Measuring Clinically Meaningful Change in Outcomes for Youth With Chronic Pain Following Graded Exposure Treatment

INTRODUCTION

Functional improvement is a critical outcome for individuals living with chronic pain. Graded exposure treatment (GET) has been associated with statistically significant improvements in functional outcomes for youth with chronic pain by targeting pain-related fear and avoidance.

OBJECTIVE

The aim of the present study was to explore clinically meaningful change in outcomes in adolescents with chronic pain following participation in a GET, and to then classify patients as treatment responders versus nonresponders.

MATERIALS AND METHODS

Participants included 27 youth (Mage=13.5) with chronic pain enrolled in a recently published single-arm randomized baseline trial of GET Living. Reliable change at the individual level was assessed using the Reliable Change Index (RCI). Adolescents were classified as treatment responders if they achieved a reliable change in outcomes across time points and also demonstrated a change in clinical severity range in the expected direction (ie, from severe to moderate).

RESULTS

Reliable and clinically significant improvements in pain-related fear and avoidance, functional disability, and school functioning were demonstrated at discharge, with improvements maintained at 3-month and 6-month follow-up. Among core outcomes, 48% (n=13) of patients were classified as treatment responders in one or more outcomes at discharge, with this increasing to 76% (n=19) at 3-month follow-up.

DISCUSSION

Examining reliable and clinically meaningful change (vs. statistical significance alone) provides a way to examine treatment response to an intervention and to enhance the interpretability of findings, helping to bridge the gap between clinical trials and clinical practice by providing guidelines for interpretation.

Evaluating Telehealth Implementation in the Context of Pediatric Chronic Pain Treatment during COVID-19

Telehealth has emerged as a promising healthcare delivery modality due to its ability to ameliorate traditional access-level barriers to treatment. In response to the onset of the novel coronavirus (COVID-19) pandemic, multidisciplinary pain clinics either rapidly built telehealth infrastructure from the ground up or ramped up existing services. As the use of telehealth increases, it is critical to develop data collection frameworks that guide implementation. This applied review provides a theoretically-based approach to capitalize on existing data sources and collect novel data to inform virtually delivered care in the context of pediatric pain care. Reviewed multisource data are (1) healthcare administrative data; (2) electronic chart review; (3) clinical health registries; and (4) stakeholder feedback. Preliminary telehealth data from an interdisciplinary pediatric chronic pain management clinic (PPMC) serving youth ages 8–17 years are presented to illustrate how relevant implementation outcomes can be extracted from multisource data. Multiple implementation outcomes were assessed, including telehealth adoption rates, patient clinical symptoms, and mixed-method patient-report telehealth satisfaction. This manuscript provides an applied roadmap to leverage existing data sources and incorporate stakeholder feedback to guide the implementation of telehealth in pediatric chronic pain settings through and beyond COVID-19. Strengths and limitations of the modeled data collection approach are discussed within the broader context of implementation science.

Pain Management in Children During the COVID-19 Pandemic

PURPOSE OF REVIEW

For many children, the SARS-CoV-2 pandemic has impacted the experience and treatment of their pain. This narrative review draws from the pain literature and emerging findings from COVID-19 research to highlight potentially meaningful directions for clinical consideration and empirical inquiry in the months and years to come.

RECENT FINDINGS

COVID-19 has been linked to diffuse acute pains as well as chronic pain sequelae. Contextual factors known to increase vulnerability for pain and associated functional disability have been exacerbated during the pandemic. Beyond these salient concerns has been the remarkable resilience demonstrated by patients and providers as healthcare systems have sought to harness creativity and innovative digital solutions to support optimal child wellbeing throughout this crisis.

SUMMARY

Ongoing research is needed to elucidate the short- and long-term effects of the pandemic on children's pain and to consider how the delivery of treatment via digital technology has impacted existing paradigms of pain management.

Worry about somatic symptoms as a sign of cancer recurrence: prevalence and associations with fear of recurrence and quality of life in survivors of childhood cancer

OBJECTIVE

Somatic symptoms (e.g., pain, fatigue) are common after childhood cancer and are associated with greater fear of cancer recurrence and poorer health-related quality of life (HRQoL). Qualitative studies indicate that survivors of childhood cancer (SCCs) worry about somatic symptoms as indicating cancer recurrence, which could in part explain associations between symptoms and poorer psychosocial outcomes. However, the prevalence, characteristics, and impact of symptom worry has not been quantitatively studied.

METHODS

SCCs (N = 111; 52% female; Mage at study = 17.67 years, range = 8-25 years; Mage at diagnosis = 6.70 years) across a variety of diagnoses were recruited from a pediatric cancer center in Canada and completed self-report measures of symptom worry, symptom frequency, general anxiety, fear of cancer recurrence, and HRQoL.

RESULTS

A majority (62%) of SCCs worried about at least one symptom as a sign of recurrence. Pain was the most worrisome symptom, but SCCs also reported worrying about symptoms that are rarely associated with cancer recurrence such as hunger, dizziness, and feeling cold. Symptom worry was more strongly associated with fear of cancer recurrence than the mere frequency of those symptoms, and this relationship held while controlling for treatment factors and general anxiety. Symptom worry and frequency each explained unique variance in HRQoL.

CONCLUSIONS

Worry about somatic symptoms as a sign of cancer recurrence is common and may be impactful after childhood cancer. Excessive worry about somatic symptoms could be an important target to reduce fear of recurrence and increase HRQoL in SCCs.

Pain in Youth With Sickle Cell Disease: A Report From the Sickle Cell Clinical Research and Intervention Program

OBJECTIVES

Pain is prevalent among youth with sickle cell disease (SCD). However, previous research has been limited by small sample sizes and lacked examinations of developmental differences in pain, which are critical to minimizing the development of chronic pain as youth transition into adulthood. The primary aim of the current study was to compare pain and pain interference across 4 developmental groups in a large sample of youth with SCD. The secondary aim was to identify risk factors for greater pain and pain interference.

MATERIALS AND METHODS

Utilizing a cross-sectional study design, the expression and predictors of pain and pain interference were compared across 4 developmental stages: toddlers/preschoolers (2 to 4 y), school-aged children (5 to 7 y), preadolescents (8 to 12 y), and adolescents (13 to 18 y). Participants included 386 youth with SCD and their caregivers.

RESULTS

Caregiver-reported pain and pain interference and youth-reported pain interference increased across developmental groups and plateaued approaching adolescence (multivariate analyses of variance P=0.002 for pain and P<0.001 for pain interference). Elevated fatigue, anxiety, and perceived difficulties with pain management were the most robust predictors of higher youth- and caregiver-reported pain (βs ranging from 0.15 to 0.68; P<0.001) and pain interference (βs ranging from 0.18 to 0.64; P<0.001).

DISCUSSION

Disease and treatment-related variables were not associated with pain. Self-reported pain was elevated in older versus younger developmental groups and was largely linked to anxiety, fatigue, and perceptions of pain management, thus highlighting the modifiable nature of factors influencing pain among youth with SCD.

mHealth for pediatric chronic pain: state of the art and future directions

INTRODUCTION

Chronic pain conditions are common among children and engender cascading effects across social, emotional, and behavioral domains for the child and family. Mobile health (mHealth) describes the practice of delivering healthcare via mobile devices and may be an ideal solution to increase access and reach of evidence-based behavioral health interventions.

AREAS COVERED

The aim of this narrative review is to present a state-of-the-art overview of evidence-based mHealth efforts within the field of pediatric chronic pain and consider new and promising directions for study. Given the nascent nature of the field, published mHealth interventions in all stages of development are discussed. Literature was identified through a non-systematic search in PubMed and Google Scholar, and a review of reference lists of papers that were identified as particularly relevant or foundational (within and outside of the chronic pain literature).

