Industry Payments to Cardiology Fellows and Early-Career Cardiologists.

This cohort study evaluates marketing payments from pharmaceutical and medical device manufacturers to physician trainees before and after fellowship graduation.

Trends in Operative Case Logs of Chief Residents in Surgery by Sex and Race: A 5 - Year National Study.

OBJECTIVES: A recent study of 21 institutions noted significant differences between number of cases reported during general surgery residency by trainees who are Underrepresented in Medicine (URiM) versus trainees who are not Underrepresented in Medicine (non-URiM). This study also identified differences between female residents and male residents. We partnered with the Accreditation Council for Graduate Medical Education to examine case logs reported from all accredited general surgery programs in the United States. This is the first time this data has been examined nationally. METHODS: We examined total case logs submitted by graduating residents between 2017 and 2022. Group differences in mean reported case logs were examined using paired t- tests for female versus male and URiM versus non- URiM overall case numbers. RESULTS: A total of 6,458 residents submitted case logs from 319 accredited programs. Eight-hundred and fifty-four (13%) were URiM and 5,604 (87%) were non-URiM. Over the 5-year study period, URM residents submitted 1096.95 (SD +/- 160.57) major cases versus 1115.96 (+/- 160.53) for non-URiM residents (difference =19 cases, P=0.001). Case logs were submitted by 3,833 (60.1%) male residents and 2,625 (39.9%) female residents over the five-year study period. Male residents reported 1128.56 (SD +/- 168.32) cases versus 1091.38 (+/- 145.98) cases reported by females (difference=37.18, P<0.001). When looking at Surgeon Chief and Teaching Assistant cases, there was no significant difference noted between cases submitted by URiM versus non- URiM residents. However, male residents reported significantly more in both categories than their female peers (P<0.001). CONCLUSIONS: Overall, URiM residents submitted fewer cases in the five- year study period than their non-URiM peers. The gap in submitted cases between male and female residents was more pronounced, with male residents submitting significantly more cases than their female counterparts. This finding was consistent and statistically significant throughout the entire study period, in most case categories, and without narrowing of difference over time. A difference of 30-40 cases can amount to 1-3 months of surgical training and is a concerning national trend deserving the attention of every training program and our governing institutions.

Trajectories of Hearing From Childhood to Adulthood.

OBJECTIVES: The Dunedin Multidisciplinary Health and Development Study provides a unique opportunity to document the progression of ear health and hearing ability within the same cohort of individuals from birth. This investigation draws on hearing data from 5 to 13 years and again at 45 years of age, to explore the associations between childhood hearing variables and hearing and listening ability at age 45. DESIGN: Multiple linear regression analyses were used to assess associations between childhood hearing (otological status and mid-frequency pure-tone average) and (a) age 45 peripheral hearing ability (mid-frequency pure-tone average and high-frequency pure-tone average), and (b) age 45 listening ability (listening in spatialized noise and subjective questionnaire on listening experiences). Sex, childhood socioeconomic status, and adult IQ were included in the model as covariates. RESULTS: Peripheral hearing and listening abilities at age 45 were consistently associated with childhood hearing acuity at mid-frequencies. Otological status was a moderate predicting factor for high-frequency hearing and utilization of spatial listening cues in adulthood. CONCLUSIONS: We aim to use these findings to develop a foundational model of hearing trajectories. This will form the basis for identifying precursors, to be investigated in a subsequent series of analyses, that may protect against or exacerbate hearing-associated cognitive decline in the Dunedin Study cohort as they progress from mid-life to older age.

Pasture feeding improves the nutritional, textural and techno-functional characteristics of butter.

