Pathogen Resistance Depending on Jacalin-Dirigent Chimeric Proteins Is Common among Poaceae but Absent in the Dicot Arabidopsis as Evidenced by Analysis of Homologous Single-Domain Proteins.

MonocotJRLs are Poaceae-specific two-domain proteins that consist of a jacalin-related lectin (JRL) and a dirigent (DIR) domain which participate in multiple developmental processes, including disease resistance. For OsJAC1, a monocotJRL from rice, it has been confirmed that constitutive expression in transgenic rice or barley plants facilitates broad-spectrum disease resistance. In this process, both domains of OsJAC1 act cooperatively, as evidenced from experiments with artificially separated JRL- or DIR-domain-containing proteins. Interestingly, these chimeric proteins did not evolve in dicotyledonous plants. Instead, proteins with a single JRL domain, multiple JRL domains or JRL domains fused to domains other than DIR domains are present. In this study, we wanted to test if the cooperative function of JRL and DIR proteins leading to pathogen resistance was conserved in the dicotyledonous plant Arabidopsis thaliana. In Arabidopsis, we identified 50 JRL and 24 DIR proteins, respectively, from which seven single-domain JRL and two single-domain DIR candidates were selected. A single-cell transient gene expression assay in barley revealed that specific combinations of the Arabidopsis JRL and DIR candidates reduced the penetration success of barley powdery mildew. Strikingly, one of these pairs, AtJAX1 and AtDIR19, is encoded by genes located next to each other on chromosome one. However, when using natural variation and analyzing Arabidopsis ecotypes that express full-length or truncated versions of AtJAX1, the presence/absence of the full-length AtJAX1 protein could not be correlated with resistance to the powdery mildew fungus Golovinomyces orontii. Furthermore, an analysis of the additional JRL and DIR candidates in a bi-fluorescence complementation assay in Nicotiana benthamiana revealed no direct interaction of these JRL/DIR pairs. Since transgenic Arabidopsis plants expressing OsJAC1-GFP also did not show increased resistance to G. orontii, it was concluded that the resistance mediated by the synergistic activities of DIR and JRL proteins is specific for members of the Poaceae, at least regarding the resistance against powdery mildew. Arabidopsis lacks the essential components of the DIR-JRL-dependent resistance pathway.

First report of Boeremia exigua var. exigua causing Black Spot-like symptoms on commercially grown soybean in Germany.

Soybean (Glycine max [L.] Merr.) is economically the most important protein crop grown worldwide. However, Europe largely depends on soybean imported from the Americas (European Commission 2019; Haupt and Schmid 2020). In Germany, soybean production was not formally recorded before 2016, but since then a steady increase along with an expansion of the growing area from the south of Germany to northern states occurred. In 2019 an area of 29,000 hectares was under soybean cultivation (Federal Ministry of Food and Agriculture (Germany) 2019). In the state of North Rhine-Westphalia (NRW, western part of Germany) farmers have started in recent years to cultivate soybean, making it increasingly important to monitor pathogens associated with this new crop. At the beginning of October 2019, shortly before harvest, rows of black spots on pods and stems of soybean plants cv. Viola throughout a field site near Jülich (NRW) were observed. Close observation identified them as pycnidia with similarity to symptoms reported from soybean in Austria in 2015 (Hissek and Bedlan 2016). The collected samples were thoroughly surface sterilized (two washes with 70 % EtOH, a rinse in 0.5 % sodium hypochlorite solution and a final wash in sterile double distilled water) and placed on plates containing potato dextrose agar (PDA) at 22 °C in the dark. Fungal colonies were transferred to malt extract agar plates (MEA) and examined by microscopy. Thus, 34 of 41 isolates looked morphologically similar, producing colonies that appeared dark grey with white aerial mycelium and round to irregular margins. A single spore isolate was generated and designated IPP1903. Spores derived from IPP1903 were unicellular and mostly oblong to cylindrical with a mean width of 2.6±0.3 µm and a mean length of 5.9±0.8 µm (N=50, mean value ± standard deviation). Colonies on MEA were 5.4 to 5.8 cm in diameter after growth for seven days at 20 to 25°C with a photoperiod of 12 h and 3.3 to 3.7 cm in diameter after growth for seven days in the dark at 22°C. These morphological observations led to the conclusion that the isolate may belong to the genus Phoma. To test this hypothesis, we performed a drop test with 5 M NaOH which is used routinely to check for the presence of a genus-specific metabolite. We observed a change in color, indicating a positive test result. The color change was even more pronounced on the plates incubated in the light, further confirming the presence of "metabolite E" (Boerema et al. 2004; Kövics et al. 2014). Next, DNA was extracted and PCR was performed with primers specific for ITS regions (GenBank MT397284), LSU (MT397285), rbb2 (MT414713) or tub2 (MT414712). Sequencing results of PCR products were used to create a combined phylogenetic tree, including sequences published previously (Chen et al. 2015). Our sequencing results together with the morphological observations clearly identified the fungal isolate to be Boeremia exigua var. exigua. The isolate is publicly available in the CBS collection of the Westerdijk Fungal Biodiversity Institute with the accession no. CBS 146730. Koch's postulates were fulfilled by inoculating a spore suspension of the isolate IPP1903 (5x105 ml-1 in 0.05% Tween 20 solution in distilled water) onto healthy primary leaves of twenty 14 days old soybean plants of the cultivar Abelina. While the mock-inoculated plants (inoculated with 0.05% Tween 20 solution in distilled water) stayed healthy, the inoculated plants developed lesions on the leaves after seven days. Six weeks after inoculation the fungus could be reisolated from cuttings of the infected leaves after surface-sterilization. Fungal colonies were confirmed to be B. exigua var. exigua by morphological examination and via NaOH drop test. To our knowledge, this is the first report of B. exigua var. exigua causing disease on commercially grown soybean in Germany.

