Fostering equitable change in health services: Using critical reflexivity to challenge dominant discourses in low back pain care in Australia.

OBJECTIVES: Justice and equity-focused practices in health services play a critical but overlooked role in low back pain (LBP) care. Critical reflexivity - the ability to examine and challenge power relations, and broader social issues embedded in everyday life - can be a useful tool to foster practices that are more socially just. No research has yet explored this approach in back pain health services. This study sought to understand how clinicians construct LBP in relation to broader socio-cultural-political aspects of care and explore if those constructions changed when clinicians engaged with critically reflexive dialogues with researchers. METHODS: Using critical discourse analysis methods, this qualitative study explored institutionalised patterns of knowledge in the construction of LBP care. We conducted 22 critically reflexive dialogues with 29 clinicians from two health services in Australia - a private physiotherapy clinic and a public multidisciplinary pain clinic. RESULTS: Our analyses suggested that clinicians and services often constructed LBP care at an individual level. This dominant individualistic discourse constrained consideration of justice-oriented practices in the care of people with LBP. Through dialogues, discursive constructions of LBP care expanded to incorporate systems and health service workplace practices. This expansion fostered more equitable clinical and service practices - such as assisting patients to navigate health care systems, considering patients' socioeconomic circumstances when developing treatment plans, encouraging staff discussion of possible systemic changes to enhance justice, and fostering a more inclusive workplace culture. Although such expansions faced challenges, incorporating broader discourses enabled recommendations to address LBP care inequities. CONCLUSIONS: Critical reflexivity can be a tool to foster greater social justice within health services. By expanding constructions of LBP care beyond individuals, critical reflexive dialogues can foster discussion and actions towards more equitable workplace cultures, services and systems.

'Engaging on a slightly more human level': A qualitative study exploring the care of individuals with back pain in a multidisciplinary pain clinic.

Chronic low back pain is characterised by multiple and overlapping biological, psychological, social and broader dimensions, affecting individuals' lives. Multidisciplinary pain services have been considered optimal settings to account for the multidimensionality of chronic low back pain but have largely focused on cognitive and behavioural aspects of individuals' pain. Social dimensions are usually underexplored, considered outside or beyond healthcare professionals' scope of practice. Employing Actor Network Theorist Mol's concept multiplicity, our aim in this paper is to explore how a pain service's practices bring to the fore the social dimensions of individuals living with low back pain. Drawing on 32 ethnographic observations and four group exchanges with the service's clinicians, findings suggest that practices produced multiple enactments of an individual with low back pain. Although individuals' social context was present and manifested during consultations at the pain service (first enactment: 'the person'), it was often disconnected from care and overlooked in 'treatment/management' (second enactment: 'the patient'). In contrast, certain practices at the pain service not only provided acknowledgement of, but actions towards enhancing, individuals' social contexts by adapting rules and habits, providing assistance outside the service and shifting power relations during consultations (third enactment: 'the patient-person'). We therefore argue that different practices enact different versions of an individual with low back pain in pain services, and that engagement with individuals' social contexts can be part of a service's agenda.

An Experimental and Computational Approach to Development of Mixing Processes for Miscible Liquids in Unbaffled Tanks.

PURPOSE: Mixing of liquids is a critical unit operation in the biopharmaceutical drug product manufacturing. It commonly consists of mixing miscible liquids to dilute bulk drug substance (DS) or pool multiple lots of drug substance. In the past, at-scale mixing studies have been conducted to determine the mixing parameters, namely mixing speed, and mixing time. At-scale studies have historically been utilized to overcome the challenges associated with geometric dissimilarity of mixing systems found when scaling up. In addition, such studies are quite costly, as they often use actual DS to overcome a lack of representativeness associated with simple salt trace models often employed. As a result, there is a significant need for alternative cost-effective methods that can predict mixing parameters with close agreement to actual experiments and operations. METHOD: At-scale mixing experiments were conducted using full-sized tanks and surrogate solutions. Several computational fluid dynamic (CFD) simulation methods were conducted and compared with the experiments to determine the most reliable computational techniques. RESULTS: The experiments demonstrate that surrogate solutions can be used reliably to determine mixing parameters in at-scale studies instead of the valuable drug products. Studying different CFD methods also showed that transient simulations that use a large eddy simulation (LES) viscous model and a sliding mesh can correctly predict the mixing parameters. CONCLUSION: Results of this study establish a practical and reliable methodology to perform mixing studies for miscible liquids with different kinematic viscosities. The methods discussed herein greatly reduce the routine mixing study costs in the biopharmaceutical industry and increase efficiency and accuracy of the results, allowing proactive scale-up of mixing operations.

