Dietitian-led micronutrient management in a public bariatric surgery outpatient clinic.

AIMS: This study aimed to explore the multidisciplinary team attitudes and knowledge of bariatric surgery micronutrient management (pre- and postoperative care) and to evaluate the implementation of an extended-scope of practice dietitian-led model of care for micronutrient monitoring and management. METHODS: A mixed method study design included quantitative evaluation of micronutrient testing practices and deficiency rates. Qualitative reflexive thematic analysis was used to interpret multidisciplinary experience with micronutrient monitoring in a traditional and dietitian-led model of care. In addition, deductive analysis used normalisation process theory mapping of multidisciplinary experience with the implementation of the dietitian-led model of care. RESULTS: In the traditional model, a lack of quality evidence to guide micronutrient management, and a tension in trust between surgeons and patients related to adherence to micronutrient prescriptions were described as challenges in current practice. The dietitian-led model was seen to overcome some of these challenges, increasing collaborative, and coordinated, consistent and personalised patient care that led to increased testing for and detection of micronutrient deficiencies. Barriers to sustainability of the dietitian-led model included a lack of workforce succession planning, and no clearly defined delegation for some aspects of care. CONCLUSION: An extended scope dietitian-led model of care for micronutrient management after bariatric surgery improves clinical care. Challenges such as succession planning must be considered in design of extended scope services.

Monitoring for micronutrient deficiency after bariatric surgery-what is the risk?

BACKGROUND: Bariatric surgery may increase the risk of micronutrient deficiencies; however, confounders including preoperative deficiency, supplementation and inflammation are rarely considered. OBJECTIVE: To examine the impact of bariatric surgeries, supplementation and inflammation on micronutrient deficiency. SETTING: Two public hospitals, Australia. METHODS: Participants were recruited to an observational study monitoring biochemical micronutrient outcomes, supplementation dose, inflammation and glycaemic control, pre-operatively and at 1-3, 6 and 12 months after gastric bypass (GB; Roux-en-Y Gastric Bypass and Single Anastomosis Gastric Bypass; N = 66) or sleeve gastrectomy (SG; N = 144). Participant retention at 12 months was 81%. RESULTS: Pre-operative micronutrient deficiency was common, for vitamin D (29-30%), iron (13-22%) and selenium (39% GB cohort). Supplement intake increased after surgery; however, dose was <50% of target for most nutrients. After SG, folate was vulnerable to deficiency at 6 months (OR 13 [95% CI 2, 84]; p = 0.007), with folic acid supplementation being independently associated with reduced risk. Within 1-3 months of GB, three nutrients had higher deficiency rates compared to pre-operative levels; vitamin B1 (21% vs. 6%, p < 0.01), vitamin A (21% vs. 3%, p < 0.01) and selenium (59% vs. 39%, p < 0.05). Vitamin B1 deficiency was independently associated with surgery and inflammation, selenium deficiency with improved glycaemic control after surgery and inflammation, whilst vitamin A deficiency was associated with inflammation only. CONCLUSION: In the setting of prophylactic post-surgical micronutrient prescription, few nutrients are at risk of de novo deficiency. Although micronutrient supplementation and monitoring remains important, rationalising high-frequency biochemical testing protocols in the first year after surgery may be warranted.

Patient experiences with micronutrient and overall nutrition management after bariatric surgery: identifying facilitators and barriers to implementing care.

