Magnitude and time to peak oxygenation effect of prone positioning in ventilated adults with COVID-19 related acute hypoxemic respiratory failure.

BACKGROUND: Prone positioning may improve oxygenation in acute hypoxemic respiratory failure and was widely adopted in COVID-19 patients. However, the magnitude and timing of its peak oxygenation effect remain uncertain with the optimum dosage unknown. Therefore, we aimed to investigate the magnitude of the peak effect of prone positioning on the PaO2 :FiO2 ratio during prone and secondly, the time to peak oxygenation. METHODS: Multi-centre, observational study of invasively ventilated adults with acute hypoxemic respiratory failure secondary to COVID-19 treated with prone positioning. Baseline characteristics, prone positioning and patient outcome data were collected. All arterial blood gas (ABG) data during supine, prone and after return to supine position were analysed. The magnitude of peak PaO2 :FiO2 ratio effect and time to peak PaO2 :FIO2 ratio effect was measured. RESULTS: We studied 220 patients (mean age 54 years) and 548 prone episodes. Prone positioning was applied for a mean (±SD) 3 (±2) times and 16 (±3) hours per episode. Pre-proning PaO2 :FIO2 ratio was 137 (±49) for all prone episodes. During the first episode. the mean PaO2 :FIO2 ratio increased from 125 to a peak of 196 (p < .001). Peak effect was achieved during the first episode, after 9 (±5) hours in prone position and maintained until return to supine position. CONCLUSIONS: In ventilated adults with COVID-19 acute hypoxemic respiratory failure, peak PaO2 :FIO2 ratio effect occurred during the first prone positioning episode and after 9 h. Subsequent episodes also improved oxygenation but with diminished effect on PaO2 :FIO2 ratio. This information can help guide the number and duration of prone positioning episodes.

Accounting for animal movement improves vaccination strategies against wildlife disease in heterogeneous landscapes.

Oral baiting is used to deliver vaccines to wildlife to prevent, control, and eliminate infectious diseases. A central challenge is how to spatially distribute baits to maximize encounters by target animal populations, particularly in urban and suburban areas where wildlife such as raccoons (Procyon lotor) are abundant and baits are delivered along roads. Methods from movement ecology that quantify movement and habitat selection could help to optimize baiting strategies by more effectively targeting wildlife populations across space. We developed a spatially explicit, individual-based model of raccoon movement and oral rabies vaccine seroconversion to examine whether and when baiting strategies that match raccoon movement patterns perform better than currently used baiting strategies in an oral rabies vaccination zone in greater Burlington, Vermont, USA. Habitat selection patterns estimated from locally radio-collared raccoons were used to parameterize movement simulations. We then used our simulations to estimate raccoon population rabies seroprevalence under currently used baiting strategies (actual baiting) relative to habitat selection-based baiting strategies (habitat baiting). We conducted simulations on the Burlington landscape and artificial landscapes that varied in heterogeneity relative to Burlington in the proportion and patch size of preferred habitats. We found that the benefits of habitat baiting strongly depended on the magnitude and variability of raccoon habitat selection and the degree of landscape heterogeneity within the baiting area. Habitat baiting improved seroprevalence over actual baiting for raccoons characterized as habitat specialists but not for raccoons that displayed weak habitat selection similar to radiocollared individuals, except when baits were delivered off roads where preferred habitat coverage and complexity was more pronounced. In contrast, in artificial landscapes with either more strongly juxtaposed favored habitats and/or higher proportions of favored habitats, habitat baiting performed better than actual baiting, even when raccoons displayed weak habitat preferences and where baiting was constrained to roads. Our results suggest that habitat selection-based baiting could increase raccoon population seroprevalence in urban-suburban areas, where practical, given the heterogeneity and availability of preferred habitat types in those areas. Our novel simulation approach provides a flexible framework to test alternative baiting strategies in multiclass landscapes to optimize bait-distribution strategies.