There is an increasing consumer desire for pasture-derived dairy products, as outdoor pasture-based feeding systems are perceived as a natural environment for animals. Despite this, the number of grazing animals globally has declined as a result of the higher milk yields achieved by indoor, total mixed ration feeding systems, in addition to the changing climatic conditions and lower grazing knowledge and infrastructure. This has led to the development of pasture-fed standards, stipulating the necessity of pasture and its minimum requirements as the primary feed source for products advertising such claims, with various requirements depending on region for which it was produced. This work investigates the differences in the composition and techno-functional properties of butters produced from high, medium and no pasture allowance diets during early, mid and late lactation. Butters were produced using milks collected from 3 feeding systems: outdoor pasture grazing (GRS; high pasture allowance); indoor total mixed ration (TMR; no pasture allowance); and a partial mixed ration (PMR; medium pasture allowance) system, which involved outdoor pasture grazing during the day and indoor TMR feeding at night. Butters were manufactured during early, mid and late lactation. Creams derived from TMR feeding systems exhibited the highest milk fat globule size. The fatty acid profiles of butters also differed significantly as a function of diet, and could be readily discriminated by partial least squares analysis. The most important fatty acids in such analysis, as indicated by their highest variable importance projection scores, were CLA C18:2 cis-9 trans-11 (rumenic acid), C16:1 n-7 trans (trans-palmitoleic acid), C18:1 trans (elaidic acid), C18:3 n-3 (α-linolenic acid) and C18:2 n-6 (linoleic acid). Increasing pasture allowances resulted in reduced crystallization temperatures and hardness of butters, while concurrently increasing the 'yellow' b* color. Yellow color was strongly correlated with Raman peaks commonly associated with carotenoids. The milk fat globule size of cream decreased with advancing stage of lactation and churning time of cream was lowest in early lactation. Differences in the fatty acid and triglyceride contents of butter as a result of lactation and dietary effects demonstrated significant correlations with the hardness, rheological, melting and crystallization profiles of the butters. This work highlighted the improved nutritional profile and functional properties of butter with increasing dietary pasture allowance, primarily as a result of increasing proportions of unsaturated fatty acids. Biomarkers of pasture feeding (response in milk proportionate to the pasture allowance) associated with the pasture-fed status of butters were also identified as a result of the significant changes in the fatty acid profile with increasing pasture allowance. This was achieved through the use of 3 authentic feeding systems with varying pasture allowances, commonly operated by farmers around the world and conducted across 3 stages of lactation.

Dementia, dementia's risk factors and premorbid brain structure are concentrated in disadvantaged areas: National register and birth-cohort geographic analyses.

INTRODUCTION: Dementia risk may be elevated in socioeconomically disadvantaged neighborhoods. Reasons for this remain unclear, and this elevation has yet to be shown at a national population level. METHODS: We tested whether dementia was more prevalent in disadvantaged neighborhoods across the New Zealand population (N = 1.41 million analytic sample) over a 20-year observation. We then tested whether premorbid dementia risk factors and MRI-measured brain-structure antecedents were more prevalent among midlife residents of disadvantaged neighborhoods in a population-representative NZ-birth-cohort (N = 938 analytic sample). RESULTS: People residing in disadvantaged neighborhoods were at greater risk of dementia (HR per-quintile-disadvantage-increase = 1.09, 95% confidence interval [CI]:1.08-1.10) and, decades before clinical endpoints typically emerge, evidenced elevated dementia-risk scores (CAIDE, LIBRA, Lancet, ANU-ADRI, DunedinARB; ß's 0.31-0.39) and displayed dementia-associated brain structural deficits and cognitive difficulties/decline. DISCUSSION: Disadvantaged neighborhoods have more residents with dementia, and decades before dementia is diagnosed, residents have more dementia-risk factors and brain-structure antecedents. Whether or not neighborhoods causally influence risk, they may offer scalable opportunities for primary dementia prevention.

A blood biomarker of the pace of aging is associated with brain structure: replication across three cohorts.

