Management of Black Spot of Rose with Winter Fungicide Treatment.

Fungicides were evaluated for their efficacy against black spot of rose, caused by Diplocarpon rosae, when applied during winter months to hybrid tea rose plants in two studies. One study, conducted at two Auburn University campus sites, consisted of applications of horticultural oil, chlorothalonil plus an antitranspirant, and cyproconazole, along with nontreated plants; one site included triforine applications. Rose canes were treated two and three times between late October and February in 1996-97 and 1997-98, respectively; then plants were examined every 2 to 4 days beginning in mid-February for onset of symptoms of black spot. In both years, winter applications of fungicides (chlorothalonil, cyproconazole, and triforine) delayed disease onset compared with treatments without fungicides (nontreated and oil applications). Decreased plant defoliation, as well as improved plant vigor, were observed through the 1998 growing season following fungicidal winter treatments at campus sites; winter treatments with oil did not suppress disease compared with no treatment. In a second study started in November 1997, at a site near Shorter, AL, three systemic fungicides (myclobutanil, cyproconazole, and triforine) were applied to rose canes during the winter; nontreated plants were included. Decreased disease symptoms and defoliation of rose plants were observed early in the 1998 and 1999 seasons following winter applications of cyproconazole and triforine compared with myclobutanil or nontreated plants. Winter treatments with these fungicides did not consistently provide season-long reduction of black spot. However, season-long plant vigor and flower production on plants were improved at the Shorter site following winter applications of any of the above systemic fungicides compared with nontreated plants.

Quality of care and use of the medical home in a state-funded capitated primary care plan for low-income children.

OBJECTIVE: To evaluate the quality of care and use of the medical home in a state-funded capitated insurance plan for low-income children-the Colorado Child Health Plan (CCHP). DESIGN: A retrospective cohort study using medical record review at pediatric and family practice offices in 4 geographic areas of Colorado. At each practice, CCHP-enrolled children (6 months to 6.5 years) and 2 controls were selected, 1 with Medicaid (MK) and 1 with private insurance (PI), matched by date of birth to the CCHP-enrolled child (N = 596). CCHP-enrolled children with a diagnosis of asthma, aged 3 to 18 years, and asthmatic children with MK and PI, matched by age, were also selected from each practice (N = 139). RESULTS: Quality of preventive services were comparable in the 3 groups. CCHP-enrolled children made more health maintenance visits than MK-enrolled children (1.3 CCHP vs.9 MK vs 1.1 PI) and were more frequently screened for lead (8.1% CCHP vs 3.4% MK vs 1.2% PI) and anemia (5.0% CCHP vs 4.4% MK vs 2.4% PI) than children in either control group. Documented immunization rates were similar in the 3 groups, but a shift in location of immunization from public health clinics to the primary care site was seen in the CCHP group. CCHP-enrolled children made more office visits for acute care than did MK-enrolled children (4.1 CCHP vs 3.1 MK vs 3.4 PI), but a higher proportion of these visits took place at the medical home rather than the emergency department for the CCHP group (.04) as compared with the MK (.07) or PI (.06) groups. Asthmatic children in the CCHP group made more preventive office visits for maintenance therapy and more frequently used the primary care site rather than the emergency department for acute exacerbations than did children with PI (mean ratio of emergency department visits to total acute visits.04 CCHP vs.06 MK vs.19 PI). CONCLUSIONS: Despite capitated reimbursement for primary care services, CCHP provided children from low-income families with preventive, acute, and chronic care services of comparable quantity and quality to those received by children with MK or PI. The program was associated with a shift of immunization location to the primary care site and increased health maintenance care for new enrollees. CCHP-enrolled children used their medical home for the majority of acute health needs and were not high utilizers of emergency department or hospital services.

Contingency management in outpatient methadone treatment: a meta-analysis.

A meta-analysis was conducted on contingency management interventions in outpatient methadone treatment settings. The outcome measure of interest was drug use during treatment, as detected through urinalysis. The results confirm that contingency management is effective in reducing supplemental drug use for these patients. The analysis of behavioral interventions yielded an overall effect size (r) of 0.25 based on 30 studies. Significant moderators of outcomes included type of reinforcement provided, time to reinforcement delivery, the drug targeted for behavioral change, number of urine specimens collected per week, and type of subject assignment. These factors represent important considerations for reducing drug use during treatment.

