High 3He/4He in central Panama reveals a distal connection to the Galápagos plume.

It is well established that mantle plumes are the main conduits for upwelling geochemically enriched material from Earth's deep interior. The fashion and extent to which lateral flow processes at shallow depths may disperse enriched mantle material far (>1,000 km) from vertical plume conduits, however, remain poorly constrained. Here, we report He and C isotope data from 65 hydrothermal fluids from the southern Central America Margin (CAM) which reveal strikingly high 3He/4He (up to 8.9RA) in low-temperature (≤50 °C) geothermal springs of central Panama that are not associated with active volcanism. Following radiogenic correction, these data imply a mantle source 3He/4He >10.3RA (and potentially up to 26RA, similar to Galápagos hotspot lavas) markedly greater than the upper mantle range (8 ± 1RA). Lava geochemistry (Pb isotopes, Nb/U, and Ce/Pb) and geophysical constraints show that high 3He/4He values in central Panama are likely derived from the infiltration of a Galápagos plume-like mantle through a slab window that opened ∼8 Mya. Two potential transport mechanisms can explain the connection between the Galápagos plume and the slab window: 1) sublithospheric transport of Galápagos plume material channeled by lithosphere thinning along the Panama Fracture Zone or 2) active upwelling of Galápagos plume material blown by a "mantle wind" toward the CAM. We present a model of global mantle flow that supports the second mechanism, whereby most of the eastward transport of Galápagos plume material occurs in the shallow asthenosphere. These findings underscore the potential for lateral mantle flow to transport mantle geochemical heterogeneities thousands of kilometers away from plume conduits.

Improving Access to Hepatitis C Treatment Using Clinical Pharmacist Services in an Uninsured, At-Risk Population at a Community Health Center.

While published cure rates for new hepatitis C virus (HCV) treatments exceed 90%, barriers such as cost, medication access, housing or phone service instability, and substance use complicate medication adherence for uninsured, at-risk populations. Lincoln Community Health Center (LCHC) Pharmacy, in collaboration with primary care providers and care coordination professionals, implemented clinical pharmacist services to facilitate treatment of HCV infection in uninsured patients using manufacturers' patient assistance programs (PAP). Eighty-four (84) uninsured patients initiated treatment at LCHC using PAP during the first two years of the program. Nearly all patients (65/67 or 97%) who completed lab monitoring at 12 weeks post-treatment achieved undetectable viral load or a sustained virologic response (SVR-12), considered a proxy for cure. Successfully treating HCV infection in an uninsured, at-risk population may be achieved in a safety-net community health center by incorporating clinical pharmacist services into a team-based model.

Reaching the Hard-to-Reach: Outcomes of the Severe Hypertension Outreach Intervention.

INTRODUCTION: Severe hypertension (≥180 mmHg systolic or ≥110 mmHg diastolic) is associated with a twofold increase in the relative risk of death. At the authors' Federally Qualified Health Center in the Southeast, 39% of adults (n=8,695) had hypertension, and 3% (n=235) were severe. The purpose of this project was to lower blood pressure and improve the proportion of patients achieving the Agency for Healthcare Research and Quality goal for blood pressure. METHODS: This quality improvement project was performed in 2017 in three 3-month Plan, Do, Study, Act cycles using a multidisciplinary outreach model in a community-based primary care setting. A clinical team including physicians, nurses, patient navigators, behavioral health counselors, and pharmacists contacted adult patients with severe hypertension (≥180/110 mmHg), scheduled visits, and established blood pressure and medication management goals. The data review and analysis concluded in 2019. RESULTS: Among patients with blood pressure ≥180/110 mmHg (n=235), the average age was 57 years (SD=12 years), 37% (n=87) were male, 82% (n=193) were Black, and 46% (n=108) were uninsured. The majority of those contacted attended a follow-up appointment within the 9-month project (77%, n=181) and achieved an improved systolic blood pressure (87%, n=167) and diastolic blood pressure (76%, n=146). Target blood pressure of <140/90 mmHg was achieved in 29% of patients (n=53). Medication possession ratio improved from 23% to 40% among patients reached by pharmacists (n=30). Fewer deaths occurred in those reached by the intervention than in those not reached (n=1 vs n=3). CONCLUSIONS: Multidisciplinary outreach and use of evidence-based guidelines (Eighth Joint National Committee) were associated with lower blood pressure in patients with severe hypertension.

Current state of biologic pharmacovigilance in the European Union: improvements are needed.

