Prescribed fire increases plant-pollinator network robustness to losses of rare native forbs.

Restoration efforts often focus on changing the composition and structure of invaded plant communities, with two implicit assumptions: (1) functional interactions with species of other trophic levels, such as pollinators, will reassemble automatically when native plant diversity is restored and (2) restored communities will be more resilient to future stressors. However, the impact of restoration activities on pollinator richness, plant-pollinator interaction network structure, and network robustness is incompletely understood. Leveraging a restoration chronosequence in Pacific Northwest prairies, we examined the effects of restoration-focused prescribed fire and native forb replanting on floral resources, pollinator visitation, and plant-pollinator network structure. We then simulated the effects of plant species loss/removal scenarios on secondary extinction cascades in the networks. Specifically, we explored three management-relevant plant loss scenarios (removal of an abundant exotic forb, removal of an abundant forb designated a noxious weed, and loss of the rarest native forb) and compared them to control scenarios. Pyrodiversity and proportion of area recently burned increased the abundance and diversity of floral resources, with concomitant increases in pollinator visitation and diversity. Pyrodiversity also decreased network connectance and nestedness, increased modularity, and buffered networks against secondary extinction cascades. Rare forbs contributed disproportionately to network robustness in less restored prairies, while removal of typical "problem" plants like exotic and noxious species had relatively small impacts on network robustness, particularly in prairies with a long history of restoration activities. Restoration actions aimed mainly at improving the diversity and abundance of pollinator-provisioning plants may also produce plant-pollinator networks with increased resilience to plant species losses.

Wildfires Influence Mercury Transport, Methylation, and Bioaccumulation in Headwater Streams of the Pacific Northwest.

The increasing frequency and severity of wildfires are among the most visible impacts of climate change. However, the effects of wildfires on mercury (Hg) transformations and bioaccumulation in stream ecosystems are poorly understood. We sampled soils, water, sediment, in-stream leaf litter, periphyton, and aquatic invertebrates in 36 burned (one-year post fire) and 21 reference headwater streams across the northwestern U.S. to evaluate the effects of wildfire occurrence and severity on total Hg (THg) and methylmercury (MeHg) transport and bioaccumulation. Suspended particulate THg and MeHg concentrations were 89 and 178% greater in burned watersheds compared to unburned watersheds and increased with burn severity, likely associated with increased soil erosion. Concentrations of filter-passing THg were similar in burned and unburned watersheds, but filter-passing MeHg was 51% greater in burned watersheds, and suspended particles in burned watersheds were enriched in MeHg but not THg, suggesting higher MeHg production in burned watersheds. Among invertebrates, MeHg in grazers, filter-feeders, and collectors was 33, 48, and 251% greater in burned watersheds, respectively, but did not differ in shredders or predators. Thus, increasing wildfire frequency and severity may yield increased MeHg production, mobilization, and bioaccumulation in headwaters and increased transport of particulate THg and MeHg to downstream environments.

Community-Level Factors are Predictors of Severe Maternal Morbidity Among American Indian and Alaska Native Pregnant People in the Pacific Northwest in a Multilevel Logistic Regression.

INTRODUCTION: American Indian/Alaska Native (AI/AN) pregnant people face barriers to health and healthcare that put them at risk of pregnancy complications. Rates of severe maternal morbidity (SMM) among Indigenous pregnant people are estimated to be twice that of non-Hispanic White (NHW) pregnant people. METHODS: Race-corrected Oregon Hospital Discharge and Washington Comprehensive Hospital Abstract Reporting System data were combined to create a joint dataset of births between 2012 and 2016. The analytic sample was composed of 12,535 AI/AN records and 313,046 NHW records. A multilevel logistic regression was used to assess the relationship between community-level, individual and pregnancy risk factors on SMM for AI/AN pregnant people. RESULTS: At the community level, AI/AN pregnant people were more likely than NHW to live in mostly or completely rural counties with low median household income and high uninsured rates. They were more likely to use Medicaid, be in a high-risk age category, and have diabetes or obesity. During pregnancy, AI/AN pregnant people were more likely to have insufficient prenatal care (PNC), gestational diabetes, and pre-eclampsia. In the multilevel model, county accounted for 6% of model variance. Hypertension pre-eclampsia, and county rurality were significant predictors of SMM among AI/AN pregnant people. High-risk age, insufficient PNC and a low county insured rate were near-significant at p < 0.10. DISCUSSION: Community-level factors are significant contributors to SMM risk for AI/AN pregnant people in addition to hypertension and pre-eclampsia. These findings demonstrate the need for targeted support in pregnancy to AI/AN pregnant people, particularly those who live in rural and underserved communities.