Continuous twice daily or once daily amoxicillin prophylaxis compared with placebo for children with recurrent acute otitis media.

OBJECTIVE: To determine the effectiveness of amoxicillin administered continuously twice daily vs. once daily vs. placebo to prevent new episodes of acute otitis media (AOM). DESIGN: Randomized, double blind, placebo-controlled clinical trial at a hospital-based general pediatric clinic and a private pediatric practice, both in Denver, CO. PARTICIPANTS: One hundred ninety-four children (age 3 months through 6 years) were enrolled with 3 documented AOM episodes within the prior 6 months, without ventilating tubes or associated anatomic defects, immunodeficiency disorders or allergy to penicillin. Thirty-six were noncompliant and were excluded from the study, leaving 158 evaluable subjects. INTERVENTIONS: The amoxicillin dosage was 20 mg/kg/day either bid or qd. After randomization to placebo twice daily (bid), amoxicillin once daily (qd)/placebo qd or amoxicillin bid, patients were followed monthly and were also seen for upper respiratory infection symptoms during enrollment in the trial. Development of two new AOM episodes terminated the patients from the study. MEASUREMENTS/MAIN RESULTS: Incidence density (ID) measurements were calculated for all study subjects and were stratified by age and season. Overall study subjects in all 3 arms of the trial had 7243 days at risk during which time they developed 56 new AOM episodes for a annual ID of 2.82. There were no significant differences in the IDs between amoxicillin qd vs. bid or amoxicillin (bid or qd) vs. placebo. After stratifying by age and season of enrollment, there were no significant differences in ID rates among the 3 groups. The proportion of subjects remaining otitis-free was 63% for the placebo group, 64% for once daily amoxicillin and 61% for twice daily amoxicillin. CONCLUSION: While once-a-day dosing was equivalent to twice-a-day dosing for amoxicillin prophylaxis, there was no benefit of amoxicillin prophylaxis compared with a placebo control in preventing new AOM episodes. Because of the potential of excessive antibiotic use to promote the acquisition of resistant pneumococci and the lack of effectiveness in this trial, routine use of amoxicillin prophylaxis should be discouraged.

Practice variations among pediatricians and family physicians in the management of otitis media.

OBJECTIVES: To determine theoretical practice patterns and Medicaid practices in the management of persistent and recurrent otitis media by family physicians and pediatricians in Colorado. METHODS: Members of the Colorado chapters of the American Academy of Pediatrics and the Colorado Academy of Family Medicine were surveyed with the use of two hypothetical case management scenarios for which they were asked to indicate which International Classification of Diseases, Ninth Revision, Medicaid codes they would use. Physicians were presented with two case scenarios (one involving a persistent asymptomatic middle ear effusion and the second involving recurrent otitis media) and were asked to choose from a variety of management options, including observation, antibiotic therapy, decongestants, corticosteroids, antibiotic prophylaxis, and referral for ventilation tube surgery. RESULTS: Family physicians would have prescribed high-cost antibiotics (amoxicillin plus clavulanate potassium, cefaclor, or cefixime) to treat persistent middle ear effusions twice as often as pediatricians would have (P < .002). At the 6-week visit, 50 family physicians (43%) would administer an oral decongestant either alone or in combination with other therapy as compared with 16 (14%) of pediatricians (P < .001). Family physicians would refer patients for ventilating tube surgery three times more often than pediatricians at the 9-week visits (P < .001). Recurrent episodes of acute otitis media would be managed similarly by both physician groups. Respondents reported a wide variety of International Classification of Diseases, Ninth Revision, coding, often coding persistent effusions as acute otitis or as unspecified otitis media. CONCLUSIONS: The findings of this survey document the wide variation in practice patterns for treating children with persistent otitis media and children with recurrent otitis media in Colorado.

Time-frequency analyses of thyroarytenoid myoelectric activity in normal and spasmodic dysphonia subjects.

