Tele-Savvy Outcomes of Non-Hispanic Black American and White Caregivers

BACKGROUND AND OBJECTIVES

Tele-Savvy is a synchronous/asynchronous psychoeducation program for caregivers of community-dwelling persons living with Alzheimer's disease and related dementias (ADRD) designed to increase caregivers' competence and confidence (mastery) in caregiving. Its overall efficacy was tested in a randomized controlled trial.

RESEARCH DESIGN AND METHODS

This secondary data analysis examined the caregiver mastery and psychological health (i.e., perceived stress, depressive symptoms, and burden) outcome of 153 non-Hispanic Black American and White caregivers (31 non-Hispanic Black American and 122 White caregivers) from baseline to 6 months postintervention. Given the difference in the sample sizes of Black and White caregivers, a descriptive post hoc subgroup analysis was conducted of 21 non-Hispanic Black American and 20 White adult children and grandchildren caregivers.

RESULTS

In the overall sample, Black American caregivers demonstrated higher levels of mastery and lower levels of distress than White caregivers at baseline and across all time points. Over time, White caregivers, but not Black American caregivers, experienced significantly improved levels of mastery and significantly lowered levels of depression. Within the subgroup analysis, except for a moderate effect size in the management of situation scores over time among Black American adult children caregivers, similar results were obtained.

DISCUSSION AND IMPLICATIONS

The findings highlight the strengths and shortcomings of the Tele-Savvy program in improving caregiver mastery and reducing negative psychological health outcomes. Intentionally tailoring the Tele-Savvy program to certain racial and caregiving groups may hold promise in meeting the needs of more ADRD caregivers.

CLINICAL TRIAL REGISTRATION

NCT03033875.

Evaluating the Dyadic Benefits of Early-Phase Behavioral Interventions: An Exemplar Using Data from Couples Living with Parkinson's Disease

BACKGROUND AND OBJECTIVES

There are a growing number of early-phase (i.e., Stage I, NIH Stage Model) interventions targeted at family care dyads navigating chronic health conditions in older adults. Currently, benefits of these interventions are often evaluated for older adults and their family care partners separately, even when controlling for interdependence. Without understanding benefits (and potential harms) for dyads as a whole, understanding of program impact is incomplete. Moreover, few health behavior interventions involving dyads include relational measures to ensure no unintended consequences for the dyad or account for within-dyad pre-test risk level.

RESEARCH DESIGN AND METHODS

We used secondary data from a quasi-experimental trial involving 39 couples in which one member of the dyad was living with Parkinson's Disease as an exemplar demonstration of three proposed approaches: an above-zero approach, a pre-test risk status approach, and an expanded pattern analysis matrix approach.

RESULTS

Approaches provided evidence for dyadic benefits of the intervention compared to the wait-list comparison condition, but carry different assumptions that did not always categorize dyads similarly.

DISCUSSION AND IMPLICATIONS

Implications of using each approach and selecting different benchmarks for defining success are discussed. The descriptive approaches proposed provide rationale for more intentional evaluation of small-sample, early-phase dyadic interventions.

The Effect of Tele-Savvy on Sleep Quality and Insomnia in Caregivers of Persons Living with Dementia

Introduction

Sleep disturbance is prevalent in caregivers of persons living with dementia (PLwD). Tele-Savvy, a 7-week virtual psychoeducational intervention, enhances caregivers' competence and self-care, and reduces depression. While not explicitly designed to do so, Tele-Savvy can potentially improve caregivers' disturbed sleep. The present study aimed to examine the longitudinal effects of Tele-Savvy on caregivers' sleep quality and insomnia.

Methods

This was a secondary data analysis of a 3-arm randomized control trial [Tele-Savvy (active treatment), Healthy Living (attention control), and usual care (waitlist control)]. Multilevel mixed modeling with intent-to-treat principles tested for group, time, and group-by-time effects. Effect sizes were estimated for all changes from baseline to the initial 6-month post-intervention point. Following completion of the 6-month post-randomization delay, we examined combined outcomes for Tele-Savvy.

Results

Participants (n=137; mean age 64.7 years) were predominantly female (68.6%) and White (68.6%). We found no initial group-by-time effects for the Pittsburgh Sleep Quality Index (PSQI) and the Insomnia Severity Index (ISI). For the combined Tele-Savvy group, there was a statistically significant improvement in ISI scores across time (p=0.050). The combined Tele-Savvy effect size for PSQI was d=0.126 and ISI was d=0.310.

Discussion

Tele-Savvy resulted in a significant long-term reduction in insomnia symptoms in this sample of caregivers of PLwD and demonstrated a positive trend for improvement in their sleep quality. Since sleep disturbance is so prevalent among caregivers of PLwD, the inclusion of sleep health education into psychoeducation caregiver interventions may yield even better outcomes for caregivers.

Intersectionality in nursing research: A scoping review

Background

An intersectional approach to health research provides an analytical foundation to explain the multidimensionality of health status, resource accessibility, privilege, oppression, and current and historical context. The use of intersectionality in health research has known limitations. Its use in health-related fields too often focuses on outcomes, such as health disparities, rather than processes, such as power structures and social determinants.

Objective

This scoping review serves to examine how intersectionality has been implemented by nurses in the peer-reviewed literature. We offer insight into how it may be incorporated to inform future nursing research and healthcare provision.

Design & Methods

Systematic searches of PubMed (n = 257), SCOPUS (n = 807), EMBASE (n = 396), CINAHL (n = 224), and Health Source: Nursing and Academics (n = 491), published since the seminal publication on intersectionality (1989 - 2023), identified 131 research articles that met inclusion and exclusion criteria. Data extraction and synthesis were used to describe the breadth and depth of the literature specific to the application of intersectionality in nursing research.

Results

The included studies used intersectionality to examine the intersections of numerous identities, such as race, gender, and immigration status. However, most studies were descriptive/observational in nature, underreported their methods, and conducted deficit-based research instead of strength-based inquiries. Of note, the vast majority of included articles were published within the last five years.

Conclusions

Future researchers using intersectionality as a framework can improve their approach by reporting clear definitions and operationalization of intersectionality. Observational science dominated the included studies; future research should focus on intervention development and evaluation using an intersectional lens. Lastly, caution should be placed on research that focuses solely on deficits among marginalized communities, which places scientists at risk of perpetuating stereotypes or enhancing already-existing stigmas.

Opportunities and challenges for biomarker discovery using electronic health record data

Electronic health records (EHRs) have become increasingly relied upon as a source for biomedical research. One important research application of EHRs is the identification of biomarkers associated with specific patient states, especially within complex conditions. However, using EHRs for biomarker identification can be challenging because the EHR was not designed with research as the primary focus. Despite this challenge, the EHR offers huge potential for biomarker discovery research to transform our understanding of disease etiology and treatment and generate biological insights informing precision medicine initiatives. This review paper provides an in-depth analysis of how EHR data is currently used for phenotyping and identifying molecular biomarkers, current challenges and limitations, and strategies we can take to mitigate challenges going forward.

Sleep Profiles of Caregivers for Persons Living with Dementia: A Qualitative Study

Sleep disturbance is prevalent among caregivers of people living with dementia. However, gaps exist about caregivers' sleep patterns before and during their caregiving trajectory. This exploratory secondary analysis using a qualitative descriptive approach aimed to (1) identify and describe current caregivers' patterns of change in sleep before and during caregiving, and (2) understand caregivers' perceptions of their current sleep compared to their pre-caregiving sleep. We conducted semi-structured interviews with 19 caregivers taking part in a larger randomized controlled trial. Participants were female (n = 11), white (n = 13) and on average 63 years of age. Interview questions focused on caregivers' sleep patterns. The interviews were audio-recorded using a videoconferencing platform and ranged from 20 to 45 minutes. We conducted thematic analysis of the interview transcripts. Three distinct caregiver-sleep profiles emerged from the qualitative data: changed and dissatisfied, changed and satisfied, and unchanged and dissatisfied. Caregivers whose sleep was categorized as changed reported a difference when comparing their current sleep pattern to their pre-caregiving sleep pattern. This was usually a change from good to poor sleep. Caregivers whose sleep was unchanged had poor sleep pre-caregiving and continued to have poor sleep during caregiving. Caregivers also reported being satisfied or dissatisfied with their current sleep pattern, defined in terms of distress and impairment. These three subtypes highlight the heterogeneity of caregivers' sleep experiences and debut a useful clinical framework with which to identify, categorize, and target caregivers at risk for sleep disturbance, many who may be ready to engage in behaviors to improve their sleep. Knowing caregivers' sleep profiles will enable health care providers and researchers to determine caregivers' needs and readiness for interventions then work collaboratively with them to improve their sleep problems.