What is already known on this subject? American Indian and Alaska Native pregnant people face higher rates of severe maternal morbidity and mortality, and the risk is exacerbated for rural Indigenous pregnant people.What this study adds? This publication uses a multilevel model to assess the contribution of community-level factors in severe maternal morbidity risk for American Indian and Alaska Native pregnant people. This analysis highlights the important role that rurality, prenatal care adequacy and access to insurance play in maternal morbidity risk and discusses how those risks are disproportionately felt by American Indian and Alaska Native pregnant people in the Pacific Northwest.

Invader removal triggers competitive release in a threatened avian predator.

Changes in the distribution and abundance of invasive species can have far-reaching ecological consequences. Programs to control invaders are common but gauging the effectiveness of such programs using carefully controlled, large-scale field experiments is rare, especially at higher trophic levels. Experimental manipulations coupled with long-term demographic monitoring can reveal the mechanistic underpinnings of interspecific competition among apex predators and suggest mitigation options for invasive species. We used a large-scale before-after control-impact removal experiment to investigate the effects of an invasive competitor, the barred owl (Strix varia), on the population dynamics of an iconic old-forest native species, the northern spotted owl (Strix occidentalis caurina). Removal of barred owls had a strong, positive effect on survival of sympatric spotted owls and a weaker but positive effect on spotted owl dispersal and recruitment. After removals, the estimated mean annual rate of population change for spotted owls stabilized in areas with removals (0.2% decline per year), but continued to decline sharply in areas without removals (12.1% decline per year). The results demonstrated that the most substantial changes in population dynamics of northern spotted owls over the past two decades were associated with the invasion, population expansion, and subsequent removal of barred owls. Our study provides experimental evidence of the demographic consequences of competitive release, where a threatened avian predator was freed from restrictions imposed on its population dynamics with the removal of a competitively dominant invasive species.

Quantifying contributions of natural variability and anthropogenic forcings on increased fire weather risk over the western United States.

Previous studies have identified a recent increase in wildfire activity in the western United States (WUS). However, the extent to which this trend is due to weather pattern changes dominated by natural variability versus anthropogenic warming has been unclear. Using an ensemble constructed flow analogue approach, we have employed observations to estimate vapor pressure deficit (VPD), the leading meteorological variable that controls wildfires, associated with different atmospheric circulation patterns. Our results show that for the period 1979 to 2020, variation in the atmospheric circulation explains, on average, only 32% of the observed VPD trend of 0.48 ± 0.25 hPa/decade (95% CI) over the WUS during the warm season (May to September). The remaining 68% of the upward VPD trend is likely due to anthropogenic warming. The ensemble simulations of climate models participating in the sixth phase of the Coupled Model Intercomparison Project suggest that anthropogenic forcing explains an even larger fraction of the observed VPD trend (88%) for the same period and region. These models and observational estimates likely provide a lower and an upper bound on the true impact of anthropogenic warming on the VPD trend over the WUS. During August 2020, when the August Complex "Gigafire" occurred in the WUS, anthropogenic warming likely explains 50% of the unprecedented high VPD anomalies.

Genetic Diversity Analysis of Anisogramma anomala in the Pacific Northwest and New Jersey.