Interprofessional academic health center leadership development: the case of the University of Alabama at Birmingham's Healthcare Leadership Academy.

AIM: The study describes the genesis of the University of Alabama at Birmingham's Healthcare Leadership Academy (HLA), highlights the HLA's outcomes, discloses how the HLA has changed, and delineates future directions for academic health center (AHC) interprofessional leadership training. BACKGROUND: While interprofessional training is recognized as an important component of the professional education for health professionals, AHCs have not focused on interprofessional leadership training to prepare future AHC leaders. As professional bureaucracies, AHCs require leadership distributed across different professions; these leaders not only should be technical experts, but also skilled at interprofessional teamwork and collaborative governance. METHODS: The HLA is examined using the case method, which is supplemented with a descriptive analysis of program evaluation data and outcomes. RESULTS: The HLA has created a networked community of AHC leaders; the HLA's interprofessional team projects foster innovative problem solving. CONCLUSIONS: Interprofessional leadership training expands individuals' networks and has multiple organizational benefits.

Oral Rabies Vaccination of Raccoons (Procyon lotor) across a Development Intensity Gradient in Burlington, Vermont, USA, 2015-2017.

Management of the raccoon rabies virus variant in North America is conducted primarily using oral rabies vaccination (ORV). When a sufficient proportion of the population is vaccinated (∼60%), rabies transmission can be eliminated. To date, ORV programs have successfully controlled and eliminated raccoon rabies in rural areas, but there has been less success in urban areas. We studied the proportions of rabies virus neutralizing antibodies (RVNA) in a raccoon (Procyon lotor) population during a 3-yr ORV trial in developed areas of Burlington, Vermont, US. We used a modified N-mixture model to estimate raccoon abundance, RVNA seroprevalence, and capture rates jointly to examine factors that relate to ORV success to better inform management. We found that raccoon abundance was lower in less-developed areas compared to urban centers. Raccoon RVNA seroprevalence decreased as population abundance increased; it increased as the average age of the population increased. Nontarget opossum (Didelphis virginiana) captures correlated with a decrease in raccoon RVNA seroprevalence in low-development areas, suggesting that they may be competing for baits. The target bait density across the entire study area was 150 baits/km2, but a hand baiting strategy was heavily concentrated on roads, resulting in uneven bait densities within sampling sites (0-484 baits/km2). Uneven bait distribution across the study area may explain low RVNA seroprevalence in some locations. Our results suggest that increases in bait density across the study area may improve RVNA seroprevalence and support annual ORV to account for raccoon population turnover.

Evaluation of contingency actions to control the spread of raccoon rabies in Ohio and Virginia.

The raccoon (Procyon lotor) variant of the rabies virus (RRV) is enzootic in the eastern United States and oral rabies vaccination (ORV) is the primary strategy to prevent and control landscape spread. Breaches of ORV management zones occasionally occur, and emergency "contingency" actions may be implemented to enhance local control. Contingency actions are an integral part of landscape-scale wildlife rabies management but can be very costly and routinely involve enhanced rabies surveillance (ERS) around the index case. We investigated two contingency actions in Ohio (2017-2019 and 2018-2021) and one in Virginia (2017-2019) using a dynamic, multi-method occupancy approach to examine relationships between specific management actions and RRV occurrence, including whether ERS was sufficient around the index case. The RRV occupancy was assessed seasonally at 100-km2 grids and we examined relationships across three spatial scales (regional management zone, RRV free regions, and local contingency areas). The location of a grid relative to the ORV management zone was the strongest predictor of RRV occupancy at the regional scale. In RRV free regions, the neighbor effect and temporal variability were most important in influencing RRV occupancy. Parenteral (hand) vaccination of raccoons was important across all three contingency action areas, but more influential in the Ohio contingency action areas where more raccoons were hand vaccinated. In the Virginia contingency action area, ORV strategies were as important in reducing RRV occupancy as a hand vaccination strategy. The management action to trap, euthanize, and test (TET) raccoons was an important method to increase ERS, yet the impacts of TET on RRV occupancy are not clear. The probability of detecting additional cases of RRV was exceptionally high (>0.95) during the season the index case occurred. The probability of detecting RRV through ERS declined in the seasons following initial TET efforts but remained higher after the contingency action compared to the ERS detection probabilities prior to index case incidence. Local RRV cases were contained within one year and eliminated within 2-3 years of each contingency action.