Luminescence and Covalency in Ytterbium-Doped CrX3 (X = Cl, Br, I) van der Waals Compounds.

The layered 2D van der Waals ferromagnets CrX3 (X = Cl, Br, I) show broad d-d photoluminescence (PL). Here we report preparation, structural characterization, and spectroscopic studies of all three CrX3 compounds doped with the optical impurity, Yb3+. EXAFS measurements show very similar Cr K-edge and Yb L-edge data for each doped compound, and good fits of the latter are obtained for structures having Yb3+ occupying substitutional octahedral sites. Yb-X bond lengths are systematically ∼0.25 Å larger than their Cr-X counterparts. 4 K PL measurements show efficient sensitization of Yb3+ luminescence upon photoexcitation into lattice absorption bands [Cr3+ d-d and ligand-to-metal charge-transfer (LMCT)] for all three compounds, converting their nondescript broadband d-d PL into sharp f-f emission. The PL of CrCl3:Yb3+ and CrBr3:Yb3+ occurs at energies typical for [YbX6]3- with these halides, with PL decay times of 0.5-1.0 ms at 4 K, but CrI3:Yb3+ displays anomalously low-energy Yb3+ emission and an unusually short PL decay time of only 8 µs at 4 K. Data analysis and angular overlap model (AOM) calculations show that Yb3+ in CrI3:Yb3+ has a lower spin-orbit splitting energy than reported for any other Yb3+ in any other compound. We attribute these observations to exceptionally high covalency of the Yb3+ f orbitals in CrI3:Yb3+ stemming primarily from the shallow valence-shell ionization potentials of the iodide anions.

Efficient in vitro digestion of lipids and proteins in bovine milk fat globule membrane ingredient (MFGMi) and whey-casein infant formula with added MFGMi.

The relative immaturity of the infant digestive system has the potential to affect the bioavailability of dietary lipids, proteins, and their digested products. We performed a lipidomic analysis of a commercial bovine milk fat globule membrane ingredient (MFGMi) and determined the profile of lipids and proteins in the bioaccessible fraction after in vitro digestion of both the ingredient and whey-casein-based infant formula without and with MFGMi. Test materials were digested using a static 2-phase in vitro model, with conditions simulating those in the infant gut. The extent of digestion and the bioaccessibility of various classes of neutral and polar lipids were monitored by measuring a wide targeted lipid profile using direct infusion-mass spectrometry. Digestion of abundant proteins in the ingredient and whey-casein infant formula containing the ingredient was determined by denaturing PAGE with imaging of Coomassie Brilliant Blue stained bands. Cholesterol esters, diacylglycerides, triacylglycerides, phosphatidylcholines, and phosphatidylethanolamines in MFGMi were hydrolyzed readily during in vitro digestion, which resulted in marked increases in the amounts of free fatty acids and lyso-phospholipids in the bioaccessible fraction. In contrast, sphingomyelins, ceramides, and gangliosides were largely resistant to simulated digestion. Proteins in MFGMi and the infant formulas also were hydrolyzed efficiently. The results suggest that neutral lipids, cholesterol esters, phospholipids, and proteins in MFGMi are digested efficiently during conditions that simulate the prandial lumen of the stomach and small intestine of infants. Also, supplementation of whey-casein-based infant formula with MFGMi did not appear to alter the profiles of lipids and proteins in the bioaccessible fraction after digestion.

Magnetic Amplification at Yb3+ "Designer Defects" in the van der Waals Ferromagnet CrI3.