Anisogramma anomala, a biotrophic ascomycete, causes eastern filbert blight (EFB) of hazelnuts (Corylus spp.). EFB is endemic in eastern North America, preventing the commercial production of European hazelnut (C. avellana L.). In contrast, the historic absence of A. anomala in the Pacific Northwest (PNW) supported the development of a robust hazelnut industry. Circa 1960, A. anomala was inadvertently introduced into southwestern Washington, causing orchard devastation. Distribution of the pathogen in the PNW has been hypothesized to be the result of a single-point introduction. This study aimed to investigate the single-point introduction hypothesis of A. anomala by comparing the genetic diversity of A. anomala samples from the PNW and New Jersey (NJ). Specimens from the main PNW production region (n = 60) and an area within the pathogen's native range, NJ (n = 151), were genotyped using 15 simple sequence repeat (SSR) markers. The following were used to assess genetic diversity and population structure: allelic summary statistics, discriminant analysis of principal components, network median-joining tree, analysis of multilocus genotypes, and allelic population diversity analysis. Analyses separated the samples into one cluster containing all the PNW isolates, and five clusters of NJ isolates. The PNW samples were nearly genetically uniform, and the NJ isolates were diverse. These findings support the hypothesis that A. anomala in the PNW was derived from a single-point introduction and corroborate previous studies that have shown A. anomala is very diverse in NJ. This indicates that maintaining restrictions on the movement of Corylus into the PNW is important to prevent the introduction of new populations of A. anomala, thus protecting the PNW hazelnut industry.

An ecosystem approach to mentoring research faculty in schools of nursing: The pacific northwest interdependence mentoring model.

BACKGROUND: Mentoring can facilitate faculty career development and retention. Given ongoing challenges in academic nursing (e.g., shrinking number of experienced mentors), it is necessary to revisit and improve upon existing mentoring models and practices to support current and future nurse researchers. PURPOSE: To describe the development of a new faculty-to-faculty research mentoring model. METHODS: Construction of a model describing mentoring needed by research-focused nurse faculty based on analysis of the literature alongside the authors' personal experiences. FINDINGS: The Pacific Northwest Interdependence Mentoring Model (PIMM) describes academic nursing as an ecosystem that fosters caring, trust, solidarity, equity, openness, and interdependent relationships among research faculty, administration, institutions, and funding sources. DISCUSSION: Although mentoring environments differ in unique strengths, weaknesses, mission, culture, and values, the PIMM's approach could be applicable for many schools of nursing and beyond to support the growth of the nursing discipline.

Density-dependent habitat selection alters drivers of population distribution in northern Yellowstone elk.

Although it is well established that density dependence drives changes in organismal abundance over time, relatively little is known about how density dependence affects variation in abundance over space. We tested the hypothesis that spatial trade-offs between food and safety can change the drivers of population distribution, caused by opposing patterns of density-dependent habitat selection (DDHS) that are predicted by the multidimensional ideal free distribution. We addressed this using winter aerial survey data of northern Yellowstone elk (Cervus canadensis) spanning four decades. Supporting our hypothesis, we found positive DDHS for food (herbaceous biomass) and negative DDHS for safety (openness and roughness), such that the primary driver of habitat selection switched from food to safety as elk density decreased from 9.3 to 2.0 elk/km2 . Our results demonstrate how population density can drive landscape-level shifts in population distribution, confounding habitat selection inference and prediction and potentially affecting community-level interactions.

Informal Caregiving Among American Indians and Alaska Natives in the Pacific Northwest.

Unpaid or informal caregivers are people who provide assistance without compensation to adults and children who require care beyond typical needs. Although often rewarding, informal caregiving can be associated with high rates of depression, stress, anxiety, sleep and endocrine system disruption, immunosuppression, and general morbidity and mortality. Few recent studies of informal caregivers have included data from American Indians and Alaska Natives (AI/AN). Given this noteworthy gap in the literature, we surveyed a total of 225 AI/ANs attending two cultural, community functions in the Pacific Northwest to gain a general understanding of frequency of caregiving, caregiver and recipient characteristics, caregiving duties, support needs, and financial, emotional, and physical strains as a consequence of caregiving. Of the 225 participants who completed the survey, 90 (40%) indicated that they had been an unpaid caregiver for a month or more and 28 (12%) were current unpaid caregivers. Consistent with prior research, most caregivers (84%) reported satisfaction from providing help, but 84% of caregivers reported experiencing "increased stress," 40% reported financial strain, and 34% reported decreased health "because of involvement with providing care." Our data also suggested a disproportionate impact on AI/AN women given higher rates of being a caregiver compared to other populations and less support from others in their communities. Our data suggest similarities for AI/AN caregivers with other groups of caregivers but also emphasize the importance of including AI/AN populations in future research in order to understand ways to best serve their unique needs.

