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Intravenous lipid emulsion (ILE; Intralipid) therapy, a standard treatment in local anesthetic toxicity, has demonstrated therapeutic efficacies for a number of different drug class-mediated toxicities. Some of these varied drug groups include antipsychotics, antidepressants, antiarrhythmics, and calcium channel blockers. To meet the objective of describing the growing number of indications for Intralipid therapy and any diverse effects and/or failures of Intralipid therapy in reversing multiple drug toxicities, we queried several Internet search engines with the key words "intravenous lipid emulsion therapy," "Intralipid," "lipid emulsion," and "local anesthetic systemic toxicity," resulting in the identification of 31 case reports for descriptive analysis. These case reports included 49 separate drug overdose cases involving ten separate drug classes which were successfully reversed with Intralipid. The education of clinicians regarding the beneficial and varied roles of Intralipid therapy in different clinical settings is warranted, particularly in terms of the potential for Intralipid therapy to reverse the toxicities of non-local anesthetic drugs.

Objective: To alert clinicians to the climatic conditions that can precipitate outbreaks of the rodent-borne infectious diseases most often associated with flooding disasters, leptospirosis (LS), and the Hantavirus-caused diseases, hemorrhagic fever with renal syndrome (HFRS) and Hantavirus pulmonary syndrome (HPS); to describe the epidemiology and presenting clinical manifestations and outcomes of these rodent-borne infectious diseases; and to recommend both prophylactic therapies and effective control and prevention strategies for rodent-borne infectious diseases., Design: Internet search engines, including Google®, Google Scholar®, Pub Med, Medline, and Ovid, were queried with the key words as search terms to examine the latest scientific articles on rodent-borne infectious disease outbreaks in the United States and worldwide to describe the epidemiology and presenting clinical manifestations and outcomes of LS and Hantavirus outbreaks., Setting: Not applicable., Participants: Not applicable., Interventions: Not applicable., Main Outcome Measure: Rodent-borne infectious disease outbreaks following heavy rainfall and flooding disasters., Results: Heavy rainfall encourages excessive wild grass seed production that supports increased outdoor rodent population densities; and flooding forces rodents from their burrows near water sources into the built environment and closer to humans., Conclusions: Healthcare providers should maintain high levels of suspicion for LS in patients developing febrile illnesses after contaminated freshwater exposures following heavy rainfall, flooding, and even freshwater recreational events; and for Hantavirus-caused infectious diseases in patients with hemorrhagic fevers that progress rapidly to respiratory or renal failure following rodent exposures.

Background: Gnathostomiasis, a helminthic infection commonly reported in Southeast Asia and Latin America, may follow consumption of raw seafood infected with muscle-encysted larvae of Gnathostoma species nematodes. As a result of increasingly exotic tastes for local ethnic dishes, including raw seafood, some regions outside of gnathostome-endemic areas import live species for raw consumption. This may facilitate imported human gnathostomiasis or potentially the establishment of this zoonosis in formerly nonendemic regions. Traveling to a gnathostome-endemic area is no longer a criterion for diagnosis. The objectives of this review are to enhance clinician awareness of this infection by describing the behavioral risk factors for its acquisition, life-cycle, clinical manifestations, diagnosis, management, and prevention., Methods: Internet search engines were queried with the key medical subject heading words. Case reports, case series, epidemiological investigations, and laboratory studies were reviewed; high risk behaviors for gnathostomiasis were identified; and human cases were stratified as cutaneous gnathostomiasis, visceral gnathostomiasis, neurognathostomiasis, and ocular gnathostomiasis., Results: The greatest risk factors for gnathostomiasis included the consumption of raw freshwater seafood dishes in endemic regions and the consumption of raw imported or domestic seafood dishes in households and ethnic restaurants in many nonendemic regions., Conclusions: Gnathostomiasis is no longer a disease of returning travelers, and autochthonous cases may be anticipated to increase as a result of the importation of live Gnathostoma-infected species and the potential establishment of regional zoonoses of Gnathostoma-infected wild species. Since the eradication of gnathostomiasis is unlikely given the global distribution of Gnathostoma nematodes, the only effective preventive strategy is to educate persons in endemic and nonendemic areas that fish, eels, frogs, snakes, and birds must be cooked thoroughly first before eating and not eaten raw or marinated. The onset of migratory subcutaneous swellings with hyper-eosinophilia weeks to months after consuming raw seafood should provoke suspicion of gnathostomiasis., (© 2015 International Society of Travel Medicine.)