Neuromuscular blockade and oxygenation changes during prone positioning in COVID-19.

PURPOSE: Neuromuscular blockers (NMBs) are often used during prone positioning to facilitate mechanical ventilation in COVID-19 related ARDS. However, their impact on oxygenation is uncertain. METHODS: Multi-centre observational study of invasively ventilated COVID-19 ARDS adults treated with prone positioning. We collected data on baseline characteristics, prone positioning, NMB use and patient outcome. We assessed arterial blood gas data during supine and prone positioning and after return to the supine position. RESULTS: We studied 548 prone episodes in 220 patients (mean age 54 years, 61% male) of whom 164 (75%) received NMBs. Mean PaO2:FiO2 (P/F ratio) during the first prone episode with NMBs reached 208 ± 63 mmHg compared with 161 ± 66 mmHg without NMBs (Δmean = 47 ± 5 mmHg) for an absolute increase from baseline of 76 ± 56 mmHg versus 55 ± 56 mmHg (padj < 0.001). The mean P/F ratio on return to the supine position was 190 ± 63 mmHg in the NMB group versus 141 ± 64 mmHg in the non-NMB group for an absolute increase from baseline of 59 ± 58 mmHg versus 34 ± 56 mmHg (padj < 0.001). CONCLUSION: During prone positioning, NMB is associated with increased oxygenation compared to non-NMB therapy, with a sustained effect on return to the supine position. These findings may help guide the use of NMB during prone positioning in COVID-19 ARDS.

Demographic, environmental and physiological predictors of gastrointestinal parasites in urban raccoons.

Raccoons are host to diverse gastrointestinal parasites, but little is known about the ecology of these parasites in terms of their interactions with each other during coinfections, their interactions with host physiology and environmental factors, and their impact on raccoon health and survival. As a first step, we investigated the patterns of parasite infection and their demographic distribution in an urban-suburban population of raccoons trapped in the summers and autumns of 2018 and 2019. We collected faecal samples, demographic data, morphometric measurements, and blood smears, and used GPS data to classify trapping location by land cover type. Faecal floats were performed to detect and quantify gastrointestinal nematode eggs and coccidia oocysts, and white blood cell differentials were performed on blood smears to characterise white blood cell distributions. Data were analysed cross-sectionally and, where possible, longitudinally, using generalised linear models. Overall, 62.6% of sampled raccoons were infected with gastrointestinal nematodes, and 82.2% were infected with gastrointestinal coccidia. We analysed predictors of infection status and faecal egg count for three different morphotypes of nematode-Baylisascaris, strongyle, and capillariid nematodes-and found that infection status and egg count varied with Year, Month, Age class, Land cover, and coinfection status, though the significance of these predictors varied between nematode types. Gastrointestinal coccidia prevalence varied with Year, Month, Age class, strongyle infection status, and capillariid infection status. Coccidia oocyst counts were lower in adults and in October, but higher in females and in raccoons trapped in areas with natural land cover; furthermore, coccidia oocysts were positively associated with capillariid faecal egg counts. We found no evidence that gastrointestinal parasites influenced raccoon body condition or overwinter mortality, and so conclude that raccoons, though harbouring diverse and abundant gastrointestinal parasites, may be relatively tolerant of these parasites.

Are rabid raccoons (Procyon lotor) ready for the rapture? Determining the geographic origin of rabies virus-infected raccoons using RADcapture and microhaplotypes.

