Graduate medical education well-being directors in the United States: who are they, and what does the role entail?

BACKGROUND: Institutional Graduate Medical Education (GME) Well-being Director (WBD) roles have recently emerged in the United States to support resident and fellow well-being. However, with a standard position description lacking, the current scope and responsibilities of such roles is unknown. This study describes the scope of work, salary support, and opportunities for role definition for those holding institutional leadership positions for GME well-being. METHODS: In November 2021, 43 members of a national network of GME WBDs in the United States were invited to complete a cross-sectional survey that included questions about job responsibilities, percent effort, and dedicated budget, and a free text response question about unique leadership challenges for GME WBDs. The survey was analyzed using descriptive statistics for quantitative data and thematic analysis for qualitative data. RESULTS: 26 members (60%) responded. Most were physicians, and the majority identified as female and White. Median percent effort salary support was 40%. A small minority reported overseeing an allocated budget. Most respondents worked to improve access to mental health services, oversaw institution-wide well-being programs, designed or delivered well-being content, provided consultations to individual programs, met with trainees, and partnered with diversity, equity, and inclusion (DEI) efforts. GME WBDs described unique challenges that had implications for perceived effectiveness related to resources, culture, institutional structure, and regulatory requirements in GME. DISCUSSION: There was high concordance for several key responsibilities, which may represent a set of core priorities for this role. Other reported responsibilities may reflect institution-specific needs or opportunities for role definition. A wide scope of responsibilities, coupled with limited defined budgetary support described by many GME Well-being Directors, could limit effective role execution. Future efforts to better define the role, optimize organizational reporting structures and provide funding commensurate with the scope of work may allow the GME Well-being Director to more effectively develop and execute strategic interventions.

How do we achieve blinding in modern electronic and paper medical records during the conduct of transfusion trials?

BACKGROUND: Regulatory aspects of transfusion medicine add complexity in blinded transfusion trials when considering various electronic record keeping software and blood administration processes. The aim of this study is to explore strategies when blinding transfusion components and products in paper and electronic medical records. METHODS: Surveys were collected and interviews were conducted for 18 sites across various jurisdictions in North America to determine solutions applied in previous transfusion randomized control trials. RESULTS: Sixteen responses were collected of which 11 had previously participated in a transfusion randomized control trial. Various solutions were reported which were specific to the laboratory information system (LIS) and electronic medical record (EMR) combinations although solutions could be grouped into four categories which included the creation of a study product code in the LIS, preventing the transmission of data from the LIS to the EMR, utilizing specialized stickers and labels to conceal product containers and documents in the paper records, and modified bedside procedures and documentation. DISCUSSION: LIS and EMR combinations varied across sites, so it was not possible to determine combination-specific solutions. The study was able to highlight solutions that may be emphasized in future iterations of LIS and EMR software as well as procedural changes that may minimize the risk of unblinding.

The selection and preparation of red cell components for intrauterine transfusion: A national survey.

BACKGROUND AND OBJECTIVES: The practice regarding the selection and preparation of red blood cells (RBCs) for intrauterine transfusion (IUT) is variable reflecting historical practice and expert opinion rather than evidence-based recommendations. The aim of this survey was to assess Canadian hospital blood bank practice with respect to red cell IUT. MATERIALS AND METHODS: A survey was sent to nine hospital laboratories known to perform red cell IUT. Questions regarding component selection, processing, foetal pre-transfusion testing, transfusion administration, documentation and traceability were assessed. RESULTS: The median annual number of IUTs performed in Canada was 109 (interquartile range, 103-118). RBC selection criteria included allogeneic, Cytomegalovirus seronegative, irradiated, fresh units with most sites preferentially providing HbS negative, group O, RhD negative, Kell negative and units lacking the corresponding maternal antibody without extended matching to the maternal phenotype. Red cell processing varied with respect to target haematocrit, use of saline reconstitution (n = 4), use of an automated procedure for red cell concentration (n = 1) and incorporation of a wash step (n = 2). Foetal pre-transfusion testing uniformly included haemoglobin measurement, but additional serologic testing varied. A variety of strategies were used to link the IUT event to the neonate post-delivery, including the creation of a unique foetal blood bank identifier at three sites. CONCLUSION: This survey reviews current practice and highlights the need for standardized national guidelines regarding the selection and preparation of RBCs for IUT. This study has prompted a re-examination of priorities for RBC selection for IUT and highlighted strategies for transfusion traceability in this unique setting.

