Procedure-Focused Escape Room: A Pilot Study on Teaching High-Stakes Technical Skills in Anesthesia Residents.

Background: High-stakes yet clinically infrequent procedures are challenging to teach. Escape rooms may offer an innovative solution through game-based learning. There is limited guidance on how to design an escape room focused on physical puzzles. We designed and implemented a procedure-focused escape room to teach high-stakes procedures to anesthesiology residents. Methods: We selected 5 procedural skills relevant to anesthesiology residents through a modified Delphi technique: fiberoptic intubation, rapid infuser setup, intraosseous line placement, flexible bronchoscopy, and supraglottic airway exchange. We designed associated skills stations and linked them in sequence using an elaborate series of puzzles, locks, keys, and codes. The total cost of puzzle equipment was $169.53. After pilot testing, we implemented the escape room from July to November 2022. We assessed residents using a single group pretest-posttest study design. Results: Forty-three of 55 (78%) eligible anesthesiology residents participated in the escape room. Thirty-one residents completed the surveys. Resident self-efficacy significantly improved for each of the 5 procedures. Twenty-six of 27 (96%) residents preferred the escape room over a typical procedural skills workshop. Conclusions: This pilot study demonstrated the feasibility of a procedure-focused escape room for teaching high-stakes technical skills. We identified 3 lessons in procedure-focused escape room design: set participant caps intentionally, optimize resource usage, and maximize reproducibility. Participating in a single escape room session significantly increased resident self-efficacy. Residents strongly preferred the escape room format over a traditional procedural skills workshop.

A case report and anesthetic implications of situs inversus totalis in video-assisted thoracoscopic pulmonary resection.

Introduction and importance: Reports are limited on video-assisted thoracoscopic surgery for lung malignancy of patients with situs inversus totalis (SIT). Patients with SIT have significant anatomic differences with implications that are important for surgery, anesthesia, and nursing to understand in order to provide care for this patient population. Case presentation: A 64-year-old man with SIT and lung adenocarcinoma needed flexible bronchoscopy and wedge resection of a 9×8 mm adenocarcinoma in the right upper lobe and underwent video-assisted thoracoscopic surgery. Clinical discussion: Preoperative planning, including collaboration with the surgical team, allowed safe monitoring, induction of anesthesia, and airway isolation in this patient allowing them to have successful resection of their pulmonary malignancy. Postoperative care was enhanced by detailed communication and understanding of the patient's anatomy and implications of this condition for post anesthesia care unit nursing care. Conclusion: Patients with rare clinical conditions and backgrounds may require surgical and anesthetic intervention. The authors describe important anesthetic considerations of preoperative evaluation, airway management, cardiac monitoring, and vascular access that should be noted and taken into account for patients with SIT. Proper preparation, planning, and communication allow for patients with SIT to safely undergo surgical procedures.

Esophagectomy Enhanced Recovery After Surgery Initiative Results in Improved Outcomes.

BACKGROUND: Esophagectomy for esophageal cancer is a procedure with high morbidity and mortality. This study developed a Multidisciplinary Esophagectomy Enhanced Recovery Initiative (MERIT) pathway and analyzed implementation outcomes in a single institution. METHODS: The MERIT pathway was developed as a practice optimization and quality improvement initiative. Patients were studied from November 1, 2021 to June 20, 2022 and were compared with historical control subjects. The Wilcoxon rank sum test and the Fisher exact test were used for statistical analysis. RESULTS: The study compared 238 historical patients (January 17, 2017 to December 30, 2020) with 58 consecutive MERIT patients. There were no significant differences between patient characteristics in the 2 groups. In the MERIT group, 49 (85%) of the patients were male, and their mean age was 65 years (range, 59-71 years). Most cases were performed for esophageal cancer after neoadjuvant therapy. Length of stay improved by 27% from 11 to 8 days (P = .27). There was a 12% (P = .05) atrial arrhythmia rate reduction, as well as a 9% (P = .01) decrease in postoperative ileus. Overall complications were reduced from 54% to 35% (-19%; P = .01). CONCLUSIONS: This study successfully developed and implemented an enhanced recovery after surgery pathway for esophagectomy. In the first year, study investigators were able to reduce overall complications, specifically atrial arrhythmias, and postoperative ileus.

