Penicillin resistance in bovine Staphylococcus aureus: Genomic evaluation of the discrepancy between phenotypic and molecular test methods.

Staphylococcus aureus is a major pathogen in humans and animals. In cattle, it is one of the most important agents of mastitis, causing serious costs in the dairy industry. Early diagnosis and adequate therapy are therefore 2 key factors to deal with the problems caused by this bacterium, and benzylpenicillin (penicillin) is usually the first choice to treat these infections. Unfortunately, penicillin resistance testing in bovine S. aureus strains shows discrepant results depending on the test used; consequently, the best method for assessing penicillin resistance is still unknown. The aim of this study was therefore to find a method that assesses penicillin resistance in S. aureus and to elucidate the mechanisms leading to the observed discrepancies. A total of 146 methicillin-sensitive S. aureus strains isolated from bovine mastitis were tested for penicillin resistance using a broth microdilution [minimum inhibitory concentration (MIC)] and 2 different disk diffusion protocols. Furthermore, the strains were analyzed for the presence of the bla operon genes (blaI, blaR1, blaZ) by PCR, and a subset of 45 strains was also subjected to whole genome sequencing (WGS). Discrepant results were obtained when penicillin resistance of bovine S. aureus was evaluated by disk diffusion, MIC, and PCR methods. The discrepancies, however, could be fully explained by WGS analysis. In fact, it turned out that penicillin resistance is highly dependent on the completeness of the bla operon promotor: when the bla operon was complete based on WGS analysis, all strains showed MIC ≥1 µg/mL, whereas when the bla operon was mutated (31-nucleotide deletion), they were penicillin sensitive except in those strains where an additional, bla operon-independent resistance mechanism was observed. Further, WGS analyses showed that penicillin resistance is truly assessed by the MIC assay. In contrast, caution is required when interpreting disk diffusion and PCR results.

Genotypes of Staphylococcus aureus: On-farm epidemiology and the consequences for prevention of intramammary infections.

Staphylococcus aureus is a highly contagious mastitis-causing pathogen infecting dairy cattle worldwide. Previous studies have shown the presence of different genotypes (GT) on farms. In Switzerland, Staph. aureus genotype B (GTB) is contagious, whereas GTC and other genotypes cause sporadic, noncontagious mastitis. In this study, we evaluated the epidemiological properties of Staph. aureus, together with its genotypes and spa types, on Swiss dairy farms. A total of 21 dairy farms were sampled throughout Switzerland; 10 farms were positive for the contagious Staph. aureus GTB and 11 farms were negative for GTB. Samples were taken from milk, body surfaces of dairy cattle and other animals, milkers, milking equipment, and environmental sites (e.g., parlor, washing room, stall floor, manger, and bedding). The epidemiology of Staph. aureus depended markedly on the genotype. Staphylococcus aureus GTB was associated with mammary gland, intramammary infections (IMI), and milking clusters, whereas GTC and other genotypes were related to cow and other animal surfaces and occasionally to environment. Genotype C was by far the most common subtype in cattle and was found on GTB-negative and GTB-positive farms. Each farm had a predominant genotype, such as GTB, GTC, GTA, or GTF, but a few farms were almost free from Staph. aureus. The genotypes and spa types of Staph. aureus detected in the noses of milkers clearly differed from those found in dairy cattle, other animals, milking equipment, and the environment. Exceptions were GTS (spa type t034) and GTF (t899), which crossed the species barrier. In most cases, however, the species barrier was maintained because Staph. aureus is adapted to a particular host and even to particular body sites. As biological properties differ among the genotypes, new guidelines to prevent IMI caused by different genotypes were established: classical measures to prevent IMI caused by contagious pathogens still hold for GTB but not for Staph. aureus genotypes that are opportunistic colonizers of bovine skin (e.g., GTC and GTA). For those genotypes, protection of the skin from minor lesions and wounds, particularly on the hocks, is essential.