Current state of technical transfusion medicine practice for out-of-hospital blood transfusion in Canada.

BACKGROUND AND OBJECTIVES: Canadian out-of-hospital blood transfusion programmes (OHBTPs) are emerging, to improve outcomes of trauma patients by providing pre-hospital transfusion from the scene of injury, given prolonged transport times. Literature is lacking to guide its implementation. Thus, we sought to gather technical transfusion medicine (TM)-specific practices across Canadian OHBTPs. MATERIALS AND METHODS: A survey was sent to TM representatives of Canadian OHBTPs from November 2021 to March 2022. Data regarding transport, packaging, blood components and inventory management were included and reported descriptively. Only practices involving Blood on Board programme components for emergency use were included. RESULTS: OHBTPs focus on helicopter emergency medical service programmes, with some supplying fixed-wing aircraft and ground ambulances. All provide 1-3 coolers with 2 units of O RhD/Kell-negative red blood cells (RBCs) per cooler, with British Columbia trialling coolers with 2 units of pre-thawed group A plasma. Inventory exchanges are scheduled and blood components are returned to TM inventory using visual inspection and internal temperature data logger readings. Coolers are validated to storage durations ranging from 72 to 124 h. All programmes audit to manage wastage, though there is no consensus on appropriate benchmarks. All programmes have a process for documenting units issued, reconciliation after transfusion and for transfusion reaction reporting; however, training programmes vary. Common considerations included storage during extreme temperature environments, O-negative RBC stewardship, recipient notification, traceability, clinical practice guidelines co-reviewed by TM and a common audit framework. CONCLUSION: OHBTPs have many similarities throughout Canada, where harmonization may assist in further developing standards, leveraging best practice and national coordination.

A reduced potential for lameness bacterial transmission by Lucilia sericata larvae and flies through metamorphosis.

Lameness in sheep is one of the most serious issues on farms in the UK and worldwide, affecting over 90% of all UK sheep flocks. Despite its severity and prevalence, there are knowledge gaps regarding transmission routes of bacterial pathogens associated with infectious lameness in sheep. As larvae of Lucilia sericata are commonly found on foot lesions on lame sheep, it was hypothesised that the flies or their larvae could harbour lameness associated bacteria. This study examined the gut contents of larvae obtained from the foot lesions of lame sheep and compared them to control larvae collected from infested cat food on the same farm. Of particular interest, were the presence of three different bacterial genera associated with lameness; Fusobacterium necrophorum, Dichelobacter nodosus and Treponema spp., for which viability was also investigated. Larvae were cultured In vitro and some allowed to metamorphose into flies before specific PCR assays were carried out on the gut contents. Results showed a significant association between the bacteria on the feet of the sheep and those within the larvae. Although the gut contents of all larvae found on sheep feet contained one or more of the lameness bacteria, none of the bacteria were recovered from the adult flies, suggesting a level of gut remodelling during metamorphosis. Interestingly, Treponema spp. and Fusobacterium spp. were viable when isolated from gut contents of larvae. Maintenance of infection from larvae to fly did not occur. However, it still remains important to control both disease and insect populations of farms to maintain animal welfare.

Comparison of clinical cure rates from footrot and contagious ovine digital dermatitis using zinc sulphate foot bathing and topical oxytetracycline: A randomised trial.

BACKGROUND: This study reports the clinical cure rates of topical oxytetracycline and 10% zinc sulphate foot bathing for treatment of interdigital dermatitis (ID), footrot (FR) and contagious ovine digital dermatitis (CODD) in lambs. METHODS: The study was a randomised controlled trial of 75 lambs. Group A (n = 38) was foot bathed daily for 5 days in 10% zinc sulphate for 15 minutes and group B was treated with daily topical oxytetracycline for 5 days. On days 0, 7, 14, 28 and 42, lambs were scored for locomotion and foot lesions were recorded. RESULTS: The initial cure rates for ID were 96.20% and 97.00%; for FR, 100% and 95%; and for CODD, 90.09% and 83.33% for zinc sulphate and oxytetracycline, respectively. By day 42, these had changed to 53.16% and 61% for ID; 47.82% and 70% for FR; and 100% and 83.33% for CODD. There were no significant differences in cure rates between the treatments for most time points. LIMITATIONS: The sample size was small, and further studies in larger cohorts and different classes of sheep are required before the findings can be translated into recommendations for clinical practice. CONCLUSION: Both treatments achieved cure rates that are comparable to reported cure rates using systemic antibiotics and could be an effective alternative.