Discrimination, Sexual Violence, Depression, Post-traumatic Stress Disorder, and Social Support among Black Women

BACKGROUND

Black Americans face significant discrimination associated with mental health disorder, which may be exacerbated among sexually victimized people. Social support may buffer that relationship.

METHODS

Cross-sectional data from a retrospective cohort study were analyzed to examine if discrimination and sexual victimization overlap to exacerbate symptoms of depression and post-traumatic stress disorder (PTSD) and to determine the extent to which social support moderated that association among Black women living in Baltimore, Maryland [138 non-abused (no physical/sexual victimization) and 98 abused (sexually victimized) since age 18].

RESULTS

Symptoms of depression and PTSD were independently associated with discrimination. Multilinear regression showed social support from friends moderated the association between discrimination and depressive symptoms among sexually abused participants only.

CONCLUSION

Discrimination may exacerbate symptoms of depression and PTSD more for sexually victimized Black women, but sources of informal social support may attenuate adverse effects of discrimination on depressive symptoms among members of that group.

ASSOCIATIONS BETWEEN HEALTH AND POSITIVE AFFECT IN SPOUSAL DEMENTIA CARE DYADS

Little is known about the conditions that foster greater positive affect in the daily lives of spousal dementia care dyads in the early stages of dementia. This study aimed to examine the extent to which multiple indicators of health, including activities of daily living needs, quality of life, and the person with dementia’s behavioral symptoms were associated with each partner’s positive affect in daily life. Using secondary baseline data from a randomized controlled trial testing a stress reduction intervention in 63 couples (N=126), we examined whether individuals’ multiple health indicators were associated with their own positive affect (actor effects) and their partner’s positive affect (partner effects). Actor partner interdependence model results showed that for both persons with dementia and spouses, actor quality of life was the greatest predictor of positive affect, controlling for all other actor and partner health indicators (β=.04, SE=.01, t(67.1)=3.36, p=.001).

COVID-19 Vaccine Hesitancy Among Health Care Workers in Four Health Care Systems in Atlanta

Coronavirus disease 2019 (COVID-19) vaccine hesitancy among health care workers (HCWs) undermines community vaccine confidence. Predictors and reasons for HCW hesitancy in the Atlanta region were evaluated using a survey between May and June 2021. Vaccine hesitancy was highest in younger and less educated HCWs. Interventions to address vaccine hesitancy in HCWs are necessary.

Barriers to accessing and engaging in healthcare as potential modifiers in the association between polyvictimization and mental health among Black transgender women

BACKGROUND

Black transgender women endure pervasive polyvictimization (experiencing multiple forms of violence throughout the lifespan). Polyvictimization is associated with poor mental health. Black transgender women also face barriers in access to healthcare, but the extent that such barriers modify the association between polyvictimization and poor mental health has not been described using convergent mixed-methods analysis.

METHODS

This convergent mixed-methods secondary analysis employs an intersectional lens and integrates two inter-related datasets to describe barriers to healthcare and the extent that such barriers modify the association between polyvictimization and mental health among Black transgender women. Investigators used survey data (n = 151 participants) and qualitative interview data (n = 19 participants) collected from Black transgender women (age 18 years and older) in Baltimore, MD and Washington, DC between 2016 and 2018. Analyses include thematic content analysis, bivariate analysis, joint display, and multivariate linear regression analysis examining mediation and moderation.

RESULTS

Joint display illuminated three domains to describe how barriers to healthcare present among Black transgender women-Affordability, Accessibility, and Rapport and Continuity. Independent t-tests revealed significantly higher polyvictimization, Post Traumatic Stress Disorder (PTSD), and depression scores among participants who reported at least one barrier to healthcare (BHI) compared to those who reported no barriers. BHI significantly moderated and partially mediated the association between polyvictimization and PTSD symptom severity and BHI fully mediated the association between polyvictimization and depressive symptom severity-when accounting for age and location.

DISCUSSION

Findings highlight the importance of access to healthcare in modifying the association between polyvictimization and PTSD and depression symptom severity among Black transgender women. Findings call for immediate interventions aimed at reducing barriers to healthcare and improved training for clinical providers serving Black transgender women.

Promoting Caregiver Mastery in Black American Dementia Caregivers

Over 6 million older Americans live with Alzheimer's disease and related dementias; Black American older adults' prevalence is more than twice that of non-Hispanic White older adults. The Black American dementia caregiving experience can be encapsulated within the Black Family Socioecological Context Model, which provides a conceptual basis for examining social determinants of health at individual, family, community, and societal levels with careful consideration for how the intersection of race, gender, and class of Black American dementia caregivers influences the multiple dimensions of their caregiving experiences. Family dynamics, community setting, and health care systems have a potentially bidirectional influence on these caregivers, which is shaped by historical and ongoing systemic and institutional racism and general disenfranchisement. This Forum article outlines how the Social Cognitive Theory offers ways for Black American dementia caregivers to achieve a sense of mastery within the complicated and fraught ecology within which their caregiving occurs. We propose a research agenda to create programs and interventions for enhancing a sense of mastery among Black American dementia caregivers. Two concepts in particular, "constraints" and "efficacy expectations," provide ways to create a systematic approach to developing successful coping strategies for the constraints perceived by individuals as they undertake and function in the caregiving role. The recognition of the complexity of the caregiving ecosystem and intersectionality of caregivers' experience and identity emphasize the importance of individualization: Each caregiver's experience of this ecosystem-and therefore each Black American dementia caregiver's way to mastery within it-will be uniquely shaped and experienced.

Barriers to Pain Management: Incongruence in Black Cancer Caregiving Dyads

CONTEXT

To effectively manage cancer pain, there is a need to understand how caregiving dyads appraise symptoms. Dyadic appraisal of symptoms influences whether the dyad perceives the patient's pain is managed well and whether they are on the same page with their appraisal. Beliefs can act as barriers to the dyadic appraisal.

OBJECTIVES

This secondary data analysis examined incongruence within Black cancer caregiving dyads regarding beliefs about pain management and potential medication side effects using the Barriers Questionnaire-13. Associated factors were also examined.

METHODS

Guided by the Theory of Dyadic Illness Management, dyadic multilevel modeling was conducted with data from 60 Black cancer caregiving dyads to determine the dyadic appraisal of beliefs about pain management and potential medication side effects, which includes the average perception of barriers within the dyad (i.e., dyadic average) and the dyadic incongruence (i.e., gap between patient and caregiver).

RESULTS

On average, Black cancer caregiving dyads reported moderate barriers regarding pain management (2.262 (SE=0.102, P<0.001) and medication side effects (2.223 (SE=0.144, P<0.001). There was significant variability across dyads regarding barriers to pain management and medication side effects. Lower patient education and higher patient-reported pain interference were significantly associated with more perceived barriers to pain management and potential medication side effects. Incongruence within dyads regarding barriers to pain management and medication side effects were significantly associated with the caregiver's report of patient's pain interference.

CONCLUSION

Findings suggest the importance of appraisal that includes both members of Black cancer caregiving dyads regarding pain management.

Gender-specific predictors of poor sleep quality and insomnia among caregivers of persons living with dementia

Caregiving for a person living with dementia (PLwD) may influence sleep patterns. Gaps exists about whether caregiver and PLwD factors impact sleep differentially based on caregivers’ gender. The aim of this secondary data analysis was to identify predictors of sleep quality and insomnia in a sample of caregivers, stratified by gender, participating in a randomized controlled trial of a psychoeducational intervention. Outcome measures were sleep quality (Pittsburgh Sleep Quality Index, PSQI) and insomnia (Insomnia Severity Index, ISI). Participants (n=261) also completed measures about caregivers’ perceived stress, burden, depression, and self-care, and PLwD’s behaviors (i.e., apathy, sleep disorders). Linear regression modeling was used to identify the overall predictors of poor sleep quality (PSQI > 5; 52% of the sample) and insomnia (ISI > 7; 41% of the sample). Caregivers were primarily female (70.5%), White (73.6%), mean age of 64.6 (±11.2) years, and typically caring for a spouse (65.9%). For male caregivers, predictors of poor sleep quality were assisting the PLwD with instrumental activities of daily living and PLwD neuropsychiatric symptoms (F=4.45, p<.001); while caregiver self-care and PLwD neuropsychiatric symptoms predicted insomnia (F=4.49, p<.001). For female caregivers, the predictors of poor sleep quality were caregiver depressive symptoms and burden, and frequency of PLwD behavioral problems (F=4.46, p<.001); however, only perceived stress predicted insomnia (F=4.32, p<.001). Various factors related to caregiving appear to be more important than others in predicting sleep outcomes of male/female caregivers. Health care professionals should acknowledge gender differences when designing and implementing programs and interventions to improve sleep.

