Lacy-Nichols and Williams’ examination of the food industry illustrates how it altered its approach from mostly oppositional to regulation to one of appeasement and co-option. This reflection builds upon this by using a commercial determinants of health (CDoH) lens to understand, expose and counter industry co-option, appeasement and partnership strategies that impact public health. Lessons learned from tobacco reveal how tobacco companies maintained public credibility by recruiting scientists to produce industry biased data, co-opting public health groups, gaining access to policy elites and sitting on important government regulatory bodies. Potential counter solutions to food industry appeasement and co-option include (i) understanding corporate actions of health harming industries, (ii) applying mechanisms to minimize industry engagement, (iii) dissecting industry relationship building, and (iv) exposing the negative effects of public private partnerships (PPPs). Such counter-solutions might help to neutralise harmful industry practices, products and policies which currently threaten to undermine healthy food policies. Characterizing this approach as ‘part of the solution’ Lacy-Nichols and Williams illustrate how this strategy emerged and diffused through the food industry in the context of growing market and regulatory threats to the industry. In particular, they detail how this ‘part of the solution’ strategy can be characterized by agility and responsiveness as seen through three key pillars, (1) regulatory response and capture, (2) relationship building, and (3) new market strategies. In this reflection, we discuss the role of corporate credibility in social norms, driven by the three key pillars of strategies and responses identified by the authors. We build upon this analysis by emphasizing the importance of using a commercial determinants of health (CDoH) lens to help explain the vector-host-disease epidemiology causal pathway of diseases. In particular, we illustrate lessons learned from tobacco control as well as some key examples that have emerged in food and nutrition as potential solutions to counter these corporate actions and strategies.Lacy-Nichols and Williams’ examination of the evolving change of the food industry over the last couple of decades provides important implications for public health and beyond. This insightful piece documents how the food industry altered its approach from mostly oppositional and sometimes hostile to regulation to one of appeasement and co-option. Two-thirds of all NCD deaths are related tobacco use, alcohol misuse, poor diet and physical inactivity.During the 20th century substantial progress was made in controlling and preventing infectious diseases . In contrast, in the 21st century we are currently witnessing a dramatic increase in non-communicable diseases (NCDs) , which account for approximately 41 million deaths per year, representing 71% of annual global deaths, of which 85% occur in low- and middle-income countries. encompass the three pillars the authors explored (1) regulatory response and capture, (2) relationship building, and (3) new market strategies, among others. In doing so, emerging CDoH frameworks recognize proximal risk factor determinants (direct or downstream) impacts on disease/injury and death but shift focus towards more distal causes  that shape proximal risk factors. In particular, health harming industries  act as commercial vectors of disease that infect populations (host) through marketing practices, capturing institutions, delaying policy implementation, among others (environment) that encourage the consumption of unhealthy commodities (agent). Thus, further application of a CDoH approach can help guide our observations and research to understand the causal pathways of injury/disease and death and provide solutions to such identified problems related to commercial actions, strategies and approaches.While biological, behavioral, and social elements are all determinants of NCDs, over the last decade a new wave of research and concentration has begun to systematically focus on corporate and commercial factors that negatively impact health. CDoH, which are strategies and approaches used by businesses and corporations to promote products and choices that are harmful to health, Through lawsuits in the United States, previously secret internal tobacco industry documents were made publicly available, which were digitalized in the UCSF  Industry Documents Library among other public domains. These documents severely hurt the industry’s credibility as they provided a firsthand look into understanding the industry’s internal planning, political practices and marketing strategies. Researchers were able to get behind the veil and essentially study the corporate vector of disease (tobacco industry) and expose its deceptive tactics to undermine the negative impact of tobacco on health. These efforts led to important published research that revealed how tobacco companies for decades maintained public credibility by recruiting scientists to produce industry biased data to downplay the effects of smoking and secondhand smoke, publishing favorable industry positions in prestigious academic journals, co-opting and dividing public health groups, gaining access to policy elites and sitting on important membership boards and government regulatory bodies.For decades the tobacco industry acted as a legitimate stakeholder until the 1990s when the public discovered that the companies had lied about the addictive nature of nicotine. Yet, scholars have found that implementing FCTC Article 5.3 has not been easy as further mechanisms are needed to apply to specific contexts and deal with issues such as existing public-private partnerships. Additionally, the FCTC is still far from being implemented entirely in some low- and middle-income countries due to limited understanding and engagement beyond health agencies, as some government agencies , continue to work closely with the tobacco industry as close allies.Exposing the tobacco industry vector also helped lead to the adoption of the first and only global health treaty, the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), which recommends a series of supply and demand-side measures to reduce tobacco consumption globally. More importantly, the FCTC established Article 5.3, which essentially prevents tobacco companies from participating in government meetings and decision-making policy processes (aka part of the solution). The implementation of FCTC Article 5.3 guidelines has led to important fundamental shifts in minimizing tobacco industry executives and lobbyists from interacting with government officials and influencing policy decisions. These groups could further encourage policy-makers to establish whole-of-government (multiple government departments) cohesive policies which could help minimize inter-sectoral conflict and align in reducing health harming industry influence.Given these challenges civil society groups could examine FCTC Article 5.3 as a policy instrument to highlight success in establishing awareness and support for fundamental norm change related to industry conflicts of interest (COI).i) understanding and exposing the corporate actions of health harming industries, (ii) developing and applying mechanisms to minimize engagement with health harming industries, (iii) revealing the networks and relationship building among public and private actors, and (iv) exposing the negative effects of public private partnerships (PPPs) for policy implementation.As with tobacco, there are important ways to counter the credibility and power of food, beverage and agribusiness corporate actors in public health policy-making. We propose some of these solutions, which include , For instance, investigation around the connection and revolving doors of politicians and industry, has been effective in further accountability demands of claim-holders.Similar to studying other vectors of disease, dissecting the corporate vector from within can provide details on the important role corporate networks and relationship building of health harming industries has in sustaining their credibility and participation. Overcoming industry relationship building is a complex strategy but with the aid of better science around policy networks analysis, and exposure and potential risk associated to those, can support efforts to better scrutinize actors close to the decision-making venues. Surveillance and anger from food producer and peasant groups, key members of food production chains and largely ignored in the political economy of food corporations, have risen up against corporate actions and narratives. For example, generating greater visibility in the media and collective global civil society discussions resulted in a strong movement and opposition against the Food System Summit lead by the United Nations, an initiative to transform the global food system into a more sustainable and equitable one. The civil society mechanism, representing many claim-holders globally, opposed the initiative, as it was perceived as an industry-coopted one.Furthermore, analyzing industry global commodity chains can expose how particular parts of the commodity chain have been exploited by corporate elites. Thus, it is important to question these industry entanglements and implement mechanisms that establish transparency guidelines, COI disclosures, and accountability measures to ensure these projects benefit the public rather than corporate interests. While government funding continues to be a constraint in rejecting industry lead PPPs, generating further discussion and accountability measures can help minimize these entanglements that reinforce private interests over public interests such as the UK Responsibility Deal. Weak architecture for the global governance of nutrition and disagreements in the nutrition community on the advisability of engaging the private sector, are challenges faced to resist these engagements in relation to food policy.Another important area to expose is the industry’s usage of PPPs to establish and maintain credibility. PPPs, which are typically collaborations between government agencies and private sector companies to finance, build and operate projects , have increasingly grown due to the demand to find alternatives for financing public programs. Despite industry promises that these programs will help the public, PPPs to date have produced minimal public gains and instead have allowed industries to appeal to resource strapped agencies, establish entrenched cooperative government relations, and ultimately gain credibility to avoid government regulations. Adopting a CDoH approach helps us identify health harming industries as corporate vectors of disease and regulate their practices to better address the NCD epidemic. Exposing industry harming practices, products and policies, in combination with advocacy strategies, and government accountability mechanisms, have shown to be antidotes for addressing the vector of disease. Research exploring how these changes are affecting social norms and behaviors positively can provide evidence to further support solutions that minimize industry ‘part of the solution’ narratives and approaches. Not applicable. Authors declare that they have no competing interests. EC and AC conceptualized the idea and together co-wrote and revised the article.