The use of Special-Order products in England between 2012 and 2020: An insight into the need for Point-of-Care manufacturing.

Point-of-care manufacturing such as 3D printing has recently received significant attention from regulatory bodies and the pharmaceutical industry. However, little information is available on the quantity of the most prescribed patient-specific items, their dosage form, and why they were required to be dispensed. In England, 'Specials' are unlicensed medicines formulated to meet the requirements of a specific prescription, prescribed if no suitable licensed alternative exists. This work aims to quantify and examine trends in the prescribing of 'Specials' in England during 2012-2020, using the NHS Business Services Authority (NHSBSA) database. Quarterly prescription data from NHSBSA for the top 500 'Specials' by quantity from 2012 to 2020 were compiled yearly. The changes in net ingredient cost, the number of items, British National Formulary (BNF) drug category, dosage form, and a potential reason for requiring a 'Special' were identified. In addition, the cost-per-unit was calculated for each category. The total spending on 'Specials' decreased by 62 % from £109.2 M in 2012 to £41.4 M in 2020, primarily due to a 55.1 % reduction in the number of 'Specials' items issued. The most frequently prescribed dosage form type of 'Special' was oral dosage forms (59.6 % of all items in 2020) particularly oral liquids. The most common reason for prescribing a 'Special' was an inappropriate dosage form (74 % of all 'Specials' in 2020). The total number of items dropped over the 8 years as commonly prescribed 'Specials' such as melatonin and cholecalciferol became licensed. In conclusion, the total spending on 'Specials' dropped from 2012 to 2020 primarily due to a reduction in the number of 'Specials' items issued and pricing changes in the Drug tariff. Based on the current demand for 'special order' products, these findings are instrumental for formulation scientists to identify 'Special' formulations to design the next generation of extemporaneous medicine to be produced at the point of care.

Serologic reactivity of unidentified specificity in antenatal testing and hemolytic disease of the fetus and newborn: The BEST collaborative study.

BACKGROUND: The clinical significance of serologic reactivity of unidentified specificity (SRUS) in pregnancy is not clear based on available literature. The aim of this study is to determine if SRUS is associated with hemolytic disease of the fetus and newborn (HDFN). STUDY DESIGN AND METHODS: Retrospective data were collected from eight institutions over an 11-year study period (2010-2020), when available (5/8 sites). The outcome of the pregnancies with SRUS-no, mild, moderate, or severe HDFN-was determined. RESULTS: SRUS was demonstrated in 589 pregnancies. After excluding those with incomplete data, a total of 284 pregnancies were included in the primary HDFN outcome analysis. SRUS was detected in 124 (44%) pregnancies in isolation, and none were affected by HDFN. Of 41 pregnancies with SRUS and ABO incompatibility, 37 (90%) were unaffected, and 4 (10%) were associated with mild HDFN. Of 98 pregnancies with SRUS and concurrent identifiable antibody reactivity(s), 80 (81%) were unaffected, and 19 (19%) were associated with mild to severe HDFN. There was 1 case of mild HDFN and 1 case of severe HDFN in the 21 pregnancies with SRUS, ABO incompatibility, and concurrent identifiable antibody reactivity(s), and 19 (90%) were unaffected by HDFN. Among all patients with repeat testing, newly identified alloantibodies or other antibodies were identified in 63 of 212 (30%) patients. Although most were not clinically significant, on occasion SRUS preceded clinically significant antibody(s) associated with HDFN (3%, 5/188). CONCLUSION: The antenatal serologic finding of SRUS in isolation is not associated with HDFN but may precede clinically significant antibodies.

