An advanced clinician practitioner in arthritis care can improve access to rheumatology care in community-based practice.

OBJECTIVE: To facilitate access and improve wait times to a rheumatologist's consultation, this study aimed to 1) determine the ability of an advanced clinician practitioner in arthritis care (ACPAC)-trained extended role practitioner (ERP) to triage patients with suspected inflammatory arthritis (IA) for priority assessment by a rheumatologist and 2) determine the impact of an ERP on access-to-care as measured by time-to-rheumatologist-assessment and time-to-treatment-decision. MATERIALS AND METHODS: A community-based ACPAC-trained ERP triaged new referrals for suspected IA. Patients with suspected IA were booked to see the rheumatologist on a priority basis. Diagnostic accuracy of the ERP to correctly identify priority patients; the level of agreement between ERP and rheumatologist (Kappa coefficient and percent agreement); and the time-to-treatment-decision for confirmed cases of IA were investigated. Retrospective chart review then compared time-to-rheumatologist-assessment and time-to-treatment-decision in the solo-rheumatologist versus the ERP-triage model. RESULTS: One hundred twenty-one patients were triaged. The ERP designated 54 patients for priority assessment. The rheumatologist confirmed IA in 49/54 (90.7% positive predictive value [PPV]). Of the 121 patients, 67 patients were designated as nonpriority by the ERP, and none were determined to have IA by the rheumatologist (100% negative predictive value [NPV]). Excellent agreement was found between the ERP and the rheumatologist (Kappa coefficient 0.92, 95% CI: 0.84-0.99). In the ERP-triage model, time-from-referral-to-treatment-decision for patients with IA was 73.7 days (SD 40.4, range 12-183) compared with 124.6 days (SD 61.7, range 26-359) in the solo-rheumatologist model (40% reduction in time-to-treatment-decision). CONCLUSION: A well-trained and experienced ERP can shorten the time-to-Rheumatologist-assessment and time-to-treatment-decision for patients with suspected IA.

Outbreak of Smut Caused by Tilletia maclaganii on Cultivated Switchgrass in Iowa.

Switchgrass (Panicum virgatum L.), a prairie grass native to Iowa, is cultivated for forage and biomass production. During the late 1990s, biomass and seed yields of switchgrass grown in southern Iowa began to decline, and the reduction has been attributed to unidentified diseases. In 1999, many plants in previously low-yielding fields were stunted and flowered prematurely. Glumes had an uncharacteristic purple pigmentation, and seeds had been replaced by fungal spores. A smut fungus identified as Tilletia maclaganii (Berk.) G.P. Clinton (1) was associated consistently with fields that yielded poorly. Teliospores were red-orange when immature and turned dark brown as they matured. Teliospores were globose to slightly irregular, ≈18 to 25 µm in diameter, finely verrucose, with a thick exospore. True sterile cells also were present. T. maclaganii infects switchgrass and has been reported previously in Iowa (2), although it is found only occasionally on the state's native switchgrass. The prevalence and incidence of disease was surveyed in late August 1999. A weighted random sampling procedure was used to select switchgrass production fields from 60 fields involved in the Chariton Valley Biomass Project. Fields were located in Appanoose, Lucas, Monroe, and Wayne counties in southern Iowa. The sampling procedure was designed so the probability of each field being chosen was proportional to its area. This resulted in samples being taken from 17 fields representing ≈50% of the total area of the 60 fields. All sampled fields were planted with the predominant cultivar, Cave-in-Rock. In each field, five 1-m2 samples (≈60 to 250 tillers) were taken from arbitrary points. The incidence of smut (percentage of tillers with smut) was calculated for each sample. Smut was found in 15 of 17 fields. We estimated that 50 to 82% of the area in switchgrass production in these counties was infested with T. maclaganii. The mean incidence of smut was estimated at 10.1% of all tillers in the area. Incidence in individual fields ranged from 0 to 70%. Fields with incidence >50% yielded less than half of the expected biomass. Some infested seed-production fields were a total loss in 1999. This disease presents a serious threat to the cultivation of switchgrass for biomass production in southern Iowa. The disease cycle for T. maclaganii is poorly documented, but because switchgrass is a perennial species, it is likely that affected fields will have recurring epidemics. Susceptibility of other cultivars is unknown but needs to be investigated. References: (1) G. W. Fischer. 1953. Manual of the North American Smut Fungi. Ronald Press, NY. (2) J. C. Gilman and W. A. Archer. The fungi of Iowa parasitic on plants. Iowa State College J. Sci. 3:299, 1929.

Waste Corn as a Point Source of Inoculum for Aspergillus flavus in the Corn Agroecosystem.