INTRODUCTION: Pharmacovigilance is essential to monitoring the safety profiles of authorized medicines. Compared with small-molecule drugs, biological drugs are more complex, more susceptible to structural variability due to manufacturing processes, and have the potential to induce immune-related reactions, underscoring the importance of safety monitoring for these products. Although highly similar to reference products, biosimilars are not expected to be structurally identical. For these reasons, proper reporting of potential adverse drug reactions (ADRs) using distinguishable names and batch numbers is essential for accurate tracing of all biological drugs. To address the need for robust pharmacovigilance, the European Parliament and Council of the European Union provided legislation regarding pharmacovigilance of biologics in 2010. AREAS COVERED: This narrative review examines the current state of pharmacovigilance for biologics in the European Union (EU) and discusses relevant information on pharmacovigilance of biosimilars, the current EU pharmacovigilance system, and areas that could be improved. EXPERT OPINION: Although steps have been taken to improve pharmacovigilance of biologics in the EU, several enhancements can still be made, including additional training for healthcare professionals on ADR reporting, the use of 2D barcodes that enhance traceability, and an open discussion of potentially missed opportunities in the pharmacovigilance of biosimilars.

Cost and efficacy comparison of five prostate biopsy modalities: a platform for integrating cost into novel-platform comparative research.

BACKGROUND: The cornerstone of prostate cancer diagnosis remains the transrectal ultrasound-guided biopsy (TRUS-BX), which most frequently occurs in the office setting under local anesthesia. However, there are now other techniques of prostate biopsy aimed at improving outcomes such as patient comfort, significant cancer detection, and infectious complications. The purpose of the present study is to compare the cost and efficacy outcomes of five different approaches. METHODS: We compared the comprehensive costs of a random sample size of 20-30 cases from each of the following: (1) local anesthesia TRUS-BX (reference), (2) sedation TRUS-BX, (3) general anesthesia transperineal template biopsy (TP), (4) sedation MRI-TRUS fusion biopsy (FB), and (5) sedation in-bore MRI biopsy (IB-MRI). Cost categories included pre-procedure, anesthesia pharmacy and recovery, and the technical/professional costs from urology, radiology, and pathology services. For procedure outcomes, we compared the larger cohorts of TRUS-BX, TP, and FB in terms of indication, cancer yield, and downstream decision impact. RESULTS: Compared with standard TRUS-BX, the total costs of sedation TRUS-BX, TP, FB, and IB-MRI increased significantly ×1.9 (90%), ×2.5 (153%), ×2.5 (150%), and ×2.2 (125%), respectively (p < 0.001). Although there was no statistical difference between the total costs of TP, FB, and IB-MRI, these costs were significantly higher than those of TRUS-BX under either local anesthesia or sedation (p < 0.05). The cost of TRUS-BX under sedation was significantly higher than that of TRUS-BX under local anesthesia (p < 0.001). Compared to TRUS-BX, more significant cancers were detected in FB (16% vs. 36%) and TP (16% vs. 34%) groups (p < 0.001). CONCLUSIONS: Compared with standard TRUS-BX, the additions of imaging, sedation anesthesia, and transperineal template increase costs significantly, and can be considered along with known improvements in accuracy and side effects. Ongoing efforts to combine imaging and transperineal biopsy, especially in an outpatient/local anesthesia setting may lead to a higher cost/benefit.

Assessing adult attention deficit hyperactivity disorder (ADHD) in the university setting.

OBJECTIVE: To address the increasing demand for assessments of Adult Attention Deficit Hyperactivity Disorder (ADHD), the primary author developed a protocol for Counseling and Psychological Services (CAPS) at Stanford University's Vaden Student Health Center to improve the efficiency of such evaluations. PARTICIPANTS: As part of quality assurance, we reviewed the charts of Stanford students who sought assessment for ADHD before the protocol was implemented (September 2011-June 2013) and after the protocol was established (October 2013-August 2014). An IRB exemption was obtained. METHODS: The protocol includes questionnaires that solicit detailed clinical information from a variety of sources prior to the student's initial visit. RESULTS: A peer chart review of 35 randomly selected charts showed that students completing the protocol are receiving a more thorough assessment. CONCLUSION: The new Stanford ADHD protocol, designed to improve clinic efficiency, also increases the availability of relevant clinical information.

Psychological Trauma and LGBT Caregivers: A Conceptual Framework to Guide Practice.