The two-dimensional (2D) van der Waals ferromagnet CrI3 has been doped with the magnetic optical impurity Yb3+ to yield materials that display sharp multiline Yb3+ photoluminescence (PL) controlled by the magnetism of CrI3. Magneto-PL shows that Yb3+ magnetization is pinned to the magnetization of CrI3. An effective internal field of ∼10 T at Yb3+ is estimated, attributed to strong in-plane Yb3+-Cr3+ superexchange coupling. The anomalously low energy of Yb3+ PL in CrI3 reflects relatively high Yb3+-I- covalency, contributing to Yb3+-Cr3+ superexchange coupling. The Yb3+ PL energy and line width both reveal the effects of spontaneous zero-field CrI3 magnetic ordering within 2D layers below TC, despite the absence of net magnetization in multilayer samples. These results illustrate the use of optical impurities as "designer defects" to introduce unique functionality to 2D magnets.

Softer More Frequent Stools in Infants With Difficult Stooling Fed Hydrolyzed Protein Formula With Added Prebiotics: Randomized Controlled Trial.

Objective: To evaluate stool consistency in infants with reported hard or infrequent stools fed hydrolyzed protein formula with added prebiotics designed to promote stool softening. Methods: In this multi-center, double-blind, controlled study, eligible infants (28-300 days of age at enrollment) were randomized to: partially hydrolyzed cow's milk protein formula (PHF, 75% carbohydrate as lactose; 12 mg Mg/100 kcal; n = 49) or routine intact protein cow's milk-based infant formula (Control, 92% carbohydrate as lactose; 8 mg Mg/100 kcal; n = 51) over a 14-day period. Both formulas had a prebiotic blend (polydextrose and galactooligosaccharides, 4 g/L; 1:1 ratio). Parent-reported stool consistency (hard = 1 through watery = 5) and other daily outcomes were collected by diary. Endpoint stool consistency (mean score over last 3 days of study feeding) was the primary outcome. Adverse events were recorded. Results: Baseline stool consistency (Control: 1.4 ± 0.1, PHF: 1.4 ± 0.1) and frequency were similar between groups; the majority had hard (n = 61, 64%) or formed (n = 30, 32%) stools. Stool consistency became softer over Day 1-3 (Control: 2.5 ± 0.1, PHF: 2.6 ± 0.1) and remained similar from Day 4 to 6 through study end (post hoc analysis). For PHF vs Control, endpoint stool consistency was significantly softer (3.4 ± 0.1 vs 3.0 ± 0.1; P = 0.019) and frequency significantly higher (1.5 ± 0.1 vs 1.0 ± 0.1; P = 0.002). Crying, fussing, and appearance of pain during stooling decreased from baseline to study end in both groups. Formula intake, infant fussiness and incidence of adverse events were similar between groups. Conclusion: An infant formula designed to promote stool softening was well-tolerated and associated with softer, more frequent stools in infants with reported hard or infrequent stools.

Acceptance of oclacitinib maleate (Apoquel®) chewable tablets in client-owned dogs with allergic and atopic dermatitis.

BACKGROUND: The oral acceptance of oclacitinib maleate (Apoquel®) chewable tablets administered twice daily for 7 days at the labeled dose range of 0.4-0.6 mg/kg was evaluated in 121 dogs treated at ten general practice veterinary clinics in the United States. RESULTS: Dogs that were enrolled in the study were client-owned, ranged from 1 to 14 years of age, weighed 3.7 to 60.7 kg, and required twice daily treatment with Apoquel for allergic or atopic dermatitis for 7 days. One hundred and twenty-one (121) dogs with 1673 total dose administrations successfully completed the study and were included in the data summary. Out of a total number of 1673 administrations, 1533 (91.6%) were accepted voluntarily within 5 min, 134 (8%) were consumed with assistance (with food treats or by pilling) outside of the 5 min offering time and 6 (0.4%) doses were not consumed. The per dose percent acceptance rate for the 14 offered doses showed minimal variation ranging from 89.9 to 93.3%. CONCLUSIONS: Client-owned dogs from the general veterinary patient population that required treatment with oclacitinib found the chewable tablets to be very palatable and no aversion occurred with repeated dosing. Oclacitinib chewable tablets were well tolerated and are a palatable alternative to the film-coated tablet.

