The Global Epidemic of Bactrocera Pests: Mixed-Species Invasions and Risk Assessment.

Throughout the past century, the global spread of Bactrocera pests has continued to pose a significant threat to the commercial fruit and vegetable industry, resulting in substantial costs associated with both control measures and quarantine restrictions. The increasing volume of transcontinental trade has contributed to an escalating rate of Bactrocera pest introductions to new regions. To address the worldwide threat posed by this group of pests, we first provide an overview of Bactrocera. We then describe the global epidemic, including border interceptions, species diagnosis, population genetics, geographical expansion, and invasion tracing of Bactrocera pests. We further consider the literature concerning the invasion co-occurrences, life-history flexibility, risk assessment, bridgehead effects, and ongoing implications of invasion recurrences, as well as a case study of Bactrocera invasions of California. Finally, we call for global collaboration to effectively monitor, prevent, and control the ongoing spread of Bactrocera pests and to share experience and knowledge to combat it.

"Take care of their hierarchy of needs first": strategies used by data-to-care staff to address barriers to HIV care engagement.

Data-to-Care (D2C) is a public health strategy designed to engage out-of-care (OOC) persons with HIV (PWH) in HIV care. OOC PWH are identified through review of state and local HIV data and engaged in care through individualized efforts that address barriers to HIV care. Perspectives of D2C program staff can contribute to D2C program development and sustainability. We conducted semi-structured interviews in 2017 with 20 D2C program staff from Louisiana (n = 10) and Virginia (n = 10), states with distinct D2C programs. We used content and thematic analysis to analyze interview transcripts. In both states, common barriers to care for OOC PWH include limited transportation, stigma, substance use, poverty, homelessness, and mental illness. To address these barriers and engage OOC clients in HIV care, staff and programs provided transportation vouchers and housing assistance, integrated substance use and mental health services into care engagement processes, provided empathy and compassion, and assessed and addressed basic unmet needs. Identifying and addressing social and structural barriers to HIV care is a critical and often a necessary first step in engaging OOC clients in HIV care. These findings can be used for D2C program design and implementation, facilitating engagement in HIV care for OOC PWH.

Obesity and sex influence fatty infiltration of the rotator cuff: the Rotator Cuff Outcomes Workgroup (ROW) and Multicenter Orthopaedic Outcomes Network (MOON) cohorts.

BACKGROUND: Fatty infiltration (FI) is one of the most important prognostic factors for outcomes after rotator cuff surgery. Established risk factors include advancing age, larger tear size, and increased tear chronicity. A growing body of evidence suggests that sex and obesity are associated with FI; however, data are limited. METHODS: We recruited 2 well-characterized multicenter cohorts of patients with rotator cuff tears (Multicenter Orthopaedic Outcomes Network [MOON] cohort [n = 80] and Rotator Cuff Outcomes Workgroup [ROW] cohort [n = 158]). We used multivariable logistic regression to evaluate the relationship between body mass index (BMI) and the presence of FI while adjusting for the participant's age at magnetic resonance imaging, sex, and duration of shoulder symptoms, as well as the cross-sectional area of the tear. We analyzed the 2 cohorts separately and performed a meta-analysis to combine estimates. RESULTS: A total of 27 patients (33.8%) in the Multicenter Orthopaedic Outcomes Network (MOON) cohort and 57 patients (36.1%) in the Rotator Cuff Outcomes Workgroup (ROW) cohort had FI. When BMI < 25 kg/m2 was used as the reference category, being overweight was associated with a 2.37-fold (95% confidence interval [CI], 0.77-7.29) increased odds of FI and being obese was associated with a 3.28-fold (95% CI, 1.16-9.25) increased odds of FI. Women were 4.9 times (95% CI, 2.06-11.69) as likely to have FI as men. CONCLUSIONS: Among patients with rotator cuff tears, obese patients had a substantially higher likelihood of FI. Further research is needed to assess whether modifying BMI can alter FI in patients with rotator cuff tears. This may have significant clinical implications for presurgical surgical management of rotator cuff tears. Sex was also significantly associated with FI, with women having higher odds of FI than men. Higher odds of FI in female patients may also explain previously reported early suboptimal outcomes of rotator cuff surgery and higher pain levels in female patients as compared with male patients.

