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Objective: To assess the evolving global epidemiology of mushroom poisoning and to identify new and emerging mushroom poisonings and their treatments, a descriptive analysis and review of the world's salient scientific literature on mushroom poisoning was conducted.Data Source: Data sources from observation studies conducted over the period 1959-2002, and describing 28,018 mushroom poisonings since 1951, were collected from case reports, case series, regional descriptive studies, meta-analyses, and laboratory studies of mushroom poisonings and the toxicokinetics of mycotoxins.Study Selection: Studies included in the review were selected by a MEDLINE search, 1966-2004, an Ovid OLDMEDLINE search, 1951-1965, and a medical library search for sources published before 1951.Data Extraction: To better guide clinicians in establishing diagnoses and implementing therapies, despite confusing ingestion histories, data were extracted to permit an expanded syndromic classification of mushroom poisoning based on presentation timing and target organ systemic toxicity.Data Synthesis: The final 14 major syndromes of mushroom poisoning were stratified first by presentation timing and then by target organ systemic toxicity and included early (<6 hrs), late (6-24 hrs), and delayed syndromes (> or =1 day). There were eight early syndromes (four neurotoxic, two gastrointestinal, two allergic); three late syndromes (hepatotoxic, accelerated nephrotoxic, erythromelalgia); and three delayed syndromes (delayed nephrotoxic, delayed neurotoxic, rhabdomyolysis). Four new mushroom poisoning syndromes were classified including accelerated nephrotoxicity (Amanita proxima, Amanita smithiana), rhabdomyolysis (Tricholoma equestre, Russula subnigricans), erythromelalgia (Clitocybe amoenolens, Clitocybe acromelalgia), and delayed neurotoxicity (Hapalopilus rutilans). In addition, data sources were stratified by three chronological time periods with >1,000 confirmed mushroom ingestions reported and tested for any statistically significant secular trends in case fatalities from mushroom ingestions over the entire study period, 1951-2002.Conclusions: 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. Since information on natural exposures is often insufficient and incorrect, a new syndromic classification of mushroom poisoning is recommended to guide clinicians in making earlier diagnoses, especially in cases where only advanced critical care, including organ transplantation, may be life saving. [ABSTRACT FROM AUTHOR]

Objective: To assess the evolving global epidemiology of mushroom poisoning and to identify new and emerging mushroom poisonings and their treatments, a descriptive analysis and review of the world's salient scientific literature on mushroom poisoning was conducted.Data Source: Data sources from observation studies conducted over the period 1959-2002 and describing 28,018 mushroom poisonings since 1951 were collected from case reports, case series, regional descriptive studies, meta-analyses, and laboratory studies of mushroom poisonings and the toxicokinetics of mycotoxins.Study Selection: Studies included in the review were selected by a MEDLINE search, 1966-2004, an Ovid OLDMEDLINE search, 1951-1965, and a medical library search for sources published before 1951.Data Extraction: To better guide clinicians in establishing diagnoses and implementing therapies, despite confusing ingestion histories, data were extracted to permit an expanded syndromic classification of mushroom poisoning based on presentation timing and target organ systemic toxicity.Data Synthesis: The final 14 major syndromes of mushroom poisoning were stratified first by presentation timing and then by target organ systemic toxicity and included early (<6 hrs), late (6-24 hrs), and delayed syndromes (> or =1 day). There were eight early syndromes (four neurotoxic, two gastrointestinal, two allergic); three late syndromes (hepatotoxic, accelerated nephrotoxic, erythromelalgia); and three delayed syndromes (delayed nephrotoxic, delayed neurotoxic, rhabdomyolysis). Four new mushroom poisoning syndromes were classified including accelerated nephrotoxicity (Amanita proxima, Amanita smithiana), rhabdomyolysis (Tricholoma equestre, Russula subnigricans), erythromelalgia (Clitocybe amoenolens, Clitocybe acromelalgia), and delayed neurotoxicity (Hapalopilus rutilans). In addition, data sources were stratified by three chronological time periods with >1,000 confirmed mushroom ingestions reported and tested for any statistically significant secular trends in case fatalities from mushroom ingestions over the entire study period, 1951-2002.Conclusions: 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. Since information on natural exposures is often insufficient and incorrect, a new syndromic classification of mushroom poisoning is recommended to guide clinicians in making earlier diagnoses, especially in cases where only advanced critical care, including organ transplantation, may be life saving. [ABSTRACT FROM AUTHOR]