Development and evaluation of an assessment of the age-appropriateness/inappropriateness of formulations used in children.

BACKGROUND: Medicines designed for adults may be inappropriate for use in children in terms of strength, dosage form and/or excipient content. There is currently no standardised method of assessing the age-appropriateness of a medicine for paediatric use. AIM: To develop and test a tool to assess whether a dosage form (formulation) is appropriate for children and estimate the proportion of formulations considered 'inappropriate' in a cohort of hospitalised paediatric patients with a chronic illness. METHOD: A multi-phase study: patient data collection, tool development, case assessments and tool validation. Inpatients aged 0-17 years at two UK paediatric/neonatal hospitals during data collection periods between January 2015 and March 2016. Written informed consent/assent was obtained. Medicines assessed were new or regularly prescribed to inpatients as part of their routine clinical care. All medicine administration episodes recorded were assessed using the Age-appropriate Formulation tool. The tool was developed by a consensus approach, as a one-page flowchart. Independent case assessments were evaluated in 2019. RESULTS: In 427 eligible children; 2,199 medicine administration episodes were recorded. Two assessors reviewed 220 episodes in parallel: percentage exact agreement was found to be 91.7% (99/108) and 93.1% (95/102). In total, 259/2,199 (11.8%) medicine administration episodes involved a dosage form categorised as 'age-inappropriate'. CONCLUSION: A novel tool has been developed and internally validated. The tool can identify which medicines would benefit from development of an improved paediatric formulation. It has shown high inter-rater reliability between users. External validation is needed to further assess the tool's utility in different settings.

A survey of sheep and/or cattle farmers in the UK shows confusion over the diagnosis and control of rumen fluke and liver fluke.

Calicophoron daubneyi (rumen fluke) is an emerging parasitic infection of livestock across Europe. Despite increasing in prevalence, little is known about the level of awareness of rumen fluke or current control practices used by UK farmers. Fasciola hepatica (liver fluke) is a common parasitic infection of cattle and sheep in the UK. Co-infections with these parasites can present in sheep and cattle, but the only drug with reported efficacy against rumen fluke is oxyclozanide. Between December 2019 and March 2020, 451 sheep and/or cattle farmers completed an online questionnaire, capturing their awareness and current means of control for liver fluke and rumen fluke. Most respondents (70%) were aware of rumen fluke, with 14% recording its presence on their farms and 18% having previously treated for rumen fluke. Almost all respondents (99%) were aware of liver fluke and higher numbers of respondents reported its presence on farm (67%) with 88% having previously treated for liver fluke. Respondents who were aware of rumen fluke said they were concerned about the parasite (81%), although rumen fluke was less of a concern than liver fluke (p < 0.05). Of respondents who reported rumen fluke presence on their farm, 42% cited incorrect diagnostic methods, including those traditionally used to detect liver fluke. Respondents were more likely to treat annually for liver fluke, as opposed to rumen fluke (p < 0.05). The most frequently used drug for the treatment of liver fluke infection was triclabendazole (53% sheep treatments, 34% cattle treatments) and only a minority of farmers treated with a product effective against rumen fluke (oxyclozanide; 42% cattle treatments, 35% sheep treatments). A small proportion of farmers stated that they used a non-flukicide drug to treat sheep for liver fluke infection (1.6% sheep treatments). These results demonstrate a broad awareness of liver and rumen fluke in sheep and cattle, but reveal confusion amongst farmers about their diagnosis and treatment, highlighting the need to provide best practice advice to the livestock industry for the control of both parasites.

Temporal Associations Between EHR-Derived Workload, Burnout, and Errors: a Prospective Cohort Study.

