A 2–5 hard palate diabetic shock cheap 0.5 mg prandin free shipping, this approach provides excellent exposure for near fold higher oral cancer risk has been reported for patients with ly all tumors of the oral cavity type 2 diabetes symptoms quiz buy generic prandin on-line. The upper cheek flap approach is periodontal disease diabetes symptoms burning eyes buy generic prandin on line, as compared to that for patients without optimal for the resection of larger tumors of the hard palate and periodontal disease [90] diabetic diet for weight loss cheap prandin master card. Chronic inflammation caused by in the upper alveolus diabetes type 1 or 2 order prandin 2 mg online, particularly if located posteriorly diabetes in dogs alternative treatments prandin 0.5 mg. The man flammatory cells and periodontal pathogens may add to the dibulotomy approach usually involves a lip-split diabetes medications generic names buy prandin 2 mg visa, and has been burden of oral cancer [91 blood glucose needles buy cheap prandin online,92]. The risk of oral cancer was signifi preferred for advanced oral cancer because it can provide excel cantly lower in patients with oral health maintenance and den lent exposure to the oral cavity and the oropharynx [97,98]. This further enhances the Compared to midline mandibulotomy, a paramedian mandibu need for oral health education programs related to routine oral lotomy has merits for swallowing function since it preserves the health care and routine dental care to prevent oral disease, in geniohyoid and genioglossus muscles, and the anterior belly of cluding oral cancer. Paramedian mandibulotomy is an ex cellent surgical approach for access to large posteriorly located C. Surgical management of oral cancer according to subsites lesions of the oral cavity. Recommendation 11 Due to interruptions of the mandibular continuity, disturbances (A) Surgeons should choose the appropriate surgical ap of oral functions and temporomandibular joint problems can oc proach to achieve a clear surgical margin based on tumor cur [102,103]. In a study comparing the mandibu out lip-split can produce wide exposure, but may cause lotomy and mandibular lingual release approaches, no differ morbidities (weak recommendation, moderate-quality ences were observed in clinical outcomes and functions when evidence). A recent meta-analysis comparing mandibulotomy Choosing the method of surgical approach is the first step in and mandibular preservation methods concluded that mandibu planning surgery for oral cancer. The goal should be to achieve lar sparing may provide a similar clinical outcome of surgical adequate clear surgical margins and long-term survival. However, the mandibular-sparing fore, parameters such as location and extent of invasion, depth group showed a lower complication rate compared to the man of infiltration, and proximity to the mandible or maxilla should dibulotomy group. Oral cavity conditions such my approach over mandible-sparing in cases with involvement as trismus, dentition, tongue mobility, and the size of the oral of the maxilla, upper gingiva, hard/soft palate, or a combination aperture, and other factors such as dentition, size of the oral ap of multiple anatomic structures [95,105,106]. Traditionally, a 1-cm margin is taken in all planes Because the oral tongue is mainly composed of muscle tissue around a macroscopic or palpable oral tongue cancer [107,109 and there is no anatomic boundary to prevent the tumor spread, 112]. Pathologists and clinicians have agreed to define involved oral tongue tumors spread more easily than do tumors at other margins as less than 1 mm and close margins as 5 mm or less, oral cavity subsites. Thus, it is difficult to accurately evaluate the and to designate margins greater than 5 mm as clear [107,108, extent of tumor thickness before surgery. The pathological margins were reported to be much resection with adequate safety margins has a substantial effect smaller than those expected by the surgeons; this is largely due on treatment outcome and prognosis [116,117]. However, in the to margin shrinkage by about 20%–25% following resection, case of oral tongue cancer, it is very difficult to predict the de and further loss of about 10% on formalin fixation [113]. So, gree of tumor thickness by gross inspection and palpation before formalin fixation and slide preparation reduced mucous margin surgery. This results in a final pathological margins during surgical resection of oral tongue cancer is the margin of approximately 5 mm for tumors with surgeon-mea basal area of the tongue. The tumor resection margin was an im In general, since surgical resection of the oral tongue starts portant predictor for recurrence, with statistically significant from the surface of the oral tongue cancer, insufficient or close higher recurrence rate for resection margins <5 mm as com resection margins are commonly confirmed in the basal area of pared to that for margins >5 mm. On multivariate analysis, margins at this site and the thickness of the tumor are closely lower recurrence rates was noted for margins >5 mm compared related to local relapse of the primary tumor and to cervical to those for margins <5 mm. In a study comparing tumor specific survival rates in patients with margins >5 mm [107]. Some studies have reported that margins of <5 mm are associated with significantly higher local recurrence rates than are margins of ≥5 mm in oral cancer. However, no study Recommendation 14 has focused on the gingiva or the hard palate. Nevertheless, the (A) Mucosal/periosteal resection is recommended primarily effects of 5-mm margins were similar across all oral cavity sub for lesions without bone invasion (strong recommenda sites in many studies [125]. Mandibular gingival cancer primarily for lesions with bone invasion (strong recom C4-1. What is the adequate resection margin for mandibular gingival mendation, low-quality evidence). Many studies have revealed the importance of margin status as Recommendation 15 an outcome predictor in oral cancer. Such studies have suggest (A) Mucosal/periosteal resection is recommended primarily ed that a margin of ≥5 mm on final pathology was adequate for lesions without bone invasion (strong recommenda [125]. However, cancers in the maxillary gingiva and hard palate tion, low-quality evidence). Superficial erosion of the bone or tooth socket in gingival cancer is not sufficient to classify the tumor as T4, but gingival In case of the mandibular gingival cancer, selection of the surgi cancer that invades the underlying bone is designated as T4. Re to invade bone early, so it should be classified as T4 in the pre cent trends in treatment focus on preservation of mandibular sentation. As a result, most operations for gingival cancer in function due to its critical involvement in maintaining aesthetic volve removal of bone structures [127]. There are several ic review suggested that small lesions without bone invasion are resection approaches available. Similar to the maxillary gingiva, rare, but can be treated with only mucosal or periosteal resec mandibular gingival cancer without bone invasion is rare, but tion [128]. Attachment of the hard palate mucosa to the underlying peri Studies of mandibular gingiva are mainly either retrospective or osteum is different from that of the gingival mucosa. The hard case reports, and the mandibular gingiva is often studied togeth palate is a unique anatomic site because it has an abundance of er with the other oral cancer subsites; thus mandibular gingival minor salivary glands. In the future, studies focused to invade the bone later than does gingival cancer. Surgery of on gingival cancer will help provide a better basis for conclusions hard palate cancer frequently does not include removal of the of treatment and outcomes. However, management guidelines spe er oral cancer population, gingival subsite analysis is needed to cifically pertaining to hard palate cancer are based on expert better understand this separate disease entity. Enucleation is avoided Although more than 5 mm of histopathologically uninvolved for hard palate cancer because it is associated with a high risk of tissue margin from the resected tumor is usually regarded as a recurrence whether enucleation is safe for hard palate cancer re negative margin in oral cancer, most studies of “margin tissue” mains unknown [131]. Soft tissues includ the extent of maxillary gingival and hard palate surgery is ing mucosa shrink to varying extents once removed from the dependent on the size and growth of the tumor. There are vari original sites; however, due to the hardness of this tissue type, ous types of partial resection modes used for the maxillary planning the placement of 5-mm resection margins in bone is bone, i. Among them, infrastructure maxillectomy involves the mor in the bone may be unclear and lead to ambiguity in the resection of the maxillary floor below the level of the infraorbit application of bone margin. However, maxillectomy may induce functional dis 5 to 10 mm of uninvolved bone around the tumor, and other comfort. Due to the proximity of the maxillary sinuses, the sur researchers have suggested removal of at least 10 mm of unaf gery of upper gingival cancer often leads to oroantral fistulas, fected bone in the case of macroscopic tumors with suspected which may require subsequent surgical or nonsurgical recon bone involvement [135-137]. Intraoperative histologic evalua 118 Clinical and Experimental Otorhinolaryngology Vol. Some authors have suggested intraoperative cytologic scrap surgery and the plan to include safety margins are important for ings of the mandibular bone marrow to estimate the bone mar oncological safety during mandibulectomy. Finally, reconstruc gin, and have demonstrated excellent correlations with the actu tion considering both aesthetic and functional aspects is critical al pathologic status of the