Does Addition of a Longer Acting Local Anesthetic Improve Postoperative Pain After Carpal Tunnel Release? A Randomized Controlled Trial.

PURPOSE: Carpal tunnel release (CTR) is a simple and effective treatment for carpal tunnel syndrome in patients who have failed nonsurgical management. This surgery is often performed in the ambulatory clinic under local anesthesia, with lidocaine, a short-acting agent. Few studies have investigated the use of longer acting agents, such as bupivacaine, for outpatient CTR. Therefore, the aim of our study was to compare the postoperative pain experience after CTR with the use of either our standard lidocaine solution (control) or a mixture consisting of lidocaine and bupivacaine in equal amounts (intervention). METHODS: Patients undergoing CTR were randomized into control or intervention groups. Postoperative pain severity and numbness were recorded at several timepoints within the first 72 hours. The timing and quantity of postoperative analgesic use (acetaminophen and/or ibuprofen) was also documented. Both patients and assessor were blinded to allocation. RESULTS: Our study cohort included 139 patients: 67 in the control group and 72 in the intervention group. Postoperative pain scores were significantly lower in the intervention group at 6 hours (2.3 vs 3.2) and 8 hours (2.9 vs 3.9). Additionally, patients in the intervention group reported longer time to first analgesic use than those in the control group (5.2 hours vs 3.7 hours). A greater proportion of patients in the intervention group reported postoperative numbness at nearly all time points, compared to the control group. CONCLUSIONS: Our study shows that a mixture of bupivacaine and lidocaine improves early postoperative pain but causes prolonged finger numbness when compared to lidocaine alone. As both medications are effective and feasible for outpatient CTR, surgeon and patient preference should guide local anesthetic choice. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic Ib.

Serial Range of Motion and Grip Strength Measurements, Patient-Reported Outcomes, and Radiographic Thresholds Associated With Less Satisfactory Outcomes after Low-Energy Distal Radius Fracture in Women Aged 50 Years and Older.

PURPOSE: To document the change of clinical (wrist motion and grip strength) measurements and Patient-Rated Wrist Evaluation (PRWE) scores at 9 weeks and 3, 6, and 12 months after distal radius fracture (DRF) in women 50 years and older with exclusively isolated, displaced, and low-energy DRFs treated by either closed and/or open reduction and to relate these outcomes to their radiographic results. METHODS: In this retrospective single-institution cohort study, patients' post-DRF clinical measurements and PRWE scores were prospectively collected from December 2007 through September 2018 and stratified according to their final radiographic values of volar/dorsal tilt, ulnar variance, and radial inclination. RESULTS: Of the 1,319 women identified, 1,126 (85%) were treated nonsurgically, and 193 (15%) were treated operatively. At 12 months, patients averaged restoration (ratio of injured and uninjured sides' values) of 96% pronation, 95% extension, 91% supination, 81% flexion, and 80% (77% nondominant, 85% dominant) grip strength. The mean PRWE score was 39.5 at week 9 and 14.4 at 12 months with 54% of patients scoring <10 and 13% scoring zero. The mean volar/dorsal tilt, ulnar variance, and radial inclination values in those treated nonsurgically were 1.4° dorsal, +3.9 mm, and 18.0°, respectively. Analogous values in patients treated surgically were 6° volar, +2.6 mm, and 22°, respectively. Volar tilt ≥25°, dorsal tilt >10°, ulnar variance >+7.5 mm, and radial inclination ≤13° were thresholds beyond which motion and grip strength were reduced and/or PRWE scores increased. In general, older patients experienced more residual deformity and were less likely to have undergone surgery. CONCLUSIONS: Generally, outcomes were satisfactory for patients with radiographic results within identified thresholds for acceptable fracture reduction. Outcomes were significantly less favorable for patients with radiographic results beyond these thresholds; for these patients, early surgical intervention should be considered. Low-energy DRFs should prompt bone density investigation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic 2b.

Coronal translation of the forearm, proximal capitate, and ulnar styloid predict radial inclination in distal radius fractures in older female patients.

