Storied reflections: Development of a longitudinal interdisciplinary curriculum to improve patient-provider communication.

Objective: This article details the development of an interdisciplinary graduate medical education (GME) narrative curriculum. Methods: Descriptive statistics were conducted for the narrative session surveys. Two separate qualitative analyses were conducted. First, content and thematic analyses of the open-ended questions in the survey using NVIVO software occurred. Second, an inductive analysis of the participants' 54 stories was performed to identify unique themes not related to the prompt topics. Results: Quantitative survey results demonstrated that 84% of learners' felt the session benefited their personal or professional sense of wellbeing and resilience, 90% of learners believed the sessions aided in their ability to listen more effectively, and 86% of learners could apply what they practiced or witnessed. Qualitative analysis of survey data showed learners focused on patient care and listening. Thematic analysis of participants' narratives revealed strong feelings and emotions, struggles with time management, increase in self- and other-awareness, and challenges managing job-life balance. Conclusion: The longitudinal interdisciplinary Write-Read-Reflect narrative exchange curriculum is cost-effective, sustainable, and demonstrably valuable to learners and their program directors across multiple disciplines. Innovation: The program was designed for 4 graduate programs' learners to simultaneously experience a narrative exchange model to improve patient-provider communication, support professional resilience, and deepen relationship-centered care skills.

Comparing imidacloprid, clothianidin, and azoxystrobin runoff from lettuce fields using a soil drench or treated seeds in the Salinas Valley, California.

Neonicotinoid insecticide use has increased over the last decade, including as agricultural seed treatments (application of chemical in a coating to the seed prior to planting). In California, multiple crops, including lettuce, can be grown using neonicotinoid treated seeds or receive a direct neonicotinoid soil application (drenching) at planting. Using research plots, this study compared pesticide runoff in four treatments: (1) imidacloprid seed treatment; (2) clothianidin seed treatment; (3) imidacloprid drench and an azoxystrobin seed treatment; and (4) a control with no pesticidal treatment. Neonicotinoid and azoxystrobin concentrations were measured in surface water runoff during six irrigations events in the 2020 growing seasons. Results showed runoff concentrations up to 1308 (±1200) ng L-1 for imidacloprid drench treatment, 431 (±100) ng L-1 for clothianidin seed treatment, 135 (±60) ng L-1 for imidacloprid seed treatment, and 13 (±10) ng L-1 for azoxystrobin seed treatment (treatments averaged). The percent of applied mass in runoff over the entire sampling period varied by compound; the imidacloprid seed treatment and drench were similar (0.015 and 0.019%, respectively) to the clothianidin seed treatment (0.036%) while the azoxystrobin seed treatment was much higher (15%). Although the proportion of imidacloprid in runoff was similar for imidacloprid treatments, the mass applied during soil drench was > 4x the amount applied from the imidacloprid seed treatment. Surface soils were collected before planting and at the end of the trial. The neonicotinoids were detected in soil throughout the study and average maximum concentrations were 9-13 ng g-1; azoxystrobin was detected in only two soils at concentrations up to 0.57 ng g-1. These results elucidate the comparative mass runoff resulting from planting treated seed and soil drench applications and highlight the value of additional work to characterize off-site transport from the many commodities that may be utilizing treated seeds.

Spatial variability of phytoplankton in a shallow tidal freshwater system reveals complex controls on abundance and community structure.