bone margin [135,138]. For this reason, choice of graft In principle, a positive bone margin involved by cancer in materials should be made with caution, and preoperative simu creases risk of morbidity; this may influence postoperative addi lation of reconstruction should be performed using computer tional treatment plans, and lead to an unfavorable prognosis. This section addresses However, as previously discussed, low impact of the pathologic recommendations about resection and reconstruction of the status of a bone margin on local disease control and survival mandible in oral cancer. A subsequent question pertaining sion of the spreading pattern and invasion routes is essential to to safety margins in mandibulectomy concerns the extent to determine the optimal level and extent of mandibulectomy in which the buttress of the remnant mandible should be preserved oral cancer. Clinical evaluation of mandibular invasion is per in the case of marginal mandibulectomy. Barttelbort and Ariyan formed by bimanual assessment of the cortical thickening or [139] compared the amount of residual bone necessary to with fixity of the tumor mass in relation to the mandible. The authors per veolar nerve paresthesia or pathological fractures are also highly formed incremental osteotomies on fresh cadaver mandibles by suspicious signs of mandible invasion. They proved that at least 1 cm of view article, clinical evaluation carries a sensitivity ranging from bone at the inferior border of the mandible should be kept to 32% to 96% [141]. There is no consensus regarding the most reduce the risk of fracture in marginal mandibulectomy. Accord reliable imaging modality for the identification of mandibular ing to the report, surgeons may reinforce the remaining mandi involvement in oral cancer. There have been no investigations ble with reconstruction plates if the height of nonviolent bones into methods for predicting mandible invasion with 100% reli is less than 10 mm [140]. Is mandibulectomy mandatory when oral cancer abuts the peri have been used with varying degrees of sensitivity and specifici osteum of the mandible? Another point for consideration in the assessment of mandi ble invasion is the pattern of tumor infiltration to the bone. It Recommendation 16 has been known that there are two invasion patterns of oral (A) Mandibulectomy can be waived if the tumor abuts the cancer to the mandible. In the infiltrative pattern, digits and is periosteum of the mandible (weak recommendation, low lands of tumor advance independently into the cancellous spac quality evidence). In the erosive pattern, the tumor propagates on a broad front (B) Mucosal/periosteal resection can be considered for le with a connective tissue layer and active osteoclasts can be seen sions without bone invasion (weak recommendation, low separating the tumor from the bone [143]. Summary and comparison of the imaging techniques in de Mandibular invasion in oral cancer is an important determinant tecting mandible invasion of oral cavity cancer of the manner of reconstruction as well as the extent of resec tion. Management of the mandible is a very important part of Imaging modality Sensitivity (%) Specifcity (%) oral cancer surgery in terms of complete tumor removal and Plan radiography 79. If violation of the mandible by the tumor is obvious, it is Values are presented as mean (range). Guidelines for Surgical Management of Oral Cancer 119 studied survival in relation to cancer invasion patterns and ever, in cases where the periosteum of the mandible is abutted found that the 3-year recurrence-free survival in the infiltrative by the oral tumor, the necessity and validity of mandibulectomy pattern group was 30%, compared with 73% in the erosive pat is unclear. What is the appropriate extent of mandibulectomy to be applied and lower cancer-specific survival rates compared to erosive pat when oral cancer invades the marrow of the mandible? Intriguingly, the authors identified no statistical difference in local recurrence or survival compared to patients with the Recommendation 17 erosive pattern regardless of bony involvement histologically. Shaha [146] in (B) Segmental mandibulectomy can be considered for those sisted that whenever the tumor is close to the mandible or is ad with an irradiated or edentulous thin mandible (weak herent to the periosteum, marginal mandibulectomy should be recommendation, low-quality evidence). However, for cases in which [148] performed a prospective study of 51 patients with oral the medullary bone is definitely involved, the decision is more cancer with suspicious mandibular bone involvement and who problematic, and such cases may be subjected to segmental re subsequently underwent segmental or hemimandibulectomy. Additionally, the prognostic impact of mandibular rence-free and cancer-specific survivals were similar in patients invasion by oral cancer is controversial, and there have been re without or with bone invasion, and local disease control rates ports of decreased survival rates and increased recurrence with were not different between patients with microscopically posi bone invasion as well as reports of decreased survival rates in tive versus negative bone margins. If the inferior alveolar nerve canal is considered with subsequent planning on mandibulectomy. How involved, a segmental mandibulectomy beyond the mandibular 120 Clinical and Experimental Otorhinolaryngology Vol. It has been generally accepted sidered to be a “closed margin,” and that less than 1 mm is de that once the inferior alveolar canal is destroyed by invasive tu fined as an “involved margin” [154]. The optimal resection mar mors, anterior and posterior perineural extension takes place in gin of oral cavity cancer to achieve clear margins histopathologi both the edentulous and the dentate mandible. It is well known that shrinkage mandibulectomy would be a better choice for these patients of tissue occurs during tissue processing like fixation, embed [150]. In addition, cases with previous irradiation to the mandi ding, cutting, and mounting [155,156]. The extent of tissue sisted that a segmental mandibulectomy is indicated for such shrinkage is variable depending on the type and site of cancer cases. Contrac On the other hand, other researchers have reported that there ture of 41% to 47. The authors suggested that local recurrence is usually a deep margin should be at least 10 mm. However, considering a result of positive soft tissue margins and does not correlate anatomical features like a mandible near the tumor, it may be with the type of mandibulectomy [152]. In such suggested that mandible-sparing surgery is oncologically safe in cases, widest margins are indicated, if possible. Accordingly, it would be relevant to evaluate segmental mandibulectomy to obtain adequate margins [142, whether a safety margin must be acquired in mandibulectomy 162]. Additionally, sublingual glands and/or submandibular ducts despite the lack of benefit on disease control or survival, consid may be sacrificed when they are included in the deep resection ering that segmental resection compromises the patient’s quality margins [163,164]. Therefore, it could be concluded that marginal mandibu moved with the sublingual glands in cases of sublingual lymph lectomy is an oncologically sound procedure if the tumor is not node metastasis [165,166]. However, the final decision of the method of man dibulectomy should be based on case-by-case clinical judgment Recommendation 19 by the surgeon. The buccinator muscle and its over fers to the distance from the tumor edge to the cut edge of the lying fascia are the only barriers preventing the spread of buccal specimen. Once the tumor penetrates beyond the buccinator mus designated as a “clear margin. Guidelines for Surgical Management of Oral Cancer 121 barrier to limit the spread [169]. Careful preoperative evaluation should mended that when the tumor was confined within submucosal be made regarding adjacent bone invasion, because of layer, the buccinator muscle was to be spared, and if the tumor the limited space between the mucosa and the mandible extended to the buccinator, the tumor was to be resected to in (strong recommendation, moderate-quality evidence). Oral cancer frequently shows microscopic spread beyond rior to the third molar has a large surface with abundant pores gross resection margins, which alters the margin status [175, on the cortex, which makes it easy to infiltrate the marrow as 176]. When the tumor reaches the marrow, it may margin status, but some may argue that frozen sections do not progress horizontally through the inferior alveolar canals and alter surgical margin status [177-179]. The incidence of pathologically-proven mandibular in may be a useful adjunctive technique for acquiring free resec volvement in surgical specimens was reported to be about tion margins, but further research is required regarding this as 12%–53% [185-188]. Given this, invasion of the inferior alveolar canal, this nerve could be en bloc resection including the buccinator with its overlying fas spared in cases with a grossly intact inferior alveolar canal. But cia even for tumors confined within the submucosal layer has if the inferior alveolar canals are invaded, sufficient resection in potential benefit to achieve clear deep resection margins. If the cluding the inferior alveolar nerve should be performed, due to tumor invades the buccinator muscles, the optimal surgical re the possibility of perineural spread [189]. If there is inadequate section may be extended to the fat pads of the buccal space. Therefore, if enough rently, an interincisal distance of 35 mm or less is the accepted surgical resection margin (>10 mm) is secured, it is better to cutoff point for trismus [191]. Studies show that overlying skin and deep resection margin is more than 13 mm 55%–80% of oral cancer patients have preoperative or postop (skin thickness, 