Antibiotic usage in chronic rhinosinusitis: analysis of national primary care electronic health records.

BACKGROUND: The aim of this study was to analyse rates of antibiotic usage in chronic rhinosinusitis (CRS) in primary care in England and Wales and to identify trends in the choice of antibiotics prescribed. METHODS: We used linked data from primary care EHRs, with diagnoses coded using the Read terminology (Clinical Practice Research Datalink) from consenting general practices, with (2) hospital care administrative records (Hospital Episode Statistics, HES recorded using ICD-10). RESULTS: From the total of 88,317 cases of CRS identified, 40,462 (46%) had an antibiotic prescription within 5 days of their first CRS diagnosis. Of patients receiving a first line antibiotic within 5 days of CRS diagnosis, over 80%, in each CRS group, received a subsequent prescription for an antibiotic. Within 5 years of diagnosis, 9% are estimated to have had 5 or more antibiotics within 5 days of a CRS-related consultation. With data spanning almost 20 years, it was possible to discern trends in antibiotics prescriptions, with a clear increasing trend towards macrolide and tetracycline prescribing evident. CONCLUSIONS: While antibiotics may have been prescribed for acute exacerbations, we have found high rates of repeated antibiotic prescription in some patients with CRS in primary care. There is a need for stronger evidence on the role of antibiotics in CRS management.

Risk of mortality and cardiovascular events following macrolide prescription in chronic rhinosinusitis patients: a cohort study using linked primary care electronic health records.

BACKGROUND: Macrolide antibiotics have demonstrated important anti-inflammatory and immunomodulatory properties in chronic rhinosinusitis (CRS) patients. However, reports of increased risks of cardiovascular events have led to safety concerns. We investigated the risk of all-cause and cardiac death, and cardiovascular outcomes, associated with macrolide use. METHODOLOGY: Observational cohort (1997-2016) using linked data from the Clinical Practice Research Datalink, Hospital Episodes Statistics, and the Office for National Statistics. Patients aged 16-80 years with CRS prescribed a macrolide antibiotic or penicillin were included, comparing prescriptions for macrolide antibiotics to penicillin. Outcomes were all-cause mortality, cardiac death, myocardial infarction, stroke, diagnosis of peripheral vascular disease, and cardiac arrhythmia. RESULTS: Analysis included 320,798 prescriptions received by 66,331 patients. There were 3,251 deaths, 815 due to cardiovascular causes, 925 incident myocardial infarctions, 859 strokes, 637 diagnoses of peripheral vascular disease, and 1,436 cardiac arrhythmias. A non-statistically significant trend towards increased risk of myocardial infarction during the first 30 days following macrolide prescription was observed. No statistically significant short- or long-term risks were observed for macrolide prescription. No significant risks were identified for clarithromycin in particular. CONCLUSIONS: Although not statistically significant, our best estimates suggest an increased short-term risk of myocardial infarction in patients with CRS following macrolide prescription, supporting previous observational evidence. However, confounding by indication remains a possible explanation for this apparent increased risk. We found no evidence of longer term increased risks.

An evaluation of the quality of evidence available to inform current bone conducting hearing device national policy.

OBJECTIVES: In 2016, NHS England published the commissioning policy on Bone Conducting Hearing Devices (BCHDs). This policy was informed by updated evidence on the clinical and cost-effectiveness of BCHDs as well as by the 2013 Bone Anchored Hearing Aid (BAHA) policy. Commissioning policies set the criteria for service delivery and therefore have a major impact on the care received by patients. It is important that stakeholders have a good appreciation of the available evidence informing policy, as this will promote engagement both with the policy and with future research leading on from the policy. In this article, we provide stakeholders with a transparent and pragmatic assessment of the quality of the body of evidence available to inform current BCHD national policy. METHOD: (i) A systematic review of the literature on BCHDs published since the development of the 2013 policy was performed in September 2016, adhering to PRISMA recommendations. The search terms used were as follows bone conduction; bone conducting; bone anchor; BAHA; Bone Anchored Hearing Aid; Bone Conducting Hearing Device; BCHD; Bone Conducting Hearing Implant; BCHI; Sophono; Bonebridge; Soundbite; Ponto; Hearing aid; implant; device; hearing device. Publications that could inform current BCHD policy were included. The quality of included articles was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. (ii) The quality of evidence referenced by the 2013 BAHA policy was assessed using the GRADE system. RESULTS: (i) Of the 2576 publications on BCHDs identified by the systematic search, 39 met the inclusion criteria for further analysis. Using the GRADE criteria, the quality of evidence was classified as of 'very low quality'. (ii) The 2013 BAHA policy was informed by 14 references. The GRADE system classifies the quality of evidence that informed the policy as of 'very low quality'. CONCLUSIONS: The GRADE system defines the body of evidence available to inform current national BCHD policy as of 'very low quality'. There is an urgent need for high-quality research to help make informed policy decisions about the care of patients with hearing loss. An (inter)national registry of BCHDs could address this need.