In many communities, health care providers, public health officials, community groups, and individual citizens are concerned about potential connections between the environment and public health. The relationship between health outcomes and the environment is complex, and information in the form of a community profile can help concerned parties begin to understand how the environment may be affecting public health. For this study, a profile was created with data on population and economic characteristics, environmental sources, and public health outcomes. The data were drawn from local, state, and national sources in a geographic information system (GIS) format. A critical component of this process was the collection of patient household data with an environmental health exposure form. The form was developed in a pilot project supported by the U.S. Environmental Protection Agency. A community environmental health profile could be used on a limited basis for hypothesis building and as a catalyst for obtaining more information about individual patients, families, or neighborhoods. General relationships between the environment and health outcome data could be observed, and suggestions made for follow-up analyses and studies. Health care providers and public health officials could use data obtained from a GIS-based profile, along with data gathered from patients, to examine potential environmental exposures in a community and to justify screening tests or other interventions. In addition, profiling of neighborhoods according to environment-related health outcomes could help with medical diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Natural killer (NK) cells are an important first-line of defense against malignant cells. Because of the potential for increased cancer risk from astronaut exposure to space radiation, we determined whether microgravity present during spaceflight affects the body's defenses against leukemogenesis. Human NK cells were cultured for 48 h under normal gravity and simulated microgravity (sμG), and cytotoxicity against K-562 (CML) and MOLT-4 (T-ALL) cells was measured using standard methodology or under continuous sμG. This brief exposure to sμG markedly reduced NK cytotoxicity against both leukemias, and these deleterious effects were more pronounced in continuous sμG. RNA-seq performed on NK cells from two additional healthy donors provided insight into the mechanism(s) by which sμG reduced cytotoxicity. Given our prior report of space radiation-induced human T-ALL in vivo, the reduced cytotoxicity against MOLT-4 is striking and raises the possibility that μG may increase astronaut risk of leukemogenesis during prolonged missions beyond LEO., (© 2024. The Author(s).)

Objetives: To evaluate the impact of cholecalciferol (D₃) supplementation using clinical and paraclinical variables in patients with RA and vitamin D insufficiency and deficiency., Methods: A randomized, double-blind, placebo-controlled study included patients from 5 to 40 years with a diagnosis of RA and vitamin D insufficiency and deficiency. They were supplemented for 8 weeks with 4000 or 5000 IU, depending on age. Total nasal symptoms score (TNSS) was measured monthly and 25(OH)D₃ levels at baseline and at the end of the study., Results: A total of 31 patients were included, with a mean age of 18.19 years. In the active group, there was a significant improvement in symptomatology with respect to the TNSS score and an increase in serum vitamin D levels (p < 0.01). There were no adverse reactions with cholecalciferol or placebo., Conclusions: Supplementing patients with vitamin D₃, at the evaluated dose, together with conventional treatent for allergic rhinitis results in symptoms and quality of life improvement in patients with this disease., Competing Interests: Los autores declaran no tener conflicto de intereses.

Because mushroom poisonings are increasing worldwide after ingestions of known, newly described, and formerly considered edible species, the objectives of this review are to describe the global epidemiology of nephrotoxic mushroom poisonings, to identify nephrotoxic mushrooms, to present a toxidromic approach to earlier diagnoses of nephrotoxic mushroom poisonings based on the onset of acute renal failure, and to compare the outcomes of renal replacement management strategies. Internet search engines were queried with the keywords to identify scientific articles on nephrotoxic mushroom poisonings and their management during the period of 1957 to the present. Although hepatotoxic, amatoxin-containing mushrooms cause most mushroom poisonings and fatalities, nephrotoxic mushrooms, most commonly Cortinarius species, can cause acute renal insufficiency and failure. Several new species of nephrotoxic mushrooms have been identified, including Amanita proxima and Tricholoma equestre in Europe and Amanita smithiana in the United States and Canada. In addition, the edible, hallucinogenic mushroom Psilocybe cubensis has been noted recently via mass spectrometry as a rare cause of acute renal insufficiency. Renal replacement therapies including hemodialysis are often indicated in the management of nephrotoxic mushroom poisonings, with renal transplantation reserved for extracorporeal treatment failures., (Copyright © 2021 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