BACKGROUND: Adherence to perioperative guideline recommendations for prophylactic supplementation and regular biochemical monitoring is suboptimal. However, little is known about the patient perspective on this postoperative challenge. OBJECTIVES: To qualitatively explore patient experiences of postoperative micronutrient management and identify patient-reported barriers and facilitators to the provision of nutrition care. SETTING: Two tertiary public hospitals in Queensland, Australia. METHODS: Semi-structured interviews were conducted with 31 participants 12 months after bariatric surgery. Inductive analysis of interview transcripts was performed using applied thematic analysis, and deductive analysis was performed by aligning interview themes against the Theoretical Domains Framework and the Capability, Motivation, and Opportunity Behavior Change Wheel Framework. RESULTS: Participants' perceptions of engagement with the bariatric surgery multidisciplinary team greatly influenced their experience with overall nutrition care, including but not exclusive to micronutrient care. At times, this engagement negatively impacted patients' experiences with their nutrition care and related to varied acceptance of healthcare advice from the team or, at times, an unmet desire for person-centered communication styles. Engaging person-centered care techniques had a positive influence on patient experience with micronutrient and overall nutrition care. Micronutrient management (taking supplements and having regular blood tests) was broadly accepted and enabled by the presence of established medication and blood test routines preoperatively. However, challenges did exist and were practical in nature. Incorporating education on habit-forming techniques was identified as a facilitator to assist with micronutrient management. CONCLUSION: Although participants mostly accept embedding micronutrient management into their life, developing interventions that focus on habit-forming skills and that enable multidisciplinary teams to provide person-centered care is recommended to enhance care after surgery.

Remote glucose monitoring is feasible for patients and providers using a commercially available population health platform.

Objective: Remote patient monitoring (RPM) holds potential to enable more individualized and effective care for patients with type 1 diabetes (T1D), but requires population analytics to focus limited clinical resources on patients most in need. We explored the feasibility of RPM from patient and provider standpoints using a commercially available data analytic platform (glooko Population Health) among a cohort of youth with T1D. Study design: Patients aged 1-20 years with established T1D (≥12 months) and CGM use (≥3 months) were recruited to participate. Participants' CGM devices were connected to the glooko app and linked to the research team's glooko account during a one-month baseline period. This was followed by a six-month intervention period during which participants with >15% of glucose values >250 mg/dl or >5% of values <70 mg/dl each month were contacted with personalized diabetes management recommendations. Participants were surveyed about their experiences, and effects on glycemic control were estimated via change in glucose management indicator (GMI) generated from CGM data at baseline and completion. Changes in time spent within various glucose ranges were also evaluated, and all glycemic metrics were compared to a non-randomized control group via difference-in-difference regression, adjusting for baseline characteristics. Results: Remote data-sharing was successful for 36 of 39 participants (92%). Between 33%-66% of participants merited outreach each month, and clinician outreach required a median of 10 minutes per event. RPM was reported to be helpful by 94% of participants. RPM was associated with a GMI change of -0.25% (P=0.047) for the entire cohort, and stratified analysis revealed greatest treatment effects among participants with baseline GMI of 8.0-9.4% (GMI change of -0.68%, P=0.047; 19.84% reduction in time spent >250 mg/dl, P=0.005). Conclusions: This study demonstrates the feasibility of RPM for patients with T1D using a commercially available population health platform, and suggests that RPM with clinician-initiated outreach may be particularly beneficial for patients with suboptimal glycemic control at entry. However, larger randomized studies are needed to fully explore the glycemic impact of RPM. Clinical trial registration: https://clinicaltrials.gov/ct2/show/NCT04696640, identifier NCT04696640.

Comparative effectiveness of hysteroscopic and laparoscopic sterilization for women: a retrospective cohort study.