Physiotherapists Both Reproduce and Resist Biomedical Dominance when Working With People With Low Back Pain: A Qualitative Study Towards New Praxis.

Despite recommendations to incorporate physical and psychosocial factors when providing care for people with back pain, research suggests that physiotherapists continue to focus on biological aspects. This study investigated how interpersonal and institutional norms influence this continued enactment of the biological aspects of management. We used theoretically-driven analysis, drawing from Foucauldian notions of power, to analyse 28 ethnographic observations of consultations and seven group discussions with physiotherapists. Analysis suggested that physiotherapy training established expectations of what a physiotherapist 'should' focus on, and institutional circumstances strongly drew the attention of physiotherapists towards biological aspects. Resistance to these forces was possible when, for example, physiotherapists reflected upon their practice, used silences and pauses during consultations, and actively collaborated with patients. These circumstances facilitated use of non-biomedical management approaches. Findings may assist physiotherapists to rework the enduring normative focus on biomedical aspects of care when providing care for patients with back pain.

Ferromagnetism and Spin-Polarized Luminescence in Lead-Free CsEuCl3 Perovskite Nanocrystals and Thin Films.

The emergence of next-generation spintronic and spin-photonic technologies will be aided by the development of materials showing strongly coupled magnetic, electronic, and optical properties. Through a combination of magneto-photoluminescence and magnetic circular dichroism spectroscopies we demonstrate strong magneto-optical responses from CsEuCl3 perovskite nanocrystals and thin films in the near-UV/visible region, stemming from the f-d transitions centered at the B-site Eu2+ cations. We show that this material undergoes a ferromagnetic phase transition at ∼3 K in both the nanocrystal and thin-film samples, resulting in complete spin alignment and indicating intrinsic ferromagnetism. We also report the observation of spin-polarized photoluminescence in the presence of a magnetic field at cryogenic temperatures, saturating with a large polarization ratio (ΔI/I = (IL - IR)/(IL + IR)) of nearly 30% at modest magnetic fields (∼2 T). These results highlight CsEuCl3 as an intrinsically ferromagnetic, luminescent metal-halide perovskite with potentially interesting implications for future spin-based technologies using perovskites.

Beyond Forensic Evidence: Examining Sexual Assault Medical Forensic Exam Mechanisms that Influence Sexual Assault Case Outcomes.

Despite the widespread use of sexual assault medical forensic exams (SAMFEs), practitioners and researchers continue to debate the role of SAMFEs and the evidence they provide in the investigation and prosecution of sexual assault cases. Using data from a review of sexual assault cases reported to police between 2015 and 2017 in two jurisdictions (n = 534), we use logistic regression examine whether the presence of a SAMFE predicts the likelihood of achieving criminal case processing outcomes and whether the relationship of the SAMFE with criminal case processing outcomes is moderated by other legal and extralegal case characteristics. We did not find evidence that the presence of a SAMFE in a case significantly predicts whether a suspect will be identified, arrested, or convicted overall, but we did find evidence of the SAMFE's injury documentation value for arrest. Researchers and practitioners should account for the multiple ways SAMFEs can influence decision-making in future research and policymaking.

Nutrient Intake Adequacy from Food and Beverage Intake of US Children Aged 1-6 Years from NHANES 2001-2016.

The early years, between the ages of one and six, are a period of rapid physical, social and cognitive growth and a nutritionally adequate diet is an important factor for optimum development. We investigated the micronutrient adequacy and status of young US children aged 1-6 years (n = 9848) using 24-h dietary recall interviews completed by parents and caregivers participating in the National Health and Nutrition Examination Survey (NHANES) 2001-2016. data. The proportion of the sample not meeting the Dietary Reference Intakes (DRI) increased with increasing age and was most pronounced for calcium. Despite adequate iron intake, 7.4% and 2.5% had signs of iron deficiency and anemia based on serum ferritin and hemoglobin levels, with younger children and WIC participants at most risk and Non-Hispanic Black children the least. Vitamin B6 intake was adequate, but 6.4% had serum pyridoxal-5-phosphate deficiency. For vitamin E, 69% had intakes below the estimated average requirement (EAR), yet serum deficiency was only detected in 0.9%. Vitamin D intake was inadequate for 87%, but true deficiency may be overestimated. Mean DHA intake was 24 mg/d, well below expert recommendations of 70-100 mg/day. Iron and vitamin B6 deficiency and inadequate calcium, fiber, choline, potassium and DHA intakes are a concern for a significant percentage of young children. The discrepancy between nutrient intakes and serum deficiency levels needs to be further investigated.

