Acceptability of 'as needed' biologic therapy in psoriasis: insights from a multi-stakeholder mixed methods study.

OBJECTIVES: Biologic therapies have led to increasing numbers of patients with psoriasis who have clear or nearly clear skin. Current practice is that biologic therapy is continued indefinitely in these patients, contributing to a substantial long-term drug and healthcare burden. 'As needed' biologic therapy in psoriasis may address this, however our understanding of patient and clinician perceptions of this strategy is limited. METHODS: We first conducted UK-wide online scoping surveys of patients with psoriasis and dermatology clinicians to explore their views on 'as needed' biologic therapy. Using topic guides informed by these survey findings, we then carried out qualitative focus groups with patients and clinicians. Themes were identified using reflexive thematic analysis. RESULTS: Of 67 patients and 27 clinicians completing the scoping surveys, 67% (43/64) and 78% (21/27), respectively, supported the use of 'as needed' biologic therapy. Respondents highlighted advantages such as a reduction in healthcare burden and greater ownership of care. Challenges included logistics of 'as needed' drug provision and potential risks of disease flare and drug immunogenicity. Focus groups comprised 15 patients with psoriasis (9 female [60%], average disease duration 32 years [range 9-64 years]) and 9 dermatology clinicians (8 female [89%], average dermatology experience 20 years [range 8-33 years]). Both patients and clinicians felt that an 'as needed' treatment approach will deliver a reduction in treatment burden and present an opportunity for patient-led ownership of care. Both groups highlighted the importance of ensuring ongoing access to medication and discussing the potential impact of psoriasis recurrence. Patient preferences were influenced by their lived experiences, particularly previous difficulties with medication delivery logistics and establishing disease control. Clinician perspectives were informed by personal experience of their patients adapting their own dosing schedules. Clinicians highlighted the importance of targeted patient selection for an 'as needed' approach, ongoing disease monitoring, and prompt re-access to medications upon psoriasis recurrence. CONCLUSION: These data indicate that 'as needed' biologic therapy in psoriasis is acceptable for both patients and clinicians. Formal assessment of clinical effectiveness and cost effectiveness is warranted, to enable the real-world potential of this approach to be realised.

Seasonality and Geography Have a Greater Influence than the Use of Chlorine-Based Cleaning Agents on the Microbiota of Bulk Tank Raw Milk.

Cleaning of the production environment is vital to ensure the safety and quality of dairy products. Although cleaning with chlorine-based agents is widely adopted, it has been associated with detrimental effects on milk quality and safety, which has garnered increasing interest in chlorine-free cleaning. However, the influence of these methods on the milk microbiota is not well documented. This study investigated the factors that influence the raw milk microbiota, with a focus on the differences when chlorine-based and chlorine-free cleaning of milking equipment are used. Bulk tank raw milk was sampled during three sampling months (April, August, and November), from farms across Ireland selected to capture the use of different cleaning methods, i.e., exclusively chlorine-based (n = 51) and chlorine-free cleaning (n = 92) and farms that used chlorine-free agents for the bulk tank and chlorine-based cleaning agents for the rest of the equipment (n = 28). Shotgun metagenomic analysis revealed the significant influence of seasonal and geographic factors on the bulk tank milk microbiota, indicated by differences in diversity, taxonomic composition, and functional characteristics. Taxonomic and functional profiles of samples collected in November clustered separately from those of samples collected in other months. In contrast, cleaning methods only accounted for 1% of the variation in the bulk tank milk bacterial community, and samples collected from farms using chlorine-based versus chlorine-free cleaning did not differ significantly, suggesting that the chlorine-free approaches used did not negatively impact microbiological quality. This study shows the value of shotgun metagenomics in advancing our knowledge of the raw milk microbiota. IMPORTANCE The microbiota of raw milk is affected by many factors that can control or promote the introduction of undesirable microorganisms. Chlorine-based cleaning agents have been commonly used due to their effectiveness in controlling undesirable microorganisms, but they have been associated with the formation of chlorine residues that are detrimental to product quality and may impact consumer health. Chlorine-free alternatives have been recommended in some countries, but the influence of cleaning agents on the milk microbiota is unknown. Here, we investigated the influence of cleaning methods and other factors on bulk tank raw milk. Results showed that season and location had a greater influence on the milk microbiota than the cleaning agents used. Indeed, the similar microbiota compositions of raw milk from farms that used chlorine-based and those that used chlorine-free cleaning methods supports the further use of chlorine-free cleaning agents in dairy production.

