Industry Actor Use of Research Evidence: Critical Analysis of Australian Alcohol Policy Submissions

OBJECTIVE

Governments' limited adoption of evidence-based policies to reduce alcohol-related harm has been partly attributed to alcohol industry influence. A better understanding of industry political strategy may help protect public policy against vested interests. We examined how industry actors used scientific evidence in their submissions to government alcohol policy consultations.

METHOD

We conducted a content analysis of 214 submissions from industry actors in 21 Australian public consultations between 2013 and 2017. Represented industry actors included alcohol producers and retailers, trade associations, licensees, and associated entities that derive commercial benefit from alcohol (e.g., advertising companies). Adapting an existing framework, we classified industry practices into two categories: (a) misuse of evidence and (b) denial of the effectiveness of evidence-based strategies.

RESULTS

Almost all submissions (91%) denied the effectiveness of evidence-based strategies; the most common denial practices were making unsubstantiated claims about adverse effects of policies (76%) and promoting alternatives without evidence (71%). The misuse of scientific evidence was apparent in 66% of submissions. Trade associations, producers, and retailers were most likely to use such practices.

CONCLUSIONS

The extent to which the examined industry actors misused scientific evidence in their submissions to a wide range of alcohol policy consultations in Australia suggests the need for governments to consider excluding the industry from consultation on the regulation of alcohol.

Consensus-based clinical recommendations and research priorities for anticoagulant thromboprophylaxis in children hospitalized for COVID-19-related illness

BACKGROUND

Observational studies indicate that children hospitalized with COVID-19-related illness, like adults, are at increased risk for venous thromboembolism (VTE). A multicenter phase 2 clinical trial of anticoagulant thromboprophylaxis in children hospitalized with COVID-19-related illness has recently been initiated in the United States. To date, there remains a paucity of high-quality evidence to inform clinical practice world-wide. Therefore, the objective of this scientific statement is to provide consensus-based recommendations on the use of anticoagulant thromboprophylaxis in children hospitalized for COVID-19-related illnesses, and to identify priorities for future research.

METHODS

We surveyed 20 pediatric hematologists and pediatric critical care physicians from several continents who were identified by Pediatric/Neonatal Hemostasis and Thrombosis Subcommittee leadership as having experience and expertise in the use of anticoagulant thromboprophylaxis and/or the management of COVID-19-related illness in children. A comprehensive review of the literature on COVID-19 in children was also performed.

RESULTS

Response rate was 90%. Based on consensus of expert opinions, we suggest the administration of low-dose low molecular weight heparin subcutaneously twice-daily as anticoagulant thromboprophylaxis (in the absence of contraindications, and in combination with mechanical thromboprophylaxis with sequential compression devices, where feasible) in children hospitalized for COVID-19-related illness (including the multisystem inflammatory syndrome in children [MIS-C]) who have markedly elevated D-dimer levels or superimposed clinical risk factors for hospitalassociated VTE. For children who are clinically unstable or have severe renal impairment, we suggest the use of unfractionated heparin by continuous intravenous infusion as anticoagulant thromboprophylaxis. In addition, continued efforts to characterize VTE risk and risk factors in children with COVID-19, as well as to evaluate the safety and efficacy of anticoagulant thromboprophylaxis strategies in children hospitalized with COVID-19-related illness (including MIS-C) via cooperative multicenter trials, were identified among several key priorities for future research.

CONCLUSION

These consensus-based recommendations on the use of anticoagulant thromboprophylaxis in children hospitalized for COVID-19-related illnesses and priorities for future research will be updated as high-quality evidence emerges.

Nothing to lose: a grounded theory study of patients' and healthcare professionals' perspectives of being involved in the consent process for oncology trials with non-curative intent

BACKGROUND

Clinical cancer research trials may offer little or no direct clinical benefit to participants where a cure is no longer possible. As such, the decision-making and consent process for patient participation is often challenging.

AIM

To gain understanding of how patients make decisions regarding clinical trial participation, from the perspective of both the patient and healthcare professionals involved.

METHODS

In-depth, face to face interviews using a grounded theory approach. This study was conducted in a regional Cancer Centre in the United Kingdom. Of the 36 interviews, 16 were conducted with patients with cancer that had non-curative intent and 18 with healthcare professionals involved in the consent process.

