Factors influencing diabetes-related foot ulcer healing in Australian adults: A prospective cohort study.

OBJECTIVE: Diabetes-related foot ulceration (DFU) is a common limb-threatening condition, which is complex and subsequently challenging to manage. The aim of this study was to determine the contribution of a range of clinical and social factors to the healing of diabetes-related foot ulceration in an Australian population. RESEARCH DESIGN AND METHODS: This was a prospective cohort study of individuals with diabetes-related foot ulceration (DFU). Age, sex, medical history, medications, dietary supplementation (e.g. vitamin C intake) and smoking history were elicited at baseline. The index of relative socio-economic disadvantage (IRSD) was calculated. The Australian Eating Survey and International Physical Activity Questionnaire-short were administered. Wound history, size, grade, time to healing and infection were captured and monitored over 6 months. Logistic regression was performed to determine the relationship between healing and diet quality, toe systolic pressure, wound size at, IRSD, infection and previous amputation. RESULTS: A total of 117 participants were included. The majority were male n = 96 (82%), socio-economically disadvantaged (mean IRSD 965, SD 60), and obese (BMI 36 kg/m2 , SD 11) with a long history of diabetes (20 years, SD 11). Wounds were predominantly neuropathic (n = 85, 73%) and classified 1A (n = 63, 54%) on the University of Texas wound classification system with few infections (n = 23, 16%). Dietary supplementation was associated with 4.36 increased odds of healing (95% 1.28-14.84, p = 0.02), and greater levels of socio-economic advantage were also associated with increased odds of healing (OR 1.01, 95% CI 1.01-1.02, p = 0.03). CONCLUSIONS: In this cohort study of predominantly neuropathic, non-infected DFU, individuals who had greater levels of socio-economic advantage had significantly greater odds of DFU healing. Diet quality was poor in most participants, with individuals taking supplementation significantly more likely to heal.

qPCR Assays for Sensitive and Rapid Detection of Quambalaria Species from Plant Tissues.

Several species from the genus Quambalaria (order Microstromatales) cause diseases on eucalypts (Eucalyptus and related genera) both in plantations and natural ecosystems. We developed real-time quantitative PCR (qPCR) assays to rapidly detect and distinguish five Quambalaria species. The design of the species-specific qPCR assay for each species, Q. pitereka (PIT), Q. coyrecup (COR), Q. cyanescens (CYN), Q. pusilla (PUS), and Q. eucalypti (EUC), was based on the ITS region and was evaluated for specificity and sensitivity. The PIT, COR, and CYN qPCR assays could amplify as little as 10 fg µl-1 from pure cultures, whereas PUS and EUC qPCR assays could amplify 100 fg µl-1 of their target species. The PIT, COR, and CYN qPCR assays were further validated using naturally and artificially infected samples of their plant host Corymbia calophylla. These assays will be used for rapid diagnostics and future experiments on the infection process.

A qPCR Assay for the Detection of Phytophthora cinnamomi Including an mRNA Protocol Designed to Establish Propagule Viability in Environmental Samples.

Phytophthora cinnamomi causes root and collar rot in many plant species in natural ecosystems and horticulture. A species-specific primer and probe PCIN5 were designed based on a mitochondrial locus encoding subunit 2 of cytochrome c oxidase (cox2). Eight PCR primers, including three forward and five reverse, were designed and tested in all possible combinations. Annealing temperatures were optimized for each primer pair set to maximize both specificity and sensitivity. Each set was tested against P. cinnamomi and two closely related clade 7 species, P. parvispora and P. niederhauseri. From these tests, five primer pairs were selected based on specificity and, with a species-specific P. cinnamomi probe, used to develop quantitative real-time PCR (qPCR) assays. The specificity of the two most sensitive qPCR assays was confirmed using the genomic DNA of 29 Phytophthora isolates, including 17 isolates of 11 species from clade 7, and representative species from nine other clades (all except clade 3). The assay was able to detect as little as 150 ag of P. cinnamomi DNA and showed no cross-reaction with other Phytophthora species, except for P. parvispora, a very closely related species to P. cinnamomi, which showed late amplification at high DNA concentrations. The efficiency of the qPCR protocol was evaluated with environmental samples including roots and associated soil from plants artificially infected with P. cinnamomi. Different RNA isolation kits were tested and evaluated for their performance in the isolation of RNA from environmental samples, followed by cDNA synthesis, and qPCR assay. Finally, a protocol was recommended for determining the presence of P. cinnamomi in recalcitrant environmental samples.