Background: The Scorpaenidae are a large family of venomous marine fish that include scorpionfish, lionfish, and stonefish. Although most stonefish are confined to the Indo-Pacific, scorpionfish are distributed in the tropics worldwide, and two species of Indo-Pacific lionfish were inadvertently introduced into the Eastern Atlantic in the 1990s. Since then, lionfish have invaded shallow reef systems in the Eastern Atlantic, Gulf of Mexico, and Caribbean Sea. All of these regions are popular travel destinations for beachcombing, fishing, swimming, and scuba diving-recreational activities that increase risks of Scorpaenidae envenomation., Methods: To meet the objectives of describing species-specific presenting clinical manifestations, diagnostic and treatment strategies, and outcomes of Scorpaenidae envenomation in travelers, Internet search engines were queried with the key words., Results: Well-conducted, retrospective epidemiological investigations of Scorpaenidae envenomation case series concluded: (1) most cases occurred in young adult male vacationers visiting endemic regions; (2) victims sought medical attention for pain control within 2 hours of injury and presented with intense pain, edema, and erythema in affected extremities; (3) systemic manifestations and surgical interventions were relatively uncommon following initial management with hot water soaks and parenteral analgesics; (4) all cases required tetanus prophylaxis; deeply penetrating, lacerated, and necrotic wounds required antibiotic prophylaxis; and (5) equine Fab stonefish antivenom does have antigen-neutralizing cross-reactivities with both Indo-Pacific and Atlantic Scorpaenidae species and is indicated in severe scorpionfish and stonefish envenomation worldwide., Conclusions: Travel medicine practitioners should counsel their patients about Scorpaenidae envenomation risks in endemic regions and maintain a high index of suspicion regarding Scorpaenidae envenomation in all travelers returning from tropical beach and ocean holidays and reporting painful fish sting injuries., (© 2015 International Society of Travel Medicine.)

: Bacterial infections following aquatic injuries occur commonly in fishermen and vacationers after freshwater and saltwater exposures. Internet search engines were queried with the key words to describe the epidemiology, clinical manifestations, diagnostic and treatment strategies and outcomes of both the superficial and the deeper invasive infections caused by more common, newly emerging and unusual aquatic bacterial pathogens. Main findings included the following: (1) aquatic injuries often result in gram-negative polymicrobial infections with marine bacteria; (2) most marine bacteria are resistant to 1st- and 2nd-generation penicillins and cephalosporins; (3) nontuberculous, mycobacterial infections should be considered in late-onset, culture-negative and antibiotic-resistant marine infections; (4) superficial marine infections and pre-existing wounds exposed to seawater may result in deeply invasive infections and sepsis in immunocompromised patients. With the exception of minor marine wounds demonstrating localized cellulitis, most other marine infections and all gram-negative and mycobacterial marine infections will require therapy with antibiotic combinations.

Background: Dirofilariasis is a zoonotic nematode infection of domestic and wild carnivores that can be transmitted to man by infected mosquitoes., Methods: Internet search engines were queried with the key words to examine case reports, series, and descriptive analyses of animal and human dirofilariasis to meet the objectives of this review to describe the increasing prevalence of animal and human dirofilariasis worldwide; to resolve misconceptions regarding the pathophysiology and outcomes of animal versus human dirofilariasis; and to recommend new strategies for the diagnosis, management, and prevention of human dirofilariasis in travelers., Results: Descriptive epidemiological studies in the United States and Europe have now established dirofilariasis as an emergent parasitic disease of dogs and man. Global warming has extended the mosquito-vector-borne transmission cycles, enzootic distributions, and canine microfilarial prevalences of the disease to non-endemic regions., Conclusions: Travel medicine clinicians must remain vigilant regarding the possibilities of human pulmonary dirofilariasis when solitary "coin lesions" appear on screening chest X-rays or abdominal neuroimaging studies in asymptomatic patients without peripheral hypereosinophilia. The least invasive diagnostic methods are recommended. Future investigations should focus on conducting active epidemiological surveillance for dirofilariasis in humans and animals; on improving canine dirofilarial chemoprophylaxis; and on developing new, rapid molecular methods for diagnosing and differentiating human dirofilarial infections., (© 2014 International Society of Travel Medicine.)