Highly luminescent and catalytically active suprastructures of magic-sized semiconductor nanoclusters.

Metal chalcogenide magic-sized nanoclusters have shown intriguing photophysical and chemical properties, yet ambient instability has hampered their extensive applications. Here we explore the periodic assembly of these nanoscale building blocks through organic linkers to overcome such limitations and further boost their properties. We designed a diamine-based heat-up self-assembly process to assemble Mn2+:(CdSe)13 and Mn2+:(ZnSe)13 magic-sized nanoclusters into three- and two-dimensional suprastructures, respectively, obtaining enhanced stability and solid-state photoluminescence quantum yields (from <1% for monoamine-based systems to ~72% for diamine-based suprastructures). We also exploited the atomic-level miscibility of Cd and Zn to synthesize Mn2+:(Cd1-xZnxSe)13 alloy suprastructures with tunable metal synergy: Mn2+:(Cd0.5Zn0.5Se)13 suprastructures demonstrated high catalytic activity (turnover number, 17,964 per cluster in 6 h; turnover frequency, 2,994 per cluster per hour) for converting CO2 to organic cyclic carbonates under mild reaction conditions. The enhanced stability, photoluminescence and catalytic activity through combined cluster-assembly and metal synergy advance the usability of inorganic semiconductor nanoclusters.

Community Approaches to Sexual Assault: VAWA's Role and Survivors' Experiences.

This article reviews two types of community-based approaches to addressing sexual assault that survivors may encounter-sexual assault nurse examiners and victim advocates from nonprofit community agencies-and highlights ways that the Violence Against Women Act (VAWA) and its reauthorizations have influenced this work. We also review information on the intersections of the work of these providers with police and prosecutors and include how these relate to survivors' experiences. We conclude with thoughts that look forward to future research on these issues emphasizing authentic engagement of practitioners and survivors in the research process.

Laboratory and field studies to investigate the efficacy of a novel, orally administered combination product containing moxidectin, sarolaner and pyrantel for the prevention of heartworm disease (Dirofilaria immitis) in dogs.

BACKGROUND: Dirofilaria immitis is a filarial parasite of dogs that can cause serious or fatal cardiopulmonary disease. Three studies were conducted to evaluate the efficacy and safety of monthly treatment with moxidectin in a chewable tablet product in combination with sarolaner and pyrantel to prevent heartworm disease in dogs after experimental challenge and in a clinical field study in the USA. METHODS: In two laboratory studies, dogs (8 per group) that had been inoculated 30 days prior with 50 third-stage D. immitis larvae were randomized to treatment on Day 0 with placebo or combination product, at the minimum dose of 24 µg/kg moxidectin, 2 mg/kg sarolaner and 5 mg/kg pyrantel (as pamoate salt). Study 2 also included groups treated with tablets containing moxidectin-alone (24 µg/kg) or sarolaner-alone (2 mg/kg). Efficacy was evaluated ~ 5 months after inoculation by adult heartworm counts at necropsy. In the field study, 410 dogs ≥ 8 weeks-old from 23 USA veterinary clinics were treated for 11 months with either combination product at 24-48 µg/kg moxidectin, 2-4 mg/kg sarolaner and 5-10 mg/kg pyrantel (n = 272) or Heartgard® Plus (ivermectin/pyrantel) at the label recommended dose rate (n = 138). Efficacy was evaluated on Day 330 using antigen and microfilaria testing to assess adult heartworm infection. RESULTS: In the laboratory studies, there were no heartworms recovered from any dog treated with the combination product or moxidectin alone and all dogs treated with placebo or sarolaner-alone were infected with 20-44 adult heartworms. In the field study, all dogs treated with the combination product tested negative for heartworm infection on Day 330, whereas two dogs treated with Heartgard® Plus tested positive. The Heartgard® Plus-treated dogs that tested heartworm positive were from the lower Mississippi River Valley region, where heartworm resistance has been confirmed to occur. The combination product was well tolerated in all studies. CONCLUSIONS: In laboratory studies, no heartworms were recovered from dogs treated with a single dose of the novel combination product containing moxidectin, sarolaner and pyrantel. Additionally, in the field study no dog tested positive for adult heartworm infection when dosed with the combination product monthly for 11 months, while two dogs treated with Heartgard® Plus tested positive.