EXPERT OPINION

mHealth is a promising interventional modality with early evidence suggesting it is primed to enhance behavioral health delivery and patient outcomes. There are many exciting future directions to be explored including drawing inspiration from digital health technology to generate new ways of thinking about the optimal treatment of pediatric chronic pain.

Adaptive Parenting Among Low-Income Black Mothers and Toddlers' Regulation of Distress

Parenting differs in purpose and strategy according to cultural background (Brooks-Gunn & Markman, 2005; Iruka, LaForett, & Odom, 2012). The current study tests a unique latent factor score, Adaptive Parenting, that represents culturally-relevant, positive parenting behaviors: maternal coping with stress through reframing, maternal scaffolding of toddlers' learning during a low-stress task, and maternal commands during a high-stress task. Participants were Black mothers (N = 119; M_age  = 27.78) and their 24- to 30-month-old toddlers. Families were part of a broader study examining family resilience among urban, low-income young children and their families. Results demonstrate that the proposed variables align on a single factor and positively predict toddlers' emotion regulation. Findings are discussed in the context of Black culturally-specific parenting processes.

Indications of Susceptibility to Calonectria pseudonaviculata in Some Common Groundcovers and Boxwood Companion Plants

Knowing the host range of a pathogen is critical to developing and implementing effective disease management programs. Calonectria pseudonaviculata (Cps) is known to attack a number of species, varieties, and cultivars in the genus Buxus as well as three Pachysandra species (Pachysandra terminalis, Pachysandra procumbens, and Pachysandra axillaris) and several Sarcococca species, all in the Buxaceae family. The objective of this study was to evaluate non-Buxaceae groundcovers and companion plants commonly associated with boxwood plantings for their susceptibility to Cps. Twenty-seven plant species belonging to 21 families were exposed to different levels of inoculum: 50 to 300 conidia per drop for detached leaf assays and 30,000 to 120,000 conidia per 1 ml for whole-plant assays. Inoculated plants were incubated in humid environments for at least 48 h to facilitate infection. Cps infection and sporulation were observed on 12 plant species: Alchemilla mollis, Arctostaphylos uva-ursi, Brunnera macrophylla, Epimedium × youngianum, Galium odoratum, Geranium sanguineum, Phlox subulata, Tiarella cordifolia, Callirhoe involucrata, Iberis sempervirens, Mazus reptans, and Vinca minor. These results suggest that there may be more hosts of Cps commonly grown in nurseries and landscapes. If corroborated by observations of natural infection, these findings have implications for the Boxwood Blight Cleanliness Program instituted by the National Plant Board and for planning disease mitigation at production and in the landscape.

Fathering across contexts: The moderating role of respiratory sinus arrhythmia in predicting toddler emotion regulation

Caregivers play an integral role in promoting children's emotion regulation, while children's individual physiology affects how they respond to the caregiving environment. Relatively little is known about how fathering influences toddler emotion regulation, particularly within African American and low-income communities, where risk related to the development of emotion regulation is higher. This study investigated relations among fathering, toddler parasympathetic regulation, and toddler emotion regulation in a sample of 92 families. Fathering was assessed during two interactions: engagement following a stressor during a triadic task and a dyadic play task. Respiratory sinus arrhythmia (resting and reactivity) was obtained as an index of toddler parasympathetic arousal. Findings demonstrated an association between fathers' engagement poststressor and toddler emotion regulation. Toddler RSA moderated this association: toddlers with elevated levels of resting RSA benefitted from parenting engagement following a stressor. Fathering during play did not relate to toddler emotion regulation. The importance of fathering and physiologic contexts in early regulatory development is discussed.

Best-Evidence for the Rehabilitation of Chronic Pain Part 1: Pediatric Pain

Chronic pain is a prevalent and persistent problem in middle childhood and adolescence. The biopsychosocial model of pain, which accounts for the complex interplay of the biological, psychological, social, and environmental factors that contribute to and maintain pain symptoms and related disability has guided our understanding and treatment of pediatric pain. Consequently, many interventions for chronic pain are within the realm of rehabilitation, based on the premise that behavior has a broad and central role in pain management. These treatments are typically delivered by one or more providers in medicine, nursing, psychology, physical therapy, and/or occupational therapy. Current data suggest that multidisciplinary treatment is important, with intensive interdisciplinary pain rehabilitation (IIPT) being effective at reducing disability for patients with high levels of functional disability. The following review describes the current state of the art of rehabilitation approaches to treat persistent pain in children and adolescents. Several emerging areas of interventions are also highlighted to guide future research and clinical practice.

Sleep moderates the association between routines and emotion regulation for toddlers in poverty

Routines in the family are a potential source of resilience for at-risk children and support children's emerging emotion regulation. Meanwhile, inadequate sleep has been linked with deficits in cognitive processes to attend to environmental stimuli and with poor emotion regulation for children. The detrimental effects of poor sleep are potentially worse in low-income children. The aim of the current study was to examine the moderating role of sleep in the association between family routines and emotion regulation in toddlers in poverty. We analyzed data of 130 toddlers (24-31 months; 58% boys) from low-income, primarily African American families. Mothers completed questionnaires about child routines (Child Routines Questionnaire; CRQ; Wittig, 2005).To measure emotion regulation, toddlers completed an observed behavioral task meant to elicit frustration (Lab-TAB-Locomotor Version; Goldsmith & Rothbart, 1991). As hypothesized, adequate sleep (> 11 hr) fully moderated the association between routines and observed emotion regulation. There was no effect of routines on emotion regulation for toddlers with inadequate amounts of sleep. Analyses controlled for toddler respiratory sinus arrhythmia (RSA) as well as maternal emotion dysregulation (the Emotional Dysregulation Scale; EDS; Westen, Muderrisoglu, Fowler, Shedler, & Koren, 1997). These results emphasize the importance of sufficient sleep in at-risk toddlers. Furthermore, the results suggest that the effectiveness of family interventions focusing on family health to increase toddler emotion regulation could be improved by incorporating sleep interventions/routines. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Phytophthora ×stagnum nothosp. nov., a new hybrid from irrigation reservoirs at ornamental plant nurseries in Virginia

A novel Phytophthora species was frequently recovered from irrigation reservoirs at several ornamental plant production facilities in eastern Virginia. Initial sequencing of the internal transcribed spacer (ITS) region of this species generated unreadable sequences due to continual polymorphic positions. Cloning and sequencing the ITS region as well as sequencing the mitochondrially encoded cytochrome c oxidase 1 and beta-tubulin genes revealed that it is a hybrid between P. taxon PgChlamydo as its paternal parent and an unknown species genetically close to P. mississippiae as its maternal parent. This hybrid has some diagnostic morphological features of P. taxon PgChlamydo and P. mississippiae. It produces catenulate hyphal swellings, characteristic of P. mississippiae, and chlamydospores, typical of P. taxon PgChlamydo. It also produces both ornamented and relatively smooth-walled oogonia. Ornamented oogonia are another important diagnostic character of P. mississippiae. The relatively smooth-walled oogonia may be indicative of oogonial character of P. taxon PgChlamydo. The new hybrid is described here as Phytophthora ×stagnum.