Objectives: Given the loss of laboratory infrastructure following flooding disasters, the objectives of this review were (1) to describe current practices in the treatment of aquatic injuries and infections in nondisaster scenarios; (2) to describe how lessons learned from the management of superficial and invasive infections in survivors of the 2004 Indian Ocean tsunami could improve current management practices; (3) to stratify waterborne infections by causative agents and preferred saline levels; and (4) to recommend initial wound and empiric antibiotic management strategies for specific aquatic infections., Design: Retrospective systematic review., Setting: Not applicable., Participants: References were selected to provide clinicians with a broader knowledge of causative aquatic pathogens and their antimicrobial susceptibilities., Interventions: Internet search engines were queried with key words to identify salient case reports, retrospective series, observational studies, and additional references on wound and antimicrobial management from Southeast Asian and other countries providing intensive care to tsunami survivors and from other similar series on the management of flooding and near-drowning victims., Main Outcome Measures: Identify causative pathogens of aquatic infections and their antimicrobial susceptibilities in flooding disaster victims and recommend effective arsenals of empiric antimicrobial therapies., Results: The causative pathogens of wound and systemic infections in near-drowning and tsunami survivors ranged from typical human skin and enteric contaminants to aquatic organisms and soil contaminants, including fungi. There was an early predominance of polymicrobial Gram-negative causative organisms in wound infections, Unanticipated, delayed mycobacterial and fungal infections occurred frequently, even after traumatic wounds healed., Conclusions: Clinicians who care for victims of flooding disasters and near-drowning can apply lessons learned from the management of tsunami survivors to selecting initial antimicrobials for empiric therapy of aquatic injuries based on their sources and distributions of aquatic exposures.

Background: Bacterial skin and soft tissue infections (SSTIs) in travelers often follow insect bites and can present a broad spectrum of clinical manifestations ranging from impetigo to necrotizing cellulitis. Significant SSTIs can also follow marine injuries and exposures in travelers, and the etiologies are often marine bacteria., Methods: To meet the objectives of describing the pathogen-specific presenting clinical manifestations, diagnostic and treatment strategies, and outcomes of superficial and deep invasive infections in travelers caused by commonly encountered and newly emerging marine bacterial pathogens, Internet search engines were queried with the key words as MESH terms., Results: Travel medicine practitioners should maintain a high index of suspicion regarding potentially catastrophic, invasive bacterial infections, especially Aeromonas hydrophila, Vibrio vulnificus, Chromobacterium violaceum, and Shewanella infections, following marine injuries and exposures., Conclusions: Travelers with well-known risk factors for the increasing severity of marine infections, including those with open wounds, suppressed immune systems, liver disease, alcoholism, hemochromatosis, hematological disease, diabetes, chronic renal disease, acquired immunodeficiency syndrome, and cancer, should be cautioned about the risks of marine infections through exposures to marine animals, seawater, the preparation of live or freshly killed seafood, and the accidental ingestion of seawater or consumption of raw or undercooked seafood, especially shellfish. With the exception of minor marine wounds demonstrating localized cellulitis or spreading erysipeloid-type reactions, most other marine infections and all Gram-negative and mycobacterial marine infections will require therapy with antibiotic combinations., (© 2014 International Society of Travel Medicine.)

Electrophysiological abnormalities of the QT interval of the standard electrocardiogram are not uncommon. Congenital long QT syndrome is due to mutations of several possible genes (genotype) that result in prolongation of the corrected QT interval (phenotype). Abnormalities of the QT interval can be acquired and are often drug-induced. Torsades de Pointes (TP) is an arrhythmia that is a result of aberrant repolarization/QT abnormalities. If not recognized and corrected quickly, QT interval abnormalities may precipitate potentially fatal ventricular dysrhythmias. The main mechanism responsible for the development of QT prolongation is blockade of the rapid component of the delayed rectifier potassium current (I kr), encoded for by the human-ether-a-go-go-related gene (hERG). The objectives of this review were (1) to describe the electrical pathophysiology of QT interval abnormalities, (2) to differentiate congenital from acquired QT interval abnormalities, (3) to describe the currently known risk factors for QT interval abnormalities, (4) to identify current drug-induced causes of acquired QT interval abnormalities, and (5) to recommend immediate and effective management strategies to prevent unanticipated dysrhythmias and deaths from QT abnormalities in the perioperative period.