Systematic review of the limited evidence base for treatments of Eustachian tube dysfunction: a health technology assessment.

BACKGROUND: The Health Technology Assessment programme commissioned a wide-ranging review of treatments for adult Eustachian tube dysfunction. Treatments range from advice and observation and pharmacological treatments to surgical options. OBJECTIVE: (i) To assess the evidence for interventions for adults with a clinical diagnosis of Eustachian tube dysfunction and (ii) to identify priorities for future research. TYPE OF REVIEW: Systematic review (PROSPERO registration CRD42012003035) adhering to PRISMA guidance. SEARCH: An extensive search of 15 databases including MEDLINE, EMBASE and CENTRAL (up to October 2012). EVALUATION METHOD: Controlled and uncontrolled studies of interventions for adult Eustachian tube dysfunction were included. Because of insufficient data, the protocol was amended to also include controlled studies with mixed adult/child populations. Risk of bias was assessed. Narrative synthesis was employed due to high clinical heterogeneity. RESULTS: Interventions assessed were pharmacological treatments [two randomised controlled trials (RCTs), one controlled non-randomised trial (CCT), 159 patients]; mechanical pressure equalisation devices (one randomised controlled trial, one CCT, 48 patients); and surgery, including laser tuboplasty (seven case series, 192 patients), balloon dilatation (three case series, 103 patients), myringotomy without grommet insertion (two case series, 121 patients), transtubal steroids (one case series, 11 patients) and laser coagulation (one retrospective controlled study, 40 patients). All studies had high risk of bias except two pharmacological trials; one had low risk and one unclear risk. No evidence was found for many treatments. The single low risk of bias RCT (n = 91; 67% adults) showed no effect of nasal steroids and favoured placebo for improved middle ear function (RR 1.20, 95% CI 0.91-1.58) and symptoms (P = 0.07). Other studies showed improvements in middle ear function for mechanical devices, antihistamine/ephedrine and nasal decongestant, but they had significant methodological weaknesses including insufficient length of follow-up. None of the surgical studies were adequately controlled, and many reported high levels of co-intervention. Therefore, observed benefits for tuboplasty and balloon dilatation in symptoms, middle ear function or hearing could not be reliably attributed to the interventions assessed. There was variability in definitions of the condition. CONCLUSION: Eustachian tube dysfunction is a poorly defined condition. Due to the limited and poor-quality evidence, it is inappropriate to make conclusions on the effectiveness of any intervention; the evidence base is insufficient to guide recommendations for a trial of any particular intervention. Consensus on diagnostic criteria for Eustachian tube dysfunction is required to inform inclusion criteria of future trials.

Six-year follow-up study of bone mineral density in patients with systemic lupus erythematosus.