Effect of thermoresistant protease of Pseudomonas fluorescens on rennet coagulation properties and proteolysis of milk.

This study aimed to investigate the effect of different activity levels of a thermoresistant protease, produced by Pseudomonas fluorescens (ATCC 17556), on the cheesemaking properties of milk and proteolysis levels. Sterilized reconstituted skim milk powder was inoculated with the bacteria, and after incubation, centrifuged to obtain a supernatant-containing protease. Raw milk was collected and inoculated to obtain a protease activity of 0.15, 0.60, and 1.5 U/L of milk (treatments P1, P4, and P10, respectively). One sample was not inoculated (control) and noninoculated supernatant was added to a fifth sample to be used as a negative control. Samples were stored at 4°C for 72 h. After 0, 48, and 72 h, the rennet coagulation properties and proteolysis levels were assessed. The protease produced was thermoresistant, as no significant differences were observed in the activity in the pasteurized (72°C for 15 s) and nonpasteurized supernatants. The chromatograms and electrophoretograms indicated that the protease preferably hydrolyzed κ-casein and ß-casein, and levels of proteolysis increased with added protease activity over storage time. The hydrolysis of αS-caseins and major whey proteins increased considerably in P10 milk samples. At 0 h, the increase in the level of protease activity decreased the rennet coagulation time (RCT, min) of the samples, possibly due to synergistic proteolysis of κ-casein into para-κ-casein. However, over prolonged storage, hydrolysis of ß-casein and αS-casein increased in P4 and P10 samples. The RCT of P4 samples increased over time and the coagulum became softer, whereas P10 samples did not coagulate after 48 h of storage. In contrast, the RCT of P1 samples decreased over time and a firmer coagulum was obtained, possibly due to a lower rate of hydrolysis of ß-casein and αS-casein. Increased levels of protease could result in further hydrolysis of caseins, affecting the processability of milk over storage time.

Effect of Pseudomonas fluorescens proteases on the quality of Cheddar cheese.

The objective of this study was to investigate the effect of adding different levels of a thermoresistant protease produced by a Pseudomonas fluorescens strain to milk on the manufacture and quality of Cheddar cheese. Fresh raw milk was collected, standardized, and pasteurized at 72°C for 15 s, and the enzyme was added to give a protease activity of 0.15 or 0.60 U/L (treatments P1 and P4, respectively), while one sample had no enzyme added (control). Milk was stored at 4°C for 48 h and Cheddar cheese was manufactured after 0 and 48 h of storage. Results indicated that the protease was active in milk during 48 h of storage; however, its effect on milk composition was minimal. The protein that was preferentially hydrolyzed by the protease over storage was ß-casein, followed by κ-casein. The mean cheese yield and recovery of fat and protein obtained for all cheeses were not affected by protease activity. The protease showed low activity during cheese manufacture, possibly because of unfavorable conditions, including low pH. One of the factors that might have influenced protease activity was the pH of the curd (approximately 6.55 after acidification and 5.35 at milling), which was lower than that at which the enzyme would have optimum activity (pH 7 to 9). Consequently, the composition, pH, patterns of proteolysis, and hardness of all cheeses produced were similar and in accordance with values expected for that type of cheese, independently of the protease activity level. However, slight increases in proteolysis were observed in P4 cheeses and produced using milk stored for 48 h. Both the P1 and P4 cheeses had higher concentrations of free amino acids (FAA) compared with the control, whereas urea-PAGE electrophoretograms indicated a greater breakdown of caseins in the P4 cheese samples, which may be related to possible increases in numbers of proteolytic bacteria in milk during storage. Therefore, the thermoresistant psychrotrophic bacterial protease(s) tested in this study may affect the manufacture or quality of Cheddar cheese during ripening to a relatively limited extent. However, controlling initial levels of proteolytic bacteria in raw milk remains essential, because proteolysis affects the development of flavor and texture in cheese.

Monitoring residue concentrations in milk from farm and throughout a milk powder manufacturing process.