As a major health hazard, the incidence of coronary heart disease has been increasing year by year. Although coronary revascularization, mainly percutaneous coronary intervention, has played an important role in the treatment of coronary heart disease, major adverse cardiovascular events (MACE) such as recurrent or persistent angina pectoris after coronary revascularization remain a very difficult problem in clinical practice.Given the high probability of MACE after coronary revascularization, the aim of this study was to develop and validate a predictive model for MACE occurrence within 6 months based on machine learning algorithms.A retrospective study was performed including 1004 patients who had undergone coronary revascularization at The People’s Hospital of Liaoning Province and Affiliated Hospital of Liaoning University of Traditional Chinese Medicine from June 2019 to December 2020. According to the characteristics of available data, an oversampling strategy was adopted for initial preprocessing. We then employed six machine learning algorithms, including decision tree, random forest, logistic regression, naïve Bayes, support vector machine, and extreme gradient boosting (XGBoost), to develop prediction models for MACE depending on clinical information and 6-month follow-up information. Among all samples, 70% were randomly selected for training and the remaining 30% were used for model validation. Model performance was assessed based on accuracy, precision, recall, F1-score, confusion matrix, area under the receiver operating characteristic (ROC) curve (AUC), and visualization of the ROC curve.P<.05) between the groups without and with MACE. Coupled with these significant factors, among the six machine learning algorithms, XGBoost stood out with an accuracy of 0.7788, precision of 0.8058, recall of 0.7345, F1-score of 0.7685, and AUC of 0.8599. Further exploration of the models to identify factors affecting the occurrence of MACE revealed that use of anticoagulant drugs and course of the disease consistently ranked in the top two predictive factors in three developed models.Univariate analysis showed that 21 patient characteristic variables were statistically significant (The machine learning risk models constructed in this study can achieve acceptable performance of MACE prediction, with XGBoost performing the best, providing a valuable reference for pointed intervention and clinical decision-making in MACE prevention. The treatment of coronary heart disease has experienced major advances with respect to thrombolysis , percutaIn recent years, there has been an explosion of studies on MACE risk assessment, which can be divided into rule-based expert systems, statistical-based analysis techniques, and machine learning (ML)-based prediction models . As a reThese studies have indicated that ML has better predictive performance over conventional statistical approaches. Hence, it might be a better choice to develop a predictive model by capitalizing on the strong generalization and robustness of ML methods. However, in clinical reality, a nonnegligible problem is that the distribution of data is often imbalanced and can even be severely imbalanced in some cases ; that isData imbalance is a common clinical occurrence . For exaAccordingly, to achieve risk prediction of MACE after coronary revascularization, the aim of this study was to establish prediction models using ML algorithms based on sufficient data processing. First, the SMOTE technique was adopted to balance the initial imbalanced data set. For model construction, six algorithms were respectively employed to build six predictive models, and then the optimal model was determined according to systematic comparison and evaluation. The models were then further explored to identify factors affecting the occurrence of MACE. This study can therefore provide a valuable reference for pointed intervention and clinical decision-making in MACE prevention.We retrospectively collected the medical records of patients who underwent coronary revascularization at The People’s Hospital of Liaoning Province and Affiliated Hospital of Liaoning University of Traditional Chinese Medicine from June 2019 to December 2020, including clinical information and follow-up information within 6 months of surgery.The general inclusion criteria were as follows: (1) age ≥18 years and ≤85 years; (2) patients with previous coronary revascularization (including CABG and/or PCI).Exclusion criteria were as follows: (1) patients with incomplete medical records and unable to provide original surgical information; (2) patients who had not undergone coronary revascularization or for whom the surgery failed; (3) patients who required mechanical assistive therapy with an intraaortic balloon pump (IABP) after successful coronary revascularization treatment, since these patients are critically ill, requiring IABP treatment to maintain vital signs and do not have indications for discharge or follow-up; (4) combined with other heart diseases such as malignant arrhythmia, cardiac insufficiency before and after surgery , or severe cardiopulmonary insufficiency, as these patients are in a severe condition and have underlying diseases resulting in a poor prognosis or even surgical intervention, leading to lack of follow-up or are already at the endpoint before enrollment; and (5) patients with neuropathy or those who may not be able to participate in the study due to literacy, language, or other communication barriers.Before data modeling, data analysis and preprocessing are indispensable . We usedThe preliminary exploratory analysis revealed that the original data set had a category imbalance problem; that is, the ratio of the number of samples with and without MACE was approximately 1:3, which would affect the performance of the final risk prediction model to a certain extent. Therefore, we determined that the original data set should first be processed by equalization. Currently, the main strategies to solve the imbalanced classification problem include oversampling and undersampling , among wSMOTE is a novel oversampling technique proposed by Chawla et al , which hx in the minority class, calculate the Euclidean distance between x and all samples in the minority class and obtain its k-nearest neighbors.(1) For each sample x at random.(2) Select several samples from the k-nearest neighbors of nx, a new sample is synthesized according to the formula:(3) For each randomly selected neighbor Depending on the sampling rate, we set the execution time and repeated the above process. Finally, we obtained the final minority class by combining the synthetic samples with the original samples.χ2 test, whereas the measurement data are presented as means (SD) and analyzed by t tests. A P value less than .05 was accepted to indicate statistical significance.All data were statistically analyzed with SPSS 26.0 software. The enumeration data are expressed as count (percentage), processed with a ML algorithms are characterized by better performance compared with traditional statistical methods in risk prediction, which were selected for modeling in MACE prediction in this study. We randomly separated the entire data set into a training set and validation set with an approximate ratio of 7:3, in which the training set was used to construct the prediction model and the validation set was used to verify and evaluate the model performance. Six ML algorithms were employed to construct risk prediction models: decision tree (DT), random forest (RF), logistic regression (LR), naïve Bayes (NB), support vector machine (SVM), and extreme gradient boosting (XGBoost). Among them, RF and XGBoost are ensemble ML classifiers and the others are single classifiers. Throughout the experiment, we implemented modeling and evaluation using Python 3.8 with open-source Python libraries. During the training process, the optimal parameters were determined by 10-fold cross-validation to prevent overfitting, and then we obtained the final ML-based risk models of MACE prediction.The performance of ML models is often assessed with certain evaluation metrics . The bleFor classification tasks, the confusion matrix  is also Based on the confusion matrix, the values of the other evaluation metrics can be readily calculated, as follows:Where TP is true positive, TN is true negative, FP is false positive, and FN is false negative.This study was approved by the Institutional Review Board of The Affiliated Hospital of Liaoning University of Traditional Chinese Medicine (2019034FS(KT)-016-02).P<.05) between the groups without and with MACE, namely age, smoking, work, course of the disease, family history, seasonal onset, previous myocardial infarction, dyslipidemia, brain infarction, cardiac insufficiency, traditional Chinese medicine (TCM) treatment, anticoagulant drugs, antiarrhythmic drugs, diuretic, lansoprazole injection, bleeding events, left atrial diameter (LAD), left ventricular ejection fraction (LVEF), bypass surgery, Hamilton anxiety scale (HAMA), and Hamilton depression scale (HAMD).Based on expert experience, a total of 1004 samples with 41 characteristic variables were finally adopted for model construction after data preprocessing, including 251 cases with MACE and 753 cases without MACE. The detailed statistical information of the feature variables and results of the univariate analysis of MACE are shown in To cope with data imbalances in the original data sets, the SMOTE algorithm was employed. The sample distribution before and after oversampling is shown in Taking whether MACE occurred within 6 months as the label and 21 statistically significant factors in the univariate analysis as features, the MACE risk prediction models were constructed by DT, RF, LR, NB, SVM, and XGBoost, respectively. As the central aspect, model evaluation is quite essential. First, we comprehensively compared ML algorithms before and after oversampling to test the effectiveness of the SMOTE strategy, with specific results presented The ROC curves for the six ML algorithms based on balanced data sets are detailed in As another method to assess the effectiveness of classification, the confusion matrices of all methods are illustrated in For a deeper exploration and interpretation of the constructed models, the relative importance of feature variables in each MACE-predicting model is shown in descending order in As shown in MACE such as recurrent angina can still occur after coronary revascularization, thus affecting the efficacy and prognosis of surgery. Detecting the postoperative characteristics of patients and combining them with preoperative information to establish a risk assessment model can provide timely warning of the risk of MACE occurrence, thereby helping medical staff and patients to intervene in a timely manner and achieve the purpose of treating the disease before it occurs . In thisAccording to existing studies, the risk factors of MACE after coronary revascularization can be roughly divided into two categories : (1) uncThe secondary prevention of coronary heart disease consists of two main measures: (1) identification and control of risk factors and (2) appropriate drug therapy . For druCoronary heart disease belongs to the category of “chest pain” or “heartache” in TCM. The main purpose of treatment is to reduce the incidence of angina pectoris, heart failure, myocardial infarction, and other adverse cardiovascular events . In receWith establishment of the bio-psycho-social medical model, the important role of psychological factors on the occurrence and development of diseases is becoming more widely recognized . A largeThere are several practical deficiencies and limitations of this study. First, the amount of data available for analysis was limited. It is well known that the performance of ML algorithms depends to a certain extent on the sample size and that the model constructed cannot achieve the best performance, and may even be overfitted, with a small data set. In the future, with data supplementation and further research, we will consider more complex ML algorithms, including deep-learning algorithms, to obtain more accurate and efficient prediction models for clinical observation and research. Second, this was a retrospective study from two centers . There is a lack of follow-up data on clinical factors and relevant disease progression; thus, a large multicenter sample study is desired for further generalizability and reliability of the results. Last but not least, in addition to numerical structured data such as vital signs and laboratory tests, clinical electronic medical records also contain a massive amount of unstructured data in the form of text such as patients’ complaints, diagnostic records, and medication information; thus, determining the best ways to use such unstructured information for data analysis and modeling will be the focus of future research. Moreover, we plan to integrate structured and unstructured data comprehensively to develop a risk assessment model to predict the risk probability of MACE in patients with coronary heart disease after revascularization.In this study, we developed and evaluated risk prediction models for MACE within 6 months after coronary revascularization by utilizing available clinical variables and postoperative follow-up information with ML algorithms. The constructed model can effectively identify high-risk patients with good performance, and the factors that may be associated with MACE were also explored and analyzed in-depth, which is of great significance to provide a reference for medical staff to carry out risk management.