OBJECTIVE: To compare real-world effectiveness of hysteroscopic to laparoscopic sterilization. DESIGN: Retrospective cohort of Medicaid claims for hysteroscopic or laparoscopic sterilization procedures performed in California, 2008-2014. After excluding postpartum procedures, we applied log-linear (Poisson) event-history regression models for clustered person-period data, weighted for propensity to receive either sterilization procedures, and adjusted for sociodemographic and clinical variables to examine the poststerilization pregnancy rates. SETTING: Clinics, hospitals. PATIENT(S): Women aged 18-50 years with Medicaid claims between January 1, 2008, and August 31, 2014. INTERVENTION(S): Hysteroscopic or laparoscopic sterilization procedure. MAIN OUTCOME MEASURE(S): Poststerilization pregnancy measured by pregnancy-related claims. RESULT(S): Among women with hysteroscopic (n = 5,906) or laparoscopic (n = 23,965) sterilization, poststerilization pregnancy claims were identified for 4.74% of women after hysteroscopic sterilization and 5.57% after laparoscopic sterilization. The pregnancy rates decreased over time after either procedure. Twelve months after the procedure, the crude incidence of pregnancy claims was higher for hysteroscopic sterilization than for laparoscopic sterilization (3.26 vs. 2.61 per 100 woman-years), but the propensity-weighted adjusted incidence rate ratio was 1.06 (95% confidence interval [CI], 0.85-1.26). Between 13 and 24 months after the procedure, there were fewer pregnancies for women after hysteroscopic sterilizations than for those after laparoscopic sterilizations (adjusted incidence rate ratio, 0.63 [95% CI, 0.45-0.88]), with no statistically significant differences in later years. The cumulative pregnancy rates 5 years after sterilization were lower with hysteroscopic sterilization than with laparoscopic sterilization (6.26 vs. 7.22 per 100 woman-years; propensity-weighted, adjusted risk ratio, 0.76 [95% CI, 0.62-0.90]). The poststerilization pregnancy rates varied by age and race/ethnicity. CONCLUSION(S): The pregnancy rates after female sterilization are higher than expected, whether performed hysteroscopically or laparoscopically. These findings are reassuring that the effectiveness of hysteroscopic sterilization was not inferior to laparoscopic sterilization. CLINICAL TRIAL REGISTRATION NUMBER: NCT03438682.

Comparative Effectiveness and Safety of Intrauterine Contraception and Tubal Ligation.

BACKGROUND: Tubal ligation remains common in the USA, especially among low-income patients. OBJECTIVE: To compare the effectiveness and safety of intrauterine contraceptives (IUC) to laparoscopic tubal ligation for Medicaid clients. DESIGN: We partnered with patient and clinician stakeholders to conduct a retrospective cohort study using California Medicaid claims for patients who had an IUC placed or laparoscopic tubal ligation performed in 2008-2014, excluding procedures performed within 42 days of a birth. We applied log-linear (Poisson) event-history regression models for clustered person-period data to adjust for sociodemographic variables and pre-procedure health status when examining associations between these contraceptive procedures and claims related to contraceptive failure, complications, and pain in the first year post-procedure. KEY RESULTS: We identified 35,705 patients who had a levonorgestrel IUC placed, 23,628 patients who had a copper IUC placed, and 23,965 patients who underwent laparoscopic tubal ligation. In unadjusted analyses, rates of pregnancy within 1 year were similar following levonorgestrel IUC (2.40%) or copper IUC placement (2.99%) or tubal ligation (2.64%). In adjusted analyses, compared to tubal ligation, pregnancy was less common following placement of a levonorgestrel IUC (adj IRR 0.72, 95% CI 0.64-0.82) and similar with placement of a copper IUC (adj IRR 0.92, 95% CI 0.82-1.05). Procedural complications such as infection (0.35% vs. 2.91%) were significantly less common with IUC placement than tubal ligation. Claims for pelvic and abdominal pain decreased in frequency with time since all procedures; 6 to 12 months post-procedure, pelvic pain claims were less common after levonorgestrel IUC (adj IRR 0.69, 95% CI 0.65-0.73) or copper IUC placement (adj IRR 0.70, 95% CI 0.66-0.75) than tubal ligation. CONCLUSIONS: IUC appears at least as effective as laparoscopic tubal ligation at 1-year post-procedure with lower rates of infection and pelvic pain 6 to 12 months post-procedure. CLINICAL TRIAL REGISTRATION: NCT03438682.