3 mm), the skin may be preserved. The potential benefit of these additional proce surgery provides an opportunity to acquire safe margin for can dures is that these procedures may help avoid revision surgery cers actually invading into the masticator space. Fibrosis of the surgical field needs not appropriate to club all patients with masticator space in to destruct greater tissue destruction to achieve the purpose. The significance of more than 4 mm of tumor What is the appropriate strategy for the management of depth was identified as an important predictor of occult node cervical lymph nodes in oral cancer? Management for clinically negative neck (N–) in patients with tions for early oral cancer [205,209]. Researchers ob served an increase in occult node metastasis for tumors with a Recommendation 21 depth of 4 mm or more. Rates of regional metastatic spread differ by subsites, and sufficient evidence is lacking for making recom C8-2. However, it can be proposed that most pathologic cervical node information for patients with oral can cases with oral cancer higher than T2 should be candidates for cer [211-213]. Guidelines for Surgical Management of Oral Cancer 123 In the last 20 years, quality of life has been assessed as an es T2N0) [225]. Results revealed a 94%-negative predictive value sential secondary outcome along with survival rates. Thus, an with routine hematoxylin and eosin stain, while the value im assessment of the quality of life for oral cancer patients has be proved to 96% with additional sectioning of the sentinel node come an important aspect of postoperative care and even a tar and immunohistochemical analysis. T2 lesions (negative predictive are associated with lower rates of complications and faster re value, 100% vs. Cervical lymph node metastasis has been identified as one of the most important prognostic factors for patients with oral can C8-3. Metastasis to the lymph node occurs in about half cancer of the oral cancer patients at the initial stage of diagnosis [230]. It has been found that lymph node metastasis predicates a 50% decrease in survival rates [231]. Increased evidence of the effects of sentinel node biopsies on Treatment of metastatic lymph nodes should be performed early stage oral cancer has been released over the past decade. Since that time, results of the American College of Sur lymph nodes resulted in excellent regional control. The key geons Oncology Group examined the accuracy of sentinel node learning from these trials is that cervical lymph node metastasis biopsy in 140 patients of oral cancer in the early-stage (T1– occurs in a predictive pattern. According to a study by Shah et 124 Clinical and Experimental Otorhinolaryngology Vol. However, several factors such as advanced T stage, resection, patient’s morbidity, and surgeon’s preference multiple clinically positive nodes, and extracapsular spread were (strong recommendation, low-quality evidence). Microvascular free flap is the primarily rate of contralateral lymph node metastasis was 11% [242]. The recommended reconstructive method for most of the oral soft occult rate dropped to 2. Contralateral lymph node metas flap methods may be indicated in specific situations [246]. The objectives of soft tissue flap reconstruc What are the appropriate reconstruction methods for oral tion for tongue defects after tumor resection are to preserve cancer defects? Soft tissue reconstruction for oral cancer defects proper speech and swallowing functions [248]. Flap reconstruc tion is usually required if more than 50% of the tongue is re sected [247]. There are two retrospective case-control studies di Recommendation 25 rectly comparing the functional outcomes between free flap re (A) Flap reconstruction is recommended to preserve ade constructions and primary closure after hemiglossectomy quate speech and swallowing in patients with consider [249,250].
Food-insufficient children are more likely to receive lower math scores or repeat a grade while food-insufficient teens are more likely to be 10 suspended from school ketones in urine diabetes in dogs generic prandin 2mg on line. In 35 2011 Orange County Community Health Assessment addition blood glucose diary printable purchase genuine prandin, there is significant research advocating the importance of integrating health into education diabetes in dogs wiki buy generic prandin pills. Studies have found that education exerts the strongest influence on health diabetes type 1 stories best buy for prandin, more so than 12 income and occupation diabetes cdc purchase prandin master card, and that more formal education is associated with lower death rates diabetes type 1 vomiting cheap prandin 2mg amex. Education leads to higher income levels metabolic disease and cancer order 1 mg prandin otc, allowing individuals to purchase better medical care and healthier food diabetes insipidus merck purchase prandin online. Graduates benefit from access to health resources and information, higher education, and supportive social networks—all of which are associated with better long-term 13 health. A recent research review suggested that investments to improve educational 14 achievement “can save more lives than can medical advances. In contrast, “the less schooling people have, the higher their levels of risky health behaviors such as smoking, being 16 overweight, or having a low level of physical activity. The rankings found that states requiring health education spent less overall on health. Coordinated School Health Programs that include both health education and physical education are gaining momentum. One study of third and fourth grade students found that students who received comprehensive school health education scored higher on reading and math 21 assessments than a control group. Students also benefit from a planned, sequential K-12 22 physical education curriculum, particularly for stemming obesity. Physical education encourages lifelong physical activity, and adding time during the school day for physical activity 23 does not appear to detract from students’ academic performance. Separate chapters or sections of this report are devoted to tobacco, substance abuse, and physical activity. The rate is 36 2011 Orange County Community Health Assessment 100% for Asians, about 86% for white and multi-racial students, about 74% for Black students, and 70% for Latino students. The four-year graduation rate for Chapel Hill Carrboro City schools has gone up as well, from 75. The steady increase in four-year graduation rates for Orange County and Chapel Hill-Carrboro schools could have a positive long-term impact on health status of young adults. Figure 8: Map of Orange County Educational Facilities Schools (universities, community colleges, and public/private grade schools) are concentrated in city limits and the major corridors of I-85 and Hwy 86. Disagreement was skewed by income bracket—those who made less than $25,000 disagreed about equal access to education in schools more than those who made over $50,000 (21% disagree vs. Qualitative: Focus Groups When discussing education in Orange County, there was a lack of consensus among participants about the quality of the school systems in the county. One participant spoke highly of the school system in Chapel Hill saying that it is one of the main draws for residents to come here. Another voiced the opposite opinion and explained that the school system is great for students on both extremes—gifted and talented or learning disabled—but less supportive for students that are “middle of the road. Similarly, other participants have made it clear that education is highly valued in this community, but has set up the potential for elitism or inequality between those who have attended college and those who have not. Other groups talked about the need for more focused education, such as computer classes for adults, or drug and alcohol prevention for youth. Overall, it was clear that many participants felt that education was key to quality of life and health. Current Initiatives and Activities Both Chapel Hill-Carrboro City and Orange County Schools are working to prevent school dropout and acknowledge that there are multiple issues related to dropping out. For example, minority students and English Language Learners experience a significant achievement gap and may feel discouraged. Undocumented immigrant students may also feel stress and experience more obstacles to higher education opportunities due to their uncertain legal status. Residents are somewhat transient, especially if associated with the University, and young students may feel a lack of school connectedness. Individual, family, social, or emotional issues may also contribute to a higher likelihood of students dropping out of school. There is an ongoing focus in both districts to improve teaching by promoting best instructional practices and supplying funding as available to meet the needs of students who are at-risk academically. There are also efforts statewide, such as those through the Adelante Education Coalition, to address some of these barriers to education. The mission is to close the achievement gap by preparing all students for college readiness and success in a global society. Students apply for admission and take both community college courses and honors level high school courses. Community-based programs Boomerang is a community-based alternative learning program for students who are suspended out-of-school for up to 10 days; emphasis on resiliency and making positive relationships with school and community adults. Academic success, health status, and risk behaviors tend to occur in a cyclical fashion among younger students, making analysis challenging. It is important to note that researchers are calling for more significant research on the pathways through which education leads to better health and longer life expectancy. Measuring the Effects of Education on