ADVANCED DIAGNOSTIC IMAGING AND PATHOLOGIC FINDINGS OF THYROID LESIONS IN TWO SHORT-BEAKED ECHIDNAS (TACHYGLOSSUS ACULEATUS).

Two zoo-maintained short-beaked echidnas (Tachyglossus aculeatus) had long histories of intermittent anorexia and lethargy. Case 1 presented with a recurrence of these signs after transfer to another facility and died shortly after arrival. A focal area of hyperattenuation within the paratracheal tissue of the cranial mediastinum was noted antemortem on CT. Postmortem, this corresponded with severe thyroid follicular hyperplasia with lymphoplasmacytic thyroiditis. Additional findings included a systemic fungal infection without an inflammatory response, suggesting underlying factors such as torpor or immunosuppression. In Case 2, an intrathoracic mass was identified during a preshipment examination. CT confirmed a contrast-enhanced mass compressing the cranial vena cava and right atrium, and the animal was euthanized. The mass was diagnosed histologically as thyroid adenocarcinoma. These cases report thyroiditis and thyroid adenocarcinoma in echidna and describe the use of IV contrast and CT as a diagnostic aid in this species.

Reproductive tract neoplasia in adult female Asian elephants (Elephas maximus).

Recent reports have highlighted a lower-than-expected prevalence of neoplasia in elephants and suggested mechanisms for cancer resistance. But despite infrequent reports in the literature, uterine neoplasia is common in managed Asian elephants (Elephas maximus). This study is an archival review of reproductive tract neoplasia in 80 adult female Asian elephant mortalities in managed care facilities in the United States from 1988 to 2019. Neoplasms occurred in 64/80 (80%) of cases. Most were in the uterus (63/64; 98%) with only a single case of ovarian neoplasia. Myometrial leiomyomas were present in 57/63 (90%) cases with uterine neoplasia. Uterine adenocarcinoma was present in 8/63 (13%) cases. Remaining cases included endometrial adenoma (2), focal carcinoma in situ in endometrial polyps (1), anaplastic carcinoma (1), endometrial hemangioma (1), primitive neuroectodermal tumor (PNET; 1), and angiosarcoma (1). One case with uterine adenocarcinoma had a separate pelvic mass histologically characterized as an anaplastic sarcoma. Distant metastases were documented in 5/8 (63%) cases of uterine adenocarcinoma, and in the uterine anaplastic carcinoma, PNET, and angiosarcoma. Four uterine adenocarcinomas and one carcinoma in situ were examined immunohistochemically for pan-cytokeratin, vimentin, and estrogen receptor. In all, neoplastic cells were pan-cytokeratin positive and vimentin negative, and in 2 cases were immunoreactive for estrogen receptor. Results show that female reproductive tract neoplasia, particularly of the uterus, is common in Asian elephants and is not limited to leiomyomas. Importantly, uterine neoplasms have the potential to impact fecundity and may represent obstacles to conservation in managed care.

Blood stream infections in children in the first year after liver transplantation at Wits Donald Gordon Medical Centre, South Africa.

Children who undergo liver transplantation and subsequently develop BSI are at risk for adverse outcomes. Research from high-income settings contrasts the dearth of information from transplant centers in low- and middle-income countries, such as South Africa. Therefore, this study from Johannesburg aimed to describe the clinical and demographic profile of children undergoing liver transplantation, and determine the incidence and pattern of BSI and associated risk factors for BSI during the first year after liver transplant. Pediatric liver transplants performed from 2005 to 2014 were reviewed. Descriptive analyses summarized donor, recipient, and post-transplant infection characteristics. Association between BSI and sex, cause of liver failure, age, nutritional status, PELD/MELD score, graft type, biliary complications, and acute rejection was determined by Fisher's exact test; and association with length of stay by Cox proportional hazards regression analysis. Survival estimates were determined by the Kaplan-Meier method. Sixty-five children received one transplant and four had repeat transplants, totaling 69 procedures. Twenty-nine BSI occurred in 19/69 (28%) procedures, mostly due to gram-negative organisms, namely Klebsiella species. Risk for BSI was independently associated with biliary atresia (44% BSI in BA compared to 17% in non-BA transplants; P = .014) and post-operative biliary complications (55% BSI in transplants with biliary complications compared to 15% in those without; P = .0013). One-year recipient and graft survival was 78% (CI 67%-86%) and 77% (CI 65%-85%), respectively. In Johannesburg, incident BSI, mostly from gram-negative bacteria, were associated with biliary atresia and post-operative biliary complications in children undergoing liver transplantation.