Digital recordings of thyroarytenoid (TA) myoelectric activity (via percutaneous hooked-wire electrodes) were obtained for 10 normal control subjects and 10 subjects with spasmodic dysphonia during performance of five tasks of varying complexity: quiet breathing, Valsalva maneuver, whispered /i/, voiced /i/, and "beep beep went the heap." Time-frequency power spectral density functions, PSD(f,t), were determined for a selected segment of the signals, and measures of median frequency, mean frequency, bandwidth, and center frequency of PSD(f,t) were derived for each sample point. Statistical median, mean, standard deviation, minimum, maximum, and mode of the power spectral density measures were computed to compose feature vectors for each TA myoelectric recording. Statistical pattern recognition procedures using maximum likelihood classification tests were applied to the feature space to discriminate disordered from normal speakers for each task. Findings indicate a high level of discriminability between subject groups for phonated speaking tasks in contrast to low levels of discriminability for whispered and nonspeech tasks. Graphical presentations of three-dimensional PSD(f,t) plots are given that illustrate changes in spectral characteristics of TA EMG at the onset of laryngospasm.

Statistical analyses of electromyographic activity in spasmodic dysphonic and normal control subjects.

Heterogeneity in the quality and task sensitivity of vocal symptoms in the spasmodic dysphonia (SD) population contributes to controversy as to whether this is a single disorder or two disorders with different etiologies (neurogenic versus psychogenic). Perceptual and acoustic assessments of vocal symptoms are inadequate to resolve this controversy. However, myoelectric events are intimately proximal to the source of vocal disruption and may be informative. The present report employs statistical modeling of quantitative amplitude measures of electromyographic activity recorded from thyroarytenoid to examine neuromotor bases of vocal symptoms in SD. Consideration of perceptual ratings of the quality and task sensitivity of vocal symptoms in the context of statistical models provides support for the conclusion that the range of vocal symptoms identified as SD represents a single, neurogenic disorder.

Theoretical cost effectiveness of management options for children with persisting middle ear effusions.

OBJECTIVE: The purpose of this theoretical study is to assess the cost effectiveness of options involving observation, antibiotics alone, corticosteroids alone, corticosteroids plus antibiotics, and surgery to clear persisting middle ear effusions during three visits. METHODOLOGY: In a hypothetical case the expected average per patient expenditures are calculated using the efficacy rates determined by the meta-analysis of randomized controlled clinical trials involving corticosteroids plus an antibiotic (six trials), corticosteroids alone (three trials), and antibiotic alone (four trials). In this analysis, all children whose bilateral middle ear effusions persist for 12 weeks despite medical management are referred for ventilating tubes. RESULTS: The most cost-effective intervention combination is corticosteroid plus an antibiotic at visit 1 (6 weeks after diagnosis of acute otitis media) followed by a second antibiotic in nonresponders at visit 2 (9 weeks after diagnosis of acute otitis media) and referral for ventilating tubes in nonresponders at visit 3 (12 weeks after diagnosis of acute otitis media). The expected average expenditures per case to clear the bilateral middle ear effusions is $600.91 based on reimbursement of private practice charges and $350.27 based on Medicaid reimbursement (all payments to providers are based on 1992 data from Colorado). The difference in the expected average total expenditures per case between this most cost-effective approach versus the use of sequential courses of antibiotics followed by surgery is $372.81 ($973.72-$600.91) with full reimbursement of private practice charges and $202.57 ($552.84-$350.27) with Medicaid reimbursement. In clearing the middle ear effusion, the average estimated travel expenses per case is $21.46, and lost parental wages per case are $45.12. When the expenditures associated with an additional 6-month follow-up period are included, the expected average per case expenditures is $1088.54 with reimbursement of private practice charges and @659.00 with Medicaid reimbursement. The difference in the expected average per case expenditures to clear the effusions and follow-up for 6 months between the most cost-effective approach using corticosteroids plus antibiotics at the 6- and 9-week visits followed by surgery in nonresponders at 12 weeks versus sequential courses of antibiotics is $405.30 ($1493.84-$1088.54) with reimbursement of private practice charges and $217.32 ($876.32-$659.00) with Medicaid reimbursement. RECOMMENDATIONS: Although the analysis does not consider risks, side effects, and parental or provider preferences, the findings suggest that the implementation of cost-effective clinical guidelines can potentially reduce national expenditures for managing persistent middle ear effusions.