North America is recognized for the exceptional richness of rabies virus (RV) wildlife reservoir species. Management of RV is accomplished through vaccination targeting mesocarnivore reservoir populations, such as the raccoon (Procyon lotor) in Eastern North America. Raccoons are a common generalist species, and populations may reach high densities in developed areas, which can result in contact with humans and pets with potential exposures to the raccoon variant of RV throughout the eastern United States. Understanding the spatial movement of RV by raccoon populations is important for monitoring and refining strategies supporting the landscape-level control and local elimination of this lethal zoonosis. We developed a high-throughput genotyping panel for raccoons based on hundreds of microhaplotypes to identify population structure and genetic diversity relevant to rabies management programs. Throughout the eastern United States, we identified hierarchical population genetic structure with clusters that were connected through isolation-by-distance. We also illustrate that this genotyping approach can be used to support real-time management priorities by identifying the geographic origin of a rabid raccoon that was collected in an area of the United States that had been raccoon RV-free for 8 years. The results from this study and the utility of the microhaplotype panel and genotyping method will provide managers with information on raccoon ecology that can be incorporated into future management decisions.

Immunotherapy in the treatment of advanced prostate cancer.

Prostate cancer is a complex disease, and treatment selection is informed by numerous variables depending on the stage of disease. Moreover, patient expectations and the impact of treatment-related adverse events may influence treatment choices. Available treatment options over the course of the disease have included surgery, radiation therapy, hormonal therapy, immunotherapy, and chemotherapy. This complexity requires an understanding of a wide range of treatment options and the support of a multidisciplinary team that involves urologists, radiation oncologists, diagnostic radiologists, pathologists, and medical oncologists. Collaboration among these physicians allows for a comprehensive treatment strategy that addresses the individual needs of the patient throughout the course of his disease. Prior to 2004, treatment options for metastatic castrate-resistant prostate cancer (CRPC) were limited to therapies for palliation of pain and reduction of skeletal-related events. Over the past 7 years, four therapeutic options-three within the last 2 years-that provide a survival benefit in this setting have been approved. These therapies have diverse mechanisms, perhaps reflecting the complex nature of advanced prostate cancer. Among them is sipuleucel-T, the first autologous immunotherapy approved for any cancer. This review will discuss the rapidly changing treatment environment for metastatic CRPC and the increased exploration of immunotherapeutic approaches to advanced prostate cancer.

Data-Driven Management-A Dynamic Occupancy Approach to Enhanced Rabies Surveillance Prioritization.

Rabies lyssavirus (RABV) is enzootic in raccoons across the eastern United States. Intensive management of RABV by oral rabies vaccination (ORV) has prevented its spread westward and shown evidence of local elimination in raccoon populations of the northeastern US. The USDA, Wildlife Services, National Rabies Management Program (NRMP) collaborates with other agencies to implement broad-scale ORV and conducts extensive monitoring to measure the effectiveness of the management. Enhanced Rabies Surveillance (ERS) was initiated during 2005 and updated in 2016 to direct surveillance efforts toward higher-value specimens by assigning points to different methods of encountering specimens for collection (strange-acting, roadkill, surveillance-trapped, etc.; specimen point values ranged from 1 to 15). We used the 2016-2019 data to re-evaluate the point values using a dynamic occupancy model. Additionally, we used ERS data from 2012-2015 and 2016-2019 to examine the impact that the point system had on surveillance data. Implementation of a point system increased positivity rates among specimens by 64%, indicating a substantial increase in the efficiency of the ERS to detect wildlife rabies. Our re-evaluation found that most points accurately reflect the value of the surveillance specimens. The notable exception was that samples from animals found dead were considerably more valuable for rabies detection than originally considered (original points = 5, new points = 20). This work demonstrates how specimen prioritization strategies can be used to refine and improve ERS in support of wildlife rabies management.

Serological Responses of Raccoons and Striped Skunks to Ontario Rabies Vaccine Bait in West Virginia during 2012-2016.