Root and Stem Rot of Begonia Caused by Phytopythium helicoides in Virginia

In the summer of 2011, severe root and stem rot of begonia (Begonia × semperflorens-cultorum cv. Vodka Dark Red) was observed during a field trial. Seventy-eight percent of the plants had symptoms included foliar blight, blackened and rotting roots, rotting stems, and collapsing crown, often leading to plant death. Isolation from the diseased plant roots consistently recovered a Pythium-like species and 41 isolates were subcultured for identification. These isolates produced very similar single-strand conformation polymorphism (SSCP) fingerprints (2), which were distinct from those of other oomycete pathogens known to attack begonia (1). These isolates produced proliferous, ovoid to globose, terminal, and papillate sporangia which were 30.6 to 45.4 μm (av. 38.7 μm) in length and 20.5 to 35.4 μm (av. 28.2 μm) in width. Oogonia were produced in single culture grown in clarified V8 juice agar. These smooth-walled oogonia were mostly aplerotic and 28.9 to 36.8 μm (av. 33.1 μm) in diameter. Each contained a single oospore with a diameter of 23.7 to 34.4 μm (av. 26.9 μm). Single to multiple antheridia were attached lengthwise to each oogonium. These morphological characteristics match the description of Phytopythium helicoides (= Pythium helicoides) (3). The identity of these isolates was confirmed by sequencing the rDNA internal transcribed spacer (ITS) 1 and 2 regions. ITS sequence of the representative isolate 55C7 (GenBank Accession No. KC907734) had 97 to 99% homology with P. helicoides sequences in GenBank. Two isolates, 55C7 and 56A7, were tested for pathogenicity to begonia in the summer of 2012. Twelve plants per isolate were inoculated by injecting ground P. helicoides-colonized rice grains into the root soil using a long-neck funnel. Sterile rice grains were used on control plants. Aboveground symptoms including foliar blight, stem rot, and collapsing crown were observed 7 days after inoculation and the disease progressed for additional 6 weeks. At 7 weeks, all inoculated plants showed different symptom levels. Four and 10 plants inoculated with 55C7 and 56A7, respectively, were already dead. Begonia roots showed severe symptoms including blackening, stunted growth, and rotting. Seven of 12 control plants also had notable symptoms due to cross contamination. Isolates recovered from all symptomatic plants had identical SSCP fingerprints to those of isolates 55C7 and 56A7. To our knowledge, this is the first report of P. helicoides attacking begonia plants. The avenue of this pathogen entering the 2011 field trial remains unknown. The field trial in 2011 and pathogenicity test in 2012 indicate that this pathogen is potentially destructive to begonia. Additional research is warranted to identify the origin and dissemination of this pathogen to mitigate the risk to begonia production. References: (1) C. X. Hong et al. Plant Dis. 92: 1201, 2008. (2) P. Kong et al. FEMS Microbiol. Lett. 240:229, 2003. (3) A. J. van der Plaats-Niterink. Monograph of the Genus Pythium. Centraalbureau voor Schimmelcultures, Baarn, the Netherlands, 1981.

Phytophthora hedraiandra Detected from Irrigation Water at a Perennial Ornamental Plant Nursery in Virginia

Water survey for Phytophthora spp. by baiting with rhododendron leaves in April 2006 at a perennial ornamental plant nursery in Virginia detected five isolates showing a unique, previously unknown single-strand conformation polymorphism (SSCP) fingerprint (1). These cultures were isolated from two reservoirs at different depths of water column from surface to 2 m. They were homothallic and produced smooth-surfaced spherical oogonia with an average diameter of 27 μm on 10% V8 agar. Oospores were aplerotic. The paragynous antheridia were averaging 12 μm in diameter. Sporangia were papillate, spherical to ovoid, averaging 39 by 28 μm (length by width). They were caducous with short (<4 μm) pedicels. Chlamydospores and hyphal swellings were not observed. Two isolates were sequenced for rDNA internal transcribed spacer (ITS) 1 and 2 regions and cytochrome oxidase subunit 1 (Cox 1) gene. ITS sequences of both isolates (GenBank Accession Nos. JN376065 and JN376066) were identical to that of Phytophthora hedraiandra type culture (GenBank Accession No. AY707987). Also, the Cox 1 sequence of an isolate (Accession No. JN376067) had 99% homology with that of the type culture (GenBank Accession No. AY69115). Pathogenicity of both isolates was tested on Rhododendron catawbiense and Viburnum tinus, two known hosts of P. hedraiandra (2). For each isolate and host, five leaves and stems on potted plants were wounded by needles and then inoculated by placing over each wound a 5-mm² mycelial plug from a 7-day-old culture and securing with Parafilm. V8 agar was used instead of mycelial plugs on control plants. After inoculation, each plant was enclosed in a plastic bag for 1 day and then incubated at 22°C with a 12-h photoperiod. Distilled water was sprayed daily for 5 days postinoculation (dpi) until disease symptoms were observed. At 15 dpi, 3 of the 10 inoculated rhododendron leaves and 6 of the 10 stems showed leaf lesions, wilting, dieback, and cankers, eventually leading to rhododendron death. Two of the 10 viburnum leaves and 4 of the 10 stems showed similar symptoms. Leaf lesions were approximately 3 to 5 cm in diameter. P. hedraiandra was recovered from diseased tissues and all resulting cultures showed an identical SSCP fingerprint to tested isolates as well as a P. hedraiandra isolate from Minnesota (3). No symptom developed on control plants. To our knowledge, this is the first report of P. hedraiandra in Virginia. Considering neither host plant has been grown or bought for resale by this nursery, this study indicates that P. hedraiandra may have a wider host range than is currently known. This possibility and the importance of water dispersal for P. hedraiandra in disease epidemiology warrant further investigation. References: (1) P. Kong et al. Fungal Genet. Biol. 39:238, 2003. (2) W. A. Man in't Veld et al. Eur. J. Plant Pathol. 117:25, 2007. (3) B. W. Schwingle et al. Plant Dis. 90:109, 2006.

Phytophthora aquimorbida sp. nov. and Phytophthora taxon 'aquatilis' recovered from irrigation reservoirs and a stream in Virginia, USA

Two distinct subgroups (L2 and A(-2)) were recovered from irrigation reservoirs and a stream in Virginia, USA. After molecular, morphological and physiological examinations, the L2 subgroup was named Phytophthora aquimorbida and the A(-2) designated as Phytophthora taxon 'aquatilis'. Both taxa are homothallic. P. aquimorbida is characterized by its noncaducous and nonpapillate sporangia, catenulate and radiating hyphal swellings and thick-walled plerotic oospores formed in globose oogonia mostly in the absence of an antheridium. P. taxon 'aquatilis' produces plerotic oospores in globose oogonia mostly with a paragynous antheridium. It has semi-papillate, caducous sporangia with variable pedicels, but it does not have hyphal swelling. Analyses of ITS, CO1, β-tubulin and NADH1 sequences revealed that P. aquimorbida is closely related to P. hydropathica, P. irrigata and P. parsiana, and P. taxon 'aquatilis' is related to P. multivesiculata. The optimum temperature for culture growth is 30 and 20 C for P. aquimorbida and P. taxon 'aquatilis' respectively. Both taxa were pathogenic to rhododendron plants and caused root discoloration, pale leaves, wilting, tip necrosis and dieback. Their plant biosecurity risk also is discussed.

Zoospore interspecific signaling promotes plant infection by Phytophthora

BACKGROUND

Oomycetes attack a huge variety of economically and ecologically important plants. These pathogens release, detect and respond to signal molecules to coordinate their communal behaviors including the infection process. When signal molecules are present at or above threshold level, single zoospores can infect plants. However, at the beginning of a growing season population densities of individual species are likely below those required to reach a quorum and produce threshold levels of signal molecules to trigger infection. It is unclear whether these molecules are shared among related species and what their chemistries are.