Oryza sativa L.) is considered as a staple food for more than half of the global population, and sustaining productivity under a scarcity of resources is challenging to meet the future food demands of the inflating global population. The aerobic rice system can be considered as a transformational replacement for traditional rice, but the widespread adaptation of this innovative approach has been challenged due to higher losses of nitrogen (N) and reduced N-use efficiency (NUE). For normal growth and developmental processes in crop plants, N is required in higher amounts. N is a mineral nutrient and an important constituent of amino acids, nucleic acids, and many photosynthetic metabolites, and hence is essential for normal plant growth and metabolism. Excessive application of N fertilizers improves aerobic rice growth and yield, but compromises economic and environmental sustainability. Irregular and uncontrolled use of N fertilizers have elevated several environmental issues linked to higher N losses in the form of nitrous oxide (N2O), ammonia (NH3), and nitrate (NO3–), thereby threatening environmental sustainability due to higher warming potential, ozone depletion capacities, and abilities to eutrophicate the water resources. Hence, enhancing NUE in aerobic rice has become an urgent need for the development of a sustainable production system. This article was designed to investigate the major challenge of low NUE and evaluate recent advances in pathways of the N cycle under the aerobic rice system, and thereby suggest the agronomic management approaches to improve NUE. The major objective of this review is about optimizing the application of N inputs while sustaining rice productivity and ensuring environmental safety. This review elaborates that different soil conditions significantly shift the N dynamics via changes in major pathways of the N cycle and comprehensively reviews the facts why N losses are high under the aerobic rice system, which factors hinder in attaining high NUE, and how it can become an eco-efficient production system through agronomic managements. Moreover, it explores the interactive mechanisms of how proper management of N cycle pathways can be accomplished via optimized N fertilizer amendments. Meanwhile, this study suggests several agricultural and agronomic approaches, such as site-specific N management, integrated nutrient management (INM), and incorporation of N fertilizers with enhanced use efficiency that may interactively improve the NUE and thereby plant N uptake in the aerobic rice system. Additionally, resource conservation practices, such as plant residue management, green manuring, improved genetic breeding, and precision farming, are essential to enhance NUE. Deep insights into the recent advances in the pathways of the N cycle under the aerobic rice system necessarily suggest the incorporation of the suggested agronomic adjustments to reduce N losses and enhance NUE while sustaining rice productivity and environmental safety. Future research on N dynamics is encouraged under the aerobic rice system focusing on the interactive evaluation of shifts among activities and diversity in microbial communities, NUE, and plant demands while applying N management measures, which is necessary for its widespread adaptation in face of the projected climate change and scarcity of resources.Rice ( Oryza sativa L.) is cultivated widely across the globe, except in Antarctica due to the icy conditions throughout the year. About 90% of the global rice is cultivated in Asia, the topmost continent for rice cultivation  under the transformed aerobic rice system. The second section of the article specifies the investigation of challenges due to high N losses associated with the aerobic rice system and how an aerobic rice system can be an important and eco-efficient rice production system under changing climatic conditions. Moreover, it also reviews the major factors impacting the N management and NUE. The final section expands toward the evaluation of several agricultural and agronomic management measures aiming to reduce the high N losses, while increasing the NUE and grain yield under an aerobic rice system with limited threats to environmental safety.Climate change is a reality and subsequently impacts the population, ecosystems, and livelihoods . Due to 2) concentrations from 284 to 410 ppm from 1832 to 2013  annual report 6 (AR6) working group I (WGI) report, and most of this temperature change was noticed in the last 30 years of the 19th century . Three m to 2013 , respect to 2013 . Moreove to 2013 . Meanwhiy oceans , 2015. Hy oceans .Climate is considered as one of the environmental components for the success or failure of a crop plant. It assists and plays an important role in short- and long-term crop planning, particularly under changed climate conditions or climate disaster events . Past cl4) emissions but serve several issues of environmental hazards due to high N losses via volatilization and leaching.Global rice production has been threatened due to uneven and unsteady climatic variabilities, particularly in Asia. Climate change and rice production are closely interlinked with each other, as the flooded rice system contributes to GHG emissions and causes global warming, thus climate change ultimately impacts the rice cultivation system . AccordiThe emission of GHGs from either flooded or modified rice soil is majorly dependent on soil organic matter (OM) content, land use, cropping intensity and pattern, irrigation management, microbial abundance and functioning, soil chemical and physical properties, and environmental variables . MoreoveRice is an important staple food crop in many countries around the globe. In Asia, the social and economic stability is mostly dependent on flooded rice production, and it is a key element for the livelihood and dietary requirements of more than two billion population worldwide . Convent–1 with approximately 60% water saving was observed  and nitrate (NO3–)  . Under ttilizers . Synthet in soil . However in soil . Several in soil .4 oxidation under rice flooded conditions have also been considered. Under conventional flooding and aerobic rice systems, the irrigation methods and management practices directly affect the availability, uptake, and loss of soil N  oxidation, denitrification, and fixation  and N immobilization (conversion of inorganic N to organic) principally through microbial assimilation activities, consequently causing accumulation of NH4+ in the soil  is termed as nitrification   and ammonia-oxidizing archaea (AOA)  . Recent ea (AOA) . A Positea (AOA) . Howeverea (AOA) . So, undNitrospira species  belonging to the genera Nitrospira, Nitrobacter, Nitrospina, and Nitrococcus , which can also serve as alternative electron acceptors  contents, are ensured with optimized microbial functioning in the reduction of N oxides  is being manufactured via chemo-denitrification or nitrification process  is converted into gaseous NH3 or reduced inorganic form (NH4+) as the end product, as discussed in the previous sections  and other metabolic pathways. Moreover, it has also been described earlier that if the NH4+ N is not readily taken up by the microbial communities or excessively present than required in the metabolic processes, it will lead to high N losses to the ambient environment, soil, or water for plant uptake via nitrification  and organic N to NO3– via intermediate NO2– without acquiring any of their required energy  more obviously in soil with high pH  under differential availability of soil C  and microbial C and N content  are significantly positively associated with other fungal species in the rhizosphere of wild rice, while marginally a set of only three groups of AMF  are strongly positively correlated with other fungi that harbor in the rhizosphere of domesticated rice varieties  was designed aiming to increase the nutrient-use efficiency of major nutrients, such as N, phosphorus (P), and potassium (K), and to generate field-specific fertilizer recommendations . The SSNIntegrated nutrient management (INM) includes the optimum and balanced use of indigenous N components, i.e., plant residues, organic manures, biological N fixation, mineral N fertilizers, and their complementary interactive pathways to increase N recovery and NUE . The pos4+-containing N fertilizers, NO3–-containing N fertilizers are more susceptible to leaching, whereas the former is more prone to volatilization loss than the latter. A range of slow- and controlled-release N fertilizers are now commercially available, and their utilization along with potential mitigation strategies leads to a sustainable agricultural production system by limiting N losses and thereby improving NUE  due to the replacement of conventional methods with an aerobic rice system, as several novel developments have depicted shifts in N cycle during this transformation. This study also discusses that N losses either in the form of gaseous volatilization or leaching are high under the aerobic rice system due to coupled nitrification-denitrification processes under the AWD irrigation approach, making it less economic and restricting its successful adaptation. Moreover, this study unveils the roles of important microbial communities, how an aerobic rice system can be an eco-efficient production approach through management measures, and which factors impact the management measures and hinder high NUE under this transformed rice system. This study discussed the interactive management mechanisms of how proper management of the N cycle can be accomplished through optimized N fertilizer inputs along with compound form amendments. Meanwhile, several agricultural adjustments, such as SSNM, INM, and incorporation of enhanced use efficiency N fertilizers, are also suggested that may interactively impact the activities and abundance of microbial communities involved in the overall N cycle and improve plant N uptake. Moreover, resource conservation and management approaches like crop residue management, green manuring, improved genetic breeding, and precision farming measures are intimated to increase the NUE under the aerobic rice system. Hence, it has been concluded that after careful insights into the pathways of the N cycle under aerobic soil conditions, incorporation of the suggested agronomic adjustive measures can reduce N losses, thereby enhancing NUE under the aerobic rice system while ensuring higher grain yield and environmental safety.Globally, for widespread adaptation of the aerobic rice system, it is necessary to conduct research focusing on how interactive activities of microbial communities, such as ammonia oxidizers, nitrifiers, and denitrifiers, change under varying soil conditions. Currently, a major challenge associated with the aerobic rice system is the limited understanding of the relationships among different microbial communities when incorporating any N fertilizer management measure. Due to limited knowledge about interactive features among N management measures, and shifts in microbial communities and their functioning, NUE in aerobic rice system is really infelicitous. Moreover, the interactive evaluation of spatial and temporal changes in abundance, diversity, and functioning of microbial communities under aerobic soil conditions while undertaking any of the agronomic management measures is still limited. Incorporation of agronomic management measures for aerobic rice system aiming toward increasing NUE while reducing the N losses may likely impact the activities and abundance of soil microbial communities and soil biochemical features. Therefore, coupled understanding of changes in soil biochemical properties and microbial communities while incorporating N management approaches can additionally favor in increasing the overall NUE in the aerobic rice system. Thus, further research studies on aerobic rice systems are encouraged to design experiments focusing on the interactive evaluation of shifts among activities and diversity of microbial communities, plant N demands, and N management measures. This will improve the knowledge and understanding of the response mechanisms in terms of abundance, diversity, and activities of soil microbial communities under different agronomic N management practices that may further help in improving NUE and reducing N losses for higher grain yield and environmental safety.MF and HF gestated the idea and collected and compiled the relevant literature for the study. MF and MU visualized and validated the figures. MF, HF, OR, ZM, MY, MK, SF, XW, and MU helped in the write-up of the original draft. All authors carefully read, revised, and approved the article for submission.