Current and projected global distribution of Phytophthora cinnamomi, one of the world's worst plant pathogens.

Globally, Phytophthora cinnamomi is listed as one of the 100 worst invasive alien species and active management is required to reduce impact and prevent spread in both horticulture and natural ecosystems. Conversely, there are regions thought to be suitable for the pathogen where no disease is observed. We developed a climex model for the global distribution of P. cinnamomi based on the pathogen's response to temperature and moisture and by incorporating extensive empirical evidence on the presence and absence of the pathogen. The climex model captured areas of climatic suitability where P. cinnamomi occurs that is congruent with all available records. The model was validated by the collection of soil samples from asymptomatic vegetation in areas projected to be suitable by the model for which there were few records. DNA was extracted, and the presence or absence of P. cinnamomi was determined by high-throughput sequencing (HTS). While not detected using traditional isolation methods, HTS detected P. cinnamomi at higher elevations in eastern Australia and central Tasmania as projected by the climex model. Further support for the climex model was obtained using the large data set from south-west Australia where the proportion of positive records in an area is related to the Ecoclimatic Index value for the same area. We provide for the first time a comprehensive global map of the current P. cinnamomi distribution, an improved climex model of the distribution, and a projection to 2080 of the distribution with predicted climate change. This information provides the basis for more detailed regional-scale modelling and supports risk assessment for governments to plan management of this important soil-borne plant pathogen.

A nurse extern simulation experience through an innovative hospital-college partnership.

Nursing students in Gwinnett Hospital System's summer Nurse Extern Program participated in an innovative initiative that promoted critical thinking, prioritization, and teamwork. A collegial partnership between the Gwinnett Hospital System Learning Resources Department and the Georgia Perimeter College Department of Nursing used simulation as a patient care teaching methodology. Simulation may be one methodology that hospital-college partnerships can pursue in developing and achieving nursing excellence in future nurses.

Comparison of Primers for the Detection of Phytophthora (and Other Oomycetes) from Environmental Samples.

Many oomycetes are important plant pathogens that cause devastating diseases in agricultural fields, orchards, urban areas, and natural ecosystems. Limitations and difficulties associated with isolating these pathogens have led to a strong uptake of DNA metabarcoding and mass parallel sequencing. At least 21 primer combinations have been designed to amplify oomycetes, or more specifically, Phytophthora species, from environmental samples. We used the Illumina sequencing platform to compare 13 primer combinations on mock communities and environmental samples. The primer combinations tested varied significantly in their ability to amplify Phytophthora species in a mock community and from environmental samples; this was due to either low sensitivity (unable to detect species present in low concentrations) or a lack of specificity (an inability to amplify some species even if they were present in high concentrations). Primers designed for oomycetes underestimated the Phytophthora community compared to Phytophthora-specific primers. We recommend using technical replicates, primer combinations, internal controls, and a phylogenetic approach for assigning a species identity to OTUs or ASVs. Particular care must be taken if sampling substrates where hybrid species could be expected. Overall, the choice of primers should depend upon the hypothesis being tested.

A loop-mediated isothermal amplification (LAMP) assay for the detection of Cryptotermes brevis West Indian drywood termite (Blattodea: Kalotermitidae).

Cryptotermes brevis is one of the most destructive invasive termites in the subtropics and tropics and is a common biosecurity intercept at the Australian border. Drywood termite species are cryptic and difficult to identify morphologically in situations when soldiers or imagos are unavailable. We developed a novel DNA based loop-mediated isothermal amplification (LAMP) assay to detect C. brevis and differentiate it from other drywood termites. Validated voucher specimens of 30 different drywood termite species were obtained from several insect collections from which DNA was extracted and amplified. The amplicons containing partial mitochondrial 16S rRNA were sequenced and a DNA database was created from which C. brevis LAMP primers were developed, optimized, and tested. The assay was assessed against a range of target and non-target species and found to be specific, successfully amplifying the target specimens of C. brevis in under 30 min. Amplification success was variable against C. brevis faecal pellets due to minute, unmeasurable or degraded DNA. This LAMP test is a new tool for the rapid detection of C. brevis that will enable faster and less destructive management of drywood termite infestations.