Work-family culture within hospitals: An interdepartmental analysis of employee engagement and retention.

BACKGROUND: Helping employees balance their work and family needs is increasingly pivotal for attracting, engaging, and retaining key talent in health care. Yet, emerging theory and anecdotal evidence suggest that, within organizations, there is considerable variation between departments or units regarding how employees' lives outside work are supported. Despite top management's efforts to develop a unified organizational work-family culture, departments have a tendency to take on their own culture, norms, and traditions such that some are more supportive than others. PURPOSE: We investigate whether more positive work-family cultures improve functioning within hospital departments. METHODOLOGY/APPROACH: We surveyed 680 hospital employees nested within 60 departments at a hospital located in the southeastern United States. RESULTS: Departments with a more (vs. less) positive work-family culture tend to have higher levels of (a) employee engagement, (b) pride in their organization, (c) confidence in management and leadership, and (d) intention to remain with the organization. Our analyses were robust when splitting the sample between clinical (e.g., nurses and physicians) and nonclinical (e.g., office, clerical, and support services) roles. CONCLUSION: Our study sheds further light on the importance of a positive work-family culture within hospitals. The key to instilling a positive, organization-wide work-family culture may be through a department-by-department focus. PRACTICE IMPLICATIONS: Benefits of positive work-family cultures within departments can extend beyond job-related attitudes and can potentially enhance recruitment strategies, improve a hospital's external image to the public, and lead to improvements in patient care and more positive patient experiences.

Rapid detection of viable Legionella pneumophila in tap water by a qPCR and RT-PCR-based method.

AIMS: A molecular method for a rapid detection of viable Legionella pneumophila of all serogroups in tap water samples was developed as an alternative to the reference method (ISO). Legionellae are responsible for Legionnaires' disease, a severe pneumonia in humans with high lethality. METHODS AND RESULTS: The developed method is based on a nutritional stimulation and detection of an increase in precursor 16S rRNA as an indicator for viability. For quantification, DNA was detected by qPCR. This method was compared to the ISO method using water samples obtained from public sports facilities in Switzerland. The sensitivity and specificity were 91 and 97%, respectively, when testing samples for compliance with a microbiological criterion of 1000 cell equivalents per l. CONCLUSION: The new method is sensitive and specific for Leg. pneumophila and allows results to be obtained within 8 h upon arrival, compared to one week or more by the ISO method. SIGNIFICANCE AND IMPACT OF THE STUDY: The method represents a useful tool for a rapid detection of viable Leg. pneumophila of all serogroups in water by molecular biology. It can be used as an alternative to the ISO method for official water analysis for legionellae and particularly when a short test time is required.

Sanitation of Staphylococcus aureus genotype B-positive dairy herds: A field study.

Staphylococcus aureus is one of the most widespread mastitis pathogens infecting dairy cattle worldwide. In Switzerland, different bovine genotypes of Staph. aureus have been identified, and genotype B (GTB) was demonstrated to be a highly contagious subtype, causing herd problems in cattle. As the efficacy of antibiotic therapy against Staph. aureus is not satisfactory, the most promising strategy for controlling this udder pathogen is the implementation of specific sanitation programs for affected farms. The aim of the present longitudinal study was the field evaluation of 2 analytical approaches for the sanitation of Staph. aureus GTB-positive dairy herds. We compared a new real-time quantitative PCR (qPCR) assay based on the detection of the unique target gene adlb with classical bacteriology. Sanitation was successfully achieved using both analytical methods, but the qPCR approach showed some main advantages, namely the use of clean (instead of aseptically collected) milk samples facilitates sample collection in terms of time and costs, enabling the sampling of entire herds during a regular milking procedure and by the farm staff. The high inclusivity and exclusivity of the new target gene adlb enable very specific detection of only the genotype of interest. Because of the very high diagnostic sensitivity of qPCR, each GTB-positive cow can be correctly identified at any time point during lactation, allowing farmers to continuously update milking groups to prevent transmission during milking. Milk sample analysis becomes more objective, faster, less expensive, and more suitable for routine application, enabling the sanitation of even big herds in short time.