RESULTS

'Nothing to lose' was identified as the core category that underpinned all other data within the study. This highlighted the desperation articulated by participants, who asserted trial participation was the 'only hope in the room'. The decision regarding participation was taken within a 'trusting relationship' that was important to both patients and professionals. Both were united in their 'fight against cancer'. These two categories are critical in understanding the decision-making/consent process and are supported by other themes presented in the theoretical model.

CONCLUSION

This study presents an important insight into the complex and ethically contentious situation of consent in clinical trials that have non-curative intent. It confirms that patients with limited options trust their doctor and frequently hold unrealistic hopes for personal benefit. It highlights a need for further research to develop a more robust and context appropriate consent process.

Hemozoin in Malarial Complications: More Questions Than Answers

Plasmodium parasites contain various virulence factors that modulate the host immune response. Malarial pigment, or hemozoin (Hz), is an undegradable crystalline product of the hemoglobin degradation pathway in the parasite and possesses immunomodulatory properties. An association has been found between Hz accumulation and severe malaria, suggesting that the effects of Hz on the host immune response may contribute to the development of malarial complications. Although the immunomodulatory roles of Hz have been widely investigated, many conflicting data exist, likely due to the variability between experimental set-ups and technical limitations of Hz generation and isolation methods. Here, we critically assess the potential immunomodulatory effects of Hz, its role in malarial complications, and its potential effects after parasite clearance.

Re-thinking the main goals of biological sciences: is it possible to build new knowledge without fundamental research?

Relationships between collective scientific knowledge and country's economic prosperity and competitiveness have been described. Hence, interaction between industry and academic institutions is seen as a way to valorize this knowledge at social and economic levels. The ability to translate scientific knowledge in social and economic benefits is now receiving most of the funding for public research. However, and despite the evident long-term benefits of funding applied science, drastic reduction of budget for fundamental research may eventually lead to the opposite outcome.

Considerations for using race and ethnicity as quantitative variables in medical education research

Throughout history, race and ethnicity have been used as key descriptors to categorize and label individuals. The use of these concepts as variables can impact resources, policy, and perceptions in medical education. Despite the pervasive use of race and ethnicity as quantitative variables, it is unclear whether researchers use them in their proper context. In this Eye Opener, we present the following seven considerations with corresponding recommendations, for using race and ethnicity as variables in medical education research: 1) Ensure race and ethnicity variables are used to address questions directly related to these concepts. 2) Use race and ethnicity to represent social experiences, not biological facts, to explain the phenomenon under study. 3) Allow study participants to define their preferred racial and ethnic identity. 4) Collect complete and accurate race and ethnicity data that maximizes data richness and minimizes opportunities for researchers' assumptions about participants' identity. 5) Follow evidence-based practices to describe and collapse individual-level race and ethnicity data into broader categories. 6) Align statistical analyses with the study's conceptualization and operationalization of race and ethnicity. 7) Provide thorough interpretation of results beyond simple reporting of statistical significance. By following these recommendations, medical education researchers can avoid major pitfalls associated with the use of race and ethnicity and make informed decisions around some of the most challenging race and ethnicity topics in medical education.

Learning from history: do not flatten the curve of antiviral research!

Here, we explore the dynamics of the response of the scientific community to several epidemics, including Coronavirus Disease 2019 (COVID-19), as assessed by the numbers of clinical trials, publications, and level of research funding over time. All six prior epidemics studied [bird flu, severe acute respiratory syndrome (SARS), swine flu, Middle East Respiratory Syndrome (MERS), Ebola, and Zika] were characterized by an initial spike of research response that flattened shortly thereafter. Unfortunately, no antiviral medications have been discovered to date as treatments for any of these diseases. By contrast, the HIV/AIDS pandemic has garnered consistent research investment since it began and resulted in drugs being developed within 7 years of its start date, with many more to follow. We argue that, to develop effective treatments for COVID-19 and be prepared for future epidemics, long-term, consistent investment in antiviral research is needed.

Strengthening national nutrition research: rationale and options for a new coordinated federal research effort and authority

BACKGROUND

The US faces remarkable food and nutrition challenges. A new federal effort to strengthen and coordinate nutrition research could rapidly generate the evidence base needed to address these multiple national challenges. However, the relevant characteristics of such an effort have been uncertain.