The experiments reported in this research paper aimed to investigate differences in the levels of chlorate (CHLO), perchlorate (PCHLO), trichloromethane (TCM) and iodine residues in bulk tank (BT) milk produced at different milk production periods, and to monitor those levels throughout a skim milk powder (SMP) production chain (BTs, collection tankers [CTs], whole milk silo [WMS] and skim milk silo [SMS]). Chlorate, PCHLO and iodine were measured in SMP, while TCM was measured in the milk cream. The CHLO, TCM and iodine levels in the mid-lactation milk stored in the WMS were lower than legislative and industrial specifications (0.0100 mg/kg, 0.0015 mg/kg and 150 µg/l, respectively). However, in late-lactation, these levels were numerically higher than the mid-lactation levels and specifications. Trichloromethane accumulated in the cream portion after separation. Perchlorate was not detected in any of the samples. Regarding iodine, the levels in mid-lactation reconstituted SMP were higher than that required by manufacturers (100 µg/l), indicating that the levels in milk should be lower than 142 µg/l. The higher residue levels observed in late-lactation could be related to the low milk volume produced during that period and changes in sanitation practices, while changes in feed management could have affected iodine levels. This study could assist in controlling and setting limits for CHLO, TCM and iodine levels in milk, ensuring premium quality dairy products.

Microbiological quality of milk from farms to milk powder manufacture: an industrial case study.

The experiments reported in this research paper aimed to track the microbiological load of milk throughout a low-heat skim milk powder (SMP) manufacturing process, from farm bulk tanks to final powder, during mid- and late-lactation (spring and winter, respectively). In the milk powder processing plant studied, low-heat SMP was produced using only the milk supplied by the farms involved in this study. Samples of milk were collected from farm bulk tanks (mid-lactation: 67 farms; late-lactation: 150 farms), collection tankers (CTs), whole milk silo (WMS), skim milk silo (SMS), cream silo (CS) and final SMP. During mid-lactation, the raw milk produced on-farm and transported by the CTs had better microbiological quality than the late-lactation raw milk (e.g., total bacterial count (TBC): 3.60 ± 0.55 and 4.37 ± 0.62 log 10 cfu/ml, respectively). After pasteurisation, reductions in TBC, psychrotrophic (PBC) and proteolytic (PROT) bacterial counts were of lower magnitude in late-lactation than in mid-lactation milk, while thermoduric (LPC-laboratory pasteurisation count) and thermophilic (THERM) bacterial counts were not reduced in both periods. The microbiological quality of the SMP produced was better when using mid-lactation than late-lactation milk (e.g., TBC: 2.36 ± 0.09 and 3.55 ± 0.13 cfu/g, respectively), as mid-lactation raw milk had better quality than late-lactation milk. The bacterial counts of some CTs and of the WMS samples were higher than the upper confidence limit predicted using the bacterial counts measured in the farm milk samples, indicating that the transport conditions or cleaning protocols could have influenced the microbiological load. Therefore, during the different production seasons, appropriate cow management and hygiene practices (on-farm and within the factory) are necessary to control the numbers of different bacterial groups in milk, as those can influence the effectiveness of thermal treatments and consequently affect final product quality.

The effect of different precooling rates and cold storage on milk microbiological quality and composition.

The objective of this study was to measure the effect of different milk cooling rates, before entering the bulk tank, on the microbiological load and composition of the milk, as well as on energy usage. Three milk precooling treatments were applied before milk entered 3 identical bulk milk tanks: no plate cooler (NP), single-stage plate cooler (SP), and double-stage plate cooler (DP). These precooling treatments cooled the milk to 32.0 ± 1.4°C, 17.0 ± 2.8°C, and 6.0 ± 1.1°C, respectively. Milk was added to the bulk tank twice daily for 72 h, and the tank refrigeration temperature was set at 3°C. The blend temperature within each bulk tank was reduced after each milking event as the volume of milk at 3°C increased simultaneously. The bacterial counts of the milk volumes precooled at different rates did not differ significantly at 0 h of storage or at 24-h intervals thereafter. After 72 h of storage, the total bacterial count of the NP milk was 3.90 ± 0.09 log10 cfu/mL, whereas that of the precooled milk volumes were 3.77 ± 0.09 (SP) and 3.71 ± 0.09 (DP) log10 cfu/mL. The constant storage temperature (3°C) over 72 h helped to reduce bacterial growth rates in milk; consequently, milk composition was not affected and minimal, if any, proteolysis occurred. The DP treatment had the highest energy consumption (17.6 ± 0.5 Wh/L), followed by the NP (16.8 ± 2.7 Wh/L) and SP (10.6 ± 1.3 Wh/L) treatments. This study suggests that bacterial count and composition of milk are minimally affected when milk is stored at 3°C for 72 h, regardless of whether the milk is precooled; however, milk entering the tank should have good initial microbiological quality. Considering the numerical differences between bacterial counts, however, the use of the SP or DP precooling systems is recommended to maintain low levels of bacterial counts and reduce energy consumption.