Mastery Goals for Black American Dementia Caregivers

About 5.8 million older American adults live with Alzheimer’s disease and related dementias; Black American older adults’ prevalence is more than twice that of non-Hispanic white older adults. The Black American dementia caregiving experience can be pictured within the Black Family Social-Ecological Context Model, which provides a conceptual basis for examining social determinants of health at individual, family, community, and societal levels with careful consideration for how the intersecting identities of race, gender, and class of Black American caregivers influence the multiple dimensions of their caregiving experiences. Family dynamics, community setting, and healthcare systems have a potentially bidirectional influence on these caregivers, which is informed by the larger historical reality of systemic racism and general disenfranchisement. This paper outlines how Stress Process and Perceived Control frameworks offer ways for Black American dementia caregivers to achieve a sense of mastery within the complicated and fraught ecology within which their caregiving occurs. We propose a research and development agenda to create a program for enhancing a sense of mastery among Black American dementia caregivers. Two concepts in particular, “constraints” and “efficacy expectations,” provide ways to develop a systematic approach to developing successful coping strategies for the constraints perceived by individuals as they undertake and function in the caregiving role. The recognition of the complexity of the caregiving ecosystem and intersectionality of caregivers’ experience emphasize the importance of individualization: each caregiver’s experience of this ecosystem– and therefore each Black American caregiver’s way to mastery within it– will be uniquely shaped and experienced.

Sleep Phenotypes of Caregivers for Persons Living With Dementia

Sleep disturbance is prevalent among caregivers of people living with dementia. Gaps exist regarding when caregivers begin to experience sleep disturbance along their caregiving trajectory. This study aimed to identify and describe phenotypes of current caregivers’ sleep patterns before and during caregiving and describe caregivers’ perception of their current sleep quality relative to their pre-caregiving sleep. We conducted semi-structured interviews with 19 caregivers participating in a larger, randomized controlled trial. Interviews were about caregivers’ sleep patterns and were conducted after caregivers completed the first 6 months of the study. Interviews were audio-recorded using a videoconferencing platform and ranged from 20 to 45 minutes. We conducted thematic analysis of the interview transcripts. Four distinct caregiver-sleep phenotypes emerged from the qualitative data: Changed and Dissatisfied, Changed and Satisfied, Unchanged and Dissatisfied, and Unchanged and Satisfied. Caregivers whose sleep was categorized as Changed experienced a difference in their pre-caregiving sleep, usually from good to poor sleep. Caregivers whose sleep was Unchanged had poor sleep pre-caregiving and continued to have poor sleep during caregiving. Caregivers also reported being Satisfied or Dissatisfied with their current sleep pattern, defined in terms of daily distress and impairment. These 4 subtypes highlight the heterogeneity of caregivers’ sleep experiences and debut a useful clinical framework with which to identify, categorize, and target caregivers at risk for sleep disturbance. Identifying caregivers’ sleep phenotypes will enable healthcare providers to determine caregivers’ needs and readiness for interventions.

Congruence of pain perceptions between Black cancer patients and their family caregivers

PURPOSE

This cross-sectional study evaluated congruence in pain assessment among Black cancer patients taking opioids for pain and their family caregivers and the effects of patient-reported depressive symptoms and cognitive complaints on the congruence.

METHODS

Patient-reported pain scores (current, average, and worst pain severity and pain interference) and caregiver proxy scores were independently assessed (Brief Pain Inventory). Patient-reported depressive symptoms (Patient Health Questionnaire-8) and cognitive complaints (Cognitive Difficulties Scale) were also assessed. Paired t-test, intraclass correlation coefficient (ICC), and Bland-Altman (BA) plots were used to evaluate group and dyad level congruence in pain assessment. The influence of patient depressive symptoms and cognitive complaints on congruence was examined using bivariate analyses and BA plots.

RESULTS

Among 50 dyads, 62% of patients and 56% of caregivers were female. Patients were older than caregivers (57 vs. 50 years, p = .008). Neither statistically significant (t-test) nor clinically relevant mean differences in pain severity and interference were found at a group level. At the dyad level, congruence was poor in pain now (ICC = 0.343) and average pain severity (ICC = 0.435), but moderate in worst pain severity (ICC = 0.694) and pain interference (ICC = 0.603). Results indicated better congruence in pain severity between patients with depressive symptoms and their caregivers, compared to patients without depressive symptoms. Patient CDS scores had no significant correlations with score differences between patients and caregivers in any pain variables.

CONCLUSION

Congruence varied depending on how the analysis was done. More information is needed to understand pain assessment between patients and caregivers.

REDCap on FHIR: Clinical Data Interoperability Services

BACKGROUND

Despite widespread use of electronic data capture (EDC) systems for research and electronic health records (EHR), most transfer of data between EHR and EDC systems is manual and error prone. Increased adoption of Health Level Seven Fast Healthcare Interoperability Resource (FHIR) application programming interfaces (APIs) in recent years by EHR systems has increased the availability of patient data for external applications such as REDCap.

OBJECTIVE

Describe the development of the REDCap Clinical Data Interoperability Services (CDIS) module that provides seamless data exchange between the REDCap research EDC and any EHR system with a FHIR API. CDIS enables end users to independently set up their data collection projects, map EHR data to fields, and adjudicate data transfer without project-by-project involvement from Health Information Technology staff.

METHODS

We identified two use cases for EHR data transfer into REDCap. Clinical Data Pull (CDP) automatically pulls EHR data into user-defined REDCap fields and replaces the workflow of having to transcribe or copy and paste data from the EHR. Clinical Data Mart (CDM) collects all specified data for a patient over a given time period and replaces the process of importing EHR data for registries from research databases. With an iterative process, we designed our access control, authentication, variable selection, and mapping interfaces in such a way that end users could easily set up and use CDIS.

RESULTS

Since its release, the REDCap CDIS has been used to pull over 19.5 million data points for 82 projects at Vanderbilt University Medical Center. Software and documentation are available through the REDCap Consortium.

CONCLUSIONS

The new REDCap Clinical Data and Interoperability Services (CDIS) module leverages the FHIR standard to enable real-time and direct data extraction from the EHR. Researchers can self-service the mapping and adjudication of EHR data into REDCap. The uptake of CDIS at VUMC and other REDCap consortium sites is improving the accuracy and efficiency of EHR data collection by reducing the need for manual transcription and flat file uploads.

Using poetry as data to explore daily and formal care decision making within African American dementia dyads

There is limited research exploring how daily and formal care decision making occurs within African American dementia dyads as well as how these dyads navigate decision making across the dementia trajectory. Through semi-structured interviews, five African American dementia dyads shared their decision-making processes. We used a multimethod approach to the analysis of data, including qualitative and quantitative content analysis and the creation of I Poems. This novel use of I Poems provided a uniquely personal account of the lived experiences of the African American persons living with dementia, while other analyses revealed that within dyads, daily care decision making was led by African American persons living with dementia, whereas formal care decision making varied between dyads. There was intra-dyad congruence regarding who the final decision maker was in daily and formal care. Clinicians and researchers may be able to tailor interventions based on the dyad's involvement in these decision-making processes.

