Acadia National Park (ANP) is located on Mt. Desert Island, ME on the U.S. Atlantic coast. ANP is routinely a top-ten most popular National Park with over four million visits in 2022. The overall contribution and negative effects of long-range atmospheric transport and local sources of dioxin-like contaminants endangering natural and wildlife resources is unknown. Dioxin-like (DL) contaminants polychlorinated dibenzo-p-dioxins (∑PCDD) and polychlorinated dibenzofurans (∑PCDF), non-ortho coplanar PCBs (∑CP4), and polychlorinated naphthalenes (∑PCNs) were measured at the McFarland Hill air monitoring station (44.37⁰N, 68.26⁰W). On a mass/volume basis, total PCNs averaged 90.9 % (788 fg/m3) of DL contaminants measured annually, with 92.9 % of the collected total in the vapor-phase. Alternatively, total dioxin/furans (∑PCDD/Fs) represented 71.6 % of the total toxic equivalence (∑TEQ) (1.018 fg-TEQ/m3), with 69.7 % in the particulate-phase. Maximum concentrations measured for individual sampling events for ∑PCDD/F, ∑CP4, and ∑PCN were 159 (winter), 139 (summer), and 2100 (autumn), fg/m3 respectively. Whereas the maximum ∑TEQ concentrations for individual sampling events for ∑PCDD/F, ∑CP4, and ∑PCN were 2.8 (autumn), 0.38 (summer), and 0.71 (autumn), fg-TEQ/m3 respectively. Pearson correlations were calculated for ∑PCDD/Fs and ∑PCN particulate/vapor-phase air concentrations and PM2.5 wood smoke \"indicator\" species. The most significant correlations were observed in autumn for particulate-phase ∑PCDD/Fs suggesting a relationship between visitation-generated combustion sources (campfires and/or waste burning) or climate-change mediated forest fires. Significant Clausius-Clapeyron (C-C) correlations observed for particulate-phase ∑PCDDs (r2=0.567) as ambient temperatures decreased suggests a connection between localized domestic heating sources or visitor-based burning of wood/trash resources. Alternatively, highly significant C-C vapor-phase ∑CP4-PCBs correlations (r2=0.815) implies that the majority of ∑CP4-PCB loading to ANP is from long-range atmospheric transport processes. Based on these findings, Acadia National Park should be classified as a remote site with minor depositional impacts from ∑PCDD/Fs, ∑CP4-PCBs, and ∑PCN atmospheric transport or local diffuse sources.

This article is based on an interview study of 24 Swedish veterans who experienced deteriorating mental health and increased suffering without meeting the criteria for a PTSD diagnosis. With no clinical answers as to the cause of their deteriorating mental health, they have been thrown into a veteran\'s health limbo. The analysis was based on an inductive logic. A key finding of the analysis was a kind of deep-seated permanent moral conflict that could be conceptualized as moral injury. Such an injury can give rise to intense guilt, shame, anxiety, anger, dejection, bitterness, identity issues and more. The results section of the article details five different yet for the sample representative cases of moral injury and their implications. The notion of moral injury is linked to Mead\'s division of the self into an I and me, where me is the socially constructed part of the self that is charged with the morality of a group. Thus, a moral me played a key role in the development of moral injury. The conceptual apparatus illustrates a new way of understanding experiences that can create suffering and negatively impact a veteran\'s mental health. Future research is encouraged that examines this topic, national designs for addressing moral injury, screening for moral injury, and methods for healing included.

This study aimed to determine the impact of dietary black peppercorn (BP) and xylanase (XYL) alone or in combination on growth performance, dietary energy, nutrient digestibility and blood lipid profile when fed to male Ross 308 broiler chickens from the ages of 7 to 21 d. A wheat-soy-based basal feed that was formulated to be 0.42 MJ lower in metabolizable energy (ME) was mixed. The basal feed was then split into four batches, with the first batch set aside as the basal control; the second batch was supplemented with freshly milled BP; the third batch was supplemented with XYL; the fourth batch was supplemented with both BP and XYL, as in the previous two batches. Each diet was fed to eight pens, with two birds in a pen, following randomization. Feeding BP reduced bird growth and most of the digestibility coefficients but increased blood high-density lipoprotein (p < 0.05). Dietary XYL increased bird growth, dietary ME and nutrient digestibility (p < 0.05). In addition, XYL increased hepatic carotenoids and coenzyme Q10, but reduced blood low-density lipoprotein (p < 0.05). There were no BP by XYL interactions (p > 0.05) observed. Further research is needed to identify the optimum level of BP in broiler diets.