Since the 1990s, oral rabies vaccination (ORV) has been used successfully to halt the westward spread of the raccoon rabies virus (RV) variant from the eastern continental USA. Elimination of raccoon RV from the eastern USA has proven challenging across targeted raccoon (Procyon lotor) and striped skunk (Mephitis mephitis) populations impacted by raccoon RV. Field trial evaluations of the Ontario Rabies Vaccine Bait (ONRAB) were initiated to expand ORV products available to meet the rabies management goal of raccoon RV elimination. This study describes the continuation of a 2011 trial in West Virginia. Our objective was to evaluate raccoon and skunk response to ORV occurring in West Virginia for an additional two years (2012-2013) at 75 baits/km2 followed by three years (2014-2016) of evaluation at 300 baits/km2. We measured the change in rabies virus-neutralizing antibody (RVNA) seroprevalence in targeted wildlife populations by comparing levels pre- and post-ORV during each year of study. The increase in bait density from 75/km2 to 300/km2 corresponded to an increase in average post-ORV seroprevalence for raccoon and skunk populations. Raccoon population RVNA levels increased from 53% (300/565, 95% CI: 50-57%) to 82.0% (596/727, 95% CI: 79-85%) during this study, and skunk population RVNA levels increased from 11% (8/72, 95% CI: 6-20%) to 39% (51/130, 95% CI: 31-48%). The RVNA seroprevalence pre-ORV demonstrated an increasing trend across study years for both bait densities and species, indicating that multiple years of ORV may be necessary to achieve and maintain RVNA seroprevalence in target wildlife populations for the control and elimination of raccoon RV in the eastern USA.

Placebo Oral Rabies Vaccine Bait Uptake by Small Indian Mongooses (Herpestes auropunctatus) in Southwestern Puerto Rico.

The small Indian mongoose (Herpestes auropunctatus) is a rabies reservoir in areas of the Caribbean including Puerto Rico, but no rabies vaccination program targeting this host exists. We used two derivatives of iophenoxic acid (IPA) to evaluate placebo oral rabies vaccine bait uptake by mongooses in southwestern Puerto Rico. We hand-distributed baits at an application rate of 200 baits/km2 at three, 400 ha, sites during autumn 2016 and spring 2017. Each site contained 90-100 cage traps in a 100 ha central trapping area. We used ethyl-IPA as a biological marker during the autumn and methyl-IPA during the spring. We live captured mongooses for 10 consecutive days, beginning 1 wk following bait application. We obtained a serum sample from captured mongooses and analyzed the sera for ethyl- and methyl-IPA by liquid chromatography-mass spectrometry. During autumn 2016, 63% (55/87) mongooses sampled were positive for ethyl-IPA. In spring 2017, 69% (85/123) of mongooses were positive for methyl-IPA. Pooling seasons, accounting for recaptures between years, and disregarding marker type, 74% (133/179) unique mongooses were positive for IPA biomarker, indicating bait consumption during either the autumn, spring, or both trials. We conclude that distributing baits at an application rate of 200 baits/km2 is sufficient to reach over 60% of the target mongoose population in dry forest habitats of Puerto Rico.

Evaluation of rabies virus characterization to enhance early detection of important rabies epizootic events in the United States.

OBJECTIVE: To evaluate rabies virus (RABV) characterization data obtained from animal specimens submitted to the US public health rabies surveillance system and propose a standardized approach to sample selection for RABV characterization that could enhance early detection of important rabies epizootic events in the United States. SAMPLE: United States public health rabies surveillance system data collected from January 1, 2010, through December 31, 2015. PROCEDURES: Data were reviewed to identify RABV-positive specimens for which virus characterization would likely provide information regarding any of 4 overarching events (discovery of novel variants, translocation of RABV variants, host-shift events, and any unusual rabies-related event) that could substantially alter animal rabies epizootiology in the United States. These specimens were designated as specimens of epizootiological importance (SEIs). Estimates of the additional number of specimens that public health laboratories could expect to process each year if all SEIs underwent RABV characterization were calculated. RESULTS: During the 6-year period, the mean annual number of SEIs was 855 (95% CI, 739 to 971); the mean number of SEIs that underwent virus characterization was 270 (95% CI, 187 to 353). Virus characterization of all SEIs would be expected to increase the public health laboratories' test load by approximately 585 (95% CI, 543 to 625) specimens/y. CONCLUSIONS AND CLINICAL RELEVANCE: Prioritization of RABV characterization of SEIs may improve early detection of rabies events associated with RABV host shifts, variant translocations, and importation. Characterization of SEIs may help refine wildlife rabies management practices. Each public health laboratory should evaluate testing of SEIs to ensure diagnostic laboratory capacity is not overstretched.