Companies increasingly set science-based targets (SBTs) for reducing greenhouse gas emissions. We review literature on SBTs to understand their potential for aligning corporate emissions with the temperature goal of the Paris Agreement.SBT adoption by larger, more visible companies in high-income countries has accelerated. These companies tend to have a good prior reputation for managing climate impacts and most appear on track for meeting their scope 1 and 2 SBTs. More research is needed to distinguish between substantive and symbolic target-setting and understand how companies plan to achieve established SBTs. There is no consensus on whether current target-setting methods appropriately allocate emissions to individual companies or how much freedom companies should have in setting SBTs. Current emission accounting practices, target-setting methods, SBT governance, and insufficient transparency may allow companies to report some emission reductions that are not real and may result in insufficient collective emission reductions. Lower rates of SBT diffusion in low- and middle-income countries, in certain emission-intensive sectors, and by small- and medium-sized enterprises pose potential barriers for mainstreaming SBTs. While voluntary SBTs cannot substitute for more ambitious climate policy, it is unclear whether they delay or encourage policy needed for Paris alignment.We find evidence that SBT adoption corresponds to increased climate action. However, there is a need for further research from a diversity of approaches to better understand how SBTs may facilitate or hinder a just transition to low-carbon societies. Science-based targets (SBTs) translate the temperature goal of the Paris Agreement to company-level greenhouse gas (GHG) emission reduction commitments. To date, more than 1000 companies have set SBTs, which are widely associated with serious intentions on climate action. For example, the UK government conflated SBTs with “strong climate credentials” in their call for corporate sponsors for the COP26 event , and theThe concept has also attracted critical attention. When the practice of setting SBTs was in its infancy, Trexler and Schendler  argued tHere, we provide the first review of the academic literature on SBTs to shed light on their role in meeting the Paris temperature goal. We synthesize the findings of this literature using three lenses: existing company engagement with SBTs, appraisal of SBT methods and governance, and the prospects of SBT diffusion and interactions with policy. We then conclude with the implications of current findings and knowledge gaps for actors developing methods and guidance for setting SBTs, policymakers, and future research.The SBT term has only recently been used in the context of companiesSBTi is a partnership between CDP (formerly the Carbon Disclosure Project), the United Nations Global Compact, the World Resources Institute, and the World Wildlife Fund and is funded through target certification fees and various corporate and charitable foundations . SBTi ofSBTi currently recommends two target-setting methods, which are integrated in the organization’s target calculation tool, for scope 1 and 2 emissionsFor some sectors, SBTi allows or requires companies to use sector-specific target-setting methods, of which some are variants of ACA and SDA  and othFor scope 3 emissionsAll SBTs must cover a minimum of 5 years and a maximum of 15 years from the date of submission to SBTi for approval . While companies are free to choose their base year, SBTi recommends the use of the latest year for which data without an atypical emission profile are available. In general, companies should express SBTs as percentage reduction in absolute emissions or emission intensities . For scope 2, SBTi also permits targeting increased procurement of renewable electricityWhereas companies normally commit to setting an SBT, submit an SBT for approval, and wait for the SBTi to validate the SBT , the SBTSince its creation in 2015, SBTi has approved targets for more than 1,000 companies Must focus on SBTs for climate change Must address SBTs substantially Must involve a novel analysis We considered literature already known to us, performed searches on Google ScholarThe process led to the identification of seventeen studies included in this review , 56–58. Existing company engagement with SBTs: what drives companies to set SBTs, how does SBT adoption affect company climate action, and are companies on track to achieve their SBTs?Appraisal of SBT methods and governance: do target-setting methods and governance align collective corporate action to the Paris temperature goal and is corporate emission disclosure sufficient for assessing this alignment?Prospects of SBT diffusion: will voluntary SBT adoption continue to grow, will it be sufficient for aligning the private sector to the Paris Agreement, and how might SBTs interact with existing and emerging policy?The first author reviewed all studies, identified relevant topics covered, and assigned a set of topics and associated studies to each author. Each author then evaluated the methods and findings of their assigned studies, performed an initial synthesis of the literature for their assigned topics, and presented their evaluation and synthesis to the full research team. The full research team collaboratively judged the interpretation and relevance of each study and synthesized the collective findings. Our findings are organized by the following research lenses, which emerged from this process:The seventeen studies were mostly published in peer-reviewed journals, commonly related to the broad fields of climate change, environmental protection, or sustainability, but in some cases with a narrower focus, e.g., sustainable finance , global According to the literature reviewed, companies are more likely to set emission targets (SBTs and others) if they are larger, more visible, and already disclose emissions and have lower absolute emissions . Of these target-setting companies, those with higher emissions, higher perceived business risk from climate change, experience setting and achieving ambitious targets, and higher reputation for managing climate impacts are more likely to set SBTs. Findings that companies set SBTs to ensure sufficiently ambitious targets, confer legitimacy on climate efforts, and mitigate business risk from climate change suggest both substantive and symbolic motives. There is mixed evidence as to whether SBTs lead to more ambitious targets, but companies with SBTs report higher investments in emission reduction initiatives. There is some evidence that climate-related investments may not be sufficiently leveraged to achieve SBTs. Nonetheless, companies are making good progress towards achieving their scope 1 and 2 SBTs. Achievement of scope 3 SBTs has proven more challenging, likely due to the lack of control companies have over these emissions.Two preprint studies empirically investigated target-setting practices. Bolton and Kacperczyk  considerFreiberg et al.  investigSeveral additional studies touched on the drivers of SBT adoption. Piper and Longhurst   . Bjørn eRegarding scope 3 targets, Li et al.  noted thIn their abovementioned studies of company performance against established SBTs, SBTi  and GiesEven for companies disclosing emissions in a comprehensive and consistent way, there may be issues. Trexler and Schendler  expresseSpecifically for scope 3 emissions, Li et al.  argued tWhile SBT uptake has increased substantially since the establishment of the SBTi in 2015, uneven representation of low- and middle-income countries and certain sectors poses a potential barrier for mainstreaming SBTs. Discussion about the role normative, mimetic, and coercive (regulatory) pressures might play in mainstreaming SBTs has been accompanied by descriptions of a few relevant initiatives , but systematic assessments of the effectiveness of such initiatives are lacking. There are debates about whether voluntary SBTs will enable more ambitious climate policy. Overall, the literature does not provide a compelling case that the voluntary approach will be sufficient for aligning the private sector to the Paris Agreement.In 2015, Trexler and Schendler  and Fig.SBTs are mostly set by companies in high-income countries, with mainstreaming in low- and middle-income countries seemingly far-off Fig. . Yet, SBThe currently uneven representation of sectors among SBTs  are not sufficient conditions for society-wide decarbonization in the scale that is needed , 6, 45. In their study of the drivers and effects of SBT-setting, Bolton and Kacperczyk  also expOverall, the reviewed literature involves different assumptions and expectations of the “policy spill-over”  of SBTs.Our literature review points to several actions that SBTi can take to improve the integrity of SBTs and the chances of a positive global impact. To increase transparency, SBTi could document the decision-making process and selection criteria behind its recommendation of two specific target-setting methods (ACA and SDA), explicitly communicate the value judgments embedded in target-setting methods, and require companies with approved targets to publish information about the target-setting method and related company data. To increase the legitimacy of SBTs, SBTi could require companies with approved targets to periodically report third-party verified emission (and activity) data to a central, open access database, prevent companies from reporting emission reductions that are not real through market-based mechanisms, and reconsider the concept of SBTs for “renewable electricity procurement.” To increase uptake and the potential for positive impact, SBTi should target companies not already recognized for their climate disclosures  and increase efforts to recruit SMEs, companies in low- and middle-income countries, and companies in high-emitting sectors.Our study also points to implications for policymakers. First, voluntary SBTs cannot substitute for the policies needed to reduce GHG emissions sufficiently to meet the Paris temperature goal. The uptake across regions and sectors is too uneven and it is unlikely that initial target progress will continue in the absence of new policy. Moreover, the potentials for creative emission accounting and incomplete emission disclosure make it difficult to even assess target progress and the effect on global emissions. Second, if policymakers aim to co-regulate SBTs with the SBTi (as proposed by Lister ), work iThere is growing emphasis on the role of SBTs to decarbonize the private sector as part of global effort to achieve the temperature goal of the Paris Agreement. The emerging body of literature related to existing company engagement with SBTs (lens 1) shows a relationship between company engagement with SBTs and prior experience reporting emissions, setting internal targets and achieving emission reductions; SBT-setting companies on average are setting higher percentage emission reduction targets than internal target-setting companies (but perhaps over a longer timeframe), reporting increased investment towards emission reductions and making progress towards achieving scope 1 and 2 SBTs; evidence of both symbolic and substantive action; and lacking engagement from the largest emitting companies. Definitive conclusions are hindered