Development of a new real-time quantitative PCR assay for the detection of Staphylococcus aureus genotype B in cow milk, targeting the new gene adlb.

The specific and reliable diagnosis of mastitis pathogens is essential for successful sanitation programs. The aim of the present study was to develop and evaluate a new real-time quantitative PCR (qPCR) assay for the very sensitive and specific detection of Staphylococcus aureus genotype B in cow milk samples. This mastitis pathogen is contagious and particularly prevalent in Switzerland and other central European countries. The new test is based on a rapid preparation of bacteria, followed by DNA isolation and qPCR for a unique target gene coding for the adhesion-like bovine protein (adlb). The inclusivity of the new target gene was 97% and the exclusivity 98%, meaning that other genotypes and bacterial species could be excluded with high reliability. The limit of detection of the new assay was 235 staphylococcal cell equivalents/mL of culture. The new test shows high intra- and interassay repeatability. Results are available within 2 d after sampling, allowing farmers and veterinarians to apply sanitation measures immediately. Based on the results of a preliminary field study, the diagnostic sensitivity and specificity of the new qPCR assay are 99 and 100%, respectively. The new analytical procedure is straightforward and can be applied for routine diagnostics.

Bovine Staphylococcus aureus: Subtyping, evolution, and zoonotic transfer.

Staphylococcus aureus is globally one of the most important pathogens causing contagious mastitis in cattle. Previous studies using ribosomal spacer (RS)-PCR, however, demonstrated in Swiss cows that Staph. aureus isolated from bovine intramammary infections are genetically heterogeneous, with Staph. aureus genotype B (GTB) and GTC being the most prominent genotypes. Furthermore, Staph. aureus GTB was found to be contagious, whereas Staph. aureus GTC and all the remaining genotypes were involved in individual cow disease. In addition to RS-PCR, other methods for subtyping Staph. aureus are known, including spa typing and multilocus sequence typing (MLST). They are based on sequencing the spa and various housekeeping genes, respectively. The aim of the present study was to compare the 3 analytic methods using 456 strains of Staph. aureus isolated from milk of bovine intramammary infections and bulk tanks obtained from 12 European countries. Furthermore, the phylogeny of animal Staph. aureus was inferred and the zoonotic transfer of Staph. aureus between cattle and humans was studied. The analyzed strains could be grouped into 6 genotypic clusters, with CLB, CLC, and CLR being the most prominent ones. Comparing the 3 subtyping methods, RS-PCR showed the highest resolution, followed by spa typing and MLST. We found associations among the methods but in many cases they were unsatisfactory except for CLB and CLC. Cluster CLB was positive for clonal complex (CC)8 in 99% of the cases and typically positive for t2953; it is the cattle-adapted form of CC8. Cluster CLC was always positive for tbl 2645 and typically positive for CC705. For CLR and the remaining subtypes, links among the 3 methods were generally poor. Bovine Staph. aureus is highly clonal and a few clones predominate. Animal Staph. aureus always evolve from human strains, such that every human strain may be the ancestor of a novel animal-adapted strain. The zoonotic transfer of IMI- and milk-associated strains of Staph. aureus between cattle and humans seems to be very limited and different hosts are not considered as a source for mutual, spontaneous infections. Spillover events, however, may happen.

Staphylococcus aureus genotype B and other genotypes isolated from cow milk in European countries.

