Synovial sarcoma with intra-abdominal metastasis causing hemoperitoneum: a case-report.

Synovial sarcoma is a rare soft tissue sarcoma which frequently involves the upper or lower extremities. Soft tissue sarcomas including synovial sarcoma have a propensity to metastasize to the lungs, and there are very few reports of metastatic lesions in other locations.Here, we report a case of a 49-year-old patient who underwent neoadjuvant chemoradiation for an upper extremity synovial sarcoma and presented approximately 4 years later with abdominal pain and hemoperitoneum and was ultimately found to have metastatic synovial sarcoma involving the greater curvature of the stomach and surrounding peri-gastric soft tissue. We describe the multidisciplinary management of this complex patient presentation and propose that expanded surveillance imaging beyond that of the local tumor resection bed and the chest may be beneficial especially in tumors with high-risk features.

Global Analysis of Hemileia vastatrix Populations Shows Clonal Reproduction for the Coffee Leaf Rust Pathogen Throughout Most of Its Range.

Hemileia vastatrix is the most important fungal pathogen of coffee and the causal agent of recurrent disease epidemics that have invaded nearly every coffee growing region in the world. The development of coffee varieties resistant to H. vastatrix requires fundamental understanding of the biology of the fungus. However, the complete life cycle of H. vastatrix remains unknown, and conflicting studies and interpretations exist as to whether the fungus is undergoing sexual reproduction. Here we used population genetics of H. vastatrix to infer the reproductive mode of the fungus across most of its geographic range, including Central Africa, Southeast Asia, the Caribbean, and South and Central America. The population structure of H. vastatrix was determined via eight simple sequence repeat markers developed for this study. The analyses of the standardized index of association, Hardy-Weinberg equilibrium, and clonal richness all strongly support asexual reproduction of H. vastatrix in all sampled areas. Similarly, a minimum spanning network tree reinforces the interpretation of clonal reproduction in the sampled H. vastatrix populations. These findings may have profound implications for resistance breeding and management programs against H. vastatrix.

Does community-based health insurance protect women from financial catastrophe after cesarean section? A prospective study from a rural hospital in Rwanda.

BACKGROUND: The implementation of community-based health insurance in (CBHI) in Rwanda has reduced out of pocket (OOP) spending for the > 79% of citizens who enroll in it but the effect for surgical patients is not well described. For all but the poorest citizens who are completely subsidized, the OOP (out of pocket) payment at time of service is 10%. However, 55.5% of the population is below the international poverty line meaning that even this copay can have a significant impact on a family's financial health. The aim of this study was to estimate the burden of OOP payments for cesarean sections in the context of CBHI and determine if having it reduces catastrophic health expenditure (CHE). METHODS: This study is nested in a larger randomized controlled trial of women undergoing cesarean section at a district hospital in Rwanda. Eligible patients were surveyed at discharge to quantify household income and routine monthly expenditures and direct and indirect spending related to the hospitalization. This was used in conjunction with hospital billing records to calculate the rate of catastrophic expenditure by insurance group. RESULTS: About 94% of the 340 women met the World Bank definition of extreme poverty. Of the 330 (97.1%) with any type of health insurance, the majority (n = 310, 91.2%) have CBHI. The average OOP expenditure for a cesarean section and hospitalization was $9.36. The average cost adding transportation to the hospital was $19.29. 164 (48.2%) had to borrow money and 43 (12.7%) had to sell possessions. The hospital bill alone was a CHE for 5.3% of patients. However, when including transportation costs, 15.4% incurred a CHE and including lost wages, 22.6%. CONCLUSION: To ensure universal health coverage (UHC), essential surgical care must be affordable. Despite enrollment in universal health insurance, cesarean section still impoverishes households in rural Rwanda, the majority of whom already lie below the poverty line. Although CBHI protects against CHE from the cost of healthcare, when adding in the cost of transportation, lost wages and caregivers, cesarean section is still often a catastrophic financial event. Further innovation in financial risk protection is needed to provide equitable UHC.

Access to Essential Surgical Care in Chiapas, Mexico: A System-Wide Geospatial Analysis.

