Grow the Pie: Interdepartmental Cooperation as a Method for Achieving Operational Efficiency in an Emergency Department.

BACKGROUND: Despite sufficient literature analyzing macroscopic and microscopic methods of addressing emergency department (ED) operations, there is a paucity of studies that analyze methods between these extremes. OBJECTIVE: We conducted a quasi-experimental study incorporating a pre/post-intervention comparison to determine whether interdepartmental cooperation is effective at improving ED operations by combining microscopic and macroscopic concepts. METHODS: We performed an analysis of operational and financial data from a cooperative investment in imaging transport personnel between the emergency and radiology departments. Our primary outcome, order to table time (OTT), measured imaging times by modality (computed tomography [CT], ultrasound [US], magnetic resonance imaging [MRI]). These were compared for statistically significant change before and after the intervention. Our secondary outcome, gross profit, was calculated using the revenue generated from gained outpatient studies minus the associated direct personnel costs. RESULTS: Transporters improved OTTs by decreasing median imaging times from 132 min to 116 min (p < 0.0005). Efficiency improved for CT scans with median time decreasing from 142 min to 114 min (p < 0.0005). Transport hires had adverse effects on US, with an increase in median OTT from 91 min to 99 min (p < 0.018). MRI experienced a similar trend in OTT, as median times worsened from 215 min to 235 min (p < 0.225). The investment in transporters generated a gross profit of $1.03 million for the radiology department over 9 months. CONCLUSIONS: Interdepartmental cooperation is a broadly applicable macroscopic method that is effective at achieving microscopic, site-specific gains in ED efficiency. Transporters provided operational gains for the ED and financial gains for the radiology department.

Next-generation transgenic cotton: pyramiding RNAi and Bt counters insect resistance.

Transgenic crops producing insecticidal proteins from the bacterium Bacillus thuringiensis (Bt) are extensively cultivated worldwide. To counter rapidly increasing pest resistance to crops that produce single Bt toxins, transgenic plant 'pyramids' producing two or more Bt toxins that kill the same pest have been widely adopted. However, cross-resistance and antagonism between Bt toxins limit the sustainability of this approach. Here we describe development and testing of the first pyramids of cotton combining protection from a Bt toxin and RNA interference (RNAi). We developed two types of transgenic cotton plants producing double-stranded RNA (dsRNA) from the global lepidopteran pest Helicoverpa armigera designed to interfere with its metabolism of juvenile hormone (JH). We focused on suppression of JH acid methyltransferase (JHAMT), which is crucial for JH synthesis, and JH-binding protein (JHBP), which transports JH to organs. In 2015 and 2016, we tested larvae from a Bt-resistant strain and a related susceptible strain of H. armigera on seven types of cotton: two controls, Bt cotton, two types of RNAi cotton (targeting JHAMT or JHBP) and two pyramids (Bt cotton plus each type of RNAi). Both types of RNAi cotton were effective against Bt-resistant insects. Bt cotton and RNAi acted independently against the susceptible strain. In computer simulations of conditions in northern China, where millions of farmers grow Bt cotton as well as abundant non-transgenic host plants of H. armigera, pyramided cotton combining a Bt toxin and RNAi substantially delayed resistance relative to using Bt cotton alone.

Potential shortfall of pyramided transgenic cotton for insect resistance management.

To delay evolution of pest resistance to transgenic crops producing insecticidal proteins from Bacillus thuringiensis (Bt), the "pyramid" strategy uses plants that produce two or more toxins that kill the same pest. In the United States, this strategy has been adopted widely, with two-toxin Bt cotton replacing one-toxin Bt cotton. Although two-toxin plants are likely to be more durable than one-toxin plants, the extent of this advantage depends on several conditions. One key assumption favoring success of two-toxin plants is that they kill insects selected for resistance to one toxin, which is called "redundant killing." Here we tested this assumption for a major pest, Helicoverpa zea, on transgenic cotton producing Bt toxins Cry1Ac and Cry2Ab. Selection with Cry1Ac increased survival on two-toxin cotton, which contradicts the assumption. The concentration of Cry1Ac and Cry2Ab declined during the growing season, which would tend to exacerbate this problem. Furthermore, analysis of results from 21 selection experiments with eight species of lepidopteran pests indicates that some cross-resistance typically occurs between Cry1A and Cry2A toxins. Incorporation of empirical data into simulation models shows that the observed deviations from ideal conditions could greatly reduce the benefits of the pyramid strategy for pests like H. zea, which have inherently low susceptibility to Bt toxins and have been exposed extensively to one of the toxins in the pyramid before two-toxin plants are adopted. For such pests, the pyramid strategy could be improved by incorporating empirical data on deviations from ideal assumptions about redundant killing and cross-resistance.