Background: Although there have been recent advances in the development of photoprotective clothing and broad-spectrum sunscreens, few peer-reviewed publications have focused on photoprotection recommendations for travelers., Methods: In order to describe the adverse health effects of excessive ultraviolet (UV) radiation exposures; review recent studies of public perceptions regarding photoprotection and sun exposure behaviors; identify special populations at increased risks of drug-induced photosensitivity reactions and UV-induced skin cancers; and recommend several effective photoprotection strategies for travelers, Internet search engines were queried with the key words as search terms to examine the latest references on photoprotection and the epidemiology of UV-associated skin cancers., Results: Observational studies have demonstrated that the public knows little about proper sunscreen protection, selection, and use, and often abuses sunscreens for intentional UV overexposures. Cohort studies have identified special populations at increased risks of UV-associated skin cancers without the proper use of sunscreens and photoprotective clothing including children, fair-skinned persons, patients taking photosensitizing drugs, and organ transplant recipients (OTRs). Clinical investigations support the regular use of broad-spectrum sunscreens to prevent the development of premalignant actinic keratoses (AK) in all sun-exposed subjects, especially OTRs; to prevent the development of squamous cell carcinomas from new AK in sun-exposed subjects, especially OTRs; to possibly prevent the development of cutaneous malignant melanomas in children and adults; and to possibly prevent the development of basal cell carcinomas in OTRs., Conclusions: Recommended photoprotection strategies for travelers should include avoiding intense sunlight, wearing photoprotective clothing, wearing sunglasses, and selecting the right sunscreen for their skin type. Travel medicine practitioners should counsel travelers about photoprotection and encourage travelers to take advantage of recent advances in the development of more effective broad-spectrum sunscreens and photoprotective clothing for themselves and their children., (© 2012 International Society of Travel Medicine.)

Paragonimiasis is a parasitic infection of the lungs caused by zoonotic lung flukes of the genus Paragonimus. Most cases are reported from Asia and caused by P. westermani following consumption of raw crustaceans. With the exception of imported cases, human paragonimiasis was rarely described prior to 1984 in the United States (US), which has only one indigenous lung fluke species, P. kellicotti. Between 1984 and 2010, 15 cases of P. kellicotti paragonimiasis were reported in the United States. This study will analyze all US cases and compare an earlier series of six cases reported during the period 1984-2005 with a recently reported cluster of nine cases from Missouri during the period 2006-2010 in order to determine any significant behavioral and/ or recreational risk factors for paragonimiasis and to recommend early diagnostic, treatment and preventive strategies. Significant behavioral and recreational risk factors included eating raw crayfish while on canoeing trips on local rivers (p = 0.002), eating raw crayfish while on canoeing trips in Missouri (p = 0.002), and eating raw crayfish while intoxicated (p = 0.007). The male:female case ratio was 9.3:1.0 and more than 80% of cases presented with fever, cough, pleural effusions and peripheral eosinophilia. One patient developed cerebral paragonimiasis, and one patient died of pneumonic sepsis. Clinicians should inquire about consumption of raw or undercooked crayfish in all patients with unexplained fever, cough, eosinophilia and pleural effusions returning from camping or canoeing adventures in P. kellicotti-endemic areas of the Mississippi River Drainage Basin; institute diagnostic evaluation by specific parasitological and serological methods and treat all cases as soon as possible to avoid the pulmonary and cerebral complications of paragonimiasis.

Objectives: To describe the acute health impacts of the Deepwater Horizon oil spill in Louisiana as compared with the acute health impacts reported from prior crude oil spills. To predict potential chronic health impacts in Louisiana as compared with the chronic health impacts reported from prior crude oil spills., Setting: Offshore and onshore coastal southeastern Louisiana., Patients and Participants: Oil spill offshore and onshore cleanup workers and the general population of coastal southeastern Louisiana., Interventions: Not applicable to an observational study., Main Outcome Measures: Adverse acute health effects of petrochemical and dispersant exposures in highly exposed offshore and onshore cleanup workers and the general population; prior chronic adverse health effects reported from prior oil spills; and predicted chronic adverse health effects based on intensity of chemical exposures and on seroprevalences of genetic polymorphisms., Results: Acute health effects in cleanup workers mirrored those reported in cleanup workers following prior oil spills as ranked by systems (and by symptoms). Acute health effects in lesser exposed members of the general population mirrored those reported in similar coastal residents following prior oil spills but differed from cleanup workers as ranked by systems (and symptoms)., Conclusions: Subpopulations of cleanup workers and the general population with specific conditions or genetic polymorphisms in enzyme systems that detoxify polycyclic aromatic hydrocarbons in petrochemicals and glycols in dispersants will require long-term surveillance for chronic adverse health effects including cancer, liver and kidney diseases, mental health disorders, and fetal alcohol spectrum disorders.