An Ambulatory Antimicrobial Stewardship Initiative to Improve Diagnosis and Treatment of Urinary Tract Infections in Children.

BACKGROUND: Antibiotic stewardship efforts should standardize treatment of common infections when possible. Urinary tract infections (UTIs) are common in children and require appropriate diagnostic methods and treatment. A pediatric emergency department (ED) identified an opportunity to improve care by standardizing uncomplicated UTI diagnostic testing and treatment according to local bacterial resistance patterns from January 2017 to December 2018. METHODS: Using the Model for Improvement, researchers undertook a quality improvement (QI) initiative to standardize the diagnosis and treatment of uncomplicated UTI in children ages 3 months to 12 years in a pediatric ED. Multiple Plan-Do-Study-Act (PDSA) cycles were used, engaging both nurses and physicians, to implement an evidence-based clinical algorithm. Primary aims were to achieve 100% of targeted patients with suspected UTI having appropriately ordered and collected specimens and to increase the frequency of targeted patients receiving algorithm-recommended antibiotics at discharge to 80%. Balancing measures included ED length of stay and revisits to the ED related to UTI. RESULTS: During this initiative, 458 children were assessed for UTI, of whom 75 received a UTI diagnosis. Guideline-concordant urine collection procedure improved from 54.7% to 96.2%. After project initiation, 100% of all antibiotic prescriptions for UTI were guideline-concordant. These changes have been sustained for 19 months since the initiative began. There was no change in UTI-related ED revisits or ED length of stay. CONCLUSIONS: This QI initiative achieved standardization of specimen collection and treatment for pediatric UTI in the ED setting, and no adverse outcomes were observed at the institution.

Designing and implementing an outpatient management pathway for patients with newly diagnosed insulin-dependent diabetes mellitus.

OBJECTIVE: Recently, our team transitioned to an outpatient diabetes education model for patients with newly diagnosed insulin-dependent diabetes mellitus (IDDM) after concerns arose regarding inconsistent education provided in the hospital, as well as additional emotional stress attributed to hospitalization. To optimize this model, an improvement initiative was implemented to redesign the outpatient care processes, refine patient education content and identify ideal educational strategies. Specific aims were to (a) achieve family self-management, (b) reduce stress and (c) ensure family and provider satisfaction with the outpatient pathway. RESEARCH DESIGN AND METHODS: Using a multidisciplinary team and formal quality improvement (QI) methods, we redesigned content and format of the pathway based on results from key measures and Plan-Do-Study-Act (PDSA) cycles. Primary outcome measures included self-efficacy, stress and satisfaction. RESULTS: We achieved our goal self-management skills, while maintaining high satisfaction for patients and providers throughout the implementation and refinement of the pathway. Key pathway components include refined education content, interactive educational tools and close collaboration with social work. Multiple PDSA cycles and pathway modifications were completed, including early social work involvement and simplification of education resources; however, we found modifying the stress experienced by parents to be a challenge. The majority of the stress relates to factors that are difficult to modify, specifically emotional burden and interpersonal distress, and is rarely attributed to regimen- or physician-related distress. CONCLUSION: During the transition to an outpatient pathway, we achieved our satisfaction and self-management goals but were unsuccessful in achieving our goals for minimizing stress associated with a new diagnosis of a chronic illness.

Highly selective room temperature acetylene sorption by an unusual triacetylenic phosphine MOF.