A primer for using transgenic insecticidal cotton in developing countries.

Many developing countries face the decision of whether to approve the testing and commercial use of insecticidal transgenic cotton and the task of developing adequate regulations for its use. In this review, we outline concepts and provide information to assist farmers, regulators and scientists in making decisions concerning this technology. We address seven critical topics: 1) molecular and breeding techniques used for the development of transgenic cotton cultivars, 2) properties of transgenic cotton cultivars and their efficacy against major insect pests, 3) agronomic performance of transgenic cotton in developing countries, 4) factors affecting transgene expression, 5) impact of gene flow between transgenic and non-transgenic cotton, 6) non-target effects of transgenic cotton, and 7) management of pest resistance to transgenic cotton.

Effects of refuge contamination by transgenes on Bt resistance in pink bollworm (Lepidoptera: Gelechiidae).

Refuges of non-Bacillus thuringiensis (Bt) cotton, Gossypium hirsutum L., are used to delay Bt resistance in pink bollworm, Pectinophora gossypiella (Saunders) (Lepidoptera: Gelechiidae), a pest that eats cotton seeds. Contamination of refuges by Bt transgenes could reduce the efficacy of this strategy. Previously, three types of contamination were identified in refuges: 1) homozygous Bt cotton plants, with 100% of their seeds producing the Bt toxin Cry1Ac; 2) hemizygous Bt plants with 70-80% of their seeds producing Cry1Ac; and 3) non-Bt plants that outcrossed with Bt plants, resulting in bolls with Cry1Ac in 12-17% of their seeds. Here, we used laboratory bioassays to examine the effects of Bt contamination on feeding behavior and survival of pink bollworm that were resistant (rr), susceptible (ss), or heterozygous for resistance (rs) to Cry1Ac. In choice tests, rr and rs larvae did not differ from ss in preference for non-Bt versus Bt seeds. Survival of rr and rs also did not differ from ss on artificial outcrossed bolls (a mixture of 20% Bt and 80% non-Bt cotton seeds). On artificial hemizygous Bt bolls (70% Bt seeds) and homozygous Bt bolls (100% Bt seeds), rr had higher survival than ss, although rs and ss did not differ. In a simulation model, levels of refuge contamination observed in the field had negligible effects on resistance evolution in pink bollworm. However, in hypothetical simulations where contamination conferred a selective advantage to rs over ss individuals in refuges, resistance evolution was accelerated.

Effects of seasonal changes in cotton plants on the evolution of resistance to pyramided cotton producing the Bt toxins Cry1Ac and Cry1F in Helicoverpa zea.

BACKGROUND: In pests with inherently low susceptibility to Bacillus thuringiensis (Bt) toxins, seasonal declines in the concentration of Bt toxins in transgenic crops could accelerate evolution of resistance by increasing the dominance of resistance. Here, we evaluated Helicoverpa zea survival on young and old cotton plants that produced the Bt toxins Cry1Ac and Cry1F or did not produce Bt toxins. RESULTS: Using a strain selected for resistance to Cry1Ac in the laboratory, its parent strain that was not selected in the laboratory, and their F1 progeny, we showed that resistance to Cry1Ac + Cry1F cotton was partially dominant on young and old plants. On Cry1Ac + Cry1F cotton, redundant killing was incomplete on young plants but nearly complete on old plants. No significant fitness costs on non-Bt cotton occurred on young plants, but large recessive costs affected survival on old plants. Simulation models incorporating the empirical data showed that the seasonal changes in fitness could delay resistance to Cry1Ac + Cry1F cotton by inducing low equilibrium frequencies of resistance alleles when refuges are sufficiently large. CONCLUSION: Our results suggest that including effects of seasonal changes in fitness of pests on Bt crops and refuge plants can enhance resistance risk assessment and resistance management. © 2017 Society of Chemical Industry.