BACKGROUND: The temporal progression and workload-related causal contributors to physician burnout are not well-understood. OBJECTIVE: To characterize burnout's time course and evaluate the effect of time-varying workload on burnout and medical errors. DESIGN: Six-month longitudinal cohort study with measurements of burnout, workload, and wrong-patient orders every 4 weeks. PARTICIPANTS: Seventy-five intern physicians in internal medicine, pediatrics, and anesthesiology at a large academic medical center. MAIN MEASURES: Burnout was measured using the Professional Fulfillment Index survey. Workload was collected from electronic health record (EHR) audit logs and summarized as follows: total time spent on the EHR, after-hours EHR time, patient load, inbox time, chart review time, note-writing time, and number of orders. Wrong-patient orders were assessed using retract-and-reorder events. KEY RESULTS: Seventy-five of 104 interns enrolled (72.1%) in the study. A total of 337 surveys and 8,863,318 EHR-based actions were analyzed. Median burnout score across the cohort across all time points was 1.2 (IQR 0.7-1.7). Individual-level burnout was variable (median monthly change 0.3, IQR 0.1-0.6). In multivariable analysis, increased total EHR time (ß=0.121 for an increase from 54.5 h per month (25th percentile) to 123.0 h per month (75th percentile), 95%CI=0.016-0.226), increased patient load (ß=0.130 for an increase from 4.9 (25th percentile) to 7.1 (75th percentile) patients per day, 95%CI=0.053-0.207), and increased chart review time (ß=0.096 for an increase from 0.39 (25th percentile) to 0.59 (75th percentile) hours per patient per day, 95%CI=0.015-0.177) were associated with an increased burnout score. After adjusting for the total number of ordering sessions, burnout was not statistically associated with an increased rate of wrong-patient orders (rate ratio=1.20, 95%CI=0.76-1.89). CONCLUSIONS: Burnout and recovery were associated with recent clinical workload for a cohort of physician trainees, highlighting the elastic nature of burnout. Wellness interventions should focus on strategies to mitigate sustained elevations of work responsibilities.

Effects of Persistent Exposure to COVID-19 on Mental Health Outcomes Among Trainees: a Longitudinal Survey Study.

BACKGROUND: The rapid spread of the coronavirus disease 2019 (COVID-19) has created considerable strain on the physical and mental health of healthcare workers around the world. The effects have been acute for physician trainees-a unique group functioning simultaneously as learners and care providers with limited autonomy. OBJECTIVE: To investigate the longitudinal effects of physician trainee exposure to patients being tested for COVID-19 on stress, anxiety, depression, and burnout using three surveys conducted during the early phase of the pandemic. DESIGN: Longitudinal survey study. PARTICIPANTS: All physician trainees (N = 1375) at an academic medical center. MAIN MEASURE: Assess the relationship between repeated exposure to patients being tested for COVID-19 and stress, anxiety, depression, and burnout. KEY RESULTS: Three hundred eighty-nine trainees completed the baseline survey (28.3%). Of these, 191 and 136 completed the ensuing surveys. Mean stress, anxiety, and burnout decreased by 21% (95% confidence interval (CI): - 28 to - 12%; P < 0.001), 25% (95% CI: - 36 to - 11%; P < 0.001), and 13% (95% CI: - 18 to - 7%; P < 0.001), respectively, per survey. However, for each survey time point, there was mean increase in stress, anxiety, and burnout per additional exposure: stress [24% (95% CI: + 12 to + 38%; P < 0.001)], anxiety [22% (95% CI: + 2 to + 46%; P = 0.026)], and burnout [18% (95% CI: + 10 to + 28%; P < 0.001)]. For depression, the association between exposure was strongest for the third survey, where mean depression scores increased by 33% per additional exposure (95% CI: + 18 to + 50%; P < 0.001). CONCLUSIONS: Training programs should adapt to address the detrimental effects of the "pileup" of distress associated with persistent exposure through adaptive programs that allow flexibility for time off and recovery.

Scholarly activity training in pediatric pulmonology fellowship programs.

