Accuracy of Emergency Medicine Residents Using Point-of-Care Ultrasound (POCUS) to Detect Retained Stingray Barbs.

BACKGROUND: Stingray envenomation is a common presenting complaint for coastal emergency departments in the United States. Currently, radiograph is the gold standard to evaluate for a retained stingray barb, but ultrasound may be a useful tool to detect retained barbs. OBJECTIVE: To determine if emergency medicine residents could use ultrasound to identify stingray barbs embedded in animal tissue models. A secondary objective was to determine if resident experience affected their ability to detect stingray barbs. METHODS: Thirty-two emergency medicine residents participated in the study. After a short didactic session on foreign body identification with ultrasound, they rotated through six simulation stations and were asked to identify whether a stingray barb was present in pig and chicken tissue models. They were given 2 min per model to identify the presence, size, and depth of a stingray barb. Pre- and postexperiment surveys were collected to assess the residents' level of experience and confidence regarding foreign body identification using ultrasound. RESULTS: Residents accurately identified barbs in chicken drumsticks with a sensitivity of 72.92% (95% confidence interval [CI] 63.89-81.48) and a specificity of 64.58% (95% CI 54.16-74.08), and in pig's feet with a sensitivity of 50.00% (95% CI 39.62-60.38) and specificity of 68.75% (95% CI 58.48-77.82). There was no statistically significant difference regarding accuracy for any outcome measured based on experience or level of training. CONCLUSIONS: The use of point-of-care ultrasound by novice sonographers lacks sensitivity to identify retained stingray barbs in animal models and is not significantly impacted by resident experience with point-of-care ultrasound.

Drowning rule-out with novices (DROWN) in ultrasound.

Objectives: Non-fatal drownings confer significant morbidity and mortality in the United States. Chest radiograph (CXR) is typically used as a screening modality for interstitial edema but lacks sensitivity early after submersion. No study has evaluated lung ultrasound in assessing for pulmonary edema after submersion events and we hypothesized that lung point-of-care (POC) ultrasound can identify interstitial edema in patients presenting after non-fatal drownings. Methods: Patients presenting to the emergency department after a submersion event were eligible if a CXR was obtained as part of their care. Emergency medicine residents performed a lung POC ultrasound and provided a "novice" interpretation of "normal" or "abnormal," which was independently reviewed by a blinded expert sonographer. Patients were contacted 2 weeks after presentation to assess for late sequela. Results: A prospective convenience sample of 59 patients included 21 adults (36%) and 38 children (64%) enrolled over 17 months with a median age of 6. Twenty-four (41%) patients had abnormalities on CXR. Of these, 20 patients had a positive ultrasound per novice interpretation. Compared to CXR, ultrasound had an overall sensitivity of 83% and a specificity of 66% for detecting pulmonary edema in non-fatal drownings. Notably, out of 35 subjects with a negative CXR, there were 12 (34%) cases with a positive lung ultrasound, 10 of which required hospital admission. Conclusion: Lung POC ultrasound has a moderate sensitivity and specificity when performed by novice sonographers to detect pulmonary edema presenting to an ED setting after a non-fatal drowning event.

Plastic, It's What's for Dinner: A Preliminary Comparison of Ingested Particles in Bottlenose Dolphins and Their Prey.

Microplastic ingestion was reported for common bottlenose dolphins (Tursiops truncatus) inhabiting Sarasota Bay, FL, USA, a community that also has prevalent exposure to plasticizers (i.e., phthalates) at concentrations higher than human reference populations. Exposure sources are currently unknown, but plastic-contaminated prey could be a vector. To explore the potential for trophic exposure, prey fish muscle and gastrointestinal tract (GIT) tissues and contents were screened for suspected microplastics, and particle properties (e.g., color, shape, surface texture) were compared with those observed in gastric samples from free-ranging dolphins. Twenty-nine fish across four species (hardhead catfish, Ariopsis felis; pigfish, Orthopristis chrysoptera; pinfish, Lagodon rhomboides; and Gulf toadfish, Opsanus beta) were collected from Sarasota Bay during September 2022. Overall, 97% of fish (n = 28) had suspected microplastics, and GIT abundance was higher than muscle. Fish and dolphin samples contained fibers and films; however, foams were common in dolphin samples and not observed in fish. Suspected tire wear particles (TWPs) were not in dolphin samples, but 23.1% and 32.0% of fish muscle and GIT samples, respectively, contained at least one suspected TWP. While some similarities in particles were shared between dolphins and fish, small sample sizes and incongruent findings for foams and TWPs suggest further investigation is warranted to understand trophic transfer potential.