Chlorate and Other Oxychlorine Contaminants Within the Dairy Supply Chain.

The presence of chlorate in milk and dairy products can arise from the use of chlorinated water and chlorinated detergents for cleaning and sanitation of process equipment at both farm and food processor level. Chlorate and other oxychlorine species have been associated with inhibition of iodine uptake in humans and the formation of methemoglobin, with infants and young children being a high-risk demographic. This comprehensive review of chlorate and chlorine derivatives in dairy, highlights areas of concern relative to the origin and/or introduction of chlorate within the dairy supply chain. This review also discusses the associated health concerns, regulations, and chemical behavior of chlorate and chlorine-derived by-products, and provides a summary of mechanisms for their detection and removal.

Effect of pre-milking teat disinfection on new mastitis infection rates of dairy cows.

BACKGROUND: The practise of teat disinfection prior to cluster attachment for milking is being adopted by farmers in Ireland, particularly where there are herd issues with new infection rates. Pre-milking teat disinfection has been shown to reduce bacterial numbers on teat skin and to be most effective against environmental bacteria such as Escherichia coli and Streptococcus uberis. A split udder design experiment was undertaken on two research herds (A = 96 cows: B = 168 cows) to test the benefit of pre-milking teat disinfection on new mastitis infection levels. The disinfectant was applied to the left front and right hind teats of all cows in each herd and the right front and left hind teats received no disinfectant treatment prior to milking over a complete lactation. Individual quarter foremilk samples were taken on 5 occasions during the lactation and all clinical cases were recorded. The presence and number of staphylococcus and streptococcus bacteria on teat skin of a random sample of experimental cows (n = 20) was measured on 3 occasions during lactation (April, June, and October). RESULTS: Pre-milking teat disinfection had no significant impact on quarter SCC and new infection rates (P > 0.05). The median SCC was 169 (95% CI = 144-198) × 103 cells/mL and 170 (95% CI = 145-199) × 103 cells/mL for disinfected teats and non-disinfected teats, respectively. There were no differences in SCC observed between herds (A = 161 (95% CI = 127-205) × 103 cells/mL; B = 169 (95% CI = 144-198) × 103 cells/mL) over the complete lactation. Bacterial levels on teat skin were reduced significantly with pre-milking teat disinfection compared to teats receiving no disinfectant (P < 0.001). Total infections (clinical and sub-clinical) were similar for disinfected teats (n = 36) and not disinfected teats (n = 40), respectively. Staphylococcus aureus (n = 47) and Strep. uberis (n = 9) were identified as the predominant bacteria in quarter foremilk samples with both clinical and sub-clinical infections. CONCLUSION: SCC and new infection rates were similar in non-disinfected teats and disinfected (pre-milking) teats. The routine application of pre-milking teat disinfectant in pasture-grazed herds is unlikely to be of benefit where herd SCC is below 200 × 103 cells/mL.

Impacts of Seasonal Housing and Teat Preparation on Raw Milk Microbiota: a High-Throughput Sequencing Study.

In pasture-based systems, changes in dairy herd habitat due to seasonality results in the exposure of animals to different environmental niches. These niches contain distinct microbial communities that may be transferred to raw milk, with potentially important food quality and safety implications for milk producers. It is postulated that the extent to which these microorganisms are transferred could be limited by the inclusion of a teat preparation step prior to milking. High-throughput sequencing on a variety of microbial niches on farms was used to study the patterns of microbial movement through the dairy production chain and, in the process, to investigate the impact of seasonal housing and the inclusion/exclusion of a teat preparation regime on the raw milk microbiota from the same herd over two sampling periods, i.e., indoor and outdoor. Beta diversity and network analyses showed that environmental and milk microbiotas separated depending on whether they were sourced from an indoor or outdoor environment. Within these respective habitats, similarities between the milk microbiota and that of teat swab samples and, to a lesser extent, fecal samples were apparent. Indeed, SourceTracker identified the teat surface as the most significant source of contamination, with herd feces being the next most prevalent source of contamination. In milk from cows grazing outdoors, teat prep significantly increased the numbers of total bacteria present. In summary, sequence-based microbiota analysis identified possible sources of raw milk contamination and highlighted the influence of environment and farm management practices on the raw milk microbiota. IMPORTANCE: The composition of the raw milk microbiota is an important consideration from both a spoilage perspective and a food safety perspective and has implications for milk targeted for direct consumption and for downstream processing. Factors that influence contamination have been examined previously, primarily through the use of culture-based techniques. We describe here the extensive application of high-throughput DNA sequencing technologies to study the relationship between the milk production environment and the raw milk microbiota. The results show that the environment in which the herd was kept was the primary driver of the composition of the milk microbiota composition.