UNLABELLED: Long-term bone mineral density (BMD) changes and the associated factors in systemic lupus erythematosus (SLE) patients were assessed. Despite the remarkably low overall bone loss, significant spine bone loss was associated with the use of glucocorticoids, use of antimalarials, and lower 25-hydroxyvitamin D levels, stressing the importance of prevention of osteoporosis and vitamin D deficiency in SLE patients. INTRODUCTION: The aim of this study is to assess the BMD changes in patients with SLE and to identify the associated factors. METHODS: Demographic and clinical data of 126 SLE patients were collected, and BMD measurements of the lumbar spine and the total hip were performed by dual-energy X-ray absorptiometry at baseline and follow-up. Statistical analyses were performed using independent Mann-Whitney U tests and linear regression analyses. RESULTS: At baseline, 39.7 % of the patients (90 % female, mean age 39 ± 12.2 years) had osteopenia, and 6.3 % had osteoporosis. The median follow-up duration was 6.7 years (range 1.9-9.3 years). Mean changes in BMD at the lumbar spine (-0.08 %/year) and the hip (-0.20 %/year) were not significant. During follow-up, 70 % of the patients used glucocorticoids. The mean ± SD daily glucocorticoid dose was 5.0 ± 5.0 mg. In multiple regression analysis, BMD loss at the spine was significantly associated with higher daily glucocorticoid dose and lower baseline 25-hydroxyvitamin D levels. BMD loss at the hip was associated with lower 25-hydroxyvitamin D levels at baseline, reduction of body mass index, and baseline use of antimalarials. CONCLUSIONS: In this 6-year follow-up study, bone loss was remarkably low. A dose-dependent relationship between glucocorticoid use and spinal bone loss was found. In addition, the use of antimalarials and lower 25-hydroxyvitamin D levels at baseline were associated with BMD loss. These findings underline the importance of prevention and treatment of vitamin D deficiency and osteoporosis in SLE, especially in patients using glucocorticoids or antimalarials.

Strobilurin (QoI) Resistance in Populations of Erysiphe necator on Grapes in Michigan.

Powdery mildew, caused by Erysiphe necator, is the most common and destructive disease of grapes (Vitis spp.) worldwide. In Michigan, it is primarily controlled with fungicides, including strobilurins (quinone outside inhibitors [QoIs]). Within the United States, resistance to this class of fungicides has been reported in E. necator populations in some east coast states. Among 12 E. necator isolates collected from five Michigan vineyards in 2008, one carried the G143A single-nucleotide mutation responsible for QoI resistance. This isolate was confirmed to be resistant in a conidium germination assay on water agar amended with trifloxystrobin at 0.001, 0.01, 0.1, 1, 10, or 100 µg/ml and salicylhydroxamic acid (100 mg/liter). The mutant isolate was able to germinate on media amended with 100 µg/ml trifloxystrobin, whereas a representative wild-type isolate did not germinate at concentrations higher than 0.1 µg/ml. In 2009, 172 isolates were collected from a total of 21 vineyards (juice and wine grapes): three vineyards with no fungicide application history (baseline sites), six research vineyards, and 12 commercial vineyards. QoI resistance was defined as the effective concentration that inhibited 50% of conidial germination (EC50) > 1 µg/ml. Isolates from baseline sites had EC50 values mostly below 0.01 µg/ml, while isolates that were highly resistant to trifloxystrobin (EC50 > 100 µg/ml) occurred in five research and three commercial wine grape vineyards at frequencies of 40 to 100% and 25 to 75% of the isolates, respectively. The G143A mutation was detected in every isolate with an EC50 > 1 µg/ml. These results suggest that fungicide resistance may play a role in suboptimal control of powdery mildew observed in some Michigan vineyards and emphasizes the need for continued fungicide resistance management.

First Report of Blueberry Leaf Rust Caused by Thekopsora minima on Vaccinium corymbosum in Michigan.