Floral Colonization Dynamics and Specificity of Aureobasidium pullulans Strains Used to Suppress Fire Blight of Pome Fruit

Aureobasidium pullulans is used as a biocontrol agent for fire blight protection in organic apple and pear production. We assessed colonization of pome flowers by A. pullulans in orchards located near Corvallis, OR and Wenatchee, WA. Blossom Protect, a mix of A. pullulans strains CF10 and CF40, and its citrate-based companion, Buffer Protect, were sprayed at 70% bloom. Later in bloom, the population size of putative A. pullulans on flowers was estimated by dilution plating; plate scrapings of putative A. pullulans were then sampled and subjected to a PCR analysis. Sequenced PCR amplicons of the internal transcribed spacer region and the elongase gene confirmed the presence of A. pullulans, whereas a multiplex PCR with primers specific to CF10 and CF40 was used to determine the presence of the introduced strains. At Corvallis, a wet spring environment, A. pullulans, was recovered from most (>90%) Bartlett pear and Golden Delicious apple flowers sampled from experimental trees, regardless of whether the trees were treated with Blossom Protect. Nevertheless, population size estimates of A. pullulans on the flowers were correlated with the number of times Blossom Protect was sprayed on the trees. At Wenatchee, an arid spring environment, A. pullulans was detected on most flowers from trees treated with Blossom Protect, but only on a minority of flowers from nontreated controls. In both locations, the combined incidence of strains CF10 and CF40 on flowers averaged 89% on Blossom Protect-treated trees, but only 27% on adjacent, nontreated trees. During subsequent trials, the efficacy of Blossom Protect for fire blight control was compared with alternative yeast isolates, with each applied with Buffer Protect; local isolates of A. pullulans and Cryptococcus neoformans and a postharvest biocontrol strain of Cystofilobasidium infirmominiatum were used All yeast strains suppressed fire blight to a degree; however, in each of four trials, the level of suppression was highest with Blossom Protect, and it was significantly superior (P ≤ 0.05) to other yeast isolates in two of the trials. Because A. pullulans strains CF10 and CF40 were detected primarily on flowers on trees treated with Blossom Protect, and because they were detected much less frequently on nearby nontreated tress, we recommend treating every tree row with Blossom Protect at least once for organic fire blight suppression.

Physician response to implementation of genotype-tailored antiplatelet therapy

Physician responses to genomic information are vital to the success of precision medicine initiatives. We prospectively studied a pharmacogenomics implementation program for the propensity of clinicians to select antiplatelet therapy based on CYP2C19 loss-of-function variants in stented patients. Among 2,676 patients, 514 (19.2%) were found to have a CYP2C19 variant affecting clopidogrel metabolism. For the majority (93.6%) of the cohort, cardiologists received active and direct notification of CYP2C19 status. Over 12 months, 57.6% of poor metabolizers and 33.2% of intermediate metabolizers received alternatives to clopidogrel. CYP2C19 variant status was the most influential factor impacting the prescribing decision (hazard ratio [HR] in poor metabolizers 8.1, 95% confidence interval [CI] [5.4, 12.2] and HR 5.0, 95% CI [4.0, 6.3] in intermediate metabolizers), followed by patient age and type of stent implanted. We conclude that cardiologists tailored antiplatelet therapy for a minority of patients with a CYP2C19 variant and considered both genomic and nongenomic risks in their clinical decision-making.

Presenting multiple drug alerts in an ambulatory electronic prescribing system: a usability study of novel prototypes

OBJECTIVE

This study explores alternative approaches to the display of drug alerts, and examines whether and how human-factors based interface design can be used to improve the prescriber's perception about drug alert presentation, signal detection from noisy alert data, and their comprehension of clinical decision support during electronic prescribing.

METHODS

We reviewed issues with presenting multiple drug alerts in electronic prescribing systems. User-centered design, consisting of iterative usability and prototype testing was applied. After an iterative design phase, we proposed several novel drug alert presentation interfaces; expert evaluation and formal usability testing were applied to access physician prescribers' perceptions of the tools. We mapped drug alert attributes to different interface constructs. We examined four different interfaces for presenting multiple drug alerts.

RESULTS

A TreeDashboard View was better perceived than a text-based ScrollText View with respect to the ability to detect critical information, the ability to accomplish tasks, and the perceptional efficacy of finding information.

CONCLUSION

A robust model for studying multiple drug-alert presentations was developed. Several drug alert presentation interfaces were proposed. The TreeDashboard View was better perceived than the text-based ScrollText View in delivering multiple drug alerts during a simulation of electronic prescribing.

Mechanistically compatible mixtures of bacterial antagonists improve biological control of fire blight of pear

Mixtures of biological control agents can be superior to individual agents in suppressing plant disease, providing enhanced efficacy and reliability from field to field relative to single biocontrol strains. Nonetheless, the efficacy of combinations of Pseudomonas fluorescens A506, a commercial biological control agent for fire blight of pear, and Pantoea vagans strain C9-1 or Pantoea agglomerans strain Eh252 rarely exceeds that of individual strains. A506 suppresses growth of the pathogen on floral colonization and infection sites through preemptive exclusion. C9-1 and Eh252 produce peptide antibiotics that contribute to disease control. In culture, A506 produces an extracellular protease that degrades the peptide antibiotics of C9-1 and Eh252. We hypothesized that strain A506 diminishes the biological control activity of C9-1 and Eh252, thereby reducing the efficacy of biocontrol mixtures. This hypothesis was tested in five replicated field trials comparing biological control of fire blight using strain A506 and A506 aprX::Tn5, an extracellular protease-deficient mutant, as individuals and combined with C9-1 or Eh252. On average, mixtures containing A506 aprX::Tn5 were superior to those containing the wild-type strain, confirming that the extracellular protease of A506 diminished the biological control activity of C9-1 and Eh252 in situ. Mixtures of A506 aprX::Tn5 and C9-1 or Eh252 were superior to oxytetracycline or single biocontrol strains in suppressing fire blight of pear. These experiments demonstrate that certain biological control agents are mechanistically incompatible, in that one strain interferes with the mechanism by which a second strain suppresses plant disease. Mixtures composed of mechanistically compatible strains of biological control agents can suppress disease more effectively than individual biological control agents.

Control of fire blight by Pseudomonas fluorescens A506 and Pantoea vagans C9-1 applied as single strains and mixed inocula

The biological control agents Pseudomonas fluorescens A506 and Pantoea vagans C9-1 were evaluated individually and in combination for the suppression of fire blight of pear or apple in 10 field trials inoculated with the pathogen Erwinia amylovora. The formulation of pathogen inoculum applied to blossoms influenced establishment of the pathogen and the efficacy of biological control. Pantoea vagans C9-1 suppressed fire blight in all five trials in which the pathogen was applied as lyophilized cells but in none of the trials in which the pathogen was applied as freshly harvested cells. In contrast, Pseudomonas fluorescens A506 reduced disease significantly in only one trial. A mixture of the two strains also suppressed fire blight, but the magnitude of disease suppression over all field trials (averaging 32%) was less than that attained by C9-1 alone (42%). The two biological control agents did not antagonize one another on blossom surfaces, and application of the mixture of A506 and C9-1 to blossoms resulted in a greater proportion of flowers having detectable populations of at least one bacterial antagonist than the application of individual strains. Therefore, the mixture of A506 and C9-1 provided less disease control than expected based upon the epiphytic population sizes of the antagonists on blossom surfaces. We speculate that the biocontrol mixture was less effective than anticipated due to incompatibility between the mechanisms by which A506 and C9-1 suppress disease.

Factors Influencing Epidemiology and Management of Blackberry Rust in Cultivated Rubus laciniatus

The blackberry rust pathogen Phragmidium violaceum was first observed in Oregon in spring 2005 on both commercially cultivated Rubus laciniatus (Evergreen blackberry) and naturalized R. armeniacus (Himalayan blackberry). Several commercial plantings suffered severe economic losses. In 2006 to 2008, all five spore stages of this autoecious, macrocyclic rust pathogen were observed annually, and asexual perennation of the pathogen on old leaves or in leaf buds was not evident in the disease cycle. In field experiments, teliospore germination and infection by basidiospores occurred mostly during April. On potted "trap" plants exposed for periods of 1 week under dense collections of dead leaves bearing teliospores, basidiospore infection was associated with wetness durations of >16 h with mean temperatures >8°C. Trap plants placed under the bundles of collected leaves frequently developed spermagonia, whereas only 1 of 630 trap plants placed in a production field of R. laciniatus became diseased, an indication that the effective dispersal distance of basidiospores may be limited. In growth chambers programmed for constant temperatures of 5, 10, 15, 20, 25, and 30°C, a minimum of six continuous hours of leaf wetness was required for infection by urediniospores, with >9 h required for moderate infection (>4 pustules/cm²) at 15 and 20°C. With diurnal temperature regimes averaging 5, 10, 15, 20, or 25°C, urediniospore germination and infection was highest in the range of 5 to 15°C; similarly, in the diurnal environment, >9 h of leaf wetness was required to attain moderate infection. In the field, lime sulfur applied as a delayed dormant treatment significantly suppressed teliospore germination and basidiospore infection. Over two seasons, one application of myclobutanil, a demethylation-inhibitor fungicide, applied in early May near the time of spermagonial appearance provided effective suppression of the summer epidemic.