OBJECTIVES

Our aim was to provide an objective, informative summary of 1) the mounting diet-related health burdens facing our nation and corresponding economic, health equity, national security, and sustainability implications; 2) the current federal nutrition research landscape and existing mechanisms for its coordination; 3) the opportunities for and potential impact of new fundamental, clinical, public health, food and agricultural, and translational scientific discoveries; and 4) the various options for further strengthening and coordinating federal nutrition research, including corresponding advantages, disadvantages, and potential executive and legislative considerations.

METHODS

We reviewed government and other published documents on federal nutrition research; held various discussions with expert groups, advocacy organizations, and scientific societies; and held in-person or phone meetings with >50 federal staff in executive and legislative roles, as well as with a variety of other stakeholders in academic, industry, and nongovernment organizations.

RESULTS

Stark national nutrition challenges were identified. More Americans are sick than are healthy, largely from rising diet-related illnesses. These conditions create tremendous strains on productivity, health care costs, health disparities, government budgets, US economic competitiveness, and military readiness. The coronavirus disease 2019 (COVID-19) outbreak has further laid bare these strains, including food insecurity, major diet-related comorbidities for poor outcomes from COVID-19 such as diabetes, hypertension, and obesity, and insufficient surveillance on and coordination of our food system. More than 10 federal departments and agencies currently invest in critical nutrition research, yet with relatively flat investments over several decades. Coordination also remains suboptimal, documented by multiple governmental reports over 50 years. Greater harmonization and expansion of federal investment in nutrition science, not a silo-ing or rearrangement of existing investments, has tremendous potential to generate new discoveries to improve and sustain the health of all Americans. Two identified key strategies to achieve this were as follows: 1) a new authority for robust cross-governmental coordination of nutrition research and other nutrition-related policy and 2) strengthened authority, investment, and coordination for nutrition research within the NIH. These strategies were found to be complementary, together catalyzing important new science, partnerships, coordination, and returns on investment. Additional complementary actions to accelerate federal nutrition research were identified at the USDA.

CONCLUSIONS

The need and opportunities for strengthened federal nutrition research are clear, with specific identified options to help create the new leadership, strategic planning, coordination, and investment the nation requires to address the multiple nutrition-related challenges and grasp the opportunities before us.

Consolidating RRI and Open Science: understanding the potential for transformative change

In European research and innovation policy, Responsible Research and Innovation (RRI) and Open Science (OS) encompass two co-existing sets of ambitions concerning systemic change in the practice of research and innovation. This paper is an exploratory attempt to uncover synergies and differences between RRI and OS, by interrogating what motivates their respective transformative agendas. We offer two storylines that account for the specific contexts and dynamics from which RRI and OS have emerged, which in turn offer entrance points to further unpacking what 'opening up' to society means with respect to the transformative change agendas that are implicit in the two agendas. We compare differences regarding the 'how' of opening up in light of the 'why' to explore common areas of emphasis in both OS and RRI. We argue that while both agendas align with mission-oriented narratives around grand societal challenges, OS tends to emphasize efficiency and technical optimisation over RRI's emphasis on normative concerns and democracy deficits, and that the two agendas thus contrast in their relative legitimate emphasis on doable outcomes versus desirable outcomes. In our conclusion, we reflect on the future outlook for RRI and OS' co-existence and uptake, and on what their respective ambitions for transformation might mean for science-society scholars and scholarship.

Political psychophysiology A primer for interested researchers and consumers

The past decade has seen a rapid increase in the number of studies employing psychophysiological methods to explain variation in political attitudes and behavior. However, the collection, analysis, and interpretation of physiological data present novel challenges for political scientists unfamiliar with the underlying biological concepts and technical skills necessary for utilizing this approach. Our objective in this article is to maximize the effectiveness of future work utilizing psychophysiological measurement by providing guidance on how the techniques can be employed most fruitfully as a complement to, not a replacement for, existing methods. We develop clear, step-by-step instructions for how physiological research should be conducted and provide a discussion of the issues commonly faced by scholars working with these measures. Our hope is that this article will be a useful resource for both neophytes and experienced scholars in lowering the start-up costs to doing this work and assessing it as part of the peer review process. More broadly, in the spirit of the open science framework, we aim to foster increased communication, collaboration, and replication of findings across political science labs utilizing psychophysiological methods.