Patient-Centered Safety Outcomes After Hysteroscopic Compared With Laparoscopic Sterilization.

OBJECTIVE: To evaluate the real-world safety of hysteroscopic compared with laparoscopic surgical sterilization. METHODS: We conducted a retrospective cohort study of Medicaid claims for hysteroscopic or laparoscopic sterilization procedures performed in California, 2008-2014, among women aged 18-50 years. After excluding postpartum procedures, we applied log-linear (Poisson) event-history regression models for clustered person-period data, weighted for propensity to receive either sterilization procedures, and adjusted for sociodemographic and clinical characteristics that may affect outcomes of interest to patients and physicians. We assessed the following outcomes: procedural complications, additional surgical procedures (eg, hysterectomy), repeat sterilization procedures, pelvic pain, pelvic inflammatory disease (PID), abdominal pain, nonabdominal pain, and abnormal uterine bleeding. RESULTS: We identified 5,906 women who had undergone hysteroscopic and 23,965 who had undergone laparoscopic sterilization. After adjusting for sociodemographic and health history, women who had hysteroscopic sterilization were less likely to have claims for procedural complications (eg, transfusion, P<.001) on the day of surgical sterilization and additional surgical procedures (eg, hysterectomy, P=.002 at day 2-3 months postprocedure) than laparoscopic sterilization. Claims for a repeat attempt at sterilization were more common after hysteroscopic sterilization within 1 year (adjusted incident rate ratio 3.48, 95% CI 2.69-4.27) and within 5 years (adjusted incident rate ratio 2.32, 95% CI 1.84-2.79) than laparoscopic sterilization. Claims for pelvic pain (adjusted incident rate ratio 0.77, 95% CI 0.65-0.92 at 2 years), abdominal pain (adjusted incident rate ratio 0.80, 95% CI 0.68-0.93 at 7-12 months), and PID (adjusted incident rate ratio 0.55, 95% CI 0.33-0.93 at 2 years) were less common after hysteroscopic than laparoscopic sterilization. Although abnormal uterine bleeding claims were more common after hysteroscopic than laparoscopic sterilization up to 12 months postprocedure (adjusted incident rate ratio 1.37, 95% CI 1.06-1.77 at 7-12 months), there were no significant differences between methods 1 year after the procedure. CONCLUSION: Compared with laparoscopic sterilization, hysteroscopic sterilization was followed by more claims for repeat sterilization procedures and abnormal uterine bleeding, but fewer procedural complications and fewer claims for pelvic or abdominal pain. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03438682.

Iron, Vitamin B12, Folate and Copper Deficiency After Bariatric Surgery and the Impact on Anaemia: a Systematic Review.

Bariatric surgery may increase the risk of iron, vitamin B12, folate and copper deficiencies, which can cause anaemia. This review aims to critique the evidence on the prevalence of these nutritional deficiencies and the impact on anaemia in the first 12 months after surgery. PRISMA and MOOSE frameworks, the NHMRC evidence hierarchy and The Academy of Nutrition and Dietetics bias tool were used to systematically critique current literature. Seventeen studies reported on deficiency prevalence with the majority being of low quality. Important confounders to serum micronutrient levels were not adequately considered. Results on the prevalence of nutritional anaemias were also lacking. Further investigation into the prevalence of iron, vitamin B12, folate and copper deficiency and its impact on anaemia in bariatric surgery is needed.

Patient and carer experience of nutrition care throughout treatment for head and neck cancer: a systematic qualitative review and thematic synthesis.

Nutrition care plays a critical role in the provision of best practice care to head and neck cancer (HNC) patients, with carers playing an important role in supporting patients to maintain nutrition intake. This qualitative systematic review investigated patient and carer experience of nutrition care throughout and beyond HNC treatment. Five databases were systematically searched for qualitative studies reporting on patient and carer experience of nutrition care throughout HNC. Twenty-five studies including 435 patients and 46 carers were identified, revealing three themes: information and support in the healthcare setting, enteral feeding challenges and management, and life outside hospital. Findings highlight the importance of providing individualised person-centred nutrition care to patients with HNC and their carers. Further qualitative research is needed to inform healthcare professionals about the needs of patients and carers to provide appropriate support throughout the treatment trajectory across and between different treatment modalities.