Development and Pilot Testing of a Programmatic System for Competency Assessment in US Anesthesiology Residency Training.

BACKGROUND: In 2018, a set of entrustable professional activities (EPAs) and procedural skills assessments were developed for anesthesiology training, but they did not assess all the Accreditation Council for Graduate Medical Education (ACGME) milestones. The aims of this study were to (1) remap the 2018 EPA and procedural skills assessments to the revised ACGME Anesthesiology Milestones 2.0, (2) develop new assessments that combined with the original assessments to create a system of assessment that addresses all level 1 to 4 milestones, and (3) provide evidence for the validity of the assessments. METHODS: Using a modified Delphi process, a panel of anesthesiology education experts remapped the original assessments developed in 2018 to the Anesthesiology Milestones 2.0 and developed new assessments to create a system that assessed all level 1 through 4 milestones. Following a 24-month pilot at 7 institutions, the number of EPA and procedural skill assessments and mean scores were computed at the end of the academic year. Milestone achievement and subcompetency data for assessments from a single institution were compared to scores assigned by the institution's clinical competency committee (CCC). RESULTS: New assessment development, 2 months of testing and feedback, and revisions resulted in 5 new EPAs, 11 nontechnical skills assessments (NTSAs), and 6 objective structured clinical examinations (OSCEs). Combined with the original 20 EPAs and procedural skills assessments, the new system of assessment addresses 99% of level 1 to 4 Anesthesiology Milestones 2.0. During the 24-month pilot, aggregate mean EPA and procedural skill scores significantly increased with year in training. System subcompetency scores correlated significantly with 15 of 23 (65.2%) corresponding CCC scores at a single institution, but 8 correlations (36.4%) were <30.0, illustrating poor correlation. CONCLUSIONS: A panel of experts developed a set of EPAs, procedural skill assessment, NTSAs, and OSCEs to form a programmatic system of assessment for anesthesiology residency training in the United States. The method used to develop and pilot test the assessments, the progression of assessment scores with time in training, and the correlation of assessment scores with CCC scoring of milestone achievement provide evidence for the validity of the assessments.

Quality characteristics and sensory evaluation of protein-rich baked snacks for adults with chronic kidney disease: a proof of concept study.

BACKGROUND: Adults with chronic kidney disease (CKD) have different protein requirements than the general population. Limited protein-rich baked snack options are available for CKD adults. The purpose of this proof of concept study was to develop two protein-rich baked snacks made with whey protein isolate and soy protein isolate and to evaluate their quality characteristics and sensory perceptions for adults with CKD. METHODS: A control formulation was obtained from the American Association of Cereal Chemists to develop three formulations-dried milk (control), whey protein isolate and soy protein isolate at an unbaked weight of 30 g. Product quality characteristics included moisture content, water activity, shape and size, and texture profile. For the sensory perception, healthy adults (n = 101) and adults with CKD (n = 57) completed a 9-point hedonic scale for appearance, flavor, texture, and overall acceptability. RESULTS: Protein content for the whey protein isolate and soy protein isolate reached 20% total weight. Despite containing similar moisture, both formulations were harder than the control (p < 0.001). Healthy participants preferred the whey protein isolate-based snack over the soy protein isolate-based snack for all attributes (p < 0.05). Differences in the same attributes were not perceived among CKD participants (p > 0.05). Open-ended responses from both healthy and CKD participants indicated that the soy protein isolate formulation was softer and sweeter compared to the whey protein isolate formulation. CONCLUSION: Overall, adults with CKD preferred both the whey protein isolate-and soy protein isolate-formulated snacks. These protein-rich baked snacks can be further modified to serve as an alternative snack choice for adults with CKD and used in future clinical trials.

Intrathecal Opioid Use in Kidney Transplantation: An Observational Cohort Study.