A Tale of Two D-Dimers: Comparison of Two Assay Methods to Evaluate Deep Vein Thrombosis or Pulmonary Embolism.

BACKGROUND: D-dimer testing rules out deep vein thrombosis (DVT) and pulmonary embolism (PE) in low-risk emergency department (ED) patients. Most research has measured fibrin-equivalent units (FEUs), however, many laboratories measure D-dimer units (DDUs). OBJECTIVE: Our aim was to determine whether either DDU measurements or FEU measurements can rule out DVT/PE using traditional or age-related cutoff values. METHODS: We performed a de-identified multicenter retrospective evaluation of D-dimer in nonpregnant adult ED patients to evaluate for DVT/PE. DDUs were multiplied by 2 to determine equivalent FEUs prior to analysis. Sensitivity measurements for D-dimer were calculated for FEUs, DDUs, combined FEU/DDUs, and multiple age-adjusted values. RESULTS: We identified 47,088 ED patients with a D-dimer laboratory value (27,307 FEUs/19,781 DDUs) and 1623 DVT/PEs. The median combined FEU/DDU D-dimer was 400 ng/mL FEUs (interquartile range [IQR] 300-900 ng/mL FEUs) for patients without a DVT/PE vs 2530 ng/mL FEU (IQR 1094-6000 ng/mL FEUs) with a DVT/PE (p < 0.001), overall sensitivity of 87.3% (95% confidence interval [CI] 87.0-87.6%) and negative predictive value of 99.3% (95% CI 99.2-99.4%). Individually, FEUs performed better than DDUs, with sensitivities of 88.0% (95% CI 85.8-89.9%) and 86.1% (95% CI 83.1-88.7%), respectively; however, this difference was not statistically significant. Combined age-adjusted performance had a sensitivity of 90.3% (95% CI 88.3-92.0%); however, a new DDU-only age-adjusted criteria had the highest sensitivity of 91.1% (95% CI 87.9-93.6%). CONCLUSIONS: Our undifferentiated D-dimer measurements had a slightly lower sensitivity to rule out DVT/PE than reported previously. Our data support using either DDU or FEU measurements for all ages or when using various age-adjusted criteria to rule out DVT/PE.

A Correlational Analysis of Phthalate Exposure and Thyroid Hormone Levels in Common Bottlenose Dolphins (Tursiops truncatus) from Sarasota Bay, Florida (2010-2019).

Phthalates are chemical esters used to enhance desirable properties of plastics, personal care, and cleaning products. Phthalates have shown ubiquitous environmental contamination due to their abundant use and propensity to leach from products to which they are added. Following exposure, phthalates are rapidly metabolized and excreted through urine. Common bottlenose dolphins (Tursiops truncatus) sampled from Sarasota Bay, Florida, have demonstrated prevalent di(2-ethylhexyl) phthalate (DEHP) exposure indicated by detectable urinary mono(2-ethylhexyl) phthalate (MEHP) concentrations. Widespread exposure is concerning due to evidence of endocrine disruption from human and laboratory studies. To better understand how phthalate exposure may impact dolphin health, correlations between relevant hormone levels and detectable urinary MEHP concentrations were examined. Hormone concentrations measured via blood serum samples included triiodothyronine (T3), total thyroxine (T4), and free thyroxine (FT4). Urinary MEHP concentrations were detected in 56% of sampled individuals (n = 50; mean = 8.13 ng/mL; s.d. = 15.99 ng/mL). Adult female and male FT4 was significantly correlated with urinary MEHP concentrations (adult female Kendall's tau = 0.36, p = 0.04; adult male Kendall's tau = 0.42, p = 0.02). Evidence from this study suggests DEHP exposure may be impacting thyroid hormone homeostasis. Cumulative effects of other stressors and resultant endocrine impacts are unknown. Further research is warranted to understand potential health implications associated with this relationship.