Aims: The aims of this study were to identify means to quantify coronal plane displacement associated with distal radius fractures (DRFs), and to understand their relationship to radial inclination (RI). Methods: From posteroanterior digital radiographs of healed DRFs in 398 female patients aged 70 years or older, and 32 unfractured control wrists, the relationships of RI, quantifiably, to four linear measurements made perpendicular to reference distal radial shaft (DRS) and ulnar shaft (DUS) axes were analyzed: 1) DRS to radial aspect of ulnar head (DRS-U); 2) DUS to volar-ulnar corner of distal radius (DUS-R); 3) DRS to proximal capitate (DRS-PC); and 4) DRS to DUS (interaxis distance, IAD); and, qualitatively, to the distal ulnar fracture, and its intersection with the DUS axis. Results: In the study (fracture) and control groups, respectively, the mean values were: RI, 17.2° (SD 7.2°; -7° to 35°) and 25.6° (SD 2.6°; 21° to 30°); DRS-U, 13.5 mm (SD 1.7; 4.9 to 20.8) and 15.3 mm (SD 0.72; 13.8 to 16.3); DUS-R, 13.4 mm (SD 2.1; 4.8 to 18.5) and 12.0 mm (SD 0.99; 9.7 to 13.9); DRS-PC (positive value radial to DRS, negative value ulnar), 0.14 mm (SD 5.4; -10.9 to 22.7) and -6.1 mm (SD 1.6; -10.6 to -2.3); and IAD, 25.3 mm (SD 2.5; 17.6 to 31.1) and 27.1 mm (SD 1.5; 24.5 to 31.0). All means were significantly different between the study and control groups. RI correlated strongly with DRS-PC. Ulnar styloid fracture intersection with the DUS axis, reflective of ulnar translation of both radial and ulnar shafts, was associated with significantly lower RI. Conclusion: After DRF, the relationship of the proximal capitate to the DRS axis in the coronal plane correlates with the final radial inclination. Additionally, ulnar styloid intersection with the DUS axis is associated with even lower radial inclination. DRF reduction should seek to restore the normal coronal relationship of both radial and ulnar shafts to their distal counterparts.

Empowering future pharmacists - Embedding prescribing in the United Kingdom pharmacy undergraduate degree.

INTRODUCTION: Pharmacy education within the United Kingdom (UK) is on the cusp of a major change with the integration of pharmacist independent prescribing into the undergraduate Master of Pharmacy (MPharm) degree and foundation year. This presents an opportunity for schools of pharmacy to completely review and redesign the MPharm degree in order to embed prescribing. This commentary details what needs to change within the MPharm degree and how these changes can be enacted. COMMENTARY: The learning outcomes for the new degree place greater emphasis on diagnostic and consultation skills, risk management, professional judgement, and leadership. Course content needs to be sequenced so that complexity builds throughout the programme and clinical skills are taught and practised within the context of prescribing. There will be more emphasis on higher-order cognitive skills, such as collaborative clinical decision-making, considering potential risks and benefits. Teaching will need to align with learning on placements and time needs built into the curriculum for preparation and debrief sessions following placements and simulation scenarios. The increased responsibility that comes with prescribing rights will require review of how professional identity is formed and professionalism skills are taught and assessed. IMPLICATIONS: Pharmacists' expertise in medicines means that they are well-placed to be prescribers, which will help meet health service demands. Long-term funding will be required for placements in community, general practice, and hospital settings, including the provision of training and support to pharmacists mentoring students on placements. In spite of the challenges of curriculum redesign, this opportunity is wholeheartedly welcomed.

Correlation between superior humeral head migration and proximal long head of biceps tendon pathology in patients with and without rotator cuff tears using magnetic resonance imaging and radiography.