LGBT adults face unique risk factors such as social isolation, discrimination, and victimization, and occasionally th ey engage in detrimental behaviors like high alcohol and drug use and risky sexual activity that negatively impacts psychological/physical health. These risks can affect their overall health and stress the relationship with an older caregiver/recipient-partner following exposure to acute medical event. The experience of an acute medical event among a LGBT caregiving partner can result in psychological trauma. In this article the authors present a conceptual framework involving stress process theory, life course theory, and family systems perspective to understand the effect of stressors on LGBT caregiving partners. Implications for social work practice include assessing, coordinating care, counseling and negotiating services at micro level, engaging family-centered approaches to support positive transition to caregiving role at mezzo level, and advocating for policy and cultural shifts to supports and diminish stigma of this group.

Comparison of Nondiabetic Retinal Findings Identified With Nonmydriatic Fundus Photography vs Ultrawide Field Imaging in an Ocular Telehealth Program.

IMPORTANCE: Ultrawide field imaging (UWFI) is increasingly being used in teleophthalmology settings. Given the greater area of the retina imaged, we evaluated the ability of UWFI vs nonmydriatic fundus photography (NMFP) to detect nondiabetic retinal findings in a teleophthalmology program. OBSERVATION: We conducted a retrospective single-center comparative cohort study from January 1, 2011, to June 30, 2013, imaging 3864 and 3971 consecutive teleophthalmology patients (7728 and 7942 eyes) using NMFP and UWFI, respectively. Standard diabetic retinopathy evaluation and nondiabetic findings were compared between the 2 imaging modalities. In patients without diabetic retinopathy (2243 by NMFP and 2252 by UWFI), the rate of identification of nondiabetic findings by NMFP (451 patients [20.1%]) and UWFI (490 [21.8%]) were comparable (P = .19). Ultrawide field imaging increased the identification of choroidal nevi by 27% (406 eyes [5.3%] by NMFP vs 545 eyes [6.9%] by UWFI; P < .001) and chorioretinal atrophy or scarring by 116% (50 eyes [0.6%] by NMFP vs 101 eyes [1.3%] by UWFI; P < .001). No peripheral retinal findings were identified with NMFP, while UWFI detected 25 retinal tears (0.3%; P < .001), 54 lattice and peripheral degenerations (0.7%; P < .001), and 142 cases of vitreous detachment or floaters (1.8%; P < .001). Data analysis was performed from November 1, 2013, to May 1, 2014. CONCLUSIONS AND RELEVANCE: In eyes without diabetic retinopathy, approximately 20% may have ocular findings identified on retinal imaging, which emphasizes the role of retinal imaging in patients with diabetes mellitus type 1 and type 2 regardless of the severity of retinopathy. In this cohort, UWFI increased the identification of peripheral retinal and vitreous pathologic findings.

Real-Time Ultrawide Field Image Evaluation of Retinopathy in a Diabetes Telemedicine Program.

OBJECTIVE: To evaluate the ability of trained nonphysician retinal imagers to perform diabetic retinopathy (DR) evaluation at the time of ultrawide field retinal (UWF) imaging in a teleophthalmology program. RESEARCH DESIGN AND METHODS: Clinic patients with diabetes received Joslin Vision Network protocol retinal imaging as part of their standard medical care. Retinal imagers evaluated UWF images for referable DR at the time of image capture. Training of the imagers included 4 h of standardized didactic lectures and 12 h of guided image review. Real-time evaluations were compared with standard masked gradings performed at a centralized reading center. RESULTS: A total of 3,978 eyes of 1,989 consecutive patients were imaged and evaluated. By reading center evaluation, 3,769 eyes (94.7%) were gradable for DR, 1,376 (36.5%) had DR, and 580 (15.3%) had referable DR. Compared with the reading center, real-time image evaluation had a sensitivity and specificity for identifying more than minimal DR of 0.95 (95% CI 0.94-0.97) and 0.84 (0.82-0.85), respectively, and 0.99 (0.97-1.00) and 0.76 (0.75-0.78), respectively, for detecting referable DR. Only three patients with referable DR were not identified by imager evaluation. CONCLUSIONS: Point-of-care evaluation of UWF images by nonphysician imagers following standardized acquisition and evaluation protocols within an established teleophthalmology program had good sensitivity and specificity for detection of DR and for identification of referable retinal disease. With immediate image evaluation, <0.1% of patients with referable DR would be missed, reading center image grading burden would be reduced by 60%, and patient feedback would be expedited.

