Distribution of Xylella fastidiosa in Blueberry Stem and Root Sections in Relation to Disease Severity in the Field.

Xylella fastidiosa causes bacterial leaf scorch, a new disease of southern highbush blueberry in the southeastern United States. Infections occlude the xylem of affected plants, causing drought-like symptoms and, eventually, plant death. To assess the likelihood of mitigation of bacterial leaf scorch through cultural practices such as pruning or hedging of affected plants, we determined the localization and population density of X. fastidiosa in naturally infected blueberry plants with varying levels of bacterial leaf scorch severity. Stem segments were sampled from the current season's growth down to the base of the plant, as were root segments on plants that were either asymptomatic or had light, moderate, or severe symptoms in three plantings affected by the disease. Stem sap was extracted from each segment and population densities of X. fastidiosa were determined using real-time polymerase chain reaction with species-specific primers. Detection frequencies were lowest (but non-zero) in sap from asymptomatic plants and highest in plants with severe symptoms. In asymptomatic plants, detection was generally least frequent (0 to 20.0%) in top and root sections and highest (4.6 to 55.6%) in middle and base stem sections. As disease severity increased, detection frequencies in roots increased to >80% in two plantings and to 60% in the third planting. Overall, detection frequencies were highest (>80%) in middle and base stem sections of plants from the moderate and severe disease classes. The lowest bacterial titers (averaging 0 to 2.1 × 101 CFU per 50 µl of sap) were observed in top and root sections of asymptomatic plants, whereas the highest titers (generally between 104 and 105 CFU per 50 µl of sap) were obtained from middle, base, and root sections of plants from the moderate and severe classes. The presence of the bacterium in middle and base stem sections at low disease severity indicates rapid distribution of X. fastidiosa in affected plants. Because the pathogen accumulates in the roots at moderate and high disease severity levels, management strategies such as pruning and mowing are unlikely to be effective in curing affected plants from bacterial leaf scorch.

A randomised controlled trial of sublingual buprenorphine-naloxone film versus tablets in the management of opioid dependence.

BACKGROUND: Buprenorphine-naloxone sublingual film was introduced in 2011 in Australia as an alternative to tablets. This study compared the two formulations on subjective dose effects and equivalence, trough plasma levels, adverse events, patient satisfaction, supervised dosing time, and impact upon treatment outcomes (substance use, psychosocial function). METHODS: 92 buprenorphine-naloxone tablet patients were recruited to this outpatient multi-site double-blind double-dummy parallel group trial. Patients were randomised to either tablets or film, without dose changes, over a 31 day period. RESULTS: No significant group differences were observed for subjective dose effects, trough plasma buprenorphine or norbuprenorphine levels, adverse events and treatment outcomes. Buprenorphine-naloxone film took significantly less time to dissolve than tablets (173±71 versus 242±141s, p=0.007, F=7.67). CONCLUSIONS: The study demonstrated dose equivalence and comparable clinical outcomes between the buprenorphine-naloxone film and tablet preparations, whilst showing improved dispensing times and patient ratings of satisfaction with the film.

The intussusception antireflux valve is ineffective in preventing cholangitis in biliary atresia.

Cholangitis is the most common complication after portoenterostomy for biliary atresia. The construction of an intussusception valve in the Roux-en-Y limb of the portoenterostomy has been advocated as a means to ameliorate this complication. The authors reviewed the records of children who underwent portoenterostomy to assess the incidence and severity of cholangitis, as well as outcome. The children were divided into two groups according to whether they did not have (group I) or did have (group II) an antireflux valve in the Roux limb of the bilioenteric conduit. There were 19 children in each group. There were no significant differences between the groups with respect to age at time of portoenterostomy or length of follow-up (Table 1). Nine group I patients are alive and well; five died and five have had or are awaiting transplantation. In group II, 10 patients are alive and well, eight have had transplantation, and one is awaiting transplantation. Outcome with respect to death or the need for liver transplantation because of progressive hepatic failure is not different between the groups (P = 1.0, Fisher's 2 x 2). The incidence of cholangitis was evaluated by comparing the average number of episodes of cholangitis during the follow-up period, the number of episodes per year, and the number of episodes in the first postoperative year (when this complication is most prevalent). Analysis of the data showed no difference in incidence between those with valved and nonvalved biliary conduits. The severity of cholangitis, judged by total length of antibiotic treatment, did not differ between the groups. It appears that the presence of an intussusception valve in the Roux-en-Y biliary conduit does not affect the incidence of cholangitis or the outcome after portoenterostomy, over short-term follow-up.

Portal vein thrombosis: treatment of variceal hemorrhage by endoscopic variceal ligation.

Thirty-one endoscopic variceal ligation (EVL) procedures have been done in seven consecutively treated children who had esophageal varices resulting from portal vein thrombosis. Using an elastic band ligature device attached to a standard flexible endoscope, the varices in the distal 5 cm of the esophagus were mechanically strangulated. Typically, one to three varices were banded at each session. The children were between 8 months and 19 years of age at the onset of variceal bleeding. Treatment initially required frequent procedures (every 2 to 4 weeks), but the interval was gradually extended to biannual or annual. Treatment was assessed by survival, complications, incidence of rebleeding, and obliteration of varices. Each patient had from 3 to 9 EVL sessions. There were no deaths related to EVL. There were no complications. Only one patient had rebleeding in the interval between sessions. The follow-up period is 3 to 12 years. In three of the six surviving patients, the varices have been completely eradicated. The remaining three are completing treatment. Endoscopic variceal ligation is safe efficacious treatment for control of variceal bleeding caused by portal vein thrombosis. In our experience, the technique has eliminated the need for portosystemic shunting in this patient population.

Surgical jaundice in infants: other than biliary atresia.

After biliary atresia, the lesions responsible for surgical jaundice in the infant are perforation of the common bile duct, choledochal cyst, bile plug syndrome, and miscellaneous congenital lesions in descending order of frequency. Perforation of the common bile duct commonly presents with an insidious onset of bilious ascites and is best treated by simple peritoneal drainage. Choledochal cyst usually presents later in childhood but presents in infancy if obstruction of the biliary tree is complete or near complete. Excision is the treatment of choice. Any condition leading to alteration in bile composition may cause bile plug syndrome. Spontaneous resolution is the rule: occasionally, intraoperative irrigation is necessary. Most miscellaneous lesions lend themselves to operative correction.

Perineal Crohn's disease.

Crohn's disease has frequent perineal manifestations, including rectovaginal fistulas. This association is not widely recognized, especially in the gynecologic literature. Six cases of presumptive or documented Crohn's disease associated with rectovaginal fistulas and a review of the literature are presented. The need for a high degree of suspicion and a gastroenterologic evaluation is emphasized. Conservative management is stressed in view of the poor healing characteristics of perineal tissue in these patients. Alternative surgical approaches, including local repair, proximal diversion, and curative total proctocolectomy/ileostomy, are presented. Local repair is fraught with problems including postoperative breakdown and recurrence, yet proctocolectomy is a radical, but curative, procedure. An understanding of the ramifications of surgical intervention along with thorough patient counseling are required in managing these patients.