Factors influencing outcome in children treated with antibiotics for acute otitis media.

Factors affecting outcome were analyzed from 3 antibiotic clinical trials that had identical case definition and outcome criteria. Overall 102 subjects with acute otitis media had an initial tympanocentesis, were enrolled in one of the clinical trials, were randomized to receive 10 days of oral treatment and had a posttherapy visit. The antibiotics used were cefixime (38), cefaclor (25), loracarbef (14), amoxicillin plus clavulanate (16) or amoxicillin (9). Fifty-five of the 102 (54%) study subjects were classified as cured or improved at the 21- to 28-day posttherapy visit. Factors analyzed in relation to outcome included antibiotic administered, isolation of a pathogen from the middle ear aspirate, study subject age and sex, history of recurrent otitis media, unilateral vs. bilateral involvement, season of enrollment and history of antibiotic administration in the month before enrollment. Univariate analysis identified the following four factors associated with higher posttherapy visit failure rates: a history of recurrent otitis media; enrollment during winter respiratory season (December through March); a history of being treated with an antibiotic during the month before enrollment; and administration of cefaclor compared with other antibiotics. However, only a history of recurrent otitis media and enrollment during the winter respiratory season met the 0.05 significance level for entry into a model derived from logistic regression to assess interactions among factors. Clinical guidelines for the management of otitis media should take into consideration that children with a prior history or recurrent otitis media and infection during the winter season more often fail to respond to antibiotic treatment and have a higher risk of developing a persistent middle ear effusion.

Immunoglobulin G, total and subclass, in children with or without recurrent otitis media.

Total IgG and subclasses IgG1, IgG2, IgG3, and IgG4 were measured in 89 subjects with recurrent otitis media. There was no significant difference between the groups with respect to the arithmetic or geometric mean levels for total IgG or subclasses IgG1, IgG2, IgG3, or IgG4.

Effectiveness of continuous vs. intermittent amoxicillin to prevent episodes of otitis media.

The effectiveness of continuous compared with intermittent amoxicillin prophylaxis administered to subjects with a history of recurrent otitis media enrolled during the winter respiratory infection season was assessed in a prospective single blinded clinical trial. Patients with three or more chart-documented episodes of otitis media (OM) in the preceding 6 months were enrolled and randomly assigned to each treatment group. Patients in the continuous group received amoxicillin twice a day every day for up to 4 months. During the same period patients in the intermittent group received amoxicillin twice a day only when they developed respiratory symptoms of congestion, runny nose or cough. Among the 30 patients receiving continuous amoxicillin who were followed for at least 3 months, 22 (73%) had no OM episodes and 8 (28%) had one OM episode. Among the 25 patients receiving intermittent amoxicillin for at least 3 months, 13 (52%) had no OM episodes, 8 (32%) had 1 episode and 4 (16%) had 2 episodes. Significantly fewer patients had fewer than 2 OM episodes on continuous compared with intermittent amoxicillin (P less than 0.04). The incidence density was 0.46 episode/120 days at risk in the continuous treatment group compared with 1.10 episodes/120 days at risk for intermittent treatment (P less than 0.03). Among patients 12 months or older the incidence density of OM episodes per 120 days was 3.5 times higher in the intermittent amoxicillin group (0.80) compared with the continuous amoxicillin group (0.23) (P = 0.05). The incidence densities of the continuous vs. intermittent therapy groups did not differ significantly for patients younger than 12 months of age. The findings suggest that continuous amoxicillin prophylaxis may be more effective than intermittent treatment in preventing OM episodes in patients 12 months or older with a history of recurrent otitis media.

Multichannel electromyographic observations in spasmodic dysphonia patients and normal control subjects.