The new ligand tris(p-carboxyphenylethynyl)phosphine (P{C[triple bond, length as m-dash]CC6H4-4-CO2H}3) was used to synthesize a permanently porous Mn(ii)-based acetylenic phosphine coordination material, PCM-48. This triply-interpenetrated MOF contains 1-D microchannels that are decorated with electron-rich and adsorbate-accessible acetylenic moieties and phosphine lone pairs. PCM-48 has a moderate room-temperature C2H2 adsorption capacity (25.54 cm3 g-1) and displays high separation selectivities for C2H2 over CH4 (C2H2/CH4 = 23.3), CO2 (C2H2/CO2 = 4.3), and N2 (C2H2/N2 = 76.9) at 296 K.

Improving Timeliness of ß-Agonist and Corticosteroid Administration in Patients With Acute Wheezing.

OBJECTIVE: Timely delivery of ß-agonists and steroids to patients with acute recurrent wheezing is a key component of the National Heart, Lung, and Blood Institute recommended emergency department (ED) asthma care. We conducted an ED improvement initiative to standardize asthma care and improve time to treatments. METHODS: Our multidisciplinary team identified key contributing factors to timeliness, developed key driver diagrams, implemented and refined a management pathway, designed and executed rapid cycle improvements, and implemented interventions. A time series design was used to analyze outcomes with baseline data and continuous monitoring during active intervention steps. The primary outcomes analyzed were the times to first ß-agonist and steroid administration. Secondary outcomes included admission rate, ED length of stay, and ED revisits. RESULTS: Assignment of the Pediatric Asthma Score, our initial pathway step, occurred in most patients within the first several months. Time to first ß-agonist administration decreased from the baseline mean of 76 minutes to 27 minutes. Time to steroid administration decreased from the baseline mean of 108 minutes to 49 minutes. Mean monthly admission rate remained at 22% with no special cause variation identified. The ED revisit rate was not negatively impacted and, in most months, was 0%. CONCLUSIONS: By standardizing asthma care in our ED and redesigning care delivery processes, care variation decreased and significant improvements in timeliness of ß-agonist and steroid administration occurred.

A blinded, randomized, placebo-controlled trial of the safety of lokivetmab (ZTS-00103289), a caninized anti-canine IL-31 monoclonal antibody in client-owned dogs with atopic dermatitis.

BACKGROUND: Lokivetmab (ZTS-00103289) is a caninized anti-canine IL-31 monoclonal antibody that has demonstrated efficacy in reducing pruritus associated with atopic dermatitis (AD) in dogs in field trials. HYPOTHESIS/OBJECTIVES: This study evaluated the safety of lokivetmab in a randomized, double blind, placebo-controlled trial in client owned dogs with AD with minimal restrictions on concomitant medications and co-morbidities. ANIMALS: Clinicians at 14 veterinary clinics enrolled client owned dogs (n = 245) with chronic AD. METHODS: Dogs were randomized at a 2:1 ratio to receive either lokivetmab (1.0-3.3 mg/kg) or placebo administered subcutaneously on days 0 and 28. Clinicians examined dogs, and collected blood and urine for assessment of clinical pathology and immunogenicity (days 0, 28 and 42). RESULTS: There were no immediate hypersensitivity reactions (e.g. wheals, vomiting). Discomfort at administration occurred in 5.1% of dogs and was similar in frequency and severity between lokivetmab- and placebo-treated groups. Pruritus was reported as an adverse event during the study less frequently in the lokivetmab-treated group (4.9% and 19.3%, respectively); otherwise, adverse events occurred at a similar frequency between treatment groups. There were no clinically important differences between groups in clinical pathology results. Treatment-induced immunogenicity was found in 2.5% of lokivetmab treated dogs. A wide variety of concomitant medications were used with no clinically apparent adverse interactions. CONCLUSIONS AND CLINICAL IMPORTANCE: Among a diverse population of 162 client owned dogs with a clinical diagnosis of AD, treatment with two monthly doses of lokivetmab was safe, based on observed adverse events and clinical pathology results over a 42 day period.