Zoonotic orthopoxvirus outbreaks have occurred repeatedly worldwide, including monkeypox in Africa and the United States, cowpox in Europe, camelpox in the Middle East and India, buffalopox in India, vaccinia in South America, and novel emerging orthopoxvirus infections in the United States, Europe, Asia, and South America. Waning smallpox immunity may increase the potential for animal-to-human transmission followed by further community transmission person-to-person (as demonstrated by monkeypox and buffalopox outbreaks) and by contact with fomites (as demonstrated by camelpox, cowpox, and, possibly, Alaskapox). The objectives of this review are to describe the disease ecology, epidemiology, clinical manifestations, prevention, and control of human infections with animal orthopoxviruses and to discuss the association with diminished population herd immunity formerly induced by vaccinia vaccination against smallpox. Internet search engines were queried with key words, and case reports, case series, seroprevalence studies, and epidemiologic investigations were found for review., (Copyright © 2021 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

Rodents can transmit infectious diseases directly to humans and other animals via bites and exposure to infectious salivary aerosols and excreta. Arthropods infected while blood-feeding on rodents can also transmit rodent-borne pathogens indirectly to humans and animals. Environmental events, such as wet winters, cooler summers, heavy rains, and flooding, have precipitated regional rodent-borne infectious disease outbreaks; these outbreaks are now increasing with climate change. The objectives of this review are to inform wilderness medicine providers about the environmental conditions that can precipitate rodent-borne infectious disease outbreaks; to describe the regional geographic distributions of rodent-borne infectious diseases in North America; and to recommend prophylactic treatments and effective prevention and control strategies for rodent-borne infectious diseases. To meet these objectives, Internet search engines were queried with keywords to identify scientific articles on outbreaks of the most common regional rodent-borne infectious diseases in North America. Wilderness medicine providers should maintain high levels of suspicion for regional rodent-borne diseases in patients who develop febrile illnesses after exposure to contaminated freshwater after heavy rains or floods and after swimming, rafting, or paddling in endemic areas. Public health education strategies should encourage limiting human contact with rodents; avoiding contact with or safely disposing of rodent excreta; avoiding contact with contaminated floodwaters, especially contact with open wounds; securely containing outdoor food stores; and modifying wilderness cabins and campsites to deter rodent colonization., (Copyright © 2021 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

Ticks are versatile vectors of infectious diseases and transmit a broad range of pathogens, including bacteria, viruses, and parasites. Ticks harbor pathogens without infection and share pathogens with other ticks while feeding together on a host. The primary objective of this review is to identify tickborne viral pathogens in the United States, focusing on emerging pathogens. Additional objectives include describing the epidemiology of tick-transmitted viruses, identifying the most common tick vectors of viral pathogens in the United States, identifying the most common tick-transmitted viruses worldwide, and recommending effective strategies for the prevention and treatment of tickborne viral infections. Flaviviruses transmitted by ixodid ticks cause most tickborne viral infections that present clinically as either encephalitis or hemorrhagic fever. Recently, several new tickborne viruses have emerged in the United States, including Bourbon virus, Heartland virus, Powassan virus, and the severe fever with thrombocytopenia syndrome virus transmitted by a tick recently introduced from China, the Asian long-horned tick (Haemaphysalis longicornis). In most cases, there are no specific drug therapies for tickborne viral infections, and treatment is supportive. Vaccination, personal protection, landscape management, and wildlife management are all effective strategies for the primary prevention and control of tickborne viral infectious diseases., (Copyright © 2020 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

Hurricane Katrina caused unprecedented flood damage to New Orleans, Louisiana, and has been the costliest hurricane in US history. We analyzed the environmental and public health outcomes of Hurricane Katrina by using Internet searches to identify epidemiological, sociodemographic, and toxicological measurements provided by regulatory agencies.Atmospheric scientists have now warned that global warming will increase the proportion of stronger hurricanes (categories 4-5) by 25% to 30% compared with weaker hurricanes (categories 1-2).With the new $14.6 billion Hurricane Storm Damage Risk Reduction System providing a 100-year storm surge-defensive wall across the Southeast Louisiana coast, New Orleans will be ready for stronger storms in the future.

