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To evaluate the performance characteristics of urinalysis and urine microscopy parameters for predicting urine culture results and to implement a reflex urine culture program.We reviewed the charts of all patients presenting to our clinic January-March 2013 and June-August 2014, excluding those who were catheter-dependent or with urinary diversions. We assessed the association of urinalysis and urine microscopy parameters on urine culture outcomes defining a positive urinalysis as nitrite-positive and/or the presence of ≥5 white blood cells per high-powered field with bacteria and a positive urine culture as ≥10 000 colony-forming units/mL excluding diphtheroids. We carried out logistic regression to assess for predictors of positive urine culture to inform implementation of a reflex urine culture program.A total of 2764 patients were evaluated. Logistic regression using urinalysis variables identified positive nitrites (odds ratio 18.6, P 0.001) and large leukocyte esterase (odds ratio 41.8, P 0.001) as the strongest predictors of positive urine culture. Logistic regression using urine microscopy variables identified50 white blood cells per high-powered field (odds ratio 13.6, P 0.001) and moderate/many bacteria (odds ratio 16.8, P 0.001) as the strongest predictors of positive urine culture. We used our positive urinalysis definition to implement the reflex urine culture program and noted a 60% reduction in urine culture rates over the first 3 months of implementation.A urine positive for nitrites and/or ≥50 white blood cells per high powered field with bacteria seems to have a strong association with a positive urine culture and the best negative predictive value. A reflex urine culture program is an effective strategy to decrease the rates of unnecessary urine culture and their associated costs.

Urinalysis (UA) and urine culture (UCx) are commonly performed tests in the urology clinic. Many of these urine studies are performed prior to the patient visit may not always be indicated, thus contributing to unintended consequences such as antibiotic use and costs without enhancing patient care. Our objective was to perform a quality improvement initiative aimed to assess the utility of routine UA/UCx.The practice pattern at our site's Veteran Affairs (VA) urology clinic prior to 2014 was to obtain routine UA/UCx on most clinic visits prior to patient evaluation. Starting in 2014, we designed an intervention whereby our nurse practitioner triaged all new patient referrals and selectively ordered UA/UCx. We performed multivariable logistic regression to assess for predictors of obtaining UA or UCx.A total of 1308 patients were seen in January-March 2013 and 1456 in June-August 2014 and were included in this analysis. Fewer patients in 2014 received UA (59.8% versus 70.0%, p0.001) and UCx (49.6% versus 64.2%, p0.001). There was a decreased odds of obtaining UA in 2014 (OR 0.52, p0.001) as well as a decreased odds of obtaining UCx in 2014 (OR0.38, p0.001) on multivariable logistic regression. The results of UA/UCx only rarely resulted in change of management in either cohort (3%). Selective ordering resulted in an estimated cost savings of $4915.08/month in UCx costs alone.Our quality improvement initiatives reduced rates of UA/UCx testing when providers assess patients prior to ordering these tests. The implication of this initiative is significant cost savings for the healthcare system.

In April 2017, the project ‘Belgian Plant Sentinel Network’ started as part of the Euphresco-IPSN2 network. The botanical gardens and arboreta of the network contain diverse plant collections with both exotic and native taxa that can be used as sentinels by recording their sensitivity to either native or to (newly) introduced pests and diseases. One of the case studies focused on monitoring phytoplasma diseases in trees, especially on Ulmus spp. To monitor these species, a total of 117 root samples were taken from collection trees in five botanical gardens and arboreta in Flanders, Belgium. Total genomic DNA was extracted by a CTAB protocol (Doyle and Doyle 1990). The 16S rRNA gene was partially amplified using the phytoplasma universal primer pairs P1/P7 (Deng and Hiruki 1991) followed by nested PCR with primer pairs R16F2/R2 (Lee et al. 1995) as diagnostic test, and P1/Tint (Smart et al. 1996) on positive samples for sequencing reasons. Additionally, specific group V nPCR targeting the secY (primer sets FD9f2L/FD9r followed by FD9f3L/FD9r2L) gene, according to Arnaud et al. (2007), was done to yield a nested PCR product of 1,174 bp, and finally, a short fragment from the tuf gene was generated following the Q-Bank methodology for Q-phytoplasma (www.Q-bank.eu). In one location in Vlaams Brabant, one sample, roots from an Ulmus minor subsp. canescens tree (∼8 years old) tested positive for the presence of a phytoplasma. The sample was taken in March 2018 (early spring) and only consisted of roots. An amplified fragment of ∼1,600 bp (P1/Tint) was gel purified (SmartPure, Eurogentec) and directly sequenced (Macrogen, Amsterdam, the Netherlands). The obtained partial sequence of the 16S ribosomal RNA gene (1,516 bp) was submitted to GenBank (accession MH583020.2). This sequence revealed the closest homology (99%) with ‘Candidatus Phytoplasma ulmi’ strains from the U.S.A. (AF189214.1) and Czech Republic (EU184021). In addition, the secY and tuf fragment were directly bidirectionally sequenced and the sequences of the resulting contigs, 1,027 bp (MH727566) and 367 bp (MK491655), respectively, were also submitted to GenBank. Phylogenetic analysis was undertaken (MEGA version 7.0.26) on the 16S, secY, and tuf fragments, indicating the phytoplasma to be a member of ‘Ca. P. ulmi’, 16SrV subgroup A, and showing the genetic relationship with other ‘Ca. P. ulmi’ isolates previously reported in Europe. Virtual RFLP on the 16S fragment using iPhyClassifier (Zhao et al. 2009) confirmed this result. All other Ulmus trees from the five botanical gardens and arboreta, as well as related Zelkova trees (Z. carpinifolia and Z. serrata) and a Celtis aetnensis tree, tested negative. In addition, the phytoplasma survey on elm has expanded to the complete affected botanical garden (28 Ulmus or related trees) and to lane trees from the surrounding area. A second sampling of the same tree in May 2018 confirmed the presence of ‘Ca. P. ulmi’ on new root and leaf samples. From July onward, yellowing and partial branch decay could be observed on the affected tree. All additional samples from the botanical garden and surrounding area tested negative. To our knowledge, this is the first report of ‘Ca. P. ulmi’ on Ulmus in Belgium. Considering the other recent findings in Europe, we suspect that ‘Ca. P. ulmi’ is likely to be distributed throughout the region, but with few previous reports, rather than being a new emerging risk.