Mites are mostly ubiquitous, bothersome pests with few species of medical importance and, of these, most are scabies mites, trombiculid larval mites and animal and plant mites. All patients with scabies and their close household, institutional and sexual contacts should be informed that scabies is a highly transmissible ectoparasitic infestation and that several topical treatments and an effective oral treatment are readily available and highly effective at present. Sexually active patients with scabies should be screened for other sexually transmitted diseases, particularly human immunodeficiency virus (HIV) and human T-cell lymphotrophic virus type1 (HTLV-1) infections. Finally, only the Asian and Eurasian Leptotrombidium species of trombiculid larval mites (or chiggers) can transmit scrub typhus in endemic regions of Asia, Eurasia, and the South Pacific, and only the house-mouse mite can transmit rickettsialpox in both urban and rural dwellings worldwide, including the southern United States.

Health care workers, including anesthesia providers, are often exposed to different infectious disease processes. In the operating room, anesthesia providers, nurses, and surgical staff use universal precautions as a standard of practice. The novel influenza A (H1N1) epidemic has heightened concerns because diagnosis is often delayed and transmission can affect those in a close radius to the infected host. The objectives of this report are to describe the intensive care management and outcomes of severe H1N1 viral infection in a patient in the last trimester of pregnancy and to review the epidemiology, management, and outcomes of similar US cases.

Most emerging infectious diseases today, such as West Nile virus and sudden acute respiratory distress syndrome (SARS), arise from zoonotic reservoirs and many are transmitted by arthropod vectors. Ticks are among the most competent and versatile arthropod vectors of infectious diseases because ticks of all ages and both sexes remain infectious for generations without having to reacquire infections from reservoir hosts. Today, ticks transmit the most common arthropod-borne infectious disease in the United States (US), Lyme disease (LD); and the most lethal arthropod-borne infectious disease in the US, Rocky Mountain spotted fever (RMSF). Both LD and RMSF are endemic in Louisiana and the Gulf South. Ticks have also become frequent vectors of emerging zoonotic diseases in the Gulf South, including southern tick-associated rash illness (STARI), transmitted by the lone star tick, and Maculatum disease, transmitted by the Gulf Coast tick. Recent environmental changes and human lifestyle choices now place humans and ticks together outdoors in the Gulf South for longer periods in welcoming ecosystems for breeding, blood-feeding, and infectious disease transmission. An increasing incidence of emerging and re-emerging, endemic infectious diseases transmitted by existing and unanticipated tick vectors may be expected.

Today most emerging infectious diseases, such as West Nile virus and severe acute respiratory syndrome (SARS), arise in the natural environment as zoonoses and are often imported into the United States (US). The most common helminthic infections that can cause eosinophilic meningitis (EoM) in the US, neuroangiostrongyliasis and baylisascariasis, share many of the characteristics of emerging infectious diseases. Neuroangiostrongyliasis, a rodent zoonosis caused by the rat lungworm, Angiostrongylus cantonensis, is now endemic in the US following the importation of infected rats on container ships and African land snails, the parasite's intermediate hosts, as biological controls and exotic pets. Baylisascariasis, a raccoon zoonosis, caused by the raccoon roundworm, Baylisascaris procyonis, has extended its US distribution range from suburban neighborhoods in the northern US to the Southeast and West Coast since the 1980s. Both A. cantonensis and B. procyonis are now enzootic in Louisiana and have caused EoM in humans. This review analyzes scientific articles selected by MEDLINE search, 1966-2008, in order to assess the evolving epidemiology of EoM in the US, and specifically in Louisiana; and to alert Louisiana clinicians to populations at increased risk of helminthic EoM as a result of age, ethnicity, lifestyle, food choices, location of permanent residence, or recent travel in the Americas or Caribbean. Most parasitic diseases causing EoM are no longer confined to tropical countries; they are now endemic in the US and in Louisiana and more cases may be anticipated.