BACKGROUND: Kidney transplant is the most common transplant operation performed in the United States. Although various approaches to pain management have been described, the optimal analgesic strategy remains undefined. Specifically, the role of intrathecal opioids in this patient population has not been comprehensively evaluated. METHODS: Using a retrospective cohort design, data from kidney transplant operations at a single tertiary care medical center between August 1, 2017, and July 31, 2022, were extracted. Inverse probability of treatment weighting (IPTW) was used to assess differences in clinical outcomes based on the presence or absence of intrathecal opioid administration before surgical incision. The primary outcome was total opioid exposure expressed in milligram morphine equivalents (MME) in the first 72 hours postoperatively, with secondary outcomes including total MME (intraoperative plus postoperative MME, postoperative pain scores, and the presence of postoperative nausea/vomiting [PONV], pruritus, or adverse events). RESULTS: A total of 1014 kidney transplants in 1012 unique patients were included, with 411 (41%) receiving intrathecal opioids preoperatively. Hydromorphone was the intrathecal opioid used in all cases with median dose of 100 µg (interquartile range [IQR], 100, 100; range 50-200). Subjects receiving intrathecal opioids had significantly lower postoperative opioid requirements at 72 hours (30 [0-68] vs 64 [22, 120] MME), with ratio of geometric means in the IPTW analysis (ratio of geometric means 0.34, 95% confidence interval [CI], 0.26-0.43; P < .001). Similar findings were observed for total opioids (45 [30-75] vs 75 [60-90] MME; ratio of geometric means 0.58, 95% CI, 0.54-0.63; P < .001). Maximum reported pain scores in the intrathecal group were lower at 24 hours (4 [2-7] vs 7 [5, 8]; OR, 0.28; 95% CI, 0.21-0.37 for experiencing a higher pain score with intrathecal opioids, P < .001) and 72 hours (6 [4-7] vs 7 [5-8]; OR, 0.41; 95% CI, 0.31-0.54; P < .001). Patients receiving intrathecal opioids were more likely to experience PONV (225 of 411 [55%] vs 232 of 603 [38%]; OR, 2.16; 95% CI, 1.63-2.86; P < .001). CONCLUSIONS: Intrathecal opioid administration was associated with improved pain outcomes in patients undergoing kidney transplantation, including lower opioid requirements and pain scores through 72 hours. However, this was accompanied by an increased risk of PONV.

Chemical and physical properties of winter squash and their correlation with liking of their sensory attributes.

Cucurbita moschata, commonly known as squash or pumpkin, is a member of the Cucurbitaceae family originating from Central America. This species is regarded as heat tolerant and disease resistant and is commonly used in breeding programs. Calabaza (wintersquash) is an emerging market type of C. moschata with increasing popularity in the United States; however, limited research has been conducted to understand how sensory qualities influence consumers' acceptability and willingness to pay (price). This study compared the sensory perception of C. moschata accessions grown in the continental southeastern United States with their physical and chemical properties using squash prepared from fresh and frozen states. The eight accessions investigated included five hybrids of calabaza from the University of Florida (University of Florida Tropical Pumpkin #), two commercial cultivars of calabaza (La Estrella and Soler), and one butternut squash cultivar (Waltham). The evaluation of fresh calabaza revealed significant differences in consumer preference among cultivars in addition to correlations with sensory attributes. UFTP8 and UFTP24 received the highest ratings, whereas UFTP38 and 'La Estrella' were rated lowest. Interestingly, the evaluation of frozen calabaza revealed UFTP8 and 'Waltham' Butternut squash as the highest in ranking, while UFTP38 and 'La Estrella' retained the lowest ranking. Consumer ratings of fresh samples revealed positive correlations between overall liking, sweetness liking, and texture liking with willingness to pay and soluble solids content (SSC). For calabaza intended for the frozen market, the color, hardness, and SSC were identified as the most significant parameters impacting willingness to pay. These results show how quality attributes can play a crucial role in consumers perception of quality and significantly influence their reported willingness to pay. PRACTICAL APPLICATION: Producers and breeders can use positively correlated attributes as indicators of overall liking and to determine pricing for C. moschata products.

Intraoperative Dysrhythmias Cease After Venting During Intramedullary Nailing of an Impending Femur Fracture: A Case Report.