Biological aging is the correlated decline of multi-organ system integrity central to the etiology of many age-related diseases. A novel epigenetic measure of biological aging, DunedinPACE, is associated with cognitive dysfunction, incident dementia, and mortality. Here, we tested for associations between DunedinPACE and structural MRI phenotypes in three datasets spanning midlife to advanced age: the Dunedin Study (age=45 years), the Framingham Heart Study Offspring Cohort (mean age=63 years), and the Alzheimer's Disease Neuroimaging Initiative (mean age=75 years). We also tested four additional epigenetic measures of aging: the Horvath clock, the Hannum clock, PhenoAge, and GrimAge. Across all datasets (total N observations=3380; total N individuals=2322), faster DunedinPACE was associated with lower total brain volume, lower hippocampal volume, greater burden of white matter microlesions, and thinner cortex. Across all measures, DunedinPACE and GrimAge had the strongest and most consistent associations with brain phenotypes. Our findings suggest that single timepoint measures of multi-organ decline such as DunedinPACE could be useful for gauging nervous system health.

Learner Assessment and Program Evaluation: Supporting Precision Education.

ABSTRACT: Precision education (PE) systematically leverages data and advanced analytics to inform educational interventions that, in turn, promote meaningful learner outcomes. PE does this by incorporating analytic results back into the education continuum through continuous feedback cycles. These data-informed sequences of planning, learning, assessing, and adjusting foster competence and adaptive expertise. PE cycles occur at individual (micro), program (meso), or system (macro) levels. This article focuses on program- and system-level PE.Data for PE come from a multitude of sources, including learner assessment and program evaluation. The authors describe the link between these data and the vital role evaluation plays in providing evidence of educational effectiveness. By including prior program evaluation research supporting this claim, the authors illustrate the link between training programs and patient outcomes. They also describe existing national reports providing feedback to programs and institutions, as well as 2 emerging, multiorganization program- and system-level PE efforts. The challenges encountered by those implementing PE and the continuing need to advance this work illuminate the necessity for increased cross-disciplinary collaborations and a national cross-organizational data-sharing effort.Finally, the authors propose practical approaches for funding a national initiative in PE as well as potential models for advancing the field of PE. Lessons learned from successes by others illustrate the promise of these recommendations.

Systems-Based Practice 20 Years On: Navigating the System for Better Care.

ABSTRACT: Systems-based practice (SBP) was introduced as 1 of 6 core competencies in 1999 because of its recognized importance in the quality and safety of health care provided to patients. Nearly 25 years later, faculty and learners continue to struggle with understanding and implementing this essential competency, thus hindering the medical education community's ability to most effectively teach and learn this important competency.Milestones were first introduced in 2013 as one effort to support implementation of the general competencies. However, each specialty developed its milestones independently, leading to substantial heterogeneity in the narrative descriptions of competencies including SBP. The process to create Milestones 2.0, and more specifically, the Harmonized Milestones, took this experience into account and endeavored to create a shared language for SBP across all specialties and subspecialties. The 3 subcompetencies in SBP are now patient safety and quality improvement, systems navigation for patient-centered care (coordination of care, transitions of care, local population health), and physician's role in health care systems (components of the system, costs and resources, transitions to practice). Milestones 2.0 are also now supported by new supplemental guides that provide specific real-world examples to help learners and faculty put SBP into the context of the complex health care environment.While substantially more resources and tools are now available to aid faculty and to serve as a guide for residents and fellows, much work to effectively implement SBP remains. This commentary will explore the evolutionary history of SBP, the challenges facing implementation, and suggestions for how programs can use the new milestone resources for SBP. The academic medicine community must work together to advance this competency as an essential part of professional development.

The Association of Subspecialty and Sex with Industry Payments to Internal Medicine Physicians Who Recently Completed Training.