Emergency Department Clinicians' Attitudes Toward Opioid Use Disorder and Emergency Department-initiated Buprenorphine Treatment: A Mixed-Methods Study.

INTRODUCTION: Emergency department (ED) visits related to opioid use disorder (OUD) have increased nearly twofold over the last decade. Treatment with buprenorphine has been demonstrated to decrease opioid-related overdose deaths. In this study, we aimed to better understand ED clinicians' attitudes toward the initiation of buprenorphine treatment in the ED. METHODS: We performed a mixed-methods study consisting of a survey of 174 ED clinicians (attending physicians, residents, and physician assistants) and semi-structured interviews with 17 attending emergency physicians at a tertiary-care academic hospital. RESULTS: A total of 93 ED clinicians (53% of those contacted) completed the survey. While 80% of respondents agreed that buprenorphine should be administered in the ED for patients requesting treatment, only 44% felt that they were prepared to discuss medication for addiction treatment. Compared to clinicians with fewer than five years of practice, those with greater experience were less likely to approve of ED-initiated buprenorphine. In our qualitative analysis, physicians had differing perspectives on the role that the ED should play in treating OUD. Most physicians felt that a buprenorphine-based intervention in the ED would be feasible with institutional support, including training opportunities, protocol support within the electronic health record, counseling and support staff, and a robust referral system for outpatient follow-up. CONCLUSION: ED clinicians' perception of buprenorphine varied by years of practice and training level. Most ED clinicians did not feel prepared to initiate buprenorphine in the ED. Qualitative interviews identified several addressable barriers to ED-initiated buprenorphine.

Best Practices for Lactation Support at Conferences and Standardized Testing Centers.

Breastfeeding has demonstrable benefits for children and their mothers; however, breastfeeding can be particularly difficult for women who return to the workplace in the months after a child's birth. The challenge of continuing to provide breast milk to an infant after a mother returns to work is evident in the day-to-day lives of health professionals who choose to do so and is reflected in the literature, which shows a marked reduction in breastfeeding rates corresponding to a woman's return to work. These barriers are even more apparent when travel is required for professional obligations or advancement, such as to attend or present at national conferences or to take standardized examinations at test centers. This article provides guidelines and practical advice for event organizers and testing centers to support a lactating mother's ability to provide for her child without compromising her professional career. In particular, we describe the physical requirements of lactation spaces, considerations for milk storage, ways to create a lactation-friendly environment, and unique considerations and accommodations for test takers and test centers. Supporting lactating health professionals should be seen as part of a larger endeavor to support gender equity, advance women in medicine, and integrate wellness and family into our professional lives.

Variations in pediatric trauma transfer patterns in Northern California pediatric trauma centers (2001-2009).