The Grande Ronde Model Watershed: Integrating Science into Restoration Implementation and Adaptive Management.

Watershed conservation groups throughout the Pacific Northwest coordinate and implement watershed and habitat restoration to recover Pacific salmon Oncorhynchus spp. Many watershed organizations struggle with implementing an adaptive management process that integrates monitoring data and the latest science into their restoration programs. We describe the evolution and lessons learned from the Grande Ronde Model Watershed (GRMW), one of the longest running watershed organizations coordinating fish habitat restoration projects. Since 1992, the GRMW has initiated nearly 300 habitat restoration projects and their partners more than 600 projects. These projects have evolved from an opportunistic approach, focusing on small-scale riparian fencing and instream structures to a data driven, collaborative processes for identifying, ranking, and implementing large process-based floodplain projects using the latest science. The GRMW recently developed an adaptive management process to assess restoration goals and priorities, and a multi-scale monitoring program that leverages the extensive data collected by partners, and periodic collection of LiDAR to evaluate past, current, and future restoration projects. These recently developed components, which are based on the collective history of the GRMW, provide important lessons for other watershed restoration organizations. These include partnering with local organizations to collect monitoring data; use of a transparent multi-scale process for prioritizing restoration; development of a stepwise process for design and implementation of priority projects; a formal adaptive management process with a designated lead to use the latest science to modify goals, priorities, project selection, and design; and use of remotely sensed data to assist with multi-scale monitoring of project success.

Informing conservation decisions to target private lands of highest ecological value and risk of loss.

Natural habitats on private lands are potentially important components of national biodiversity conservation strategies, yet they are being rapidly lost to development. Conservation easements and other means of protecting these habitats have expanded in use and will be most effective if they target private lands of highest biodiversity value and risk of loss. We developed a Biodiversity Conservation Priority Index (BCPI) based on ecological value and risk of habitat loss for remaining areas of natural vegetation cover (NVC) in the northwestern United States and addressed two questions: (1) Which remaining NVC on private lands is the highest priority for biodiversity conservation based on ecological value and risk of development? And (2) are conservation easements in NVC placed preferentially in locations of high biodiversity conservation priority? Drawing on the concept of ecological integrity, we integrated five metrics of ecological structure, function, and composition to quantify ecological value of NVC. These included net primary productivity, species richness, ecosystem type representation, imperiled species range rarity, and connectivity among "Greater Wildland Ecosystems." Risk of habitat loss was derived from analysis of biophysical and sociodemographic predictors of NVC loss. Ecological value and risk of loss were combined into the BCPI. We then analyzed spatial patterns of BCPI to identify the NVC highest in biodiversity conservation priority and examined the relationship between BCPI and conservation easement status. We found that BCPI varied spatially across the study area and was highest in western and southern portions of the study area. High BCPI was associated with suburban and rural development, roads, urban proximity, valley bottom landforms, and low intensity of current development. Existing conservation easements were distributed more towards lower BCPI values than unprotected NVC at both the study area and region scales. The BCPI can be used to better inform land use decision making at local, regional, and potentially national scales in order to better achieve biodiversity goals.

Top-down regulation of hemlock woolly adelgid (Adelges tsugae) in its native range in the Pacific Northwest of North America.