Staphylococcus aureus is globally one of the most important pathogens causing contagious mastitis in cattle. Previous studies, however, have demonstrated in Swiss cows that Staph. aureus isolated from bovine intramammary infection is genetically heterogeneous, with Staph. aureus genotype B (GTB) and GTC being the most prominent genotypes. In addition, Staph. aureus GTB was found to be contagious, whereas Staph. aureus GTC and all the remaining genotypes were involved in individual cow disease. The aim of this study was to subtype strains of Staph. aureus isolated from bovine mastitic milk and bulk tank milk to obtain a unified view of the presence of bovine staphylococcal subtypes in 12 European countries. A total of 456 strains of Staph. aureus were subjected to different typing methods: ribosomal spacer PCR, detection of enterotoxin genes, and detection of gene polymorphisms (lukE, coa). Major genotypes with their variants were combined into genotypic clusters (CL). This study revealed 5 major CL representing 76% of all strains and comprised CLB, CLC, CLF, CLI, and CLR. The clusters were characterized by the same genetic properties as the Swiss isolates, demonstrating high clonality of bovine Staph. aureus. Interestingly, CLB was situated in central Europe whereas the other CL were widely disseminated. The remaining 24% of the strains comprised 41 genotypes and variants, some of which (GTAM, GTBG) were restricted to certain countries; many others, however, were observed only once.

A multiarm randomized field trial evaluating strategies for udder health improvement in Swiss dairy herds.

The aims of this study were to quantify the effectiveness of specialist advice about udder health in Swiss dairy herds and to compare 3 different udder health improvement strategies against a negative control group. In 2010, 100 Swiss dairy herds with a high (between 200,000 and 300,000 cells/mL) yield-corrected bulk milk somatic cell count (YCBMSCC) were recruited for a 1-yr multiarm randomized field trial. The herds were visited between September and December 2011 to evaluate udder health-management practices and then randomly allocated into 1 of 4 study arms containing 25 herds each. The negative control study arm received neither recommendations for improving udder health nor any active support. The remaining 75 farmers received a herd-specific report with recommendations to improve udder health management. The positive control study arm received no further active support during 2012. The veterinarian study arm received additional support in the form of monthly visits by their herd veterinarian. Finally, the study group study arm received support in the form of bimonthly study group meetings where different topics concerning udder health were discussed. One year later, implementation of recommendations and changes in udder health were assessed. Of the recommendations given, 44.3% were completely implemented, 23.1% partially, and 32.6% were not implemented. No differences in implementation of recommendations were noted between the 3 study arms. At study enrollment, farmers were asked for the study arm of their preference but were subsequently randomly assigned to 1 of the 4 study arms. Farmers that were assigned to the study arm of their preference implemented more recommendations than farmers assigned to a study arm not of their preference. No decrease in the within-herd prevalence of cows that had a high (≥200,000 cells/mL) composite somatic cell count was observed in herds that had a YCBMSCC ≥200,000 cells/mL at the start of intervention. However, the 3 study arms with intervention (positive control, the veterinarian, and the study groups) prevented an increase in the within-herd prevalence of cows that had a high somatic cell count in herds with a low YCBMSCC at the start of the intervention compared with the negative control study arm. In the year after sending the report, herds assigned to the study group study arm had a reduced incidence rate of treated mastitis cases in comparison with the year before sending the report.

Genotype-specific risk factors for Staphylococcus aureus in Swiss dairy herds with an elevated yield-corrected herd somatic cell count.