Implications of pathogenesis by Erwinia amylovora on rosaceous stigmas to biological control of fire blight

As a prerequisite to infection of flowers, Erwinia amylovora grows epiphytically on stigmas, which provide a conducive habitat for bacterial growth. Stigmas also support growth of several other bacterial genera, which allows for biological control of fire blight; although, in practice, it is very difficult to exclude E. amylovora completely from this habitat. We investigated the dynamics of growth suppression of E. amylovora by comparing the ability of virulent and avirulent strains of E. amylovora to compete with each other on stigmas of pear, apple, and blackberry, and to compete with a co-inoculated mixture of effective bacterial antagonists. When strains were inoculated individually, virulent E. amylovora strain Ea153N attained the highest population size on stigmas, with population sizes that were approximately double those of an avirulent hrpL mutant of Ea153 or the bacterial antagonists. In competition experiments, growth of the avirulent derivative was suppressed by the antagonist mixture to a greater extent than the virulent strain. Unexpectedly, the virulent strain enhanced the population size of the antagonist mixture. Similarly, a small dose of virulent Ea153N added to inoculum of an avirulent hrpL mutant of Ea153 significantly increased the population size of the avirulent strain. A pathogenesis-gene reporter strain, Ea153 dspE::gfp, was applied to flowers and a subset of the population expressed the green fluorescent protein while growing epiphytically on stigmas of apple. These results are consistent with the hypothesis that virulent E. amylovora modifies the epiphytic habitat presented by the stigma through a pathogenesis-related process, which increases host resources available to itself and, coincidentally, to nonpathogenic competitors. Over nine orchard trials, avirulent Ea153 hrpL significantly suppressed the incidence of fire blight four times compared with six for the antagonist mixture. The degree of biological control achievable with an avirulent strain of E. amylovora likely is limited by its inability to utilize the stigmatic habitat to the same degree as a virulent strain.

Gemcitabine, vinorelbine, and pegylated liposomal doxorubicin (GVD), a salvage regimen in relapsed Hodgkin's lymphoma: CALGB 59804

BACKGROUND

Because of high single-agent activity and modest toxicity, we hypothesized the combination of gemcitabine (G), vinorelbine (V), and pegylated liposomal doxorubicin (D) would be an effective salvage therapy for Hodgkin's lymphoma (HL).

PATIENTS AND METHODS

A total of 91 patients participated. GVD was administered on days 1 and 8 every 21 days at doses of G 1000 mg/m(2), V 20 mg/m(2), and D 15 mg/m(2) for transplant-naive patients, and G 800 mg/m(2), V 15 mg/m(2), and D 10 mg/m(2) for post-transplant patients.

RESULTS

The dose-limiting toxicity was mucositis for the transplant-naive patients and febrile neutropenia for post-transplant patients. The overall response rate (RR) for all patients was 70% [95% confidence interval (CI) 59.8, 79.7], with 19% complete remissions. The 4-year event-free and overall survival rates in transplant-naive patients treated with GVD followed by autologous transplant were 52% (95% CI 0.34, 0.68) and 70% (95% CI 0.49, 0.84), and in the patients in whom prior transplant failed, these were 10% (95% CI 0.03, 0.22) and 34% (95% CI 0.17, 0.52), respectively.

CONCLUSIONS

GVD is a well-tolerated, active regimen for relapsed HL with results similar to those reported for more toxic regimens. High RRs in patients in whom prior transplant failed confirms this regimen's activity even in heavily pretreated patients.

Landscape controls on mercury in streamwater at Acadia National Park, USA

Fall and spring streamwater samples were analyzed for total mercury (Hg) and major ions from 47 locations on Mount Desert Island in Maine. Samples were collected in zones that were burned in a major wildfire in 1947 and in zones that were not burned. We hypothesized that Hg concentrations in streamwater would be higher from unburned sites than burned watersheds, because fire would volatilize stored Hg. The Hg concentrations, based on burn history, were not statistically distinct. However, significant statistical associations were noted between Hg and the amount of wetlands in the drainage systems and with streamwater dissolved organic carbon (DOC). An unexpected result was that wetlands mobilized more Hg by generating more DOC in total, but upland DOC was more efficient at transporting Hg because it transports more Hg per unit DOC. Mercury concentrations were higher in samples collected at lower elevations. Mercury was positively correlated with relative discharge, although this effect was not distinguished from the DOC association. In this research, sample site elevation and the presence of upstream wetlands and their associated DOC affected Hg concentrations more strongly than burn history.

Controls on mercury and methylmercury deposition for two watersheds in Acadia National Park, Maine

Throughfall and bulk precipitation samples were collected for two watersheds at Acadia National Park, Maine, from 3 May to 16 November 2000, to determine which landscape factors affected mercury (Hg) deposition. One of these watersheds, Cadillac Brook, burned in 1947, providing a natural experimental design to study the effects of forest type on deposition to forested watersheds. Sites that face southwest received the highest Hg deposition, which may be due to the interception of cross-continental movement of contaminated air masses. Sites covered with softwood vegetation also received higher Hg deposition than other vegetation types because of the higher scavenging efficiency of the canopy structure. Methyl mercury (MeHg) deposition was not affected by these factors. Hg deposition, as bulk precipitation and throughfall was lower in Cadillac Brook watershed (burned) than in Hadlock Brook watershed (unburned) because of vegetation type and watershed aspect. Hg and MeHg inputs were weighted by season and vegetation type because these two factors had the most influence on deposition. Hg volatilization was not determined. The total Hg deposition via throughfall and bulk precipitation was 9.4 microg/m(2)/year in Cadillac Brook watershed and 10.2 microg/m(2)/year in Hadlock Brook watershed. The total MeHg deposition via throughfall and bulk precipitation was 0.05 microg/m(2)/year in Cadillac Brook watershed and 0.10 microg/m(2)/year in Hadlock Brook watershed.

Mass balances of mercury and nitrogen in burned and unburned forested watersheds at Acadia National Park, Maine, USA

Precipitation and streamwater samples were collected from 16 November 1999 to 17 November 2000 in two watersheds at Acadia National Park, Maine, and analyzed for mercury (Hg) and dissolved inorganic nitrogen (DIN, nitrate plus ammonium). Cadillac Brook watershed burned in a 1947 fire that destroyed vegetation and soil organic matter. We hypothesized that Hg deposition would be higher at Hadlock Brook (the reference watershed, 10.2 microg/m(2)/year) than Cadillac (9.4 microg/m(2)/year) because of the greater scavenging efficiency of the softwood vegetation in Hadlock. We also hypothesized the Hg and DIN export from Cadillac Brook would be lower than Hadlock Brook because of elemental volatilization during the fire, along with subsequently lower rates of atmospheric deposition in a watershed with abundant bare soil and bedrock, and regenerating vegetation. Consistent with these hypotheses, Hg export was lower from Cadillac Brook watershed (0.4 microg/m(2)/year) than from Hadlock Brook watershed (1.3 microg/m(2)/year). DIN export from Cadillac Brook (11.5 eq/ha/year) was lower than Hadlock Brook (92.5 eq/ha/year). These data show that approximately 50 years following a wildfire there was lower atmospheric deposition due to changes in forest species composition, lower soil pools, and greater ecosystem retention for both Hg and DIN.

Paleoecological assessment of watershed history in PRIMENet watersheds at Acadia National Park, USA

Paleoecological reconstructions of forest stand histories for two upland watersheds at Acadia National Park in Maine were completed to support related watershed chemistry studies. The project hypothesis was that forest type and fire history influence long-term cycling and storage of atmospheric mercury and nitrogen within watersheds. The reconstructions document differences in major vegetation composition and disturbance between the burned and unburned watersheds during the past several centuries. Pollen and charcoal stratigraphies from organic sediment accumulations in forested wet depressions indicate that the present experimental design of contrasting disturbance and forest histories has persisted during recent centuries. The unburned watershed has been dominated by spruce (Picea rubens) and fir (Abies balsamea) for 500 years or more and has not recently burned or been substantially cleared. The burned watershed is dominated by a heterogeneous forest of patchy hardwood, mixed wood, and softwood stands. A large portion of this watershed burned severely in 1947 and probably more than once in the 1800s, and has supported heterogeneous successional forests for 200 years or longer. Overall, these results support the underlying premise that the experimental design of this watershed research can be used to infer landscape controls on biogeochemical processes.