Leaf rust symptoms have been noticed sporadically on northern highbush blueberry plants (Vaccinium corymbosum L.) in Michigan for the past 8 years. In 2009, leaf rust was seen in several cultivated blueberry fields and on greenhouse-grown blueberry plants in southwest Michigan. In 2010, leaf rust was widespread throughout western Michigan and particularly evident in the fall, sometimes resulting in premature defoliation. Cultivars Rubel, Jersey, Elliott, Liberty, and Brigitta were most commonly affected. Both the 2009 and 2010 growing seasons were characterized by above-average precipitation in early to mid-summer. Early symptoms on the adaxial leaf surface consisted of roughly circular yellow spots that later developed brown, necrotic centers. Older lesions were more angular and sometimes surrounded by a purplish border. In the fall, a "green island" effect was sometimes apparent around the lesions. On the abaxial side, numerous yellow-to-orange rust pustules (uredinia) were visible. Uredinia were dome shaped, erumpent, 100 to 400 µm in diameter, clustered, and sometimes coalescing. Urediniospores were broadly obovate with dark yellowish content and measured 19 to 25 × 16 to 20 µm (average 22 × 18 µm, n = 30). Spore walls were hyaline, echinulate, and 1.0 to 1.5 µm thick with obscure germ pores. Uredinia were examined with light and scanning electron microscopy for the presence of conspicuous ostiolar cells characteristic of Naohidemyces vaccinii (Wint.) Sato, Katsuya et Y. Hiratsuka, but none were observed. No telia or teliospores were observed. On the basis of morphology, the pathogen was identified as Thekopsora minima P. Syd. & Syd. (3,4) and a sample was deposited in the U.S. National Fungus Collection (BPI 881107). Genomic DNA was extracted from urediniospores of rust isolates from six different locations, and a 267-bp fragment of the ITS2 region was amplified and sequenced using the primers ITS3 and ITS4 (GenBank Accession No. HQ661383). All sequences were identical to each other and shared 99% identity (232 of 234 bp) with a T. minima isolate from South Africa (GenBank Accession No. GU355675). The alternate host, hemlock (mostly Tsuga canadensis L.) is a common and valuable conifer in the Michigan landscape. Hemlock trees were not examined for the presence of aecia but are assumed to play a role in the epidemiology of the disease in Michigan because leaf rust tends to be more severe near hemlock trees. Pucciniastrum vaccinii (G. Wint.) Jorst. was considered the causal agent of blueberry leaf rust until Sato et al. (1,4) identified three unique species. While T. minima has been reported on black huckleberry (Gaylussacia baccata [Wangenh.] K. Koch) in Michigan (4), to our knowledge, this is the first report of T. minima on highbush blueberry in the state. T. minima has been reported on highbush blueberry in Delaware and New York (4), Japan (2), and South Africa (3). The severity of the outbreak in 2010 warrants further research into economic losses, epidemiology, and management of the disease. References: (1) D. F. Farr and A. Y. Rossman. Fungal Databases. Systematic Botany and Mycology Laboratory, ARS, UDSA. Retrieved from http://nt.ars-grin.gov/fungaldatabases/ , 2010. (2) T. Kobayashi. Page 1227 in: Index of Fungi Inhabiting Woody Plants in Japan. Host, Distribution and Literature. Zenkoku-Noson-Kyoiku Kyokai Publishing Co., Tokyo, 2007. (3) L. Mostert et al. Plant Dis. 94:478, 2010. (4) S. Sato et al. Trans. Mycol. Soc. Jpn. 34:47, 1993.

First Report of Stem Blight Caused by Calonectria colhounii (Anamorph Cylindrocladium colhounii) on Greenhouse-Grown Blueberries in the United States.