Strategy for the reduction of Trichloromethane residue levels in farm bulk milk.

High fat dairy products, such as butter and margarine can be contaminated during the milk production process with a residue called Trichloromethane (TCM), which results from the use of chlorine based detergent solutions. Although, TCM concentrations in Irish products are not at levels that are a public health issue, such contamination can cause marketing difficulties in countries to which Irish products are being exported. In an attempt to reduce such milk residues, a template procedure was developed, tried and tested on 43 farms (from 3 processing companies). This involved identifying farms with high TCM milk, applying corrective action in the form of advice and recommendations to reduce TCM and re-measuring milks from these farms. Trichloromethane in milk was measured by head-space gas chromatography with electron capture detector. The TCM reduction strategy proved successful in significantly reducing the levels in milk in the farms tested, e.g. TCM was reduced from 0.006 to the target of 0.002 mg/kg (P < 0.05). The strategy was then applied to farms who supplied milk to six Irish dairy processors with the objective of reducing TCM in those milks to a level of ≤ 0.002 mg/kg. Initially, milk tankers containing milks from approximately 10-15 individual farms were sampled and analysed and tankers with high TCM (>0.002 mg/kg) identified. Individual herd milks contributing to these tankers were subsequently sampled and analysed and farms supplying high TCM identified. Guidance and advice was provided to the high TCM milk suppliers and levels of TCM of these milk supplies were monitored subsequently. A significant reduction (minimum P < 0.05) in milk TCM was observed in 5 of the 6 dairy processor milks, while a numerical reduction in TCM was observed in the remaining processor milk.

Remission of chronic actinic dermatitis on baricitinib: A case report.

Chronic actinic dermatitis (CAD) is an immune-mediated photodermatosis characterised by eczematous, pruritic changes to sun-exposed skin. The pathophysiology of CAD is poorly understood, with current explanations including a hypersensitivity reaction and cross-reactivity to contact allergens. The disease is often refractory to immunosuppressive treatment and has a marked impact on patient quality of life. Janus kinase inhibitors (JAKi) are a novel class of small molecules licenced for the management of certain inflammatory conditions, including atopic dermatitis We present the case of a 69-year-old gentleman with a history of severe CAD, unresponsive to standard therapies, who was prescribed baricitinib, a janus kinase (JAK) inhibitor as a single agent treatment for his disease. The patient experienced a dramatic clinical improvement with this therapy. In addition, normalisation of photo test and improvement of patch test results following treatment were observed. There is one previous case report in the literature describing the clinical response of patients with CAD to JAK inhibitor therapy, but no comment on pre or post treatment photo testing, patch testing or photo-patch testing results was made. In this case report, we discuss our understanding of the role of JAK inhibitors in CAD and highlight a potential new therapeutic avenue for this disabling disease.

Chlorate Levels in Dairy Products Produced and Consumed in Ireland.

In recent years, chlorate has become a residue of concern internationally, due to the risk that it poses to thyroid gland function. However, little is known about its occurrence in dairy products of Irish origin. To address this, a study was conducted in which samples of milk (n = 317), cream (n = 199), butter (n = 178), cheese (n = 144) and yoghurt (n = 440) were collected from grocery stores in the Republic of Ireland. Sampling was conducted across spring, summer, autumn and winter of 2021. Samples from multiple manufacturers of each respective dairy product were procured and analysed for chlorate using UPLC-MS/MS. Chlorate was detected in milk, cream, natural, blueberry, strawberry and raspberry yoghurts. Mean chlorate levels detected in these products were 0.0088, 0.0057, 0.055, 0.067, 0.077 and 0.095 mg kg-1, respectively. Chlorate was undetected in butter and cheese (<0.01 mg kg-1). All products sampled, except yoghurt, were found to be compliant with the EU limit for chlorate in milk (0.10 mg kg-1). Some manufacturers produced product with greater incidence and levels of chlorate. Chlorate levels from samples tested at different times of the year did not differ significantly, with the exception of strawberry and raspberry yoghurts which had higher chlorate levels in the winter period.