Red meat allergies have followed tick bites on every continent except Antarctica. The sensitizing antigen is galactose-α-1,3-galactose (α-gal), an oligosaccharide constituent of nonprimate blood and meat, acquired by ticks during animal bloodfeeding. Because red meat allergy after tick bites is a worldwide phenomenon, the objectives of this review were to describe the global epidemiology of red meat allergy after tick bites and its immunological mechanisms; to identify the human risk factors for red meat allergy after tick bites; to identify the most common tick vectors of red meat allergy worldwide; to describe the clinical manifestations, diagnostic confirmation, and management of patients with red meat allergy after tick bites; and to recommend strategies for the prevention of tick bites. To meet these objectives, Internet search engines were queried with keywords to select scientific articles for review. The keywords included ticks , tick bites , allergy , anaphylaxis , and meat allergy . The study period was defined as 1980-2019. The major risk factors for red meat allergy after tick bites included male sex, non-B blood type, systemic mastocytosis, a bioprosthetic (bovine or porcine) heart valve, and preexisting allergies to gelatin or animal dander. Following confirmation by challenge testing, patients with red meat allergies should avoid red meats, foods containing gelatin, and intravenous immunotherapy with monoclonal antibodies such as cetuximab and infliximab produced in SP2/0 mouse cell lines. Red meat allergy after tick bites represents an emerging threat from tick bites in addition to infectious diseases.

Historically, human trichinellosis was caused by Trichinella spiralis and transmitted to humans by consumption of undercooked domestic pork. Today, most cases of trichinellosis are caused by other Trichinella species and transmitted by consumption of raw or undercooked wild game meats. Given the increasing global prevalence of wild animal meat-linked trichinellosis, the objectives of this review are: 1) to describe the life cycle and global distribution of Trichinella worms; 2) to describe the changing epidemiology of trichinellosis; 3) to describe the clinical phases of trichinellosis; 4) to recommend the latest diagnostic tests; and 5) to recommend treatment and prevention strategies. Internet search engines were queried with keywords as subject headings to meet the objectives of this review. Although trichinellosis surveillance systems and laws regulating commercial pork production have limited T spiralis-caused trichinellosis in Europe and the United States, trichinellosis due to consumption of raw and undercooked wild boar and feral hog meat continues to occur throughout Southeast Asia. Trichinellosis due to consumption of raw or undercooked meats of other infected game, such as bear, deer, moose, and walrus, continues to occur worldwide. Only adherence to hygienic practices when preparing wild game meats and cooking wild game meats to recommended internal temperatures can prevent transmission of trichinellosis to humans. Wilderness medicine clinicians should be prepared to advise hunters and the public on the risks of game meat-linked trichinellosis and on how to diagnose and treat trichinellosis to prevent fatal complications., (Copyright © 2020 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

The objectives of this review are to describe the acquired and hereditary causes of methemoglobinemia, to recommend the most sensitive diagnostic tests, and to enable critical care clinicians to rapidly detect and treat methemoglobinemia. To meet these objectives, Internet search engines were queried with the keywords to select articles for review that included case reports, case series, observational, longitudinal, and surveillance studies. The most common causes of methemoglobinemia include oxidizing reactions to cocaine-derived anesthetics, such as benzocaine and lidocaine, to antibiotics, such as dapsone and other sulfonamides, and to gases, such as nitric oxide. Additionally, CO-oximetry is superior to standard pulse oximetry in detecting methemoglobinemia. Finally, effective treatments for methemoglobinemia include intravenous administration of methylene blue, ascorbic acid, and riboflavin. In this manuscript we will discuss methemoglobinemia, how it occurs, and how to treat it.

Purpose of Review: Approximately 20% of patients undergoing surgery develop persistent lower extremity pain following total knee arthroplasty. Animal studies have confirmed that prolonged tourniquet time increases the risk of endoneural ischemia and can mediate or modulate the development of chronic pain. The use of Near InfraRed Spectroscopy (NIRS) adjacent to nerve tissue, previously described as ONG has been shown to detect early neural compromise and has demonstrated clinical utility in carpal tunnel diagnosis., Recent Findings: In this pilot study, we recruited 10 healthy adult volunteers to undergo oxyneurography (ONG) and sensory nerve conduction testing (sNCT). We performed testing on the upper and lower extremities in each individual. The tourniquet was applied followed by measurements of sNCT and ONG as described. We observed a significant drop in the mean ONG index at 3 and 5 min following tourniquet inflation in upper and lower extremities. Similar to raw ONG values, there was significant variability in sNCT measurements, which in general increased from baseline with tourniquet inflation. In the upper extremity, there was a significant increase in sNCT with tourniquet inflation, while in the lower extremity, there was a trend towards significance. The use of ONG can be supported as a diagnostic tool to detect nerve ischemia and to potentially reduce the incidence of tourniquet-mediated or -modulated neural ischemia and reduce the development of chronic post-tourniquet pain.