CASE: A 76-year-old woman with multiple myeloma and osteoporosis presented with right hip pain and an impending atypical femoral fracture in the setting of chronic bisphosphonate use. After preoperative medical optimization, she was scheduled for prophylactic intramedullary nail fixation. Intraoperatively, the patient experienced episodes of severe bradycardia and asystole associated with intramedullary reaming, which ceased after distal venting of the femur. No additional intraoperative or postoperative complications were encountered, and the patient recovered uneventfully. CONCLUSION: Femoral canal venting may be an appropriate intervention for similar transient dysrhythmias caused by intramedullary reaming.

Optimal spatial evaluation of a pro rata vaccine distribution rule for COVID-19.

The COVID-19 Vaccines Global Access (COVAX) is a World Health Organization (WHO) initiative that aims for an equitable access of COVID-19 vaccines. Despite potential heterogeneous infection levels across a country, countries receiving allotments of vaccines may follow WHO's allocation guidelines and distribute vaccines based on a jurisdictions' relative population size. Utilizing economic-epidemiological modeling, we benchmark the performance of this pro rata allocation rule by comparing it to an optimal one that minimizes the economic damages and expenditures over time, including a penalty representing the social costs of deviating from the pro rata strategy. The pro rata rule performs better when the duration of naturally- and vaccine-acquired immunity is short, when there is population mixing, when the supply of vaccine is high, and when there is minimal heterogeneity in demographics. Despite behavioral and epidemiological uncertainty diminishing the performance of the optimal allocation, it generally outperforms the pro rata vaccine distribution rule.

The effect of CO2 concentration on yeast fermentation: rates, metabolic products, and yeast stress indicators.

This research aimed to assess how the partial removal of carbon dioxide affects fermentations to provide a better understanding of how the manipulation of carbon dioxide concentration can be used to optimize industrial fermentations. To achieve this, fermentation kinetics, fermentation metabolic products, and yeast stress indicators were analyzed throughout ongoing brewing fermentations conducted under partial vacuum with atmospheric pressure controls. The partial vacuum reduced the solubility of carbon dioxide in the media and decreased the time necessary to reach carbon dioxide saturation. The effect was an increased rate of fermentation, and significantly more viable cells produced under vacuum pressure compared to controls. Ethanol, glycerol, and volatile organic compound concentrations were all significantly increased under partial vacuum, while indicators of yeast stress (trehalose) were reduced. Additionally, as the number of yeast cells was higher under partial vacuum, less sugar was consumed per volume of yeast cell. This study measured fermentation kinetics, metabolic products, and yeast health to holistically assess the effect of partial vacuum during a batch fermentation and found significant differences in each that can be individually exploited by researchers and industry. SUMMARY: An exploration of batch yeast fermentation in a low-pressure environment, with a focus on the health and productivity of the yeast cells.

Air temperature spikes increase bacteria presence in drinking water wells downstream of hog lagoons.

>44 million United States residents depend on private drinking water wells that are federally unregulated. Maintaining a clean groundwater supply for populations without access to public water systems is essential to supporting public health and falls to state regulators and private well owners. Yet, monitoring practices do not reflect the fact that groundwater pollution risk varies seasonally and with proximity to nearby surface-contaminated sites. Examination of nearly 50,000 well water samples across North Carolina, ranked second nationally in domestic well dependence and swine production, from 2013 to 2018 reveals a uniform sampling schedule but a variable risk of bacterial contamination within each calendar year. We document a threshold of 32.2 °C (90 °F) where total coliform bacteria and Escherichia coli (E. coli) detection in private well water spikes near swine lagoons but is absent from "upstream" wells and otherwise unexplained by a variety of other known contamination sites. Closing the gap between perceived and actual risks of drinking water contamination has potential to improve public health. State regulations and federal guidelines should consider coordinating domestic well sampling with seasonally and spatially fluctuating risks of groundwater contamination. Findings from this study are generalizable, having implications for other parts of the world with water sources that have the potential to get contaminated by nearby surface sources of human and animal waste, such as manure applications and leaching septic systems.