Improving HIV medical care engagement by attending to status disclosure and social support.

Expeditious linkage and consistent engagement in medical care is important for people with HIV's (PWH) health. One theory on fostering linkage and engagement involves HIV status disclosure to mobilize social support. To assess disclosure and social support's association with linkage and engagement, we conducted a qualitative study sampling black and Latino men who have sex with men (MSM of color) in the U.S. Participants' narratives presented mixed results. For instance, several participants who reported delaying, inconsistent access, or detachment from care also reported disclosing for support purposes, yet sporadic engagement suggests that their disclosure or any subsequent social support have not assisted. The findings contribute to the literature that questions disclosure and social support's influence on care engagement, especially when decontextualized from circumstances and intentions. Our findings suggest the mechanics of disclosure and social support require planned implementation if intending to affect outcomes, especially among MSM of color. From the findings, we explore steps that may bolster interventions seeking to anchor medical care engagement.

The impact of wrong-site surgery on dental undergraduate teaching: a survey of UK dental schools.

INTRODUCTION: Patient safety within dental education is paramount. Wrong-site surgery (WSS) tooth extraction is not uncommon and is a significant never event (NE) in dentistry. This study aimed to explore dental schools' undergraduate experience of NEs, safety interventions implemented and the impact on student experience. METHODS: All 16 UK dental schools were surveyed via email. RESULTS: The response rate was 100%. A modified World Health Organization (WHO) checklist was used within institutions (94%) including pre-operative briefings and recording teeth on whiteboards (81%, respectively). Students were directly supervised performing extractions (63%) utilising a 1:4 staff: student ratio. WSS by students was reported in 69% of schools, with student experience being impacted by an increased patient safety focus. DISCUSSION: This study demonstrated an increased utilisation of an adapted WHO checklist. Modification of practices to ensure patient safety was demonstrated at all schools, irrespective of student WSS occurrences. Institutions experiencing student NEs commonly implemented WHO checklists and recording teeth for extraction on whiteboards. Other strategies included direct staff supervision and pre-operative briefings. CONCLUSION: UK dental schools have increased the emphasis on patient safety by the implementation of national healthcare models, for example WHO checklists and pre-operative briefings. These strategies both aim to improve communication and teamwork. Increased levels of staff supervision foster greater quality of teaching; however, this has resulted in reduced student clinical experience. A proposed minimum standard for undergraduate surgery is suggested to ensure safe and competent dental practitioners of the future.

Differential response to larval crowding of a long- and a short-lived medfly biotype.

Response of endophytic fruit fly species (Tephritidae) to larval crowding is a form of scramble competition that may affect important life history traits of adults, such as survival and reproduction. Recent empirical evidence demonstrates large differences in adult life history traits, especially longevity, among Mediterranean fruit fly (Ceratitis capitata; "medfly") biotypes obtained from different regions of the world. However, whether the evolution of long lifespan is associated with response to stress induced by larval crowding has not been fully elucidated. We investigated, under constant laboratory conditions, the response of a short- and a long-lived medfly biotypes to stress induced by larval crowding. Survival and development of larvae and pupae and the size of resulting pupae were recorded. The lifespan and age-specific egg production patterns of the obtained adults were recorded. Our findings reveal that increased larval density reduced immature survival (larvae and pupae) in the short-lived biotype but had rather neutral effects on the longed-lived one. Only larvae of the long-lived biotype were capable of prolonging their developmental duration under the highest crowding regime to successfully pupate and emerge as adults. Response of emerging adults to larvae crowding conditions was similar in the two medfly biotypes. Those individuals emerging from high larval density regimes had reduced longevity and fecundity. Long-lived biotype individuals, however, appeared to suffer a higher cost in longevity compared with the short-lived one. The importance of our findings to understand the evolution of long lifespan is discussed.

