Responsibilities and Interests of Pediatricians Practicing Hospital Medicine in the United States

BACKGROUND AND OBJECTIVES: In 2016, the American Board of Medical Specialties (ABMS) approved pediatric hospital medicine (PHM) as the newest pediatric subspecialty. To characterize development of the field, this article aims to: (1) describe the responsibilities and practice settings of US pediatricians self-identifying as hospitalists; and (2) determine how exclusive PHM practice, compared with PHM practice in combination with general or subspecialty care, was associated with professional development interests. METHODS: Pediatricians enrolling in the 2017-2018 American Board of Pediatrics (ABP) Maintenance of Certification program were offered a voluntary survey about their responsibilities, interests, and practice settings. Logistic regression was employed to characterize associations between exclusive PHM practice and: (1) interest in quality improvement (QI) leadership; (2) intention to take the PHM certifying exam; (3) satisfaction with allocation of professional time; and (4) intention to maintain more than one ABP certification. RESULTS: The survey response rate was 70.0%; 1662 (13.1%) self-reported PHM practice. Four hundred ninety-one (29.5%) practiced PHM exclusively, 518 (31.1%) practiced PHM and general pediatrics, and 653 (39.3%) practiced PHM and one or more subspecialties. Respondents reporting exclusive PHM practice were significantly more likely to report interest in QI leadership or consultation (adjusted odds ratio [OR], 1.39; 95% CI, 1.09-1.79), PHM exam certification (adjusted OR, 7.10; 95% CI, 5.45-9.25), and maintenance of more than one ABP certification (adjusted OR, 2.64; 95% CI, 1.89-3.68). CONCLUSIONS: Hospitalists reported diverse clinical and nonclinical responsibilities. Those practicing PHM exclusively expressed high levels of interest in board certification and QI leadership. Ongoing monitoring of PHM responsibilities and practice settings will be important to support the professional development of the PHM workforce.

Biosimilar strategic implementation at a large health system

Disclaimer In an effort to expedite the publication of articles , AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose This article highlights one health system’s response to the market influx of biosimilars with the establishment of a process for formulary review and selection of preferred agents and support for therapeutic interchanges. Summary Through assessment of available literature, insurance payor coverage, and manufacturer-anticipated approvals of biosimilars, a strategic stance was developed to guide biosimilar order preparation, review, adoption, and implementation. The electronic medical record (EMR) is prepared for biosimilar implementation at least 6 to 12 months ahead of anticipated formulary review. The review includes assessment of a class (reference product and available biosimilars) after at least 2 biosimilars become available. Key health-system departments and clinicians are enlisted to support review of clinical, safety, and economic implications. Implementation of a preferred product relies on standard education, formulary availability, and staff awareness to address any perceived patient safety concerns and gather provider support. The standard steps developed now apply to all future biosimilar reviews, adoption plans, and ongoing monitoring. Barriers evaluated include changes in payor coverage and challenges in preparation of the EMR for future biosimilars, meeting precertification team education needs, and providing operational support for pharmacy inventory. Conclusion To date, use of 5 preferred biosimilar products has led to significant cost savings to the institution, and the process has been endorsed by providers. The institution’s successes can be attributed to clear communication with stakeholders and the development of a deliberate process, led by a multidisciplinary leadership team, for managing formulary, safety, and operational barriers in a thoughtful and systematic manner.

Regulatory challenges for tree seed source and certification in Indonesia: documentation versus productivity perspectives

Permen LHK:P.3/MENLHK/SETJEN/KUM.1/1/2020 and Perdirjen RLPS:P.05/V-SET/2010 are two major regulations for forest tree seed implementation in Indonesia. Referring some Articles in the Regulations, it seems to need further investigation and analysis because primary task of seed source has been confusing with tasks of genetic resources, breeding, and plantation. Varies in reproductive system and advanced technology are also neglected. In addition, documentative (referred as by-process) seems to be main priority rather than ensuring actual seed productivity (referred as by-product). Such condition causes some irrelevant standards in the regulations and posed a contra-productive for the seed sources and further certification. As a result, it tends to eliminate many potential stands as seed source, and poses a causality negative impact diminishing tree grower’s interest for supplying seed and maintaining genetic resources. These problems and along with the increasing difficulty in seed supply have become challenges for the importance of ongoing monitoring and assessment of the existing regulations. This paper proposes some ideas addressing such challenges through regulatory improvements in optimizing the task of seed source, such as re-defining some standards, and focusing on real seed productivity. The improved regulation is also expected to stimulate involvement of community in seed source activities and maintaining potential genetic resources.

Surveillance of SARS-CoV-2 in extensive monitoring of municipal wastewater: key issues to yield reliable results

Several studies have detected SARS-CoV-2 in the stool of infected people as in urban wastewater. The quantification of SARS-CoV-2 in wastewater appears today as a powerful tool that can help in Wastewater-based epidemiology (WBE). The goal is to improve the prediction of new waves of COVID-19 outbreaks and provide an early warning of the evolution of the infection. In this research, we highlighted some practical and scientific aspects that emerged during an extensive ongoing monitoring campaign carried out on a large number of wastewater treatment plants located in the province of Trento (North Italy) and aimed at the detection of SARS-CoV-2 in raw municipal wastewater. The open issues underline are related to the collection and storage (sampling protocol, storage and heat treatment), to the molecular analysis (enrichment phase), and to the mathematical calculation of SARS-CoV-2 load in wastewater, suitable for WBE (standard curve to obtain the concentration of genomic units and flow rate measurements). This study provides some insights that can help in the implementation of surveillance plans in other regions.