RESULTS

Zoospore-free fluids (ZFF) from Phytophthora capsici, P. hydropathica, P. nicotianae (ZFFnic), P. sojae (ZFFsoj) and Pythium aphanidermatum were cross tested for stimulating plant infection in three pathosystems. All ZFFs tested significantly increased infection of Catharanthus roseus by P. nicotianae. Similar cross activities were observed in infection of Lupinus polyphyllus and Glycine max by P. sojae. Only ZFFnic and ZFFsoj cross induced zoospore aggregation at a density of 2 × 10³ ml⁻¹. Pure autoinducer-2 (AI-2), a component in ZFF, caused zoospore lysis of P. nicotianae before encystment and did not stimulate plant infection at concentrations from 0.01 to 1000 μM. P. capsici transformants with a transiently silenced AI-2 synthase gene, ribose phosphate isomerase (RPI), infected Capsicum annuum seedlings at the same inoculum concentration as the wild type. Acyl-homoserine lactones (AHLs) were not detected in any ZFFs. After freeze-thaw treatments, ZFF remained active in promoting plant infection but not zoospore aggregation. Heat treatment by boiling for 5 min also did not affect the infection-stimulating property of ZFFnic.

CONCLUSION

Oomycetes produce and use different molecules to regulate zoospore aggregation and plant infection. We found that some of these signal molecules could act in an inter-specific manner, though signals for zoospore aggregation were somewhat restricted. This self-interested cooperation among related species gives individual pathogens of the same group a competitive advantage over pathogens and microbes from other groups for limited resources. These findings help to understand why these pathogens often are individually undetectable until severe disease epidemics have developed. The signal molecules for both zoospore aggregation and plant infection are distinct from AI-2 and AHL.

Phytophthora pini Leonian resurrected to distinct species status

Phytophthora pini was named by Leonian in 1925, but this species was largely ignored until 1956 and then merged with P. citricola by Waterhouse in 1963. This study compared the ex-type and ex-authentic cultures of these two species with isolates of P. plurivora and the P. citricola subgroups Cil I and III reported previously. Examination of these isolates revealed that the ex-type culture of P. pini is identical to P. citricola I. Phytophthora pini Leonian therefore is resurrected to distinct species status and redescribed here with a Latin description, replacing P. citricola I. Molecular, physiological and morphological descriptions of this species are presented. The molecular description includes DNA sequences of five nuclear and mitochondrial regions as well as PCR-SSCP fingerprints. The relationship among the above species and other species recently segregated from the P. citricola complex also is discussed.

Foliar Blight of Annual Vinca (Catharanthus roseus) Caused by Phytophthora tropicalis in Virginia

Annual vinca (Catharanthus roseus), also known as Madagascar periwinkle, has been cultivated as a major color crop for landscape and as an herbal medicine. This plant performs well in dry, warm locations with full sun or partial shade. Two-month-old diseased plants (cv. First Kiss Blueberry) with blighted leaves and stems were received from a local nursery in Suffolk, VA in May 2009. The disease began with dark, greenish black lesions on young leaves. Lesions gradually became tan or brown and leaves wilted and curled and finally turned necrotic. Brown, sunken lesions beginning at the branching points were typical symptoms on blighted stems and shoots. Blighted areas and spots were approximately 30 to 90 mm long and 20 to 40 mm wide on leaves and 40 mm long on stems. A Phytophthora species previously unknown to attack this plant was consistently isolated from diseased leaves and stems, and resultant isolates were grown on PARP-V8 agar. These isolates produced papillate sporangia on umbellate sympodium. Sporangia were mostly ellipsoid with a length/breadth ratio of >1.8 and tapered base; they were caducous with a long pedicel (usually >50 μm). These isolates also produced chlamydospores that averaged 31 μm in diameter. The isolates were identified as Phytophthora tropicalis by morphology. The identity was confirmed by DNA fingerprinting (1) and sequence analysis of ribosomal DNA internal transcribed spacers (GenBank Accession No. GQ478707). For pathogenicity studies, a zoospore suspension of 1,100 spores per milliliter was sprayed onto the foliage of 50-day-old healthy plants of the same cultivar grown in pine bark medium in six 10-cm-diameter plastic containers with a hand mister in the evening until runoff. Control plants were sprayed with tap water. Plants were placed in a tray containing a small amount of water and enclosed in plastic tents overnight to facilitate infection. The tents were removed the following morning, and plants were kept in a greenhouse under natural light and watered as needed. Within 4 days, all six inoculated plants developed foliar symptoms similar to what was observed on the diseased plant samples from the production nursery. The pathogen was reisolated from infected leaves and stems and its identity was confirmed by colony PCR-single-strand conformation polymorphism (3). The pathogenicity test was repeated once with the same results. Phytophthora aerial blight is a common destructive disease of annual vinca, which is usually caused by P. nicotianae. To our knowledge, this is the first report of foliar blight caused by P. tropicalis on annual vinca in Virginia. According to the head grower who submitted the disease samples, this new disease caused 10% crop loss of annual vinca this past spring. P. tropicalis was previously reported to attack ornamental shrubs, including Pieris japonica and Rhododendron catawbiense (2). This study indicates that P. tropicalis could be a potential threat to herbaceous annual crops as well. References: (1) M. E. Gallegly and C. X. Hong. Phytophthora: Identifying Species by Morphology and DNA Fingerprints. The American Phytopathological Society, St. Paul, MN, 2008. (2) C. Hong et al. Plant Dis. 90:525, 2006. (3) P. Kong et al. J. Microbiol. Methods 61:25, 2005.

The avocado subgroup of Phytophthora citricola constitutes a distinct species, Phytophthora mengei sp. nov

Isolates from avocado tree cankers have been recognized as a distinct subgroup within the P. citricola complex since 1974, both morphologically and molecularly (isozyme and amplified fragment length polymorphism [AFLP] analyses). This subgroup is formally separated from P. citricola after comparative DNA fingerprinting and sequence analyses of the ITS region, as well as by morphological examinations. This new taxon is homothallic, produces plerotic oospores with paragynous antheridia and noncaducous semipapillate sporangia. Morphologically it differs from other species of Waterhouse group III by producing many large bizarre-shaped sporangia and smaller oogonia with asymmetric capitate antheridia. It belongs to clade 2 and is phylogenetically closer to P. siskiyouensis, P. capsici and P. tropicalis than to P. citricola. P. mengei can be easily differentiated from its relatives in the same clade and other species of this morpho-group by DNA fingerprints and sequence analysis. This new taxon is named Phytophthora mengei sp. nov.

Zoosporic tolerance to pH stress and its implications for Phytophthora species in aquatic ecosystems

Phytophthora species, a group of destructive plant pathogens, are commonly referred to as water molds, but little is known about their aquatic ecology. Here we show the effect of pH on zoospore survival of seven Phytophthora species commonly isolated from irrigation reservoirs and natural waterways and dissect zoospore survival strategy. Zoospores were incubated in a basal salt liquid medium at pH 3 to 11 for up to 7 days and then plated on a selective medium to determine their survival. The optimal pHs differed among Phytophthora species, with the optimal pH for P. citricola at pH 9, the optimal pH for P. tropicalis at pH 5, and the optimal pH for the five other species, P. citrophthora, P. insolita, P. irrigata, P. megasperma, and P. nicotianae, at pH 7. The greatest number of colonies was recovered from zoospores of all species plated immediately after being exposed to different levels of pH. At pH 5 to 11, the recovery rate decreased sharply (P < or = 0.0472) after 1-day exposure for five of the seven species. In contrast, no change occurred (P > or = 0.1125) in the recovery of any species even after a 7-day exposure at pH 3. Overall, P. megasperma and P. citricola survived longer at higher rates in a wider range of pHs than other species did. These results are generally applicable to field conditions as indicated by additional examination of P. citrophthora and P. megasperma in irrigation water at different levels of pH. These results challenge the notion that all Phytophthora species inhabit aquatic environments as water molds and have significant implications in the management of plant diseases resulting from waterborne microbial contamination.