by current incomplete and inconsistent corporate disclosures. Additional research is needed to understand the mechanisms linking emission reporting and internal target-setting and achievement to SBT setting, distinguish between symbolic and substantive SBT adoption, identify investments and actions that lead to SBT progress, assess companies’ ability to achieve SBTs in the long-term, understand the extent to which companies can influence and monitor scope 3 SBT achievement, and perhaps most importantly, understand the specific barriers to SBT adoption by high-emitting companies and companies in underrepresented regions. This will require access to standardized, transparent corporate disclosure on targets, investments, and progress as well as rigorous hypothesis formulation and testing to understand the specific drivers, barriers, and outcomes of SBT engagement. Moreover, there is a lot to gain from more diversity in methodological approaches including both qualitative  and mixed methods research.At least seven methods for setting SBTs have been proposed, each using different target equations, global emission scenarios, and subjective allocation principles to translate global allowable emissions to individual companies. The emerging literature on target-setting methods and governance (lens 2) raises concerns as to whether the two recommended SBT-setting methods, use of renewable energy certificates, and flexible scope 3 accounting approaches and target-setting approaches will impede collective alignment with the Paris temperature goal. Apart from one study that theoretically validated the concern about existing methods leading to a combined overshoot of global allowable emissions, the validity and impact of these concerns remain largely untested. While these concerns can (and should) be theoretically and empirically analyzed, more fundamental questions relate to value judgments  inherentRegarding the prospects for SBT diffusion (lens 3), emerging literature shows some evidence of mainstreaming, but uptake is still low in the most polluting industries, in low- and middle-income countries, and by SMEs. Given the urgency of climate change, the insufficiency of current public policy, and the emphasis on voluntary SBTs as a means for decarbonizing the private sectors, there is a critical need for studies from a variety of perspectives on how SBTs interact with existing and emerging climate policy. This includes exploring under what conditions SBTs may speed up or slow down more ambitious policy and how SBT influence total corporate greenhouse gas emissions. Regarding the last point, SBTs should be positioned in the broader literature on political economy, political ecology, and climate justice by asking questions such as given the global nature of capital and commodity flows, how may SBTs facilitate or hinder a just development between the Global North and Global South? With its focus on production, how may SBTs impact (in)equalities in consumption and consumption-based GHG emissions? How do companies seek to square SBTs with continued profit accumulation and what are the consequences thereof? Addressing such questions reflects the reality that any operational target will always be a socio-political choice and highlights the need for continued reflexivity and critical scrutiny of SBT-related practices.


Sertraline is one of the most commonly used antidepressants worldwide and is one of the first-choice treatments for depression during pregnancy. This study is aimed at testing the possible association between sertraline intrauterine exposure and congenital cardiac and vascular disorder occurrences by assessing the publicly available US Food and Drug Administration Adverse Event Reporting System (FAERS).  Disproportionality analysis and Bayesian analysis were used to mine FAERS for suspected congenital cardiac and vascular disorder data for sertraline intrauterine exposure from the first quarter of 2004 to the second quarter of 2021.  Among the 914 cases of sertraline used with congenital cardiovascular disease in the FAERS database, the reporting areas were mainly in the United States and Europe. The number of adverse events reported every year since 2004 has no many differences. Congenital anomalies are the most frequently reported serious clinical outcome. Among the 69 positive signals detected from 914 cases, 31 were invalid signals, and 38 were valid signals according to criteria. The most common ones are heart disease congenital, atrial septal defect, ventricular septal defect, patent ductus arteriosus, and persistent fetal circulation.  Mining FAERS data can analyze and study the adverse reactions of sertraline in a more comprehensive and in-depth manner, thereby effectively reducing the risk of clinical medication. The prevalence rate of depression during pregnancy is high, ranging from 7% to 20% . DepressSelective serotonin reuptake inhibitors (SSRIs) are considered as the most prescribed antidepressants during pregnancy because of its wealth and reassuring of data . ApproxiSome countries or organizations have established pharmacovigilance systems, such as the US Food and Drug Administration (FDA), European Medicines Agency (EMA), and the World Health Organization (WHO), for adverse drug reaction (ADR) monitoring. The FDA's Adverse Event Reporting System (FAERS) is the largest repository of passively reported adverse drug events worldwide . Given tA retrospective pharmacovigilance study was performed using data from FAERS database covering period from the first quarter of 2004 to the second quarter of 2021. FAERS is a spontaneous reporting system (SRS) that contains adverse event reports, medication error reports, and product quality complaints resulting in adverse events submitted to FDA by healthcare professionals, consumers, manufacturers, and patients. The database contains demographic information, drug information, and reaction information. Each report has a primary suspected drug with one or more adverse drug reactions (ADR) and may include other drugs taken by the patient .The ASCII data files of the FAERS contain demographic and administrative information (DEMO), drug information (DRUG), adverse events (REAC), patient outcomes (OUTC), report sources (RPSR), therapy start dates and end dates for reported drugs (THER), and indications for use (INDI).A total of 15881123 reports were retrieved from the FAERS. A deduplication procedure was performed according to the FDA's recommendations to select the latest FDA_DT with the same CASEID and select the higher PRIMARYID when CASEID and FDA_DT are both the same, resulting in a reduction in the number of reports to 13327865. On the basis of the PRIMARYID of the deduplicated DEMO, DRUG and REAC were both deduplicated as well.FAERS data requires substantial curated cleaning and normalizing before they can be used appropriately; otherwise, data can have material impact on analysis results. We used Python (version 3.8) and PostgreSQL (version 12) to deal with cleaning and normalizing process which includes merging data, deduplicating records, applying standardized vocabularies with drug names mapped to RxNorm concepts and indications and outcomes mapped to SNOMED-CT concepts, and normalizing reaction to MedDRA (version 24.0) concepts and used the R software (version 4.1.0) to statistical compute drug-reaction signals. “Sertraline” was chosen as the drug name with a reported role code “PS” (primary suspect drug)  and reacBoth disproportionality analysis and Bayesian analysis applied with the use of the reporting odds ratio (ROR), proportional reporting ratio (PRR), Bayesian confidence propagation neural network (BCPNN), and multi-item gamma Poisson shrinker (MGPS) algorithms were used to investigate the potential signals between the drug and the specific adverse event of interest. The equations and criteria for the four algorithms above –25 are dAll procedures performed in this study involving human participants were in accordance with the 1964 Helsinki declaration. This study was exempted from approval by the ethics committee of the Second Hospital of Shandong University.In total, 914 cases of intrauterine sertraline exposure with fetal congenital cardiovascular disease were identified in the FAERS database. Of these events, 43% occurred in male offspring, 42.23% occurred in female offspring, and 14.77% of the events were gender unknown . It noteThe number of adverse events reported every year since 2004 has no many differences, which demonstrates the stable safety of sertraline for a long period . The majAmong the 69 positive signals detected from 914 cases, 31 were invalid signals, and 38 were valid signals according to criteria. The most common ones are heart disease congenital (PT: 10019273), atrial septal defect (PT: 10003664), ventricular septal defect (PT: 10047298), patent ductus arteriosus (PT: 10034130), and persistent fetal circulation (PT: 10034708) .The most common clinical indications for sertraline in the report were depression 355 (51.52%) and anxiety 136 (19.74%), which are consistent with the indications of sertraline . Since tSSRI may be associated with an increased risk for birth defects or congenital heart defects overall , 26, 27,Embryonic development is a complex process; it is commonly accepted that the first trimester of pregnancy is a key period in fetal development . Therefore, studies in the literature have explored the effects of intrauterine exposure of sertraline in the first trimester on the fetus. However, in these studies, the number of malformations after exposure is small, which is related to the lower incidence of fetal malformations. The number of positive cases may cause deviations in the results. FAERS database collects the global adverse drug reaction reporting data, which has a higher population base. We analyzed the FAERS database and obtained 914 cases of fetal heart development related adverse reactions after sertraline exposure and obtained 69 adverse reaction entries through statistical analysis, which obtained more positive results compared with the previous literature. The vast majority of the 69 adverse reactions significantly related to sertraline intrauterine exposure were structural abnormalities of fetal cardiovascular system, of which 38 were strongly significantly associated with, except that “trisomy 21” was not related to cardiovascular system; the other 31 were adverse reactions of cardiovascular system, which were structural malformations. The above results from the real-world analysis of FAERS have also been more accurately verified by echocardiography in the studies performed by Ansah et al.  and KoldIn sertraline's instructions, persistent pulmonary hypertension (PPHN) is the only clearly stated description of adverse reactions of fetal malformations; the relationship between it and SSRIs has been discussed in related studies . MasarwaIn the results of this study, one of the items of abnormal offspring development caused by sertraline intrauterine exposure is corrected transposition of great vessels. Corrected transposition of great vessels is a rare complex congenital heart disease often accompanied by ventricular septal defect, pulmonary artery stenosis or atresia, Ebstein-like malformation of the tricuspid valve, and median heart, and is worth noting because it has the highest reporting