The Atlantic hurricane season of 2005 was not an ordinary season, and Hurricane Katrina was not an ordinary hurricane. Hurricane Katrina damaged more than 93,000 square miles of Gulf of Mexico coastline, displaced more than 1 million residents from New Orleans, and flooded more than 80 percent of New Orleans for weeks, which killed more than 1,300 people, mostly New Orleanians. Inland regional state and local healthcare and human services agencies rushed to assist evacuees, most of whom were uninsured or displaced without employer healthcare coverage. The initial evacuation brought more than 350,000 evacuees seeking shelter to the greater Baton Rouge area, LA, 80 miles north of New Orleans, the closest high ground. This investigation describes the rapid needs assessment developed and conducted by the Capital Area Human Services District of the greater Baton Rouge area, a quasi-governmental human services authority, the regional provider of state-funded mental health, addictive disorders, and developmental disabilities services, on a sample of 6,553 Katrina evacuees in the greater Baton Rouge area. In the event of catastrophic natural and manmade disasters, state and federal decision makers should follow the National Incident Management System and support local designated lead agencies with additional resources as requested. They must rely on designated lead agencies to use their knowledge of the locale, local resources, and relationships with other providers and volunteers to respond rapidly and efficiently to evacuee needs identified through a designated, concise tool that is singularly utilized across the impacted region by all providers to determine the needed response.

Head louse and scabies mite infestations are common among pre-school and school-age children, and topical pesticides are frequently prescribed to treat such conditions. Ectoparasite resistance to the safest and most commonly prescribed pyrethrin/pyrethroid pesticides for ectoparasitic infections has, however, been increasing since the 1980s. The increasing resistance of these arthropods to the safest pesticides may lead to greater use of more toxic, alternative pesticides to control infestations and to prevent institutional outbreaks. MEDLINE and Cochrane searches, 1966-2008, were conducted to assess the impact of increasing pesticide resistance on prescribing practices for ectoparasitic infections and to describe the evolving global epidemiology of pediatric poisonings by more toxic pediculicides and miticides, including carbamates, organochlorines, and organophosphates. Pharmacists, physicians, and poison control personnel should be fully informed about increasing pesticide resistance among the most commonly encountered ectoparasites of children and the institutionalized and be prepared to prevent and to treat accidental home and institutional pesticide poisonings with more toxic pesticides.

Insect bites and stings, often complicated by allergic reactions or skin infections with community-acquired pathogens, are common sources of morbidity following hurricanes and flooding disasters. The hymenopterids are the most commonly stinging arthropods to cause allergic reactions, and include bees, wasps, and ants. To assess the evolving epidemiology of hymenopterid-inflicted injuries, and the impact of hurricanes and flooding disasters on hymenopterid-inflicted injuries in the United States, an epidemiological analysis of the scientific literature on hymenopterid stings and allergic sting reactions was conducted by MEDLINE search, 1966-2006. The increasing incidence of hymenopterid-inflicted injuries following hurricanes and flooding disasters was described. Common immunological reactions to hymenopterid-inflicted injuries were stratified by clinical severity and outcome. Current recommendations for management, prevention, and prophylaxis of hymenopterid-inflicted injuries were presented. Hymenopterid stings and allergic reactions remain common indications for emergency department visits, especially following hurricanes and flooding disasters. Unrecognized anaphylactic reactions to hymenopterid stings remain significant causes of unanticipated deaths outdoors in young people. Disaster planners and managers are obliged to alert regional healthcare providers of the increased risks of hymenopterid-inflicted injuries following flooding disasters and to assure that emergency drug formularies are properly stocked to treat hymenopterid-inflicted injuries.