Background: The biomechanical role of the proximal long head of the biceps tendon (PLHB) in glenohumeral joint stability remains controversial. This retrospective study aims to correlate between humeral head migration and PLHB pathology in patients with and without rotator cuff tendon tears using imaging. Methods: Seventy-nine patients who underwent 3T magnetic resonance imaging of the shoulder were retrospectively reviewed. Imaging findings were documented by a fellowship-trained musculoskeletal radiologist. PLHB tendon diameter change, contour irregularity, and signal intensity change were assessed. Rotator cuff status was given a binary assignment of intact vs. torn. Radiographs were used for measurement of the acromiohumeral distance and a cutoff value of 7 mm was set as a lower limit of normal. Results: In the cohort of 79 shoulders, 41.8% (33/79) of patients had intact PLHB tendon and rotator cuff, 26.6% (21/79) demonstrated isolated PLHB tendon pathology, 13.9% (11/79) demonstrated isolated rotator cuff tears, and 17.7% (14/79) demonstrated concomitant PLHB tendon pathology and rotator cuff tears. Acromiohumeral distance was preserved in 97.0% (32/33) of patients with intact PLHB tendon and rotator cuff, 28.6% (6/21) of patients with isolated PLHB tendon pathology, 81.8% (9/11) of patients with isolated rotator cuff tears, and 14.3% (2/14) of patients with concomitant PLHB tendon pathology and rotator cuff tears (P < .0001). Conclusion: Results of this study have shown that a statistical correlation was present between superior humeral head migration and PLHB tendon pathology with or without rotator cuff tears, compared to rotator cuff pathology alone. Findings suggest that intact PLHB tendon plays an important role in glenohumeral stability.

Cannabis use patterns among patients with upper extremity conditions at the time of legalization in Canada.

BACKGROUND: Recreational cannabis use was legalized in Canada in 2018. Cannabis use patterns and patient attitudes toward cannabis use, particularly in the context of these legal changes, are not well understood. Our aim was to evaluate baseline cannabis use patterns and attitudes at the time of legalization among patients with upper extremity conditions in Canada. METHODS: In 2018, we conducted a multicentre cross-sectional survey study of 1561 patients with upper extremity conditions at 7 surgical centres. Participants were asked whether they currently use cannabis. If yes, they were asked questions regarding usage patterns and perceptions of cannabis use, including likelihood of use, safety and comfort discussing it with their physician. RESULTS: In the 6 months after legalization, 790 (51%) participants felt that cannabis was safer than prescription narcotics, with 450 (29%) currently using cannabis. Reasons for cannabis use included pain (56%), stress (51%) and recreation (42%). Of the 1105 patients not using cannabis, 267 (24%) were more likely to consider it after legalization. Of the 450 cannabis users, 73 (16%) had been using it for less than 6 months, 206 (46%) stated they were more comfortable discussing cannabis with their physician after legalization and 195 (43%) were using cannabis more than 4 times per week. CONCLUSION: Many patients with upper extremity conditions were regularly using cannabis. Patients were more comfortable discussing cannabis with their physician than before legalization. Treating surgeons should be aware of these trends and expect to receive questions regarding cannabis use.

Upper Extremity Injuries in Rock Climbers: Diagnosis and Management.

Rock climbing places substantial stress on the upper extremities and can lead to unique injuries not common to other sports. With increasing popularity of the sport, hand surgeons are expected to see more patients with these pathologies. An understanding of the sport, accurate diagnoses, and appropriate treatment protocols are critical to maintain climbers' competitive abilities.

Magnitude, Direction, Temporal Patterns, and Frequency of Loss of Distal Radius Fracture Reduction in Women 50 Years and Older.