Quantifying the effects of species traits on predation risk in nature: A comparative study of butterfly wing damage.

Evading predators is a fundamental aspect of the ecology and evolution of all prey animals. In studying the influence of prey traits on predation risk, previous researchers have shown that crypsis reduces attack rates on resting prey, predation risk increases with increased prey activity, and rapid locomotion reduces attack rates and increases chances of surviving predator attacks. However, evidence for these conclusions is nearly always based on observations of selected species under artificial conditions. In nature, it remains unclear how defensive traits such as crypsis, activity levels and speed influence realized predation risk across species in a community. Whereas direct observations of predator-prey interactions in nature are rare, insight can be gained by quantifying bodily damage caused by failed predator attacks. We quantified how butterfly species traits affect predation risk in nature by determining how defensive traits correlate with wing damage caused by failed predation attempts, thereby providing the first robust multi-species comparative analysis of predator-induced bodily damage in wild animals. For 34 species of fruit-feeding butterflies in an African forest, we recorded wing damage and quantified crypsis, activity levels and flight speed. We then tested for correlations between damage parameters and species traits using comparative methods that account for measurement error. We detected considerable differences in the extent, location and symmetry of wing surface loss among species, with smaller differences between sexes. We found that males (but not females) of species that flew faster had substantially less wing surface loss. However, we found no correlation between cryptic coloration and symmetrical wing surface loss across species. In species in which males appeared to be more active than females, males had a lower proportion of symmetrical wing surface loss than females. Our results provide evidence that activity greatly influences the probability of attacks and that flying rapidly is effective for escaping pursuing predators in the wild, but we did not find evidence that cryptic species are less likely to be attacked while at rest.

The failure of success: cyclic recurrences of a globally invasive pest.

In the six decades since 1960, the oriental fruit fly, Bactrocera dorsalis (Hendel), has been announced successfully eradicated in California by the U.S. Department of Agriculture a total of 564 times. This includes eradication declarations in one city a total of 25 different years, in 12 cities 8-19 different years, and in 101 cities 2-7 different years. We here show that the false negatives in declaring elimination success hinge on the easily achieved regulatory criteria, which have virtually guaranteed the failure of complete extirpation of this pest. Analyses of the time series of fly detection over California placed on a grid of 100-km2 cells revealed (1) partial success of the eradication program in controlling the invasion of the oriental fruit fly; (2) low prevalence of the initial detection in these cells is often followed by high prevalence of recurrences; (3) progressively shorter intervals between years of consecutive detections; and (4) high likelihood of early-infested cells also experiencing the most frequent outbreaks. Facing the risk of recurrent invasions, such short-term eradication programs have only succeeded annually according to the current regulatory criteria but have failed to achieve the larger goal of complete extirpation of the oriental fruit fly. Based on the components and running costs of the current programs, we further estimated the efficiency of eradication programs with different combinations of eradication radius, duration, and edge impermeability in reducing invasion recurrences and slowing the spread of the oriental fruit fly. We end with policy implications including the need for agricultural agencies worldwide to revisit eradication protocols in which monitoring and treatments are terminated when the regulatory criteria for declaring eradication are met. Our results also have direct implications to invasion biologists and agriculture policy makers regarding long-term risks of short-term expediency.

On the Three Properties of Stationary Populations and Knotting with Non-stationary Populations.

A population is considered stationary if the growth rate is zero and the age structure is constant. It thus follows that a population is considered non-stationary if either its growth rate is nonzero and/or its age structure is non-constant. We propose three properties that are related to the stationary population identity (SPI) of population biology by connecting it with stationary populations and non-stationary populations which are approaching stationarity. One of these important properties is that SPI can be applied to partition a population into stationary and non-stationary components. These properties provide deeper insights into cohort formation in real-world populations and the length of the duration for which stationary and non-stationary conditions hold. The new concepts are based on the time gap between the occurrence of stationary and non-stationary populations within the SPI framework that we refer to as Oscillatory SPI and the Amplitude of SPI.