Terpene volatiles mediates the chemical basis of blueberry aroma and consumer acceptability.

Flavor is among the most important traits valued by consumers of fresh fruits. Human perception of flavor occurs primarily through two main sensory inputs, taste and aroma. Through retronasal olfaction, volatile organic compounds (VOCs) emitted by the fruit are able to produce the sensation of aroma which when combined with gustatory inputs from the tongue together underly our perception of the thousands of flavors we experience throughout our lives. In blueberry, breeders have observed that some genotypes possess berries with unique 'floral' and 'sweet' flavor and aroma notes. The potential impact these characteristics might have on consumer acceptability is largely unknown and represents an opportunity to better understand how aroma attributes affect the perception of blueberry flavor. In this study, we dissected the main components of blueberry aroma and associated it with consumer predilections by pairing metabolomics with sensory analysis. Our contribution in this study is four-fold: (i) first, we differentiated genotypes with floral and sweet aroma notes and confirmed that such characteristics are preferred by consumers; (ii) at the chemical level, we showed that a group of eight terpenoid volatiles (p-cymene, myrtenal, linalool, L-carvenol, geranyl acetone, geranyl acetate, D-limonene and ß-myrcene) constitute the primary metabolic group associated with these aroma sensations; (iii) we demonstrated that aromatic genotypes can be classified using metabolomics; and finally, (iv) we combined pedigree and metabolomic information and showed the importance of metabolomic data for flavor-assisted selection. Our findings open new avenues to explore the phenomenon of flavor in blueberries and also allow us to present an emerging view about flavor and provide a detailed blueprint of how this targeted trait could be addressed in fruit and vegetable breeding.

Instrumental and sensory analyses of fruit quality attributes of grafted grape tomatoes in high tunnel organic production systems.

BACKGROUND: 'Vegetative' and 'generative' tomato rootstock types have been proposed based on their different effects on tomato scion growth performance; however, their impacts on fruit quality have not been characterized. No study has been conducted in which the effects of rootstock on grape tomato quality attributes were assessed using sensory and instrumental methods of evaluation. Here, we conducted two experiments to examine the influence of 'DR0141TX', 'Estamino', and 'Multifort' rootstocks (vegetative, generative, and uncharacterized, respectively) on fruit quality properties of determinate and indeterminate grape tomato scions under organic production in high tunnels, including color, size, firmness, dry matter content, soluble solids content (SSC), titratable acidity (TA), pH, and consumer sensory attributes. RESULTS: In both experiments, grafting 'Sweet Hearts' indeterminate grape tomato onto 'DR0141TX', 'Estamino', or 'Multifort' increased fruit size and led to negligible effects on sensory attributes and instrumental measurements of fruit quality attributes. For 'BHN 1022' determinate grape tomato, rootstocks did not exhibit any major impact on fruit quality attributes in Experiment 1. However, fruit quality was compromised by grafting per se and rootstocks, especially 'Multifort', in Experiment 2, as reflected by reduced SSC, TA, and SSC/TA and lower scores for overall appearance, overall acceptability, tomato flavor, overall texture, and sweetness. CONCLUSION: In general, 'vegetative' and 'generative' rootstocks showed comparable effects on sensory evaluations and instrumental measurements of grape tomato quality attributes for both indeterminate and determinate scions. More research is needed to better characterize rootstock effects on fruit quality, including the flavor-related compounds under different growing conditions. © 2022 Society of Chemical Industry.

There and back again; historical perspective and future directions for Vaccinium breeding and research studies.

The genus Vaccinium L. (Ericaceae) contains a wide diversity of culturally and economically important berry crop species. Consumer demand and scientific research in blueberry (Vaccinium spp.) and cranberry (Vaccinium macrocarpon) have increased worldwide over the crops' relatively short domestication history (~100 years). Other species, including bilberry (Vaccinium myrtillus), lingonberry (Vaccinium vitis-idaea), and ohelo berry (Vaccinium reticulatum) are largely still harvested from the wild but with crop improvement efforts underway. Here, we present a review article on these Vaccinium berry crops on topics that span taxonomy to genetics and genomics to breeding. We highlight the accomplishments made thus far for each of these crops, along their journey from the wild, and propose research areas and questions that will require investments by the community over the coming decades to guide future crop improvement efforts. New tools and resources are needed to underpin the development of superior cultivars that are not only more resilient to various environmental stresses and higher yielding, but also produce fruit that continue to meet a variety of consumer preferences, including fruit quality and health related traits.