BACKGROUND: Long travel times to reach essential surgical care in Chiapas, Mexico's poorest state, can delay lifesaving procedures and contribute to adverse outcomes. Geographical access to surgical facilities is 1 of the 6 indicators of the Lancet Commission on Global Surgery and has been measured extensively worldwide. Our objective is to determine the population with 2-h geographical access to facilities capable of performing the Bellwether procedures (laparotomy, cesarean delivery, and open fracture repair). This is the first study in Mexico to assess access to surgical facilities, including both the fragmented public sector and the private sector. METHODS: In this cross-sectional study, conducted from June 2019 to January 2020, Bellwether capable surgical facilities from all health systems in Chiapas were geocoded and assessed through on-site data collection, Ministry of Health databases, and verified via telephone. Geospatial analyses were performed on Redivis. RESULTS: We identified 59 Bellwether capable hospitals, with 17.5% (n = 954,460) of the state residing more than 2 h from surgical care in public and private health systems. Of those, 22 facilities had confirmed 24/7 Bellwether capability, and 23% (n = 1,178,383) of the affiliated population resided more than 2 h from these hospitals. CONCLUSIONS: Our study shows that the Ministry of Health and employment-based health coverage could provide timely access to essential surgical care for the majority of the population. However, the fragmentation of the healthcare system leaves a gap that contributes to delays in care and unmet emergency surgical needs.

Global Surgery Electives: A Strategy to Improve Care to Domestic Underserved Populations?

BACKGROUND: In the United States, a shortage of general surgeons exists, primarily in rural, poor, and minority communities. Identification of strategies that increase resident interest in underserved regions provides valuable information in understanding and addressing this shortage. In particular, surgical experience abroad exposes residents to practice in low-resource and rural settings. As residency programs increasingly offer global surgery electives, we explore whether the presence of an international surgical rotation affects graduates' future practice patterns in underserved communities domestically. METHODS: We surveyed general surgery residency graduates at a single academic institution. Those who finished general surgery residency from 2001 to 2018 were included. Participant demographics, current practice demographics, and perceptions related to global surgery and underserved populations were collected. Respondents were stratified based on whether they did ("after") or did not ("before") have the opportunity to participate in the Kijabe rotation (started in 2011), defined by graduation year. RESULTS: Out of 119 eligible program graduates, 64 (53.7%) completed the survey, and 33 (51.6%) of the respondents graduated following the implementation of the Kijabe rotation. Two participants defined their primary current practice location as international. Fifteen (45.5%) in the "After" group indicated an interest in working with underserved populations following residency, compared to 5 (17.8%) of the "Before" group (P = 0.074). Furthermore, 20 (60.6%) respondents in the "After" group expressed interest in working with underserved populations even if it meant making less money. In the "Before" group, only 13 (46.4%) responded similarly (P = 0.268). Eleven (9.2%) residents rotated at Kijabe. Those who participated in the Kijabe rotation reported an uninsured rate of 36.7% for their current patient population, compared to rate of 13.9% in those who did not rotate there (P = 0.22). CONCLUSIONS: At a single institution, our results suggest that participation in an international surgical rotation in a resource-constrained setting may be associated with increased care for underserved populations in future clinical practice. These results could be due to self-selection of residents who prioritize global surgery as part of their residency experience, or due to increased exposure to underserved patients through global surgery.

Variability of water, sanitation, and hygiene conditions and the potential infection risk following cesarean delivery in rural Rwanda.

Safe water, sanitation, and hygiene (WASH) is critical for the prevention of postpartum infections. The aim of this study was to characterize the WASH conditions women are exposed to following cesarean section in rural Rwanda. We assessed the variability of WASH conditions in the postpartum ward of a district hospital over two months, the WASH conditions at the women's homes, and the association between WASH conditions and suspected surgical site infection (SSI). Piped water flowed more consistently during the rainy month, which increased availability of water for drinking and handwashing (p < 0.05 for all). Latex gloves and hand-sanitizer were more likely to be available on weekends versus weekdays (p < 0.05 for both). Evaluation for suspected SSI after cesarean section was completed for 173 women. Women exposed to a day or more without running water in the hospital were 2.6 times more likely to develop a suspected SSI (p = 0.027). 92% of women returned home to unsafe WASH environments, with notable shortfalls in handwashing supplies and sanitation. The variability in hospital WASH conditions and the poor home WASH conditions may be contributing to SSIs after cesarean section. These relationships must be further explored to develop appropriate interventions to improve mothers' outcomes.

Population structure of Guyanagaster necrorhizus supports termite dispersal for this enigmatic fungus.

Understanding how species accomplish dispersal of their propagules can shed light on how they are adapted for their ecosystem. Guyanagaster necrorhizus is a sequestrate fungus, meaning its dispersal propagules, or spores, are entirely enclosed within a fruiting body, termed a sporocarp. This fungus is most closely related to Armillaria and its allies. While Armillaria species form mushrooms and have forcibly discharged spores, G. necrorhizus spores have lost this ability, and by necessity, must be passively dispersed. However, G. necrorhizus does not possess characteristics of other sequestrate fungi with known dispersal mechanisms. Repeated observations of termites feeding on G. necrorhizus sporocarps, and spores subsequently adhering to their exoskeletons, led to the hypothesis that termites disperse G. necrorhizus spores. To test this hypothesis, we used microsatellite markers and population genetics analyses to understand patterns of clonality and population structure of G. necrorhizus. While Armillaria individuals can spread vegetatively over large areas, high genotypic diversity in G. necrorhizus populations suggests spores are the primary mode of dispersal. Spatial genetic structure analyses show that G. necrorhizus sporocarps within 238 m of each other are more closely related than would be expected by chance and conservative estimates from population assignment tests suggest gene flow no longer occurs between sporocarps separated by 2 km. These distances are consistent with previous studies analysing foraging distances of the termites found associated with G. necrorhizus sporocarps. Termites have rarely been recorded to specifically target fungal sporocarps, making this a potentially novel fungal-insect interaction.

Resolved phylogeny and biogeography of the root pathogen Armillaria and its gasteroid relative, Guyanagaster.

BACKGROUND: Armillaria is a globally distributed mushroom-forming genus composed primarily of plant pathogens. Species in this genus are prolific producers of rhizomorphs, or vegetative structures, which, when found, are often associated with infection. Because of their importance as plant pathogens, understanding the evolutionary origins of this genus and how it gained a worldwide distribution is of interest. The first gasteroid fungus with close affinities to Armillaria-Guyanagaster necrorhizus-was described from the Neotropical rainforests of Guyana. In this study, we conducted phylogenetic analyses to fully resolve the relationship of G. necrorhizus with Armillaria. Data sets containing Guyanagaster from two collecting localities, along with a global sampling of 21 Armillaria species-including newly collected specimens from Guyana and Africa-at six loci (28S, EF1α, RPB2, TUB, actin-1 and gpd) were used. Three loci-28S, EF1α and RPB2-were analyzed in a partitioned nucleotide data set to infer divergence dates and ancestral range estimations for well-supported, monophyletic lineages. RESULTS: The six-locus phylogenetic analysis resolves Guyanagaster as the earliest diverging lineage in the armillarioid clade. The next lineage to diverge is that composed of species in Armillaria subgenus Desarmillaria. This subgenus is elevated to genus level to accommodate the exannulate mushroom-forming armillarioid species. The final lineage to diverge is that composed of annulate mushroom-forming armillarioid species, in what is now Armillaria sensu stricto. The molecular clock analysis and ancestral range estimation suggest the most recent common ancestor to the armillarioid lineage arose 51 million years ago in Eurasia. A new species, Guyanagaster lucianii sp. nov. from Guyana, is described. CONCLUSIONS: The armillarioid lineage evolved in Eurasia during the height of tropical rainforest expansion about 51 million years ago, a time marked by a warm and wet global climate. Species of Guyanagaster and Desarmillaria represent extant taxa of these early diverging lineages. Desarmillaria represents an armillarioid lineage that was likely much more widespread in the past. Guyanagaster likely evolved from a gilled mushroom ancestor and could represent a highly specialized endemic in the Guiana Shield. Armillaria species represent those that evolved after the shift in climate from warm and tropical to cool and arid during the late Eocene. No species in either Desarmillaria or Guyanagaster are known to produce melanized rhizomorphs in nature, whereas almost all Armillaria species are known to produce them. The production of rhizomorphs is an adaptation to harsh environments, and could be a driver of diversification in Armillaria by conferring a competitive advantage to the species that produce them.

Model selection as a tool for phylogeographic inference: an example from the willow Salix melanopsis.

Phylogeographic inference has typically relied on analyses of data from one or a few genes to provide estimates of demography and population histories. While much has been learned from these studies, all phylogeographic analysis is conditioned on the data, and thus, inferences derived from data that represent a small sample of the genome are unavoidably tenuous. Here, we demonstrate one approach for moving beyond classic phylogeographic research. We use sequence capture probes and Illumina sequencing to generate data from >400 loci in order to infer the phylogeographic history of Salix melanopsis, a riparian willow with a disjunct distribution in coastal and the inland Pacific Northwest. We evaluate a priori phylogeographic hypotheses using coalescent models for parameter estimation, and the results support earlier findings that identified post-Pleistocene dispersal as the cause of the disjunction in S. melanopsis. We also conduct a series of model selection exercises using IMa2, Migrate-n and ∂a∂i. The resulting ranking of models indicates that refugial dynamics were complex, with multiple regions in the inland regions serving as the source for postglacial colonization. Our results demonstrate that new sources of data and new approaches to data analysis can rejuvenate phylogeographic research by allowing for the identification of complex models that enable researchers to both identify and estimate the most relevant parameters for a given system.

A Comparison of Thirty-Day Clinical and Echocardiographic Outcomes of Patients Undergoing Transcatheter vs. Surgical Aortic Valve Replacement for Native Aortic Insufficiency.

OBJECTIVES: We aim to compare in-hospital and 30-day outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) for native aortic insufficiency (AI). BACKGROUND: TAVR is increasingly used off-label in patients with AI deemed high risk for SAVR. There is a paucity of data comparing TAVR and SAVR with current commercially available TAVR devices. METHODS: A single-center, retrospective cohort study of patients undergoing TAVR or SAVR for native AI between 2014 and 2020 was performed. Data were obtained from the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database, Transcatheter Valve Therapy (TVT) registry, and chart review. In-hospital and 30-day outcomes are reported. RESULTS: Of 125 total patients, 91 underwent SAVR and 34 underwent TAVR. The TAVR group had a higher STS predictive risk of mortality (PROM) (TAVR = 3.96 %, SAVR = 1.25 %, p < 0.0001). In the postoperative period, the SAVR group had higher rates of new-onset atrial fibrillation (20.9 % vs. 0 %, p < 0.001), while the TAVR group had higher rates of complete heart block requiring permanent pacemaker implantation (20.6 % vs. 2.2 %, p < 0.001). There was no difference in in-hospital or 30-day mortality, stroke, myocardial infarction, residual AI, or repeat valve intervention. CONCLUSIONS: Despite higher STS PROM and more comorbidities, patients who underwent TAVR for AI had similar in-hospital and 30-day outcomes as patients who underwent SAVR for AI. These results support TAVR in selected high-risk patients with AI, with the knowledge that pacemaker needs may be higher than patients undergoing SAVR.

Draft Genome Sequence of an Unusual Ectomycorrhizal Fungus, Pseudotulostoma volvatum.

Here, we report the draft genome sequence of Pseudotulostoma volvatum, an unusual ectomycorrhizal fungus in the "mold" order Eurotiales (Ascomycota, Pezizomycotina). The assembled genome is 60.4 Mbp and contains an estimated 5,492 genes. Compared with closely related species, the P. volvatum genome is depauperate in secondary metabolite gene clusters.

Surgical Capacity Building in Low- and Middle-Income Countries: Lessons for Thoracic Surgery.

There is great need for intentional investment in capacity building for thoracic surgical conditions. This article provides a brief overview of thoracic surgical capacity building for low- and middle-income countries using the Lancet framework of infrastructure, workforce, financing, and information management. The authors highlight the needs, opportunities, and challenges that are relevant for the thoracic surgical community, as it aims to increase care for patients with these conditions globally.

Diversity and distribution of tropical ectomycorrhizal fungi.

The tropics were long considered to have few ectomycorrhizal fungi, presumably due to a paucity of ectomycorrhizal host plants relative to higher-latitude ecosystems. However, an increase in research in tropical regions over the past 30 years has greatly expanded knowledge about the occurrence of tropical ectomycorrhizal fungi. To assess their broad biogeographic and diversity patterns, we conducted a comprehensive review and quantitative data analysis of 49 studies with 80 individual data sets along with additional data from GlobalFungi to elucidate tropical diversity patterns and biogeography of ectomycorrhizal fungi across the four main tropical regions: the Afrotropics, the Neotropics, Southeast Asia, and Oceania. Generalized linear models were used to explore biotic and abiotic influences on the relative abundance of the 10 most frequently occurring lineages. We also reviewed the available literature and synthesized current knowledge about responses of fungi to anthropogenic disturbances, and their conservation status and threats. We found that /russula-lactarius and /tomentella-thelephora were the most abundant lineages in the Afrotropics, the Neotropics, and Southeast Asia, whereas /cortinarius was the most abundant lineage in Oceania, and that /russula-lactarius, /inocybe, and /tomentella-thelephora were the most species-rich lineages across all of the tropical regions. Based on these analyses, we highlight knowledge gaps for each tropical region. Increased sampling of tropical regions, collaborative efforts, and use of molecular methodologies are needed for a more comprehensive view of the ecology and diversity of tropical ectomycorrhizal fungi.

The Effect and Feasibility of mHealth-Supported Surgical Site Infection Diagnosis by Community Health Workers After Cesarean Section in Rural Rwanda: Randomized Controlled Trial.

BACKGROUND: The development of a surgical site infection (SSI) after cesarean section (c-section) is a significant cause of morbidity and mortality in low- and middle-income countries, including Rwanda. Rwanda relies on a robust community health worker (CHW)-led, home-based paradigm for delivering follow-up care for women after childbirth. However, this program does not currently include postoperative care for women after c-section, such as SSI screenings. OBJECTIVE: This trial assesses whether CHW's use of a mobile health (mHealth)-facilitated checklist administered in person or via phone call improved rates of return to care among women who develop an SSI following c-section at a rural Rwandan district hospital. A secondary objective was to assess the feasibility of implementing the CHW-led mHealth intervention in this rural district. METHODS: A total of 1025 women aged ≥18 years who underwent a c-section between November 2017 and September 2018 at Kirehe District Hospital were randomized into the three following postoperative care arms: (1) home visit intervention (n=335, 32.7%), (2) phone call intervention (n=334, 32.6%), and (3) standard of care (n=356, 34.7%). A CHW-led, mHealth-supported SSI diagnostic protocol was delivered in the two intervention arms, while patients in the standard of care arm were instructed to adhere to routine health center follow-up. We assessed intervention completion in each intervention arm and used logistic regression to assess the odds of returning to care. RESULTS: The majority of women in Arm 1 (n=295, 88.1%) and Arm 2 (n=226, 67.7%) returned to care and were assessed for an SSI at their local health clinic. There were no significant differences in the rates of returning to clinic within 30 days (P=.21), with high rates found consistently across all three arms (Arm 1: 99.7%, Arm 2: 98.4%, and Arm 3: 99.7%, respectively). CONCLUSIONS: Home-based post-c-section follow-up is feasible in rural Africa when performed by mHealth-supported CHWs. In this study, we found no difference in return to care rates between the intervention arms and standard of care. However, given our previous study findings describing the significant patient-incurred financial burden posed by traveling to a health center, we believe this intervention has the potential to reduce this burden by limiting patient travel to the health center when an SSI is ruled out at home. Further studies are needed (1) to determine the acceptability of this intervention by CHWs and patients as a new standard of care after c-section and (2) to assess whether an app supplementing the mHealth screening checklist with image-based machine learning could improve CHW diagnostic accuracy. TRIAL REGISTRATION: ClinicalTrials.gov NCT03311399; https://clinicaltrials.gov/ct2/show/NCT03311399.

Learning NOTSS While Tying Knots: Integrating the Nontechnical Skills for Surgeons Course With Technical Surgical Skills Training, A Mixed Methods Study.

Objective: The aims of this study were to describe the process of integrating 2 established training programs, Nontechnical skills for surgeons, and a traditional essential surgical skills course and to measure the impact of this integrated course on the behaviors of interprofessional surgical teams in Rwandan district hospitals. Background: Surgical errors and resulting adverse events are due to variability in both technical and nontechnical surgical skills. Providing technical and nontechnical skills training to the perioperative team may enhance the learning of both of these skills and promote safe intraoperative patient care. Methods: A quality improvement framework guided the process of integrating essential surgical skills and nontechnical skills into a single training program for surgical teams. The resulting 2-day training program was delivered to 68-person teams from 17 hospitals. Nontechnical skills for surgeons was taught through didactics and in the operating room, where preoperative briefing, intraoperative interactions, and postoperative debriefing were used as essential and nontechnical skills teaching moments. Postcourse surveys, follow-up interviews, focus groups, and direct observation of participants in the operating room were conducted to assess how participants implemented the knowledge and skills from the training into practice. Results: Ninety-seven percent of the participants reported that they were satisfied with the course. Follow-up participant interviews and focus groups reported that the course helped them to improve their preoperative planning, intraoperative communication, decision-making, and postoperative debriefing. Conclusions: It is possible to implement an integrated essential surgical skills and nontechnical skills training course. Integrating nontechnical skills into essential surgical skills courses may enhance learning of these skills.

Transcriptomics Reveals the Putative Mycoparasitic Strategy of the Mushroom Entoloma abortivum on Species of the Mushroom Genus Armillaria.

During mycoparasitism, a fungus-the host-is parasitized by another fungus-the mycoparasite. The genetic underpinnings of these relationships have been best characterized in ascomycete fungi. However, within basidiomycete fungi, there are rare instances of mushroom-forming species parasitizing the reproductive structures, or sporocarps, of other mushroom-forming species, which have been rarely investigated on a genetic level. One of the most enigmatic of these occurs between Entoloma abortivum and species of Armillaria, where hyphae of E. abortivum are hypothesized to disrupt the development of Armillaria sporocarps, resulting in the formation of carpophoroids. However, it remains unknown whether carpophoroids are the direct result of a mycoparasitic relationship. To address the nature of this unique interaction, we analyzed gene expression of field-collected Armillaria and E. abortivum sporocarps and carpophoroids. Transcripts in the carpophoroids are primarily from E. abortivum, supporting the hypothesis that this species is parasitizing Armillaria. Most notably, we identified differentially upregulated E. abortivum ß-trefoil-type lectins in the carpophoroid, which we hypothesize bind to Armillaria cell wall galactomannoproteins, thereby mediating recognition between the mycoparasite and the host. The most differentially upregulated E. abortivum transcripts in the carpophoroid code for oxalate decarboxylases-enzymes that degrade oxalic acid. Oxalic acid is a virulence factor in many plant pathogens, including Armillaria species; however, E. abortivum has evolved a sophisticated strategy to overcome this defense mechanism. The number of gene models and genes that code for carbohydrate-active enzymes in the E. abortivum transcriptome was reduced compared to other closely related species, perhaps as a result of the specialized nature of this interaction. IMPORTANCE By studying fungi that parasitize other fungi, we can understand the basic biology of these unique interactions. Studies focused on the genetic mechanisms regulating mycoparasitism between host and parasite have thus far concentrated on a single fungal lineage within the Ascomycota. The work presented here expands our understanding of mycoparasitic relationships to the Basidiomycota and represents the first transcriptomic study to our knowledge that examines fungal-fungal relationships in their natural setting. The results presented here suggest that even distantly related mycoparasites utilize similar mechanisms to parasitize their host. Given that species of the mushroom-forming pathogen Armillaria cause plant root-rot diseases in many agroecosystems, an enhanced understanding of this interaction may contribute to better control of these diseases through biocontrol applications.

Global Distribution and Richness of Armillaria and Related Species Inferred From Public Databases and Amplicon Sequencing Datasets.

Armillaria is a globally distributed fungal genus most notably composed of economically important plant pathogens that are found predominantly in forest and agronomic systems. The genus sensu lato has more recently received attention for its role in woody plant decomposition and in mycorrhizal symbiosis with specific plants. Previous phylogenetic analyses suggest that around 50 species are recognized globally. Despite this previous work, no studies have analyzed the global species richness and distribution of the genus using data derived from fungal community sequencing datasets or barcoding initiatives. To assess the global diversity and species richness of Armillaria, we mined publicly available sequencing datasets derived from numerous primer regions for the ribosomal operon, as well as ITS sequences deposited on Genbank, and clustered them akin to metabarcoding studies. Our estimates reveal that species richness ranges from 50 to 60 species, depending on whether the ITS1 or ITS2 marker is used. Eastern Asia represents the biogeographic region with the highest species richness. We also assess the overlap of species across geographic regions and propose some hypotheses regarding the drivers of variability in species diversity and richness between different biogeographic regions.

Understanding Barriers and Facilitators to Behavior Change After Implementation of an Interdisciplinary Surgical Non-Technical Skills Training Program in Rwanda.

OBJECTIVE: Nontechnical skills, such as situation awareness, decision making, leadership, communication, and teamwork play a crucial role on the quality of care and patient safety in the operating room (OR). In our previous work, we developed an interdisciplinary training program, based on the NOTSS (Non-Technical Skills for Surgeons) taxonomy. The aim of this study was to understand the challenges faced by Rwandan surgical providers, who had undergone NOTSS training, to apply these nontechnical skills during subsequent operative surgery. SETTING DESIGN: A sequential exploratory mixed method study design was used to assess how participants who took the NOTSS in Rwanda applied nontechnical skills in surgical care delivery. The qualitative phase of this study deployed a constructivist grounded theory approach. Findings from the qualitative phase were used to build a quantitative survey tool that explored themes that emerged from the first phase. PARTICIPANTS: Participants were nurses and resident from the departments of Surgery, Anesthesia, Obstetric, and Gynecology, from the University of Rwanda who attended the NOTSS course in March 2018. RESULTS: A total of 25 participants and 49 participants were respectively enrolled in the qualitative phase and quantitative phase. Participants noted that nontechnical skills implementation in clinical practice was facilitated by working with other personnel also trained in NOTSS, anticipation, and preparation ahead of the time; while lack of interdisciplinary communication, hierarchy, work overload, and an inconsistently changing environment compromised nontechnical skills implementation. Nontechnical skills were useful both inside and outside the operating. Participants reported that nontechnical skills implementation resulted in improved team dynamics, safer patient care, and empowerment. CONCLUSION: Surgical care providers who took the NOTSS course subsequently implemented nontechnical skills both inside and outside of the OR. Human and system-based factors affected the implementation of nontechnical skills in the clinical setting.

Amanita in the Guineo-Congolian rainforest: Epitypes and new species from the Dja Biosphere Reserve, Cameroon.

Four epitypes and three new species of Amanita (Amanitaceae, Agaricales, Agaricomycetes, Basidiomycota) are described from Guineo-Congolian rainforests of Cameroon. Amanita echinulata, A. fulvopulverulenta, A. robusta, and A. bingensis are epitypified based on collections that are the first since the species were described nearly a century ago. Morphological features of the epitypes are described and enumerated. Amanita minima, Amanita luteolamellata, and A. goossensfontanae are described as new and added to the known macromycota of tropical Africa. Habit, habitat, and known distribution are provided for each species. Sequence data for the internal transcribed spacer (ITS) locus are provided for types and other collections of all taxa, and a molecular phylogenetic analysis across the genus Amanita corroborates morphology-based infrageneric placement for each.

Symbiotic nitrogen fixation in the reproductive structures of a basidiomycete fungus.

Nitrogen (N) fixation is a driving force for the formation of symbiotic associations between N2-fixing bacteria and eukaryotes.1 Limited examples of these associations are known in fungi, and none with sexual structures of non-lichenized species.2-6 The basidiomycete Guyanagaster necrorhizus is a sequestrate fungus endemic to the Guiana Shield.7 Like the root rot-causing species in its sister genera Armillaria and Desarmillaria, G. necrorhizus sporocarps fruit from roots of decaying trees (Figures 1A-1C),8 and genome sequencing is consistent with observations that G. necrorhizus is a white-rotting decomposer. This species also represents the first documentation of an arthropod-dispersed sequestrate fungus. Numerous species of distantly related wood-feeding termites, which scavenge for N-rich food, feed on the mature spore-bearing tissue, or gleba, of G. necrorhizus. During feeding, mature spores adhere to termites for subsequent dispersal.9 Using chemical assays, isotope analysis, and high-throughput sequencing, we show that the sporocarps harbor actively N2-fixing Enterobacteriaceae species and that the N content within fungal tissue increases with maturation. Untargeted proteomic profiling suggests that ATP generation in the gleba is accomplished via fermentation. The use of fermentation-an anaerobic process-indicates that the sporocarp environment is anoxic, likely an adaptation to protect the oxygen-sensitive nitrogenase enzyme. Sporocarps also have a thick outer covering, possibly to limit oxygen diffusion. The enriched N content within mature sporocarps may offer a dietary inducement for termites in exchange for spore dispersal. These results show that the flexible metabolic capacity of fungi may facilitate N2-fixing associations, as well as higher-level organismal associations.