Perceptions of Diet Quality, Advice, and Dietary Interventions in Individuals with Diabetes-Related Foot Ulceration; A Qualitative Research Study.

BACKGROUND: Dietary intake is a recognised contributor to healing in diabetes-related foot ulceration (DFU). However, it is currently unknown how individuals with DFU perceive their diet, and what is deemed an acceptable dietary intervention. Therefore, the aims of this study were to explore perceptions of diet quality, previous dietary advice, and dietary interventions in individuals with DFU, and secondly to determine acceptable dietary interventions in individuals with DFU to assist with wound healing. METHODS: A qualitative study using reflexive thematic analysis was undertaken. Individuals with active or recent history of DFU were recruited from a high-risk foot service. Semi-structured interviews were undertaken. RESULTS: Nineteen participants were included with three themes identified: A complex relationship with food, perceptions of food, diet and dietitians, and self-management. Dietary misconceptions were common. Self-perceived diet quality varied, with most unaware of how diet could impact wound healing. Many expressed barriers relating to food agency (purchasing, preparing, and accessing food). Participants expressed a strong preference for personalised, face-to-face dietary advice and nutritional supplementation. CONCLUSIONS: There is a need for personalised dietary re-education and assistance with food agency in this cohort to overcome commonly held misconceptions of diet and improve dietary intake to facilitate wound healing.

EEG artifacts in the intensive care unit setting.

Obtaining a quality EEG in the intensive care unit (ICU) is a very rewarding experience for the EEG technologist. "Quality" is defined as a measure of excellence or state of being free from defects. It takes more than knowing how to obtain a quality record; it takes hands-on experience and time. Electroencephalography is a valuable neurodiagnostic tool in critically ill patients. However, the ICU is a challenging environment to obtain a high quality EEG tracing because artifacts are exceedingly common. Dealing with artifact effectively is an essential function of the EEG technologist. The goal of this paper is to review both physiological and nonphysiological artifacts commonly encountered in an ICU setting. How to recognize, troubleshoot, and prove that an EEG pattern is an artifact will be reviewed for the novice EEG technologist.

Re-evaluation of Phytophthora Species Isolated During 30 Years of Vegetation Health Surveys in Western Australia Using Molecular Techniques.

For 30 years, large-scale aerial photography has been used to map the extent of Phytophthora dieback disease in native forests in the southwest of Western Australia, with validation of the observations involving routine testing of soil and root samples for the presence of Phytophthora cinnamomi. In addition to P. cinnamomi, six morpho-species have been identified using this technique: P. citricola, P. megasperma, P. cryptogea, P. drechsleri, P. nicotianae, and P. boehmeriae. In recent years, many new Phytophthora species have been described worldwide, often with similar morphology to existing species; thus, as many of the isolates collected in Western Australia have been difficult to identify based on morphology, molecular identification of the morpho-species is required. Based on amplification of the internal transcribed spacer (ITS) region of the rDNA gene, sequence data of more than 230 isolates were compared with those of existing species and undescribed taxa. P. inundata, P. asparagi, P. taxon PgChlamydo, P. taxon personii, and P. taxon niederhauserii were identified based on sequence data. Phylogenetic analysis revealed that nine potentially new and undescribed taxa can be distinguished. Several of the new taxa are morphologically indistinguishable from species such as P. citricola, P. drechsleri, and P. megasperma. In some cases, the new taxa are closely related to species with similar morphology (e.g., P.sp.4 and P. citricola). However, the DNA sequences of other new taxa such as P.sp.3 and P.sp.9 show that they are not closely related to morphologically similar species P. drechsleri and P. megasperma, respectively. Most of the new taxa have been associated with dying Banksia spp., while P.sp.2 and P.sp.4 have also been isolated from dying Eucalyptus marginata (jarrah). Some taxa (P.sp.3, 6, and 7) appear to have limited distribution, while others like P.sp.4 are widespread.

Sensitivities of nasal and rectal swabs for detection of methicillin-resistant Staphylococcus aureus colonization in an active surveillance program.