Pathogenicity to Ornamental Plants of Some Existing Species and New Taxa of Phytophthora from Irrigation Water

Eighteen isolates from 12 species of Phytophthora, including several new taxa, were tested for pathogenicity to six ornamental and four vegetable species. The following three inoculation methods were used depending on infection court targeted: vermiculite culture inoculation for roots, agar block inoculation for fruit, and zoospore inoculation for foliage. All six new taxa (P. irrigata, P. hydropathica, Dre III, Cil I, Cip-like, and Gon I) are pathogenic to one or more test plants. Specifically, taxon Cil I was identified as a growing threat to horticultural crops, particularly ornamental crops in container production nurseries. The potential host list of P. tropicalis was expanded to four new families (Apocynaceae, Asteraceae, Begoniaceae, and Fabaceae) and one additional genus within each of three existing families (Ericaceae, Cucurbitaceae, and Solanaceae). New potential hosts were also identified for other existing species of Phytophthora. The practical implications of these results in crop health management programs for both ornamental and vegetable crops locally, and for development and implementation of agricultural biosecurity programs globally, are discussed.

Phytophthora tropicalis Isolated from Diseased Leaves of Pieris japonica and Rhododendron catawbiense and Found in Irrigation Water and Soil in Virginia

An unidentified species of Phytophthora was isolated from irrigation water at a production nursery in Suffolk, VA in 2000 and 2001. Water samples were assayed using a filtration method (3). A similar species was recovered from soil samples collected in two mixed-hardwood forests in Fairfax County in 2002. Soil samples were air dried, remoistened, flooded, and then baited with rhododendron and camellia leaf pieces at room temperature (22 to 24°C) (2). A Phytophthora sp. was recovered from bait pieces cultured on PARPH-V8 selective medium (2). This same species also was isolated from symptomatic leaves of Pieris japonica cv. Temple Bells and Rhododendron catawbiense cv. Maximum Roseum at a garden center in Virginia Beach in 2004. On P. japonica, symptoms appeared as water-soaked, necrotic lesions and marginal necrosis on leaves and necrosis of shoot tips; on R. catawbiense, symptoms were wilting, dieback, and death of shoots. Representative isolates produced semipapillate to papillate sporangia with tapered bases that were caducous and had long pedicels (16 to 120 μm). Sporangia on four isolates were measured: mean lengths were 40.6 to 48.4 μm, mean widths were 26.9 to 31.4 μm, and length/width ratios consistently were 1.5. Sporangia occasionally were distorted and had dual apices, and they often contained a large globule after zoospore release. Chlamydospores ranged from 25 to 32 μm in diameter. All isolates were heterothallic; four isolates paired with known isolates of P. nicotianae were found to be mating type A1. Optimum temperature for mycelium growth on cornmeal agar was 25°C with slight growth at 35°C by some isolates and no growth at 4°C. These morphological characteristics were mostly consistent with those of P. tropicalis (1). P. tropicalis is reported to have sporangia that are papillate, have lengths of 40 to 55 μm, widths of 19 to 27 μm, and length/width ratios of 1.8 to 2.4 (1). The identity of these isolates as P. tropicalis was confirmed using single-strand conformational polymorphism analysis with comparison to a reference isolate (4). These isolates have been retained in permanent collections in the Hong and Jeffers labs. One isolate from each host plant and one isolate from irrigation water were tested for pathogenicity; agar blocks of mycelium (4 × 4 mm) were placed on wounded and nonwounded leaves of P. japonica cv. Mountain Fire and R. catawbiense cv. Olga plants and wrapped with Parafilm to prevent desiccation. Lesions formed on wounded and nonwounded leaves after 4 days at 20 to 30°C, and P. tropicalis was reisolated; no lesions formed on noninoculated control leaves. To our knowledge, this is the first report of P. tropicalis in the continental United States, in irrigation water systems, and as a cause of Phytophthora foliage blight on P. japonica and R. catawbiense (1). This study suggests that the host range of this pathogen is not limited to tropical plants. Although this pathogen did not cause significant economic loss in the garden center surveyed, it was isolated in irrigation water at the production nursery from late spring through fall. An investigation of its impact on nursery crops is warranted. References: (1) M. Aragaki and J. Y. Uchida. Mycologia 93:137, 2001. (2) A. J. Ferguson and S. N. Jeffers. Plant Dis. 83:1129, 1999. (3) C. X. Hong et al. Phytopathology 92:610, 2002. (4) P. Kong et al. Fungal Genet. Biol. 39:238, 2003.

Effects of Zoospore Concentration and Application Pressure on Foliage Blight of Catharanthus roseus Caused by Phytophthora nicotianae

This study investigated the effects of inoculum concentration, application pressure, use of carbon dioxide (CO₂), and agitation associated with passage through a spray nozzle on zoospore survival and on foliage blight caused by Phytophthora nicotianae. In a greenhouse experiment, plants of Catharanthus roseus were inoculated by spraying zoospore suspensions at pressures of 210, 420, and 630 kPa (30, 60, and 90 lbs/in² [psi]). A low-pressure 35-kPa (5-psi) control inoculation was provided with a hand-operated aspirator-type mister. There was a consistent reduction in level of disease with increased application pressure, regardless of the zoospore concentration. To determine the source of this disease reduction, laboratory assays were conducted. Zoospore suspensions were pressurized to 210, 420, and 630 kPa with CO₂ or air, then transferred from the pressure bottle into a flask by either spraying or pouring. From the flask, the suspensions were spread over plates of PARP-V8 agar and incubated for 72 h, at which time total colony numbers were recorded. CO₂ significantly reduced zoospore survival. Pressure strength and method of spore transfer out of pressure bottles also impacted survival to lesser extents. There were significant interactions between pressure source and means of spore suspension transfer, and between pressure strength and means of spore transfer. These results may lead to development of alternative methods of water decontamination to prevent inoculum from entering crop systems through irrigation water.

Single-strand conformational polymorphism analysis of the ribosomal internal transcribed spacer 1 for rapid species identification within the genus Pythium

Single-strand conformational polymorphism (SSCP) of the ribosomal internal transcribed spacer 1 (ITS-1) was characterized for 58 isolates of Pythium, representing 41 species from the five groups of Plaats-Niterink. Thirty-one species each produced a distinct SSCP pattern. Three species produced more than one unique pattern, corresponding to morphological subgrouping. The remaining seven species produced three distinct patterns with two or three morphologically similar species sharing a pattern. A successful blind test with four samples and the identification of eight previously unknown isolates from irrigation water demonstrated the reliability of this technique for species identification. Each SSCP pattern was defined and described by the positions of the top and bottom bands and the number of bands in between, which allows laboratories to use this technique without need to access the type isolates of Pythium species.