Cryptococcus neoformans, a soil-dwelling fungus found worldwide, can cause cryptococcosis, an opportunistic fungal infection of the lungs and central nervous system. One former member of the C neoformans complex, Cryptococcus gattii, has caused meningitis in immunosuppressed and immunocompetent persons in endemic regions in Africa and Asia. Between 1999 and 2004, C gattii caused outbreaks of human cryptococcosis in unexpected, nonendemic, nontropical regions on Vancouver Island, Canada, and throughout the US Pacific Northwest and California. C gattii was recognized as an emerging species with several genotypes and a unique environmental relationship with trees that are often encountered in the wilderness and in landscaped parks. Because C gattii infections have a high case-fatality rate, wilderness medicine clinicians should be aware of this emerging pathogen, its disease ecology and risk factors, its expanding geographic distribution in North America, and its ability to cause fatal disease in both immunosuppressed and immunocompetent persons., (Copyright © 2019 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

Introduction: Histoplasma capsulatum is a dimorphic fungus that causes histoplasmosis, a sporadic endemic mycosis with environmental, occupational, and wilderness exposure-related risk factors. The objectives of this review are to describe these risk factors, to alert clinicians to the different presenting manifestations of histoplasmosis, and to recommend effective management and prevention strategies., Methods: Internet search engines were queried with keywords to select articles for review over the study period, 1950 to 2018. Articles selected for review included case series, epidemiologic analyses of surveillance data, clinical and laboratory updates, immunologic investigations, and observational and longitudinal studies. Articles excluded from review included systemic mycosis reviews and clinicopathologic conference reports., Results: The principal transmission mechanism of histoplasmosis is by inhalation of spores aerosolized by soil disruption, resulting in pneumonic infections ranging from asymptomatic to disseminated. Although histoplasmosis is more common in endemic regions, nonendemic regions have reported increasing autochthonous and imported cases. Immunocompromised persons are at significantly increased risks of contracting histoplasmosis. Environmental and wilderness-related risk factors for histoplasmosis include bird and bat watching, cave and cave entrance exploration, and bamboo removal and burning. Occupational risk factors for histoplasmosis include road construction, roofing, bridge and water tower work, demolition, and masonry., Conclusions: Histoplasmosis can result in considerable morbidity. Increased awareness of disease risk factors among the public and the international healthcare community will improve the timely diagnosis and treatment of histoplasmosis and prevent disease progression and dissemination., (Copyright © 2018 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

Acute appendicitis is one of the most common surgical emergencies in paediatrics. However, acute appendicitis in early infancy is an uncommon condition. Furthermore, strangulation of the small intestine through appendicular knotting is described as very unusual in the literature and is generally not well-diagnosed in the clinical context. This article reports the case of a 23-month-old girl who entered the emergency department with a three-day history of abdominal symptoms and who died in less than 24 hours without receiving surgical intervention. The case turned judicial at the request of the parents who claimed lack of clarity in the diagnosis. A medico-legal autopsy was ordered to clarify the cause and manner of death. The autopsy documented herniation, strangulation and torsion of a 70 cm segment of the jejunum/ileum through an appendicular knot caused by the attachment of the distal end of the inflamed appendage to the ileum. The case is relevant because it is the first case of death by appendicular knot and strangulation of small bowel in an infant reported in the literature. The importance of autopsy to clarify the clinical diagnosis is noted.