Spasmodic dysphonia is primarily a disorder of vocalization. Increasing evidence, however, suggests that individuals with this disorder comprise a heterogeneous population characterized by abnormal motor control throughout the vocal tract. Multichannel simultaneous electromyography was performed on 11 spasmodic dysphonia patients and 10 normal awake subjects to investigate both the distribution of neuromotor abnormality within the vocal tract (eg, intrinsic and extrinsic laryngeal muscles, tongue, and palate) and the contribution of activation of higher central nervous system centers to observed abnormality. Experimental tasks ranged from vegetative (quiet breathing) to simple linguistic (short sentences). Digitized electromyographic signals were analyzed to compute the amplitude envelope and extract a set of parameters that represent amplitude characteristics. Electrode insertions were cross-validated by quantitative analysis of patterns of activation across selected reference tasks and by traditional qualitative methods. Between-group differences were found for measures of normalized median and peak token amplitudes. These differences are both task- and measure-dependent. Results highlight the complex and interactive effects of muscle, task, and quantitative measures on between-group differences.

Respiratory rate: measurement of variability over time and accuracy at different counting periods.

The respiratory rates/minute of 97 children were monitored every 10-15 minutes over one hour, by an observer and by pneumogram, at which times two 30 second and one 60 second counts were obtained. The children were under 5 years of age with lower respiratory tract infections (n = 20), upper respiratory tract infections (n = 34), or controls without acute respiratory infection (n = 43). The difference between respiratory rate count determined simultaneously by observation and pneumogram in relation to their mean count was analysed for the 60 second counting period, 30 plus 30 second period, and the 30 second period doubled. The mean difference for the 60 second period was 1.79, for the 30 plus 30 second period 1.42, and for the 30 second period doubled 1.72. The variability between respiratory rate counts determined by observation and pneumogram was significantly lower in counts obtained when the subject was sleeping and higher when agitated compared with obtaining a count when the subject was awake and calm or feeding. The variability was also significantly lower in subjects with lower respiratory tract infections compared with those with upper respiratory tract infections and control subjects without respiratory symptoms. In the same patient, over the one hour, 50% of the 60 second counts varied by up to 14 breaths/minute and 75% by up to 21 breaths/minute. The least variability was seen in children with a lower respiratory tract infection, who tended to maintain their rapid breathing in contrast to those with an upper respiratory tract infection and controls without respiratory symptoms. About 10% of initial 30 second counts, 12% of 60 second, and 16% of initial and repeat 30 second attempts to obtain accurate counts failed. Failures occurred more frequently in children <2 months of age and those agitated. The data from this study suggest that one minute's counting either at a stretch or in two blocks of 30 second intervals is better than counting the respiratory rate for 30 seconds, when the child is either awake and calm or when asleep.

Laryngeal electromyographic activity in adductor and abductor spasmodic dysphonia.

Vocal symptoms in spasmodic dysphonia (SD) range from strain-strangle phonation and glottal-stop phonatory breaks of adductor SD to breathy phonation and aspirate phonatory breaks of abductor SD. Many SD subjects show both symptom types. Heterogeneity in vocal symptoms contributes to controversy surrounding the etiology(s) of SD. Acoustic/perceptual analyses of vocal symptoms are inconclusive in resolving this controversy. This investigation moves the search for distinguishing features of adductor and abductor SD to the level of neuromuscular control and analysis of intrinsic laryngeal muscle (adductor and abductor) activity. Subjects rated perceptually as primarily adductor or abductor SD sustained production of vegetative gestures and isolated speech sounds (/i/ and /s/). Qualitative and quantitative analyses of electromyographic signals recorded from thyroarytenoid (TA) failed to differentiate SD subjects by symptom type. Analysis of TA and posterior cricoarytenoid (PCA) activity in one abductor SD revealed high levels in both muscles during production of the voiced vowel. Data suggest that a possible explanation for symptom heterogeneity in SD is the relation between disrupted neuromotor input to laryngeal muscles and reflexive or conscious compensations constrained by laryngeal biomechanics.

Systems architecture for quantification of dynamic myoelectric and kinematic activity of the human vocal tract.