Health and Civic Engagement: Proceedings of the Copenhagen Symposium. According to Healthy People 2020, health care access is defined as “timely use 1 of personal health services to achieve the best health outcomes. According to the Agency for Healthcare Research and Quality, there are three prerequisites to accessing healthcare services: 1) the ability to enter and navigate the healthcare system; 2) the ability to identify and use convenient healthcare locations; and, 3) the ability to establish a good 2 working relationship with a medical provider where communication is easy. First, navigating the healthcare system is easier to do when a person has adequate financial resources and health insurance to pay for services. Second, gaining access to the best healthcare sites often requires the ability to travel within or outside the community. Last, to form a trusting relationship with a medical provider a person must feel comfortable with communicating and asking questions, which is generally the result of having a consistent provider or medical home. Not having these essential resources may lead to barriers that can keep a person from truly capitalizing on or benefiting from the preventive care and/or treatment plans available for maintaining health. With increased access to care, a resident may have a better chance of improving health outcomes and increasing his or her life span. By reducing the number of uninsured individuals, it is believed that pressures placed on emergency rooms will 3 be eased as more individuals establish a medical home and fewer will delay receiving the care 4 and medications needed for treating an illness. Secondary Data: Major Findings For many Orange County residents, health care services are accessible. Research indicates that communities with a higher primary care provider to population ratio have better health 8 outcomes, including lower infant mortality rate and higher life expectancy. While Orange County has a strong public health and medical community, there are still many 9 residents who cannot access the health care services available in this county. In addition to medical insurance, factors contributing to a resident’s inability to access health care services include the concentration of health care resources in the southern part of the county, inadequate transportation systems in the central and northern part of the county; language barriers, recent relocation to the county from another country, and perceived disparities (or racism) within health care facilities. All of these factors were cited in previous Orange County Community Health Assessments in 10 discussions on access to health care. The current recession is another factor that may be affecting residents’ ability to access health 11 services. Towards the end of 2007, the country began realizing the effects of an economic downturn with business closings, layoffs, and less spending. According to the 2009 North Carolina Economic Index, the state’s unemployment rate rose between December 2007 and January 2009 from 4. The state’s rise in unemployment rates is consistent with a rise in uninsured residents. In Orange County, estimates of non-elderly (0-64 years) uninsured rose 14 from 16. Close to 28% of residents did not visit a doctor for a routine (general physical exam) checkup within the past year. In 2007, just 10% of Orange County residents answered “Yes” to the same question showing that the 15 number of residents who are unable to pay for medical services is increasing. Six percent of respondents go to a hospital clinic, 4% go to an urgent care clinic, 4% use the hospital emergency room, and 3% most often frequent the Carrboro community health clinic when sick. Of those who listed specific problems getting health care, reasons included: did not have health insurance; could not afford the costs or deductible/co-pay was too high; for some other reason; could not get an appointment; did not know where to go; did not have a way to get there; and their insurance did not cover what they needed. Eighty-four percent of residents surveyed visited a doctor for a routine checkup within the past year, 7% in the past one to two years, 3% three to five years ago, 4% over five years ago, and 2% had never had a routine checkup. Reasons cited were: could not afford the costs or their deductible/co-pay was too high; did not have health insurance; had insurance that did not cover what they needed; had problems with Medicare part D; and prescriptions were backordered and not available. Sixty-one percent of those surveyed normally get their flu vaccine at a private doctor’s office, 15% at their workplace, and 8% at their local pharmacy. Regarding transportation, in order to get to health care, 87% of those surveyed usually drive themselves to appointments; 7% have someone else drive them; 4% take public transportation; 2% walk or bike; and less than 1% use the senior center, Orange or Social Services buses. Qualitative: Focus Groups Focus group discussions supported secondary data regarding barriers to accessing health care services in Orange County. According to outcome data, persons who had limited English proficiency, lower income levels, inadequate transportation, and/or inadequate insurance had more difficulty obtaining services. The limited English proficient groups in particular mentioned a lack of available appointments at affordable local health care centers as a particular barrier to access. Current Initiatives and Activities In North Carolina, poor, rural, and minority residents have more problems with accessing health 16 care services. This group was followed by American Indians at 25%, Blacks/African Americans at 21%, Asian/Pacific Islanders at 16% and non-Hispanic whites at 17 14%. The Burmese/Karen refugee population from Burma is the newest Orange county resident group. An estimated 800 45 2011 Orange County Community Health Assessment 18 1,000 people from Burma live in the Chapel Hill and Carrboro area. Due to the economic 19 downturn, fewer refugees have been arriving to the area since 2008. All newly arrived refugees to Orange County have a communicable disease screening by Orange County Health Department Refugee Health. Piedmont Health Services’ Carrboro Community Health Center provides comprehensive care to the Burmese/Karen refugee population and served 471 clients 21 in 2010. Transportation was cited in the 2007 Orange County Community Health Assessment as a barrier to accessing health care services for northern Orange and rural residents in particular. With no major public transportation advancements to connect north and south occurring or planned, it is not surprising that some residents cited transportation as a barrier to accessing health care in this 2011 survey. Orange County has limited public transportation particularly in the central and northern parts of the county. Residents without access to a personal vehicle may experience transportation difficulties. Efforts at increasing public transportation between Hillsborough and Chapel Hill have increased. In July 2011, the Town of Hillsborough and county (through Orange Public Transportation) created the Hillsborough Circulator, which is a free in town bus service that connects passengers to various destinations including the Durham Tech community college campus (Hwy 86), the Wal-Mart/Home Depot shopping center (Hampton Pointe Blvd. The county’s Orange Bus offers seniors (60+) and residents with disabilities transportation from their residence to their medical care providers or shopping. Medication access is also a concern and agencies are taking steps to bridge this gap. Piedmont Health Services has improved medication access for seniors and others by offering prescriptions 24 at a low cost. The Orange County Health Department has a limited number of low-cost, primary care medications available and the department’s Medication Assistance Program locates available programs for chronic disease medications by using websites such as 25 needymeds. Many area pharmacies, such as Walmart, now offer the “$4 Program” that covers up to a 30-day supply of eligible drugs at commonly prescribed dosages. Recent changes in Orange County that affect access to care are: Increased health and medical resources in the central to northern part of Orange County: Three new medical practices have opened in Hillsborough since 2007 adding access to primary care providers and pediatric offices for the central to northern part of the county. The health department recently completed renovations to the lower level of Whitted Human Services Center. The health clinic will expand to include more exam rooms and work space for nutrition services. The dental clinic recently expanded from four to eight operatories (exam rooms) to serve clients 28 more efficiently. One of the first survey questions asked what participants liked most and least about living in Orange County. According to survey data, “Access to quality medical care” (5%) and “Good public transportation, low-traffic roads and bike friendly roads” (6%) are within the top 10 things people like most about living in Orange County. More respondents (17%), however, felt that transportation, sidewalks/roads, and traffic were detractors for the county. Most survey respondents reported visiting a private doctor when needing a flu vaccination (61%) and when sick (72%) Both findings indicate that many Orange County residents have a medical home that they can turn to for preventive care and treatment. In addition, 84% of respondents reported having a routine check-up within the last year, suggesting that many residents take advantage of the health care resources available to them. Not surprising, survey data showed that not all residents are able to access health care services or have health insurance to make access easier and more affordable. Participants were asked to report whether in the past year they had problems getting