BACKGROUND: Scholarly activity training is a required component of pediatric pulmonology fellowship programs. However, there are no data on resources and barriers to training and factors associated with fellow productivity. METHODS: We surveyed US pediatric pulmonology fellowship program directors (FPDs) between March and October 2019. Our primary outcome was fellow productivity (>75% of fellows in the past 5 years had a manuscript accepted in a peer-reviewed journal). Analyses included descriptive statistics, χ2 and Fisher's exact tests for categorical values, and t-test or Wilcoxon rank-sum test for numerical values. RESULTS: Sixty-one percent (33/54) of FPDs completed the survey. Seventy-nine percent reported that most fellows completed clinical, basic science, or translational research. However, only 21% reported that most fellows pursued research positions after graduation; academic clinical positions were more common. For 21%, lack of funding and competing clinical responsibilities were barriers to completing the scholarly activity. Only 39% had highly productive programs; those FPDs were more likely to be highly satisfied with fellow scholarly activity products (p = 0.049) and have >6 publications in the previous 3 years (p = 0.03). Fifty-two percent of FPDs believed that pediatric pulmonary training should be shortened to 2 years for those pursuing clinical or clinician-educator careers. CONCLUSIONS: Barriers to scholarly activity training in pediatric pulmonology programs threaten the pipeline of academic pediatric pulmonologists and physician-investigators. Aligning fellow scholarly activity and clinical training with the skills required in their postgraduate positions could optimize the utilization of limited resources and better support career development.

Impact of research on contagious ovine digital dermatitis on the knowledge and practices of UK sheep farmers and veterinarians.

BACKGROUND: Contagious ovine digital dermatitis (CODD) is a common foot disease of sheep which causes a severe form of lameness and can be difficult to control. Recent research has provided evidence-based guidance on diagnosis, treatment and farm management control. The aim of this study was to determine the uptake of this guidance on the knowledge and practices of UK sheep farmers and veterinarians and identify priorities for future research. METHODS: Data were collected in 2019-2020 by electronic surveys of UK sheep veterinarians and farmers distributed through sheep industry organisations and social media. RESULTS: Two hundred eight-four sheep farmers and 77 veterinarians responded to the surveys. Fifty-two per cent of farmers and 70% of vets considered that their management of CODD had improved as a direct result of recent research evidence on the disease. The principle areas improved for both sectors were biosecurity advice and use of antibiotic treatments. Farmers and veterinarians reported that the priorities for future research should be in therapeutics, vaccine development and the understanding of disease transmission. CONCLUSION: There has been strong uptake of recent evidence-based veterinary medicine by farmers and veterinarians for the management of CODD, particularly in the areas of biosecurity and responsible antibiotic use.

WHO essential medicines for children 2011-2019: age-appropriateness of enteral formulations.

INTRODUCTION: The WHO Essential Medicine List for children (EMLc) is used for promoting access to medicines. The age-appropriateness of enteral (oral and rectal) formulations for children depend on their adaptability/flexibility to allow age-related or weight-related doses to be administered/prescribed and the child's ability to swallow, as appropriate. There is scant information on the age-appropriateness of essential enteral medicines for children. OBJECTIVE: To evaluate the age-appropriateness of enteral essential medicines. MATERIALS AND METHODS: Age-appropriateness of all enteral formulations indicated and recommended in the EMLc 3rd to 7th (2011-2019) editions were determined by assessing swallowability and/or dose adaptability for children under 12 years, stratified into five age groups. RESULTS: Enteral formulations in the EMLc were more age-appropriate for older children aged 6-11 years than for younger children. In the 3rd edition, for older children, 77%, n=342, of formulations were age-appropriate. For younger children, age-appropriateness decreased with age group: 34% in those aged 3-5 years, 30% in those aged 1-2 years, 22% among those aged 28 days to 11 months and 15% in those aged 0-27 days. Overall, similar proportions were found for the 7th edition. In contrast, the majority of medicines in the 7th list were age-appropriate in targeted diseases like HIV and tuberculosis. CONCLUSION: Most recommended enteral essential medicines in EMLc 2011 and 2019 were not age-appropriate for children <6 years. Medicines which are not age-appropriate must be manipulated before administration, leading to potential issues of safety and efficacy. Evaluation of the age-appropriateness of formulations for medicines to be included in EMLc could improve access to better medicines for children in the future.

Contagious Ovine Digital Dermatitis: A Novel Bacterial Etiology and Lesion Pathogenesis.