PURPOSE: To determine the magnitude, direction, temporal patterns, and frequency of reduction loss following nonsurgical, closed treatment of distal radius fractures in women 50 years and older and correlate these observations with bone mineral density and age. METHODS: We reviewed registry data on 1,148 patients 50 years and older with distal radius fractures managed by closed reduction and cast immobilization. Radial inclination (RI), ulnar variance (UV), and radial tilt (RT) were measured immediately and at 1, 2, 3, 6, 9, and 12 weeks after reduction. Magnitude, direction, frequency, and patterns of change were compared at each time point and correlated with bone mineral density T-scores and age using paired t tests in a mixed effects model. RESULTS: Over 12 weeks, RI decreased by 3° ± 5°, the majority occurring in the first 2 weeks and significantly correlated with bone mineral density T-score and age. Unexpectedly, RI increased over time in 5% of patients. Ulnar variance increased by 2.3 ± 1.7 mm, the majority occurring in the first 3 weeks and correlated with age. Radial tilt changed by 7° ± 11° in those displacing dorsally and 8° ± 12° in those displacing volarly at 12 weeks, with the majority occurring in the first 3 weeks and significantly correlating with age. Ulnar variance and RT continued to change by small increments between weeks 3 and 6. Nearly 90% of our cohort experienced measurable loss of reduction and 50% changed at least 5° RI, 11° RT, and 2 mm UV. CONCLUSIONS: Most distal radius fracture managed with closed reduction and casting have some loss of reduction, the majority occurring in the first 3 weeks and correlated with increased age and osteoporosis. This guides clinicians in informing patients about expected reduction loss, frequency of clinical and radiographic follow-up, and timing of discussions regarding the need for surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Coracoclavicular bursal changes on MRI: a diagnostic consideration in patients with shoulder pain and reduced coracoclavicular distance.

OBJECTIVE: To describe MRI changes of the coracoclavicular bursa in patients presenting with shoulder pain and examine whether there is an association with coracoclavicular distance measurements. METHODS: Retrospective analysis of 198 shoulder 3T MRI scans for patients with shoulder pain was performed. Two musculoskeletal trained radiologists read all MRI scans. Inter-reader and intra-reader agreements for the bursal changes were assessed using the Kappa coefficient. The coracoclavicular distance was stratified into three intervals: < 5 mm, 5-10 mm, and > 10 mm. Statistical analysis for the coracoclavicular bursal changes and coracoclavicular distance was conducted using Fisher's exact test. RESULTS: Coracoclavicular bursal changes were detected in 9% (n = 18/198) of patients. There was a statistically significant association between coracoclavicular distance (< 5 mm) and the presence of coracoclavicular bursal changes (p-value = 0.011). All patients (100%, n = 18/18) with coracoclavicular bursal fluid presented with shoulder pain with 44.5% of the patients (n = 8/18) describing anterior shoulder pain. A statistically significant association was detected between coracoclavicular bursal changes and anterior shoulder pain (p-value = 0.0011). Kappa coefficient for the bursal changes inter-reader agreement was moderate (0.67) and the intra-reader agreement was almost perfect (0.91). CONCLUSION: Coracoclavicular bursal changes were detected in 9% of shoulder MRI scans and were associated with reduced coracoclavicular distance (< 5 mm) suggesting an underlying mechanical disorder such as a friction or an impingement process. Documenting coracoclavicular bursal changes in the MRI report could help address patients' concerns and guide further management particularly in the context of shoulder pain and coracoclavicular distance of less than 5 mm.

Four-Corner Arthrodesis With Differing Methods of Osteosynthesis: A Systematic Review.

PURPOSE: The purpose of this study was to compare the union rates and clinical outcomes of 4-corner arthrodesis with different methods of osteosynthesis. METHODS: A systematic review of studies published in Ovid, Medline, Embase, and PubMed was conducted. Primary studies that reported clinical and radiographic results following 4-corner arthrodesis for scapholunate advanced collapse (SLAC), scaphoid nonunion advanced collapse (SNAC), or other types of wrist arthritis in human subjects were eligible. Biomechanical or cadaveric studies, case reports, studies that did not define and report a radiographic union rate, reviews and technical articles, studies that did not report the method of osteosynthesis, and studies that used multiple methods of osteosynthesis, but did not separate results for individual methods of osteosynthesis were excluded. Radiographic union rate, range of motion, and grip strength were analyzed. RESULTS: We identified and reviewed 291 full texts, selecting 57 studies for coding. The radiographic union rate did not significantly differ between studies using K-wire, screw, staple, nonlocking plate, metal locking plate, and radiolucent locking plate osteosynthesis. Fixation method significantly affected flexion, but pairwise comparison did not reveal any significant differences between individual groups. Grip strength as a percentage of the contralateral limb was significantly lower in studies with metal locking plate fixation compared to K-wire fixation (63.2% vs 82.6%). There were no other statistically significant differences between groups with respect to flexion, extension, radial deviation, ulnar deviation, and grip strength. CONCLUSIONS: All methods of osteosynthesis result in similar union rates, with no significant differences between methods. While there are some significant differences in range of motion and grip strength, these differences are unlikely to be clinically relevant. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Unsalvageable Radial Head in Patients Aged 30 Years and Younger.