Allonymous science: the politics of placing and shifting credit in public-private nutrition research

Ideally, guidelines reflect an accepted position with respect to matters of concern, ranging from clinical practices to researcher behaviour. Upon close reading, authorship guidelines reserve authorship attribution to individuals fully or almost fully embedded in particular studies, including design or execution as well as significant involvement in the writing process. These requirements prescribe an organisation of scientific work in which this embedding is specifically enabled. Drawing from interviews with nutrition scientists at universities and in the food industry, we demonstrate that the organisation of research labour can deviate significantly from such prescriptions. The organisation of labour, regardless of its content, then, has consequences for who qualifies as an author. The fact that fewer food industry employees qualify is actively used by the food industry to manage the credibility and ownership of their knowledge claims as allonymous science: the attribution of science assisted by authorship guidelines blind to all but one organisational frame.

Organizational Supports for Research Evidence Use in State Public Health Agencies: A Latent Class Analysis

OBJECTIVE

Use of research evidence in public health decision making can be affected by organizational supports. Study objectives are to identify patterns of organizational supports and explore associations with research evidence use for job tasks among public health practitioners.

DESIGN

In this longitudinal study, we used latent class analysis to identify organizational support patterns, followed by mixed logistic regression analysis to quantify associations with research evidence use.

SETTING

The setting included 12 state public health department chronic disease prevention units and their external partnering organizations involved in chronic disease prevention.

PARTICIPANTS

Chronic disease prevention staff from 12 US state public health departments and partnering organizations completed self-report surveys at 2 time points, in 2014 and 2016 (N = 872).

MAIN OUTCOME MEASURES

Latent class analysis was employed to identify subgroups of survey participants with distinct patterns of perceived organizational supports. Two classify-analyze approaches (maximum probability assignment and multiple pseudo-class draws) were used in 2017 to investigate the association between latent class membership and research evidence use.

RESULTS

The optimal model identified 4 latent classes, labeled as "unsupportive workplace," "low agency leadership support," "high agency leadership support," and "supportive workplace." With maximum probability assignment, participants in "high agency leadership support" (odds ratio = 2.08; 95% CI, 1.35-3.23) and "supportive workplace" (odds ratio = 1.74; 95% CI, 1.10-2.74) were more likely to use research evidence in job tasks than "unsupportive workplace." The multiple pseudo-class draws produced comparable results with odds ratio = 2.09 (95% CI, 1.31-3.30) for "high agency leadership support" and odds ratio = 1.74 (95% CI, 1.07-2.82) for "supportive workplace."

CONCLUSIONS

Findings suggest that leadership support may be a crucial element of organizational supports to encourage research evidence use. Organizational supports such as supervisory expectations, access to evidence, and participatory decision making may need leadership support as well to improve research evidence use in public health job tasks.

Evidencing the impact of cancer trials: insights from the 2014 UK Research Excellence Framework

INTRODUCTION

An impactful clinical trial will have real-life benefits for patients and society beyond the academic environment. This study analyses case studies of cancer trials to understand how impact is evidenced for cancer trials and how impact evaluation can be more routinely adopted and improved.

METHODS

The United Kingdom (UK) Government allocates research funding to higher-education institutions based on an assessment of the institutions' previous research efforts, in an exercise known as the Research Excellence Framework (REF). In addition to each institution's journal publications and research environment, for the first time in 2014, allocation of funding was also dependent on an evaluation of the wider, societal impact of research conducted. In the REF2014, impact assessment was performed by evaluation of impact case studies. In this study, case studies (n = 6637) submitted by institutions for the REF2014 were accessed and those focussing on cancer trials were identified. Manual content analysis was then used to assess the characteristics of the cancer trials discussed in the case studies, the impact described and the methods used by institutions to demonstrate impact.

RESULTS

Forty-six case studies describing 106 individual cancer trials were identified. The majority were phase III randomised controlled trials and those recruiting patients with breast cancer. A list of indicators of cancer trial impact was generated using the previous literature and developed inductively using these case studies. The most common impact from a cancer trial identified in the case studies was on policy, in particular citation of trial findings in clinical guidelines. Impact on health outcomes and the economy were less frequent and health outcomes were often predicted rather than evidenced. There were few descriptions identified of trialists making efforts to maximise trial impact.