Sporulation of Aspergillus flavus was detected on kernels in deposits of waste corn close to corn storage cribs and bins at 18 locations throughout Iowa in 1991 and 1992. A. flavus was detected in spore traps located 3 m from the deposits and was isolated from nitidulid beetles within the deposits or in insect traps within 3 m of the deposits. A. flavus also was isolated from asymptomatic corn kernels in the deposits and from soil beneath the deposits. Linear dispersal gradients of airborne conidia of A. flavus, sampled at distances of 2, 6, 10, and 14 m from waste corn deposits into adjacent cornfields, were detected at three sampling times between 28 July and 1 September 1992 at Cedar Rapids and Williamsburg, Iowa. Linear dispersal gradients from the deposits also were detected for A. flavus-infested nitidulid beetle species Carpophilus lugubris and Glischrochilus quadrisignatus. The incidence of A. flavus infection on corn leaves, silks, and kernels in the fields adjacent to the deposits were correlated to numbers of airborne conidia at each sampling time at both locations. In a field experiment in Ames in which waste corn was placed in the center of individual corn plots, linear dispersal of conidia of A. flavus and plant infection gradients similar to those found from natural deposits were detected at distances of 1.7 to 8.5 m from the deposits at four sampling times from 6 August to 26 September 1992. Few airborne conidia of A. flavus were detected, and no infection of leaves, silks, and kernels by A. flavus occurred in the corresponding noninfested control plots. This study showed that deposits of waste corn infested with A. flavus found in the vicinity of corn storage cribs and bins are point sources of inoculum for A. flavus in the corn agroecosystem.

Effects of T-2 mycotoxin ingestion on phagocytosis of Aspergillus fumigatus conidia by rabbit alveolar macrophages and on hematologic, serum biochemical, and pathologic changes in rabbits.

Rabbits were given T-2 mycotoxin orally at 0, 0.25, 0.5, and 0.75 mg/kg of body weight/day for 21 days. Only rabbits in the 0.75 mg/kg/day group (4 of 5 rabbits) died. Alveolar macrophages were harvested on day 22 and used for in vitro phagocytosis of killed Aspergillus fumigatus conidia. Cultures included sera from untreated rabbits or rabbits treated with T-2. Phagocytosis was significantly (P less than 0.01) reduced in cultures that used serum from rabbits treated with 0.5 mg of T-2/kg/day and alveolar macrophages from untreated rabbits or rabbits treated with T-2. There was little reduction in phagocytosis when alveolar macrophages from rabbits treated with T-2 and normal serum were used. Ingestion of 0.5 mg of T-2 toxin/kg/day significantly (P less than 0.05) reduced weight gain, serum alkaline phosphatase activity, serum sorbitol dehydrogenase activity, and serum bacteriostasis. Similar changes were found in the 0.75 mg/kg/day group, as well as a significant (P less than 0.05) reduction in PCV, total WBC, and differential leukocyte counts. Neutrophil counts decreased, but not significantly (0.05 less than P less than 0.10). Significant changes were not detected in alanine transaminase activity, aspartate transaminase activity, blood urea nitrogen concentration, or complement hemolytic activity. Histopathologic changes consisting of centrilobular hepatocellular swelling, mild portal and periportal fibrosis and lymphocyte necrosis within secondary lymphoid tissues developed in most rabbits treated with T-2. Thymic atrophy, bile duct reduplication, and lymphocyte depletion of secondary lymphoid tissues developed in the group given 0.75 mg/kg/day.(ABSTRACT TRUNCATED AT 250 WORDS)

Pathologic, hematologic, and serologic changes in rabbits given T-2 mycotoxin orally and exposed to aerosols of Aspergillus fumigatus conidia.

The influence of immunosuppression by T-2 mycotoxin on the fungal disease aspergillosis was investigated in rabbits. Four groups of rabbits (groups 1A, 1B, 3A, and 3B) were given 0.5 mg of T-2 toxin/kg of body weight/day, PO; in addition, rabbits of groups 3A and 3B were exposed to aerosols of Aspergillus fumigatus conidia from days 7 through 16. Rabbits of groups 2A and 2B were exposed to A fumigatus aerosols, but were not given T-2 toxin, and rabbits of group 0 served as controls. Two rabbits of group 1A, 1 rabbit of group 1B, and 1 rabbit of group 3A died before scheduled necropsy. Rabbits of groups 1A, 2A, and 3A were killed and necropsied on day 17, and the remaining rabbits (groups 0, 1B, 2B, and 3B) were killed and necropsied on day 28. Changes caused by T-2 toxin included leukopenia, marginal anemia, and increased number of and morphologic changes in nucleated erythrocytes by day 21, followed by a regenerative hematologic response. Serum alkaline phosphatase and sorbitol dehydrogenase activities and antibody response to A fumigatus (as measured by an indirect hemagglutination test) were decreased by T-2 toxin ingestion. Rabbits with aspergillosis had leukocytosis, increased PCV, and increased antibody response to A fumigatus. Histologic lesions consisting of centrilobular hepatocellular swelling, portal and periportal fibrosis, and lymphocyte necrosis and/or depletion within secondary lymphoid tissue were observed in most rabbits treated with T-2 toxin. Normal defense mechanisms against A fumigatus infection were compromised by T-2 treatment, as evidenced by the severity and extent of lung lesions, greater number of hyphal elements observed, and greater number of colonies of A fumigatus isolated from rabbits of groups 3A and 3B. There were no significant changes in group-0 rabbits.

Deterioration of high-moisture corn.

Two small, leaky silos were filled with normal high-moisture corn (HMC), and two with HMC severely infested by Helminthosporium maydis. Counts of mesophilic bacteria, lactobacilli, coliforms, yeasts, and molds were made on corn samples as received and periodically thereafter during 220 days of storage. Temperature and gas levels also were monitored. Sequential changes in the populations of lactobacilli, yeasts, and molds were determined during spoilage of HMC. These population changes were compared on the basis of the variables encountered in the present study as well as with the results of previous studies conducted on normal HMC stored under adequate conditions. Heavy infestation by H. maydis had no appreciable effect on HMC preservation.