odds ratio of ROR, PRR, and EBGM. Moreover, corrected transposition of great vessels has not been noticed in previous sertraline-related studies. Moreover, due to the highest reporting odds ratio of the corrected transposition of great vessels but the low frequency, there may be statistical deviations. The pathogenesis of corrected transposition of great vessels is still unclear; the specific mechanism of sertraline interfering with fetal programming in uterus requires further experimental research.Among the fetal adverse reactions significantly related to sertraline exposure analyzed in this study, three terms are more interesting, namely, trisomy 21, trisomy 18, and trisomy 13, of which trisomy 21 is strongly related. At present, no reports and studies have been retrieved about the intrauterine exposure of sertraline during pregnancy and the chromosomal abnormalities of the offspring. However, with the existence of 5-HT and its receptor in female reproductive system and subsequent functional researches, 5-HT was believed to play an important role in egg maturation and early embryonic development . In animThe specific mechanism of fetal cardiovascular malformation caused by sertraline intrauterine exposure is not clear. In this study and previous literature, the gender of offspring did not show a significant correlation with cardiovascular malformations in sertraline exposed cases, suggesting that gender has nothing to do with the incidence . Animal Further excavation of the FAERS database can expand new ideas for evaluating the safety of drugs used during pregnancy and is a research method that is worthy of further in-depth development. But this method also has limitations. First, because FAERS data is a voluntary report, including public reports, there are problems such as underreporting, selective reporting, and lack of information. In addition, although the analysis shows that there is a statistical correlation between the drug and the adverse event, the actual causality still needs further verification. In addition, most of the FAERS data come from European and American populations and relatively few Asian populations.In this study, ADR signal detection is carried out through the FAERS database; a comprehensive and in-depth analysis indicated that the maternal application of sertraline during pregnancy has a significant association with cardiac abnormalities of offspring. This result provides new supplements for the related adverse reactions in the instructions and also provides an objective basis for clinical safe medication. At the same time, the detection of adverse reaction signals should also rely on large, well-organized epidemiologic studies to obtain relatively sufficient evidence.


European green agricultural policies have been relaxed to allow cultivation of fallow land to produce animal feed and meet shortfalls in exports from Ukraine and Russia. However, conversion of semi-natural habitats will disproportionately impact long term biodiversity and food security. In their Comment in @CommsEarth, Manuel Morales and colleagues argue that we must act now to protect green agricultural policies in the EU to ensure food security in the future. Following the outbreak of war in Ukraine, the European Commission proposed a series of short and medium-term relaxations to CAP’s environmental commitments to offset expected shortages in grain imports and enhance food security4.The European Union’s new (2023–2027) Common Agricultural Policy (CAP) aims to reverse current environmental degradation and biodiversity declines in European farmlandHere, we argue that policy changes to allow cultivation of fallow land will disproportionately impact biodiversity and support further intensification of livestock production. Thus, ultimately, these changes in policy may sacrifice long term biodiversity and agricultural sustainability in Europe, in favour of modest increases in current agricultural production and alleged improvements of food security.5. The Ukraine war and international sanctions on Russia are threatening the import of these products to the EU. Ukrainian winter cereal, maize and sunflower production is expected to decrease by 20–30%, at least during the 2022–2023 season, and similar reductions in Russian exports are also expected5. Therefore agro-industry lobbies and farmers’ organisations in Brussels, some political parties in the European parliament and some countries’ administrations perceive a need to increase agricultural production6 and, as a means to offset expected shortages, are pressing to relax or remove CAP’s environmental commitments. Mechanisms supporting these commitments include enhanced conditionality , voluntary measures of Rural Development Programmes (i.e. agri-environment-climate-measures) and Greening measures . A call made to mobilise all relevant international groups during the informal meeting held on 2 March 2022 by Member States’ agriculture and food ministers, with the exception of Denmark, Germany and Italy, may reflect such pressure6. Indeed, the European Commission has finally proposed a series of “short- and medium-term actions to enhance global food security and to support farmers and consumers in the EU”4. In regard to land-use, actions refer to the cultivation of fallows, which are protected by green payments for keeping land in good agricultural and environmental conditions and, adequately managed , support high levels of biodiversity and ecosystem services7 es7 Fig. . More pr5. Even the European Commission, while acknowledging the vulnerability of European farmers to animal feed import shortages and increased costs, clearly stated that food supply is not at risk in the EU4. Indeed, EU-based production supplies 79% of the feed proteins consumed in European livestock farming, 90% of feed cereals and 93% of other products such as Dried Distillers’ Grains and Solubles or beet pulp8. In 2020, the EU was completely self-sufficient with respect to dairy products, pork, beef, veal, poultry, and cereals. It remained the largest global exporter of agri-food products, in spite of the COVID-19 pandemic8.However, the FAO does not draw the same conclusions about the possible world impacts of the conflict and recommends finding alternative suppliers, instead suggesting using existing food stocks, diversifying domestic crops and reducing fertiliser dependence and food waste as mechanisms to help guarantee Europe’s food supplies and sovereignty10. In addition, cultivating fallow land to support intensive livestock-based agriculture will undermine the EU’s Farm-to-Fork strategy and CAP’s ‘Food and Health’ objective of reducing meat consumption to favour a more sustainable and healthier diet among European consumers11. Encouraging the growth of intensive livestock farming through enabling cultivation of fallow lands will increase environmental damage, biodiversity loss and public health risks. Thus, the recent relaxations of the new CAP compromise several of its fundamental objectives, along with those of other elements of the Green Deal, such as the EU’s Nature Restoration Law12.Any increase in production from cultivating fallow land will therefore likely be used to feed intensively reared livestock and sustain cattle feed exports. Supporting the increasing trend of feed exports and industrial intensive livestock farming does not align with the EU’s Green Deal due to the negative impacts on air, soil and water quality13. Even a moderate increase in food production at the expense of the semi-natural habitats remaining in farmland landscapes , which support most of Europe’s farmland biodiversity and its associated ecosystem services14, will seriously damage farmland biodiversity and sustainability in European agricultural landscapes15. For example, a comprehensive study carried out on 169 farms across 10 European countries showed that semi-natural habitats, including fallows, occupied 23% of the land but hosted 49% of vascular plant, earthworm, spider, and wild bee species; a 10% decrease of these habitats if reclaimed for food production would cause exponential decreases in biodiversity, but only moderate linear increases in production15. Furthermore, the loss of semi-natural habitats in arable systems, fallows among them, would negatively affect arthropod functional diversity and the ecosystem services it supports, which may affect agriculture production14.The duration of the war in Ukraine and its effects on provision of raw materials to Europe is hard to foresee. We acknowledge the uncertainties and input costs faced by farmers but calls for further agricultural intensification may be largely unjustified at this stage. Specifically, cultivating semi-natural habitats like long-term or unploughed annual fallows will have serious environmental costs, including an increase in pesticide and fertiliser application, since fallows often occupy less productive land18, adjusting the amount of cultivated surface in relation to landscape structure and composition19, or relocating crops that are more in demand to areas where production is optimal without increasing the total cultivated area20.There are alternatives to cultivating semi-natural habitats that may (and need to) be assessed to achieve a more strategic European agricultural policy able to meet food demands while maintaining the sustainability principles and improvements of the food-production chain sought by the Farm-to-Fork strategy. Proposals include agro-ecological approaches to increase production through the enhancement of ecosystem services such as pollination and biological control1, the EU is at risk of engaging in a hasty and misguided strategy on food production jeopardising the green transition13. As an alternative to such a ‘business as usual’ reaction, the EU has now the opportunity to consolidate the mentioned environmental and social objectives of the new CAP3. A more sustainable agriculture, resilient to food supply crises (present and future), should be based on ecological functionality of farmland, which ultimately depends on the conservation of its biodiversity16, along with measures to counter climate change. Responses to this and other challenges on the new CAP should be assessed with a long-term perspective and based on robust scientific evidence before undermining its environmental ambitions13.After decades of costly implementation and reforms of agricultural and conservation policies