needed health care. Some of the respondents who were unable to access care reported issues such as not having health insurance (or enough health insurance); being unable to afford deductibles or co-pays; not being able to schedule an appointment; and transportation. These are all consistent with national findings for why many people have difficulty accessing health care services. Similarly, survey data showed that 10% of respondents had difficulty filling a needed prescription and, for some, this was due to high deductibles, lack of or inadequate health insurance, and medications that were out of stock. Similarly, white respondents were more likely to report “very good” and “excellent” health statuses than minorities. Orange County Health Assessment survey data revealed that most respondents (87%) drove themselves to health care appointments while 7% were driven by someone else, 2% walked or biked, and 4% used public transportation. It is good to see a high percentage of persons who report using personal transportation to get health care services. This finding shows that transportation is not the largest barrier against accessing health care services in the county. However, focus group discussions showed that residents who rely on public transportation have more difficulty accessing services. Some Orange County Health Department staff who provide direct service report anecdotally that clients who rely on public transportation often have difficulty in maintaining appointments. Several participants provided examples of how personal or environmental limitations prevented them from accessing health care services. In one discussion, a participant with limited English skills shared a story in which she was denied health care services because she did not bring someone who could interpret information for them. In addition to showing how limited English skills can keep a person from getting needed care, this example also shows that some medical facilities in the county may not be equipped to serve non-English speaking clients who need care and information. In a second discussion, a person shared difficulties in getting to Whitted Human Services Center in Hillsborough from the southern end of the county for medical appointments via public transportation and walking. Participants expressed interest in having more urgent care clinics throughout the county to reduce dependency on emergency rooms for minor issues and reduce waiting times when receiving care. According to a small, 2010 assessment of Karen refugee residents in Orange County, socioeconomic barriers have the greatest impact on health care access. Some adult refugees are eligible for Refugee Medicaid for health care the first eight months of resettlement. When they lose their Refugee Medicaid, they changed health care usage patterns by postponing doctor appointments, seeking medical care only for emergency, not keeping follow up medical 30 appointment and not filling necessary prescriptions. Since Access to Health Care was voted as the number one priority in Orange County, it is especially important to work together on plans to improve access. Some recommended evidence-based methods are as follows: 48 2011 Orange County Community Health Assessment 1. Improve resources available to uninsured residents that will help them navigate the health care system a. Develop a Navigators Program for persons new to the county and its health care system b. Develop educational materials explaining/promoting the free or reduced-cost health care resources available in Orange County. Develop a distribution plan to make sure information gets to appropriate audiences. Nonetheless, just guaranteeing access to a provider does not ensure that individuals will receive all the recommended health services. Studies have shown that adults and children 31 generally only receive about half of the recommended health services. Begin researching the feasibility of developing more urgent care facilities in the county and better promote existing centers. Urgent care facilities are needed, but should be used for urgent needs and not as a primary source of care. For a healthier county, there is the need to set a high value on providing access to primary care, continuity of care, and prevention for the citizens. Develop a targeted public information campaign to promote prescription and medical services in the county. This will include promotion of free or reduced-cost health care medication assistance programs such as the $4 medication list. Minority Health and Health Disparities, Health Care Access: Health Profile of North Carolinians: 2009 Update. Without insurance, many have problems getting needed health care and often delay or do not get care because of the cost. Although Orange County is ranked number one in the state for the ratio of primary care physicians to citizens, there are limited places for low cost 1 or free medical care in Orange County. The uninsured tend to use emergency departments for their primary care needs and have limited access to preventive screening. According to Prevention for the Health of North Carolina, people with a regular primary care doctor more often get preventive services and have less hospitalizations because of earlier 4 medical care. Since the uninsured often delay care over time, they may have more serious conditions, more hospitalizations, and more disabilities when they finally seek care. Employees with poor health may have increased 5 absenteeism, and students with poor health may have difficulty learning.
If you get fruit to set diabetes test blood cheap prandin 2 mg fast delivery, the growing fruit can stand higher humidity diabetes insipidus vasopressin prandin 2mg, so those of you in areas with somewhat dry late springs (when the blooms are appearing) can have pomegranate fruit even if your humidity gets higher during the summer blood sugar 32 generic 1 mg prandin with mastercard. High humidity during the ripening stage may cause the fruit to split as it ripens overt diabetes definition order prandin 2 mg visa. If you are using the fruit for juice this in not a problem just wash the fruit and juice it diabetes diet food list order prandin line. But there are areas in the United States that have average winter low temperatures above 12 degrees F and can grow pomegranates but the fruit will not ripen because of the short summers blood glucose of 100 buy line prandin. Areas such as western Oregon and Washington and the middle section of the East Coast of the United States have this problem diabetic zucchini fritters cheap prandin 0.5mg online. Also diabetes mellitus type 2 code buy prandin 0.5mg low price, in recent years, there have been developed some early ripening varieties in California. There are the early ripening varieties Sverkhranniy (means super early) which ripens in August, and Sumbar which ripens in late August or early September as well as several others. Sumbar and Sverkhranniy are being tested in the Willamette Valley of Oregon where they should ripen well before the cool weather starts. See the Propagation Section for how to get a start of some of the early varieties or check with nurseries about early ripening varieties. Most of the early ripening varieties are also soft-seeded and most have a sweet taste. These soft-seeded early pomegranates do not store quite as long as others but usually will store for up to 3 months. The American variety Granada is an early 20 the Incredible Pomegranate ripening variety (ripening in about mid-August) that might be of use in short summer areas. If you have a very, very short summer there is no answer but to grow in pots and bring inside to ripen. They grow in Saudi Arabia where the temperatures commonly reach 120 degrees F in the summer. In the United States commonly available pomegranates do best in areas where the temperatures are close to or above 85 degrees F for more than 120 days. In order to raise their prize pomegranates, they raise bushy varieties that they bend to the ground in the fall and pile dirt on them until they are completely covered. In the past, all the work was done by hand, but now they have machinery designed to do this work. In areas of southern Russia where they have snow cover all winter they raise pomegranate varieties like ‘Agat’ which is a low growing variety. You do not have to keep them very warm (above 12 degrees F) so little heat is required. In the Midwest, pomegranates are grown in large pots and brought inside an unheated building (with some light) to rest for the winter, as an example. The building provided enough heat from the daytime sunshine to keep the nighttime temperatures warmer. When you see references to covered methods of growing pomegranates this is what they mean. They trap 21 Plant and Fruit some of the warmth of the sun in daytime which keeps the nights warmer. There are two layers of plastic applied over the structures to trap and hold the heat. The ends are usually opened up and the very bottom section of the sides is rolled up in the summertime to allow the heat to escape. In the fall they close them again (before any danger of frost) to help ripen the fruit with warmer temperatures. If you use this method just be sure that the humidity does not get too high, pomegranates do not like high humidity. The next thing you must consider is site location; this includes soil, water and light exposure. The difference between pomegranates and many other fruit trees is the wide range of soils in which the pomegranate will grow. From heavy clay, black earth, lime rich soils, dry rocky hillsides to sandy soil, the pomegranate will grow. Heavy clay soils tend to lighten fruit color but if the fruit is for home use this should not be a problem. The pomegranate is considered a salt-tolerant plant, but accumulation of salts in excess of 0. Pomegranates like a well-drained soil and although they can stand brief flooding, constant wet feet will kill the