BACKGROUND: Financial relationships with drug and medical device companies may impact quality of care and academic research. However, little is known when and how these financial relationships develop among newly independent physicians who recently completed from residency or fellowship programs in internal medicine (IM). OBJECTIVE: To compare patterns of industry payments among IM graduates. DESIGN: Retrospective, observational cohort study. SUBJECTS: IM graduates from residency or fellowship programs between January 2015 and December 2019. MAIN MEASURES: We analyzed Open Payments reports made between July 2015 and June 2021 to recent graduates of U.S. Accreditation Council for Graduate Medical Education (ACGME)-accredited residency and fellowship programs in IM. The primary outcome was general payments accepted by these physicians, stratified by procedural (i.e., critical care medicine/pulmonary medicine, cardiac/cardiovascular disease, and gastroenterology) and non-procedural (i.e., infectious disease, general internal medicine, and other specialties) subspecialties. The secondary outcomes included general payments stratified by sex and age at residency or fellowship training completion. KEY RESULTS: There were 41,669 IM physicians with a median age of 33.0 years. In the first 3 years after completion, the proportion of physicians accepting any general payments was 72.6%, 91.9%, and 86.8% in Critical Care Medicine/Pulmonary Medicine, Cardiac/Cardiovascular Disease, and Gastroenterology, compared to 56.1%, 52.6%, and 52.3% in Infectious Disease, General Internal Medicine, and Other Specialties (p<0.0001). After adjusting for confounding variables, the procedural group showed an increased hazard ratio (HR) for accepting any general payments and at least $5000 of general payments compared to the non-procedural group. The HRs of accepting any general payments in the procedural subspecialty were 2.26 (95% CI, 2.11-2.42) and 2.83 (95% CI, 2.70-2.97) in female and male physicians, respectively (p-value < 0.0001). CONCLUSION: Industry financial relationships among newly independent physicians in IM exist immediately after completion of training and are influenced by subspecialty, sex, and age.

Mild Traumatic Brain Injury Does Not Significantly Affect Midlife Cognitive Functioning Within the General Population: Findings From a Prospective Longitudinal Birth Cohort Study.

OBJECTIVE: To determine whether differences exist in mid-adulthood cognitive functioning in people with and without history of mild traumatic brain injury (mTBI). SETTING: Community-based study. PARTICIPANTS: People born between April 1, 1972, and March 31, 1973, recruited into the Dunedin Multidisciplinary Health and Development Longitudinal Study, who completed neuropsychological assessments in mid-adulthood. Participants who had experienced a moderate or severe TBI or mTBI in the past 12 months were excluded. DESIGN: Longitudinal, prospective, observational study. MAIN MEASURES: Data were collected on sociodemographic characteristics, medical history, childhood cognition (between 7 and 11 years), and alcohol and substance dependence (from 21 years of age). mTBI history was determined from accident and medical records (from birth to 45 years of age). Participants were classified as having 1 mTBI and more in their lifetime or no mTBI. The Wechsler Adult Intelligence Scale (WAIS-IV) and Trail Making Tests A and B (between 38 and 45 years of age) were used to assess cognitive functioning. T tests and effect sizes were used to identify any differences on cognitive functioning domains between the mTBI and no mTBI groups. Regression models explored the relative contribution of number of mTBIs and age of first mTBI and sociodemographic/lifestyle variables on cognitive functioning. RESULTS: Of the 885 participants, 518 (58.5%) had experienced at least 1 mTBI over their lifetime, with a mean number of 2.5 mTBIs. The mTBI group had significantly slower processing speed ( P < .01, d = 0.23) in mid-adulthood than the no TBI controls, with a medium effect size. However, the relationship no longer remained significant after controlling for childhood cognition, sociodemographic and lifestyle factors. No significant differences were observed for overall intelligence, verbal comprehension, perceptual reasoning, working memory, attention, or cognitive flexibility. Childhood cognition was not linked to likelihood of sustaining mTBI later in life. CONCLUSION: mTBI histories in the general population were not associated with lower cognitive functioning in mid-adulthood once sociodemographic and lifestyle factors were taken into account.

Who Australasians trusted during COVID-19: lessons from the pandemic response.