Needs must: living donor liver transplantation from an HIV-positive mother to her HIV-negative child in Johannesburg, South Africa.

The world's first living donor liver transplant from an HIV-positive mother to her HIV-negative child, performed by our team in Johannesburg, South Africa (SA) in 2017, was necessitated by disease profile and health system challenges. In our country, we have a major shortage of donor organs, which compels us to consider innovative solutions to save lives. Simultaneously, the transition of the HIV pandemic, from a death sentence to a chronic illness with excellent survival on treatment required us to rethink our policies regarding HIV infection and living donor liver transplantation . Although HIV infection in the donor is internationally considered an absolute contraindication for transplant to an HIV-negative recipient, there have been a very small number of unintentional transplants from HIV-positive deceased donors to HIV-negative recipients. These transplant recipients do well on antiretroviral medication and their graft survival is not compromised. We have had a number of HIV-positive parents in our setting express a desire to be living liver donors for their critically ill children. Declining these parents as living donors has become increasingly unjustifiable given the very small deceased donor pool in SA; and because many of these parents are virally suppressed and would otherwise fulfil our eligibility criteria as living donors. This paper discusses the evolution of HIV and transplantation in SA, highlights some of the primary ethical considerations for us when embarking on this case and considers the new ethical issues that have arisen since we undertook this transplant.

CONGENITAL CLEFT PALATE AND CARDIAC SEPTAL DEFECTS IN A NEONATAL SOUTHERN BLACK RHINOCEROS (DICEROS BICORNIS MINOR).

A female Southern black rhinoceros ( Diceros bicornis minor) calf died unexpectedly at less than 12 hr of age, after an uncomplicated birth and uneventful early postpartum period. Gross necropsy revealed a 15-cm full thickness cleft palate, a patent foramen ovale, and four septal defects ranging from 0.3 to 1 cm in diameter. Histologic findings did not reveal any significant abnormalities. Karyotyping did not indicate any significant numerical or structural chromosomal abnormalities.

Assessment of emergency responders after a vinyl chloride release from a train derailment - New Jersey, 2012.

On November 30, 2012, at approximately 7:00 am, a freight train derailed near a small town in New Jersey. Four tank cars, including a breached tank car carrying vinyl chloride, landed in a tidal creek. Vinyl chloride, a colorless gas with a mild, sweet odor, is used in plastics manufacture. Acute exposure can cause respiratory irritation and headache, drowsiness, and dizziness; chronic occupational exposure can result in liver damage, accumulation of fat in the liver, and tumors (including angiosarcoma of the liver). Because health effects associated with acute exposures have not been well studied, the New Jersey Department of Health requested assistance from the Agency for Toxic Substances and Disease Registry (ATSDR) and CDC. On December 11, teams from these agencies deployed to assist the New Jersey Department of Health in conducting an assessment of exposures in the community as well as the occupational health and safety of emergency personnel who responded to the incident. This report describes the results of the investigation of emergency personnel. A survey of 93 emergency responders found that 26% of respondents experienced headache and upper respiratory symptoms during the response. A minority (22%) reported using respiratory protection during the incident. Twenty-one (23%) of 92 respondents sought medical evaluation. Based on these findings, CDC recommended that response agencies 1) implement the Emergency Responder Health Monitoring and Surveillance (ERHMS) system for ongoing health monitoring of the emergency responders involved in the train derailment response and 2) ensure that in future incidents, respiratory protection is used when exposure levels are unknown or above the established occupational exposure limits.

Severe Illness from Methyl Bromide Exposure at a Condominium Resort--U.S. Virgin Islands, March 2015.

On March 22, 2015, the Agency for Toxic Substances and Disease Registry (ATSDR) was notified by the U.S. Environmental Protection Agency (EPA) of four cases of suspected acute methyl bromide toxicity among family members vacationing at a condominium resort in the U.S. Virgin Islands. Methyl bromide is a pesticide that has been banned in the United States for use in homes and other residential settings. An investigation conducted by the U.S. Virgin Islands Department of Health (VIDOH), the U.S. Virgin Islands Department of Planning and Natural Resources (DPNR), and EPA confirmed that methyl bromide had been used as a fumigant on March 18 in the building where the family had been residing, 2 days before they were transported to the hospital; three family members had life-threatening illness. On March 25, 2015, a stop-use order for methyl bromide was issued by DPNR to the pest control company that had performed the fumigation. Subsequent investigation revealed that previous fumigation with methyl bromide had occurred on October 20, 2014, at the same condominium resort. In addition to the four ill family members, 37 persons who might have been exposed to methyl bromide as a result of the October 2014 or March 2015 fumigations were identified by VIDOH and ATSDR. Standardized health questionnaires were administered to 16 of the 20 persons for whom contact information was available; six of 16 had symptoms consistent with methyl bromide exposure, including headache and fatigue. Pest control companies should be aware that use of methyl bromide is banned in homes and other residential settings, and clinicians should be aware of the toxicologic syndrome that exposure to methyl bromide can cause.