Rates of Epiphytic Growth of Erwinia amylovora on Flowers Common in the Landscape

We evaluated epiphytic growth of the fire blight bacterium, Erwinia amylovora, on flowers of plant species common to landscapes where pears and apples are grown. The plants were from genera regarded as important nectar and pollen sources for pollinating insects: Acer, Amelanchier, Brassica, Cytisus, Populus, Prunus, Rubus, Salix, Taraxacum, Trifolium, and Symphoricarpos. Floral bouquets were inoculated with E. amylovora and incubated in growth chambers at 15°C for 96 h. Regardless of their susceptibility to fire blight, all species from the rose family except Prunus domestica (European plum) supported epiphytic populations of E. amylovora that exceeded 1 × 10⁶ CFU/flower with relative growth rates for the populations that averaged 7% per hour. Nonrosaceous plants were generally poor supporters of epiphytic growth of the fire blight pathogen with relative growth rates averaging <4% per hour. In two seasons of field inoculations, the rosaceous non-disease-host plants, Prunus avium (sweet cherry) and Rubus armeniacus (Himalayan blackberry), yielded mean population sizes of E. amylovora that exceeded 1 × 10⁶ CFU/flower; in contrast, at 8 days after inoculation, mean population sizes of the pathogen were in the range of 5 × 10³ to 5 × 10⁴ CFU/flower on Cytisus scoparius (Scotch broom) and <1 × 10² CFU on Acer macrophylum (big leaf maple). Because vectors of E. amylovora, principally bees, visit many kinds of flowers in landscape areas between pear and apple orchards, flowers of rosaceous, non-disease-host species could serve as potential sites of inoculum increase during their periods of bloom.

Adaptation of Fire Blight Forecasting to Optimize the Use of Biological Controls

We investigated adaptation of fire blight forecasting concepts to incorporate and optimize the use of biological agents for disease suppression. The effect of temperature on growth of the bacterial antagonists, Pseudomonas fluorescens A506 and Pantoea agglomerans C9-1S, and of the pathogen Erwinia amylovora153N, on pear and apple blossoms was evaluated in growth chamber and screenhouse experiments. New blossoms were inoculated with the strains and subsequent growth was measured over 96 h. Bacterial growth rates on blossoms were described as functions of temperature. A degree hour-based "bacterial growth index" (96-h moving total of degree hours >10°C) was created to assess conduciveness of orchard environments for antagonist colonization. A comparison of this index to a disease risk index indicated that biocon-trol treatments could be timed such that the antagonists could be expected to grow to an effective population size before the disease index shifted from "low" to "moderate" risk. For six pear- and apple-production areas of Oregon and Washington, regression of actual values of the bacterial growth and disease risk indices on index values derived from 4-day temperature forecasts resulted in coefficients of determination that averaged 0.75. The "bacterial growth index" and its estimation via temperature forecasts were incorporated into a decision matrix designed to guide optimal treatment timing.

Antibiosis Contributes to Biological Control of Fire Blight by Pantoea agglomerans Strain Eh252 in Orchards

ABSTRACT Fire blight, caused by Erwinia amylovora, is the most serious bacterial disease of pear and apple trees. Biological control with strains of Pantoea agglomerans (syn. Erwinia herbicola) may provide an effective disease management strategy for fire blight. Most strains of P. agglomerans evaluated for suppression of fire blight produce compounds that inhibit the growth of E. amylovora in culture. The role of these inhibitory compounds in fire blight suppression in orchard environments has not been studied. In seven field trials in Oregon, we compared the population dynamics and disease suppression with P. agglomerans Eh252, a strain that produces a single antibiotic, with its near-isogenic antibiotic-deficient derivative, strain 10:12. Water or suspensions of Eh252 or 10:12 (1 x 10(8) CFU/ml) were applied at 30 and 70% bloom to pear or apple trees. Aqueous suspensions of freeze-dried cells of E. amylovora (3 x 10(5) CFU/ml) were applied at full bloom. Additional trees were treated with streptomycin or oxytetracycline at 30 and 70% bloom and in some experiments, 1 day after application of the pathogen. Population sizes of Eh252 or 10:12 on pear blossoms were estimated by spreading dilutions of blossom washes on culture media. Average population sizes of Eh252 and 10:12 on blossoms ranged from 10(5) to 10(7) CFU, and in five of six trials, the relative area under the population curve of Eh252 was not significantly different than that of its derivative 10:12. Both Eh252 and 10:12 reduced the growth of the pathogen on blossoms compared with inoculated water-treated controls. Eh252 significantly decreased the incidence of fire blight in six of seven field trials compared with the incidence on water-treated trees, and 10:12 similarly reduced the incidence of fire blight in four of seven trials. In three of seven field trials, trees treated with Eh252 had a significantly lower incidence of fire blight compared with trees treated 3 with 10:12. Overall,3 Eh252 reduced the incidence of fire blight by 55 +/- 8%, 10:12 by 30 +/- 6%, streptomycin by 75 +/- 4%, and oxytetracycline by 16 +/- 14%. The effectiveness of strain 10:12 compared with water treatment indicates that other mechanisms (e.g., competitive exclusion or habitat modification) also contribute to disease suppression by P. agglomerans. The increased suppression of fire blight by the parental strain Eh252 compared with the antibiotic-deficient mutant 10:12 indicates that antibiosis is an important mechanism of biological control of fire blight.

Barriers that impede the adoption of pediatric information technology

BACKGROUND

Information technology (IT) is a critical but underused component of health care. Many factors contribute to the inconsistent adoption of IT.

OBJECTIVE

To review the literature to better elucidate barriers that are likely to affect the adoption of IT by pediatric professionals.

DATA SOURCES

Manuscripts were found using a MEDLINE search combining the terms medicine, information systems, and technology transfer. I also obtained references cited by relevant articles. Finally, I explored the Internet using http://www.google.com and http://www.northernlight.com.

STUDY SELECTION

Articles discussing barriers or factors affecting the adoption of IT were considered for inclusion. Articles unrelated to clinical IT were excluded.

DATA SYNTHESIS

A variety of barriers exist that affect the adoption of useful technologies. Situational barriers include challenges imposed by the current national health environment, financial and legal risks associated with technology purchasing and use, and access to technology. The most significant barrier is that pediatric health care practitioners may lack the knowledge or training to use IT effectively.

CONCLUSIONS

Although some barriers exist that may be challenging to overcome, other barriers, such as the lack of knowledge about the uses of IT, are imminently solvable. Efforts to overcome these barriers should begin in earnest and should include educating stakeholders in the care of children and adolescents, as well as improving the knowledge about various technologies available to support pediatric and adolescent health care.

Spatial and temporal increase of eastern filbert blight in European hazelnut orchards in the pacific northwest

ABSTRACT Since its first detection in southwest Washington state 30 years ago, eastern filbert blight, caused by Anisogramma anomala, has spread slowly southward ( approximately 2 km/year) into the Willamette Valley of Oregon, an important hazelnut production region. Experiments were conducted to measure gradients of disease spread, rates of disease increase as affected by distance from an inoculum source and variation in host plant resistance, and dispersal of ascospores of A. anomala from diseased orchards. In each of 3 years, 1-year-old hazelnut trees placed from 0 to 150 m north of diseased orchards were infected uniformly and slopes of disease gradients were not significantly different from zero. In 1 year when trees also were placed south of an orchard, the disease gradient was significant (P < 0.05), with disease incidence high at the edge of the orchard and few trees infected at 10 m south of the orchard. Disease gradients were shallower and the magnitude of the area under the disease progress curve (AUDPC) greater in 0.1-ha mini-orchards of highly susceptible cv. Ennis than in mini-orchards of moderately susceptible cvs. Barcelona or Casina. Lower AUDPC values were observed in mini-orchards of Barcelona interplanted with a moderately resistant pollenizer Hall's Giant compared with the highly susceptible pollenizer Daviana. Fungicides applied biweekly starting at bud break reduced AUDPC values in Ennis mini-orchards to values observed in Barcelona and Casina mini-orchards. Data from aspirated spore samplers placed on towers adjacent to severely diseased hazelnut orchards indicated that spores of A. anomala dispersed horizontally and vertically away from the canopy during periods of extended branch wetness and, thus, show potential to be transported long distances in wind currents. Weather patterns in the Pacific Northwest may account for the relatively slow, southward spread of eastern filbert blight within Oregon's Willamette Valley. Of 196 precipitation events greater than 10 h in duration recorded from 1974 to 1995, conditions most favorable for ascospores discharge, periods with wind from the north were rare, representing <6% of total hours.