Bovine mastitis is a frequent problem in Swiss dairy herds. One of the main pathogens causing significant economic loss is Staphylococcus aureus. Various Staph. aureus genotypes with different biological properties have been described. Genotype B (GTB) of Staph. aureus was identified as the most contagious and one of the most prevalent strains in Switzerland. The aim of this study was to identify risk factors associated with the herd-level presence of Staph. aureus GTB and Staph. aureus non-GTB in Swiss dairy herds with an elevated yield-corrected herd somatic cell count (YCHSCC). One hundred dairy herds with a mean YCHSCC between 200,000 and 300,000cells/mL in 2010 were recruited and each farm was visited once during milking. A standardized protocol investigating demography, mastitis management, cow husbandry, milking system, and milking routine was completed during the visit. A bulk tank milk (BTM) sample was analyzed by real-time PCR for the presence of Staph. aureus GTB to classify the herds into 2 groups: Staph. aureus GTB-positive and Staph. aureus GTB-negative. Moreover, quarter milk samples were aseptically collected for bacteriological culture from cows with a somatic cell count ≥150,000cells/mL on the last test-day before the visit. The culture results allowed us to allocate the Staph. aureus GTB-negative farms to Staph. aureus non-GTB and Staph. aureus-free groups. Multivariable multinomial logistic regression models were built to identify risk factors associated with the herd-level presence of Staph. aureus GTB and Staph. aureus non-GTB. The prevalence of Staph. aureus GTB herds was 16% (n=16), whereas that of Staph. aureus non-GTB herds was 38% (n=38). Herds that sent lactating cows to seasonal communal pastures had significantly higher odds of being infected with Staph. aureus GTB (odds ratio: 10.2, 95% CI: 1.9-56.6), compared with herds without communal pasturing. Herds that purchased heifers had significantly higher odds of being infected with Staph. aureus GTB (rather than Staph. aureus non-GTB) compared with herds without purchase of heifers. Furthermore, herds that did not use udder ointment as supportive therapy for acute mastitis had significantly higher odds of being infected with Staph. aureus GTB (odds ratio: 8.5, 95% CI: 1.6-58.4) or Staph. aureus non-GTB (odds ratio: 6.1, 95% CI: 1.3-27.8) than herds that used udder ointment occasionally or regularly. Herds in which the milker performed unrelated activities during milking had significantly higher odds of being infected with Staph. aureus GTB (rather than Staph. aureus non-GTB) compared with herds in which the milker did not perform unrelated activities at milking. Awareness of 4 potential risk factors identified in this study guides implementation of intervention strategies to improve udder health in both Staph. aureus GTB and Staph. aureus non-GTB herds.

Bovine mastitis: the diagnostic properties of a PCR-based assay to monitor the Staphylococcus aureus genotype B status of a herd, using bulk tank milk.

Staphylococcus aureus genotype B (GTB) is a contagious mastitis pathogen in cattle, occurring in up to 87% of individuals. Because treatment is generally insufficient, culling is often required, leading to large economic loss in the Swiss dairy industry. As the detection of this pathogen in bulk tank milk (BTM) would greatly facilitate its control, a novel real-time quantitative PCR-based assay for BTM has previously been developed and is now being evaluated for its diagnostic properties at the herd level. Herds were initially classified as to their Staph. aureus GTB status by a reference method. Using BTM and herd pools of single-quarter and 4-quarter milk, the herds were then grouped by the novel assay, and the resulting classifications were compared. A total of 54 dairy herds were evaluated. Using the reference method, 21 herds were found to be GTB positive, whereas 33 were found to be negative. Considering the novel assay using both herd pools, all herds were grouped correctly, resulting in maximal diagnostic sensitivities (100%) and specificities (100%). For BTM samples, diagnostic sensitivities and specificities were 90 and 100%, respectively. Two herds were false negative in BTM, because cows with clinical signs of mastitis were not milked into the tank. Besides its excellent diagnostic properties, the assay is characterized by its low detection level, high efficiency, and its suitability for automation. Using the novel knowledge and assay, eradication of Staph. aureus GTB from a dairy herd may be considered as a realistic goal.

Mastitis diagnostics: quantitative PCR for Staphylococcus aureus genotype B in bulk tank milk.

A novel real-time quantitative PCR assay for detecting the pathogenic and contagious Staphylococcus aureus genotype B (GTB) in bulk tank milk was developed and evaluated. The detection of this pathogen in bulk tank milk would greatly facilitate its control, as it is responsible for great economic loss in Swiss dairy herds. The assay is based on the simultaneous detection of 3 GTB-typical target sequences, including 2 enterotoxin genes and a polymorphism within the leucotoxin E gene. A variety of mastitis-associated bacteria was used to validate the assays, resulting in an analytical specificity of 100% and high repeatability. The analytical sensitivity in milk was 40 cfu/mL. An exponential association between simulated cow prevalence and quantitative PCR result was observed. An initial field study revealed 1 GTB-positive herd among the 33 studied herds. This novel assay for bulk tank milk analysis is suitable for routine purposes and is expected to be an effective tool for minimizing Staph. aureus GTB in Swiss dairy herds.