Estuaries worldwide are undergoing changes to patterns of aquatic productivity because of human activities that alter flow, impact sediment delivery and thus the light field, and contribute nutrients and contaminants like pesticides and metals. These changes can influence phytoplankton communities, which in turn can alter estuarine food webs. We used multiple approaches-including high-resolution water quality mapping, synoptic sampling, productivity and nitrogen uptake rates, Lagrangian parcel tracking, enclosure experiments and bottle incubations-over a short time period to take a "spatial snapshot" of conditions in the northern region of the San Francisco Estuary (California, USA) to examine how environmental drivers like light availability, nutrients, water residence time, and contaminants affect phytoplankton abundance and community attributes like size distribution, taxonomic structure, and nutrient uptake rates. Zones characterized by longer residence time (15-60 days) had higher chlorophyll-a concentrations (9 ±â€¯4 µg L-1) and were comprised primarily of small phytoplankton cells (<5 µm, 74 ±â€¯8%), lower ammonium concentrations (1 ±â€¯0.8 µM), higher nitrate uptake rates, and higher rates of potential carbon productivity. Conversely, zones characterized by shorter residence time (1-14 days) had higher ammonium concentration (13 ±â€¯5 µM) and lower chlorophyll-a concentration (5 ±â€¯1 µg L-1) with diatoms making up a larger percent contribution. Longer residence time, however, did not result in the accumulation of large (>5 µm) cells considered important to pelagic food webs. Rather, longer residence time zones had a phytoplankton community comprised primarily of small cells, particularly picocyanobacteria that made up 38 ±â€¯17% of the chlorophyll-a - nearly double the concentration seen in shorter residence time zones (22 ±â€¯7% picocyanobacterial of chlorophyll-a). Our results suggest that water residence time in estuaries may have an effect as large or larger than that experimentally demonstrated for light, contaminants, or nutrients.

Reconnaissance of Mixed Organic and Inorganic Chemicals in Private and Public Supply Tapwaters at Selected Residential and Workplace Sites in the United States.

Safe drinking water at the point-of-use (tapwater, TW) is a United States public health priority. Multiple lines of evidence were used to evaluate potential human health concerns of 482 organics and 19 inorganics in TW from 13 (7 public supply, 6 private well self-supply) home and 12 (public supply) workplace locations in 11 states. Only uranium (61.9 µg L-1, private well) exceeded a National Primary Drinking Water Regulation maximum contaminant level (MCL: 30 µg L-1). Lead was detected in 23 samples (MCL goal: zero). Seventy-five organics were detected at least once, with median detections of 5 and 17 compounds in self-supply and public supply samples, respectively (corresponding maxima: 12 and 29). Disinfection byproducts predominated in public supply samples, comprising 21% of all detected and 6 of the 10 most frequently detected. Chemicals designed to be bioactive (26 pesticides, 10 pharmaceuticals) comprised 48% of detected organics. Site-specific cumulative exposure-activity ratios (∑EAR) were calculated for the 36 detected organics with ToxCast data. Because these detections are fractional indicators of a largely uncharacterized contaminant space, ∑EAR in excess of 0.001 and 0.01 in 74 and 26% of public supply samples, respectively, provide an argument for prioritized assessment of cumulative effects to vulnerable populations from trace-level TW exposures.

Expanded Target-Chemical Analysis Reveals Extensive Mixed-Organic-Contaminant Exposure in U.S. Streams.

Surface water from 38 streams nationwide was assessed using 14 target-organic methods (719 compounds). Designed-bioactive anthropogenic contaminants (biocides, pharmaceuticals) comprised 57% of 406 organics detected at least once. The 10 most-frequently detected anthropogenic-organics included eight pesticides (desulfinylfipronil, AMPA, chlorpyrifos, dieldrin, metolachlor, atrazine, CIAT, glyphosate) and two pharmaceuticals (caffeine, metformin) with detection frequencies ranging 66-84% of all sites. Detected contaminant concentrations varied from less than 1 ng L-1 to greater than 10 µg L-1, with 77 and 278 having median detected concentrations greater than 100 ng L-1 and 10 ng L-1, respectively. Cumulative detections and concentrations ranged 4-161 compounds (median 70) and 8.5-102 847 ng L-1, respectively, and correlated significantly with wastewater discharge, watershed development, and toxic release inventory metrics. Log10 concentrations of widely monitored HHCB, triclosan, and carbamazepine explained 71-82% of the variability in the total number of compounds detected (linear regression; p-values: < 0.001-0.012), providing a statistical inference tool for unmonitored contaminants. Due to multiple modes of action, high bioactivity, biorecalcitrance, and direct environment application (pesticides), designed-bioactive organics (median 41 per site at µg L-1 cumulative concentrations) in developed watersheds present aquatic health concerns, given their acknowledged potential for sublethal effects to sensitive species and lifecycle stages at low ng L-1.

The American College of Academic International Medicine 2017 Consensus Statement on International Medical Programs: Establishing a system of objective valuation and quantitative metrics to facilitate the recognition and incorporation of academic international medical efforts into existing promotion and tenure paradigms.