DISCUSSION

Cancer trial impact narratives for the next REF assessment exercise in 2021 can be improved by evidencing actual rather than predicted Impact, with a clearer identification of the beneficiaries of cancer trials and the processes through which trial results are used. Clarification of the individuals responsible for performing impact evaluations of cancer trials and the provision of resources to do so needs to be addressed if impact evaluation is to be sustainable.

Addressing selective reporting of experiments through predefined exclusion criteria

The pressure for every research article to tell a clear story often leads researchers in the life sciences to exclude experiments that 'did not work' when they write up their results. However, this practice can lead to reporting bias if the decisions about which experiments to exclude are taken after data have been collected and analyzed. Here we discuss how to balance clarity and thoroughness when reporting the results of research, and suggest that predefining the criteria for excluding experiments might help researchers to achieve this balance.

Top 20 Research Studies of 2019 for Primary Care Physicians

In 2019, regular surveillance of 110 English-language research journals identified 254 studies that met the criteria to become POEMs (patient-oriented evidence that matters). Physician members of the Canadian Medical Association rated these POEMs for their relevance to patients in their practices. This article summarizes the clinical questions and bottom-line answers from the top 20 POEMs of 2019. Taking blood pressure medications at night results in a large mortality reduction over six years compared with morning dosing. Automated devices are the best way to measure blood pressure. Nonfasting lipid profiles are preferred over fasting lipid profiles, and nonfasting and fasting lipid profiles are equally effective at predicting risk. The benefit of statins for primary prevention in people 75 years and older is uncertain at best. Aspirin has no net benefit for primary prevention of cardiovascular disease and has no effect on cancer outcomes. An Italian study found fecal immunochemical testing over five biennial screening cycles has a similar colorectal cancer yield as screening colonoscopy, whereas a meta-analysis found that taking aspirin, an anticoagulant, or a nonsteroidal anti-inflammatory drug has no impact on the positive predictive value of fecal immunochemical testing. Regarding infections, a meta-analysis showed that patients presenting with symptoms of acute respiratory tract infection are unlikely to have pneumonia if vital signs and the lung examination findings are normal. For streptococcal pharyngitis (strep throat), penicillin V at a dosage of 800 mg four times a day for five days is at least as effective as a dosage of 1,000 mg three times a day for 10 days. A primary care study in the United Kingdom reinforced that clinicians should counsel parents of children with lower respiratory tract symptoms to be patient, because these infections can take three weeks or more to fully resolve. Among direct oral anticoagulants, apixaban has the lowest bleeding risk, and cotreating with a proton pump inhibitor significantly reduces bleeding risk. Single ibuprofen doses from 400 to 800 mg significantly reduce acute pain to a similar degree. The two-dose recombinant zoster vaccine is much more effective than the single-dose live, attenuated vaccine but with a greater risk of injection site pain. Exercise helps reduce the risk of falls in older adults. Practice guidelines from 2019 on antithrombotics for atrial fibrillation, the management of type 2 diabetes mellitus, and screening for breast cancer were judged to be especially relevant.

Community standards for open cell migration data

Cell migration research has become a high-content field. However, the quantitative information encapsulated in these complex and high-dimensional datasets is not fully exploited owing to the diversity of experimental protocols and non-standardized output formats. In addition, typically the datasets are not open for reuse. Making the data open and Findable, Accessible, Interoperable, and Reusable (FAIR) will enable meta-analysis, data integration, and data mining. Standardized data formats and controlled vocabularies are essential for building a suitable infrastructure for that purpose but are not available in the cell migration domain. We here present standardization efforts by the Cell Migration Standardisation Organisation (CMSO), an open community-driven organization to facilitate the development of standards for cell migration data. This work will foster the development of improved algorithms and tools and enable secondary analysis of public datasets, ultimately unlocking new knowledge of the complex biological process of cell migration.

Postpositivism in Health Professions Education Scholarship

An understanding of the diversity of perspectives within the research paradigms of health professions education (HPE) is essential for rigorous research design and more purposeful engagement with the contributions of others. In this article, the authors explicitly discuss the underlying assumptions, notions of good scholarship, and shortcomings of the postpositivism research paradigm. While postpositivism is likely one of the more familiar paradigms within HPE research, it is rarely formally or explicitly described. Drawing on key literature and contemporary examples, the authors describe the ontology, epistemology, methodologies, axiology, signs of rigor, and common critiques of postpositivism. A case study provides the focus for a practical illustration of how a postpositivist approach to education research could be applied. Suggestions for further reading are provided for those who are keen to delve deeper into the history and key tenants of the postpositivist stance.