Epidemiology of the Frequency, Etiology, Direction, and Severity (FEDS) system for classifying glenohumeral instability.

HYPOTHESIS: The purpose of this multicenter epidemiologic study was to determine the distribution of patients within the Frequency, Etiology, Direction, and Severity (FEDS) classification system to determine which categories are of clinical importance. METHODS: Shoulder instability patients were identified using International Classification of Diseases, Ninth Revision coding data from 3 separate institutions from 2005-2010. Data were collected retrospectively. Details of instability were recorded in accordance with the FEDS classification system. Each patient was assigned a classification within the FEDS system. After all patients were assigned to a group, each group was individually analyzed and compared with the other groups. RESULTS: There are a total of 36 possible combinations within the FEDS system. Only 16 categories were represented by at least 1% of our patient population. Six categories captured at least 5% of all patients with shoulder instability. Only 2 categories represented greater than 10% of the population: solitary, traumatic, anterior dislocation, with 95 patients (24.8%), and occasional, traumatic, anterior dislocation, with 63 patients (16.4%). CONCLUSIONS: There are 16 categories within the FEDS classification that are clinically significant. Solitary, traumatic, anterior dislocation and occasional, traumatic, anterior dislocation were the most frequently observed in our cohort.

Home-based transcranial direct current stimulation plus tracking training therapy in people with stroke: an open-label feasibility study.

BACKGROUND: Transcranial direct current stimulation (tDCS) is an effective neuromodulation adjunct to repetitive motor training in promoting motor recovery post-stroke. Finger tracking training is motor training whereby people with stroke use the impaired index finger to trace waveform-shaped lines on a monitor. Our aims were to assess the feasibility and safety of a telerehabilitation program consisting of tDCS and finger tracking training through questionnaires on ease of use, adverse symptoms, and quantitative assessments of motor function and cognition. We believe this telerehabilitation program will be safe and feasible, and may reduce patient and clinic costs. METHODS: Six participants with hemiplegia post-stroke [mean (SD) age was 61 (10) years; 3 women; mean (SD) time post-stroke was 5.5 (6.5) years] received five 20-min tDCS sessions and finger tracking training provided through telecommunication. Safety measurements included the Digit Span Forward Test for memory, a survey of symptoms, and the Box and Block test for motor function. We assessed feasibility by adherence to treatment and by a questionnaire on ease of equipment use. We reported descriptive statistics on all outcome measures. RESULTS: Participants completed all treatment sessions with no adverse events. Also, 83.33% of participants found the set-up easy, and all were comfortable with the devices. There was 100% adherence to the sessions and all recommended telerehabilitation. CONCLUSIONS: tDCS with finger tracking training delivered through telerehabilitation was safe, feasible, and has the potential to be a cost-effective home-based therapy for post-stroke motor rehabilitation. TRIAL REGISTRATION: NCT02460809 (ClinicalTrials.gov).

Improving Linkage, Retention, and Reengagement in HIV Care in 12 Metropolitan Areas.

The Centers for Disease Control and Prevention developed the Enhanced Comprehensive HIV Prevention Planning (ECHPP) project to support 12 health departments' improvement of their HIV prevention and care portfolios in response to new national guidelines. We systematically analyzed 3 years of progress reports to learn how grantees put into practice local intervention strategies intended to link people to, and keep them in, HIV care. All grantees initiated seven activities to support these strategies: (1) improve surveillance data systems, (2) revise staffing duties and infrastructures, (3) update policies and procedures, (4) establish or strengthen partnerships, (5) identify persons not in care, (6) train personnel, and (7) create ways to overcome obstacles to receiving care. Factors supporting ECHPP grantee successes were thorough planning, attention to detail, and strong collaboration among health department units, and between the health department and external stakeholders. Other jurisdictions may consider adopting similar strategies when planning and enhancing HIV linkage, retention, and reengagement efforts in their areas. ECHPP experiences, lessons learned, and best practices may be relevant when applying new public health policies that affect community and health care practices jurisdiction-wide.