The growth of academic international medicine (AIM) as a distinct field of expertise resulted in increasing participation by individual and institutional actors from both high-income and low-and-middle-income countries. This trend resulted in the gradual evolution of international medical programs (IMPs). With the growing number of students, residents, and educators who gravitate toward nontraditional forms of academic contribution, the need arose for a system of formalized metrics and quantitative assessment of AIM- and IMP-related efforts. Within this emerging paradigm, an institution's "return on investment" from faculty involvement in AIM and participation in IMPs can be measured by establishing equivalency between international work and various established academic activities that lead to greater institutional visibility and reputational impact. The goal of this consensus statement is to provide a basic framework for quantitative assessment and standardized metrics of professional effort attributable to active faculty engagement in AIM and participation in IMPs. Implicit to the current work is the understanding that the proposed system should be flexible and adaptable to the dynamically evolving landscape of AIM - an increasingly important subset of general academic medical activities.

Prediction of fish and sediment mercury in streams using landscape variables and historical mining.

Widespread mercury (Hg) contamination of aquatic systems in the Sierra Nevada of California, U.S., is associated with historical use to enhance gold (Au) recovery by amalgamation. In areas affected by historical Au mining operations, including the western slope of the Sierra Nevada and downstream areas in northern California, such as San Francisco Bay and the Sacramento River-San Joaquin River Delta, microbial conversion of Hg to methylmercury (MeHg) leads to bioaccumulation of MeHg in food webs, and increased risks to humans and wildlife. This study focused on developing a predictive model for THg in stream fish tissue based on geospatial data, including land use/land cover data, and the distribution of legacy Au mines. Data on total mercury (THg) and MeHg concentrations in fish tissue and streambed sediment collected during 1980-2012 from stream sites in the Sierra Nevada, California were combined with geospatial data to estimate fish THg concentrations across the landscape. THg concentrations of five fish species (Brown Trout, Rainbow Trout, Sacramento Pikeminnow, Sacramento Sucker, and Smallmouth Bass) within stream sections were predicted using multi-model inference based on Akaike Information Criteria, using geospatial data for mining history and landscape characteristics as well as fish species and length (r(2)=0.61, p<0.001). Including THg concentrations in streambed sediment did not improve the model's fit, however including MeHg concentrations in streambed sediment, organic content (loss on ignition), and sediment grain size resulted in an improved fit (r(2)=0.63, p<0.001). These models can be used to estimate THg concentrations in stream fish based on landscape variables in the Sierra Nevada in areas where direct measurements of THg concentration in fish are unavailable.

Stream macroinvertebrate response models for bioassessment metrics: addressing the issue of spatial scale.

We developed independent predictive disturbance models for a full regional data set and four individual ecoregions (Full Region vs. Individual Ecoregion models) to evaluate effects of spatial scale on the assessment of human landscape modification, on predicted response of stream biota, and the effect of other possible confounding factors, such as watershed size and elevation, on model performance. We selected macroinvertebrate sampling sites for model development (n = 591) and validation (n = 467) that met strict screening criteria from four proximal ecoregions in the northeastern U.S.: North Central Appalachians, Ridge and Valley, Northeastern Highlands, and Northern Piedmont. Models were developed using boosted regression tree (BRT) techniques for four macroinvertebrate metrics; results were compared among ecoregions and metrics. Comparing within a region but across the four macroinvertebrate metrics, the average richness of tolerant taxa (RichTOL) had the highest R(2) for BRT models. Across the four metrics, final BRT models had between four and seven explanatory variables and always included a variable related to urbanization (e.g., population density, percent urban, or percent manmade channels), and either a measure of hydrologic runoff (e.g., minimum April, average December, or maximum monthly runoff) and(or) a natural landscape factor (e.g., riparian slope, precipitation, and elevation), or a measure of riparian disturbance. Contrary to our expectations, Full Region models explained nearly as much variance in the macroinvertebrate data as Individual Ecoregion models, and taking into account watershed size or elevation did not appear to improve model performance. As a result, it may be advantageous for bioassessment programs to develop large regional models as a preliminary assessment of overall disturbance conditions as long as the range in natural landscape variability is not excessive.

Environmental fate of fungicides and other current-use pesticides in a central California estuary.