This paper describes a systems architecture useful for scientific investigations that require the acquisition and analysis of multiple, time-synchronous signals in large volume. The architecture has recently been developed by this group to enhance our capability to research and quantify central nervous system function in the production of normal and pathologic speech. The architecture utilizes modern advances in desktop microcomputers and has been designed so that vocal motor control laboratories (or similar settings) with modest funding can more fully participate in comprehensive investigations of speech production. Research experiments organized with this architecture may involve many more subjects and measures than previously possible without significant increases in time and personnel resources. This paper will demonstrate the technique and practicality of this architecture as it is being used to successfully guide research to map hierarchic central nervous system regions of involvement in two speech disorders: spasmodic dysphonia and stuttering. The architecture has broad usefulness to many areas of otolaryngology and health science.

Management of chronic middle ear effusion with prednisone combined with trimethoprim-sulfamethoxazole.

Fifty-three patients were enrolled and evaluable in a randomized, double-blinded controlled clinical trial comparing prednisone for 7 days plus trimethoprim-sulfamethoxazole (TMP/SMZ) for 30 days vs. TMP/SMZ alone in treating chronic middle ear effusion (MEE). Clearing of the effusion in both ears or in one when only one was involved was called complete resolution; clearing in one of two affected ears was called partial resolution. The outcomes 2 weeks after initiation of therapy of 26 patients initially treated with prednisone plus TMP/SMZ were complete resolution in 20, partial resolution in three, and unchanged in three. The outcomes in 27 patients initially treated with TMP/SMZ alone were complete resolution in eight, partial resolution in three, unchanged in 13 and development of acute otitis media in three (P less than 0.01 for complete resolution). Two weeks after initiation of therapy, patients with a MEE that failed to clear were crossed over to the alternative regimen. Overall 29 of 41 patients (71%) who received oral prednisone plus TMP/SMZ initially or after the crossover had complete resolution of their middle ear effusion at 2 weeks after starting prednisone and TMP/SMZ. Five of 35 (14%) patients treated with prednisone plus TMP/SMZ and one of six (17%) patients treated with TMP/SMZ alone who had complete resolution at 4 weeks required subsequent referrals for tympanostomy tubes. A course of prednisone for 7 days plus TMP/SMZ for 30 days with monthly follow-up should be considered in children with MEE persisting beyond 6-8 weeks before referral for tympanostomy tube placement.

Glucose kinetics in gluconeogenesis-inhibited rats during rest and exercise.

To evaluate the role played by gluconeogenesis in blood glucose homeostasis, female Sprague-Dawley rats were injected with mercaptopicolinic acid (MPA), a gluconeogenic inhibitor. Glucose kinetics were assessed by primed, continuous infusion of [U-14C]- and [6(-3)H]glucose via an indwelling jugular catheter at rest and during submaximal exercise at 13.4 m/min on level grade. Blood samples were taken from carotid catheters and analyzed for glucose and lactate concentrations and specific activities. Tissue glycogen samples were obtained from rats after exercise as well as from unexercised animals. When compared with the sham-injected animals, MPA-treated animals had 22% lower (5.92 +/- 0.36 vs. 7.62 +/- 0.21 mM) and 44% higher (1.90 +/- 0.11 vs. 1.32 +/- 0.09 mM) resting arterial glucose and lactate concentrations, respectively. Resting glucose appearance (Ra) rates were 20% lower in the MPA-treated animals (57.2 +/- 7.5 mumol.kg-1.min-1) than in the sham-injected animals (71.1 +/- 12.1 mumol.kg-1.min-1). During exercise, Ra increased to 174.7 +/- 32.8 mumol.kg-1.min-1 in sham-injected animals. In the MPA-treated animals, there was a 35% increase during the first 15 min of exercise, followed by a decrease to the resting values. MPA-treated animals had no measurable glucose recycling at rest or during exercise. Exercise decreased blood glucose concentration (35%) and increased blood lactate concentration (160%) in the MPA-treated animals. Exercising sham-injected animals had increased blood glucose (9.8%) but no change in blood lactate concentration. Moderate depletions in liver and skeletal muscle glycogen contents were observed after exercise.(ABSTRACT TRUNCATED AT 250 WORDS)