Intensive care discharges: improving the quality of clinical handover through changes to discharge documentation.

Patients who have stepped down from intensive care tread a precarious clinical course, and the handover of care between clinical teams at this point should be treated as a high risk event. Poor handover can leave patients vulnerable to suboptimal care and preventable harm. Properly structured written discharge summaries have been shown to improve information transfer and quality of care. The National Institute for Health and Care Excellence (NICE) has published guidelines entitled "Acute illness in adults in hospital: recognising and responding to deterioration," which states that patients transferred from intensive care should have a formal structured handover supported by a written plan, and it provides minimum criteria for what information should be included. A retrospective audit was carried out (n=28) to identify if discharge summaries were compliant with these standards. Discharge summaries consistently lacked essential criteria, including psychosocial needs (29%), nutritional needs (50%), therapy needs (29%), ceilings of care (39%), and communication needs (18%). Less than a third of verbal handovers between the nursing and medical teams were documented. After consultation, a new summary template was developed and embedded into practice. The new design prompted trainees to ensure they completed adequate information in all domains of care. Additional sections were added to improve recording of when, and to whom, clinical handover took place, which led to improved clinical governance. The overall quality of discharge summaries was improved, with increased compliance in 11 out of 13 domains. Feedback from staff about the new discharge summaries was positive. This project is easily transferable, and has the potential to improve patient safety and quality of care.

Vascular Streak Dieback of cacao in Southeast Asia and Melanesia: in planta detection of the pathogen and a new taxonomy.

Vascular Streak Dieback (VSD) disease of cacao (Theobroma cacao) in Southeast Asia and Melanesia is caused by a basidiomycete (Ceratobasidiales) fungus Oncobasidium theobromae (syn. =Thanatephorus theobromae). The most characteristic symptoms of the disease are green-spotted leaf chlorosis or, commonly since about 2004, necrotic blotches, followed by senescence of leaves beginning on the second or third flush behind the shoot apex, and blackening of infected xylem in the vascular traces at the leaf scars resulting from the abscission of infected leaves. Eventually the shoot apex is killed and infected branches die. In susceptible cacao the fungus may grow through the xylem down into the main stem and kill a mature cacao tree. Infections in the stem of young plants prior to the formation of the first 3-4 lateral branches usually kill the plant. Basidiospores released from corticioid basidiomata developed on leaf scars or along cracks in the main vein of infected leaves infect young leaves. The pathogen commonly infects cacao but there are rare reports from avocado. As both crops are introduced to the region, the pathogen is suspected to occur asymptomatically in native vegetation. The pathogen is readily isolated but cultures cannot be maintained. In this study, DNA was extracted from pure cultures of O. theobromae obtained from infected cacao plants sampled from Indonesia. The internal transcribed spacer region (ITS), consisting of ITS1, 5.8S ribosomal RNA and ITS2, and a portion of nuclear large subunit (LSU) were sequenced. Phylogenetic analysis of ITS sequences placed O. theobromae sister to Ceratobasidium anastomosis groups AG-A, AG-Bo, and AG-K with high posterior probability. Therefore the new combination Ceratobasidium theobromae is proposed. A PCR-based protocol was developed to detect and identify C. theobromae in plant tissue of cacao enabling early detection of the pathogen in plants. A second species of Ceratobasidium, Ceratobasidium ramicola, identified through ITS sequence analysis, was isolated from VSD-affected cacao plants in Java, and is widespread in diseased cacao collected from Indonesia.

Characterisation of ectomycorrhizal formation by the exotic fungus Amanita muscaria with Nothofagus cunninghamii in Victoria, Australia.

The occurrence of the exotic ectomycorrhizal fungus Amanita muscaria in a mixed Nothofagus-Eucalyptus native forest was investigated to determine if A. muscaria has switched hosts to form a successful association with a native tree species in a natural environment. A mycorrhizal morphotype consistently found beneath A. muscaria sporocarps was examined, and a range of morphological and anatomical characteristics in common with those described for ectomycorrhizae formed by A. muscaria on a broad range of hosts were observed. A full description is provided. The likely plant associate was determined to be Nothofagus cunninghamii based upon anatomy of the roots. Analysis of ITS-1 and ITS-2 regions of nuclear ribosomal DNA sequences confirmed the identities of both fungal and plant associates. These findings represent conclusive evidence of the invasion of a non-indigenous ectomycorrhizal fungus into native forest and highlight the ecological implications of this discovery.