The effect of disinfectant ingredients on teat skin bacteria associated with mastitis in Irish dairy herds.

BACKGROUND: Teat disinfection is an important step in the control of mastitis within a dairy herd. The objective of this study was to evaluate the effectiveness of 96 commercially available teat disinfectant products in Ireland against bacterial isolates on teat skin. Teat disinfection products were applied to the teats of seventeen Holstein-Friesian cows. A split-udder model was used where one cow received two different teat disinfection products on each day. A composite swab sample was taken of the left teats and the right teats before and after teat disinfectant application. Swab samples were plated onto 3 different selective agars to enumerate bacterial counts of streptococcal, staphylococcal and coliform isolates. RESULTS: Streptococcal isolates were the most prominent bacterial group recovered on teat swabs taken before the application of a teat disinfection product (55.0%), followed by staphylococcal isolates (41.3%) and coliform isolates (3.7%). Products were reclassified by active ingredients (n = 9) for analysis. These ingredient groups included; chlorhexidine, chlorine dioxide, diamine, iodine, iodine and lactic acid, lactic acid, lactic acid and chlorhexidine, lactic acid and hydrogen peroxide, and lactic acid and salicylic acid. The ingredient group, chlorine dioxide, resulted in comparable reductions to the iodine group for streptococcal isolates. The ingredient group, iodine combined with lactic acid, resulted in the greatest reduction of staphylococcal isolates. When observing products individually, a product containing 1.6% w/w lactic acid combined with hydrogen peroxide was the most effective at reducing streptococcal isolates on the teat skin, whereas a product containing lactic acid combined with 0.6% w/w chlorhexidine was the most effective against staphylococcal isolates. Minor differences were observed regarding the relationship between effectiveness and active ingredient concentration between products. CONCLUSIONS: This study suggests that some teat disinfectant products achieve a higher reduction in bacterial levels against different specific bacterial groups on teat skin than other products. Therefore, when choosing a teat disinfectant product, the bacteria in the dairy herds' environment should be considered. Further studies are necessary to evaluate products efficacy against new IMIs and any possible effects on teat skin condition.

Effect of Pre-Milking Teat Foam Disinfection on the Prevention of New Mastitis Rates in Early Lactation.

The objective of this study was to determine the benefit of pre-milking teat foam disinfection on the prevention of new infections by contagious and environmental bacteria in two spring calving herds managed outdoors (Herd 1 [H1]; 331 cows and Herd 2 [H2]; 142 cows). Four pre-milking teat preparation treatments were applied post calving; with each herd receiving two treatments; using a split udder design (for approx. 15 weeks). These treatments included; (1) 'water wash, foam application and dry wipe (WFD) in H1'; (2) 'water wash and dry wipe (WD)' in H1; (3) 'foam application and dry wipe (FD)' in H2; (4) 'no teat cleaning preparation (NP)' in H2. Individual quarter foremilk samples were collected on four occasions and all clinical and sub-clinical cases were recorded. The mean SCC of quarter foremilk samples was 134 × 103 cells/mL and 127 × 103 cells/mL for WD and WFD, respectively, and 109 × 103 cells/mL and 89 × 103 cells/mL for NP and FD, respectively (p > 0.05). Lower bacterial counts were observed on teat skin that received a foaming treatment. Pre-milking teat disinfection using a foaming product may be of little benefit, in early lactation, for a pasture-based dairy herd.

Medical Student Schwartz Rounds: A Powerful Medium for Medical Student Reflective Practice.