Assessment of Barriers to Prevent the Development of Potato Tuber Blight Caused by Phytophthora infestans

Experiments were conducted in an irrigated, sandy loam soil to evaluate mulches and hill sizes as barriers to prevent the development of potato tuber blight caused by Phytophthora infestans. In mulching experiments, five treatments were applied to field plots of cv. Red LaSoda: 1, no mulch; 2, polyurethane spray foam in an 8-cm-diameter area immediately surrounding the plant stem; 3, black polyethylene film over the entire hill except near the stem; 4, a combination of treatments 2 and 3; and 5, a water-permeable, agricultural textile treated with copper hydroxide applied over the same hill area as in treatment 3. In 1998, the incidence of tuber blight in plots mulched with black film (treatments 3 and 4) averaged 32% compared with 56% in plots without this mulch (treatments 1 and 2). In 1999, incidence of tuber blight in plots with and without black film averaged 9 and 20%, respectively. Mulching the stem area with spray foam (treatments 2 and 3) did not reduce the incidence of blighted tubers when compared with the appropriate control. The copper-treated textile mulch (treatment 5) provided reductions in the incidence of tuber blight similar to those observed with the use of black polyethylene film. In a hill size experiment conducted once in 1998 and twice in 1999, three hill size treatments were established on cvs. Red LaSoda, Shepody, and Russet Burbank. Red LaSoda was the most susceptible and Russet Burbank the least susceptible to tuber blight. Comparison of blight incidence in tubers classified by depth in the hill revealed few differences among the hill size treatments, although over all treatments, tubers covered with more than 15 cm of soil had a lower incidence of blight (1 to 14%) than tubers with less soil cover (13 to 59%). Most tuber infections were apparently initiated in eyes and were not concentrated on a portion of the tuber such as the stolon (proximal) or distal end. The fact that black film and textile mulches reduced tuber infection indicates that inoculum of P. infestans can move from foliage to tubers through soil and that inoculum movement is not limited to large channels in the hill such as those created by the potato stems. The mulch treatments, however, provided only partial protection of tubers, limiting the practicality of such treatments to commercial producers. Hill size treatments had little effect on tuber blight incidence, indicating that adequate suppression of tuber infection in an environment conducive to late blight may be inseparably linked to adequate suppression of the foliar phase.

Influence of hemorrhagic shock on remifentanil: a pharmacokinetic and pharmacodynamic analysis

BACKGROUND

Hemorrhagic shock is known to alter significantly the pharmacokinetics of fentanyl, an opioid that requires delivery to the liver for metabolism. The authors hypothesized that the pharmacokinetics and pharmacodynamics of remifentanil, an esterase metabolized opioid that does not require delivery to a metabolic organ, would be altered less by hemorrhagic shock that those of fentanyl.

METHODS

Sixteen pigs were assigned randomly to control and shock groups. The shock group was bled using an isobaric hemorrhage model. Remifentanil 10 microg x kg(-1) x min(-1) was infused for 10 min to both groups. Arterial samples were collected for remifentanil concentration assay. Pharmacokinetic parameters were estimated using a three-compartment model. The electroencephalogram spectral edge was used as a measure of drug effect. The pharmacodynamics were characterized using a sigmoid inhibitory maximal effect model.

RESULTS

Remifentanil blood levels were higher in the shocked group. The central clearance was slower and the central compartment was smaller in shocked animals. No difference between groups was observed in the magnitude or time course of the remifentanil-induced decrease in spectral edge.

CONCLUSIONS

Hemorrhagic shock altered the pharmacokinetics of remifentanil, suggesting that less remifentanil would be required to maintain a target plasma concentration. However, because of its rapid metabolism, the impact of hemorrhagic shock on the concentration decline of remifentanil after termination of the infusion was minimal. Hemorrhagic shock did not alter the pharmacodynamics of remifentanil.

Hopkins Teen Central: Assessment of an internet-based support system for children with cystic fibrosis

Support groups are an important therapeutic intervention for patients with chronic debilitating illnesses. Patients who are difficult to assemble in one physical location may benefit from participating in an electronic support group (ESG). ESGs for adolescents have not been evaluated, although studies have shown a benefit to adult ESGs. Our goals were to create a web-based support service for adolescents with cystic fibrosis (CF) and to qualitatively and quantitatively measure the effects that such a support site could have on patients' relationships with the clinic faculty and staff, access to and interaction with peers with CF, and understanding of CF.

METHODS

A highly interactive ESG was developed after discussions with a team of CF specialists and patients. Eighteen of 37 teenagers with CF agreed to use this site. Each patient was asked to assess his or her perceived availability of and comfort with the clinic staff and faculty, perceived support available through peers, knowledge about CF, and perceived usefulness of the Internet as a support tool.

RESULTS

Participants logged into the site an average of 4 times each month. Teens who owned home computers accessed the site somewhat more frequently than did teens who were provided with home Internet access for the study. Most activity occurred in those sections of the site that described the participants and that allowed them to socialize. Over one half of the participants e-mailed each other at least once a week, with 77% e-mailing peers at least every other week. There was no significant difference in the participants' scores on a quiz about CF at the beginning and the end of the study; however, there was a significant decrease in perceptions about their knowledge about CF. At the conclusion of the study, participants believed that they had more friends who they could relate to than they did at the beginning of the study. Clinic staff noticed an increase in references to peers among the group who were using the site. In addition, 4 of the teens expressed a desire to get together to meet each other as a result of their interactions on the web site. There was no significant change in perceptions about the perceived availability and comfort with the clinic staff and faculty, support available through peers, knowledge about CF, and the usefulness of the Internet as a support environment. Managing the project was extremely easy, with virtually no technical or procedural issues arising during the study.

CONCLUSIONS

Teenagers with a chronic disease will actively participate in an ESG. The social and expressive aspects of their involvement with this support group hold much promise.

The palm as a real-time wide-area data-access device

Handheld wireless technologies offer great promise in helping to improve healthcare. However, it is not clear whether off-the-shelf wireless networking will work as well within medical centers as this technology works outside of the medical center. Therefore, we evaluated the coverage of wide-area wireless technology within two representative academic medical centers. The study determined the rate of connectivity by testing both the Palm VII and the Minstrel V modem in a set of locations typically frequented by house staff in their daily activities. Within one hospital, connectivity was 59% for OmniSky service, and 78% for Palm.net. The second hospital's connectivity was over 93% with both devices. Differences in connectivity were likely due to the number of rooms visited with externally exposed walls, the suburban versus urban location of the academic medical center, and the relative location of service transponders. When examined by the Johns Hopkins Clinical Devices Laboratory, both devices were found to operate without interfering with other hospital equipment.

Assessment of Environmental Factors Influencing Growth and Spread of Pantoea agglomerans on and Among Blossoms of Pear and Apple

ABSTRACT We evaluated effects of both physical and biological components of the environment on growth of Pantoea agglomerans on inoculated pear and apple blossoms and on spread of the bacterium to blossoms on non-inoculated trees. The center three rows of 0.35- to 0.5-ha blocks of four pear cultivars and four apple cultivars were sprayed with a suspension of streptomycin-resistant P. agglomerans strain C9-1S (C9-1S) at 20 to 60% and 60 to 90% bloom. Cultivars were chosen to create a sequence of continuous bloom from late March (d'Anjou pear) through mid-May (Red Rome apple). Each cultivar block was quartered into plots; two plots were treated twice with streptomycin sulfate near mid- and full bloom to suppress populations of indigenous bacterial epiphytes and the other two plots were treated with water. Colonization of blossoms by C9-1S and by indigenous bacterial epiphytes were monitored on inoculated trees and along transects of noninoculated trees. Immediately after spraying, C9-1S was detected principally on blossoms sampled from inoculated trees. As bloom progressed, trees up to 18 m from inoculated trees had high proportions of blossoms colonized by C9-1S. Streptomycin significantly (P </= 0.05) reduced incidence of isolation and size of detectable populations of culturable bacteria (indigenous bacteria plus C9-1S) from pear blossoms in 1998 and from apple blossoms in both 1998 and 1999, but the antibiotic treatment did not affect incidence of isolation, size of detectable populations, or spread of C9-1S compared to the water-treated control in any experiment. Across all cultivars, relative area under the curve for size of detectable populations of C9-1S on inoculated trees and for incidence of isolation of C9-1S from noninoculated trees was positively correlated with mean degree hours per day during bloom (r= 0.61 to 0.73) and negatively correlated with the proportion of days with rain (r = -0.79 to -0.84). The results indicate that establishment and growth of C9-1S on pome fruit flowers was not strongly affected by streptomycin or by competition from indigenous bacterial epiphytes and, as with Erwinia amylovora, temperature is an important environmental variable affecting successful spread of this biological control agent from blossom to blossom.