AIM: Public trust in authoritative information sources is a key element of a successful public health response to a pandemic. This study investigated which sources of COVID-19 advice were most trusted by a primarily New Zealand-based cohort and considers implications for policy and practice regarding future pandemics. METHOD: Data were from a COVID-19 vaccine intention survey presented to Australia- and New Zealand-based members of the longitudinal Dunedin Study (n=832) between ages 48 and 49, immediately before vaccines became available for the general population within New Zealand. We assessed participants' trust in specific sources of COVID-19 advice and investigated whether the pattern of responses differed by sex, socio-economic status (SES) or education. RESULTS: Doctors and healthcare providers were the most trusted source of COVID-19 advice, over and above other institutional sources. This pattern was consistent across sex, SES and education. Institutional experts were trusted significantly more by those with higher SES compared to those with lower SES, and by those with formal qualifications compared to those without formal qualifications. CONCLUSION: Our findings suggest that it is important to empower healthcare providers early in a pandemic to share advice with the public alongside other trusted sources, such as the government.

Transition to Residency: National Study of Factors Contributing to Variability in Learner Milestones Ratings in Emergency Medicine and Family Medicine.

PURPOSE: The developmental trajectory of learning during residency may be attributed to multiple factors, including variation in individual trainee performance, program-level factors, graduating medical school effects, and the learning environment. Understanding the relationship between medical school and learner performance during residency is important in prioritizing undergraduate curricular strategies and educational approaches for effective transition to residency and postgraduate training. This study explores factors contributing to longitudinal and developmental variability in resident Milestones ratings, focusing on variability due to graduating medical school, training program, and learners using national cohort data from emergency medicine (EM) and family medicine (FM). METHOD: Data from programs with residents entering training in July 2016 were used (EM: n=1,645 residents, 178 residency programs; FM: n=3,997 residents, 487 residency programs). Descriptive statistics were used to examine data trends. Cross-classified mixed-effects regression were used to decompose variance components in Milestones ratings. RESULTS: During postgraduate year (PGY)-1, graduating medical school accounted for 5% and 6% of the variability in Milestones ratings, decreasing to 2% and 5% by PGY-3 for EM and FM, respectively. Residency program accounted for substantial variability during PGY-1 (EM=70%, FM=53%) but decreased during PGY-3 (EM=62%, FM=44%), with greater variability across training period in patient care (PC), medical knowledge (MK), and systems-based practice (SBP). Learner variance increased significantly between PGY-1 (EM=23%, FM=34%) and PGY-3 (EM=34%, FM=44%), with greater variability in practice-based learning and improvement (PBLI), professionalism (PROF), and interpersonal communication skills (ICS). CONCLUSIONS: The greatest variance in Milestone ratings can be attributed to the residency program and to a lesser degree, learners, and medical school. The dynamic impact of program-level factors on learners shifts during the first year and across the duration of residency training, highlighting the influence of curricular, instructional, and programmatic factors on resident performance throughout residency.

Industry Payments Received by Residents During Training.