PURPOSE: Reflection is a core component of good medical practice and of growing importance given increasing rates of burnout in the field of medicine. Schwartz Rounds (SRs) are a group-based model of reflective practice. This study explored the utility of student-specific Schwartz Rounds as a medium for reflective practice amongst medical students entering their first year of clinical attachments, and how effective these are compared to standard organisation-wide Schwartz Rounds. METHODS: Three Medical Student Schwartz Rounds (MSSRs) were piloted over the course of a year at a major teaching hospital, focussed on the theme: "Is this what I signed up for?" Participants were asked to complete a questionnaire following the session, and this data was then analysed. RESULTS: Feedback was obtained from 93% (42/45) students who attended. Ninety per cent of students rated the sessions as "excellent or exceptional", 93% felt the MSSRs added to their "insight and self-awareness", and 90% plan to attend SRs again in the future. A thematic analysis of the qualitative feedback highlighted three broad themes from the pilot; group reflection is more profound than individual reflection, sharing experiences facilitated a greater sense of belonging, and group reflective practice can be intimidating. There was a statistically significant difference between students' ratings of MSSRs, rated 8.67/10, versus written reflection, rated 4.64/10 (p<0.01). CONCLUSION: Students were overwhelmingly positive about their experiences in this pilot, with response ratings commensurate with those from organisation-wide Schwartz Rounds. Therefore, MSSRs should be considered as a valid alternative form of reflective practice.

Tracking the Dairy Microbiota from Farm Bulk Tank to Skimmed Milk Powder.

Microorganisms from the environment can enter the dairy supply chain at multiple stages, including production, milk collection, and processing, with potential implications for quality and safety. The ability to track these microorganisms can be greatly enhanced by the use of high-throughput DNA sequencing (HTS). Here HTS, both 16S rRNA gene amplicon and shotgun metagenomic sequencing were applied to investigate the microbiomes of fresh mid- and late-lactation milk collected from farm bulk tanks, collection tankers, milk silos, skimmed milk silos, a cream silo, and powder samples to investigate the microbial changes throughout a skim milk powder manufacturing process. 16S rRNA gene analysis established that the microbiota of raw milks from farm bulk tanks and in collection tankers were very diverse but that psychrotrophic genera associated with spoilage, Pseudomonas and Acinetobacter, were present in all samples. Upon storage within the whole-milk silo at the processing facility, the species Pseudomonas fluorescens and Acinetobacter baumannii became dominant. The skimmed milk powder generated during the mid-lactation period had a microbial composition that was very different from that of raw milk; specifically, two thermophilic genera, Thermus and Geobacillus, were enriched. In contrast, the microbiota of skimmed milk powder generated from late-lactation milk more closely resembled that of the raw milk and was dominated by spoilage-associated psychrotrophic bacteria. This study demonstrates that the dairy microbiota can differ significantly across different sampling days. More specifically, HTS can be used to trace microbial species from raw milks through processing to final powdered products.IMPORTANCE Microorganisms can enter and persist in dairy at several stages of the processing chain. Detection of microorganisms within dairy food processing is currently a time-consuming and often inaccurate process. This study provides evidence that high-throughput sequencing can be used as an effective tool to accurately identify microorganisms along the processing chain. In addition, it demonstrates that the populations of microbes change from raw milk to the end product. Routine implementation of high-throughput sequencing would elucidate the factors that influence population dynamics. This will enable a manufacturer to adopt control measures specific to each stage of processing and respond in an effective manner, which would ultimately lead to increased food safety and quality.

Screening commercial teat disinfectants against bacteria isolated from bovine milk using disk diffusion.

BACKGROUND AND AIM: Teat disinfection is an important tool in reducing the incidence of bovine mastitis. Identifying the potential mastitis-causing bacterial species in milk can be the first step in choosing the correct teat disinfectant product. The objective of this study was to screen commercial teat disinfectants for inhibition against mastitis-associated bacteria isolated from various types of milk samples. MATERIALS AND METHODS: Twelve commercially available teat disinfectant products were tested, against 12 mastitis-associated bacteria strains isolated from bulk tank milk samples and bacterial strains isolated from clinical (n=2) and subclinical (n=3) quarter foremilk samples using the disk diffusion method. RESULTS: There was a significant variation (7-30 mm) in bacterial inhibition between teat disinfection products, with products containing a lactic acid combination (with chlorhexidine or salicylic acid) resulting in the greatest levels of bacterial inhibition against all tested bacteria (p<0.05). CONCLUSION: In this study, combined ingredients in teat disinfection products had greater levels of bacterial inhibition than when the ingredients were used individually. The disk diffusion assay is a suitable screening method to effectively differentiate the bacterial inhibition of different teat disinfectant products.