MANAGEMENT OF ACUTE RENAL FAILURE WITH DELAYED HYPERCALCEMIA SECONDARY TO SARCOCYSTIS NEURONA-INDUCED MYOSITIS AND RHABDOMYOLYSIS IN A CALIFORNIA SEA LION (ZALOPHUS CALIFORNIANUS).

A 3-yr-old captive-born California sea lion (Zalophus californianus) developed Sarcocystis neurona-induced myositis and rhabdomyolysis that led to acute renal failure. The sea lion was successfully managed with fluid therapy, antiprotozoals, antibiotics, anti-inflammatories, antiemetics, gastroprotectants, and diuretics, but developed severe delayed hypercalcemia, a syndrome identified in humans after traumatic or exertion-induced rhabdomyolysis. Treatment with calcitonin was added to the management, and the individual recovered fully. The case emphasizes that animals with rhabdomyolysis-induced renal failure risk developing delayed hypercalcemia, which may be life threatening, and calcium levels should be closely monitored past the resolution of renal failure.

Ranavirus (Frog Virus 3) Infection in Free-Living Three-Toed Box Turtles (Terrapene mexicana triunguis) in Missouri, USA.

Frog virus 3 (FV3) and related ranaviruses are emerging infectious disease threats to ectothermic vertebrate species globally. Although the impact of these viruses on amphibian health is relatively well studied, less is understood about their effects on reptile health. We report two cases of FV3 infection, 11 mo apart, in three-toed box turtles (Terrapene mexicana triunguis) from a wildlife rehabilitation center. Case 1 had upper respiratory signs upon intake but had no clinical signs at the time of euthanasia 1 mo later. Case 2 presented for vehicular trauma, had ulcerative pharyngitis and glossitis, and died overnight. In case 1, we detected FV3 nucleic acid with qPCR in oral swabs, kidney, liver, spleen, and tongue. In case 2, we detected FV3 in an oral swab, an oral plaque, heart, kidney, lung, liver, spleen, and tongue. We also detected FV3 nucleic acid with in situ hybridization for case 2. For both cases, FV3 was isolated in cell culture and identified with DNA sequencing. Histopathologic examination of postmortem tissue from case 1 was unremarkable, whereas acute hemorrhagic pneumonia and splenic necrosis were noted in case 2. The difference in clinical signs between the two cases may have been due to differences in the temporal course of FV3 disease at the time of necropsy. Failure to detect this infection previously in Missouri reptiles may be due to lack of surveillance, although cases may also represent a novel spillover to box turtles in Missouri. Our findings reiterate previous suggestions that the range of FV3 infection may be greater than previously documented and that infection may occur in host species yet to be tested.

Contaminated ventilator air flow sensor linked to Bacillus cereus colonization of newborns.

We investigated Bacillus cereus-positive tracheal aspirates from infants on ventilators in a neonatal intensive care unit. Multilocus sequence typing determined a genetic match between strains isolated from samples from a case-patient and from the air flow sensor in the ventilator. Changing the sterilization method for sensors to steam autoclaving stopped transmission.

Efficacy of pain control with topical lidocaine-epinephrine-tetracaine during laceration repair with tissue adhesive in children: a randomized controlled trial.