Long-term evaluation of compliance with refuge requirements for Bt cotton.

The success of the refuge strategy for delaying pest resistance to Bt crops depends on compliance by farmers. However, the accuracy of previous estimates of compliance has been questioned. We have applied a novel approach based on the use of Geographical Information System (GIS) technology to measure compliance with refuge requirements for Bt cotton in six Arizona regions from 1998 to 2003. Although compliance varied among regions, overall compliance was above 88% in five of six years. With the cooperation of farmers, our approach allows precise and economical assessment of compliance with the refuge strategy.

Pollen- and seed-mediated transgene flow in commercial cotton seed production fields.

BACKGROUND: Characterizing the spatial patterns of gene flow from transgenic crops is challenging, making it difficult to design containment strategies for markets that regulate the adventitious presence of transgenes. Insecticidal Bacillus thuringiensis (Bt) cotton is planted on millions of hectares annually and is a potential source of transgene flow. METHODOLOGY/PRINCIPAL FINDINGS: Here we monitored 15 non-Bt cotton (Gossypium hirsutum, L.) seed production fields (some transgenic for herbicide resistance, some not) for gene flow of the Bt cotton cry1Ac transgene. We investigated seed-mediated gene flow, which yields adventitious Bt cotton plants, and pollen-mediated gene flow, which generates outcrossed seeds. A spatially-explicit statistical analysis was used to quantify the effects of nearby Bt and non-Bt cotton fields at various spatial scales, along with the effects of pollinator abundance and adventitious Bt plants in fields, on pollen-mediated gene flow. Adventitious Bt cotton plants, resulting from seed bags and planting error, comprised over 15% of plants sampled from the edges of three seed production fields. In contrast, pollen-mediated gene flow affected less than 1% of the seed sampled from field edges. Variation in outcrossing was better explained by the area of Bt cotton fields within 750 m of the seed production fields than by the area of Bt cotton within larger or smaller spatial scales. Variation in outcrossing was also positively associated with the abundance of honey bees. CONCLUSIONS/SIGNIFICANCE: A comparison of statistical methods showed that our spatially-explicit analysis was more powerful for understanding the effects of surrounding fields than customary models based on distance. Given the low rates of pollen-mediated gene flow observed in this study, we conclude that careful planting and screening of seeds could be more important than field spacing for limiting gene flow.

Outcrossed cottonseed and adventitious Bt plants in Arizona refuges.

Outcrossing of non-Bt cotton (Gossypium hirsutum (L.)) in refuges by transgenic Bt cultivars could reduce the efficacy of refuges for delaying resistance in seed-feeding pests. Based on reports that outcrossing decreased as distance from Bt cotton increased in small-scale studies, we hypothesized that increasing refuge width or distance from Bt fields would reduce outcrossing. In a large-scale study in Arizona, we quantified Bt seed in refuges of experimental and commercial fields, comparing outcrossing between in-field (narrow) and external (wide) refuges and among rows of refuges at various distances from Bt fields. Some refuges, including those in tightly controlled experimental plots, contained up to 8% adventitious Bt plants. Some, but not all, Bt plants likely resulted from Bt seed in the non-Bt seed bags. We did not detect a difference in outcrossing between in-field and external refuges. However, statistical power was low because outcrossing was low (< 0.4% of seeds) in both treatments. Higher outcrossing levels (< or = 4.6% of seeds) were observed in the studies measuring outcrossing at various distances from Bt fields, yet outcrossing did not decrease as the distance from Bt fields increased. We hypothesize that Bt plants in refuges cross-pollinated surrounding non-Bt plants, overshadowing the expected association between distance from Bt fields and outcrossing.