Objectives: This study examines the impact of procedural locations and types of anesthetics on patient outcomes in non-operating room anesthesia (NORA) locations. The National Anesthesia Clinical Outcomes Registry database was examined to compare OR to NORA anesthetic complications and patient demographics., Methods: The National Anesthesia Clinical Outcomes Registry database was examined for all patient procedures from 2010 to 2013. A total of 12,252,846 cases were analyzed, with 205 practices contributing information, representing 1494 facilities and 7767 physician providers. Cases were separated on the basis of procedure location, OR, or NORA. Subgroup analysis examined outcomes from specific subspecialties., Results: NORA procedures were performed on a higher percentage of patients older than 50 years (61.92% versus 55.56%, P < 0.0001). Monitored anesthesia care (MAC) (20.15%) and sedation (2.05%) were more common in NORA locations. The most common minor complications were postoperative nausea and vomiting (1.06%), inadequate pain control (1.01%), and hemodynamic instability (0.62%). The most common major complications were serious hemodynamic instability (0.10%) and upgrade of care (0.10%). There was a greater incidence of complications in cardiology and radiology locations. Overall mortality was higher in OR versus NORA (0.04% versus 0.02%, P < 0.0001). Subcategory analysis showed increased incidence of death in cardiology and radiology locations (0.05%)., Conclusions: NORA procedures have lower morbidity and mortality rates than OR procedures, contrary to some previously published studies. However, the increased complication rates in both the cardiology and radiology locations may need to be the target of future safety investigations. Providers must ensure proper monitoring of patients, and NORA locations need to be held to the same standard of care as the main operating room. Further studies need to identify at-risk patients and procedures that may predispose patients to complications.

Amatoxins are produced primarily by 3 species of mushrooms: Amanita, Lepiota, and Galerina. Because amatoxin poisonings are increasing, the objective of this review was to identify all amatoxin-containing mushroom species, present a toxidromic approach to earlier diagnoses, and compare the efficacies and outcomes of therapies. To meet these objectives, Internet search engines were queried with keywords to select peer-reviewed scientific articles on amatoxin-containing mushroom poisoning and management. Descriptive epidemiological analyses have documented that most mushroom poisonings are caused by unknown mushrooms, and most fatal mushroom poisonings are caused by amatoxin-containing mushrooms. Amanita species cause more fatal mushroom poisonings than other amatoxin-containing species, such as Galerina and Lepiota. Amanita phalloides is responsible for most fatalities, followed by Amanita virosa and Amanita verna. The most frequently reported fatal Lepiota ingestions are due to Lepiota brunneoincarnata, and the most frequently reported fatal Galerina species ingestions are due to Galerina marginata. With the exception of liver transplantation, the current treatment strategies for amatoxin poisoning are all supportive and have not been subjected to rigorous efficacy testing in randomized controlled trials. All patients with symptoms of late-appearing gastrointestinal toxicity with or without false recovery or quiescent periods preceding acute liver insufficiency should be referred to centers providing liver transplantation. Patients with amatoxin-induced acute liver insufficiency that does not progress to liver failure will have a more favorable survival profile with supportive care than patients with amatoxin-induced acute liver failure, about half of whom will require liver transplantation., (Copyright © 2017 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

Background: Coccidioidomycosis is a regionally endemic systemic mycosis with unique risk factors. Since people travel for business or pleasure, and often in conjunction with their avocations or hobbies, the objectives of this review were to describe these and other risk factors for coccidioidomycosis; to alert travel medicine clinicians to the different presenting manifestations of coccidioidomycosis; and to recommend effective treatment, disease control and prevention strategies., Methods: To meet the objectives of this review, Internet search engines were queried with the keywords as medical subject headings over the study period, 1970-2017., Results: The principle transmission mechanism of coccidioidomycosis is by deep inhalation of aerosolized arthroconidia with resulting symptomatic pulmonary infections ranging from febrile influenza-like illnesses to fatal disseminated mycoses. In addition to residency or travel in endemic areas, persons immunocompromised by advancing age, pregnancy, cancer, corticosteroid therapy, diabetes, organ transplantation and human immunodeficiency virus infection are at significantly increased risks of contracting coccidioidomycosis. Persons of African, Asian, Filipino and Hispanic descent are also at increased risks of contracting coccidioidomycosis. Hobbies associated with coccidioidomycosis have included armadillo hunting, model airplane flying and archaeological digging. Occupational risk factors for coccidioidomycosis include endemic exposures during military maneuvers, outdoor track and field events, road construction, solar-power and wind-power farm construction, archaeological excavation and prison work., Conclusions: Coccidioidomycosis is more common in endemic and non-endemic areas than previously recognized and can result in considerable morbidity and mortality. Coccidioidomycosis is increasingly imported from endemic areas in the Western Hemisphere to non-endemic areas worldwide. Increased awareness of disease risk factors among the public and the international healthcare community will improve the timely diagnosis and treatment of coccidioidomycosis and prevent disease progression, dissemination and deaths in residents in and in travellers returning from endemic regions. A vaccine for the primary prevention of coccidioidomycosis would be cost-effective.