Necrotic stems and leaves were observed on 2- to 4-month-old, rooted microshoot plants (Vaccinium corymbosum L. 'Liberty' and 'Bluecrop', V. angustifolium Aiton 'Putte', and V. corymbosum × V. angustifolium 'Polaris') in a Michigan greenhouse in 2008 and 2009. As the disease progressed, leaves fell off and 80 to 100% of the plants died in some cases. Root rot symptoms were also observed. A fungus was isolated from stem lesions. On potato dextrose agar (PDA), cultures first appeared light tan to orange, then rusty brown and zonate with irregular margins. Chains of orange-brown chlamydospores were abundant in the medium. Macroconidiophores were penicillately branched and had a stipe extension of 220 to 275 × 2.5 µm with a narrowly clavate vesicle, 3 to 4 µm wide at the tip. Conidia were hyaline and cylindrical with rounded ends, (1-)3-septate, 48 to 73 × 5 to 7 (average 60 × 5.5) µm and were held together in parallel clusters. Perithecia were globose to subglobose, yellow, 290 to 320 µm high, and 255 to 295 µm in diameter. Ascospores were hyaline, 2- to 3-septate, guttulate, fusoid with rounded ends, slightly curved, and 30 to 88 × 5 to 7.5 (average 57 × 5.3) µm. On the basis of morphology, the fungus was identified as Calonectria colhounii Peerally (anamorph Cylindrocladium colhounii Peerally) (1,2). The internal transcribed spacer region (ITS1 and ITS2) of the ribosomal DNA and the ß-tubulin gene were sequenced (GenBank Accession Nos. HQ909028 and JF826867, respectively) and compared with existing sequences using BLASTn. The ITS sequence shared 99% maximum identity with that of Ca. colhounii CBS 293.79 (GQ280565) from Java, Indonesia, and the ß-tubulin sequence shared 97% maximum identity with that of Ca. colhounii CBS 114036 (DQ190560) isolated from leaf spots on Rhododendron sp. in North Carolina. The isolate was submitted to the Centraalbureau voor Schimmelcultures in the Netherlands (CBS 129628). To confirm pathogenicity, 5 ml of a conidial suspension (1 × 105/ml) were applied as a foliar spray or soil drench to four healthy 'Bluecrop' plants each in 10-cm plastic pots. Two water-sprayed and two water-drenched plants served as controls. Plants were misted intermittently for 2 days after inoculation. After 7 days at 25 ± 3°C, drench-inoculated plants developed necrotic, sporulating stem lesions at the soil line, while spray-inoculated plants showed reddish brown leaf and stem lesions. At 28 days, three drench-inoculated and one spray-inoculated plant had died, while others showed stem necrosis and wilting. No symptoms were observed on control plants. Fungal colonies reisolated from surface-disinfested symptomatic stem, leaf, and root segments appeared identical to the original isolate. Cy. colhounii was reported to cause a leaf spot on blueberry plants in nurseries in China (3), while Ca. crotalariae (Loos) D.K. Bell & Sobers (= Ca. ilicicola Boedijn & Reitsma) causes stem and root rot of blueberries in North Carolina (4). To our knowledge, this is the first report of Ca. colhounii causing a disease of blueberry in Michigan or the United States. Because of its destructive potential, this pathogen may pose a significant threat in blueberry nurseries. References: (1) P. W. Crous. Taxonomy and Pathology of Cylindrocladium (Calonectria) and Allied Genera. The American Phytopathological Society, St. Paul, MN, 2002. (2) L. Lombard et al. Stud. Mycol. 66:31, 2010. (3) Y. S. Luan et al. Plant Dis. 90:1553, 2006. (4) R. D. Milholland. Phytopathology 64:831, 1974.

First Report of Pythium sterilum Causing Root Rot of Blueberry in the United States.