BACKGROUND: Some children feel pain during wound closures using tissue adhesives. We sought to determine whether a topically applied analgesic solution of lidocaine-epinephrine-tetracaine would decrease pain during tissue adhesive repair. METHODS: We conducted a randomized, placebo-controlled, blinded trial involving 221 children between the ages of 3 months and 17 years. Patients were enrolled between March 2011 and January 2012 when presenting to a tertiary-care pediatric emergency department with lacerations requiring closure with tissue adhesive. Patients received either lidocaine-epinephrine-tetracaine or placebo before undergoing wound closure. Our primary outcome was the pain rating of adhesive application according to the colour Visual Analogue Scale and the Faces Pain Scale--Revised. Our secondary outcomes were physician ratings of difficulty of wound closure and wound hemostasis, in addition to their prediction as to which treatment the patient had received. RESULTS: Children who received the analgesic before wound closure reported less pain (median 0.5, interquartile range [IQR] 0.25-1.50) than those who received placebo (median 1.00, IQR 0.38-2.50) as rated using the colour Visual Analogue Scale (p=0.01) and Faces Pain Scale--Revised (median 0.00, IQR 0.00-2.00, for analgesic v. median 2.00, IQR 0.00-4.00, for placebo, p<0.01). Patients who received the analgesic were significantly more likely to report having or to appear to have a pain-free procedure (relative risk [RR] of pain 0.54, 95% confidence interval [CI] 0.37-0.80). Complete hemostasis of the wound was also more common among patients who received lidocaine-epinephrine-tetracaine than among those who received placebo (78.2% v. 59.3%, p=0.008). INTERPRETATION: Treating minor lacerations with lidocaine-epinephrine-tetracaine before wound closure with tissue adhesive reduced ratings of pain and increased the proportion of pain-free repairs among children aged 3 months to 17 years. This low-risk intervention may benefit children with lacerations requiring tissue adhesives instead of sutures. TRIAL REGISTRATION: ClinicalTrials.gov, no. PR 6138378804.

The same genotype of Sarcocystis neurona responsible for mass mortality in marine mammals induced a clinical outbreak in raccoons (Procyon lotor) 10 years later.

Here, we report the first known outbreak of clinical protozoal myeloencephalitis in naturally infected raccoons by the parasite Sarcocystis neurona. The North American opossum (Didelphis virginiana) and the South American opossum (Didelphis albiventris) are its known definitive hosts. Several other animal species are its intermediate or aberrant hosts. The raccoon (Procyon lotor) is considered the most important intermediate host for S. neurona in the USA. More than 50% of raccoons in the USA have sarcocysts in their muscles, however clinical sarcocystosis in raccoons is rare. In 2014, 38 free-living raccoons were found dead or moribund on the grounds of the Saint Louis Zoo, Missouri, USA. Moribund individuals were weak, lethargic, and mildly ataxic; several with oculo-nasal discharge. Seven raccoons were found dead and 31 were humanely euthanized. Postmortem examinations were conducted on nine raccoons. Neural lesions compatible with acute sarcocystosis were detected in eight raccoons. The predominant lesions were meningoencephalitis and perivascular mononuclear cells. Histologic evidence for the Canine Distemper Virus was found in one raccoon. Schizonts and merozoites were present in the encephalitic lesions of four raccoons. Mature sarcocysts were present within myocytes of five raccoons. In six raccoons, S. neurona schizonts and merozoites were confirmed by immunohistochemical staining with S. neurona-specific polyclonal antibodies. Viable S. neurona was isolated from the brains of two raccoons by bioassay in interferon gamma gene knockout mice and in cell cultures seeded directly with raccoon brain homogenate. Molecular characterization was based on raccoon no. 68. Molecular characterization based on multi-locus typing at five surface antigens (SnSAG1-5-6, SnSAG3 and SnSAG4) and the ITS-1 marker within the ssrRNA locus, using DNA isolated from bradyzoites released from sarcocysts in a naturally infected raccoon (no. 68), confirmed the presence of S. neurona antigen type I, the same genotype that caused a mass mortality event in which 40 southern sea otters stranded dead or dying within a 3 week period in April 2004 with S. neurona-associated disease. An expanded set of genotyping markers was next applied. This study reports the following new genotyping markers at 18S rRNA, 28S rRNA, COX1, ITS-1, RON1, RON2, GAPDH1, ROP20, SAG2, SnSRS21 and TUBA1 markers. The identity of Sarcocystis spp. infecting raccoons is discussed.

Historic occurrence of the amphibian chytrid fungus Batrachochytrium dendrobatidis in hellbender Cryptobranchus alleganiensis populations from Missouri.

The pathogenic fungus Batrachochytrium dendrobatidis (Bd) was recently detected in Missouri hellbender Cryptobranchus alleganiensis populations that have declined precipitously for unclear reasons. The objective of this study was to determine whether Bd occurred historically in Missouri hellbender populations or is a relatively novel occurrence. Epidermal tissue was removed from 216 archived hellbenders collected from 7 Missouri streams between 1896 and 1994. Histological techniques and an immunoperoxidase stain were used to confirm historic occurrence of Bd infection in hellbenders from the North Fork of the White (1969, 1973, 1975), Meramec (1975, 1986), Big Piney (1986), and Current rivers (1988). Bd was not detected in hellbenders from the Niangua, Gasconade or Eleven Point rivers. The study detected no evidence for endemism of Bd in Missouri hellbender populations prior to 1969, despite the fact that nearly one third of the hellbenders sampled were collected earlier. Our findings are consistent with the hypothesis that Bd is a non-endemic pathogen in North America that was introduced in the second half of the twentieth century.