plants. If you live in an area that has a lot of rainfall that is good as long as the water runs off and drains away from the roots of the plants. In heavy-rain areas it is again advisable to plant your pomegranates on raised beds. Water requirement for the pomegranate is variable depending on when and how much rainfall occurs. On average pomegranates need about 45 inches of water per year; this is not an absolute figure as it again depends 22 the Incredible Pomegranate when precipitation occurs. If you receive most of your rain in the spring and early summer, then the need for irrigation is lessened, but some will still be needed if you have very dry weather in the middle of the summer. If you irrigate, give the plants a deep watering at longer intervals, versus shallow frequent watering. Dry winters are good and the need for water is not very great during this period although a little moisture in the soil is best. Pomegranates can stand very dry air conditions but to produce good fruit they need some moisture in the soil. Fruit splitting is a problem if too much water is received by the plants after the fruits start to ripen. Many growers in the west stop irrigation in early August and allow the fruit to mature on what moisture is in the ground to avoid fruit splitting. Heavy rainfall in the fall when the fruit are ripening will again cause some of the fruit to split. The idea is to maintain level soil moisture throughout the growing season; it is the change in soil moisture that causes the fruit splitting. For the best fruit size, color and taste, keep your soil moisture at a constant level. Drip irrigation is also very good and maintains that level soil moisture that pomegranates like. Try not to use this method when the fruit are ripening because if you get a lot of water on the ripening fruit a lot of the fruit will split. One advantage of sprinkler irrigation is that it can help prevent damage in late spring by frost. Just turn on your sprinklers during these frosty periods and you will get less frost damage. Pomegranates can withstand long periods of drought, so if you cannot water, do not worry too much, the plants should survive. In areas such as the southeastern United States where rainfall in average years is above what the pomegranates need, you do not need to worry too much about irrigation, but fruit splitting is a problem. Try to select varieties that have some resistance to splitting such as “Kazake,” “Salavatski,” and in Florida try “Christina. Spraying diluted Calcium Hydroxide after the fruit have set has shown to be helpful in preventing fruit splitting. If you are planting more that one shrub, if possible align the shrubs east to west so that the sun will shine directly down the row all day. Just remember, too much direct sun along with high heat can cause the fruit to sunburn on one side; if this occurs, it is usually only a small percentage of the fruit and not a big problem. Planting distances should be about 12-14 feet in the row and 17-18 feet between rows for best fruit production. If you want a pomegranate hedge, plant them about 7 feet apart in a row; fruiting will not be as good but you will have a good dense hedge. Now, as to low-growing varieties, the spacing is somewhat different, you can plant as close as 5 feet with 12-14 feet between rows; such is the case with the variety “Agat”. The use of low-growing plants and close spacing has resulted in higher yields per acre in commercial production. The next items that need to be addressed are Fertilization, Pruning & Training and Weed Control. These figures are actual nitrogen so if your fertilizer has 21 % nitrogen (the first number in the three number set on the fertilizer bags) you will need about 2. If you use too much fertilizer the fruit may not ripen well; it is better to use too little than too much. You do not want to fertilize too heavily and have all the energy of the plant going to growth rather than the production of many fruit. One of the best methods to fertilize pomegranates is 24 the Incredible Pomegranate to use natural fertilizers such as well-rotted manure and compost. I would highly recommend their use in preference to commercial fertilizers to the home gardener. If this is the case with your soil, it should be applied to bring it up to optimum. Sometimes trace elements are needed, zinc in particular if the leaves of your plant show a type of unusual yellowing. It is best to take a soil test to determine what your soil needs, and then you can adjust the soil with right amendments. Just remember that in many parts of the world pomegranates are grown with no commercial fertilizer although cover crops and natural fertilizers are commonly used. Pomegranates can be grown as a single-trunk tree in the warmer sections of the country. To obtain good fruit, the plant must be pruned on a yearly basis to either a single trunk or the more desirable multiple trunks. Pomegranates have a tendency to sprout numerous suckers even when older, these must be removed. Pomegranates should not be pruned in any way the first year unless you plant a large potted plant. The reason for this is that the plants need to get established that first year without any more disruption than necessary. The second year, when they are more established, you should start your pruning and training. You will need to remove the suckers several times during the growing season, trying to keep your plant to 5-6 trunks. If you let it sucker freely it will put all its energy into growing and you will have little fruit. The suckers can take so much of the energy of the plant that the established larger trunks will die back, especially in the early years. Only if you are in an area with warm winters should you try to grow the pomegranate plant as a single trunk tree. You do this the same way you removed 25 Plant and Fruit the suckers, only leaving one sprout/trunk and taking away all others at the base. If any do, just pick a sprout from that year’s crop that is closest to the lost trunk and leave it for a replacement, and remove the old trunk. It usually takes a few years for the 5-6 trunks that you are going to leave to become established. All heavy pruning should be done during the dormant/winter season, but some light pruning to open up the plants and remove suckers can be done in the summer, usually in August. Pomegranates bear on both older wood (2-3 years old and older) as well as the current season’s growth. It is good during early pruning, before blossoming, to remove about ½ of the current season’s shoots and shorten the remaining current season’s growth a little so they will not flower. When pruning for best production when your plant gets older, remember this: the more light and air the blooms get the better the fruit set and fruit production will be. So when pruning the growth from the older 5-6 trunks, open up the middle and remove overlapping secondary limbs. Most of the fruit will be set on the outside of the shrub on new growth spurs from the older trunks. Many commercial growers also top their plants at about 10 feet in order to make picking easier. Topping does not seem to reduce production and is recommended because it does make it a lot easier to pick the fruit and to apply any sprays for pests and diseases that may occur. When plants get older and production starts dropping (20-25 years) cut the main trunks back to the ground and let some of the suckers come on and become the main producing trunks; this way you can rejuvenate your old plants. You may want to remove only a part of the old trunks each year so that you can have some fruit production until the new trunks mature. This does not work well with single trunk trees; in these trees, it is better to remove the entire trees when they get old and production drops and plant a new tree. There are occasions when the entire plant will be killed to the ground by an unusually hard freeze. If this happens, remove the dead trunks and pick 5-6 sprouts to replace them the next year. In the first several years of life the pomegranate may experience several winters that they get frozen down, if you are in a marginal area. The pomegranate has a great ability to 26 the Incredible Pomegranate re-sprout from the under ground part (xylopodium) of the plant. The xylopodium is the part that is at the beginning of the roots and at the base of the trunks, just underground. There is one fact that is constant in all varieties – young plants are more frost sensitive that mature plants, so if you have trouble the first year or two with trunks being frost bitten, they should get more frost resistant with time. The good part about the 5-6 trunk system is that if you receive a harder than normal freeze (or early/late frost) on a mature shrub, usually only one or two of the trunks are severely damaged and you can still have fruit that year from the remaining trunks. You can then remove the dead trunks and let one or two sprouts replace them and you are back to normal. With the single trunk tree, if it is killed there is nothing left for fruit that year. There is a dispute in the commercial pomegranate growing world as to whether a pomegranate should be grown as a single trunk tree or a multiple trunk shrub. In the San Joaquin Valley of California, commercial growers use the single trunk concept and think that it is the best. In most of the rest of the commercial pomegranate growing world, pomegranates are grown as a multiple trunk shrub. They all agree that the number of trunks must be limited to a small number, because if you let the plants go they will become a hedge-type plant and you will see little fruit. The one trunk system will work for anyone including commercial growers in areas that do not stand any chance of a very hard freeze that will kill the plants back. In the cooler winter areas, multiple trunks are the only way to be somewhat assured of production. Pomegranates can be trained to a trellis