Diversity in the healthcare workforce enhances access to care, reduces health disparities, and improves quality of care for underserved populations. Yet there is a paucity of women and underrepresented minority physicians in cardiology training programs, and progress toward achieving a diverse cardiology workforce has been slow. Here we review the merits of diversity in health care, the current landscape of the cardiology workforce, barriers to increasing the proportion of women and underrepresented minority cardiologists, and specific strategies that have been proposed to sustain and enhance diversity in cardiology training programs. Physician gender has been shown to impact quality of care,45 and patient-physician gender concordance has been associated with improved control of cardiovascular disease (CVD) risk factors.6 A randomized controlled trial studying the effect of physician-patient racial concordance on preventive services utilization found that Black men sought more cardiovascular preventive services—particularly invasive services—after meeting with Black physicians compared with non-Black physicians and estimated that this intervention could decrease the Black-White male gap in cardiovascular mortality by 19%.7In 2004, the Institute of Medicine issued a landmark report unequivocally stating that diversity in the healthcare workforce is critical to improving the United States (US) healthcare system.8 Given the jarring disparities in CVD treatment and outcomes in racial/ethnic minority populations and women,91011 the need to rapidly diversify the cardiovascular clinical workforce could not be more pressing. In this review, we discuss the current climate of diversity in CVD fellowship training, outline the barriers to improving diversity, equity, inclusion, and belonging (DEIB), and summarize strategies to enhance DEIB in training programs. For the purposes of this review, we focus on women and underrepresented minorities as traditionally defined in graduate medical education.In 2019, the Accreditation Council for Graduate Medical Education (ACGME) updated its Common Program Requirements to reflect an expectation that all training programs promote recruitment and retention of a diverse workforce.12 recently explained the evidence base supporting the merits of a diverse cardiovascular workforce. These benefits included (1) improved clinical care, as minoritized individuals are more likely to receive standard of care and follow medical advice when treated by a racially/ethnically concordant physician due to better communication, trust, and reduced implicit bias; (2) greater access to care in underserved communities, as underrepresented minority (URM)13 physicians more often choose to care for historically excluded populations; (3) enhanced cultural competence, as non-URM physicians working in diverse settings become better equipped to care for diverse populations; and (4) improved research quality, as diverse research teams broaden the scope of research questions, priorities, and participant enrollment.Capers et al.141516 The percentage of women matriculating in medical school and internal medicine residency has steadily increased over the past decades, and in 2019, women comprised over 50% of US medical students for the first time.17 Despite this, cardiology continues to suffer from the “residency-to-fellowship cliff” as the specialty has seen the slowest rate of increase in women trainees over time and continues to be the least diverse internal medicine specialty.1618 Only 24% of US cardiovascular disease fellows are women, with even lower proportions in procedural cardiology subspecialties—14.5% in interventional cardiology and 11% in clinical cardiac electrophysiology.19 Over the past 5 years, the percentage of women applying to cardiology fellowships has stalled at around 25%,18 and between 2006 and 2018, the proportion of female adult cardiovascular disease fellows only increased from 16% to 21%.1420 In other procedural specialties such as pulmonary and critical care medicine, gastroenterology, and general surgery, women comprise 35%, 38%, and 45% of trainees, respectively.19Despite extensively documented benefits of a diverse healthcare workforce, women and URM physicians remain underrepresented in cardiology.1421 URM trainees represent 9.9%, 8.9%, 7.4%, and 10.2% of cardiovascular disease, interventional cardiology, clinical cardiac electrophysiology, and advanced heart failure and transplant cardiology fellows, respectively.22 In the 5 years prior to 2022, URM trainees have only comprised 9% to 11% of the cardiovascular disease fellowship applicant pool,19 and between 2006 and 2016, the percentage of URM cardiovascular disease fellows increased marginally from 11% to 12%.14 Comparatively, URM comprise 9%, 10.4%, and 15.4% of pulmonary and critical care medicine, gastroenterology, and general surgery trainees.22Unlike the relatively high numbers of women in medical school and internal medicine residencies, URM physicians continue to be underrepresented at every stage of medical training.15Recent research has aimed to uncover drivers of increased diversity in training programs. A 2018 survey of 130 cardiology fellowship program directors found a correlation between program size and trainee diversity, with smaller programs being less likely to have female and URM fellows. All medium and large programs had at least one female fellow; however, 16% of small programs had none. There were no URM fellows in 40% of small programs compared to 30% of medium and 19% of large programs.14 making the field of cardiovascular medicine poorly representative of the patients whom it serves.Ultimately, these longstanding disparities reverberate across the workforce, with women and URM representing only 13% and 7.5%, respectively, of practicing adult cardiologists,Figure 1). A survey of internal medicine residents’ professional development priorities and preferences found that work-life integration, female friendliness, and positive role models ranked highest in professional development needs. Among residents, the strongest perception of the field of cardiology was of a negative culture due to adverse job conditions, interference with family life, and lack of diversity. These factors influenced career choice decisions: women and residents who did not choose careers in cardiology placed more value on work-life balance and had more negative perceptions of cardiology than those who pursued cardiology.23Several factors pose a threat to a sustainably diverse and inclusive cardiovascular workforce, including negative perceptions of culture, lack of role models and structured mentorship, biased recruitment practices, and slow adoption of evidence-based merits of diversity at the leadership level, among others  Women in Cardiology Section highlighted several of these barriers through a survey of female cardiologists, which demonstrated that over half of respondents felt pressure to take shorter maternity leave than was available—60% among fellow respondents—and only 46% reported breastfeeding beyond 6 months. Highly cited barriers to breastfeeding included inadequate breaks during clinical practice and lack of appropriate pumping space.26 For women interested in pursuing procedural cardiology subspecialties, factors such as lack of female role models, radiation exposure during childbearing years, sexual discrimination and harassment concerns, and the “old boys’ club” culture are additional deterrents.2829Women who choose to pursue cardiology contend with inequities in compensation3031 In a survey regarding barriers to increasing diversity in cardiology training programs, program directors identified the lack of “qualified candidates” and the overall culture of cardiology as the most significant barriers, followed by the lack of diversity in faculty and the program’s surrounding community.32 Although much is made of the URM pipeline problem, this does not fully explain the underrepresentation of URM physicians in cardiovascular medicine and medicine in general.The dearth of URMs entering the physician pipeline continues to be one of the most important barriers to diversifying cardiovascular medicine, owing to a combination of structural racism; lack of adequate educational resources, role models, and mentorship; and bias and discrimination at all stages of education.3334 Resource limitation is also a reported obstacle to implementing and sustaining DEIB, especially in smaller, non–university-based programs. Compared to larger and university-based programs, smaller cardiovascular training programs are less diverse and have fewer institutional support mechanisms for URM and female fellows, peer support groups, and formal mentorship/sponsorship programs.32The hostile training and workplace environments that URM physicians experience is another significant barrier to recruitment, retention, and advancement. Studies investigating training experiences of URM residents found that many experience harsher consequences for mistakes, daily microaggressions, bias, and discrimination. Additionally, they are burdened with leading and promoting institutional diversity, feel pressured to conceal parts of their racial/ethnic identity, and experience social isolation.35Finally, the lack of prioritizing diversity, inclusion, and equity by the workforce’s gatekeepers is a formidable barrier. Surprisingly, 31% of surveyed cardiology fellowship program directors were uncertain or did not believe that diversity improves quality of care. Only 6% considered diversity among the top three priorities when ranking fellowship applicants, and the majority of those who believed in the merits of diversity could not provide evidence supporting the benefits of a diverse and inclusive workforce.Figure 2).A multipronged approach is critical to enhance and sustain DEIB in cardiovascular medicine, summarized here in six major strategies: (1) prioritization of DEIB by leadership; (2) holistic applicant review; (3) implicit bias training of gatekeepers; (4) investment in pipeline and pathway programs; (5) cultural transformation and creation of support systems for women and URMs to enhance retention and advancement; and (6) leveraging resources from other key stakeholders . After learning bias mitigation techniques during the subsequent interview cycle, 48% of committee members were conscious of their bias when interviewing and 21% reported that knowledge of their IAT results impacted their admissions decisions. Since the institution of annual implicit bias reduction workshops for the selection committee, the school has consistently matriculated one of the most broadly diverse student populations in the country.3142Healthcare professionals are not immune from harboring negative implicit biases against people of color and women,3138Other bias mitigation strategies include diversification of selection committee members, intentional reflection on individual implicit biases and their impacts, provision of bias mitigation strategies on interview days, structured interviews, and blinded application reviews in which candidates’ photos and academic metrics that are subject to racial bias are concealed from committee members.4. Investment in Pipeline and Pathway Programs31 building pipeline programs complete with mentorship and networking opportunities is paramount for efforts to enhance DEIB in cardiovascular medicine. Duvernoy et al. suggested investing in outreach programs spanning the entire educational curriculum, from grade school to internal medicine residency, to ensure early exposure to careers in cardiovascular medicine and dedicated mentorship for women and URM medical students and residents.30Due to the paucity of URMs at every stage of the medical education pipeline,43 the Internal Medicine Cardiology Programs for women, Black, and Hispanic/Latinx trainees;44 and the annual Clinical Trials Research boot camp programs.45 Similarly, as another example, the American Heart Association (AHA) provides scholarships to a number of students from Historically Black Universities and Colleges to pursue advanced training in biomedical sciences, and its Supporting Undergraduate Research Experiences (SURE) program funds mentored research in cardiovascular medicine for URM students