A descriptive analysis and review of the world's salient scientific literature on stingray injuries was conducted in light of recent high-profile cases of fatal and near-fatal thoracic stingray injuries to guide clinicians in evaluating and managing stingray injuries. Data was extracted from observational and longitudinal studies over the period, 1950-2006, to permit (1) a stratification of stingray injuries as bites, penetrating lacerations with and without envenoming, and combinations of deeply penetrating and envenoming wounds; and (2) an assessment of new management strategies for thoracoabdominal penetrating trauma and non-healing, necrotic stingray wounds. Unlike their Chondrichthyes classmates, the sharks, stingrays are docile and non-aggressive; and will not attack with their spined tails, unless provoked. Although some occupations are predisposed to stingray injuries, most stingray injuries can be avoided by observing seafloors and adopting simple practices when wading, swimming, diving, or fishing in temperate oceans and some tropical freshwater river systems. All stingray injuries should be managed initially with wound irrigation to dislodge retained spine fragments and envenoming tissues and warm water immersion to inactivate heat-labile toxins.

Hymenopterid stings and subsequent allergic reactions are a common indication for emergency department visits worldwide. Unrecognized anaphylactic reactions to hymenopterid stings by apids, or bees, and vespids, or wasps, are a significant cause of sudden and unanticipated deaths outdoors in young people, with and without atopic histories. Insect bites and stings, often complicated by allergic reactions or skin infections, by community-acquired pathogens, such as methicillin-resistant Staphylococcus aureus, are common sources of morbidity following hurricanes, tropical storms, and prolonged flooding. This article will review and critically analyze the descriptive epidemiology and outcomes of hymenopterid bites, stings, and allergic reactions, especially following hurricanes and prolonged flooding disasters; stratify the immunologic reactions to hymenopterid stings by clinical severity and outcomes; and present current recommendations for management, prophylaxis, and prevention of hymenopterid stings and reactions.

With a documented increase in average global surface temperatures of 0.6 degrees C since 1975, Earth now appears to be warming due to a variety of climatic effects, most notably the cascading effects of greenhouse gas emissions resulting from human activities. There remains, however, no universal agreement on how rapidly, regionally, or asymmetrically the planet will warm or on the true impact of global warming on natural disasters and public health outcomes. Most reports to date of the public health impact of global warming have been anecdotal and retrospective in design and have focused on the increase in heat-stroke deaths following heat waves and on outbreaks of airborne and arthropod-borne diseases following tropical rains and flooding that resulted from fluctuations in ocean temperatures. The effects of global warming on rainfall and drought, tropical cyclone and tsunami activity, and tectonic and volcanic activity will have far-reaching public health effects not only on environmentally associated disease outbreaks but also on global food supplies and population movements. As a result of these and other recognized associations between climate change and public health consequences, many of which have been confounded by deficiencies in public health infrastructure and scientific debates over whether climate changes are spawned by atmospheric cycles or anthropogenic influences, the active responses to progressive climate change must include combinations of economic, environmental, legal, regulatory, and, most importantly, public health measures.

Chagas disease, or American trypanosomiasis, is an arthropod-borne protozoan infectious disease, hyperendemic throughout Latin America, caused by Trypanosoma cruzi, and transmitted to man by reduviid or kissing bugs. Throughout the Americas, Chagas disease shares many life cycle features with malaria, including transmission of infectious stages by local arthropods, exacerbation or reactivation of subclinical infections by immunosuppression (particularly HIV/AIDS) and pregnancy, and both transplacental and transfusion-related transmission. Although most cases of Chagas disease in the United States (US) are imported, significant numbers of Latin American immigrants contribute to the US blood supply and donate cadaveric tissues and organs for human transplantation, thus increasing the risks of both transfusion and transplantation-transmitted Chagas disease from unscreened blood products and transplantable tissues and organs. In addition, the risks of local reduviid bug-transmitted autochthonous or indigenous Chagas disease are also increasing as more immigrant workers enter the displaced populations of the Gulf South, including Louisiana, to assist in rebuilding efforts after Hurricanes Katrina and Rita. Although screening donated blood products for malaria remains impractical, consideration should now be given to serologically screening all donated blood and organs for Chagas disease in the US, as in most countries of Latin America, especially in high risk areas of California and the southern US, including Louisiana.

Accurate scientific predictions of the true human health outcomes of global climate change are significantly confounded by several effect modifiers that cannot be adjusted for analytically. Nevertheless, with the documented increase in average global surface temperature of 0.6 C. since 1975, there is uniform consensus in the international scientific community that the earth is warming from a variety of climatic effects, including cyclical re-warming and the cascading effects of greenhouse gas emissions to support human activities.