Effectiveness of a clinical pathway for inpatient asthma management

BACKGROUND

Clinical pathways for asthma are tools that have the potential to improve compliance with nationally recognized management guidelines, but their effect on patient outcomes has not been documented.

OBJECTIVES

To determine the effect of an asthma clinical pathway on patients' length of stay, use of nebulized beta-agonist therapy while hospitalized, and use of acute care clinics for 2 weeks after discharge.

DESIGN/METHODS

The study was a randomized, controlled trial. Patients between the ages of 2 and 18 years admitted with an asthma exacerbation and not under the care of an asthma specialist were eligible for the study. Patients were randomized either to a conventional ward (control group) or to a ward using the clinical pathway (intervention group). For 2 weeks after discharge, we collected data to determine whether patients visited a health care provider for worsening asthma.

RESULTS

One hundred ten patients (26%) were enrolled. Control and intervention groups had similar demographic and asthma severity profiles. The intervention group had an average length of stay 13 hours shorter than did the control group. In addition, at every dosing interval, the intervention group received less nebulized beta-agonist therapy. There were no deaths in either group.

CONCLUSION

A clinical pathway for inpatient asthma decreased the length of stay and beta-agonist medication use with no adverse outcomes or increased acute-care encounters through 2 weeks after discharge.

Quantifying the literature of computer-aided instruction in medical education

PURPOSE

To characterize the literature about computer-aided instruction (CAI) as it relates to medical education.

METHOD

A descriptive study using the Medline and ERIC databases, reviewing articles pertaining to CAI for medical professionals. The literature was evaluated with respect to type of article, journal, language, and year of publication.

RESULTS

The search yielded 2,840 citations, 92% of which were in English. The number of journals with at least one citation was 747. Less than 5% of the 5,147 authors had three or more articles published in the CAI literature. Of the citations with abstracts, 60% were demonstrations of a CAI application, 11% were media-comparative studies, and 13% were analyses of the CAI field. While the pace of article publication increased markedly over time, the percentages of article types did not change significantly over time. Less than 10% of CAI articles appeared in core medical journals.

CONCLUSION

Medical CAI is an increasingly popular topic of research and publication. However, these studies appear in journals with smaller circulations, are predominantly demonstration articles, and are generally written by authors with two or fewer publications. Evaluation articles remain less common. A series of analytic articles has appeared offering substantive suggestions for better research design. These suggestions appear to have gone unheeded. CAI investigators need be more aware of the gaps in the existing body of CAI publications, and the inherent difficulties of this type of research, if this literature is to move beyond this early stage of development.

An electronic menstrual cycle calendar: comparison of data quality with a paper version

OBJECTIVES

This pilot study compared a prototype electronic menstrual calendar on a handheld computer with a paper calendar for data quality and participants' perceptions.

DESIGN

Twenty-three women completed identical information about menstrual bleeding and symptoms using paper and electronic calendars for 1 month each.

RESULTS

Use of the paper calendar resulted in more missing data than the electronic calendar for bleeding characteristics (13% vs. 4%) and symptoms (35% vs. 4%). The electronic calendar's ability to log data entries revealed retrospective entry for 61% of the data. Total data entry and cleaning time was reduced by 81% with the electronic calendar. Overall, participants preferred the electronic (70%) to the paper (22%) calendar.

CONCLUSIONS

Data quality with conventional paper calendars may be poorer than recognized. The data-logging feature, unique to the electronic calendar, is critical for assessing data quality. Electronic menstrual calendars can be useful data collection tools for research in women's health.

First Report of Clover Yellow Edge Phytoplasma in Corylus (Hazelnut)

During investigations into the cause of a stunt syndrome affecting cultivated European hazelnut trees (Corylus avellana L.) in Oregon, the clover yellow edge (CYE) phytoplasma was detected for the first time in this crop. The cause of hazelnut stunt syndrome (HSS) is unknown, but the disease has been transmitted by grafting and apparently has moved within orchards through root grafts (1). Severely affected trees persist for many years, but their nut production is greatly reduced. Previous attempts to detect viruses, bacteria, and other pathogens have been unsuccessful. HSS has been observed only in Oregon and already had been present for more than 10 years when it was first reported in 1970 (1). In June, 1999, leaf samples were collected from two affected and two apparently healthy (symptomless) hazelnut trees in a field plot at Oregon State University, Corvallis, and from a healthy greenhouse-grown tree. Leaf samples were sent to the USDA Beltsville, MD, laboratory, where they were assessed for phytoplasma infection, using nested polymerase chain reactions (PCRs). PCRs were primed by phytoplasma universal primer pairs P1/P7 and F2n/R2 (3) for amplification of phytoplasma 16S ribosomal (r) DNA (16S rRNA gene) sequences according to the procedures of Gunderson and Lee (2). Phytoplasma-characteristic 1.2-kbp DNA sequences were amplified from all field-tree samples. No DNA sequences were amplified from samples of the greenhouse-grown tree. Restriction fragment length polymorphism patterns of rDNA digested with AluI, KpnI, HhaI, HaeIII, HpaII, MseI, RsaI, and Sau3A1 endonucleases indicated that all diseased hazelnut trees as well as symptomless field trees were infected by a phytoplasma classified in group 16SrIII (peach X-disease group), subgroup B (III-B, type strain CYE phytoplasma). No phytoplasmas were detected in samples from the greenhouse-grown tree. Nucleotide sequences were determined for 16Sr DNA fragments amplified from the hazelnut CYE phytoplasma in nested PCRs primed with F2n/R2. The sequences were deposited in GenBank under Accession no. AF189288. Sequence similarity between 16Sr DNAs of the hazelnut CYE strain (CYE-Or) and the Canadian clover yellow edge strain (CYE-C, GenBank Accession no. AF175304) phytoplasma was 99.9%. Decline and yellows disorders of hazelnut in Germany and Italy have been associated with infections by apple proliferation, pear decline, and European stone fruit yellows phytoplasmas (4). These phytoplasmas are classified in 16Sr group X, the apple proliferation group of phytoplasmas. This is the first report of the CYE phytoplasma infecting Corylus. References: (1) H. R. Cameron. Plant Dis. Rep. 54:69, 1970. (2) D. E. Gunderson and I.-M. Lee. Phytopathol. Mediterr. 35:144, 1996. (3) R. Jomantiene et al. HortScience 33:1069, 1998. (4) C. Marcone et al. Plant Pathol. 45:857,1996.

The use of a new mechanically advantaged syringe for performing coronary intervention

OBJECTIVE

To determine the utility of a new mechanically advantaged syringe in the performance of percutaneous coronary intervention.

BACKGROUND

A new mechanically advantaged syringe has been developed to perform cardiovascular imaging. We wanted to assess the utility of this device in the performance of small catheter percutaneous coronary intervention. Data from coronary interventions performed with the standard technique at our institution, using a 10 ml manual syringe, were compared to the use of a new mechanically advantaged syringe. Contrast utilization during the standard technique was assessed by obtaining data from fifty consecutive successful single-vessel coronary interventions (angioplasty with or without stenting). After an initial learning experience with the mechanically advantaged syringe, fifty consecutive successful single-vessel coronary interventions were assessed. Most interventions performed using the mechanically advantaged syringe were with 6 French catheters. Detailed contrast utilization information was gathered.

RESULTS

During the standard method of performing coronary intervention, 216 +/- 114 ml of contrast were used. Utilizing the mechanically advantaged OZ Power Syringe (Cardiovascular Innovations Inc., Athens, Texas), the contrast use was reduced to 66 +/- 39 ml (p < 0.0001) per case. The syringe also allowed excellent visualization despite using a smaller guide catheter system.

CONCLUSION

The OZ Power Syringe can be utilized effectively in percutaneous coronary intervention. Our preliminary data suggest that there may be reduced contrast use without sacrificing image quality.