Shoot Blight of Forsythia × intermedia in Virginia Nurseries Caused by Phytophthora nicotianae

A severe blighting of shoots on Forsythia × intermedia cv. Lynwood Gold plants was observed at several commercial nurseries in Virginia from 2001 to 2004. Crop losses ranged from 10 to 35%. Symptoms first occurred at the tips of shoots, including those that were trimmed and not trimmed, and then progressed downward. Diseased shoots wilted quickly and usually turned black, and foliage on these shoots withered and became necrotic. With PARP-V8 selective medium (2), a species of Phytophthora was isolated consistently from symptomatic shoots (including tissues from shoot tips, leaves, and stems) as well as from apparently healthy roots. These isolates produced arachnoid mycelia and numerous noncaducous, papillate sporangia but did not produce sexual structures on isolation plates; these morphological characters are consistent with those of Phytophthora nicotianae. All isolates produced a single-strand conformation polymorphism pattern typical of P. nicotianae (3). To test pathogenicity, 1-year-old, healthy-appearing cv. Lynwood Gold forsythia plants (canopy size = 100 cm × 60 cm) in four 12-liter containers were sheared. Two plants were inoculated by spraying each plant with 200 ml of a zoospore suspension (1.6 × 10⁴ spores per ml, prepared from one isolate), and the other two plants were not treated and served as controls. Plants were covered with plastic bags overnight to encourage infection and then were grown in a field (temperature range = 20 to 33°C). Severe blight developed on trimmed shoots and new shoot tips of inoculated plants within 1 week after inoculation. The same pathogen was isolated from all blighted leaf and stem pieces assayed. Blight symptoms were not observed on control plants during a 1-month observation period. Phytophthora nicotianae has been reported to attack F. viridissima in Italy (1) causing root and collar rot but not shoot blight. To our knowledge, this is the first report of shoot blight on Forsythia spp. caused by P. nicotianae and the first report of P. nicotianae on Forsythia spp. in the United States. References: (1) S. O. Cacciola et al. Plant Dis. 78:525, 1994. (2) A. J. Ferguson and S. N. Jeffers. Plant Dis. 83:1129, 1999. (3) P. Kong et al. Fun. Gen. Biol. 39:238, 2003.

Direct colony PCR-SSCP for detection of multiple pythiaceous oomycetes in environmental samples

Colony PCR was developed for detection of pythiaceous species recovered on selective agar plates without DNA extraction. A minute amount of mycelia from a single colony was picked up with a pipette tip and added directly to the PCR mix as template for DNA amplification. Successful amplification was achieved in over 95% of the colonies recovered from plant tissues, irrigation water and soil with species-specific primers or oomycete ITS-1 primers. PCR was inhibited in the case of colonies emerging from unwashed pine bark potting mix plates. Direct colony PCR with ITS-1 primers combined with single-strand conformation polymorphism analysis (SSCP) was used to determine population levels of single and multiple species in plant and environmental samples. Application of this technique for disease diagnosis and monitoring pathogen sources was explored, and the potential for studying diversity and population dynamics of other cultivated microbial communities in the environment is discussed.

First Report of Phytophthora cinnamomi on Ilex glabra in Virginia

During 2002, two nurseries in southeastern Virginia reported losses exceeding 75% of container-grown inkberry holly (Ilex glabra) cv. Shamrock. The development of necrotic leaf spots and blotches followed initial symptoms of leaf yellowing and wilting. Affected leaves rapidly turned brown and fell. Dark brown-to-black roots were washed and plated on agar media. Phytophthora cinnamomi Rands was consistently isolated and identified on the basis of its morphology (2) and single-stranded conformational polymorphism fingerprint (1). The organism had nonpapillate, internally proliferating, noncaducous, ovoid to ellipsoid sporangia that formed only in water. It did not grow at 35°C and had abundant botryose hyphal swellings, coralloid hyphae, and grape-like clusters of chlamydospores. The isolate, determined to be the A2 mating type, produced elongate cylindrical, amphigynous antheridia and oogonia with a tapered base. A pine bark potting mix amended with V8 juicetreated vermiculite colonized by the suspected pathogen was placed in 12-liter containers. Two inkberry holly cv. Shamrock liners were planted in each of three containers and two 1-yr-old plants were planted in each of three additional containers during April 2004. An identical set of six containers of noninoculated plants was also established. During June 2004, inoculated plants exhibited symptoms identical to those observed in nurseries, and P. cinnamomi was isolated. Noninoculated check plants did not develop symptoms. Japanese holly (I. crenata) was previously known as a host, but to our knowledge, this is the first report of inkberry holly (I. glabra) susceptibility. References: (1) P. Kong et al. Fungal Genet. Biol. 39:238, 2003. (2) D. J. Stamps et al. Mycol. Pap. No. 162. CAB International Mycological Institute, Wallingford, UK, 1990.

Rapid identification of Phytophthora ramorum using PCR-SSCP analysis of ribosomal DNA ITS-1

AIMS

The primary objectives of this study were to determine if a single-strand conformation polymorphism (SSCP) analysis can be used for rapid identification of Phytophthora ramorum, an important quarantine plant pathogen worldwide, and to further assess the potential of the SSCP technique as a taxonomic tool for the genus Phytophthora.

METHODS AND RESULTS

SSCP of ribosomal DNA internal transcribed spacer 1 was characterized for 12 isolates of P. ramorum, using a recently reported protocol. The SSCP patterns of this species then were compared with those of 18 closely related Phytophthora species. Phytophthora ramorum had a unique pattern and was easily distinguished from genetically, morphologically and ecologically close relatives.

CONCLUSION

An immediate benefit of this study is provision of a highly effective and efficient identification tool for P. ramorum in the quarantine process.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study also provides additional evidence demonstrating that the SSCP is an ideal DNA marker for species differentiation within the genus Phytophthora.

Efficacy of Chlorine on Multiple Species of Phytophthora in Recycled Nursery Irrigation Water

Recycled irrigation water is a primary source of inoculum for Phytophthora spp. and is capable of spreading propagules throughout nursery production. Chlorination commonly is used by the industry to disinfest recycled irrigation water; however, chlorine has not been fully researched as a disinfestant for this purpose. In this study, zoospores of seven species and eight isolates of Phytophthora were exposed for 2 min to free available chlorine at 0.25, 0.5, 1.0, 2.0, and 4.0 mg/liter. Zoospores, mycelial fragments, and culture plugs of P. nicotianae also were exposed to chlorine concentrations ranging from 0.25 to 8.0 mg/liter for periods ranging from 15 s to 8 min. In addition, chlorinated water was assayed monthly in 2000 and 2001 at two commercial nurseries, and quarterly in the first year at four other nurseries in Virginia, for chlorine and survival of pythiaceous species using a selective medium. No zoospores of any species tested survived endpoint free chlorine at 2 mg/liter, while limited mycelial fragments of P. nicotianae survived at 8 mg/liter, and mycelial plugs treated at the same level of chlorine were able to produce few sporangia. Phytophthora spp. were recovered only from nursery irrigation water with levels of free chlorine at 0.77 mg/liter or lower. The results of this study are essential for improving current chlorination protocols.

Single-strand-conformation polymorphism of ribosomal DNA for rapid species differentiation in genus Phytophthora

Single-strand-conformation polymorphism (SSCP) of ribosomal DNA of 29 species (282 isolates) of Phytophthora was characterized in this study. Phytophthora boehmeriae, Phytophthora botryosa, Phytophthora cactorum, Phytophthora cambivora, Phytophthora capsici, Phytophthora cinnamomi, Phytophthora colocasiae, Phytophthora fragariae, Phytophthora heveae, Phytophthora hibernalis, Phytophthora ilicis, Phytophthora infestans, Phytophthora katsurae, Phytophthora lateralis, Phytophthora meadii, Phytophthora medicaginis, Phytophthora megakarya, Phytophthora nicotianae, Phytophthora palmivora, Phytophthora phaseoli, Phytophthora pseudotsugae, Phytophthora sojae, Phytophthora syringae, and Phytophthora tropicalis each showed a unique SSCP pattern. Phytophthora citricola, Phytophthora citrophthora, Phytophthora cryptogea, Phytophthora drechsleri, and Phytophthora megasperma each had more than one distinct pattern. A single-stranded DNA ladder also was developed, which facilitates comparison of SSCP patterns within and between gels. With a single DNA fingerprint, 277 isolates of Phytophthora recovered from irrigation water and plant tissues in Virginia were all correctly identified into eight species at substantially reduced time, labor, and cost. The SSCP analysis presented in this work will aid in studies on taxonomy, genetics, and ecology of the genus Phytophthora.