All medical and high-risk surgical patients were screened for methicillin-resistant Staphylococcus aureus colonization over 3.5 years. The sensitivities of nasal and rectal swabs were 68% and 62%, respectively. Naris and open-skin-site swabs detected 467 (74%) of 627 adult carriers identified. Rectal swabs detected an additional 160 (26%) carriers.

eDNA from roots: a robust tool for determining Phytophthora communities in natural ecosystems.

Proper isolation and identification of Phytophthora species is critical due to their broad distribution and huge impact on natural ecosystems throughout the world. In this study, five different sites were sampled and seven methods were compared to determine the Phytophthora community. Three traditional isolation methods were conducted (i) soil baiting, (ii) filtering of the bait water and (iii) isolation from field roots using Granny Smith apples. These were compared to four sources of eDNA used for metabarcoding using Phytophthora-specific primers on (i) sieved field soil, (ii) roots from field, (iii) filtered baiting water and (iv) roots from bait plants grown in the glasshouse in soil collected from these sites. Six Phytophthora species each were recovered by soil baiting using bait leaves and from the filtered bait water. No Phytophthora species were recovered from Granny Smith apples. eDNA extracted from field roots detected the highest number of Phytophthora species (25). These were followed by direct DNA isolation from filters (24), isolation from roots from bait plants grown in the glasshouse (19), and DNA extraction from field soil (13). Therefore, roots were determined to be the best substrate for detecting Phytophthora communities using eDNA.

Clozapine (Clozaril), seizures, and EEG abnormalities.

The antipsychotic agent clozapine (ClozarilE) is reserved for the treatment of refractory psychosis. Clozapine has allowed many schizophrenic patients to lead more independent and productive lives, but its use is restricted by side effects. Clozapine has been shown to lower seizure threshold and produce significant EEG changes. Although not a commonly used drug, both clinical neurophysiology technologists and interpreting electroencephalographers need to be aware of the effects of clozapine on the EEG. We review the findings of two patients who developed neurological symptoms and EEG abnormalities that resolved following reduction of clozapine therapy.

A nosocomial outbreak of community-associated methicillin-resistant Staphylococcus aureus among healthy newborns and postpartum mothers.

BACKGROUND: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has increasingly been isolated from individuals with no predisposing risk factors; however, such strains have rarely been linked to outbreaks in the hospital setting. The present study describes the investigation of an outbreak of CA-MRSA that occurred in the maternal-newborn unit of a large community teaching hospital in Toronto, Ontario. METHODS: Screening and clinical specimens collected from mothers and newborns delivered during the outbreak period, as well as from staff on the affected unit, were submitted for microbiological testing. Computerized delivery logs and nursing notes were reviewed, and a case control study was conducted. RESULTS: Analysis by pulsed-field gel electrophoresis revealed 38 babies and seven mothers with MRSA colonization and/or infection by the same unique strain (Canadian MRSA-10-related) from September to December 2004. Isolates were characterized as having the staphylococcal chromosome cassette mec type IVa and were positive for the Panton-Valentine leukocidin gene. No one health care worker was associated with all cases; however, mothers and newborns exposed to one particular nurse (Nurse A) were almost 23 times (odds ratio 22.7, 95% CI 3.3 to 195.9) more likely to acquire MRSA than those with no such contact. MRSA was successfully isolated from Nurse A and from an environmental swab of a telephone recently used by Nurse A; both isolates matched the pulsed-field gel electrophoresis pattern of the outbreak strain. CONCLUSION: The first nosocomial outbreak of CA-MRSA among healthy newborns and postpartum mothers in Canada is described. Effective control of sustained MRSA transmission within an institution may require prompt identification, treatment and monitoring of colonized and/or infected staff.

Pathways to false-positive diagnoses using molecular genetic detection methods; Phytophthora cinnamomi a case study.

Phytophthora cinnamomi is one of the world's most invasive plant pathogens affecting ornamental plants, horticultural crops and natural ecosystems. Accurate diagnosis is very important to determine the presence or absence of this pathogen in diseased and asymptomatic plants. In previous studies, P. cinnamomi species-specific primers were designed and tested using various polymerase chain reaction (PCR) techniques including conventional PCR, nested PCR and quantitative real-time PCR. In all cases, the primers were stated to be highly specific and sensitive to P. cinnamomi. However, few of these studies tested their primers against closely related Phytophthora species (Phytophthora clade 7). In this study, we tested these purported P. cinnamomi-specific primer sets against 11 other species from clade 7 and determined their specificity; of the eight tested primer sets only three were specific to P. cinnamomi. This study demonstrated the importance of testing primers against closely related species within the same clade, and not just other species within the same genus. The findings of this study are relevant to all species-specific microbial diagnosis.