Contagious ovine digital dermatitis (CODD) is a severe and common infectious foot disease of sheep and a significant animal welfare issue for the sheep industry in the UK and some European countries. The etiology and pathogenesis of the disease are incompletely understood. In this longitudinal, experimental study, CODD was induced in 18 sheep, and for the first time, the clinical lesion development and associated microbiological changes in CODD affected feet are described over time, resulting in a completely new understanding of the etiopathogenesis of CODD. The majority of CODD lesions (83.9%) arose from pre-existing interdigital dermatitis (ID) and/or footrot (FR) lesions. All stages of foot disease were associated with high levels of poly-bacterial colonization with five pathogens, which were detected by quantitative PCR (qPCR): Treponema medium, Treponema phagedenis, Treponema pedis, Dichelobacter nodosus, and Fusobacterium necrophorum. Temporal colonization patterns showed a trend for early colonization by T. phagedenis, followed by F. necrophorum and D. nodosus, T. medium, and then T. pedis, D. nodosus was present at significantly higher predicted mean log10 genome copy numbers in FR lesions compared to both ID and CODD, while Treponema species were significantly higher in CODD and FR lesions compared to ID lesions (p < 0.001). Treatment of CODD-affected sheep with two doses of 10 mg/kg long acting amoxicillin resulted in a 91.7% clinical cure rate by 3 weeks post-treatment; however, a bacteriological cure was not established for all CODD-affected feet. The study found that in an infected flock, healthy feet, healed CODD feet, and treated CODD feet can be colonized by some or all of the five pathogens associated with CODD and therefore could be a source of continued infection in flocks. The study is an experimental study, and the findings require validation in field CODD cases. However, it does provide a new understanding of the etiopathogenesis of CODD and further supportive evidence for the importance of current advice on the control of CODD; namely, ensuring optimum flock control of footrot and prompt isolation and effective treatment of clinical cases.

Exploring Acceptability Drivers of Oral Antibiotics in Children: Findings from an International Observational Study.

Antibiotics are among the most commonly prescribed drugs in children. Adherence to the treatment with these drugs is of the utmost importance to prevent the emergence of resistant bacteria, a global health threat. In children, medicine acceptability is likely to have a significant impact on compliance. Herein we used a multivariate approach, considering simultaneously the many aspects of acceptability to explore the drivers of oral antibiotic acceptability in children under twelve, especially in toddlers and in preschoolers. Based on 628 real-life observer reports of the intake of 133 distinct medicines, the acceptability reference framework highlighted the influence of many factors such as age and sex of patients, previous exposure to treatment, place of administration, administration device, flavor agent in excipients and active pharmaceutical ingredient. These findings from an international observational study emphasize the multidimensional nature of acceptability. Therefore, it is crucial to consider all these different aspects for assessing this multi-faceted concept and designing or prescribing a medicine in order to reach adequate acceptability in the target population.

Impact of Changes in EHR Use during COVID-19 on Physician Trainee Mental Health.

OBJECTIVES: This article investigates the association between changes in electronic health record (EHR) use during the coronavirus disease 2019 (COVID-19) pandemic on the rate of burnout, stress, posttraumatic stress disorder (PTSD), depression, and anxiety among physician trainees (residents and fellows). METHODS: A total of 222 (of 1,375, 16.2%) physician trainees from an academic medical center responded to a Web-based survey. We compared the physician trainees who reported that their EHR use increased versus those whose EHR use stayed the same or decreased on outcomes related to depression, anxiety, stress, PTSD, and burnout using univariable and multivariable models. We examined whether self-reported exposure to COVID-19 patients moderated these relationships. RESULTS: Physician trainees who reported increased use of EHR had higher burnout (adjusted mean, 1.48 [95% confidence interval [CI] 1.24, 1.71] vs. 1.05 [95% CI 0.93, 1.17]; p = 0.001) and were more likely to exhibit symptoms of PTSD (adjusted mean = 15.09 [95% CI 9.12, 21.05] vs. 9.36 [95% CI 7.38, 11.28]; p = 0.035). Physician trainees reporting increased EHR use outside of work were more likely to experience depression (adjusted mean, 8.37 [95% CI 5.68, 11.05] vs. 5.50 [95% CI 4.28, 6.72]; p = 0.035). Among physician trainees with increased EHR use, those exposed to COVID-19 patients had significantly higher burnout (2.04, p < 0.001) and depression scores (14.13, p = 0.003). CONCLUSION: Increased EHR use was associated with higher burnout, depression, and PTSD outcomes among physician trainees. Although preliminary, these findings have implications for creating systemic changes to manage the wellness and well-being of trainees.