PURPOSE: Concern exists regarding the use of radial head arthroplasty (RHA) in younger patients. This study assessed clinical, functional, and radiographic outcomes of RHA in patients aged 30 years and younger. METHODS: A retrospective review identified 26 elbows that underwent a smooth stem modular RHA in patients aged 30 years and younger at a median follow-up of 3.3 years clinically and 2.9 years radiographically. The mean age was 24 ± 5 years. Indications were acute trauma in 13 patients and chronic pathologies in the remaining 13, and these 2 groups were evaluated separately. Patients underwent clinical, functional, and radiographic evaluation. RESULTS: Average arc of motion was 137° ± 16° in the cohort with acute trauma and 120° ± 24° in the cohort with chronic pathologies. Mean Patient-Rated Elbow Evaluation scores were 23 ± 18 (acute) and 31 ± 19 (chronic). Mean Quick Disabilities of the Arm, Shoulder, and Hand scores were 18 ± 15 (acute) and 23 ± 20 (chronic). Average Mayo Elbow Performance Index scores were 90 ± 9 (acute) and 80 ± 13 (chronic). Severe capitellar erosion was present in 1 patient (4%) in the cohort with chronic pathologies. Radiographic stem lucency was seen in all cases with 10 of these (38%) graded as severe. Moderate-to-severe ulnohumeral arthritis developed in 4 patients (15%), 3 of whom were in the chronic reconstruction group. Two patients (8%) required reoperation, 1 for persistent instability and 1 for stiffness, both in the cohort with chronic pathologies. CONCLUSIONS: For acute trauma and challenging chronic conditions involving the radial head in patients aged 30 years and younger, a smooth stem modular RHA is an option. Although reoperation rates based on this series are low, osteoarthritis is common when used for posttraumatic conditions and severe radiographic stem lucency was seen in greater than one-third of patients. These concerning features warrant close follow-up, and further long-term outcomes are needed. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Effect of Personalized Patient Videos on Patient Satisfaction After Arthroscopic Shoulder Surgery.

Dissatisfaction after shoulder arthroscopy may be influenced by the information that patients receive. Multimedia is an emerging modality of information delivery. The goal of this study was to evaluate whether providing patients with a personalized video of their arthroscopic shoulder surgery improved satisfaction through a multisurgeon randomized controlled study. Patients undergoing arthroscopic shoulder decompression, rotator cuff repair, or labral repair were randomized to either the intervention group, receiving a video recording of their surgery, or the control group, not receiving a video. Patients who had previous ipsilateral shoulder arthroscopy or who could not participate in follow-up were excluded. Patient satisfaction was assessed at 3 months with a visual analog scale (VAS), Likert scale, and Quick Disabilities of the Arm, Hand and Shoulder (QuickDASH) score. The intervention group included 50 participants, and the control group included 47 participants, with 18% loss to follow-up. Mean control group VAS score was 8.5±2.2 and intervention group VAS score was 9.0±1.5, a difference that was not significantly different (P=.27). No statistically significant differences were noted for Likert scale scores and QuickDASH scores. A subgroup analysis of age group, sex, surgeon, and surgical procedure showed no significant differences. Based on these findings, personalized patient videos do not appear to improve satisfaction with surgery. Surgeons should investigate other means to improve patient satisfaction in the small group of dissatisfied patients. [Orthopedics. 2021;44(3):e331-e336.].