Importance: Those responsible for medical education-specialties, sponsoring institutions, and program directors (PD)-are independently associated with the professional identity formation of the trainees with respect to potential conflicts of interest. Objective: To identify the relative degree to which factors in the training environment are associated with resident acceptance of payments from pharmaceutical and medical device companies. Design, Setting, and Participants: Cross-sectional, retrospective study of residents enrolled in the 3 largest primary-care specialties (internal medicine [IM], family medicine [FM], obstetrics and gynecology [OBGYN]) and 3 largest surgical disciplines (general surgery [GS], orthopedic surgery, and urology) during academic year 2020 to 2021. All analyses were conducted January through August 2023. Exposures: Specialty, sponsoring institutions' ownership (nonprofit, for-profit, federal government, local government, or state government), and the number of payments PDs accepted. Main outcomes and measures: Modified Poisson regression assessed the relative risk of ownership, specialty, and PD behavior on residents' acceptance of industry payments as recorded in the Open Payments Program (OPP) database. Results: In total, there were 124 715 residents in all training programs during 2020 to 2021, 12% of whom received payments totaling $6.4 million. There were 65 992 residents in training during 2020 to 2021 in the 6 specialties evaluated in this study, with 4438 in orthopedics, 1779 in urology, 9177 in GS, 5819 in OBGYN, 14 493 in FM, and 30 286 in IM. OPP records $3.9 million in payments to the 8750 residents (13.4%) who received at least 1 industry payment. The record of all payments to residents in OPP totals $6.4 million. Compared with residents in federal sponsoring institutions, those affiliated with for-profit institutions were 3.50 (95% CI, 2.32-5.28) times more likely to accept industry payments, while those affiliated with nonprofit organizations were 2.00 (95% CI, 1.36-2.93) times more likely to accept payments. Compared with IM, residents in each of the following specialties have an elevated risk of accepting payments: orthopedics, 3.21 (95% CI, 2.73-3.77) times; urology, 2.95 (95% CI, 2.44-3.56) times; GS, 1.21 (95% CI, 1.00-1.45) times; OBGYN, 1.30 (95% CI, 1.05-1.62) times. The difference in the risk of accepting a payment between FM and IM residents was not statistically significant. The number of payments PDs accepted slightly elevated the risk of residents to accept a payment by 1.01 (95% CI, 1.01-1.01). Conclusions and relevance: In this cross-sectional, retrospective study, receipt of industry payments by residents was associated with specialty, institutional control, and PD behavior.

Efforts to Recruit Diverse Resident Complements in Family Medicine.

BACKGROUND AND OBJECTIVES: Family medicine is the most demographically diverse specialty in medicine today. Specialty associations and the Accreditation Council for Graduate Medical Education (ACGME) urge residency programs to engage in systematic efforts to recruit diverse resident complements. Using responses from program directors to the ACGME's mandatory annual update, we enumerate the efforts in resident recruiting. This allows us to compare these statements to the recommendations of two highly respected commissions: the Sullivan Commission on Diversity in the Healthcare Workforce and the Institute of Medicine's In the Nation's Compelling Interest: Ensuring Diversity of the Healthcare Workforce. METHODS: We compiled the annual updates from 689 family medicine programs and analyzed them using a qualitative method called template analysis. We then classified the efforts and compared them to the recommendations of the Sullivan Commission and Institute of Medicine (IOM). RESULTS: Nearly all (98%) of the programs completed the portion of the annual update inquiring about recruiting residents. The Sullivan Commission and IOM recommended 23 steps to diversify workforce recruiting. We found that programs engaged in all but one of these recommendations. Among the most frequently employed recommendations were doing holistic reviews and using data for planning. None mentioned engaging in public awareness campaigns. Programs also implemented eight strategies not suggested in either report, with staff training in nondiscrimination policies being among the most frequently mentioned. Among program efforts not included in the Sullivan Commission or IOM recommendations were extracurricular activities; appointing diversity, equity, and inclusion (DEI) committees or advocates; subinternship (Sub-I) experiences; recruiting at conferences; blind reviews; legal compliance; and merit criteria. In total, we found 31 interventions in use. CONCLUSIONS: The Sullivan Commission's guidance, IOM recommendations, and program-developed initiatives can be combined to create a comprehensive roster of diversity recruiting initiatives. Programs may use this authoritative resource for identifying their next steps in advancing their recruiting efforts.

A blood biomarker of accelerated aging in the body associates with worse structural integrity in the brain: replication across three cohorts.