Reactivity Study of Unsymmetrical ß-Diketiminato Copper(I) Complexes: Effect of the Chelating Ring.

ß-Diketiminato copper(I) complexes play important roles in bioinspired catalytic chemistry and in applications to the materials industry. However, it has been observed that these complexes are very susceptible to disproportionation. Coordinating solvents or Lewis bases are typically used to prevent disproportionation and to block the coordination sites of the copper(I) center from further decomposition. Here, we incorporate this coordination protection directly into the molecule in order to increase the stability and reactivity of these complexes and to discover new copper(I) binding motifs. Here we describe the synthesis, structural characterization, and reactivity of a series of unsymmetrical N-aryl-N'-alkylpyridyl ß-diketiminato copper(I) complexes and discuss the structures and reactivity of these complexes with respect to the length of the pyridyl arm. All of the aforementioned unsymmetrical ß-diketiminato copper(I) complexes bind CO reversibly and are stable to disproportionation. The binding ability of CO and the rate of pyridyl ligand decoordination of these copper(I) complexes are directly related to the competition between the degree of puckering of the chelate system and the steric demands of the N-aryl substituent.

Quantifying functionals of age distributions in the wild by solving an operator equation.

Residual demography is a recent concept that has proved to be a useful tool to gain insights about the age distributions of wild populations, especially insects. We develop an operator equation that permits the derivation of functionals of the age distribution in wild populations, such as mean age, within the framework of residual demography. Our method combines information from an observed captive cohort, which consists of subjects that are sampled from the wild with unknown ages and then raised in the laboratory until death, and from a reference cohort that consists of subjects raised in the laboratory since birth of the same population. Targeting functionals such as the mean of the wild age distribution has the advantage of avoiding strong assumptions such as stationarity and stability of the population that one would need when targeting the entire survival distribution in the wild. Our main result characterizes the existence of a solution of the operator equation that yields the functional of interest. The proposed method also enjoys straightforward and easy implementation. A data example is included illustrating an application, where one aims to attain the mean age of mosquitoes in the wild, based on seasonal captive cohorts from Greece and a simulated reference cohort, separately for various summer and fall months.

The Surgical Management of Osteochondritis Dissecans of the Knee in the Skeletally Immature: A Survey of the Pediatric Orthopaedic Society of North America (POSNA) Membership.

BACKGROUND: While the characteristics of osteochondritis dissecans (OCD) of the knee that require surgery to heal have been described, several surgical techniques/procedures exist with no consensus established regarding timing of treatment and specific surgical intervention. In this study, we aim to determine current trends in surgical treatment for OCD lesions in the skeletally immature who have failed 6 months of nonoperative management by surveying a large cohort of orthopaedic surgeons. METHODS: An electronic survey designed using REDCap to capture surgeon treatment preferences for OCD lesions was distributed to members of the Pediatric Orthopaedic Society of North America (POSNA). The survey inquired about treating physicians' training and demographics. It then offered a series of clinical vignettes alongside imaging describing patients with varying degrees of severity of OCD following nonoperative treatment. Surgeons were prompted to select from a variety of multiple-choice-based options for further patient management. Standard descriptive statistics were used to summarize and compare the responses. RESULTS: Of the 129 POSNA members completing the pediatric survey, 97.7% were attending level orthopaedic surgeons, the majority identifying with an academic institution and treating mostly skeletally immature patients. In the skeletally immature population, the majority would treat intact, stable OCD lesions with drilling in a retroarticular or transarticular manner. Preferred treatment for unstable, salvageable lesions was screw fixation using bioabsorble materials or metal with variable pitch with no bone graft. The majority of respondents would treat unstable, unsalvageable OCD lesions with chondroplasty and osteochondral transplant/transfer or microfracture/drilling. CONCLUSIONS: The POSNA membership appears to agree on principle in terms of treatment modalities for various stages of OCD lesions in the skeletally immature, whereas individual techniques of achieving these principles may vary. Members endorse drilling for stable intact lesions; fixation for unstable, salvageable lesions; and "defect fill" for unsalvageable lesions. CLINICAL SIGNIFICANCE: OCD surgical treatment patterns can be used in future studies to determine which techniques are most effective for given indications, with the goal of designing a research-proven optimal treatment regimen for skeletally immature patients.