Minimizing deviant behavior in healthcare organizations: the effects of supportive leadership and job design.

In an era when healthcare organizations are beset by intense competition, lawsuits, and increased administrative costs, it is essential that employees perform their jobs efficiently and without distraction. Deviant workplace behavior among healthcare employees is especially threatening to organizational effectiveness, and healthcare managers must understand the antecedents of such behavior to minimize its prevalence. Deviant employee behavior has been categorized into two major types, individual and organizational, according to the intended target of the behavior. Behavior directed at the individual includes such acts as harassment and aggression, whereas behavior directed at the organization includes such acts as theft, sabotage, and voluntary absenteeism, to name a few (Robinson and Bennett 1995). Drawing on theory from organizational behavior, we examined two important features of supportive leadership, leader-member exchange (LMX) and perceived organizational support (POS), and two important features of job design, intrinsic motivation and depersonalization, as predictors of subsequent deviant behavior in a sample of over 1,900 employees within a large US healthcare organization. Employees who reported weaker perceptions of LMX and greater perceptions of depersonalization were more likely to engage in deviant behavior directed at the individual, whereas employees who reported weaker perceptions of POS and intrinsic motivation were more likely to engage in deviant behavior directed at the organization. These findings give rise to specific prescriptions for healthcare managers to prevent or minimize the frequency of deviant behavior in the workplace.

The impact of participative management perceptions on customer service, medical errors, burnout, and turnover intentions.

Numerous challenges confront managers in the healthcare industry, making it increasingly difficult for healthcare organizations to gain and sustain a competitive advantage. Contemporary management challenges in the industry have many different origins (e.g., economic, financial, clinical, and legal), but there is growing recognition that some of management's greatest problems have organizational roots. Thus, healthcare organizations must examine their personnel management strategies to ensure that they are optimized for fostering a highly committed and productive workforce. Drawing on a sample of 2,522 employees spread across 312 departments within a large U.S. healthcare organization, this article examines the impact of a participative management climate on four employee-level outcomes that represent some of the greatest challenges in the healthcare industry: customer service, medical errors, burnout, and turnover intentions. This study provides clear evidence that employee perceptions of the extent to which their work climate is participative rather than authoritarian have important implications for critical work attitudes and behavior. Specifically, employees in highly participative work climates provided 14 percent better customer service, committed 26 percent fewer clinical errors, demonstrated 79 percent lower burnout, and felt 61 percent lower likelihood of leaving the organization than employees in more authoritarian work climates. These findings suggest that participative management initiatives have a significant impact on the commitment and productivity of individual employees, likely improving the patient care and effectiveness of healthcare organizations as a whole.

Communicating prognosis with parents of critically ill infants: direct observation of clinician behaviors.

OBJECTIVE: Delivering prognostic information to families requires clinicians to forecast an infant's illness course and future. We lack robust empirical data about how prognosis is shared and how that affects clinician-family concordance regarding infant outcomes. STUDY DESIGN: Prospective audiorecording of neonatal intensive care unit family conferences, immediately followed by parent/clinician surveys. Existing qualitative analysis frameworks were applied. RESULTS: We analyzed 19 conferences. Most prognostic discussion targeted predicted infant functional needs, for example, medications or feeding. There was little discussion of how infant prognosis would affect infant/family quality of life. Prognostic framing was typically optimistic. Most parents left the conference believing their infant's prognosis to be more optimistic than did clinicians. CONCLUSIONS: Clinician approach to prognostic disclosure in these audiotaped family conferences tended to be broad and optimistic, without detail regarding implications of infant health for infant/family quality of life. Families and clinicians left these conversations with little consensus about infant prognosis.