Micronutrient management following bariatric surgery: the role of the dietitian in the postoperative period.

Bariatric surgery is increasingly being utilized to manage obesity and obesity related comorbidities, but may lead to the development of micronutrient deficiencies postoperatively. The anatomical, physiological, nutritional and behavioral reasons for micronutrient vulnerabilities are reviewed, along with recommendations for routine monitoring and replacement following surgery. The role the dietitian and their contribution in the postoperative identification, prevention and management of micronutrient vulnerabilities in bariatric patients is described. Specific considerations such as the nutritional and dietetic management of pregnant and lactating women post-bariatric surgery is also discussed.

Does Bariatric Surgery Cause Vitamin A, B1, C or E Deficiency? A Systematic Review.

BACKGROUND: The restrictive and/or malabsorptive nature of bariatric surgery may increase the risk for micronutrient deficiencies. This systematic review aimed to identify and critique the evidence for vitamin A, B1, C or E deficiencies associated with bariatric surgery. METHODS: This review utilised PRISMA and MOOSE frameworks with NHMRC evidence hierarchy and the American Dietetic Association bias tool to assess the quality of articles. RESULTS: Twenty-one articles were included and once critiqued all studies were of level IV grade and neutral or negative in quality. The relevance of measuring micronutrient supplementation and inflammatory markers for validity of serum vitamins is absent within the literature. CONCLUSIONS: Future research is needed to investigate the risk of deficiency for these procedures with focus on confounders to serum micronutrients.

Comparison of Patient Food Intake, Satisfaction and Meal Quality Between Two Meal Service Styles in a Geriatric Inpatient Unit.

This pilot study evaluated the introduction of a bistro evening meal service in a geriatric inpatient unit by comparing patient intake, satisfaction and meal quality of this new service to the usual central preplated service. Ten meals were observed under each condition (n = 30; mean age 79 years, 47% male). Data were collected on intake of each meal component (none, », ½, ¾, all; converted to energy and protein using known food composition data), patient satisfaction with meals (meal flavor/taste, appearance, quality, staff demeanor; seven-point scale) and meal quality (sensory properties, temperature; five-point scale). Independent t-tests were used to compare energy and protein intakes between bistro and preplated services. There was no difference in mean energy or protein intake (energy: 2524 ± 927 kJ vs. 2692 ± 857 kJ, p = 0.612; protein: 29 ± 12 g vs. 27 ± 11 g, p = 0.699) patient satisfaction or meal quality between the bistro and preplated meal services. Patients were provided with fewer meal items during the bistro service, but ate a higher proportion of what was provided to them. Implementing a bistro service did not increase intake, satisfaction or meal quality in this study, suggesting that meal plating may be only one of many factors influencing intake and satisfaction of older inpatients.

Abortion and student health services expanding the conversation with student perspectives.