HIV provider and patient perspectives on the Development of a Health Department "Data to Care" Program: a qualitative study.

BACKGROUND: U.S. health departments have not historically used HIV surveillance data for disease control interventions with individuals, but advances in HIV treatment and surveillance are changing public health practice. Many U.S. health departments are in the early stages of implementing "Data to Care" programs to assists persons living with HIV (PLWH) with engaging in care, based on information collected for HIV surveillance. Stakeholder engagement is a critical first step for development of these programs. In Seattle-King County, Washington, the health department conducted interviews with HIV medical care providers and PLWH to inform its Data to Care program. This paper describes the key themes of these interviews and traces the evolution of the resulting program. METHODS: Disease intervention specialists conducted individual, semi-structured qualitative interviews with 20 PLWH randomly selected from HIV surveillance who had HIV RNA levels >10,000 copies/mL in 2009-2010. A physician investigator conducted key informant interviews with 15 HIV medical care providers. Investigators analyzed de-identified interview transcripts, developed a codebook of themes, independently coded the interviews, and identified codes used most frequently as well as illustrative quotes for these key themes. We also trace the evolution of the program from 2010 to 2015. RESULTS: PLWH generally accepted the idea of the health department helping PLWH engage in care, and described how hearing about the treatment experiences of HIV seropositive peers would assist them with engagement in care. Although many physicians were supportive of the Data to Care concept, others expressed concern about potential health department intrusion on patient privacy and the patient-physician relationship. Providers emphasized the need for the health department to coordinate with existing efforts to improve patient engagement. As a result of the interviews, the Data to Care program in Seattle-King County was designed to incorporate an HIV-positive peer component and to ensure coordination with HIV care providers in the process of relinking patients to care. CONCLUSIONS: Health departments can build support for Data to Care efforts by gathering input of key stakeholders, such as HIV medical and social service providers, and coordinating with clinic-based efforts to re-engage patients in care.

2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears.

BACKGROUND: The purpose of this study is to help define the indications for rotator cuff repair by identifying predictors of failure of nonoperative treatment. METHODS: A prospective, multicenter, cohort study design was used. All patients with full-thickness rotator cuff tears on magnetic resonance imaging were offered participation. Baseline data from this cohort were used to examine risk factors for failing a standard rehabilitation protocol. Patients who underwent surgery were defined as failing nonoperative treatment. A Cox proportional hazards model was fit to determinethe baseline factors that predicted failure. The dependent variable was time to surgery. The independent variables were tear severity and baseline patient factors: age, activity level, body mass index, sex, Single Assessment Numeric Evaluation score, visual analog scale score for pain, education, handedness, comorbidities, duration of symptoms, strength, employment, smoking status, and patient expectations. RESULTS: Of the 433 subjects in this study, 87 underwent surgery with 93% follow-up at 1 year and 88% follow-up at 2 years. The median age was 62 years, and 49% were female patients. Multivariate modeling, adjusted for the covariates listed previously, identified patient expectations regarding physical therapy (P < .0001) as the strongest predictor of surgery. Higher activity level (P = .011) and not smoking (P = .023) were also significant predictors of surgery. CONCLUSION: A patient's decision to undergo surgery is influenced more by low expectations regarding the effectiveness of physical therapy than by patient symptoms or anatomic features of the rotator cuff tear. As such, patient symptoms and anatomic features of the chronic rotator cuff tear may not be the best features to use when deciding on surgical intervention.