system where the shrubs are planted more closely in the rows and trellised with supporting post and wires. This system has yet to show that it is any improvement and actually may lessen production as you cannot have as many trunks this way. Usually three trunks are utilized with one going each way in alignment to the row, as well as one going straight up, and the secondary growth tied to the wires. Except with very young plants where you will not want to cultivate too close to the plant. That leaves a section between the trees that will have to be either hand weeded or you can use a herbicide. But herbicides can hurt young trees and are not recommend until the trees are at least 5 years old. Such as putting down a layer of compost in these spots at least 6 inches deep again will retard weed growth, also it is good for the shrubs. Some of the organic nursery supply companies sell products that will help with the control of weeds. You will still need to irrigate in these orchards and drip irrigation is best for this type orchard but sometimes flood irrigation is practiced. The production does not seem to be as good from these non-cultivated orchards but there have been no scientific studies so we make no recommendations about ‘cultivated versus non cultivated’. But the shrubs will benefit from cross pollination by an increase in production of about 30%. Although bees can help pollinate pomegranates they are not normally the main pollinators. Some varieties are better for cross pollination than others; this is known but no research data is available at present. Two shrubs of the same variety will work for cross pollination, although two different varieties are preferred. The majority of the blooms occur from April to June and then their number decreases in the northern hemisphere. On the flowers the ovary is just a small rounding at the base when the flower opens. When pollination occurs, the ovary 28 the Incredible Pomegranate swells and the calyx becomes a “crown” on the swelling ovary. Shrubs grown from cuttings are more likely to retain their fruit in those first few years. Pomegranates seedlings start bearing at the age of 3-4 years and cloned plants (from cuttings) start bearing at the age of 2-3 years.
Propagating by seed is not just the poor man’s method of producing new plants; depending on how it is used metabolic disease of muscle symptoms order 0.5 mg prandin free shipping, it can be a very scientific method diabetes test non fasting buy discount prandin line. You 72 the Incredible Pomegranate can also get plants that are mostly true to the variety by this method if you are careful with your seed selection as any seeds that are cross pollinated will not be true to type diabetes type 1 who is at risk prandin 1mg with visa. Be warned that if you simply select a fruit without knowing where it came from diabetes diet management prandin 0.5mg, or the environment in which it was grown diabetes test on iphone order prandin on line amex, you may find yourself with inferior plants coming from its seeds diabetes testosterone buy 0.5 mg prandin with mastercard. Studies have shown that you will get a very wide variation in the type of fruit produced from pomegranates propagated by seed if no special care is taken diabetes x syndrome prandin 2mg low price. One way to obtain good true-to-variety seed is to bag the flower buds before the blooms open with big enough bags to allow for the development of the fruit diabetes insipidus patient information prandin 1mg on-line. As pomegranates are self-fruitful, some of the blooms that are bagged with develop fruit and the seed from them should be true to variety. The reason behind this is the belief that the small fruit developed later in the season when there were no pollinating insects around so these small fruit should be self-pollinated and seeds should be true to variety. The seed from the selected fruit should be dried for long enough that the seed become very dry, usually 2 weeks is enough. Some say that you should put the seed in a closed container in the refrigerator for a week before sowing. Most varieties do not need this cold period but there are some cold hardy varieties that will benefit from the cold period. If you are going to store the seed for later planting it is best to store the dried seed in a closed container in the refrigerator. If you believe that you have good seed, plant them in a flat in which you have a seed-starting medium, which is sold at many garden centers. When you have them planted, keep the flat in a warm place (70° F or warmer) with good light as well as water and in a few weeks you will have many little plants. Bottom heat will speed seed germination; seed as well as cuttings benefit from soil medium temperatures as high as 85-90° F. The germination period will vary a lot by variety but usually you should have plants emerging within 45 days, some varieties with germinate within14 days. The length of time to germination is also a factor of temperature; the higher temperatures will result in quicker germination. Once the plants reach three to four inches high they should be put in larger pots and placed outside if it is warm enough. I usually plant several plants to a pot so I can select the best one as time goes by, and to allow for plants that die. It is usually best to bring the potted plant inside the first winter before planting it outside the next spring. These seedlings are so tender that they sometimes will not stand the first winter outside. Once planted outside the spring of the second year, let your seedling grow through summer and fall and mulch well before the next winter. It should be developed enough by the next season not to need any special care, other than normal cultural requirements. The most finicky rooter will graft to another pomegranate rootstock and grow without missing a beat. We have been successful with cleft grafts, wedge grafts and whip and tongue grafts. If I had only an 8 inch cutting of a variety I really wanted, I’d cut off one node and graft it to a Wonderful or other vigorous pomegranate. I’d treat the remaining portion as you would any cutting to be rooted, giving yourself two chances of getting your desired plant. If you are not familiar with grafting, there are several books on grafting and lots of information on the web will get you started. One of the best ways to experience grafting is to check with your county agricultural agent and see if any grafting classes are going to be held close to you. The best time to graft pomegranates is in May with dormant scion-wood (cuttings) and in July with semi-hardwood cuttings. We want to stress that grafting is not the best method of pomegranate propagation. For example, if you have a hard winter that kills the tops back to the ground, there goes your graft. In the warmer parts of the country, hardiness zone 9 or higher where you are growing the pomegranate as a tree (with one trunk) this method is a reasonable way to propagate. Then, after there is good growth, they will take cuttings to root, and that way, they get more cuttings more quickly. In the summer, take a sucker and bend it over so that part of the limb is touching the ground. At the point where it will touch, cut a thin short slit in the bottom side of the limb (when it is bent to the ground)—at least 1 to 1 ½ feet from the tip of the limb. Then dig a little depression and put the cut part of the flexible limb into the hole and put dirt on that area with a good-sized rock on top of it. The tip of the branch, still be connected to the mother plant, will be sticking out. Leave it that way through the winter, and in early spring after the mother plant has leafed out, cut the sucker between the mother plant and the buried portion. More plants are lost through poor transplanting methods than by any other part of the process of getting your pomegranate established. Generally, transplanting is best done in January and February when the plants are dormant. You dig the planting hole bigger than the spread-out roots of the plant but only slightly deeper than the length of the roots. Place the plant in the hole with the roots spread out in a circle, then fill in about half the dirt. Then place more soil in the hole so that it is flush with the surface of the ground and the plant is at about the same height as it was in the nursery. Make a small ridge around the plant about three feet from the plant and fill with water. It is important to keep your young pomegranate plants watered at weekly intervals if you do not get sufficient rain, until they get established. The first winter following transplanting, mulch the plants to keep the ground warmer and to retain moisture in the soil. Then, to place an order, go to the above page and click on Products and Services that will take you there, then go to the bottom and click on – Order Form. Fill out the order form and send it in by the dates given and they will send you your cuttings at the appropriate time. For those of you that do not have a computer, you can write or call them at: National Clonal Germplasm Repository University of California-Davis One Shields Ave. Their goal is to distribute pomegranate varieties that are not available elsewhere in order to spread the germplasm (varieties) so that they will be better preserved and used. People didn’t know how easy pomegranates are to juice so they would eat some seeds or use the fruit for table decoration. We will describe the fresh use of the fruit and discuss the easiest method to remove the arils. We hope that the recipe section that follows will expand your use of the pomegranate. Cut your pomegranate in half if you have a large citrus press and press out the juice as you would an orange. If you have the standard citrus press you may need to cut the pomegranates into quarters and then press out the juice. When you have finished juicing your pomegranates let the juice set in the refrigerator a