OBJECTIVE: College students are known to experience unintended pregnancy and seek abortions. However, few student health centers currently offer abortion services. In this exploratory study, we aimed to expand understanding of student perspectives regarding on-campus abortion services. STUDY DESIGN: We invited UC Davis students to complete an anonymous web-based survey using 16 campus listservs and in-person recruitment. We elicited student knowledge of and opinions about on-campus Student Health and Counseling Services (SHCS) with 29 questions. RESULTS: The 502 participating students primarily identified as female (80%) and heterosexual (86%); most (90%) were undergraduates. In the past year, 9% of female respondents had used emergency contraception (EC), and 9% had sought clinic-based pregnancy testing. Only 68% of respondents were aware that SHCS provides EC. Although SHCS has not yet offered abortions, 24% of respondents believed that SHCS currently offers medication abortion and 13% believed that SHCS clinicians perform abortion procedures. Most respondents (64%) believed that SHCS should offer abortion services; 12% of respondents felt SHCS should not. Reasons for support of on-campus abortion services included the need to compassionately care for campus survivors of sexual assault and abortion's role in allowing students facing undesired pregnancy to complete their education. Reasons for opposition included concerns regarding SHCS's ability to offer high-quality abortion services, the potential for controversy related to on-campus abortion services and personal opposition to abortion. CONCLUSION: Most responding students favor on-campus abortion services, and a number of students incorrectly believe that abortion services are currently offered on the UC Davis campus. IMPLICATIONS: Student health centers should offer medication abortion on campus.

Impact of a Pharmacist-Managed Heart Failure Postdischarge (Bridge) Clinic for Veterans.

BACKGROUND: Hospitals that provide early postdischarge follow-up after heart failure (HF) hospitalization tend to have lower rates of readmission. However, HF postdischarge (bridge) clinics have not been extensively evaluated. OBJECTIVE: To assess the impact of a pharmacist-managed HF bridge clinic in a veteran population. METHODS: HF patients hospitalized from November 2010 to August 2013 were identified. Retrospective chart review was conducted of 122 HF patients seen at bridge clinic compared with 122 randomly selected HF patients not seen at this clinic (usual care). Primary end point was 90-day all-cause readmission and death. Secondary outcomes were 30-day all-cause readmission and death, time to first postdischarge follow-up, first all-cause readmission. RESULTS: Bridge clinic patients were at higher baseline risk of readmission and death; other characteristics were similar. 90-day death and all-cause readmission trended lower in bridge clinic patients (adjusted hazard ratio [HR] = 0.64; 95% CI = 0.40-1.02; P = 0.06). Time to first follow-up was shorter in bridge clinic patients (11 ± 6 vs 20 ± 23 days; P < 0.001); time to first all-cause readmission trended longer (40 ± 20 vs 33 ± 25days; P = 0.11). 30-day death and all-cause readmission was significantly lower in bridge clinic patients (adjusted HR = 0.44; 95% CI = 0.22-0.88; P = 0.02). CONCLUSIONS: In veteran patients hospitalized for HF, pharmacist-managed HF bridge clinic significantly reduced the time to initial follow-up compared with usual care. Improved short-term outcomes and trend toward improvement of longer-term outcomes in bridge clinic patients was shown.

Do Bedsider Family Planning Mobile Text Message and E-mail Reminders Increase Kept Appointments and Contraceptive Coverage?

OBJECTIVE: To determine whether Bedsider text message and e-mail reminders increase family planning contraceptive continuation and appointment rates. MATERIAL AND METHODS: We trained staff at three high-volume Family Planning, Access, Care, and Treatment (Family PACT) clinics to enroll women through a special portal to receive text message or e-mail reminders for contraceptive refills and clinic appointments. Women were matched by contraceptive method, time frame of index visit, age group, and language preference to Family PACT clients at comparison sites that did not use the Bedsider program. Family PACT claims data was used to assess the contraceptive coverage of Bedsider and comparison women over 12 months. We assessed differences in contraceptive coverage between the two groups using McNemar's test of matched comparisons. Clinic records from one clinic were available to assess impact on kept appointment rates. RESULTS: Of the 488 women enrolled, 370 had a claim for a hormonal method (oral contraceptive, patch, ring, contraceptive injection) in the Family PACT database. Matching resulted in 365 matched pairs. The median length of enrollment in the reminder system was 115 days (16 weeks). A greater percentage of Bedsider women returned on time for contraceptive injections than women in the comparison group. However, McNemar's test showed no differences in contraceptive coverage between the intervention and comparison groups. Kept appointment rates showed a statistically significant increase after the intervention at the clinic providing data. CONCLUSION: Contraceptive injection users showed a positive impact from receiving reminders, but overall there was no impact of the Bedsider reminders on return on time for contraceptive refills and injections. We were able to measure a significant increase in kept appointment rates at one clinic using the Bedsider text message and e-mail reminder system.