In September 2009, ~40 declining blueberry plants (Vaccinium corymbosum L. 'Jersey') were observed in a poorly drained area of a 30-year-old field near Fennville, MI. The stunted bushes had yellow leaves and defoliation; others were completely dead. The grower reported that the bushes had been declining over several years. Root samples tested positive in a Phytophthora ELISA test (Agdia Inc., Elkhart IN). Twenty root pieces (2 cm long and 2 to 3 mm in diameter) were surface disinfested and plated on Rye A agar; five yielded fungal-like colonies that were subcultured on potato dextrose agar (PDA). One isolate was white and grew slowly (3 to 4 mm/day at 22 to 24°C). Three isolates were white and grew faster (10 to 12 mm/day at 22 to 24°C) in a chrysanthemal pattern. The fifth was a Fusarium sp. DNA of the white colonies was extracted and the internal transcribed spacer (ITS) region was sequenced using ITS1 (5'-TCCGTAGGTGAACCTGCGG-3') and ITS4 (5'-TCCTCCGCTTATTGATATGC-3') primers. The slow-growing morphotype had 99% identity to Phytophthora sp. isolate 92-209C (Accession No. EU106591) in GenBank but failed to induce symptoms in multiple inoculation tests. The fast-growing morphotype (Accession No. HQ398249) had 98% identity to Pythium sterilum UASWS0265 from declining alder stands in Poland (Accession No. DQ525089). Sequencing of the COXII gene using the FM66/FM58 primer set (3) yielded a product (Accession No. HQ721468) with 100% identity to P. sterilum GD32a from forest soil in Poland (Accession No. EF421185). Hyphae were hyaline, coenocytic, and 4 to 7 µm wide with some swellings at the tips (7 to 9 µm wide). No sporangia, oogonia, or antheridia were observed. Mycelium tested positive in the ELISA test described above. According to Agdia Inc., 10 of 19 tested Pythium spp. have shown similar cross reactivity. Pythium spp. are known to cause root rot of blueberries in Oregon (2). In British Columbia, P. sterilum was commonly isolated from roots of declining blueberry bushes (4). P. sterilum Belbahri & Lefort only reproduces asexually (1). Our isolate was similar but did not produce sporangia in water or on PDA, V8 juice agar, Rye A agar, or water agar. Roots of 10 2-month-old 'Bluecrop' cuttings were placed in an aqueous suspension of rinsed mycelium (0.1 g/ml) from 21-day-old cultures grown in V8 broth or in sterile deionized water (control). After 1 h, plants were potted in peat moss/perlite (2:1) or autoclaved sand (five each) and placed in a glasshouse at 25°C. After 7 days, inoculated plants in both soil types had wilted or collapsed with significant necrosis on the roots and primary shoot. Control plants showed no symptoms. In a similar experiment with 6-month-old plants in sand, symptoms appeared after 10 to 12 days. The pathogen was recovered from surface-disinfested root and stem sections of all inoculated plants but not control plants and its identity was confirmed by sequencing of the ITS region. To our knowledge, this is the first report of P. sterilum on blueberries in the United States. While this disease appears to be uncommon in Michigan, it is a potential cause of plant decline, the diagnosis of which may be complicated by cross reactivity in ELISA testing. References: (1) L. Belbahri et al. FEMS Microbiol. Lett. 255:209, 2006. (2) D. R. Bryla and R. G. Linderman. HortScience 43:260, 2008. (3) F. N. Martin. Mycologia 92:711, 2000. (4) S. Sabaratnam. BC Plant Health Fund Final Report. B.C. Retrieved from http://www.agf.gov.bc.ca/cropprot/phf_final_report.pdf , 2008.

First Report of Juneberry Rust Caused by Gymnosporangium nelsonii on Juneberry in Michigan.

Amelanchier alnifolia (Nutt.) Nutt. ex M. Roem., commonly known as juneberry or Saskatoon serviceberry, was historically a widely used prairie fruit that is native to the Northern Great Plains, southern Yukon and Northwest Territories (4). While juneberry is an important fruit crop in the prairie provinces of Canada, small commercial plantings also occur throughout the northern United States (2), including Michigan. On July 18, 2009, severe rust symptoms were observed on plants in a 2-year-old field of A. alnifolia 'Northline' in Northport, MI. The plants had been sourced as seedlings from a nursery in Alberta, Canada in 2007. Signs and symptoms were present on fruits and leaves on virtually all of the plants. Symptomatic fruit were still immature, and on average, more than 70% of the fruit surface was covered with tubular, whitish aecia with conspicuous orange aeciospores. Portions of twigs also showed fusiform swellings (1 to 3 cm long) covered with aecia. Aecia were hypophyllous, fructicolous and caulicolous, roestelioid, and 2 to 4 mm high. The peridium was cylindric and tapering toward the apex, dehiscent at the apex, retaining a tubular shape for a long time and at times becoming lacerated on the sides with age. Peridial cells were linear rhomboidal, 50 to 105 µm long, hyaline to brownish, outer walls smooth, inner walls with small papillae, and side walls delicately verrucose-rugose with elongate papillae having variable lengths. Aeciospores were globoid, 20 to 35 × 25 to 38 µm (average 30.7 × 32.5 µm), orange to cinnamon brown, and densely verrucose with walls 2.5 to 3.5 µm thick. On the basis of these morphological characters, the host, and comparison with a reference specimen (BPI 122010), the pathogen was identified as Gymnosporangium nelsonii Arthur (1,3). The 5' region of the 28S rDNA was sequenced (GenBank Accession No. HM591299.1), confirming the identification as a species of Gymnosporangium, one distinct from previously sequenced specimens available in GenBank. The specimen has been deposited at the U.S. National Fungus Collections (BPI 880671 and 880709). Four other species found previously on Amelanchier spp. in the Midwest differ as follows: G. clavipes and G. clavariiforme have verrucose peridial cells and different 28S rDNA sequences; G. nidus-avis has rugose peridial cells; and G. corniculans has cornute peridia that dehisce from lateral slits while apices remain intact and verrucose peridial walls with verrucae on the side walls (1). The infection was likely caused by basidiospores originating from telia on Juniperus spp. in the area surrounding the field. However, no telia of G. nelsonii were found on junipers in the immediate vicinity. To our knowledge, this is the first report of G. nelsonii on juneberry in Michigan and the Midwest. Because of the devastating impact of this disease on fruit quality, fungicide programs have been devised for disease control and were effective in 2010. Juneberry growers in the Midwest need to be aware of this disease and monitor their crop carefully for symptoms and signs. References: (1) F. D. Kern. A Revised Taxonomic Account of Gymnosporangium. Pennsylvania State University Press, University Park, 1973. (2) K. Laughlin et al. Juneberry for Commercial and Home Use on the Northern Great Plains. North Dakota State University, Fargo 1996. (3) S. K. Lee and M. Kakishima. Mycoscience 40:121, 1999. (4) G. Mazza and C. G. Davidson. Page 516 in: New Crops. Wiley, New York, 1993.