Assessing Clinical Embryology Research: A Global Bibliometric Analysis

Background and Objectives: The evaluative strength of available bibliometric tools in the field of clinical embryology has never been examined in the literature. The aim is to bring insight regarding the identity of clinical embryology research, introducing concerns when solely relying on the methodology of bibliometric analysis. Materials and Methods: An all-inclusive analysis of the most bibliometrically highlighted scientific contributions regarding the cornerstones of clinical embryology was performed employing the Scopus, Web of Science (WoS) and PubMed databases, between 1978–2018. An analysis of the number of publications, respective citations and h-index, g-index, along with m-quotient is presented. The top 30 contributing authors for each distinctive area of research are listed. An attempt at visualizing the yearly published articles, clusters, and collaborations of authors, along with the geographic origin of publications, is also presented. Results: Combining all searches and keywords yielded 54,522 results. In the Scopus database, employing the keyword “In Vitro Fertilization” yielded 41,292 results. The publications of the top five authors in each research field were analytically presented and compared to the total number of publications for each respective field. The research field of Preimplantation Genetic Diagnosis/Screening/Testing was allocated the highest percentage of publications produced by the top five authors. Regarding journal bibliometrics, based on the year 2017 metrics, there are only 29 journals according to WoS that refer to “Reproductive Biology”, ranking it 187th among 235 disciplines. The USA produced the highest number of publications (12,537). Conclusion: Results indicate an explosion of interest published in the literature regarding the field of clinical embryology. Further analysis on collaborations and the trends involved should be of added value as productivity between countries varies significantly. This may guide researchers, in vitro fertilization professionals, and prospective authors during literature search, while proving useful regarding manuscript design and concurring on keywords and abstract content.

Professional standards in bibliometric research evaluation? A meta-evaluation of European assessment practice 2005-2019

Despite growing demand for practicable methods of research evaluation, the use of bibliometric indicators remains controversial. This paper examines performance assessment practice in Europe-first, identifying the most commonly used bibliometric methods and, second, identifying the actors who have defined wide-spread practices. The framework of this investigation is Abbott's theory of professions, and I argue that indicator-based research assessment constitutes a potential jurisdiction for both individual experts and expert organizations. This investigation was conducted using a search methodology that yielded 138 evaluation studies from 21 EU countries, covering the period 2005 to 2019. Structured content analysis revealed the following findings: (1) Bibliometric research assessment is most frequently performed in the Nordic countries, the Netherlands, Italy, and the United Kingdom. (2) The Web of Science (WoS) is the dominant database used for public research assessment in Europe. (3) Expert organizations invest in the improvement of WoS citation data, and set technical standards with regards to data quality. (4) Citation impact is most frequently assessed with reference to international scientific fields. (5) The WoS classification of science fields retained its function as a de facto reference standard for research performance assessment. A detailed comparison of assessment practices between five dedicated organizations and other individual bibliometric experts suggests that corporate ownership and limited access to the most widely used citation databases have had a restraining effect on the development and diffusion of professional bibliometric methods during this period.

Faculty's Perception of a Research Project Embedded in the Undergraduate Veterinary Curriculum

In this article, we describe faculty's perception of a research project embedded in the final year of the undergraduate veterinary curriculum and look at factors associated with overall perceptions of the project. We hypothesized that faculty would have a dichotomous attitude toward the research project, with faculty viewing it either positively or negatively, and that this opinion of the project would be largely influenced by the background of the faculty member-in particular, her or his role at the Royal Veterinary College. We explored this hypothesis via a questionnaire consisting of 26 questions in categorical format, Likert-scale format, and ranking format. The questions addressed faculty demographics, faculty's perceptions of the project, and generic skills. Faculty had an overall positive view of the project and found it to be a useful part of the undergraduate curriculum (83.3% found it to be useful or very useful). Faculty's perception of the project was influenced by their role at the college (p = .017), the species with which they primarily work (p = .05), and their opinion on the time spent supervising the final-year project (p = .003). We concluded that faculty view research as an important and useful part of the undergraduate veterinary curriculum.