The density of insect herbivores is regulated by top-down factors (e.g., natural enemies), bottom-up effects (e.g., plant defenses against herbivory), or a combination of both. As such, understanding the relative importance of these factors can have important implications for the establishment of effective management options for invasive species. Here, we compared the relative importance of top-down and bottom-up factors on the abundance of hemlock woolly adelgid (HWA), Adelges tsugae. HWA is invasive in eastern North America, but its native range includes the Pacific Northwest of North America where it has co-evolved with western hemlock, Tsuga heterophylla. Eastern hemlock, Tsuga canadensis, can also be found planted in city and park settings in the Pacific Northwest and the presence of both host species allowed us to directly compare the importance of predators (top-down) and host plant resistance (bottom-up) on HWA abundance by placing mesh exclusion bags on branches of both species and monitoring HWA abundance over two years. We found no evidence for bottom-up control of HWA on western hemlock (a native host). HWA established more readily on that species than on eastern hemlock on which it is a major pest in eastern North America. We found strong evidence for top-down control in that both summer and winter-active predators significantly reduced HWA densities on the branches of both tree species where predators were allowed access. These findings support the validity of the biological control program for HWA, the goal of which is to reduce outbreak populations of HWA in eastern North America.

Characterizing observable COVID-19 controls in Pacific Northwest grocery stores.

Utilizing a longitudinal, observational study, grocery store health and safety controls implemented during the COVID-19 pandemic across stores in two cities were characterized. Sixteen stores between Seattle, WA (n = 9) and Portland, OR (n = 7) were visited monthly by the study team from May 2020 to January 2021, and observations of controls were recorded using a standardized checklist in REDCap. The checklist included questions on the presence or absence of controls such as physical barriers, social distancing markers, required masking of customers, cleaning of check-out stands, and closures of store areas. Descriptive analyses were conducted to determine the proportion of stores with a certain control each month. Mixed-effects logistic regression was used to explore how controls changed over time, and whether differences were observed between cities or by income of the area the store serves. Source control (e.g., mask requirements) and engineering controls (e.g., physical barriers at checkout) were the most common and consistent controls observed across stores and over the study period. Controls such as having special hours for vulnerable populations, demarcations on aisles for directionality, and cleaning check-out stands between customers varied significantly over time (p < 0.05 in the mixed-effects model). Having an employee present to clean baskets and carts, as well as physical barriers between self-checkouts, were significantly more common in stores in areas above the median income (p < 0.05 in the mixed-effects model). To best protect workers and shoppers from infectious agents, controls should be evidence-based, consistently implemented across grocery stores, and coupled with administrative practices and policies to promote worker wellbeing.

Interactions Between Ticks and Lyme Disease Spirochetes.

Borrelia burgdorferi sensu lato causes Lyme borreliosis in a variety of animals and humans. These atypical bacterial pathogens are maintained in a complex enzootic life cycle that primarily involves a vertebrate host and Ixodes spp. ticks. In the Northeastern United States, I. scapularis is the main vector, while wild rodents serve as the mammalian reservoir host. As B. burgdorferi is transmitted only by I. scapularis and closely related ticks, the spirochete-tick interactions are thought to be highly specific. Various borrelial and arthropod proteins that directly or indirectly contribute to the natural cycle of B. burgdorferi infection have been identified. Discrete molecular interactions between spirochetes and tick components also have been discovered, which often play critical roles in pathogen persistence and transmission by the arthropod vector. This review will focus on the past discoveries and future challenges that are relevant to our understanding of the molecular interactions between B. burgdorferi and Ixodes ticks. This information will not only impact scientific advancements in the research of tick- transmitted infections but will also contribute to the development of novel preventive measures that interfere with the B. burgdorferi life cycle.

Maximizing the effectiveness of national commitments to protected area expansion for conserving biodiversity and ecosystem carbon under climate change.