Palliative care in neonatal neurology: robust support for infants, families and clinicians.

Infants with neurological injury and their families face unique challenges in the neonatal intensive care unit. As specialty palliative care support becomes increasingly available, we must consider how to intentionally incorporate palliative care principles into the care of infants with neurological injury. Here, we review data regarding neonatal symptom management, prognostic uncertainty, decision making, communication and parental support for neonatal neurology patients and their families.

Management of defoliation in Trifolium vesiculosum S. for the production of seeds / [Manejo da desfolha em Trifolium vesiculosum Savi para a produção de sementes]

The present study aims to determine the appropriate defoliation management for the production of seeds and forage in arrowleaf clover via trail analysis. The results obtained demonstrated that defoliation practices have a great influence on the composition of seed yield and germination power. In addition, when the goal is the maximum balance between dry matter production and seed yield, this can be achieved in up to two defoliation practices. These results are confirmed by analyzing the positive association between the weight of a thousand seeds and the seed yield. When the third defoliation practice is performed, it negatively correlates with the weight of a thousand seeds, suggesting that, with the increase in defoliation frequency, there is a lower weight of a thousand seeds, and, therefore, lower seed yield. Therefore, management planning in Trifolium vesiculosum Savi that aims at natural reseeding, maximum yield and seed germination must prioritize one to two defoliation practices, aiming to promote favorable conditions for the perennialization of the species. In this context, the trail analysis proved to be a useful tool as a criterion for obtaining the ideal management aiming at the production of seeds and forage in vesicular clover.(AU)

O presente estudo visa determinar o manejo de desfolha adequado para a produção de sementes e de forragem em trevo-vesiculoso via análise de trilha. Os resultados obtidos demonstraram que as práticas de desfolha possuem grande influência na composição do rendimento de sementes e no poder germinativo. Além disso, quando o objetivo for o máximo equilíbrio entre a produção de matéria seca e o rendimento de sementes, esse pode ser alcançado em até duas práticas de desfolha. Esses resultados são confirmados ao se analisar a associação positiva entre o peso de mil sementes e o rendimento de sementes. Quando realizada a terceira prática de desfolha, esta se correlaciona negativamente com o peso de mil sementes, sugerindo que, com o aumento da frequência de desfolha, ocorre menor peso de mil sementes e, por conseguinte, menor rendimento de sementes. Portanto, o planejamento do manejo em T. vesiculosum Savi que objetive a ressemeadura natural, o máximo rendimento e a germinação de sementes deve priorizar até duas práticas de desfolha, visando promover condições favoráveis para a perenização da espécie. Nesse contexto, a análise de trilha demonstrou ser uma ferramenta útil como critério para obtenção do manejo ideal visando à produção de sementes e de forragem em trevo-vesiculoso.(AU)

Menopausal hormone therapy: physician awareness of patient attitudes.