Current indications for adenoidectomy in a sample of children in the Netherlands.

OBJECTIVE: To study current indications for adenoidectomy in Dutch children. METHODS: During 6 months, ENT surgeons in 1 academic and 7 general hospitals in the Netherlands filled out a questionnaire concerning all children below 15 years of age that were selected for adenoidectomy either as a single procedure or combined with myringotomy or tympanostomy tube placement. This questionnaire collected data on patient characteristics, ENT history, and indication(s) for the procedure. RESULTS: Questionnaires were returned on 159 children. The study population was comparable to the general population of children undergoing adenoidectomy in the Dutch Health Care Services database concerning age and sex. Adenoidectomy alone was performed in 38%, adenoidectomy and myringotomy in 15%, and adenoidectomy and tympanostomy tube placement in 47%. In children selected for adenoidectomy alone, indications were recurrent upper respiratory tract infections or chronic rhinosinusitis in 60%, persistent otitis media with effusion or recurrent acute otitis media in 33%, and obstructive symptoms in 42%. In children selected for adenoidectomy and myringotomy and those selected for adenoidectomy and tympanostomy tube placement, indications were persistent otitis media with effusion or recurrent acute otitis media in 96% and 99%, recurrent upper respiratory tract infections or chronic rhinosinusitis in 88% and 59%, and obstructive symptoms in 33% and 24%, respectively. CONCLUSION: In Dutch ENT practices, almost two-thirds of adenoidectomies are combined with myringotomy or tympanostomy tube placement. The most common indication for adenoidectomy combined with myringotomy or tympanostomy tubes is middle ear disease. For adenoidectomy alone, recurrent upper respiratory tract infection is the most common indication.

First Report of Grape Root Rot Caused by Roesleria subterranea in Michigan.