Counseling About the Maternal Health Benefits of Breastfeeding and Mothers' Intentions to Breastfeed.

Objectives To evaluate the impact of counseling regarding the maternal health effects of lactation on pregnant women's intentions to breastfeed. Methods Women seeking prenatal care at an urban university hospital completed surveys before and after receiving a 5-min counseling intervention regarding the maternal health effects of breastfeeding. The counseling was delivered by student volunteers using a script and one-page infographic. Participants were asked the likelihood that breastfeeding affects maternal risk of multiple chronic conditions using 7-point Likert scales. We compared pre/post changes in individual item responses and a summary score of knowledge of the maternal health benefits of lactation (MHBL) using paired t tests. Multivariable logistic regression was used to examine the impact of increases in knowledge of MHBL on participants' intentions to breastfeed. Results The average age of the 65 participants was 24 ± 6 years. Most (72 %) were African-American and few (9 %) had college degrees. Half (50 %) had previously given birth, but few (21 %) had previously breastfed. Before counseling, few were aware of any benefits of lactation for maternal health. After counseling, knowledge of MHBL increased (mean knowledge score improved from 19/35 to 26/35, p < 0.001). Improvement in MHBL knowledge score was associated with increased intention to try breastfeeding (aOR 1.20, 95 % CI 1.02-1.42), of wanting to breastfeed (aOR 1.45, 95 % CI 1.13-1.86), and feeling that breastfeeding is important (aOR 1.21, 95 % CI 1.03-1.42). Conclusions for Practice Brief structured counseling regarding the effects of lactation on maternal health can increase awareness of the maternal health benefits of breastfeeding and strengthen pregnant women's intentions to breastfeed.

Phytophthora community structure analyses in Oregon nurseries inform systems approaches to disease management.

Nursery plants are important vectors for plant pathogens. Understanding what pathogens occur in nurseries in different production stages can be useful to the development of integrated systems approaches. Four horticultural nurseries in Oregon were sampled every 2 months for 4 years to determine the identity and community structure of Phytophthora spp. associated with different sources and stages in the nursery production cycle. Plants, potting media, used containers, water, greenhouse soil, and container yard substrates were systematically sampled from propagation to the field. From 674 Phytophthora isolates recovered, 28 different species or taxa were identified. The most commonly isolated species from plants were Phytophthora plurivora (33%), P. cinnamomi (26%), P. syringae (19%), and P. citrophthora (11%). From soil and gravel substrates, P. plurivora accounted for 25% of the isolates, with P. taxon Pgchlamydo, P. cryptogea, and P. cinnamomi accounting for 18, 17, and 15%, respectively. Five species (P. plurivora, P. syringae, P. taxon Pgchlamydo, P. gonapodyides, and P. cryptogea) were found in all nurseries. The greatest diversity of taxa occurred in irrigation water reservoirs (20 taxa), with the majority of isolates belonging to internal transcribed spacer clade 6, typically including aquatic opportunists. Nurseries differed in composition of Phytophthora communities across years, seasons, and source within the nursery. These findings suggest likely contamination hazards and target critical control points for management of Phytophthora disease using a systems approach.

Intrauterine contraception: impact of provider training on participant knowledge and provision.