Caregivers of veterans with "invisible" injuries: what we know and implications for social work practice.

Today, as a result of the longest volunteer-fought conflict in U.S. history, there are many wounded coming home not only with posttraumatic stress disorder (PTSD), but also with traumatic brain injury (TBI), which together have been called the "signature" or "invisible" injuries of the Iraq and Afghanistan wars. Caregivers are an important part of their recovery, yet little is known about them, as previous research on caregivers mostly focused on geriatric populations. According to one estimate 275,000 to 1 million people are currently caring or have cared for loved ones who have returned from Iraq and Afghanistan. These caregivers are unique in that they are younger, some with children, and they are caring for a unique under-studied population for longer periods of time. This article summarizes literature on caregivers of veterans who suffer from PTSD, TBI, or both; provides a theoretical framework; and discusses implications for social workers in assisting caregivers and their families.

Potential efficiency benefits of nonmydriatic ultrawide field retinal imaging in an ocular telehealth diabetic retinopathy program.

OBJECTIVE To compare efficiency of nonmydriatic ultrawide field retinal imaging (UWFI) and nonmydriatic fundus photography (NMFP) in a diabetic retinopathy (DR) ocular telehealth program. RESEARCH DESIGN AND METHODS Patients in this retrospective, comparative cohort study underwent NMFP and UWFI between 1 November 2011 and 1 November 2012. Images were evaluated for DR and diabetic macular edema (DME) by certified graders using a standard protocol at a centralized reading center. Identification of DR, image evaluation time, and rate of ungradable eyes were compared. RESULTS NMFP and UWFI were performed in 1,633 and 2,170 consecutive patients, respectively. No statistically significant differences were found between groups regarding age, diabetes duration, sex, ethnicity, or insulin use. The ungradable rate per patient for DR (2.9 vs. 9.9%, P < 0.0001) and DME (3.8 vs. 8.8%, P < 0.0001) was lower with UWFI than with NMFP. With UWFI, the median image evaluation time per patient was reduced from 12.8 to 9.2 min (P < 0.0001). The identification of patients with DR (38.4 vs. 33.8%) and vision-threatening DR (14.5 vs. 11.9%) was increased with UWFI versus NMFP. In a consecutive subgroup of 502 eyes of 301 patients with DR, the distribution of peripheral retinal lesions outside Early Treatment Diabetic Retinopathy Study fields suggested a more severe DR level in 9.0% (45 eyes). CONCLUSIONS In a standardized DR ocular telehealth program, nonmydriatic UWFI reduced the ungradable rate by 71% (to <3%) and reduced image evaluation time by 28%. DR was identified 17% more frequently after UWFI, and DR peripheral lesions suggested a more severe DR level in 9%. These data suggest that UWFI may improve efficiency of ocular telehealth programs evaluating DR and DME.

Imager evaluation of diabetic retinopathy at the time of imaging in a telemedicine program.

OBJECTIVE: To evaluate the ability of certified retinal imagers to identify presence versus absence of sight-threatening diabetic retinopathy (stDR) (moderate nonproliferative diabetic retinopathy or worse or diabetic macular edema) at the time of retinal imaging in a telemedicine program. RESEARCH DESIGN AND METHODS: Diabetic patients in a primary care setting or specialty diabetes clinic received Joslin Vision Network protocol retinal imaging as part of their care. Trained nonphysician imagers graded the presence versus absence of stDR at the time of imaging. These gradings were compared with masked gradings of certified readers. RESULTS: Of 158 patients (316 eyes) imaged, all cases of stDR (42 eyes [13%]) were identified by the imagers at the time of imaging. Six eyes with mild nonproliferative diabetic retinopathy were graded by the imagers to have stDR (sensitivity 1.00, 95% CI 0.90-1.00; specificity 0.97, 0.94-0.99). CONCLUSIONS: Appropriately trained imagers can accurately identify stDR at the time of imaging.

A conjunctival lesion with histological features similar to large-cell acanthoma of the skin.

Large-cell acanthoma (LCA) is a sharply demarcated epidermal lesion composed of large keratinocytes and characterized by hyperkeratosis, hypergranulosis and orthokeratosis. It usually affects actinically damaged skin. LCA is currently believed to be a distinct entity with an unclear pathogenesis and a benign biologic behavior. Here, we describe the first occurrence of LCA in the conjunctiva. The lesion recurred following initial excision, and later recurred as a carcinoma in situ following a second excision. This case suggests that LCA may have a malignant and transformation potential.