Biological aging is the correlated decline of multi-organ system integrity central to the etiology of many age-related diseases. A novel epigenetic measure of biological aging, DunedinPACE, is associated with cognitive dysfunction, incident dementia, and mortality. Here, we tested for associations between DunedinPACE and structural MRI phenotypes in three datasets spanning midlife to advanced age: the Dunedin Study (age=45 years), the Framingham Heart Study Offspring Cohort (mean age=63 years), and the Alzheimer's Disease Neuroimaging Initiative (mean age=75 years). We also tested four additional epigenetic measures of aging: the Horvath clock, the Hannum clock, PhenoAge, and GrimAge. Across all datasets (total N observations=3,380; total N individuals=2,322), faster DunedinPACE was associated with lower total brain volume, lower hippocampal volume, and thinner cortex. In two datasets, faster DunedinPACE was associated with greater burden of white matter hyperintensities. Across all measures, DunedinPACE and GrimAge had the strongest and most consistent associations with brain phenotypes. Our findings suggest that single timepoint measures of multi-organ decline such as DunedinPACE could be useful for gauging nervous system health.

Modelling potential human exposure to the urease inhibitor NBPT through the environment-food pathway.

The urease inhibitor N-(n-butyl) thiophosphoric triamide (NBPT) has recently attracted a lot of attention attributing to its efficiency in reducing ammonia loss from urea fertiliser applied to temperate grassland soils. Ammonia gas lost to the environment causes soil acidification, eutrophication and contributes to global warming through increased greenhouse gas emissions and ozone layer depletion. The active chemical NBPT blocks the soil microbial enzyme (urease) and reduces ammonia emission. Furthermore, NBPT's use in agriculture might benefit farmers by reducing reliance on expensive nitrate fertiliser and aiding in a shift to more urea-based fertiliser (using NBPT co-applied with urea is more cost-effective). The present study was carried out to characterise the potential transfer of NBPT from grass to liquid milk and compute the associated human health risks. Using probabilistic risk assessment techniques, an exposure assessment model was developed to calculate the Estimated Daily Intake (EDI) of NBPT from milk, following co-application of NBPT with a urea N-fertiliser. Results show that the predicted mean concentration of NBPT in milk is 2.5 × 10-8 mg NBPT/kg milk, while the mean daily intake (EDI) of NBPT is 5 × 10-11 mg NBPT /kg BW/day). Back-calculations revealed that, under the studied conditions, for the EDI to exceed ADI of 3 × 10-2 mg NBPT/kg BW/ day, the NBPT application rate would need to exceed the NBPT fertiliser limit (0.09-0.2% by mass of urea nitrogen) set in the Commission Regulation (EC) No 1107/2008, and the bio-transfer factor would need to be over 100% (implausible). Sensitivity analysis revealed soil pH (SPH), phytoaccumulation factor (PF), NBPT permissible levels in fertiliser (NBPT%), pasture cover (P), and grazing rotation length (t) as critical factors influencing the EDI of NBPT. The present study concludes that NBPT presents negligible risk to human health under the conditions and assumptions studied.

Measurement of grass uptake of the urease inhibitor NBPT and of the nitrification inhibitor dicyandiamide co-applied with granular urea.

Grass uptake and phytoaccumulation factors of N-(n-butyl) thiophosphoric triamide (NBPT) and dicyandiamide (DCD) were quantified. Following the application of urea fertilizer treated with the inhibitors in Irish grassland, grass samples were collected at 5, 10, 15, 20, and 30 day time intervals following five application cycles. Uptake of NBPT by grass was below the limit of quantitation of the analytical method (0.010 mg NBPT kg-1). Dicyandiamide concentrations in grass ranged from 0.004 to 28 mg kg-1 with the highest concentrations measured on days 5 and 10. A reducing trend in concentration was found after day 15. The DCD phytoaccumulation factor was ranged from 0.004% to 1.1% showing that DCD can be taken up by grass at low levels when co-applied with granular urea. In contrast, NBPT was not detected indicating that grass uptake is unlikely when co-applied with granular urea fertilizer. The contrasting results are likely due to very different longevity of DCD and NBPT along with the much lower rate of NBPT, which is used compared with DCD.

Tracing the origins of midlife despair: association of psychopathology during adolescence with a syndrome of despair-related maladies at midlife.