BACKGROUND: In California's Medicaid family planning expansion, the Family Planning, Access, Care and Treatment (Family PACT) Program, only 1.9% of contracepting women received intrauterine contraception (IUC) in 2006. Ten skills-based IUC provider trainings were offered from 2007 to 2010. OBJECTIVE: The objective was to evaluate the impact of these trainings on participant knowledge of the broad range of appropriate IUC candidates and measure changes in IUC provision following training. STUDY DESIGN: We evaluated changes in provider knowledge using a nine-item IUC Candidate Selection Scale on pre- and posttraining surveys. Changes in provision of IUC following the training were measured using Family PACT claims data. We compared changes in insertions posttraining to pretraining levels as well as to matched comparison sites that did not send trainees. RESULTS: Most participants at the training were advanced practice clinicians (70%) specializing in general primary care (77%) and practicing at community clinics (45%). Training participants increased their understanding of appropriate candidates (mean change in raw summary score=8.6, p<.001), from an average of 58% correct responses to 81%. Provider sites that participated in training provided a mean of 4.6 more women with IUC following training than during baseline (p<.01), an increase of 25% compared to only 7% increase among comparison sites. The impact of the training differed by practice size such that the largest and smallest clinics both changed IUC provision the most and had the largest differences over comparison sites. CONCLUSIONS: This study shows that skills-based training is an important strategy for the increase of IUC provision.

Identification and characterization of spontaneous deletions within the Sp11-Sp12 prophage region of Escherichia coli O157:H7 Sakai.

Prophages make up 12% of the enterohemorrhagic Escherichia coli genome and play prominent roles in the evolution and virulence of this food-borne pathogen. Acquisition and loss of and rearrangements within prophage regions are the primary causes of differences in pulsed-field gel electrophoresis (PFGE) patterns among strains of E. coli O157:H7. Sp11 and Sp12 are two tandemly integrated and putatively defective prophages carried by E. coli O157:H7 strain Sakai. In this study, we identified 3 classes of deletions that occur within the Sp11-Sp12 region, at a frequency of ca. 7.74 × 10(-4). One deletion resulted in a precise excision of Sp11, and the other two spanned the junction of Sp11 and Sp12. All deletions resulted in shifts in the XbaI fragment pattern observed by PFGE. We sequenced the inducible prophage pool of Sakai but did not identify any mature phage particles corresponding to either Sp11 or Sp12. Deletions containing pchB and psrC, which are Sp11-carried genes encoding proteins known or suspected to regulate type III secretion, did not affect the secretion levels of the EspA or EspB effector. Alignment of the Sp11-Sp12 DNA sequence with its corresponding regions in other E. coli O157:H7 and O55:H7 strains suggested that homologous recombination rather than integrase-mediated excision is the mechanism behind these deletions. Therefore, this study provides a mechanism behind the previously observed genetic instability of this genomic region of E. coli O157:H7.

Incidence of incorrectly sized graduated compression stockings and lower leg skin irregularities in postoperative orthopedic patients.

INTRODUCTION: The purpose of this study was to determine the incidence of incorrectly sized knee-high graduated compression stockings (GCS) and skin irregularities in the lower legs of postoperative orthopedic patients. METHODS: Using a descriptive study design, researchers evaluated a convenience sample of postoperative orthopedic surgical patients on each postoperative day. Surgical and non-surgical legs were measured to determine the appropriate size for knee-high GCS, and lower legs were assessed for the presence of skin irregularities (edema, erythema, ecchymosis, blistering, excessive coolness or warmth, breaks in the skin integrity) using standardized criteria. The size of GCS in use was recorded, as well as confounding variables of sex, age, and body mass index. Data were summarized with descriptive statistics, with incidence of incorrect GCS size or skin irregularities calculated as a percentage of total subjects studied. FINDINGS: Fifty-two postoperative orthopedic patients were evaluated on their operative day and on postoperative days 1 to 3. Contrary to anecdotal observations before beginning this descriptive study, the incidence of incorrectly fitting GCS was low (< or = 10%), and only 2 of 52 (< 4%) subjects had any skin irregularities in the lower leg during the study period. CONCLUSIONS: The incidence of incorrectly sized GCS and skin irregularities under GCS for postoperative orthopedic patients was small.