OBJECTIVE: Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a chronic condition with a constellation of symptoms presenting as severe and profound fatigue of ≥ 6 months not relieved by rest. ME/CFS affects health-related quality of life (HRQoL), which can be measured using multi-attribute health state utility (HSU) instruments. The aims of this study were to quantify HSUs for people living with ME/CFS, and to identify an instrument that is preferentially sensitive for ME/CFS.
METHODS: Cross-sectional national survey of people with ME/CFS using the AQoL-8D and EQ-5D-5L. Additional questions from the AQoL-8D were used as \'bolt-ons\' to the EQ-5D-5L (i.e., EQ-5D-5L-Psychosocial). Disability and fatigue severity were assessed using the De Paul Symptom Questionnaire-Short Form (DSQ-SF). HSUs were generated using Australian tariffs. Mean HSUs were stratified for sociodemographic and clinical factors. Bland-Altman plots were used to compare the three HSU instruments.
RESULTS: For the 198 participants, mean HSUs (95% confidence intervals) were EQ-5D-5L: 0.46 (0.42-0.50); AQoL-8D: 0.43 (0.41-0.45); EQ-5D-5L-Psychosocial: 0.44 (0.42-0.46). HSUs were substantially lower than population norms: EQ-5D-5L: 0.89; AQoL-8D: 0.77. As disability and fatigue severity increased, HSUs decreased in all three instruments. Bland-Altman plots revealed interchangeability between the AQoL-8D and EQ-5D-5LPsychosocial. Floor and ceiling effects of 13.5% and 2.5% respectively were observed for the EQ-5D-5L instrument only.
CONCLUSIONS: ME/CFS has a profound impact on HRQoL. The AQoL-8D and EQ-5D-5L-Psychosocial can be used interchangeably: the latter represents a reduced participant burden.

The new NICE guideline for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), published in October 2021, makes significant changes in treatment recommendations. It acknowledges the complexity of this chronic medical condition, which always impacts quality of life and can be profoundly disabling, recognising the prejudice and stigma that people with ME/CFS often experience in the absence of any specific diagnostic test. The guideline outlines steps for accurate diagnosis, recognising post-exertional malaise as a core symptom; importantly, ME/CFS can now be diagnosed after just 3 months in a bid to improve long-term health outcomes. It recommends the need for individual, tailored management by a multi-disciplinary team, ensuring that the wellbeing of the individual is paramount. The guideline makes clear that any programme based on fixed incremental increases in physical activity or exercise, for example, graded exercise therapy (GET), should not be offered as a treatment for ME/CFS and emphasises that cognitive behavioural therapy (CBT) should only be offered as a supportive intervention. Because of the rigorous methodology required by NICE Committee review and the inclusion of the testimony of people with lived experience as committee members, this guideline will influence the future diagnosis and management of ME/CFS in the UK and beyond.

UNASSIGNED: World Health Organization Collaborating Centres (WHOCCs) cooperate with the WHO on a range of strategic areas such as nursing, nutrition, mental health, chronic diseases, education, and health technologies, depending on their speciality areas. As of 2021, WHO has 47 CCs in the Eastern Mediterranean Region (EMR) collaborating on diverse areas. Four CCs in the EMR located in Egypt, Kingdom of Bahrain, Sudan, and Pakistan focus primarily on medical education (ME).
UNASSIGNED: The objective of this review of the literature is to describe the best practices in ME based on published research from the four WHOCCs in EMR. The secondary objective is to classify them based on the level of Kirkpatrick\'s model (KM) of educational outcomes.
UNASSIGNED: The contributions of WHOCCs are categorised in to five domains namely \"Curriculum Development and Course Design\", \"Student Assessment\", \"Quality, Accreditation, and Program Evaluation\", \"Teaching and Learning\" and \"Innovation in Medical Education\". Initial extraction yielded 96 articles for review, while the second level of analysis reduced the number of publications to 37 based on the date of publication within the last 5 years. Numerous best practices in ME emerged from the recently published works of these WHOCCs in the areas of learning and teaching, curriculum development, innovations in medical education, quality, and assessments in medical education. Literature from the WHOCCs on assessment and curriculum design are limited, possibly indicating opportunities for additional research.
UNASSIGNED: The researchers conclude that the WHOCCs in the EMR show transformational impact on all principal areas of research and at multiple levels.

The British National Institute for Health and Care Excellence (NICE) recently published its updated guidelines for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). NICE concluded, after an extensive review of the literature, that graded exercise therapy (GET) is harmful and should not be used, and that cognitive behavioural therapy (CBT) is only an adjunctive and not a curative treatment. Leading proponents of the cognitive behavioural model (CBmodel) find it difficult to accept this paradigm shift. In, for example, an article in The Lancet, they try to argue that the new NICE guideline is based on ideology instead of science. In this article we reviewed the evidence they used to support their claims. Our analysis shows that the trials they used in support suffered from serious flaws which included badly designed control groups, relying on subjective primary outcomes in non-blinded studies, including patients in their trials who didn\'t have the disease under investigation or had a self-limiting disease, selective reporting, outcome switching and making extensive endpoint changes, which created an overlap in entry and recovery criteria, using a post-hoc definition of recovery which included the severely ill, not publishing results that contradict their own conclusion, ignoring their own (objective) null effect, etc. The flaws in these trials all created a bias in favour of the interventions. Despite all these flaws, treatments that are said to lead to recovery in reality do not lead to objective improvement. Therefore, these studies do not support the claim that CBT and GET are effective treatments. Moreover, the arguments that are used to claim that NICE was wrong, in reality, highlight the absence of evidence for the safety and efficacy of CBT and GET and strengthen the decision by NICE to drop CBT and GET as curative treatments for ME/CFS.

