristics. Although reproductive success may be impaired in some cases, implications for fish populations are still unclear. Suspected causative contaminants include natural oestrogenic substances and synthetic oestrogen mimics. The majority of the oestrogenic activity is adsorbed to sediments, and routes of exposure may include benthic food chain transfer. Some natural androgenic substances are also being discharged to estuaries, but their activity appears low.

Pyrosequencing of Mytilus galloprovincialis cDNAs: tissue-specific expression patterns.

BACKGROUND: Mytilus species are important in marine ecology and in environmental quality assessment, yet their molecular biology is poorly understood. Molecular aspects of their reproduction, hybridisation between species, mitochondrial inheritance, skewed sex ratios of offspring and adaptation to climatic and pollution factors are priority areas. METHODOLOGY/PRINCIPAL FINDINGS: To start to address this situation, expressed genetic transcripts from M. galloprovincialis were pyrosequenced. Transcripts were isolated from the digestive gland, foot, gill and mantle of both male and female mussels. In total, 175,547 sequences were obtained and for foot and mantle, 90% of the sequences could be assembled into contiguous fragments but this reduced to 75% for the digestive gland and gill. Transcripts relating to protein metabolism and respiration dominated including ribosomal proteins, cytochrome oxidases and NADH dehydrogenase subunits. Tissue specific variation was identified in transcripts associated with mitochondrial energy metabolism, with the digestive gland and gill having the greatest transcript abundance. Using fragment recruitment it was also possible to identify sites of potential small RNAs involved in mitochondrial transcriptional regulation. Sex ratios based on Vitelline Envelop Receptor for Lysin and Vitelline Coat Lysin transcript abundances, indicated that an equal sex distribution was maintained. Taxonomic profiling of the M. galloprovincialis tissues highlighted an abundant microbial flora associated with the digestive gland. Profiling of the tissues for genes involved in intermediary metabolism demonstrated that the gill and digestive gland were more similar to each other than to the other two tissues, and specifically the foot transcriptome was most dissimilar. CONCLUSIONS: Pyrosequencing has provided extensive genomic information for M. galloprovincialis and generated novel observations on expression of different tissues, mitochondria and associated microorganisms. It will also facilitate the much needed production of an oligonucleotide microarray for the organism.

Transitions in the lives of patients with End Stage Renal Disease: a cause of suffering and an opportunity for healing.

The treatment of End Stage Renal Disease (ESRD) successfully prolongs the survival of patients with kidney disease but requires that ESRD patients cope with frequent deleterious changes in their health and life situation, and shortened survival. Although the nephrology team is well-equipped to deal with the medical and technical aspects of care, it is less well-equipped to help patients with the impact of the difficult human transitions that come with dialysis and transplant treatment. Times of great challenge can also be opportunities for personal growth and healing but this often requires outside support. We need to develop new resources specifically aimed at helping ESRD patients complete important life transitions and more research on the frequency and impact of these events.