Introduction: This project studied pain control and the development of adverse events before, during, and after the administration of hydromorphone hydrochloride for various interventional radiology (IR) procedures., Methods: We performed a retrospective analysis of 100 patients (men = 58; women = 42) sedated with peri-procedural intravenous (IV) hydromorphone in association with various IR procedures. We stratified the procedures as follows: abscess drainages (M = 8; F = 8), arteriograms (M = 1; F = 0), biliary interventions (M = 3; F = 2), bone biopsies (M = 2; F = 2), non-bone biopsies (M = 26; F = 19), non-tunneled venous catheters (M = 1; F = 1), tunneled venous catheters (M = 7; F = 5), embolization (M = 4; F = 0), IVC filter placement (M = 1; F = 1), nephrostomy tube placement (M = 1; F = 4), and percutaneous nephrolithotomy tube placements (M = 4; F = 0). We recorded the pre-, intra-, and post-procedure pain scores [numeric rating scale (NRS) with 0 = no pain to 10 = most pain] for each of the stratifications. We also recorded the total dose of hydromorphone and midazolam hydrochloride received by each gender, as well as whether any men or women received either naloxone hydrochloride or any antiemetic. Lastly, the investigators recorded the development of hypotension following hydromorphone administration and/or hypoxia as well as the need for opioid-induced intensive care unit (ICU) admission. The investigators used unpaired, two-tailed t tests, and either Yates-corrected Chi-squares or two-tailed Fisher's exact tests for continuous and categorical variables, respectively. The difference was statistically significant if p < 0.05., Results: There was no significant difference between men and women for either mean age (M = 50 years; F = 53.4 years) or mean pre-procedural pain scores (M = 1.31; F = 0.55). There was no statistically significant difference in numbers of men or women for each procedure stratification. The highest mean pre-procedure pain score was in men undergoing percutaneous nephrostomy tube placement (mean 5, SD 0). The highest mean intra-procedure pain score was in men undergoing abscess drainages (mean 2, SD 2.3). The highest mean post-procedure pain score was in men undergoing abscess drainages (mean 1.5, SD 3.5). The only mean scores that were significantly different between men and women were in pre- (M = 2.5; F = 0.6; p = 0.006) and intra-procedural (M = 2; F = 0.5; p = 0.0001) pain scores for abscess drainages. There was no statistically significant difference in the dose of either hydromorphone (M = 1.3; F = 1.3) or midazolam (M = 1.3; F = 1.3) administered. There was no statistically significant difference in opioid-induced nausea (M = 1; F = 3). One female experienced hypotension and one male experienced hypoxia within 6 h of hydromorphone administration. There were neither opioid-related ICU admissions nor naloxone administrations., Conclusions: This preliminary study indicates that IV hydromorphone ± midazolam may be a safe and effective analgesic and sedative combination for adult patients undergoing IR procedures.