Interhemispheric Inhibition Measurement Reliability in Stroke: A Pilot Study.

OBJECTIVE: Reliable transcranial magnetic stimulation (TMS) measures for probing corticomotor excitability are important when assessing the physiological effects of noninvasive brain stimulation. The primary objective of this study was to examine test-retest reliability of an interhemispheric inhibition (IHI) index measurement in stroke. MATERIALS AND METHODS: Ten subjects with chronic stroke (≥6 months) completed two IHI testing sessions per week for three weeks (six testing sessions total). A single investigator measured IHI in the contra-to-ipsilesional primary motor cortex direction and in the opposite direction using bilateral paired-pulse TMS. Weekly sessions were separated by 24 hours with a 1-week washout period separating testing weeks. To determine if motor-evoked potential (MEP) quantification method affected measurement reliability, IHI indices computed from both MEP amplitude and area responses were found. Reliability was assessed with two-way, mixed intraclass correlation coefficients (ICC(3,k) ). Standard error of measurement and minimal detectable difference statistics were also determined. RESULTS: With the exception of the initial testing week, IHI indices measured in the contra-to-ipsilesional hemisphere direction demonstrated moderate to excellent reliability (ICC = 0.725-0.913). Ipsi-to-contralesional IHI indices depicted poor or invalid reliability estimates throughout the three-week testing duration (ICC= -1.153-0.105). The overlap of ICC 95% confidence intervals suggested that IHI indices using MEP amplitude vs. area measures did not differ with respect to reliability. CONCLUSIONS: IHI indices demonstrated varying magnitudes of reliability irrespective of MEP quantification method. Several strategies for improving IHI index measurement reliability are discussed.

Focal hand dystonia: individualized intervention with repeated application of repetitive transcranial magnetic stimulation.

OBJECTIVES: To examine for individual factors that may predict response to inhibitory repetitive transcranial magnetic stimulation (rTMS) in focal hand dystonia (FHD); to present the method for determining optimal stimulation to increase inhibition in a given patient; and to examine individual responses to prolonged intervention. DESIGN: Single-subject design to determine optimal parameters to increase inhibition for a given subject and to use the selected parameters once per week for 6 weeks, with 1-week follow-up, to determine response. SETTING: Clinical research laboratory. PARTICIPANTS: A volunteer sample of subjects with FHD (N = 2). One participant had transcranial magnetic stimulation responses indicating impaired inhibition, and the other had responses within normative limits. INTERVENTIONS: There were 1200 pulses of 1-Hz rTMS delivered using 4 different stimulation sites/intensity combinations: primary motor cortex at 90% or 110% of resting motor threshold (RMT) and dorsal premotor cortex (PMd) at 90% or 110% of RMT. The parameters producing the greatest within-session increase in cortical silent period (CSP) duration were then used as the intervention. MAIN OUTCOME MEASURES: Response variables included handwriting pressure and velocity, subjective symptom rating, CSP, and short latency intracortical inhibition and facilitation. RESULTS: The individual with baseline transcranial magnetic stimulation responses indicating impaired inhibition responded favorably to the repeated intervention, with reduced handwriting force, an increase in the CSP, and subjective report of moderate symptom improvement at 1-week follow-up. The individual with normative baseline responses failed to respond to the intervention. In both subjects, 90% of RMT to the PMd produced the greatest lengthening of the CSP and was used as the intervention. CONCLUSIONS: An individualized understanding of neurophysiological measures can be an indicator of responsiveness to inhibitory rTMS in focal dystonia, with further work needed to determine likely responders versus nonresponders.