In September of 2008, declining grapevines were observed in two vineyards (Vitis interspecific hybrids 'Canada Muscat' and 'Chardonel') in Fennville, MI. Affected vines were stunted with shortened internodes and yellow leaves; others had dead cordons or were entirely dead. The grower reported that vines were losing vigor and collapsing during a period of 2 years. Renewal trunks would collapse during the second season of growth. Several symptomatic vines showed signs of root decay. On one vine, distinctive fruiting bodies (mazaedia) were apparent on the roots below the soil line and resembled those of Roesleria subterranea (Weinm.) Redhead (2,3,4). The mazaedia were 4 to 5 mm tall and 1 mm in diameter with white-to-tan stipes and powdery, gray-to-greenish hemispherical heads. Ascospores were hyaline to light grayish green, disk shaped, and 4 to 6 µm in diameter. This fungus, also known as R. hypogaea Thüm & Pass., has been previously reported to cause grape root rot, vine decline, and replant problems in North America and Europe (2,3,4). The fungus was cultured from ascospores on potato dextrose agar (PDA). Colonies grew slowly (approximately 2 mm per day at 22 to 24°C) and were green in the center. No spores were produced. DNA was extracted, and internal transcribed spacer (ITS) sequences obtained by PCR were compared with known sequences using BLASTn (1). Our isolate had 100% ITS sequence homology to an isolate from Germany, Roesleria subterranea strain IB (Accession No. EF060304.1). To test for pathogenicity, the fungus was grown in potato dextrose broth for 14 days at 22 to 24°C. An aqueous suspension (0.1 g of fungus per ml) was prepared by blending mycelia with sterile deionized water (SDW) in a food processor. Five two-node, rooted 'Chardonnay' cuttings (45 days old) were placed in the suspension. Five other cuttings were placed in SDW (control). After 3 h, plants were removed and repotted in fresh BACTO soil (Michigan Peat Company, Houston, TX) and kept in a growth chamber at 23°C with a 16/8-h light/dark cycle. After 25 days, inoculated plants were, on average, 63% smaller with 77% lower fresh-root weight and fewer fine roots than the control plants. The pathogen was recovered from surface-disinfested roots of all five inoculated plants but not from the control plants. Cultures appeared similar to the original isolate and their identity was confirmed by ITS sequencing. To our knowledge, this is the first report of R. subterranea on grapes in Michigan and the Midwest. This fungus needs to be recognized as a potential cause of vine decline and replant problems in Midwestern vineyards. References: (1) S. F. Altschul et al. J. Mol. Biol. 215:403, 1990. (2) W. Gärtel. Page 40 in: Compendium of Grape Diseases. R. C. Pearson and A. C. Goheen, eds. The American Phytopathological Society, St. Paul, MN, 1988. (3) M. Kirchmair et al. Mycol. Res. 112:1210, 2009. (4) J. R. Liberato et al. Pest and Diseases Image Library. Online publication, 2009.

Detection of Eutypa lata and Eutypella vitis in Grapevine by Nested Multiplex Polymerase Chain Reaction.

ABSTRACT Two fungi were isolated from grapevines in Michigan vineyards with Eutypa dieback symptoms: Eutypa lata and Eutypella vitis. These fungi are difficult to distinguish morphologically but are genetically distinct as determined by sequencing of the internal transcribed spacer (ITS) regions. The ITS regions of 25 Eutypa lata and 15 Eutypella vitis isolates were sequenced. Eutypa lata sequences were more variable than those of Eutypella vitis. Polymerase chain reaction (PCR) primers were designed for each species and evaluated against isolates of both fungi as well as 11 closely related Diatrypaceous fungi and 23 isolates of other fungi representing various pathogenic, saprophytic, and endophytic genera on grape and other small fruit crops. The primers were specific for their intended species. A nested multiplex PCR protocol was developed and used to successfully detect these fungi in wood samples from cankers with and without stromata from naturally infected vines as well as in artificially inoculated, potted canes. The primers developed in this study will assist in our abilities to diagnose and study the roles of Eutypa lata and Eutypella vitis in Eutypa dieback development.

[Three children with recurrent meningitis as the result of an anatomical defect]. / Drie kinderen met recidiverende meningitis als gevolg van een anatomische afwijking.

Three children, a 12-year-old girl, a 5-year-old boy and a 5-year-old girl, were referred with recurrent episodes of meningitis. After an immunological defect had been ruled out early in the diagnostic work-up, the cause appeared to be an anatomical defect. After surgical treatment, no further meningitis occurred. Recurrent meningitis in children is rare. Anatomical defects, congenital or acquired, in the otorhinolaryngological area are the main cause. Conscientious history taking, careful physical examination and imaging using high-definition cranial computed tomography are important in establishing the diagnosis. In order to minimise the risk of another episode of meningitis, the otorhinolaryngologist should be consulted immediately in the diagnostic and therapeutic process and this process should be completed as soon as possible.