Use of Mobile Messaging System for Self-Management of Chemotherapy Symptoms in Patients with Advanced Cancer.

The use of an automated text messaging intervention provided a cost-effective option for symptom management for patients experiencing cancer-related symptoms.

Enhanced Rabies Surveillance Using a Direct Rapid Immunohistochemical Test.

Laboratory-based surveillance is integral for rabies prevention, control and management efforts. While the DFA is the gold standard for rabies diagnosis, there is a need to validate additional diagnostic techniques to improve rabies surveillance, particularly in developing countries. Here, we present a standard protocol for the DRIT as an alternative, laboratory or field-based testing option that uses light microscopy as compared to the DFA. Touch impressions of brain tissue collected from suspect animals are fixed in 10% buffered formalin. The DRIT uses rabies virus-specific monoclonal or polyclonal antibodies (conjugated to biotin), a streptavidin-peroxidase enzyme, and a chromogen reporter (such as acetyl 3-amino-9-ethylcarbazole) to detect viral inclusions within infected tissue. In approximately 1 h, a brain tissue sample can be tested and interpreted by the DRIT. Evaluation of suspect animal brains tested from a variety of species in North America, Asia, Africa, and Europe have illustrated high sensitivity and specificity by the DRIT approaching 100% with results compared to DFA. Since 2005, the United States Department of Agriculture's Wildlife Services (USDA WS) program has conducted large-scale enhanced rabies surveillance efforts using the DRIT to test >94,000 samples collected from wildlife in strategic rabies management areas. The DRIT provides a powerful, economical tool for rabies diagnosis that can be used by laboratorians and field biologists to improve current rabies surveillance, prevention and control programs globally.

Rabies Surveillance Identifies Potential Risk Corridors and Enables Management Evaluation.

Intensive efforts are being made to eliminate the raccoon variant of rabies virus (RABV) from the eastern United States and Canada. The United States Department of Agriculture (USDA) Wildlife Services National Rabies Management Program has implemented enhanced rabies surveillance (ERS) to improve case detection across the extent of the raccoon oral rabies vaccination (ORV) management area. We evaluated ERS and public health surveillance data from 2006 to 2017 in three northeastern USA states using a dynamic occupancy modeling approach. Our objectives were to examine potential risk corridors for RABV incursion from the U.S. into Canada, evaluate the effectiveness of ORV management strategies, and identify surveillance gaps. ORV management has resulted in a decrease in RABV cases over time within vaccination zones (from occupancy ( ψ ¯ ) of 0.60 standard error (SE) = 0.03 in the spring of 2006 to ψ ¯ of 0.33 SE = 0.10 in the spring 2017). RABV cases also reduced in the enzootic area (from ψ ¯ of 0.60 SE = 0.03 in the spring of 2006 to ψ ¯ of 0.45 SE = 0.05 in the spring 2017). Although RABV occurrence was related to habitat type, greater impacts were associated with ORV and trap-vaccinate-release (TVR) campaigns, in addition to seasonal and yearly trends. Reductions in RABV occupancy were more pronounced in areas treated with Ontario Rabies Vaccine Bait (ONRAB) compared to RABORAL V-RG®. Our approach tracked changes in RABV occurrence across space and time, identified risk corridors for potential incursions into Canada, and highlighted surveillance gaps, while evaluating the impacts of management actions. Using this approach, we are able to provide guidance for future RABV management.