Outcomes of nonoperative management of displaced olecranon fractures in medically unwell patients.

BACKGROUND: Surgical treatment of displaced olecranon fractures in the elderly has a high rate of complications, including wound breakdown and fixation failure. The purpose of this study was to assess the clinical, radiographic, and functional outcomes of nonsurgical management of displaced olecranon fractures in low-demand elderly and medically unwell patients. METHODS: A retrospective review of 28 patients with displaced closed olecranon fractures was performed with an average follow-up of 11 months. The mean age at the time of injury was 79 ± 10 years. The average Charlson Comorbidity Index was 6.4 ± 2.6. Treatment modalities were at the discretion of the treating surgeon. A sling alone was used in 3 cases, an extension circumferential cast in 9, or a plaster or thermoplastic splint in 16. The mean period of immobilization was 5 ± 1 weeks. Outcomes included range of motion, ability to perform active overhead extension, as well as radiographic and functional outcomes. RESULTS: At final follow-up, the mean elbow range of motion for the cohort was from 28° ± 21° extension to 127° ± 15° flexion. Active overhead elbow extension against gravity was noted or documented in 24 (86%) patients. Two patients (7%) were unable to perform active extension. No pain was noted in 18 elbows, severe pain was present in 1 elbow, and the remainder reported mild occasional pain. All olecranon fractures in this cohort were displaced on the initial lateral radiograph. The mean displacement was 11 ± 7 mm. Nonunion at final radiographic outcome was observed in 23 (82%) elbows. Two (7%) patients developed skin complications related to posteriorly placed splints; one of which was severe. DISCUSSION: This study adds to the growing literature that supports nonoperative management of displaced olecranon fractures in elderly and medically unwell patients with low upper extremity demand. Patients can be counseled that they have a good chance of obtaining overhead extension, with minimal pain. Posteriorly based splints should not be used to minimize skin complications.

The Effects of Patient Resilience and Catastrophizing on Carpal Tunnel Surgical Outcomes.

Purpose: Outcomes following carpal tunnel release (CTR) are generally favorable. When patient satisfaction or symptom resolution is not as expected, understanding what factors contribute to that outcome could allow for strategies targeted at improving results. Our purpose was to determine if measurable mental health factors, specifically resilience and pain catastrophization, correlate with patients' postoperative outcomes following CTR. Methods: A prospective cohort study was performed. Ninety-four patients were recruited to take part in the study. Patients completed written consent, the Boston Carpal Tunnel Questionnaire (BCTQ), the Pain Catastrophizing Scale, and the Brief Resilience Scale. A single surgeon, or his resident under supervision, performed an open CTR under local anesthetic. Our primary outcome measure was a repeat BCTQ at 6 months. Pearson correlation coefficients and univariate analyses were performed to assess the correlation between Pain Catastrophizing Scale and Brief Resilience Scale scores and final BCTQ scores. Results: Forty-three and 63 participants completed the BCTQ at 3 and 6 months, respectively. This was 10% below the number needed to achieve appropriate power. Among those that responded, all participants showed improvement in their symptoms (P = .001). There was no correlation between patients' Pain Catastrophizing Scale or Brief Resilience Scale scores and 6-month BCTQ scores or the amount of improvement in the BCTQ at final follow-up. Conclusions: Most participants improved following CTR. Patients' self-assessed resilience, and the degree of pain catastrophization did no correlate with the amount of improvement patients had after surgery. Type of study/level of evidence: Prognostic II.

Citizen Science Uncovers Phytophthora ramorum as a Threat to Several Rare or Endangered California Manzanita Species.