Acute pain in the pediatric population has important differences in terms of biology, intrapopulation variation, and epidemiology. Discussion as to the pharmacologic considerations of anesthetic agents, such as induction agents, neuromuscular blockers, opioids, local anesthetics, and adjuvant agents, is presented in this article. Special considerations and concerns, such as risk for propofol infusion syndrome and adverse potential side effects of anesthesia agents, are discussed. Anesthesiologists managing pediatric patients need to have a firm understanding of physiologic and pharmacologic differences compared with the adult population. Future studies to improve the understanding of pharmacokinetics in the pediatric population are needed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Of all the postsurgical pain conditions, thoracotomy pain poses a particular therapeutic challenge in terms of its prevalence, severity, and ensuing postoperative morbidity. Multiple pain generators contribute to the severity of post-thoracotomy pain, and therefore a multimodal analgesic therapy is considered to be a necessary strategy. Along with opioids, thoracic epidural analgesia, and paravertebral blocks, N-Methyl-D-Aspartate (NMDA) receptor antagonists such as ketamine have been used as adjuvants to improve analgesia., Objective: We reviewed the evidence for the efficacy of intravenous and epidural administration of ketamine in acute post-thoracotomy pain management, and its effectiveness in reducing chronic post-thoracotomy pain., Study Design: Systematic literature review and an analytic study of a data subset were performed., Methods: We searched PubMed, Embase, and Cochrane reviews using the key terms "ketamine," "neuropathic pain," "postoperative," and "post-thoracotomy pain syndrome." The search was limited to human trials and included all studies published before January 2015. Data from animal studies, abstracts, and letters were excluded. All studies not available in the English language were excluded. The manuscript bibliographies were reviewed for additional related articles. We included randomized controlled trials and retrospective studies, while excluding individual case reports., Results: This systematic literature search yielded 15 randomized control trials evaluating the efficacy of ketamine in the treatment of acute post-thoracotomy pain; fewer studies assessed its effect on attenuating chronic post-thoracotomy pain. The majority of reviewed studies demonstrated that ketamine has efficacy in reduction of acute pain, but the evidence is limited on the long-term benefits of ketamine to prevent post-thoracotomy pain syndrome, regardless of the route of administration. A nested analytical study found there is a statistically significant reduction in acute post-thoracotomy pain with IV or epidural ketamine. However currently, the evidence for a role of ketamine as a preventative agent for chronic post-thoracotomy pain is insufficient due to the heterogeneity of the studies reviewed with regard to the route of administration, dosage, and outcome measures., Limitations: The evidence for a role of ketamine as a preventative agent for chronic post-thoracotomy pain is insufficient due to the heterogeneity of the studies reviewed., Conclusion: The majority of randomized controlled trials reviewed show no role for ketamine in attenuating or preventing post-thoracotomy pain syndrome at variable follow-up lengths. Therefore, additional research is warranted with consideration of risk factors and long-term follow-up for chronic post-thoracotomy pain though the evidence for benefit appears clear for acute post-thoracotomy pain.Key words: Ketamine, postoperative, thoracotomy pain, post thoracotomy pain syndrome, neuropathic pain.

Since its introduction in 1986, propofol ( two, 6-diisopropylphenol) , an intravenous sedative-hypnotic agent, has been utilized for the induction and maintenance of general anesthesia and conscious sedation in over 80 percent of cases; largely replacing thiopental ( sodium pentothal) over a decade ago. Unrestricted as a controlled substance, propofol's abuse potential emerged quickly and was highlighted by the death of pop singer, Michael Jackson, in 2009. In order to assess the epidemiological features of fatal propofol abuse, a descriptive analysis of the scientific literature was conducted using Internet search engines. Well-documented cases of fatal propofol abuse were stratified as unintentional or accidental deaths and as intentional deaths by suicides or homicides. Continuous variables were compared for differences by unpaired, two-tailed t-tests with statistical significance indicated by p-values less than 0.05. Of 21 fatal cases of propofol abuse, 18 (86 percent ) occurred in healthcare workers, mostly anesthesiologists and nurse anesthetists (n=14, 67 percent ). One case occurred in a layman who purchased propofol on the Internet. Seventeen deaths (81 percent ) were accidental; two were suicides (9.5 percent ) and two were homicides (9.5 percent ). Blood levels in intentional death cases were significantly greater than in accidental death cases (p less than 0.0001) all of which reflected initial therapeutic induction-level doses in the ranges of 2.0-2.5 mg/kg. Though lacking in analgesic effects, the abuse of propofol by young healthcare professionals, particularly operating room workers, has been significant; and likely underreported. Propofol is a dangerous drug with an evident abuse potential which often results in fatalities.

Intralipid emulsion therapy is well-established for the treatment of local-anesthetic systemic toxicities. In recent years, its role has expanded as an important therapeutic agent in the reversal of other types of drug overdoses, including certain types of antipsychotics, antidepressants, antiarrhythmics, and calcium channel blockers. A literature review identified thirty-one case reports including forty-nine separate drug overdose cases involving ten separate drug classes which were successfully reversed with Intralipid. The present clinical case study describes an elderly unresponsive woman refractory to conventional treatments after ingesting a potentially lethal amount of 5.6 grams of diltiazem in a suicide attempt. After treatment with Intralipid over a twenty-four hour period, the patient's hemodynamic and metabolic derangements were corrected and stabilized completely. Intralipid emulsion rescue therapy provides another potential strategy for the reversal of many drug toxicities, most likely by providing a lipid layer safety net for drug overdose by passive diffusion. Clinicians are urged to embrace an expanded role of Intralipid emulsion rescue therapy, not only for local anesthetic drug toxicities, but also for other lipophilic drug overdoses.