EFFECT OF HIGH-DENSITY ORAL RABIES VACCINE BAITING ON RABIES VIRUS NEUTRALIZING ANTIBODY RESPONSE IN RACCOONS ( PROCYON LOTOR).

From 2014 to 2016, we examined the effect of distributing oral rabies vaccine baits at high density (150 baits/km2) in an area of Virginia, US that was naïve to oral rabies vaccination prior to the study. We also compared the effect of baiting at high density in a naïve area to baiting at standard density (75 baits/km2) in an area that had been baited annually for 12 yr. Our results suggested that rabies virus seroconversion in raccoons ( Procyon lotor) gradually increased each year under the highdensity bait treatment. However, we did not detect a difference in seroconversion between bait density treatments. Virginia opossums ( Didelphis virginiana) were abundant in the study area and were a potentially important nontarget species that competed for oral rabies vaccine baits, but the ratio of opossums to raccoons in this study did not affect rabies virus neutralizing antibody response of the raccoon populations.

RACCOON (PROCYON LOTOR) RESPONSE TO ONTARIO RABIES VACCINE BAITS (ONRAB) IN ST. LAWRENCE COUNTY, NEW YORK, USA.

Oral rabies vaccination (ORV) campaigns have been conducted annually in the US over the past two decades to prevent raccoon (Procyon lotor) rabies, which is enzootic along the eastern region of the country from southeastern Canada to Alabama. Because raccoon rabies has been eliminated from neighboring Canadian provinces, continued detection of the variant in the US is of concern due to the potential for infected raccoons to cross the border via the St. Lawrence River. Ontario Rabies Vaccine Baits (ONRAB) containing a live, recombinant human adenovirus expressing the rabies virus glycoprotein have been under experimental use in the US since 2011. We distributed ONRAB in St. Lawrence County, New York, from 2013 to 2015 as part of field trials to evaluate serologic responses in raccoons. Prior to ONRAB distribution, rabies virus neutralizing antibody (RVNA) seroprevalence in raccoons was 45.2% (183 of 405) and increased to 57.7% (165 of 286) after 3 yr of ONRAB baiting. Postbait RVNA seroprevalence increased each year, with a lower response observed in juvenile compared with adult raccoons. The pre-ONRAB seroprevalence detected in 2013 was relatively high and was likely impacted both by elevated rabies activity in the county and the use of ORV with a different vaccine bait for 14 consecutive years prior to our study. Tetracycline biomarker prevalence increased from 1.4% prior to ONRAB baiting to 51.3% from 2013 to 2015, demonstrating bait palatability to raccoons. These data complemented related field trials conducted in West Virginia and the northeastern US.

Leading by Example: Role Modeling Resilience Helps Our Learners and Ourselves.

The issues of burnout and its consequences are some of the most prevalent topics in conversations about the practice of medicine today. Many reports have focused on the contributors that fuel this epidemic, but the time has come to begin to focus on solutions. Prominent national efforts, including a National Academy of Medicine collaborative task force and the 2017 Accreditation Council for Graduate Medical Education common program requirements' focus on wellness, are presenting opportunities for academic medicine faculty to take the lead in turning this tide. While solutions to the burnout crisis are complex, the foundations of improving this epidemic lie in restoring a sense of purpose and balance in the lives of those who work in academic medicine. The inherent value of academic medicine to improve others' lives through patient care, the advancement of knowledge, and the education of the next generation is a unique opportunity that many other professions do not share. On the best days, academic medicine faculty must remember to look for that joy and to express it to learners, and, on the worst, they must demonstrate to learners how to practice self-care and how to create personal resilience. By taking on the role of becoming resilient, faculty start to foster a culture of well-being rather than burnout and can begin to find solutions instead of continuing to describe the problem.