Vascular-Streak Dieback: A New Encounter Disease of Cacao in Papua New Guinea and Southeast Asia Caused by the Obligate Basidiomycete Oncobasidium theobromae.

ABSTRACT The basidiomycete Oncobasidium theobromae was identified as the cause of a devastating disease of cacao named vascular-streak dieback (VSD) in Papua New Guinea in the 1960s. VSD now causes losses among cacao seedlings and kills branches in mature cacao trees throughout Southeast Asia and parts of Melanesia. The characteristic symptoms include a green-spotted chlorosis and fall of leaves beginning on the second or third flush behind the stem apex, raised lenticels, and darkening of vascular traces at the leaf scars and infected xylem. Eventually complete defoliation occurs and, if the fungus spreads to the trunk, the tree will die. O. theobromae is a highly specialized, near-obligate parasite of cocoa. It is a windborne, leaf-penetrating, vascular pathogen, and may have evolved as an endophyte on an as yet unidentified indigenous host. The rate of disease spread on cocoa is limited because basidiocarps develop only on fresh leaf scars during wet weather, and basidiospores remain viable for a few hours on the night they are shed. Consequently, very few new infections occur beyond 80-m from diseased trees. Transmission of the disease through seed or infected cuttings has not been demonstrated. Strict quarantine measures applied to the movement of intact plants are crucial in reducing spread of the disease. Integrated management, including the planting of less susceptible genotypes, nursery construction and management, canopy pruning and shade management, provides effective control.

Botryosphaeria species from Eucalyptus in Australia are pleoanamorphic, producing dichomera synanamorphs in culture.

Species within the genus Botryosphaeria include some of the most widespread and important pathogens of woody plants, and have been the focus of numerous taxonomic studies in recent years. It is currently accepted that anamorphs of Botryosphaeria belong to two distinct genera, Fusicoccum and Diplodia. Species within the genus Fusicoccum commonly produce aseptate, hyaline conidia. In the present study, fungi were isolated from foliage and wood of Eucalyptus in native forests and plantations in Australia. Although these fungi produced Dichomera anamorphs in culture, they clustered within the Fusicoccum clade of Botryosphaeria based on their ITS sequence data. Four species, Botryosphaeria dothidea, B. parva, B. ribis and B. australis produced Dichomera conidia in culture. The Dichomera synanamorphs are described for these four species of Botryosphaeria. In addition, falling within the Fusicoccum clade of Botryosphaeria, two species were found to be distinct from previously described Botryosphaeria spp. based on their ITS sequences, but synonymous with D. versiformis and D. eucalypti. These observations are currently unique to isolates from host trees within the genus Eucalyptus in Australia, and the pleoanamorphic nature of these species is discussed.

A specific primer PCR and RFLP assay for the rapid detection and differentiation in planta of some Mycosphaerella species associated with foliar diseases of Eucalyptus globulus.

It is difficult to accurately identify Mycosphaerella species associated with leaf diseases of Eucalyptus based on morphological characters, as there is considerable overlap between very similar species and subspecies, and isolation from the host is not easy. Thus, a PCR and RFLP assay based on the ITS region of nr DNA was developed for the rapid detection and differentiation of M. nubilosa, M. cryptica and two non-sporing unidentified Mycosphaerella species isolated from the foliage of trees in resistant and susceptible families of E. globulus in a seed orchard at Kinglake West, Victoria, Australia. The M. nubilosa primer pair MNF/MNR was highly specific. A PCR-RFLP system based on the primer pair MCF/MCR, coupled with two restriction enzymes (DdeI and Tru1 I), differentiated M. cryptica, M. nubilosa, M. tasmaniensis and M. aff. vespa. One of the unidentified field-isolated Mycosphaerella species was identified as M. grandis on the basis of ITS sequence data while the other species remains unidentified. A PCR-RFLP system based on the primer pair U1F/U1R, coupled with the restriction enzyme StyI, differentiated between the two unidentified species. Unexpectedly, unlike isolation and culture studies, these assays detected M. nubilosa, M. cryptica and M. grandis in all single lesions examined on both juvenile and adult leaves, and on both highly resistant and highly susceptible E. globulus trees at this site.