Understanding hospitality house guests' needs: a brief case report.

A.E. Kazak's (2006) call to develop theory-driven and empirically supported programs aimed at strengthening the competencies of families affected by pediatric illness applies to both medical and nonmedical facilities and institutions that care for pediatric patients and their loved ones. M.K.W. Duncan and A. Blugis (in press, this issue) note that despite the intuitive and practical nature of Maslow's Hierarchy of Needs, no theory translates into an infallible understanding of any individual guest's needs or a program of universally applied best practice standards for meeting those needs. Using Maslow's theory as a framework, this brief report describes the complexity and fluidity of one mother's needs during her stay at a hospitality house following the birth of her premature twin babies.

Maslow's needs hierarchy as a framework for evaluating hospitality houses' resources and services.

As hospitality houses welcome greater numbers of families and families requiring longer stays, they do so in the absence of a widely accepted theory to guide their understanding of guests' needs and evaluations of how well they meet those needs. We propose A. Maslow's (1970) Hierarchy of Needs as a conceptual framework for understanding what makes a hospitality house a home for families of pediatric patients and for guiding the activities of hospitality houses' boards of directors, staff, volunteers, and donors. This article presents findings from a theory-driven evaluation of one hospitality house's ability to meet guests' needs, describes the house's best practice standards for addressing guests' needs, and suggests areas for future research.

Intra-articular median nerve incarceration after spontaneous reduction of a pediatric elbow dislocation: case report and review of the literature.

UNLABELLED: Intra-articular incarceration of the median nerve after closed reduction of an elbow dislocation is a rare and potentially devastating complication. We report the case of a 4-year-old boy who had an entrapment of the median nerve after spontaneous reduction of a posterior dislocation. All the cases previously reported in the literature are reviewed. The diagnostic algorithm and treatment options are discussed. This is the only case in the literature in which spontaneous reduction of the dislocation occurred before medical evaluation. This scenario can occur in children as young as 4 years of age. Although incarceration of the median nerve after an elbow dislocation is an uncommon complication, it must be recognized early and explored to prevent permanent disability. LEVEL OF EVIDENCE: Level IV.

Bladder teratoma in a maned wolf (Chrysocyon brachyurus).

Background: Teratomas are germ cell tumors, comprised of a mixture of tissue types and with tissue foreign to their site of origin. Case Description: A 5.5-year-old intact female maned wolf (Chrysocyon brachyurus) was treated for recurrent stranguria and suspected cystitis. Due to lack of resolution, the wolf was anesthetized for further evaluation. The urinary bladder was firm on palpation, with a markedly thickened wall and no observable lumen on ultrasound. Neoplastic infiltration was suspected on double contrast cystogram and confirmed via surgical exploration. The lesion was inoperable and the wolf was euthanized. Gross necropsy revealed two poorly distinguished masses infiltrating the urinary bladder dorsally and caudoventrally, with minimal remaining lumen. Histopathologic examination of the bladder and associated masses revealed a neoplasm comprised of multiple tissue types. Vascular invasion was noted. Conclusion: The neoplasm was diagnosed as an extragonadal teratoma. Few extragonadal teratomas have been described and this is the first report of a teratoma originating in the urinary bladder of a non-human species.

Sustained reduction in rates of hospital-onset Clostridium difficile infection using an automated electronic health record protocol.

BACKGROUND: An automated protocol was designed within our electronic medical record (EMR) to help curb the Clostridium difficile problem at our institution. The protocol will identify patients at high risk for C difficile, improve the timing of testing of patients infected on admission, and enhance the appropriateness of C difficile testing throughout the patient's hospitalization. METHODS: Admitted patients with 2 of the following 3 criteria were labeled as high risk for C difficile: admission to a medical institution in the preceding 90 days, administration of antibiotics in the preceding 90 days, or a history of C difficile. High-risk patients with diarrhea in the first 3 days of admission are identified in the EMR, and prompt testing for C difficile is done. After day 3, if diarrhea develops, a series of questions is presented to help test the appropriate patients for C difficile. RESULTS: A statistically significant reduction in rates of hospital-onset C difficile was achieved after implementation of the protocol. CONCLUSIONS: Implementation of an automated protocol for targeted testing of high-risk patients for C difficile was successful at reducing rates of hospital-onset C difficile by improving timing and appropriateness of testing.