A Species-Specific Polymerase Chain Reaction Assay for Rapid Detection of Phytophthora nicotianae in Irrigation Water

ABSTRACT Phytophthora nicotianae is a common and destructive pathogen of numerous ornamental, agronomic, and horticultural crops such as tobacco, tomato, and citrus. We have developed a species-specific polymerase chain reaction (PCR) assay for rapid and accurate detection of this pathogen in irrigation water, a primary source of inoculum and an efficient means of propagule dissemination. This PCR assay consists of a pair of species-specific primers (PN), customization of a commercial soil DNA extraction kit for purification of DNA from propagules in irrigation water, and efficient PCR protocols for primer tests and sample detection. The PN primers proved adequately specific for P. nicotianae in evaluations with 131 isolates of P. nicotianae, 102 isolates from 15 other species of Phytophthora, and 64 isolates from a variety of other oomycetes, true fungi, and bacteria. These isolates originated from a wide range of host plants, three substrates (plant tissue, soil, and irrigation water), and numerous geographic locations. The detection sensitivity is between 80 and 800 fg DNA/mul. The assay detected the pathogen in naturally infested water samples from Virginia and South Carolina nurseries more rapidly and accurately than standard isolation methods. Use of this PCR assay can assist growers in making timely disease management decisions with confidence.

Comparison of membrane filters as a tool for isolating pythiaceous species from irrigation water

ABSTRACT Filter-based isolation is the primary approach for quantifying plant pathogens in irrigation water; however, the performance of various membranes is largely unknown. This study evaluated nine hydrophilic membranes for recovery of pythiaceous species, a group of very common and destructive pathogens on numerous ornamental plants and many agronomic crops. Three sources of water samples and three plating methods were used for the membrane comparison. Durapore5, Millipore5, and Osmonics5 filtered 100 ml of irrigation water or 50 ml of irrigation runoff in 10 s or less, whereas the other membranes required 34 s to 13.5 min or even a second membrane to filter the same water sample volume. Millipore5 and Durapore5 showed greater recovery rates than other membranes for all water sources when the membranes were directly inverted onto agar plates. Durapore5 was also one of the top two membranes for spore suspension and irrigation water samples when membrane washings were spread over the agar surface. Durapore5 was the only membrane that consistently performed well for both spore suspension and irrigation water samples. These data suggest that use of Durapore5 not only increases the sensitivity of filter-based isolation for quantifying pythiaceous species in irrigation water but also saves filtering time.

Detection and Characterization of an Elm Yellows (16SrV) Group Phytoplasma Infecting Virginia Creeper Plants in Southern Florida

The polymerase chain reaction (PCR) employing phytoplasma-specific ribosomal RNA primer pair P1/P7 consistently amplified a product of expected size (1.8 kb) from 29 of 36 symptom-less Virginia creeper (Parthenocissus quinquefolia) plants growing in southern Florida. Restriction fragment length polymorphism analysis of P1/P7-primed PCR products indicated that most phytoplasmas detected in Virginia creeper were similar to phytoplasmas composing the elm yellows (16SrV) group. This relationship was verified by reamplification of P1/P7 products using an elm yellows (EY) group-specific rRNA primer pair fB1/rULWS1. rDNA products (1,571 bp) were generated by group-specific PCR from 28 phytoplasma-positive plants and 1 negatively testing plant identified by earlier P1/P7-primed PCR. Analysis of 16S rDNA sequences determined the Virginia creeper (VC) phytoplasma to be phylogenetically closest to the European alder yellows (ALY) agent, an established 16SrV-C subgroup strain. However, presence or absence of restriction sites for endonucleases AluI, BfaI, MspI, RsaI, and TaqI in the 16S rRNA and 16-23S rRNA intergenic spacer region of the VC phytoplasma collectively differentiated this strain from ALY and other 16SrV group phytoplasmas. Failure to detect the VC phytoplasma by PCR employing nonribosomal primer pair FD9f/FD9r suggests that this newly characterized agent varies from known European grapevine yellows (flavescence dorée) phyto-plasmas previously classified as 16SrV subgroup C or D strains.

The role of diabetes in hepatocellular carcinoma: a case-control study among United States Veterans

OBJECTIVE

Diabetes mellitus (DM) has been reported to increase the risk of hepatocellular carcinoma (HCC). We carried out a case-control study to examine the role of DM while controlling for several known risk factors of HCC.

METHODS

All hospitalized patients with primary liver cancer (PLC) during 1997-1999 were identified in the computerized database of the Department of Veterans Affairs, the Patient Treatment File. Controls without cancer were randomly assigned from the Patient Treatment File during the same time period. The inpatient and outpatient files were searched for several conditions including DM, hepatitis C virus (HCV), hepatitis B virus (HBV), alcoholic cirrhosis, autoimmune hepatitis, hemochromatosis, and nonspecific cirrhosis. Adjusted odds ratios (OR) were calculated in a multivariable logistic regression model.

RESULTS

We identified 823 patients with PLC and 3459 controls. The case group was older (62 yr [+/-10] vs 60 [+/-11], p < 0.0001), had more men (99% vs 97%, 0.0004), and a greater frequency of nonwhites (66% vs 71%, 0.0009) compared with controls. However, HCV- and HBV-infected patients were younger among cases than controls. Risk factors that were significantly more frequent among PLC cases included HCV (34% vs 5%, p < 0.0001), HBV (11% vs 2%, p < 0.0001), alcoholic cirrhosis (47% vs 6%, p < 0.0001), hemochromatosis (2% vs 0.3%, p < 0.0001), autoimmune hepatitis (5% vs 0.5%, p < 0.0001), and diabetes (33% vs 30%, p = 0.059). In the multivariable logistic regression, diabetes was associated with a significant increase in the adjusted OR of PLC (1.57, 1.08-2.28, p = 0.02) in the presence of HCV, HBV, or alcoholic cirrhosis. Without markers of chronic liver disease, the adjusted OR for diabetes and PLC was not significantly increased (1.08, 0.86-1.18, p = 0.4). There was an increase in the HCV adjusted OR (17.27, 95% Cl = 11.98-24.89) and HBV (9.22, 95% CI = 4.52-18.80) after adjusting for the younger age of HCV- and HBV-infected cases. The combined presence of HCV and alcoholic cirrhosis further increases the risk with an adjusted OR of 79.21 (60.29-103.41). The population attributable fraction for HCV among hospitalized veterans was 44.8%, whereas that of alcoholic cirrhosis was 51%.

CONCLUSION

DM increased the risk of PLC only in the presence of other risk factors such as hepatitis C or B or alcoholic cirrhosis. Hepatitis C infection and alcoholic cirrhosis account for most of PLC among veterans.

Gliricidia Little Leaf Disease in Costa Rica

Gliricidia sepium is a multipurpose, legume tree species native to Central America and Mexico with wide social and economic importance. Gliricidia little leaf disease (GLLD) is associated with infection by a phytoplasma and is manifested by one or more symptoms, including leaflet yellowing, leaflet size reduction, shortened internodes, and shoot proliferation, often leading to branch die-back or death of young trees. Trees with symptoms were seen in fences and natural stands in the Nicoya Peninsular and on road sides west of San Jose, Costa Rica. Shoot samples were collected from eight symptom-bearing trees in different locations and from two healthy-looking trees in the southeast where no GLLD symptoms were observed. DNA from each sample was used as template in polymerase chain reaction (PCR) with universal phytoplasma rRNA gene primers P1 and P7 (1). DNA from a GLLD-infected tree from Honduras, and a pigeon pea witches'-broom infected Cajanus cajan from Florida, served as positive controls, while DNA from healthy G. sepium and C. cajan seedlings were used as negative controls. A 1.8-kb PCR product, indicative of presence of phytoplasma DNA, was amplified from all symptom-bearing tree samples and positive control DNAs, but not from DNA from the apparently healthy trees or seedlings. Restriction fragment length pattern analysis of PCR products with a range of endonucleases showed no difference between the Honduran and Costa Rican phytoplasma isolates. The distribution and symptom types observed in Costa Rica suggest that GLLD has recently arrived from Nicaragua and is spreading southeast. Reference: (1) L. Kenyon et al. Plant Pathol. 47:671, 1998.