BACKGROUND: Due to the scarcity of specialized resources for pediatric trauma, "regionalization," or a system designed to get "the right child, to the right place, at the right time," is vital to quality pediatric trauma care. In Northern California, four pediatric trauma centers serve 3.9 million children within a geographically diverse area of 113,630 square miles. A significant proportion of children with trauma is initially triaged to nontrauma hospitals and may require subsequent transfer to a specialty center. Trauma transfer patterns to a pediatric trauma center may provide insight into regional primary triage practices. Transfers from hospitals in close proximity to pediatric trauma centers might suggest that some children could have avoided transfer with minimal additional transport time. While pediatric trauma centers are scarce and serve as regional resources, transfers from beyond the regular catchment area of a trauma center could be an indication of clinical need. OBJECTIVES: The objective of this study was to gain an understanding of patterns of pediatric trauma transfer to all pediatric trauma centers within the region as a first step in assessing the efficacy and efficiency of trauma triage. The authors examined three groups of transfer patients: transfers from within the same county as the pediatric trauma center (near transfers), transfers from counties adjacent to the pediatric trauma center (catchment transfers), and transfers from more distant counties (far transfers). The hypothesis was that catchment transfers would form the bulk of transfers, near transfers would compose < 10% of total transfers, and far transfers would be younger and more severely injured than catchment transfers. METHODS: This was a retrospective analysis of institutional trauma registry data of children < 18 years from all pediatric trauma centers in Northern California from 2001 through 2009. Transfers were characterized by the location of the transfer hospital relative to the location of the pediatric trauma center. Characteristics associated with near transfer compared to primary triage to a pediatric trauma center were identified, as well as characteristics associated with far transfer compared to catchment transfer. RESULTS: A total of 2,852 of 11,952 (23.9%) pediatric trauma patients were transfers. Near transfers comprised 24.5% of cases, catchment transfers were 37.4%, and far transfers were 38.2%. After controlling for demographic, clinical, and geographic factors, younger age, higher Injury Severity Score (ISS), public versus private insurance, and an injury mechanism of "fall" were associated with near transfer rather than direct triage. Older age, higher ISS, and mechanism of "motor vehicle crash" were associated with far rather than catchment transfer. CONCLUSIONS: This analysis of patterns of transfer to all pediatric trauma centers within Northern California gives the most comprehensive population view of pediatric trauma triage to date, to the authors' knowledge. Trauma transfers comprise an important minority of patients cared for at pediatric trauma centers. The number of near transfers documented indicates the potential to improve the primary triage process of patients to pediatric trauma centers. The frequency of far transfers substantiates the well-known shortage of pediatric trauma expertise. Development of regionwide standardized transfer protocols and agreements between hospitals, as well as standardized monitoring of the process and outcomes, could increase efficiency of care.

The effect of trauma center care on pediatric injury mortality in California, 1999 to 2011.

BACKGROUND: Trauma centers (TCs) have been shown to decrease mortality in adults, but this has not been demonstrated at a population level in all children. We hypothesized that seriously injured children would have increased survival in a TC versus nontrauma center (nTC), but there would be no increased benefit from pediatric-designated versus adult TC care. METHODS: This was a retrospective study of the unmasked California Office of Statewide Health and Planning Department patient discharge database (1999-2011). DRG International Classification of Diseases-9th Rev. (ICD-9) diagnostic codes indicating trauma were identified for children (0-18 years), and injury severity was calculated from ICD-9 codes using validated algorithms. To adjust for hospital case mix, we selected patients with ICD-9 codes that were capable of causing death and which appeared at both TCs and nTCs. Instrumental variable (IV) analysis using differential distance between the child's residence to a TC and to the nearest hospital was applied to further adjust for unobservable differences in TC and nTC populations. Instrumental variable regression models analyzed the association between mortality and TC versus nTC care as well as for pediatric versus adult TC designations, adjusting for demographic and clinical variables. RESULTS: Unadjusted mortality for the entire population of children with nontrivial trauma (n = 445,236) was 1.2%. In the final study population (n = 77,874), mortality was 5.3%, 3.8% in nTCs and 6.1% in TCs. IV regression analysis demonstrated a 0.79 percentage point (95% confidence interval, -0.80 to -0.30; p = 0.044) decrease in mortality for children cared for in TC versus nTC. No decrease in mortality was demonstrated for children cared for in pediatric versus adult TCs. CONCLUSION: Our IV TC outcome models use improved injury severity and case mix adjustment to demonstrate decreased mortality for seriously injured California children treated in TCs. These results can be used to take evidence-based steps to decrease disparities in pediatric access to, and subsequent outcomes for, trauma care. LEVEL OF EVIDENCE: Therapeutic/care management, level III.