Comparison of macular optical coherence tomography findings between postacute retinal artery occlusion and nonacute optic neuropathy.

PURPOSE: The purpose of this study was to report differentiating optical coherence tomography (OCT) findings between postacute retinal arterial occlusion (PARAO) and nonacute optic neuropathy (NAON). METHODS: A retrospective observational comparative study included 17 eyes with postacute permanent retinal arterial occlusion and 32 eyes with NAON whose assessment included a fast macular Status OCT. The macular OCT changes in the postacute phase of central retinal arterial occlusion and branch retinal arterial occlusion were, respectively, compared with those in diffuse and segmental NAON in an effort to establish differentiating features. The findings were used in the workup of four additional consecutive cases referred with suspected NAON. RESULTS: Three main features differentiating PARAO from NAON were identified on macular OCT. Complete inner retinal atrophy with loss of the normal stratification of the inner retinal layers, loss of the normal foveal depression, and marked thinning of the involved retina were characteristic findings of PARAO and were absent even in the most severe cases of NAON. The involved retina was significantly thinner in PARAO compared with that in NAON (P < 0.05). These OCT features helped establish the diagnosis of PARAO in four additional consecutive cases referred with the misdiagnosis of NAON. CONCLUSION: The extent and pattern of inner retinal atrophy differentiate PARAO from NAON and help guide the systemic workup.

Kickin' Asthma: school-based asthma education in an urban community.

BACKGROUND: In urban communities with high prevalence of childhood asthma, school-based educational programs may be the most appropriate approach to deliver interventions to improve asthma morbidity and asthma-related outcomes. The purpose of this study was to evaluate the implementation of Kickin' Asthma, a school-based asthma curriculum designed by health educators and local students, which teaches asthma physiology and asthma self-management techniques to middle and high school students in Oakland, CA. METHODS: Eligible students were identified through an in-class asthma case identification survey. Approximately 10-15 students identified as asthmatic were recruited for each series of the Kickin' Asthma intervention. The curriculum was delivered by an asthma nurse in a series of four 50-minute sessions. Students completed a baseline and a 3-month follow-up survey that compared symptom frequency, health care utilization, activity limitations, and medication use. RESULTS: Of the 8488 students surveyed during the first 3 years of the intervention (2003-2006), 15.4% (n = 1309) were identified as asthmatic; approximately 76% of eligible students (n = 990) from 15 middle schools and 3 high schools participated in the program. Comparison of baseline to follow-up data indicated that students experienced significantly fewer days with activity limitations and significantly fewer nights of sleep disturbance after participation in the intervention. For health care utilization, students reported significantly less frequent emergency department visits or hospitalizations between the baseline and follow-up surveys. CONCLUSIONS: A school-based asthma curriculum designed specifically for urban students has been shown to reduce symptoms, activity limitations, and health care utilization for intervention participants.

Success of a comprehensive school-based asthma intervention on clinical markers and resource utilization for inner-city children with asthma in Chicago: the Mobile C.A.R.E. Foundation's asthma management program.

Children with asthma in low-income households in Chicago were participants in a school-based mobile van clinic, Mobile C.A.R.E. Our objective was to investigate whether long-term follow-up changed clinical markers and resource utilization. Children were evaluated by a pediatrician in a mobile allergy clinic and classified and treated based on National Asthma Education and Prevention Program (NAEPP) guidelines. Intervention consisted of assessment of allergic environment with avoidance recommendations, institution of appropriate controller therapy and inhaler technique, education on asthma and asthma management, and expectations for asthma control. Over 20,000 children were screened, 2041 were examined at least once, and 677 children had four follow-up visits. With follow-up, there was a decrease in hospitalizations and emergency room visits. Symptomatic markers (daytime and nighttime cough, wheezing, and dyspnea symptoms), frequency of rescue inhaler use, and a quality-of-life score improved from baseline. These findings suggest that ongoing school interventions may reduce resource utilization and improve clinical symptoms. Primary care physicians may be able to deliver specialized care to large numbers of inner-city children with asthma.

Evaluation of emphysema severity and progression in a rabbit model: comparison of hyperpolarized 3He and 129Xe diffusion MRI with lung morphometry.