Detection and Differentiation of Phytoplasmas Associated with Diseases of Strawberry in Florida

Strawberry (Fragaria × ananassa Duchesne) plants with symptoms suggestive of phytoplasmal disease were identified in commercial fields and a breeder's plot in west central Florida during the 1995 to 1996 winter growing season. Affected plants were all conspicuously stunted and unproductive. Primary symptoms on cvs. Rosa Linda and Carlsbad and on a breeder's accession resembled those of strawberry green petal (SGP). Plants displayed sparse clusters of virescent flowers with enlarged sepals and phylloid receptacles that failed to develop fully into fleshy structures or redden on ripening. Symptoms on cv. Oso Grande were more typical of multiplier disease and included a proliferation of branch crowns producing numerous small leaves with spindly petioles. Oso Grande and Carlsbad originated as transplants from a nursery in Montreal, Canada, whereas Rosa Linda transplants were from Nova Scotia. Plants were assessed for phytoplasma infection by polymerase chain reaction with total DNAs from leaves and petioles as template and phytoplasma-specific ribosomal RNA primers P1 and P7 (3), or mollicute-specific ribosomal protein (rp) gene primers rpF1 and rpR4 (2). Amplification of a 1.8-kb rDNA or 1.2-kb rp gene product, respectively, confirmed infection of Rosa Linda (7 of 7 plants), Carlsbad (3 of 7), Oso Grande (4 of 4), and a single breeder's accession. No products were amplified from DNAs of healthy plants. Restriction fragment length polymorphism patterns of rDNA digested with AluI, EcoRI, HaeIII, HhaI, HpaII, KpnI, ScaI, or Tru9I endonucleases, or of rp gene products digested with AluI, DraI, RsaI, TaqI, or Tru9I, revealed no differences among phytoplasma strains affecting both Rosa Linda and Carlsbad. Collectively, patterns were comparable to those of clover phyllody and SGP phytoplasmas, two Canadian strains previously classified as members of phytoplasma 16S rRNA (rr)-ribosomal protein (rp) group 16S rI, subgroup C (16S rI-C (rr-rp)) (1). Similarly, no differences were evident among phytoplasmas associated with all four diseased Oso Grande plants. Both rDNA and rp fragment profiles associated with this cultivar were characteristic of strains such as tomato big bud and eastern aster yellows delineated as 16S rI-A (rr-rp) subgroup members (1). However, AluI rDNA and TaqI rp fragment patterns were unique, identifying Oso Grande-infecting strains as representatives of a new subgroup within the larger 16S rI (rr-rp) group. Cumulative rDNA and rp fragment profiles of the phytoplasma associated with the breeder's accession matched those of the Mexican periwinkle virescence phytoplasma, identifying this strain as a 16S rI-I (rr-rp) subgroup member (1) and a second possible etiological agent of SGP. This is the first report of phytoplasmas infecting strawberry in Florida. References: (1) D. E. Gundersen et al. Int. J. Syst. Bacteriol. 46:64, 1996. (2) P.-O. Lim and B. B. Sears. J. Bacteriol. 174:2602, 1993. (3) C. D. Smart et al. Appl. Environ. Microbiol. 62:2988, 1996.

Therapeutic imagery and athletic injuries

The rehabilitation process of an injured athlete can be accelerated if clinicians will use an imagery model in conjunction with existing therapeutic care. There is sufficient evidence to suggest a positive relationship between imagery and the healing process. Thus, we provide athletic trainers and practicing clinicians with basic information relating to the use of imagery in rehabilitation. Specifically, a sample imagery program is discussed incorporating the following prescribed steps: introducing imagery to the athlete, evaluating the athlete's imaging ability, assisting the athlete in developing basic imagery skills, and providing tips on the adjunctive use of imagery in a rehabilitation program.

Hormonal profiles and embryo quality in women with severe endometriosis treated by in vitro fertilization and embryo transfer

A study was undertaken comparing the outcomes of 30 women with infertility due to untreated severe (grade IV) pelvic endometriosis with a comparable series of 28 women whose infertility was caused solely by irreversible tubal disease. There were no significant differences in either the follicular phase or luteal phase hormonal profiles of estradiol and progesterone, but there was a significantly reduced pregnancy rate in those women with severe endometriosis. In part, this was due to the recovery of fewer oocytes from the endometriosis patients (P less than 0.001) despite the fact that the peak estradiol levels and ovarian accessibility were similar in the two groups. However, there were no significant differences in the proportion of oocytes that fertilized or the number that demonstrated normal embryo growth and high-grade embryo quality. There also appears to be an implantation inhibitory factor in patients with severe endometriosis as the pregnancy rate/embryo transferred and number of gestational sacs identified/embryo transferred were significantly reduced (P less than 0.05).

The treatment of normospermic infertility by gamete intrafallopian transfer (GIFT)

Gamete intrafallopian transfer (GIFT) was applied in 207 treatment cycles in 73 couples. The pregnancy rate in cycles with only one (2/21, 9.5%) or two (2/29, 6.9%) oocytes transferred was significantly less than that in which four oocytes (36/116, 31.0%) were replaced. The collection of more than four oocytes did not influence the pregnancy rate in that treatment cycle. The overall pregnancy rate was 24.2% (50 of 207) and was similar in the four infertility groups studied (non-occlusive tubal disorders, endometriosis, cervical factor and unexplained infertility) with 28 (56%) of the pregnancies delivered at greater than or equal to 20 weeks. The pregnancy wastage included 4 (8%) ectopic pregnancies and 3 (6%) late pregnancy losses. The 12 multiple pregnancies occurred following the transfer of three and four oocytes.

Pregnancies following pronuclear stage tubal transfer

Pronuclear stage tubal transfer (PROST) is a technique that involves in vitro fertilization (IVF) of oocytes, followed by the transfer of pronuclear oocytes into the fallopian tubes. It has been developed for its prognostic value of confirming fertilization in couples with oligospermia or asthenospermia and enabling fertilization in cases with antispermatozoal antibodies (ASAB). PROST has provided useful diagnostic information in the management of couples who have failed to conceive in other treatment programs and has particular advantages over IVF for those receiving fresh donated oocytes for ovarian failure. Fourteen pregnancies resulted from 52 transfers, providing a pregnancy rate of 27% per transfer. The pregnancy rates were higher than a matched IVF series in the male factor and female ASAB groups and reached statistical significance for the ovum donation group. It is anticipated that both pregnancy rates and fetal wastage will be improved over conventional IVF and embryo transfer for the described infertility groups.

The role of gamete intrafallopian transfer (GIFT) in the treatment of oligospermic infertility

Gamete intrafallopian transfer (GIFT) was used to treat 32 couples where the male partner was oligospermic (less than 12 X 10(6) motile spermatozoa per milliliter of semen). Initially, 100,000 motile spermatozoa were transferred per fallopian tube and no pregnancies were achieved in 11 cases. The technique was then modified so that a maximal number of motile spermatozoa were transferred (range, 0.11 to 0.90 X 10(6) spermatozoa) and 6 of 21 (29%) pregnancies resulted, with 325,000 spermatozoa being the lowest number associated with pregnancy. It appears that the modified GIFT technique, whereby an increased number of motile spermatozoa are replaced with the oocytes, is an effective therapy in the treatment of oligospermic infertility.