Ectoparasitic diseases share many features in common with emerging infectious diseases, such as Lyme disease, including hyperendemic causative agents afforded selective advantages by changing ecological or socioeconomic conditions; origination as zoonoses or as highly communicable human-to-human diseases; transmission by competent vectors; and introduction into new, susceptible host populations. Many of these ectoparasites are now developing increasing resistances to medical therapies, including the safest insecticides and repellants.

Since the 1950s, reports of severe and fatal mushroom poisonings have increased worldwide. Clinicians must consider mushroom poisoning in the evaluation of all patients who may be intoxicated by natural substances. Because information on natural exposures is often incorrect or insufficient, a new syndromic classification of mushroom poisoning is proposed to guide clinicians in making earlier diagnoses, especially in cases where only advanced critical care, including kidney or liver transplantation, may be life saving.

Caterpillars are the wormlike larval forms of butterflies and moths of the insect order Lepidoptera. Next to flies, lepidopterans are the most abundant arthropods with over 165,000 species worldwide, over 11,000 species in the United States alone, and with most species posing no human threats. Caterpillar species from several families of moths in the South can inflict serious human injuries ranging from urticarial dermatitis and conjunctivitis to atopic asthma and pan-uveitis. Since the 1970s, there have been increasing reports of dermatolgic, pulmonary, and systemic reactions following caterpillar encounters throughout the South.

Unlike other arthropods, spiders rarely transmit communicable diseases, and thus play a critical role in the ecosystem by consuming other insects that frequently transmit human diseases, such as mosquitoes, ticks, and fleas. There are more than 30,000 species of spiders worldwide, most of which are venomous, but cannot inflict serious bites due to delicate mouthparts and short fangs. Other insect bites, skin infections, and chemical- or physical-agent exposures are often misdiagnosed as spider bites. Approximately 40 species from 4 major genera of spiders in Louisiana and throughout the South, however, can cause severe human envenomings, with dermonecrosis, systemic toxicity, and, rarely, death. Spider bites can usually be prevented by simple personal and domestic measures. Early species identification and specific management may help prevent serious sequelae of spider bites.

Louisiana provides nearly 40% of domestic seafood production. America's commercial fisheries, especially coastal shellfish fisheries, now face crippling economic and environmental pressures from seafood imports, over-fishing, urban and agricultural wastewater runoff, harmful algal blooms, and coastal wetlands loss. As a result of these ecosystem stresses, seafood-borne disease now causes 37% of all foodborne illness in the United States. Louisiana and other coastal-state physicians can effectively curtail the rising threat of local shellfish-borne disease outbreaks by supporting responsible coastal restoration and regulation of commercial shell-fishing, especially oyster fishing, and by recommending careful selection and preparation of all shellfish and crustaceans.

Accurate predictions of the public health impact of hurricanes and major flooding are hampered by the absence of a dose-response relationship between hurricane-associated flooding and human health and the imprecise, often conflicting, meteorological models of climate change and hurricane landfall. Flooding is now the most common type of disaster worldwide, and flash flooding, usually associated with tropical storms, is the leading cause of weather-related deaths in the United States. As a result of climate changes and more frequently alternating ocean oscillations, hurricanes of category 3 or greater now strike the continental US approximately every 18 months. Public health officials are obligated to educate policymakers and the public about the significant threats posed to population health and quality of life by the inexorable progression of global climate change, including more water-centered disasters, such as tropical storms and hurricanes.

Louisiana's vital seafood industry provides nearly 40% of domestic seafood production. Unlike Louisianans, most Americans do not enjoy fresh seafood, yet manage to eat over 4 billion pounds of seafood annually, most of it foreign, frozen, and fried! America's commercial fisheries now face crippling economic and environmental pressures from seafood imports, over-fishing, urban and agricultural wastewater runoff, harmful algal blooms, and coastal wetlands loss. As a result of these ecosystem stresses, seafood-borne disease now causes 37% of all foodborne illness in the United States. Despite recent advisories on high mercury-containing finfish consumption, seafood provides more than a third of the world with essential dietary protein, rich in cardiovascular-protective omega-3 polyunsaturated fatty acids. Louisiana and other coastal-state physicians can effectively curtail the rising threat of local seafood-borne disease outbreaks by supporting responsible coastal restoration and regulation of commercial fishing, and by recommending careful inspection, selection, and preparation of seafood.