The current study documents the fate of current-use pesticides in an agriculturally-dominated central California coastal estuary by focusing on the occurrence in water, sediment and tissue of resident aquatic organisms. Three fungicides (azoxystrobin, boscalid, and pyraclostrobin), one herbicide (propyzamide) and two organophosphate insecticides (chlorpyrifos and diazinon) were detected frequently. Dissolved pesticide concentrations in the estuary corresponded to the timing of application while bed sediment pesticide concentrations correlated with the distance from potential sources. Fungicides and insecticides were detected frequently in fish and invertebrates collected near the mouth of the estuary and the contaminant profiles differed from the sediment and water collected. This is the first study to document the occurrence of many current-use pesticides, including fungicides, in tissue. Limited information is available on the uptake, accumulation and effects of current-use pesticides on non-target organisms. Additional data are needed to understand the impacts of pesticides, especially in small agriculturally-dominated estuaries.

Systems and strategies for identifying and enumerating children outside of family care.

Methodologies to identify and enumerate children outside of family care vary as do the vulnerability categories of the children themselves. Children outside of family care is a broad term encompassing children absent of permanent family care, e.g., institutionalized children, children on/of the street, child-headed households, separated or unaccompanied children, trafficked children, children working in exploitive labor situations, etc. This paper reviews the various methodologies applied to identify and enumerate these often hidden and/or mobile populations. Methodologies that identify and enumerate children outside of family strive to meet two objectives: (1) to estimate the number and characteristics of a specific vulnerability category and (2) to determine eligibility to receive services. The paper reviews eight methodologies; six are categorized as survey sample methods (time-location sampling, capture recapture sampling, respondent driven sampling, the neighborhood method, household surveys, and establishment surveys) while two were labeled as data management systems (child labor management system, and databases of institutions). Each review includes a concise description of the methodology, its strengths and limitations, the most appropriate population it is suited to identify and/or enumerate, and any necessary conditions. Conclusions from these reviews advocate for tailoring a methodology (or a combination of methodologies) to the specific circumstances under which it is meant to identify or enumerate children outside of family care. In addition, further research and validation studies are needed to identify the conditions under which the strategies described here can be used and to develop appropriate protocols for utilization.

Occurrence of boscalid and other selected fungicides in surface water and groundwater in three targeted use areas in the United States.

To provide an assessment of the occurrence of fungicides in water resources, the US Geological Survey used a newly developed analytical method to measure 33 fungicides and an additional 57 current-use pesticides in water samples from streams, ponds, and shallow groundwater in areas of intense fungicide use within three geographic areas across the United States. Sampling sites were selected near or within farms using prophylactic fungicides at rates and types typical of their geographic location. At least one fungicide was detected in 75% of the surface waters and 58% of the groundwater wells sampled. Twelve fungicides were detected including boscalid (72%), azoxystrobin (51%), pyraclostrobin (40%), chlorothalonil (38%) and pyrimethanil (28%). Boscalid, a carboxamide fungicide registered for use in the US in 2003, was detected more frequently than atrazine and metolachlor, two herbicides that are typically the most frequently occurring pesticides in many large-scale water quality studies. Fungicide concentrations ranged from less than the method detection limit to approximately 2000 ngL(-1). Currently, limited toxicological data for non-target species exists and the environmental impacts are largely unknown. The results of this study indicate the importance of including fungicides in pesticide monitoring programs, particularly in areas where crops are grown that require frequent treatments to prevent fungal diseases.

Cardiac carnitine leakage is promoted by cardiomyopathy.

OBJECTIVE: We investigated whether a damaged heart with cardiomyopathy (CM) influences cardiac-stored carnitines. METHODS: A sensitive, specific, carnitine-requiring yeast was used to determine blood carnitine concentration in 116 healthy subjects. For comparison with blood carnitine concentrations from patients with CM, we selected 33 male patients, ages 29 to 67 y, with evidence of CM and 24 male patients, ages 31 to 66 y, with no CM as categorized by cardiac catheterization. RESULTS: During catheterization, significantly higher concentrations of arterial blood levels of carnitines leaked from hearts of patients specifically with CM; no arterial blood carnitines leaked from hearts of patients without CM. Venous blood carnitine concentration for all patients was within the normal range. Carnitine did not accumulate in venous blood and was not a source of large amounts of leaked blood carnitines in patients with CM. CONCLUSION: CM causes leakage of carnitines from heart stores, possibly making cardiac tissue vulnerable to damage. We do not know whether cardiac carnitine leakage leads to CM or if established CM promotes cardiac carnitine leakage.