Burnout Among Surgeons in the UK During the COVID-19 Pandemic: A Cohort Study

Background Surgeon burnout has implications for patient safety and workforce sustainability. The aim of this study was to establish the prevalence of burnout among surgeons in the UK during the COVID-19 pandemic. Methods This cross-sectional online survey was set in the UK National Health Service and involved 601 surgeons across the UK of all specialities and grades. Participants completed the Maslach Burnout Inventory and a bespoke questionnaire. Outcome measures included emotional exhaustion, depersonalisation and low personal accomplishment, as measured by the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). Results A total of 142 surgeons reported having contracted COVID-19. Burnout prevalence was particularly high in the emotional exhaustion (57%) and depersonalisation (50%) domains, while lower on the low personal accomplishment domain (15%). Burnout prevalence was unrelated to COVID-19 status; however, the greater the perceived impact of COVID-19 on work, the higher the prevalence of emotional exhaustion and depersonalisation. Degree of worry about contracting COVID-19 oneself and degree of worry about family and friends contacting COVID-19 was positively associated with prevalence on all three burnout domains. Across all three domains, burnout prevalence was exceptionally high in the Core Trainee 1–2 and Specialty Trainee 1–2 grades. Conclusions These findings highlight potential undesirable implications for patient safety arising from surgeon burnout. Moreover, there is a need for ongoing monitoring in addition to an enhanced focus on mental health self-care in surgeon training and the provision of accessible and confidential support for practising surgeons.

Antimicrobial resistance in colonizing group B Streptococcus among pregnant women from a hospital in Vietnam

Few studies have been conducted on group B Streptococcus (GBS) in Vietnam. We determined the GBS colonization and antimicrobial resistance vaginal-rectal profile of 3863 Vietnamese pregnant women over 5 years. Maternal GBS colonization was characterized by antibiotic susceptibility. Overall, the GBS colonization rate was 8.02% (95% CI: 7.20–8.94%). Compared to sampling ≥ 35 weeks of gestation, the GBS colonization rate was statistically higher (p = 0.004) with sampling < 35 weeks. Among 272 antimicrobial susceptibility testing isolates, all were susceptible to ampicillin, penicillin, ceftriaxone, cefotaxime, vancomycin, and quinupristin/dalfopristin. Resistance was highest for tetracycline (89.66%), followed by erythromycin (76.23%) and clindamycin (58.21%). Multidrug resistance and resistance to ≥ 6 different antibiotics were 60.66% and 8.82%, respectively. Resistance to clindamycin but not erythromycin (L phenotype) was 2.2%. The clindamycin resistance rate was significantly increased (p = 0.005) during the study period. These data demonstrate a low rate of maternal GBS colonization. The high rate of erythromycin, clindamycin, and multidrug resistance to GBS that can be transmitted to neonates is an important risk factor to consider. β-lactams continue to be appropriate for first-line treatment and prophylaxis in the study area. Ongoing monitoring should be considered in the future.

Disparities in telehealth use: How should the supportive care community respond?

Telehealth use has increased in the setting of the COVID-19 pandemic. However, there are disparities in telehealth use based on age, income, race/ethnicity, low health, digital literacy, and limited English proficiency. There are multilevel barriers to telehealth use at the patient, health systems, telehealth portal, and policy levels. To ensure equity in telehealth services and to leverage these services to maximize the reach of health care services, concerted efforts are needed to design telehealth tools and workflows. It should include reimbursement for staff training, patient education, and technical support needed for telehealth use. Furthermore, ongoing monitoring and responsive modifications in the use of telehealth services are needed to promote telehealth equity.

Mefenoxam Sensitivity in US-8 and US-23 Phytophthora infestans from Wisconsin

The contemporary dominant clonal lineage of heterothallic Phytophthora infestans in Wisconsin, US-23, is classified as sensitive to the systemic fungicide mefenoxam and is of the A1 mating type. With the sporadic appearance of clonal lineage US-8, classified as resistant to mefenoxam and of the A2 mating type, there is a need for ongoing monitoring and characterization. Isolates of P. infestans collected from Wisconsin during the 2017 and 2018 growing seasons were tested for sensitivity to mefenoxam with discriminatory dose of 100 ppm. In 2017, both US-23 and US-8 were isolated. On average, isolates of US-23 were significantly more sensitive to mefenoxam than were US-8 isolates (P = 8e-04). There were significant differences in the sensitivity levels among the US-8 isolates (P = 2.02e-06), with a single isolate testing sensitive at 100 ppm of mefenoxam based on the one-way ANOVA. There were significant differences in the sensitivity levels among US-23 isolates (P = 3.75e-09), with two isolates showing resistance. In 2018 only US-23 was found, and isolates were tested for mefenoxam response at 0, 0.1, 1, 10, and 100 ppm. At 0.1 ppm, isolates showed significantly different levels of sensitivity (P = 2.1e-09), and a single isolate showed complete resistance. Isolates from both clonal lineages and years that exhibited moderate levels of resistance had greater variability among replicates. The phenotype of this multigenic trait comes through in the variability seen in isolates that are showing more resistance. Continued screening of P. infestans for mefenoxam sensitivity will help track the development and mechanism of resistance, as well as aid in development of best management approaches.