The apparent diffusion coefficients (ADCs) of hyperpolarized (3)He and (129)Xe gases were measured in the lungs of rabbits with elastase-induced emphysema and correlated against the mean chord length from lung histology. In vivo measurements were performed at baseline and 2, 4, 6, and 8 wk after instillation of elastase (mild and moderate emphysema groups) or saline (control group). ADCs were determined from acquisitions that used two b values. To investigate the effect of b value on the results, b-value pairs of 0 and 1.6 s/cm(2) and 0 and 4.0 s/cm(2) were used for (3)He, and b-value pairs of 0 and 5.0 s/cm(2) and 0 and 10.0 s/cm(2) were used for (129)Xe. At 8 wk after instillation, the rabbits were euthanized, and the lungs were analyzed histologically and morphometrically. ADCs for the rabbits in the control group did not change significantly from baseline to week 8, whereas ADCs for the rabbits in the emphysema groups increased significantly (P < 0.05) for all gas and b-value combinations except (129)Xe with the b-value pair of 0 and 5.0 s/cm(2). The largest percent change in mean ADC from baseline to week 8 (15.3%) occurred with (3)He and the b-value pair of 0 and 1.6 s/cm(2) for rabbits in the moderate emphysema group. ADCs (all b values) were strongly correlated (r = 0.62-0.80, P < 0.001) with mean chord lengths from histology. These results further support the ability of diffusion-weighted MRI with hyperpolarized gases to detect regional and global structural changes of emphysema within the lung.

Management of anaphylaxis in child care centers: evaluation 6 and 12 months after an intervention program.

BACKGROUND: Many young children with a history of allergic reactions or anaphylaxis spend considerable time in child care centers. We previously reported that a significant knowledge deficit exists in anaphylaxis recognition, evaluation, and treatment and that greater anaphylaxis education is needed among child care providers. OBJECTIVE: To determine whether child care centers can recognize, evaluate, and treat anaphylactic episodes in children aged 1 to 6 years 6 months and 1 year after attending an allergy seminar. METHODS: All 39 child care centers participating in the original study were selected to complete 6-month and 1-year follow-up surveys using a similar questionnaire. Those who did not attend the seminar or complete all the previous surveys were excluded. RESULTS: At 6 months and 1 year, 37 and 29 centers, respectively, completed surveys. There was a significant improvement regarding when to administer intramuscular epinephrine compared with before the allergy seminar. However, only 48% of the centers at 6 months (P = .02) and 31% at 1 year (P = .002) knew how to correctly administer intramuscular epinephrine compared with 77% four weeks after the seminar. With time, there was a significant decline in correctly recognizing typical anaphylaxis symptoms, including abdominal cramping, chest tightness, shortness of breath, low blood pressure, and diarrhea, whereas symptoms such as hives, swelling, and wheezing continued to be identified correctly. CONCLUSIONS: There is a need for renewed anaphylaxis education among child care providers. Initially, this intervention significantly increased the ability of child care center staff to recognize, evaluate, and treat anaphylaxis, but knowledge diminished gradually at 6-month and 1-year follow-up.

Recognition, evaluation, and treatment of anaphylaxis in the child care setting.

BACKGROUND: Anaphylaxis can occur anywhere. Many young children with a history of allergic reactions or anaphylaxis spend considerable time in child care centers. However, little is known about the centers' knowledge of, experience with, and capability to manage anaphylaxis. OBJECTIVE: To evaluate the ability of child care centers to recognize, evaluate, and treat anaphylactic episodes in children aged 1 to 6 years. METHODS: Eighty-five child care centers in the suburbs of Chicago were randomly selected. They were contacted by telephone and asked to participate in a study by completing an initial questionnaire. Center directors and teachers were then offered an allergy seminar addressing anaphylaxis avoidance, recognition, evaluation, and treatment. Center directors completed a questionnaire after the seminar. RESULTS: Forty-four of the 85 centers contacted agreed to participate. Forty-two surveys were completed before the seminar and 39 after the seminar. On average, each center has up to 7 children with an identifiable food allergy. Information provided by the parents was the most commonly reported source of education concerning allergies. Before seminar completion, only 24% of child care centers would administer intramuscular epinephrine for a severe allergic reaction. After the seminar, 77% of centers stated that they would administer intramuscular epinephrine (P < .001). Also, center staff significantly improved their knowledge of typical allergy symptoms and of the correct method of intramuscular epinephrine administration. CONCLUSIONS: There is a need for greater anaphylaxis education among child care providers. Our intervention significantly increased the ability of child care staff to recognize, evaluate, and treat anaphylaxis.