Global commitments to protected area expansion should prioritize opportunities to protect climate refugia and ecosystems which store high levels of irrecoverable carbon, as key components of an effective response to biodiversity loss and climate change. The United States and Canada are responsible for one-sixth of global greenhouse gas emissions but hold extensive natural ecosystems that store globally significant above- and below-ground carbon. Canada has initiated a process of protected area network expansion in concert with efforts at reconciliation with Indigenous Peoples, and acknowledged nature-based solutions as a key aspect of climate change mitigation. The US, although not a party to global biodiversity conventions, has recently committed to protecting 30% of its extent by 2030 and achieving the UNFCCC Paris Agreement's mitigation targets. The opportunities afforded by these dual biodiversity conservation and climate commitments require coordinated national and regional policies to ensure that new protected areas maximize biodiversity-focused adaptation and nature-based mitigation opportunities. We address how global commitments can best inform national policy initiatives which build on existing agency mandates for regional planning and species conservation. Previous analyses of global conservation priorities under climate change have been tenuously linked to policy contexts of individual nations and have lacked information on refugia due to limitations of globally available datasets. Comparison and synthesis of predictions from a range of recently developed refugia metrics allow such data to inform planning despite substantial uncertainty arising from contrasting model assumptions and inputs. A case study for endangered species planning for old-forest-associated species in the US Pacific Northwest demonstrates how regional planning can be nested hierarchically within national biodiversity-focused adaptation and nature-based mitigation strategies which integrate refugia, connectivity, and ecosystem carbon metrics to holistically evaluate the role of different land designations and where carbon mitigation and protection of biodiversity's resilience to climate change can be aligned.

Rates of delayed hemolytic transfusion reactions observed in a trauma center.

BACKGROUND: Delayed hemolytic transfusion reactions (DHTRs) are reported to be rare occurrences but may be more frequently observed in the trauma setting where patients are heavily transfused, followed over long inpatient admissions, and have frequent subsequent blood counts as they undergo multiple surgical interventions. STUDY DESIGN AND METHODS: We examined the rates of DHTRs on a per transfusion and per patient basis in an academic county hospital with a level 1 trauma center serving a four-state region and over a 3-year period. DHTRs were entered sequentially into a registry as they were observed, and a retrospective review of all new alloantibodies detected was performed to identify any additional DHTRs. The number of units of red blood cells (RBCs), the number of unique patients, types of alloantibodies, and number of transfusions were extracted from blood bank records. RESULTS: Twenty-nine DHTRs were observed from January 1, 2017, through December 31, 2019, from newly observed alloantibodies after a median of 12 red blood cells (RBCs) transfusions per patient. These reactions occurred in response to 24,633 unique transfusions in 6905 unique patients, so the observed rates were about 1:849 RBC transfusions and 1:238 transfused patients. Evidence of delayed hemolysis was seen in five additional patients who were transfused during emergency resuscitation and later found to have had known RBC antibodies. DISCUSSION: We report a higher rate of DHTRs than previously described to demonstrate that DHTRs are not rare in trauma centers.

Heat-Related Emergency Department Visits During the Northwestern Heat Wave - United States, June 2021.

Record high temperatures are occurring more frequently in the United States, and climate change is causing heat waves to become more intense (1), directly impacting human health, including heat-related illnesses and deaths. On average, approximately 700 heat-related deaths occur in the United States each year (2). In the northwestern United States, increasing temperatures are projected to cause significant adverse health effects in the coming years (3). During June 25-30, 2021, most of Oregon and Washington were under a National Weather Service excessive heat warning.* Hot conditions persisted in parts of Oregon, Washington, or Idaho through at least July 14, 2021. The record-breaking heat had the largest impact in Oregon and Washington, especially the Portland metropolitan area, with temperatures reaching 116°F (46.7°C), which is 42°F (5.6°C) hotter than the average daily maximum June temperature.

Mixed-conifer forest reference conditions for privately owned timberland in the southern Cascade Range.