For the last few decades, medical guidelines have recommended treating patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) with graded exercise therapy (GET) and cognitive behavioural therapy (CBT). Moreover, doctors have questioned the recovery behaviour of these patients and stimulated them to follow these treatments so that they would be able to go back to work. In this article, we reviewed trials of GET and CBT for ME/CFS that reported on work status before and after treatment to answer the question of whether doctors should continue to question the recovery behaviour of patients with ME/CFS. Our review shows that more patients are unable to work after treatment than before treatment with CBT and GET. It also highlights the fact that both treatments are unsafe for patients with ME/CFS. Therefore, questioning the recovery behaviour of patients with ME/CFS is pointless. This confirms the conclusion from the British National Institute for Health and Care Excellence (NICE), which has recently published its updated ME/CFS guideline and concluded that CBT and GET are not effective and do not lead to recovery. Studies on CBT and GET for long COVID have not yet been published. However, this review offers no support for their use in improving the recovery of patients with an ME/CFS-like illness after infection with COVID-19, nor does it lend any support to the practice of questioning the recovery behaviour of these patients.

Background and Objectives: There is some evidence that knowledge and understanding of ME among doctors is limited. Consequently, an audit study was carried out on a group of hospital doctors attending a training event to establish how much they knew about ME and their attitudes towards it. Materials and Methods: Participants at the training event were asked to complete a questionnaire, enquiring about prior knowledge and experience of ME and their approaches to diagnosis and treatment. A total of 44 completed questionnaires were returned. Responses were tabulated, proportions selecting available options determined, 95% confidence limits calculated, and the significance of associations determined by Fisher\'s exact test. Results: Few respondents had any formal teaching on ME, though most had some experience of it. Few knew how to diagnose it and most lacked confidence in managing it. None of the respondents who had had teaching or prior experience of ME considered it a purely physical illness. Overall, 91% of participants believed ME was at least in part psychological. Most participants responded correctly to a series of propositions about the general epidemiology and chronicity of ME. There was little knowledge of definitions of ME, diagnosis, or of clinical manifestations. Understanding about appropriate management was very deficient. Similarly, there was little appreciation of the impact of the disease on daily living or quality of life. Where some doctors expressed confidence diagnosing or managing ME, this was misplaced as they were incorrect on the nature of ME, its diagnostic criteria and its treatment. Conclusion: This audit demonstrates that most doctors lack training and clinical expertise in ME. Nevertheless, participants recognised a need for further training and indicated a wish to participate in this. It is strongly recommended that factually correct and up-to-date medical education on ME be made a priority at undergraduate and postgraduate levels. It is also recommended that this audit be repeated following a period of medical education.

The objective of this study was to determine the ileal digestible energy (IDE), ME, and MEn of rice, broken rice, and rice bran. The birds were fed a standard starter diet from day 0 to 14 and experimental diets from day 15 to 21 after hatching. A total of 336 birds were grouped by BW and assigned to 7 diets, each diet comprised 8 replicates with 6 birds per replicate. The diets comprised a reference diet (RD) and 6 test diets (TD). The TD contained 2 levels of rice, broken rice or rice bran that partly replaced the energy sources in the RD at 120 or 240 g/kg (rice and broken rice) or 150 or 300 g/kg (rice bran). Addition of rice or broken rice to RD linearly increased (P < 0.01) ileal digestibility of DM, energy, as well as total tract metabolizability of DM, energy, and N-corrected energy in the TD. The inclusion of rice bran in the TD linearly decreased (P < 0.01) energy digestibility and utilization in the test diet. Regressions of rice-associated, broken rice-associated, or rice bran-associated IDE, ME, or MEn intake in kcal against rice, broken rice, or rice bran intake were as follows: IDE = Y = 2 (6) + 3,185 (73) × Rice + 3,199 (72) × Broken Rice + 2,562 (61) × Rice Bran, r2 = 0.98; ME = Y = 8 (6) + 3,103 (72) × Rice + 3,190 (71) × Broken Rice + 2,709 (60) × Rice Bran, r2 = 0.98; MEn = Y = 4 (5) + 3,014 (68) × Rice + 3,092 (101) × Broken Rice + 2,624 (57) × Rice Bran, r2 = 0.98; Based on the regression equations, the IDE, ME, MEn values (kcal/kg of DM) of rice were 3,185, 3,103 and 3,014, respectively, while for broken rice, the values were 3,199, 3,190, and 3,092 and for rice bran, the values were 2,562, 2,709, and 2,624, respectively.