BACKGROUND: Physicians need to be aware of their patients' attitudes toward menopause when counseling women regarding hormone therapy, because menopausal attitudes may affect women's satisfaction with their decisions to use or not to use hormone therapy. Our objectives were to assess physician awareness of patient attitudes on issues surrounding the menopause and hormone therapy, and to determine the prevalence and correlates of hormone use. METHODS: This cross-sectional survey study was conducted in the primary care outpatient practices of an academic medical center. Surveys were simultaneously administered to female patients aged 50 to 70 years (n = 182) and their primary care physicians immediately after clinical encounters. The surveys contained questions from four established (five-point) attitudinal scales (autonomy, desire for information, philosophy of the menopause, barriers to use of hormone therapy), and questions addressing patients' degree of concern about developing various conditions. Physicians were asked to estimate their patients' attitudes. PATIENTS AND METHODS: Physicians were generally aware of patients' desire for autonomy (3.2 versus 3.2, P = 1.0), but tended to underestimate patients' desire for information (3.7 versus 4.5, P = 0.0001) and patients' perceptions of barriers to using hormone therapy (3.2 versus 3.4, P = 0.0001). They also underestimated the extent to which patients view menopause as a medical problem (3.0 versus 3.2, P = 0.0001). Physicians overestimated patients' general concern about heart disease (scale difference 0.40, P = 0.0001) and breast cancer (difference 0.23, P = 0.02). Physicians were less aware of their patients' attitudes when they were male (versus female), interns/residents (versus faculty/fellows), and less knowledgeable about menopausal hormone therapy (versus more knowledgeable). The significant predictors of hormone use on multivariate analysis were past hysterectomy, urinary incontinence, alcohol intake, and possession of knowledge regarding hormone therapy. CONCLUSIONS: Physicians incorrectly estimate some aspects of their patients' attitudes regarding menopause and hormone therapy, and certain physician characteristics may be associated with decreased awareness. To optimize hormone therapy counseling, physicians may need to increase their attention to patients' menopausal attitudes.

Differential effects of the selective D2-antagonist raclopride in the nucleus accumbens of the rat on spontaneous and d-amphetamine-induced activity.

The effect of the D2-antagonist raclopride was investigated in two test situations, which are presumed to involve dopamine (DA) transmission within the nucleus accumbens of the rat. Local injection of d-amphetamine sulphate (10 micrograms/0.5 microliter) produced a marked increase in motor activity, measured as motility, locomotion, and rearing, which was dose- and time-dependently antagonised by local injection of raclopride (0.05-5.0 micrograms/0.5 microliter). After an initial decrease, at low doses (0.05-0.25 microgram/0.5 microliter) an apparent enhancement of the d-amphetamine-induced motor activity appeared, which was most clearly seen with rearing. These lower doses, however, did not induce any clear changes in the exploratory activity in a novel environment (i.e., the second test situation). Only the higher doses used (1.0-5.0 micrograms/0.5 microliter) decreased exploratory activity during the first 5-10 min, also measured as motility, locomotion, and rearing. These data are discussed with respect to the role of D2-receptors within the nucleus accumbens of rats in the motor activity induced by a novel environment and d-amphetamine. Overall, the data underline previous notions that raclopride is a potent antagonist of DA-mediated behaviour.

Burnout and its correlates in emergency physicians: four years' experience with a wellness booth.

OBJECTIVE: To measure the degree of burnout among emergency physicians (EPs) and to identify and rank predictive factors. METHODS: Using the Maslach Burnout Inventory as well as a 79-item questionnaire, a cross-sectional survey was conducted for physician registrants at the Annual Scientific Assemblies of the American College of Emergency Physicians from 1992 to 1995. Degrees of burnout were stratified into low, moderate, and high ranges. Univariate and stepwise multiple regression analyses were conducted to identify and rank correlates to burnout scores. RESULTS: Of 1,272 registrants taking the inventory, 60% registered in the moderate to high burnout ranges. Twenty-one correlates were identified. These were classified broadly in terms of negative perceptions of self, negative practice habits and attitudes, and unhealthy lifestyles. The most highly ranked correlates were: self-recognition of burnout, lack of job involvement, negative self-assessment of productivity, dissatisfaction with career, sleep disturbances, increased number of shifts per month, dissatisfaction with specialty services, intent to leave the practice within 10 years, higher levels of alcohol consumption, and lower levels of exercise. Age and years of practice were not significant predictors of burnout. Projected attrition rates were 7.5% over 5 years and 25% over 10 years. CONCLUSIONS: Elevated levels of burnout exist among a substantial percentage of surveyed EPs. However, there is evidence for a "survivor" category of practitioners for whom burnout either does not develop or is a reversible process. The projected attrition rate over 5 and 10 years appears to be no greater than that of the average medical specialty.