Sequelae of Occult Aggression Disqualifying Young, Socially Housed, Female New Zealand White Rabbits (Oryctolagus cuniculus) from Participation in Dermal Toxicology Studies.

International animal welfare organizations and federal, regional, and institutional oversight bodies encourage social housing of gregarious species, such as New Zealand white rabbits (Oryctolagus cuniculus), to promote animal wellbeing in research, teaching, testing and farming settings. At our institution, 2 groups of female New Zealand white rabbits (approximate age, 11 wk; mean weight, 2.35 kg), compatibly paired at the vendor for 5 wk, were paired in caging or group-housed in a floor pen. The rabbits appeared compatible, demonstrating primarily affiliative behaviors throughout 6 wk of daily observations. However, occult aggression that occurred between daily observations or nocturnally resulted in skin wounding. The skin injuries, first identified during prestudy clipping of fur from the back of each rabbit 6 wk after arrival, disqualified every animal from participation in skin toxicology and muscle implantation studies. Success meeting scientific research requirements while promoting animal welfare and health when socially housing New Zealand white rabbits requires examining the behavioral repertoire of their wild counterparts, European rabbits. Factors including age, sex, and housing density influence territoriality, dominance hierarchy, social ranking, and natural, agonistic, injurious, behavioral tendencies. IACUC and other relevant oversight bodies, researchers, and animal care staff should consider this case study and the species-specific natural history of New Zealand white rabbits when assessing the harm and benefit of social housing in regard to research utility and animal welfare.

Healthcare Antibiotic Resistance Prevalence - DC (HARP-DC): A Regional Prevalence Assessment of Carbapenem-Resistant Enterobacteriaceae (CRE) in Healthcare Facilities in Washington, District of Columbia.

OBJECTIVE Carbapenem-resistant Enterobacteriaceae (CRE) are a significant clinical and public health concern. Understanding the distribution of CRE colonization and developing a coordinated approach are key components of control efforts. The prevalence of CRE in the District of Columbia is unknown. We sought to determine the CRE colonization prevalence within healthcare facilities (HCFs) in the District of Columbia using a collaborative, regional approach. DESIGN Point-prevalence study. SETTING This study included 16 HCFs in the District of Columbia: all 8 acute-care hospitals (ACHs), 5 of 19 skilled nursing facilities, 2 (both) long-term acute-care facilities, and 1 (the sole) inpatient rehabilitation facility. PATIENTS Inpatients on all units excluding psychiatry and obstetrics-gynecology. METHODS CRE identification was performed on perianal swab samples using real-time polymerase chain reaction, culture, and antimicrobial susceptibility testing (AST). Prevalence was calculated by facility and unit type as the number of patients with a positive result divided by the total number tested. Prevalence ratios were compared using the Poisson distribution. RESULTS Of 1,022 completed tests, 53 samples tested positive for CRE, yielding a prevalence of 5.2% (95% CI, 3.9%-6.8%). Of 726 tests from ACHs, 36 (5.0%; 95% CI, 3.5%-6.9%) were positive. Of 244 tests from long-term-care facilities, 17 (7.0%; 95% CI, 4.1%-11.2%) were positive. The relative prevalence ratios by facility type were 0.9 (95% CI, 0.5-1.5) and 1.5 (95% CI, 0.9-2.6), respectively. No CRE were identified from the inpatient rehabilitation facility. CONCLUSION A baseline CRE prevalence was established, revealing endemicity across healthcare settings in the District of Columbia. Our study establishes a framework for interfacility collaboration to reduce CRE transmission and infection. Infect Control Hosp Epidemiol 2017;38:921-929.

Understanding of asthma management: Medicaid parents' perspectives.

