Variation in Host and Pathogen in the Neonectria/Malus Interaction; toward an Understanding of the Genetic Basis of Resistance to European Canker.

Apple canker caused by the phytopathogenic fungus Neonectria ditissima is an economically important disease, which has spread in recent years to almost all pome-producing regions of the world. N. ditissima is able to cross-infect a wide range of apple varieties and causes branch and trunk lesions, known as cankers. Most modern apple varieties are susceptible and in extreme cases suffer from high mortality (up to 50%) in the early phase of orchard establishment. There is no known race structure of the pathogen and the global level of genetic diversity of the pathogen population is unknown. Resistance breeding is underway in many global breeding programmes, but nevertheless, a total resistance to canker has not yet been demonstrated. Here we present preliminary data from a survey of the phylogenetic relationships between global isolates of N. ditissima which reveals only slight evidence for population structure. In addition we report the results of four rapid screening tests to assess the response to N. ditissima in different apple scion and rootstock varieties, which reveals abundant variation in resistance responses in both cultivar and rootstock material. Further seedling tests show that the segregation patterns of resistance and susceptibility vary widely between crosses. We discuss inconsistencies in test performance with field observations and discuss future research opportunities in this area.

Outcomes of implementing rapid triage in the pediatric emergency department.

INTRODUCTION: Efficiency and effectiveness are often used as quality indicators in emergency departments. With an aim to improve patient throughput and departmental efficiency while decreasing left-without-being-seen (LWBS) rates, this two-group, pre-intervention, post-intervention study in a pediatric emergency department evaluated the outcomes of implementing rapid triage on arrival-to-triage time, fast track utilization, and LWBS. METHODS: We implemented rapid triage assessment integrating the Emergency Severity Index and fast track guidelines in our pediatric emergency department. Arrival-to-triage times were tracked for 1 month before and after the intervention (N = 13,910 patient visits) by recording the time the patient arrived in the department and time triage assessment was complete. Fast track utilization and LWBS rates were measured for all patients sequentially included in pre-intervention (n = 60,373) and post-intervention (n = 67,939) groups for 10 months. RESULTS: After the intervention, patients experienced a significant decrease in arrival-to-triage times compared with the pre-intervention group (P < .001), with most patients (88.3%) being triaged in less than 10 minutes after the intervention. Following implementation of fast track guidelines, patients were 14% more likely to be triaged to fast track compared with pre-intervention patients (odds ratio [OR] = 1.14, 95% confidence interval [CI] = 1.11-1.67). Additionally, patients with the lowest acuity were nearly 50% more likely to be triaged to fast track compared with pre-intervention patients (OR = 1.48, 95% CI = 1.35-1.63). Although LWBS rates were insignificant, overall acuity level of this group was lower in the post-intervention group. DISCUSSION: Although LWBS rates did not decrease with the intervention, implementation of a rapid triage system and fast track guidelines reduced arrival-to-triage times and decreased acuity in the LWBS population. Implementing rapid triage and fast track guidelines can affect nurse-sensitive patient outcomes related to safety and care delivery in a pediatric emergency department.

A rapid medical screening process improves emergency department patient flow during surge associated with novel H1N1 influenza virus.

STUDY OBJECTIVE: We compare emergency department (ED) patient flow during the fall 2009 novel H1N1-associated surge in patient volumes at an urban, tertiary care, pediatric medical center to that in the previous winter virus season. METHODS: A rapid medical screening process was instituted to manage the surge in patient census. The process included the use of a new, separate clinical area converted from office space adjacent to the ED, the introduction of a new preprinted checklist for rapid documentation of medical history and physical examination of patients with influenza-like illness, the use of classroom-style parent discharge education, and the use of preprinted discharge prescription and instructions. We compared patient flow parameters, including waiting time, length of stay, and elopement rates, and returns within 48 hours and 7 days for a comparable period in winter 2008 to 2009. RESULTS: During the first 30 days of the novel H1N1-associated surge in patient volumes (October 12 to November 10, 2009), overall ED daily volumes increased by a mean of 113 (51.8%) compared with baseline (daily increase range 49 to 118 patients). Of the 10,013 patients treated during this period, 4,287 (42.8%) had complaints consistent with influenza-like illness and 1,767 (17.6%) were treated with the rapid screening process. The mean wait time decreased from 92.9 to 81.2 minutes (difference 11.7 minutes; 95% confidence interval [CI] 10.2 to 13.2 minutes). Overall mean ED length of stay decreased from 241 to 212.3 minutes (difference 28.7 minutes; 95% CI 25.8 to 31.6 minutes). Rates of elopement were unchanged, and elopement rates as a function of daily patient volumes showed improved responsiveness to high volumes. Rates of return were unchanged within 48 hours (3.0% in 2009 versus 2.9% in 2008; odds ratio 1.03 [0.91 to 1.18]) and within 7 days (6.2% in 2009 versus 5.7% in 2008; odds ratio 1.09 [0.99 to 1.20]). The use of the rapid screening process required a mean of 23.5 (95% CI 16.4 to 30.6) additional hours per day of physician staffing and a mean of 26.3 (95% CI 18.5 to 34.1) additional hours of nursing staffing. CONCLUSION: The implementation of a rapid screening process during the fall 2009 H1N1-associated surge in patient volumes was associated with improved patient flow without affecting rates of return to the ED within 48 hours or 7 days. This was accomplished with only a modest increase in staffing.

Family presence during trauma activations and medical resuscitations in a pediatric emergency department: an evidence-based practice project.

INTRODUCTION: The existing family presence literature indicates that implementation of a family presence policy can result in positive outcomes. The purpose of our evidence-based practice project was to evaluate a family presence intervention using the 6 A's of the evidence cycle (ask, acquire, appraise, apply, analyze, and adopt/adapt). For step 1 (ask), we propose the following question: Is it feasible to implement a family presence intervention during trauma team activations and medical resuscitations in a pediatric emergency department using national guidelines to ensure appropriate family member behavior and uninterrupted patient care? METHODS: Regarding steps 2 through 4 (acquire, appraise, and apply), our demonstration project was conducted in a pediatric emergency department during the implementation of a new family presence policy. Our family presence intervention incorporated current appraisal of literature and national guidelines including family screening, family preparation, and use of family presence facilitators. We evaluated whether it was feasible to implement the steps of our intervention and whether the intervention was safe in ensuring uninterrupted patient care. RESULTS: With regard to step 5 (analyze), family presence was evaluated in 106 events, in which 96 families were deemed appropriate and chose to be present. Nearly all families (96%) were screened before entering the room, and all were deemed appropriate candidates. Facilitators guided the family during all events. One family presence event was terminated. In all cases patient care was not interrupted. DISCUSSION: Regarding step 6 (adopt/adapt), our findings document the feasibility of implementing a family presence intervention in a pediatric emergency department while ensuring uninterrupted patient care. We have adopted family presence as a standard practice. This project can serve as the prototype for others.