BACKGROUND: Midlife adults are experiencing a crisis of deaths of despair (i.e. deaths from suicide, drug overdose, and alcohol-related liver disease). We tested the hypothesis that a syndrome of despair-related maladies at midlife is preceded by psychopathology during adolescence. METHODS: Participants are members of a representative cohort of 1037 individuals born in Dunedin, New Zealand in 1972-73 and followed to age 45 years, with 94% retention. Adolescent mental disorders were assessed in three diagnostic assessments at ages 11, 13, and 15 years. Indicators of despair-related maladies across four domains - suicidality, substance misuse, sleep problems, and pain - were assessed at age 45 using multi-modal measures including self-report, informant-report, and national register data. RESULTS: We identified and validated a syndrome of despair-related maladies at midlife involving suicidality, substance misuse, sleep problems, and pain. Adults who exhibited a more severe syndrome of despair-related maladies at midlife tended to have had early-onset emotional and behavioral disorders [ß = 0.23, 95% CI (0.16-0.30), p < 0.001], even after adjusting for sex, childhood SES, and childhood IQ. A more pronounced midlife despair syndrome was observed among adults who, as adolescents, were diagnosed with a greater number of mental disorders [ß = 0.26, 95% CI (0.19-0.33), p < 0.001]. Tests of diagnostic specificity revealed that associations generalized across different adolescent mental disorders. CONCLUSIONS: Midlife adults who exhibited a more severe syndrome of despair-related maladies tended to have had psychopathology as adolescents. Prevention and treatment of adolescent psychopathology may mitigate despair-related maladies at midlife and ultimately reduce deaths of despair.

Trainee Physician Milestone Ratings and Patient Complaints in Early Posttraining Practice.

Importance: Evaluation of trainees in graduate medical education training programs using Milestones has been in place since 2013. It is not known whether trainees who have lower ratings during the last year of training go on to have concerns related to interactions with patients in posttraining practice. Objective: To investigate the association between resident Milestone ratings and posttraining patient complaints. Design, Setting, and Participants: This retrospective cohort study included physicians who completed Accreditation Council for Graduate Medical Education (ACGME)-accredited programs between July 1, 2015, and June 30, 2019, and worked at a site that participated in the national Patient Advocacy Reporting System (PARS) program for at least 1 year. Milestone ratings from ACGME training programs and patient complaint data from PARS were collected. Data analysis was conducted from March 2022 to February 2023. Exposures: Lowest professionalism (P) and interpersonal and communication skills (ICS) Milestones ratings 6 months prior to the end of training. Main Outcomes and Measures: PARS year 1 index scores, based on recency and severity of complaints. Results: The cohort included 9340 physicians with median (IQR) age of 33 (31-35) years; 4516 (48.4%) were women physicians. Overall, 7001 (75.0%) had a PARS year 1 index score of 0, 2023 (21.7%) had a score of 1 to 20 (moderate), and 316 (3.4%) had a score of 21 or greater (high). Among physicians in the lowest Milestones group, 34 of 716 (4.7%) had high PARS year 1 index scores, while 105 of 3617 (2.9%) with Milestone ratings of 4.0 (proficient), had high PARS year 1 index scores. In a multivariable ordinal regression model, physicians in the 2 lowest Milestones rating groups (0-2.5 and 3.0-3.5) were statistically significantly more likely to have higher PARS year 1 index scores than the reference group with Milestones ratings of 4.0 (0-2.5 group: odds ratio, 1.2 [95% CI, 1.0-1.5]; 3.0-3.5 group: odds ratio, 1.2 [95% CI, 1.1-1.3]). Conclusions and Relevance: In this study, trainees with low Milestone ratings in P and ICS near the end of residency were at increased risk for patient complaints in their early posttraining independent physician practice. Trainees with lower Milestone ratings in P and ICS may need more support during graduate medical education training or in the early part of their posttraining practice career.