OBJECTIVE: This article explores parental caregiver perspectives on barriers to asthma care in the Medicaid system. METHODS: Focus groups were held for parents of children with persistent asthma to identify barriers to asthma care for children insured by Medicaid in the Ypsilanti, MI area. Semistructured questions regarding health goals, asthma care, and access were used. Themes were defined as distinct categories or concepts regarding aspects of asthma care and coded. RESULTS: Thirty-six adults participated in four focus groups, 89% were the biological mother, and 64% were African American. Major themes identified included caregiver emotions, caregiver/patient knowledge, environmental issues, school/daycare support, Medicaid health-care system issues, the role of medical providers, and emerging adolescence. Parents demonstrated asthma awareness but were not confident in their role as the child's disease manager. A specific gap was seen in the caregiver's level of self-efficacy to control exposure to asthma triggers, monitor the child's symptoms, and modify medications based on asthma symptoms. CONCLUSION: Medicaid-insured families face unique barriers related to income and insurance limitations as well as issues common to others with asthma. Caregivers demonstrated a high level of asthma knowledge, but like other caregivers gaps between knowledge and behavior existed. Barriers to asthma care that may be specific to Medicaid-insured patients included difficulty maintaining continuity of care due to physician participation in Medicaid programs, and concerns about possible differences in asthma care from health-care providers due to their Medicaid insurance status.

Asthma educational seminar targeting Medicaid providers.

BACKGROUND: Medicaid-insured children have high risk of asthma but are less likely to receive care in keeping with national guidelines. We targeted providers who care for a large proportion of Medicaid-insured children and presented a 2-session multimedia asthma-education seminar that emphasizes communication and teaching techniques, to enhance providers' asthma-care teaching skills. METHODS: Five Medicaid-approved health maintenance organizations recruited pediatric primary-care providers. Providers were surveyed at baseline, 6 months, and 12 months to determine if they reported changes in their use of certain asthma-care communication techniques. RESULTS: Fifty-three of 70 participating providers completed the program and initial survey. They reported that 50% (median) of their patients were insured by Medicaid. At baseline, providers reported they were very confident of their asthma knowledge; however, they were less confident in interactions with patients/families regarding asthma self-management skills. Providers reported use of written plans less than half of the time. The response rate was 60% at 6 months and 71% at 1 year. Twenty-eight providers completed all 3 surveys. They reported significantly more frequent use of communication and counseling techniques that involved patient/parent asthma education and self-management skills at the 6-month point, that were partly sustained at 1 year. Reported provision of written asthma plans to patients had increased significantly at 6 months, but that increase was not sustained at the 1-year point. CONCLUSIONS: The seminar significantly enhanced knowledge of specific communication techniques related to asthma-teaching goals and reported use of asthma action plans to enhance self-management skills; however, these practices appear to need frequent reinforcement.

Improving physician attendance at educational seminars sponsored by Managed Care Organizations.

PURPOSE: To enhance primary care provider participation in a multi-faceted interactive asthma teaching program sponsored by managed care organizations. DESIGN: Case series of six MCO-sponsored continuing medical education (CME) sessions. METHODOLOGY: MCOs were provided with a standard set of recruitment materials. The MCO disease management divisions invited pediatric primary care providers of several types to attend the asthma teaching sessions and tracked the type of contacts employed and the success rate. Participants were awarded CME and were provided with a meal to encourage attendance. The faculty included a local physician-leader and a regional asthma expert. The sessions were scheduled by the MCO, but were given by the study group using a previously developed curriculum that emphasized material endorsed by the National Heart Lung and Blood Institute. Direct costs were tracked. PRINCIPAL FINDINGS: Overall, 53 of 299 (18 percent) providers participated in the two-part asthma CME sessions. Recruitment was significantly more successful when a physician leader participated in solicitation of providers (P < .01). Successful recruitment generally necessitated two points of contact, and phone contact appeared to yield greater success than e-mail. Scheduling conflicts and inconvenient location were the most common reasons given for not attending the seminars. Ninety percent of providers who attended the first session completed the program. The average direct cost per provider was dollar 370. CONCLUSION: Even when offering primary care providers a multifaceted interactive asthma-teaching program, physician recruitment necessitates personal and multiple contacts, and careful planning in terms of seminar location, time, and content. Interactive physician education seminars necessitate a large investment of resources but may be cost-effective if care is improved.