The Sudden Oak Death (SOD) Blitzes consist of yearly surveys led by citizen scientists designed to map the distribution of Phytophthora ramorum, cause of the forest disease called SOD, across northern California. During the 2017 Santa Cruz County SOD Blitz, six rare or endangered Arctostaphylos (manzanita) species were found to be possibly symptomatic for the first time. Symptoms included branch cankers and associated canopy mortality, and affected multiple individuals per species. Isolates of P. ramorum were obtained from each of the six species and, through a 30-day-long inoculation experiment on live plants, Koch's postulates were completed for each one of them, conclusively determining that they all are hosts of this pathogen. Two additional manzanita species were later found to be apparently symptomatic in Marin County. Inoculations on detached branches using an isolate of P. ramorum obtained from one of the six rare species from Santa Cruz County were successful, suggesting that these two species may also be hosts of P. ramorum. Detached leaves of all eight species were also successfully inoculated at the University of California-Berkeley in fall 2018 and then again in spring 2019. In these cases, the same isolate was used for all inoculations, in order to obtain information on the comparative susceptibility of the eight species in question. Both branch and leaf inoculations identified significant interspecific differences in susceptibility. The production of sporangia was low on all species but it was not zero, suggesting that sporulation may cause within-plant and limited across-plant contagion, especially in rainy years.

Genetic and phenotypic variation of Phytophthora crassamura isolates from California nurseries and restoration sites.

Phenotypic and sequence data were used to characterize 28 isolates resembling Phytophthora megasperma from 14 host species in 2 plant production facilities and 10 restoration sites across the San Francisco Bay Area (California; USA). Size of the oogonia and DNA sequences (nuclear internal transcribed spacer (ITS) and mitochondrial cytochrome c oxidase subunit 1 (COX 1)) were compared, and sensitivity to mefenoxam and pathogenicity were measured. Based on ITS 61 % of isolates matched ex-type sequences of Phytophthora crassamura from Italy, and the remainder matched or were close to the P. megasperma ex-type. However, all California P. crassamura genotypes belonged to four unique COX 1 haplotype lineages isolated from both nurseries and restoration sites. Although lineages were sensitive to mefenoxam, a significant difference in sensitivity was identified, and all continued growth in-vitro. These results suggested previous mefenoxam exposure in plant production facilities resulting in tolerance. In conclusion, all evidence pointed to a nursery origin of novel P. crassamura lineages found in California restoration sites. In this study, COX 1 sequences and oogonia size provided information relevant to identify geographic and evolutionary intraspecific variation within P. crassamura, and was additionally used to track the spread of this species from nurseries into wildlands.

Why do GPs leave direct patient care and what might help to retain them? A qualitative study of GPs in South West England.

OBJECTIVE: To identify factors influencing general practitioners' (GPs') decisions about whether or not to remain in direct patient care in general practice and what might help to retain them in that role. DESIGN: Qualitative, in-depth, individual interviews exploring factors related to GPs leaving, remaining in and returning to direct patient care. SETTING: South West England, UK. PARTICIPANTS: 41 GPs: 7 retired; 8 intending to take early retirement; 11 who were on or intending to take a career break; 9 aged under 50 years who had left or were intending to leave direct patient care and 6 who were not intending to leave or to take a career break. Plus 19 stakeholders from a range of primary care-related professional organisations and roles. RESULTS: Reasons for leaving direct patient care were complex and based on a range of job-related and individual factors. Three key themes underpinned the interviewed GPs' thinking and rationale: issues relating to their personal and professional identity and the perceived value of general practice-based care within the healthcare system; concerns regarding fear and risk, for example, in respect of medical litigation and managing administrative challenges within the context of increasingly complex care pathways and environments; and issues around choice and volition in respect of personal social, financial, domestic and professional considerations. These themes provide increased understanding of the lived experiences of working in today's National Health Service for this group of GPs. CONCLUSION: Future policies and strategies aimed at retaining GPs in direct patient care should clarify the role and expectations of general practice and align with GPs' perception of their own roles and identity; demonstrate to GPs that they are valued and listened to in planning delivery of the UK healthcare; target GPs' concerns regarding fear and risk, seeking to reduce these to manageable levels and give GPs viable options to support them to remain in direct patient care.