The overwhelming majority of information on historical forest conditions in western North America comes from public lands, which may provide an incomplete description of historical landscapes. In this study we made use of an archive containing extensive timber survey data collected in the early 1920s from privately owned forestland. These data covered over 50,000 ha and effectively represent a 19% sample of the entire area. The historical forest conditions reconstructed from these data fit the classic model of frequent-fire forests: large trees, low density, and pine-dominated. However, unlike other large-scale forest reconstructions, our study area exhibited relatively low overall variability in forest structure and composition across the historical landscape. Despite having low variability, our analyses revealed evidence of biophysical controls on tree density and pine fraction. Annual climatic variables most strongly explained the range in historical tree densities, whereas historical pine fraction was explained by a combination of topographic and climatic variables. Contemporary forest inventory data collected from both public and private lands within the same general area, albeit not a direct remeasurement, revealed substantial increases in tree density and greatly reduced pine fractions relative to historical conditions. Contemporary forests exhibited a far greater range in these conditions than what existed historically. These findings suggest that private forestland managed with multiaged silviculture may be similar to public forestland with respect to departure in forest structure and compositions from that of historical forests. However, there may be differences between management objectives that favor timber production, more typical on private lands, vs. those that favor restoration, increasingly supported on public lands.

Initial validation of the product of the signs global assessment and body surface area in atopic dermatitis.

BACKGROUND: Current valid instruments that measure the signs of atopic dermatitis in clinical trials may not be suitable for clinical practice because of their complexity. The product of a clinician-derived 5-point signs global assessment and body surface area (SGA × BSA) may represent a simple approach to quickly assess the severity of signs in patients with atopic dermatitis in clinical practice. OBJECTIVES: Evaluate the basic measurement properties of the SGA × BSA. METHODS: Retrospective chart review of patients with atopic dermatitis treated in an outpatient dermatology clinic at Oregon Health & Science University from 2015 to 2018 who had a recorded BSA and SGA. RESULTS: We identified 138 patients completing 325 clinic visits. SGA × BSA demonstrated strong and statistically significant (P < .001) correlations with the Eczema Area and Severity Index (r = 0.91, n = 19), average daily pruritus (r = 0.71, n = 177), patient global assessment (r = 0.74, n = 170), and a derived global scale composed of the average of 4 signs rated between 0 and 3 (r = 0.77, n = 282). Acceptability, responsiveness, and floor or ceiling effects of the measure were deemed adequate. Severity banding was maximized at 1, 21, and 87 (κ = 0.4902). LIMITATIONS: The patient cohort was gathered exclusively from a tertiary care clinic setting in the Pacific Northwest and lacked ethnic diversity. CONCLUSIONS: The results from this study suggest that SGA × BSA is a valid and feasible instrument for atopic dermatitis signs in clinical practice.

"We Need to Taper." Interviews with Clinicians and Pharmacists About Use of a Pharmacy-Led Opioid Tapering Program.

OBJECTIVE: To identify factors that influence or interfere with referrals by primary care providers (PCPs) to a pharmacist-led telephone-based program to assist patients undergoing opioid tapering. The Support Team Onsite Resource for Management of Pain (STORM) program provides individualized patient care and supports PCPs in managing opioid tapers. DESIGN: Qualitative interviews were conducted with referring PCPs and STORM staff. Interview guides addressed concepts from the RE-AIM framework, focusing on issues affecting referral to the STORM program. SETTING: An integrated healthcare system (HCS) in the Northwest United States. SUBJECTS: Thirty-five interviews were conducted with 20 PCPs and 15 STORM staff. METHODS: Constant comparative analysis was used to identify key themes from interviews. A codebook was developed based on interview data and a qualitative software program was used for coding, iterative review, and content analysis. Representative quotes illustrate identified themes. RESULTS: Use of the STORM opioid tapering program was influenced by PCP, patient, and HCS considerations. Factors motivating use of STORM included lack of PCP time to support chronic pain patients requiring opioid tapering and the perception that STORM is a valued partner in patient care. Impediments to referral included PCP confidence in managing opioid tapering, patient resistance to tapering, forgetting about program availability, and PCP resistance to evolving guidelines regarding opioid tapering goals. CONCLUSIONS: PCPs recognized that STORM supported patient safety and reduced clinician burden. Utilization of the program could be improved through ongoing PCP education about the service and consistent co-location of STORM pharmacists within primary care clinics.