across several academic institutions.46 The Association of Black Cardiologists (ABC) has a long track record of early and longitudinal mentorship and sponsorship for its early career members. Other professional societies also are accelerating their structured efforts in this arena.Cardiology professional societies have also accelerated efforts to build pathway programs to bolster early interest in medicine and cardiology. As one example, the ACC provides complimentary society membership to medical students and residents and has created several leadership development programs for women and URMs to connect them with career opportunities, mentors, peer networks, and educational resources, including the Young Scholars Program for high school and college students;5. Cultural Transformation and Creation of Support Systems for Women and URMs47 Provision of transparent and flexible leave policies to accommodate unforeseen pregnancy complications, radiation safety training, adequate breaks, and private spaces to facilitate lactation will contribute to a culture of inclusion and support for cardiologists with parenting responsibilities.26Efforts to enhance DEIB in cardiovascular medicine will not succeed without a concurrent cultural transformation to meet the unique challenges faced by women and URM physicians. To enhance retention and career advancement of women cardiologists, Sharma et al. advocate for structured mentorship and sponsorship programs to ensure equitable access to research grants, promotion, leadership roles, and pay parity; creative promotion pathways that do not penalize women for childbearing responsibilities; flexible training pathways that optimize work-life integration; adoption of zero tolerance policies for workplace harassment and discrimination; and transparent compensation policies.48 To this end, cardiovascular education leaders have suggested building an antiracist culture in cardiovascular fellowship training by formalizing education on systemic racism, health disparities, and social determinants of health; establishing implicit bias training and standardized mechanisms for addressing and reporting discrimination and microaggressions; actively mentoring and extending scholarly opportunities to URM physicians; ensuring shared responsibility for diversity and inclusion efforts across the program and rewarding these efforts through promotion and advancement; and seeking to understand URM personal experiences with racism and microaggressions through deliberate conversations.48Efforts to enhance retention of URM physicians will need to tackle implicit and explicit discrimination, professional isolation, lack of mentorship and sponsorship, and the “minority tax” that URM physicians face.49Eberly et al. proposed integrating antiracism practice into the clinical and research training components of the cardiovascular fellowship program through community engagement, funded opportunities for equity-focused quality improvement initiatives, and application of critical race theory to research methodology.50Cardiology fellows are also uniquely positioned to promote a culture of DEIB in their own programs. When leading diverse teams, Njoroge et al. suggest strategies such as setting rotation expectations, facilitating goal-setting, and avoiding competition among trainees; swiftly addressing bias and microaggressions against team members; actively sponsoring trainees by involving them in research projects, connecting them to mentors, providing positive feedback to their training programs; and advocating for a more inclusive culture to program leadership.6. Leverage Resources from Other Key Stakeholders32 Training programs should leverage external resources from the various professional societies that have committed resources to increasing DEIB in cardiology. For instance, since its inception in 1974, the ABC has provided scholarship and mentorship opportunities to people of color at every stage of the physician pipeline, created fellowship programs in interventional cardiology and clinical cardiac electrophysiology, formed strategic partnerships to enhance investigator diversity in clinical trials, and championed several other diversity and inclusion initiatives across the nation.5152 As another example, gender-specific mentoring in interventional cardiology is available through the Society for Cardiovascular Angiography and Interventions Women in Innovations committee’s mentoring program, aimed at connecting trainees to potential mentors across the country.53 The ACC has created resources to guide programs in recruiting a diverse workforce, held workshops to share diversity and inclusion best practices, and provided hands-on training in implicit bias mitigation to program directors.45 These resources require widespread dissemination through both formal and informal channels to reach the broader fellowship training community.Many CVD fellowship program directors lack a strategic plan to increase diversity in their programs. Nearly half reported that having access to best practice tools for candidate selection, implicit bias training, parental leave and harassment policies, and guidance with mentoring programs initiation would assist their efforts.Despite widespread recognition of the unique barriers to recruitment and retention of women and URM physicians in cardiovascular medicine, a few fellowship programs have shared successful initiatives aimed at addressing these barriers within their programs. Here, we highlight such initiatives.40In 2005, the Ohio State University Medical Center cardiovascular disease fellowship program overhauled its recruitment process to increase its fellowship diversity by (1) setting diversity as a program priority; (2) actively reaching out to external URM residents interested in cardiology; (3) emphasizing mentorship opportunities on interview day; (4) dedicating time for URM applicants to interact with URM fellows and faculty members; and (5) engaging in personalized post-interview communications with competitive applicants to reinforce the program’s interest and commitment to mentorship. Since implementing these interventions, the program has matched URM fellows for 5 consecutive years.54In 2017, the University of Pennsylvania’s female fellows-in-training (FIT) and faculty established the Penn Women in Cardiology (PWIC) program to promote the recruitment, retention, and advancement of women cardiologists. Since its inception, the PWIC has facilitated (1) skill development through targeted workshops; (2) leadership and sponsorship of FITs and early career cardiologists through attendance of national leadership conference and nominations for leadership roles in professional societies; (3) networking through institutional mentoring sessions and meetings with visiting female grand rounds speakers; (4) mentorship pairing of medical students and residents considering careers in cardiology with PWIC members who connect them with clinical and research opportunities and provide guidance through the fellowship application process; and (5) advocacy to enhance recruitment and create supportive workplace environments.54 and has developed practice guidelines to enable lactating FITs to meet their breastfeeding goals.55 These guidelines stipulate that lactating women should have access to well-equipped and appropriately designated clean and private pumping spaces and should be allowed to step away from clinical duties and mandatory engagements at needed intervals for expressing milk. Dissemination of these guidelines across the institution has allowed FITs to better integrate work and parenting responsibilities and created a more supportive environment for fellows growing their families.55As a result of the PWIC initiatives, several women have served in leadership roles in multiple professional organizations, and an increasing number of women internal medicine residents at the institution have matriculated into cardiology. PWIC also has advocated successfully for increasing dual-physician-trainee parental leave duration from 6 to 12 weeks56In 2017, the Duke Cardiovascular Disease fellowship program created multilayered interventions to increase diversity among its fellows, including (1) securing departmental commitment to diversity; (2) formation of a diversity and inclusion task force to devise best practices for recruitment; (3) diversification of program leadership and recruitment committee; (4) restructuring of the application screening process by removing US Medical Licensing Examination score criteria, blinding application reviewers to applicant photos, ensuring women and URM applicants represent at least 25% of those interviewed, and ensuring that all URM applicants are independently reviewed by the URM members of the recruitment committee; (5) restructuring the interview day to maximize interaction between women/URM applicants and potential mentors and colleagues and highlight institutional commitment to diversity; (6) soliciting input from recruitment committee, women, and URM faculty and fellows to ensure diversity in highly ranked candidates; and (7) ensuring structured mentorship for matched women and URM fellows. These interventions resulted in a sustained increase of women and URM fellows matching into the program, more than a doubling compared to the preintervention years.There remains an urgent need to diversify the cardiovascular workforce and to simultaneously change workplace culture to promote inclusion, equity, and belonging. These efforts are largely focused at the fellowship level, and adequate education and training at this early stage is necessary to cultivate a representative clinician workforce that is well equipped to care for all patients with cardiovascular disease. Achieving success in these domains will require the intentional reformation of policies, practices, and systems that persistently discriminate against women and URM physicians. Continued benchmarking, systematic assessment of the impact and effectiveness of these strategies, and dissemination of successful strategies will be critical to advance DEIB for the entire cardiovascular training community.Despite evidence that healthcare diversity improves care and reduces health disparities, women and underrepresented minority (URM) physicians remain underrepresented in the cardiology workforce.The lack of a supportive, inclusive, and equitable culture in the cardiovascular training community continues to thwart diversification efforts.Durably enriching the cardiovascular training community will require prioritization of diversity, equity, inclusion, and belonging by academic leaders; investment in pipeline programs providing mentorship and exposing women and URMs to the field of cardiology; holistic recruitment practices; universal implicit bias training with a focus on professional gatekeepers; and eradication of policies, practices, and systems that persistently discriminate against women and URM physicians.Systematic monitoring, evaluation, and dissemination of best practices for diversity, equity, inclusion, and belonging will benefit the entire cardiovascular training community.Houston Methodist is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.Houston Methodist designates this Journal-based CME activity for a maximum of learn.houstonmethodist.org/MDCVJ-18.3.Click to earn CME credit: