Detection and survey of coffee ringspot virus in Brazil.

Coffee ringspot virus (CoRSV) a member of the proposed genus "Dichorhavirus", was surveyed on commercial and research farms spanning an area responsible for the majority of Coffea arabica production in Brazil. Virus-infected plants were found at one hundred percent of locations (n = 45) sampled. All cultivars, regardless of cherry color, were found to serve as hosts, suggesting that there is limited resistance in commercially employed germplasm. Reverse transcription PCR analysis revealed that the virus is contained within symptomatic lesions, with little systemic spread throughout leaves. Phylogenetic analysis based on the ORF1 (nucleocapsid) gene identified a strong geo-spatial relationship among isolates, which clustered into three clades. Despite low genetic diversity among isolates, variation in symptom expression was observed in the experimental host Chenopodium quinoa. Our analyses support the hypothesis that the spread of CoRSV is constrained by the clonal expansion of thelytokous populations of Brevipalpus phoenicis. The widespread occurrence of this virus suggests that it is much more prevalent than previously thought.

Effect of algae or fish oil supplementation and porcine maternal stress on the adrenal transcriptome of male offspring fed a low-quality protein diet.

Offspring adrenal function may be negatively affected in utero by maternal stressors such as microbial infection. Maternal supplementation with immunomodulatory compounds such as omega-3 polyunsaturated fatty acids (n-3 PUFA) may help minimize the adverse effects of maternal stress on fetal hypothalamic-pituitary-adrenal development and improve offspring health. Presently, n-3 PUFA sources are primarily fish-based, but n-3 PUFA microalgae (AL) may be an alternative. Previously, it was determined that maternal AL or fish oil (FO) supplementation to sows, in addition to maternal stress induced by Escherichia coli lipopolysaccharide (LPS) challenge appeared to have a greater influence on the stress response of male offspring compared to females. To further elaborate on these findings, this study assessed the effects of maternal AL or FO supplementation combined with a maternal LPS challenge on adrenal gene expression in male offspring fed a nursery diet containing low-quality protein sources. Forty-eight sows were fed gestation diets starting on gestation day (gd) 75 containing either 3.12% AL, 3.1% FO, or a control diet containing 1.89% corn oil. On gd 112, half the sows in each treatment were administered 10 â€‹µg/kg LPS i.m. Piglets were weaned at 21 days of age onto a common low-quality plant-based protein diet, and one week after weaning, four piglets per sow were administered 40 â€‹µg/kg LPS i.m. Two hours later, the piglets were euthanized to obtain adrenal tissue, and total RNA was extracted to carry out transcriptome analysis using the Affymetrix GeneChip WT Plus assay and subsequent validation by real-time PCR. Analysis revealed that adrenal steroidogenesis, fatty acid metabolism and immune function were significantly influenced by maternal diet and stress. Increased expression of immune-related genes including lymphocyte antigen 96, TLR-2 and NF-κB suggests that maternal AL supplementation may increase offspring sensitivity to inflammation after weaning. Decreased expression of lymphocyte antigen 96 in male offspring from sows receiving maternal LPS challenge also suggests a possible role of maternal stress in diminishing the offspring immune response to immune stress challenge. Increased expression of the genes encoding the 11BHSD2 enzyme in offspring from sows fed FO may also reduce the magnitude of the stress response. These data provide insight to the immune and metabolic mechanisms that may be influenced by maternal diet and stress.

Measuring quality of life in a way that is meaningful to stroke patients.

OBJECTIVE: To identify predictors of poststroke quality of life. BACKGROUND: Health-related quality of life (HRQOL) measures assess the impact of disease on the physical, emotional, and social aspects of patients' lives. Although HRQOL measures are used increasingly, factors associated with HRQOL poststroke and the ability of stroke-specific versus generic HRQOL measures to predict patient-reported HRQOL are not well known. METHODS: A total of 71 patients were evaluated 1 month postischemic stroke with a new stroke-specific HRQOL measure-the SS-QOL-and the SF-36, a generic HRQOL measure. Stroke severity, impairments, and functional limitations were also measured. Demographic variables and outcome measure scores were compared between patients rating their overall HRQOL the same as pre-stroke versus those with overall HRQOL worse than prestroke. Independent predictors of overall HRQOL were identified using multivariable modeling. RESULTS: Variables associated with better overall HRQOL were higher (better) SS-QOL and Barthel Index scores, and lower (better) NIH Stroke Scale and Beck Depression Inventory scores. Independent predictors of good overall HRQOL were the SS-QOL score (odds ratio [OR], 2.97; 95% CI, 1.3, 7.1; p = 0.01) and NIH Stroke Scale score (OR, 0.69; 95% CI, 0.47, 0.99; p = 0.05). Demographic factors and SF-36 scores were not associated with overall HRQOL ratings. CONCLUSIONS: Stroke-specific quality of life score and patient impairments predict patient-reported overall health-related quality of life (HRQOL) poststroke. SF-36 scores were not associated with overall HRQOL ratings. Disease-specific HRQOL measures are more sensitive to meaningful changes in poststroke HRQOL and may thus aid in identifying specific aspects of poststroke function that clinicians and "trialists" can target to improve patients' HRQOL after stroke.

Effects of multidisciplinary case management in patients with chronic renal insufficiency.

PURPOSE: Though case management has been recommended to improve the outcomes of patients with costly or morbid conditions, it has seldom been studied in controlled trials. We performed a randomized, controlled clinical trial of an intensive, multidisciplinary case management program for patients with chronic renal insufficiency and followed patients for 5 years. PATIENTS AND METHODS: We enrolled 437 primary-care patients (73% of those eligible) with chronic renal insufficiency (estimated creatinine clearance consistently < 50 mL/min with the last serum creatinine level > 1.4 mg/dL) who were attending an urban academic general internal medicine practice. The intensive case management, administered during the first 2 years after enrollment, consisted of mandatory repeated consultations in a nephrology case management clinic staffed by two nephrologists, a renal nurse, a renal dietitian, and a social worker. Control patients received usual care. Primary outcome measurements included serum creatinine level, estimated creatinine clearance, health services use, and mortality in the 5 years after enrollment. Secondary measures included use of renal sparing and potentially nephrotoxic drugs. RESULTS: There were no differences in renal function, health services use, or mortality in the first, second, or third through fifth years after enrollment. There were significantly more outpatient visits among intervention patients, mainly because of the added visits to the nephrology case management clinic. There were also no significant differences in the use of renal sparing or selected potentially nephrotoxic drugs. The annual direct costs of the intervention were $89,355 ($484 per intervention patient). CONCLUSION: This intensive, multidisciplinary case-management intervention had no effect on the outcomes of care among primary-care patients with established chronic renal insufficiency. Such expensive and intrusive interventions, despite representing state-of-the-art care, should be tested prospectively before being widely introduced into practice.

Congenital and acquired abnormalities observed in live-born and stillborn neonates.

This report records the congenital and acquired abnormalities observed during the first 4 days of life in 21,142 live-born infants. Gross abnormalities observed in 300 stillborns also are recorded. The abnormalities are those thought to be of clinical or possibly clinical significance. Also included are other conditions ordinarily not considered to be a congenital abnormality, such as convulsions. Definitions are given when indicated. The incidence rates per 1,000 births for specific malformation noted in the first 4 days of life are provided for all births, for live births, for live births under 2,500 g, and for stillbirths. The need for accurate studies of specific forms of congenital malformations is reiterated. The rate for all malformations combined is not given since it is difficult to interpret or use for comparisons because of variations in the definition of malformation and in completeness of ascertainment in different studies.

Effect of hypertension and type II diabetes on renal function in an urban population.

End-stage renal disease is a devastating complication of essential hypertension and type II diabetes mellitus, conditions that commonly occur together. We and others have previously suggested that the outcome of both conditions may be influenced by more aggressive treatment. We examined a large general medicine outpatient population; 72% were black and 41% were diabetic (95% type II). Decreased renal function, defined as a serum creatinine greater than or equal to mg/dL, developed in 18.1%. A multivariable logistic regression analysis identified glucose control, systolic blood pressure level, and male gender as indicators of decreased renal function. These data suggested that both glucose and blood pressure control may decrease the frequency of impaired renal function. However, when these variables were controlled, blacks still had almost twice the risk for renal dysfunction of whites. The data draw attention to, and elucidate the exceptionally high incidence of renal dysfunction in hypertensive blacks with or without diabetes. Further, they may explain the inordinate numbers of blacks with hypertension requiring dialysis. Prospective trials to test the efficacy of blood pressure and glucose control on the course of renal disease in hypertensive and/or type II diabetic patients are warranted.

Comparison of serum cholesterol in children fed high, moderate, or low cholesterol milk diets during neonatal period.

The long-term effects of milk diets in infancy on the blood serum cholesterol concentrations were studied in 97 school children 7-12 yr of age. Detailed histories were available for these children with respect to their diets during infancy. The major criterion for inclusion in the study was milk (human milk, cow's milk, or commercial formula) as the exclusive source of diet cholesterol during the first 3 mo of life. Fasting blood cholesterol and triglycerides were measured in these 97 school children, and the current diets of 29 of the 97 were evaluated for daily cholesterol intake. A 7-day diet diary was recorded, the food intake was measured and analyzed for nutrients, and validity of the diets was verified by determination of urinary nitrogen excretion. Results of the study showed that the school children fed a low cholesterol formula during infancy had a mean serum cholesterol value 7-12 yr later that was lower than the mean values of the groups fed greater amounts of cholesterol in infancy. Analysis of current diets of 29 of the 97 school children showed that their current dietary intake of cholesterol was low. Dietary intake of cholesterol did not have a noticeable effect on the serum cholesterol levels of the 29 children.

Computerizing guidelines to improve care and patient outcomes: the example of heart failure.

Increasing amounts of medical knowledge, clinical data, and patient expectations have created a fertile environment for developing and using clinical practice guidelines. Electronic medical records have provided an opportunity to invoke guidelines during the everyday practice of clinical medicine to improve health care quality and control costs. In this paper, efforts to incorporate complex guidelines [those for heart failure from the Agency for Health Care Policy and Research (AHCPR)] into a network of physicians' interactive microcomputer workstations are reported. The task proved difficult because the guidelines often lack explicit definitions (e.g., for symptom severity and adverse events) that are necessary to navigate the AHCPR algorithm. They also focus more on errors of omission (not doing the right thing) than on errors of commission (doing the wrong thing) and do not account for comorbid conditions, concurrent drug therapy, or the timing of most interventions and follow-up. As they stand, the heart failure guidelines give good general guidance to individual practitioners, but cannot be used to assess quality or care without extensive "translation" into the local environment. Specific recommendations are made so that future guidelines will prove useful to a wide range of prospective users.

International food component data system.

The International Network of Food Data Systems planning conference recommends establishing nomenclature and a system of coding for use in INFOODS. The International Food Naming System would facilitate collection, tabulation, storing, and retrieval of information. The system consists of two files for each food: one describing the name in a standardized manner and another reporting chemical and biological data. The two files are linked by International Food Number (IFN). Food names consist of controlled terms called facets: origin, part, process, stage of maturity, and grade. Within each facet, such elements as genus, species, variety (scientific name) and generic name, breed or kind, and strain (English name) are defined. Elements are assigned numerical codes to facilitate sorting and storage. Carefully defined standard descriptions are used in each facet. Each descriptor is assigned an alphabetic code, an unlimited number allowing an open-ended flexible system. IFN may be incorporated into a computerized data management system and stored data searched and sorted for information retrieval on given parameters, e.g., country, state, laboratory, or kind of package. Data can be summarized to obtain averages, ranges, and standard deviations. Summarized data, linked with the International Food Names by the IFN, may be printed out in desired format.

Correlates of health care satisfaction in inner-city patients with hypertension and chronic renal insufficiency.

Barriers to effective health care are potential contributors to the increased prevalence of hypertension and hypertension-related renal disease observed in black patients. We have enrolled 333 primarily elderly (mean age 69 years) black (87%) patients with hypertension and chronic renal insufficiency into a prospective randomized trial testing the effect of intense multidisciplinary management on progression of chronic renal insufficiency. These patients have an average 6 years of education and $400-$800 monthly household income: 57% have diabetes. Our baseline data include the Patient Satisfaction Questionnaire administered by home interviewers who also recorded sociodemographic data, medications and questionnaires regarding medication compliance and symptoms related to anti-hypertensive drugs. Inpatient and outpatient vital signs, test results and diagnoses came from patients' computerized medical records. We used multiple linear regression to identify correlates of overall satisfaction. We also analyzed three subscales: access to care, financial aspects and interpersonal manner of physicians. We included only variables with univariate correlations (P < 0.05) in the models. Decreased overall satisfaction correlated with more symptoms related to anti-hypertensive drugs (P < 0.001), lower medication compliance (P = 0.01), and higher diastolic blood pressure (P = 0.08). Decreased satisfaction with access to care correlated with more symptoms related to anti-hypertensive drugs (P < 0.001) and decreased medication compliance (P = 0.08). Decreased satisfaction with financial aspects of care correlated with more symptoms related to anti-hypertensive drugs (P < 0.001), lower medication compliance (P = 0.01) and more proteinuria (P = 0.02). Finally, decreased satisfaction with interpersonal manner of physicians correlated with lower medication compliance (P < 0.001), lower albumin (P = 0.01) and sodium (P = 0.04), and higher diastolic blood pressure (P = 0.04). These cross-sectional baseline data describe a group of mostly black inner-city patients with hypertension and chronic renal insufficiency in whom decreased satisfaction with care correlates with decreased medication compliance, increased symptoms related to anti-hypertensive drug therapy, higher diastolic blood pressure and more proteinuria. Our prospective study may help determine whether improving satisfaction improves compliance and blood pressure control, and forestalls complications in this high-risk population.

Restricting medicaid payments for transportation: effects on inner-city patients' health care.

BACKGROUND: Prior approval programs have been used to control spiraling costs of Medicaid, but they are rarely formally assessed. We evaluated the effect of a change in Indiana Medicaid's policy (effective October 1, 1993) requiring prior approval to pay transportation costs. METHODS: We performed a historical cohort study comparing the health care utilization of Medicaid patients during the first 6 months of 1993 versus the first 6 months of 1994. Subjects included all Medicaid patients who visited any inpatient or outpatient site affiliated with an inner-city public hospital in the first 6 months of 1993 (N = 23,015) and 1994 (N = 23,707). RESULTS: These Medicaid patients made 82,961 visits in the first 6 months of 1993 and 79,809 visits in the first 6 months of 1994. Visits to hospital-based primary care clinics declined 16% (P < 0.001), which was partially offset by a 7% increase in visits to neighborhood health centers (P < or = 0.001). Emergency and urgent visits fell by 8%; visits for medication refills fell by 18% (P < 0.001 for each). Hospitalizations increased slightly in 1994, with no change in the number of inpatient days. There was no change in inpatient or outpatient nontransportation charges. There were no systematic reductions in selected aspects of preventive care. However, there were fewer emergency and urgent visits among patients with reactive airway disease. CONCLUSIONS: Requiring prior approval for transportation was associated with reductions in visits for primary care visits and refilling prescriptions without measurable short-term effects on charges or selected clinical parameters. Neighborhood health centers partially ameliorated the decline in primary care visits.

Pharmaceutical care program for patients with reactive airways disease.

A pharmaceutical care program for patients with reactive airways disease (RAD) is described. A pharmaceutical care program for patients with RAD was developed and implemented at 36 CVS pharmacies. The impact on patient outcomes, pharmacist job satisfaction, and other variables is currently being evaluated in a controlled trial with more than 1100 patient enrollees. Guiding the program are the beliefs that pharmacists must have clinically relevant, patient-specific data to provide appropriate care; that pharmacists must have adequate training to provide pharmaceutical care; that the program must be sensitive to organizational barriers, particularly time demands; and that there must be ongoing support for the program. The program has five components: (1) computer display of patient-specific data for patients enrolled in the study, (2) distribution of tailored patient education materials, (3) use of a resource guide to facilitate the implementation of pharmaceutical care, (4) strategies to reinforce and facilitate the program, and (5) pharmacist training. While developed for community pharmacies, the program is applicable to most ambulatory care pharmacy practices. A pharmaceutical care program for patients with RAD was developed for use in community pharmacies.

Linear models for calculating digestibile energy for sheep diets.

Equations for estimating the digestible energy (DE) content of sheep diets were generated from the chemical contents and a factorial description of diets fed to lambs in digestion trials. The diet factors were two forages (alfalfa and grass hay), harvested at three stages of maturity (late vegetative, early bloom and full bloom), fed in two ingredient combinations (all hay or a 50:50 hay and corn grain mixture) and prepared by two forage texture processes (coarsely chopped or finely chopped and pelleted). The 2 x 3 x 2 x 2 factorial arrangement produced 24 diet treatments. These were replicated twice, for a total of 48 lamb digestion trials. In model 1 regression equations, DE was calculated directly from chemical composition of the diet. In model 2, regression equations predicted the percentage of digested nutrient from the chemical contents of the diet and then DE of the diet was calculated as the sum of the gross energy of the digested organic components. Expanded forms of model 1 and model 2 were also developed that included diet factors as qualitative indicator variables to adjust the regression constant and regression coefficients for the diet description. The expanded forms of the equations accounted for significantly more variation in DE than did the simple models and more accurately estimated DE of the diet. Information provided by the diet description proved as useful as chemical analyses for the prediction of digestibility of nutrients. The statistics indicate that, with model 1, neutral detergent fiber and plant cell wall analyses provided as much information for the estimation of DE as did model 2 with the combined information from crude protein, available carbohydrate, total lipid, cellulose and hemicellulose. Regression equations are presented for estimating DE with the most currently analyzed organic components, including linear and curvilinear variables and diet factors that significantly reduce the standard error of the estimate. To estimate De of a diet, the user utilizes the equation that uses the chemical analysis information and diet description most effectively.