Metabolomic selection for enhanced fruit flavor.

Although they are staple foods in cuisines globally, many commercial fruit varieties have become progressively less flavorful over time. Due to the cost and difficulty associated with flavor phenotyping, breeding programs have long been challenged in selecting for this complex trait. To address this issue, we leveraged targeted metabolomics of diverse tomato and blueberry accessions and their corresponding consumer panel ratings to create statistical and machine learning models that can predict sensory perceptions of fruit flavor. Using these models, a breeding program can assess flavor ratings for a large number of genotypes, previously limited by the low throughput of consumer sensory panels. The ability to predict consumer ratings of liking, sweet, sour, umami, and flavor intensity was evaluated by a 10-fold cross-validation, and the accuracies of 18 different models were assessed. The prediction accuracies were high for most attributes and ranged from 0.87 for sourness intensity in blueberry using XGBoost to 0.46 for overall liking in tomato using linear regression. Further, the best-performing models were used to infer the flavor compounds (sugars, acids, and volatiles) that contribute most to each flavor attribute. We found that the variance decomposition of overall liking score estimates that 42% and 56% of the variance was explained by volatile organic compounds in tomato and blueberry, respectively. We expect that these models will enable an earlier incorporation of flavor as breeding targets and encourage selection and release of more flavorful fruit varieties.

A Novel Approach to Emergency Airway Simulation Using a 3D-printed Cricothyrotomy Task Trainer.

BACKGROUND: Cricothyrotomy is a final recourse for salvaging a difficult airway, yet most anesthesiology providers have little training, exposure, or comfort with the procedure. Pig tracheas are frequently used for training, but are single use and require special handling and storage. Other simulation models, such as mannequins and cadavers, are costly. Advances in 3dimensional (3D) printing have improved accessibility and decreased costs. This research project sought to determine whether an inexpensive 3D-printed task trainer was noninferior to pig tracheas for teaching surgical cricothyrotomy skills. METHODS: Anesthesiology residents were enrolled in an institutional review board-exempted, unblinded, randomized, controlled, single-institution, noninferiority trial. Participants were trained in the scalpel-finger-bougie technique for surgical cricothyrotomy. Participants were randomized to practice 5 repetitions on either a pig trachea or the 3D model and were assessed on time to cricothyrotomy completion on a pig trachea before and after practice. RESULTS: Demographic characteristics of the 25 workshop attendees were similar between study arms. Overall mean (SD) improvement in speed was 9 (12) seconds (P = .001). Postpractice times were similar between groups (analysis of covariance estimated difference of -0.1 seconds [95% confidence interval, -9.4 to 9.2]; P = .55). The 3D model was noninferior to the pig trachea at the prespecified noninferiority margin of 10 seconds (P = .017). CONCLUSIONS: The 3D model was noninferior to pig tracheas for improving the time to completion of a surgical cricothyrotomy. A 3D-printed model offers a viable alternative to pig tracheas for emergency airway simulation that is inexpensive, reusable, and readily modified to simulate challenging airway anatomy.

Governance structure affects transboundary disease management under alternative objectives.

BACKGROUND: The development of public health policy is inextricably linked with governance structure. In our increasingly globalized world, human migration and infectious diseases often span multiple administrative jurisdictions that might have different systems of government and divergent management objectives. However, few studies have considered how the allocation of regulatory authority among jurisdictions can affect disease management outcomes. METHODS: Here we evaluate the relative merits of decentralized and centralized management by developing and numerically analyzing a two-jurisdiction SIRS model that explicitly incorporates migration. In our model, managers choose between vaccination, isolation, medication, border closure, and a travel ban on infected individuals while aiming to minimize either the number of cases or the number of deaths. RESULTS: We consider a variety of scenarios and show how optimal strategies differ for decentralized and centralized management levels. We demonstrate that policies formed in the best interest of individual jurisdictions may not achieve global objectives, and identify situations where locally applied interventions can lead to an overall increase in the numbers of cases and deaths. CONCLUSIONS: Our approach underscores the importance of tailoring disease management plans to existing regulatory structures as part of an evidence-based decision framework. Most importantly, we demonstrate that there needs to be a greater consideration of the degree to which governance structure impacts disease outcomes.