few hours. There will be a small amount of cloudy material in the bottom of the container that needs to be discarded and you will then have beautiful tasty pomegranate juice ready for drinking or any use. A warning: Do not use a citrus reamer as it will get some of the tannin from the skin and partition material into the juice and that is not desirable. Take the pomegranate and roll it around a little, until it gets soft, then cut apart the pomegranate under water. Wrap them in cheesecloth or jelly sack then use your hands to squeeze out the juice into a bowl, squeezing gently as you do not want to squirt yourself. Follow the instructions for removing the arils and then process the seeds in a food processor or blender. Let the juice settle a few hours and remove any cloudy material from the bottom of the juice container. Another method that is used in Iran: Roll the pomegranate around, giving good pressure, but not enough to break the skin. It’s an art to push hard enough to break the arils inside without breaking the skin. When soft, carefully open a hole in the pomegranate and place a straw in and suck the juice out or just bite a bit of the skin out, spit it out and suck out the juice. The partition material and most of the skin will float to the top and the arils will go to the bottom. Another method is to cut the pomegranate in half over a large bowl then place half the fruit in the palm of your hand and squeeze gently (try not to squirt yourself). Then take a heavy wooden spoon or pin or other clean wooden object and tap the half where you have the arils loosened (it may take a hard tap); tapping the loosened arils into a bowl. The simple fact is that most pomegranate recipes for using the juice are based on two basic recipes – heavy and light pomegranate syrup. But you can get creative with some very special recipes of your own by using these basics and then adding your own ingredients. If you are using fresh pomegranates for these recipes, you can usually count on one pomegranate making about 1/2 cup of juice, depending on size of fruit. We would like to note that there seems to be some confusion of just how pomegranate grenadine is made. First, grenadine that is used in drinks nowadays is not made from pomegranates as it was; it is artificially flavored. In the Mediterranean area and the Middle East where the heavy and light pomegranate syrups are used frequently, they are referred to as Pomegranate Molasses and Pomegranate Concentrate. You can also buy this 79 Plant and Fruit already made in most Middle Eastern markets; the syrup was used in Middle Eastern cooking in much the way that wine is used in western cooking. That’s how simple it is to make pomegranate syrup yourself and it will keep in your refrigerator in a sealed jar for about four months. Pour in clean jars and use prepared clean canning rings and lids, then process in a water bath canner for 15 minutes. Pomegranate Concentrate – Light pomegranate syrup the difference between this and pomegranate molasses is that you do not use any sugar in this recipe and you have a more intense pomegranate taste. It can be used for many of the same things as pomegranate molasses— it is just a question of flavor, this being the less sweet and more tart of the two. Ingredients: Pomegranate Juice (that’s all) If you want 2 cups of syrup start with 4 cups of pomegranate juice, as it reduces by about ½ of the amount you start with. Pour juice into sauce pan and bring to boil over high heat, then reduce heat to maintain boiling action for about 25 minutes or until it thickens, stirring to prevent sticking. When juice starts to thicken, check it to see if it is ready by lifting out the spoon. This can be canned and processed the same way that you would can 80 the Incredible Pomegranate pomegranate molasses, or it can be frozen. When bottled and stored, the syrup stays good in a refrigerator for up to 2 weeks. Note: If you want a heaver syrup you can reduce it as far as 3 cups juice to 1 cup syrup— it will just take a little longer cooking time. Pomegranate Meat Sauce this sauce is used to baste meats and chicken in the latter stages of cooking, usually added in the final 1/3 of the cooking time. Or just to add to the meat juices, especially if vegetables are also cooked with the meat. Ingredients: 1 cup pomegranate juice ½ cup of lemon or orange juice (your choice, the taste will be a little different) 2 tablespoons sugar Salt and pepper to taste In the sauce pan combine all ingredients, except salt and pepper and bring to boil on high heat. Ingredients: 1 cup thick ketchup 1/3 cup pomegranate molasses 1 teaspoon of cumin 2 teaspoons of powdered garlic or minced garlic 1 teaspoon of Louisiana hot sauce 81 Plant and Fruit In saucepan combine all ingredients and simmer 5 minutes on low heat. Pomegranate Desert Sauce this sauce can be used to dribble over many desert dishes such as plain cake slices, ice cream, pancakes and many others, just use your imagination. If you use the sweet-tart type of juice you find in the grocery store you will have a sauce that has that good pomegranate taste. If you grow your own pomegranates, the sweet-tart or sour varieties are best for this sauce. If you grow or use one of the sweet pomegranates varieties reduce the sugar to 2 tablespoons. Ingredients: 1 cup pomegranate juice 1/2 cup of sugar 1 1/2 tablespoons corn starch In small saucepan combine ingredients over low heat. When combined and smooth, turn the heat to medium and bring to boil stirring constantly. Boil 1 minute, you will see it turn to a thick sauce in just a few seconds when it starts boiling; keep stirring, do not let it scorch. Try this sauce poured over thin slices of plain white cake (unfrosted) or pound cake. Ingredients: 4 cups of pomegranate juice 82 the Incredible Pomegranate 7 ½ cups of sugar ¼ cup of lemon juice 6 fluid ounces of liquid fruit pectin (this is one bottle of any brand of pectin) Combine all ingredients except pectin in large saucepan. Sugar 2 Lemons, juiced 2 Gallons of water Wine yeast and nutrient Remove the arils from the fruit. In primary fermentation vessel combine pomegranate arils, sugar and lemon juice and stir until mixed. Pour the water through a strainer, off the barley water mixture (while still hot) and onto the mixture in the primary fermentation vessel. Then strain the mixture into the secondary fermentation jar and fit with fermentation trap. With a good variety pomegranate produced and fermented under good conditions you will get a great fruity taste and aroma. They can be added to meat dishes to give them a nutty pomegranate flavor; usually after the meat is cooked as a garnish. Here is one interesting recipe: Pomegranate Rice Pilaf Ingredients: ½ cup pomegranate juice ½ cup pomegranate arils 6 oz. As written earlier, it is best to do this under water in a big enough bowl that you can easily get your hands into the bowl to break apart the sections of the fruit. When you are finished and have gotten the arils drained away from the other material, try to get as much water as possible away from the arils. Put them in a plastic freezer bag and place in the fast freeze section of your freezer. By freezing the arils with as little as water as possible they will not stick together too badly and be loose and ready to use. The juice taste will vary depending on which of the many different pomegranate varieties you have chosen or are growing. But as we have said before, chose the variety that has the juice flavor that you want – sweet-tart, sweet or sour. You will notice that I included sour in the three taste categories; I did so for a reason. Some of the sour pomegranates when juiced, with a little sugar added, make a great juice drink. The sour varieties of pomegranate juice make an excellent ingredient for light pomegranate syrup to be used in meat dishes. As to other uses for the juice, they are as numerous as your Imagination for creating meat dishes and adding a unique flavor to vegetables. There are many, many recipes on the internet giving ways to use pomegranate juice as well as several books on Mediterranean and Middle Eastern cuisine that have pomegranate recipes. The more contemporary researchers in the United States learn about fruit’s health benefits, the more attention is being paid to the pomegranate’s potential to provide antioxidants, counteract free radicals, offer tannins, ellagic acid and anthocyanins. In the next few pages, you will read a condensed version of these benefits; there are many other reference points you can consult to learn more. Free radicals are molecules in your blood stream moving about with an unpaired electron. They collide with other molecules seeking to acquire an electron and can start a chain reaction (mutation) leading to all types of problems and diseases. Free radicals occur through many natural and environmental sources: through aging, smoking, pollution, sunburn and many other causes. Antioxidants include many vitamins and minerals that have the capacity to neutralize free radicals. The most useful for disease fighting are Polyphenol antioxidants, found in pomegranates in great numbers, making our fruit a great food product for your health. Tannins are plant polyphenols that cause the tart taste in the skin of the pomegranate and are also found in smaller amounts in the juice. Tannins from bark were originally used to tan hides to make leather, hence the word tan-nins. Polyphenol antioxidants are contained in tannins—another way the pomegranate contributes to good health. Ellagic acid is a phenolic compound, again an antioxidant, which is found in many fruits and vegetables with levels much higher in blueberries and pomegranates. I like to use the reference to the steel in a car body rusting out as it becomes oxidized. I know that anti-oxidizing of steel is not physiologically what is going on with the pomegranate antioxidants, but it seems appropriate metaphorically.