Genotoxicity in native fish associated with agricultural runoff events.

The primary objective of the present study was to test whether agricultural chemical runoff was associated with in-stream genotoxicity in native fish. Using Sacramento sucker (Catostomus occidentalis), we combined field-caging experiments in an agriculturally dominated watershed with controlled laboratory exposures to field-collected water samples, and we coupled genotoxicity biomarker measurements in fish with bacterial mutagenicity analysis of water samples. We selected DNA strand breakage as a genotoxicity biomarker and Ames Salmonella mutagenicity tests as a second, supporting indicator of genotoxicity. Data from experiments conducted during rainfall runoff events following winter application of pesticides in 2000 and 2001 indicated that DNA strand breaks were significantly elevated in fish exposed to San Joaquin River (CA, USA) water (38.8, 28.4, and 53.6% DNA strand breakage in year 2000 field, year 2000 lab, and year 2001 field exposures, respectively) compared with a nearby reference site (15.4, 8.7, and 12.6% DNA strand breakage in year 2000 field, year 2000 lab, and year 2001 field exposures, respectively). Time-course measurements in field experiments supported a linkage between induction of DNA strand breakage and the timing of agricultural runoff. San Joaquin River water also caused significant reversion mutation in two Ames Salmonella tester strains. Salmonella mutagenicity corroborated in-stream effects, further strengthening a causal relationship between runoff events and genotoxicity. Potentially responsible agents are discussed in the context of timing of runoff events in the field, concordance between laboratory and field exposures, pesticide application patterns in the drainage, and analytical chemistry data.

Preservation of myocardial microcirculation during mechanical reperfusion for myocardial ischemia with either abciximab or eptifibatide.

Myocardial Blush Grade (MBG) is an angiographic method of assessing myocardial microcirculation and provides independent risk stratification among patients with normal TIMI 3 flow. Although the beneficial effect of abciximab on microvascular perfusion is well established, the efficacy of eptifibatide in the prevention of platelet aggregation and distal microembolization is less proven. After a pharmacologic shift by our institution towards the use of eptifibatide in patients with unstable angina presenting for PCI, we sought to evaluate our experience by retrospectively comparing the effect on myocardial perfusion between abciximab and eptifibatide following PCI in stable angina or acute coronary syndrome. Microcirculatory perfusion was reviewed in 101 consecutive patients (23 stable angina, 61 unstable angina, 17 non-q MI) undergoing PTCA/stenting. This comparison was between the last group of 51 patients who routinely received standard bolus and infusion of abciximab and the first group of 50 patients who began receiving standard bolus and infusion of eptifibatide. Baseline characteristics between the two groups were balanced, except for more patients with previous CABG in the eptifibatide group. Angiograms were evaluated by 2 blinded independent reviewers for MBG as follows: 0, no blush; 1, minimal blush; 2, moderate blush; and 3, normal blush. TIMI 3 flow was seen in 98 patients. MBG scores were not significantly different in the abciximab group (67% MBG 3; 31% MBG 2; 2.0% MBG 0 1) than in the eptifibatide group (58% MBG 3; 36% MBG 2; 6.0% MBG 0 1); p = 0.34. Patients with prior PTCA/stenting had lower MBG scores (0 2) compared to patients without prior PTCA (58% vs 31%; p = 0.03). There were significantly lower MBG scores in all patients with prior PTCA or CABG compared to patients without (55% vs 30%; p = 0.03). MBG scores significantly and inversely correlated with peak troponin I levels (r = -0.18, one-tailed p = 0.04). The similarity in myocardial perfusion between abciximab and eptifibatide suggests that both compounds are equally effective in reducing platelet aggregation and microembolization during mechanical reperfusion. Lower MBG scores in patients with prior PTCA or revascularization may be explained by irreversible microvascular dysfunction resulting from distal microembolization during the previous procedure. Lower MBG scores in patients with higher troponin I levels may reflect more frequent microemboli and microinfarcts during an ischemic event. Larger prospective studies need to be performed to validate these findings.