Sensory and Physicochemical Quality, Residual Fungicide Levels and Microbial Load in 'Florida Radiance' Strawberries from Different Disease Control Treatments Exposed to Simulated Supply Chain Conditions.

Strawberries are greatly appreciated for their flavor and health-promoting properties. However, current agricultural and postharvest handling practices may result in decreased fruit quality. The objective of this work was to determine the effect of conventional or reduced fungicide applications on the quality of 'Florida Radiance' strawberries exposed to supply chain conditions. Strawberries held under steady temperature had better sensory and physicochemical quality than fruit exposed to supply chain conditions, regardless of the disease control treatment. Strawberries from the reduced fungicide treatment were firmer, lost less moisture, had higher sugar and higher or similar bioactive contents than fruit from the conventional treatment. Sensory scores were better for reduced fungicide fruit held under steady temperature conditions than other treatments at the consumer level. Microbial load increased during the supply chain but results strongly suggest that washing the fruit significantly reduces the microbial load and residual fungicide levels (fludioxonil, cyprodinil, pyraclostrobin, and captan) on the fruit. Overall, the use of reduced fungicide applications to control strawberry disease constitutes a promising alternative to conventional practices. It will help reduce costs by reducing labor and the amount of fungicides used while maintaining overall strawberry quality. Moreover, avoiding abusive and fluctuating temperature conditions during the supply chain will extend shelf-life and reduce strawberry waste.

Real-World Clinical Use and Outcomes of Telavancin for the Treatment of Bone and Joint Infections: Results from the Telavancin Observational Use Registry (TOUR™).

BACKGROUND: Additional antibiotic options are needed to treat bone and joint infections caused by penicillin-resistant Gram-positive pathogens. OBJECTIVE: This subanalysis of the Telavancin Observational Use Registry (TOUR™) aimed to record real-world telavancin usage patterns in patients with bone and joint infections treated with telavancin. METHODS: TOUR was a multicenter observational-use registry study conducted at 45 US sites between January 2015 and March 2017. Patient characteristics, infection type, infecting pathogen(s), previous treatment, telavancin dosing and duration, clinical response, and adverse event data were collected by retrospective medical chart reviews. As such, inclusion/exclusion criteria were limited, and any patient receiving at least one dose of telavancin at the discretion of the treating physician was eligible. Patients were assessed as either positive clinical response, failed treatment, or indeterminate outcome. RESULTS: Of the 1063 patients enrolled in TOUR, 27.4% (291/1063) were patients with bone and joint infections including osteomyelitis (with or without prosthetic material), acute septic arthritis, and prosthetic joint infections. Most of these patients had osteomyelitis without prosthetic material (191/291; 66.0%). Among patients assessed at the end of treatment, 211/268 (78.7%) achieved a positive clinical response, 26/268 (9.7%) failed treatment, and 31/268 (11.6%) had an indeterminate outcome. The most frequent pathogen was methicillin-resistant Staphylococcus aureus (110/291; 37.8%). The median (interquartile range [IQR as Q1, Q3]) telavancin dose was 750.0 mg (IQR, 750, 750 mg) or 8.2 mg/kg (IQR, 6.8, 9.7 mg/kg) administered for a median of 26 days (IQR, 12, 42 days). These assessments were recorded in the registry ≥ 30 days after the last dose of telavancin was administered. CONCLUSIONS: Real-world data from the TOUR study show that clinicians are using once-daily telavancin with positive clinical outcomes for the treatment of bone and joint infections caused by Gram-positive pathogens. CLINICAL TRIAL REGISTRATION: This trial was registered with ClinicalTrials.gov (NCT02288234) on 11 November, 2014.