The impact of teleneurologists on acute stroke care at an advanced primary stroke centre.

INTRODUCTION: We evaluated the impact of teleneurologists on the time to initiating acute stroke care versus traditional bedside neurologists at an advanced stroke center. METHODS: This observational study evaluated time to treatment for acute stroke patients at a single hospital, certified as an advanced primary stroke centre, with thrombectomy capabilities. Consecutive stroke alert patients between 1 March, 2016 and 31 March, 2018 were divided into two groups based on their neurology consultation service (bedside neurology: 1 March, 2016-28 February, 2017; teleneurology: 1 April, 2017-31 March, 2018). Door-to-tPA time and door-to-IR time for mechanical thrombectomy were compared between the two groups. RESULTS: Nine hundred and fifty-nine stroke patients met the inclusion criteria (436 bedside neurology, 523 teleneurology patients). There were no significant differences in sex, age, or stroke final diagnosis between groups (p > 0.05). 85 bedside neurology patients received tPA and 35 had mechanical thrombectomy, 84 and 44 for the teleneurology group respectively. Door-to-tPA time (median (IQR)) was significantly higher among teleneurology (64 min (51.5-83.5)) than bedside neurology patients (45 min (34-69); p < 0.0001). There was no difference in door-to-IR times (mean ± SD) between bedside neurology (87.2 ± 33.3 min) and teleneurology (90.4 ± 33.4 min; p = 0.67). DISCUSSION: At this facility, our teleneurology services vendor was associated with a statistically significant delay in tPA administration compared with bedside neurologists. There was no difference in door-to-IR times. Delays in tPA administration make it harder to meet acute stroke care guidelines and could worsen patient outcomes.

Cumulative Incidence of Methicillin-Resistant Staphylococcus aureus Colonization in Resident Physicians Over Time.

Background Methicillin-resistant Staphylococcus aureus (MRSA) can colonize up to 14.5% of healthcare workers (HCWs). The colonization rate of HCWs or the hospital setting that contributes most to MRSA colonization is less clear. In this study, we studied new resident physicians (PGY-1), as a model for HCWs, to measure their colonization rate and hypothesized that the incidence of colonization would increase during their first year. Methodology We prospectively enrolled PGY-1 residents of multiple specialties at three academic medical centers. After obtaining informed consent, PGY-1 residents were tested for MRSA in June 2019 before starting any clinical rotations and then retested every three to four months thereafter. The coronavirus disease 2019 pandemic forced us to end the study early. If MRSA-positive, residents were treated with 2% mupirocin and retested for a cure. For comparison, upper-level residents (PGY-2-5) were also enrolled to obtain a baseline prevalence of colonization. Results We enrolled 80 PGY-1 and 81 PGY-2-5 residents in the study. The baseline prevalence of MRSA colonization was 4.94% (4/81) in PGY-2-5 residents and 2.50% (2/80) for new PGY-1 residents; however, this was not statistically significant (p = 0.68). The cumulative yearly incidence of developing MRSA colonization in PGY-1 residents was 4.51%. MRSA colonization was successfully treated in 75% of cases. Conclusions PGY-1 residents had a lower MRSA colonization rate compared to PGY-2-5 residents, although this was not statistically significant. PGY-1 residents had a small incidence of developing MRSA colonization while working in the hospital. Further research is needed to determine if this is clinically relevant to HCWs or their patients.

Novice emergency physician ultrasonography of optic nerve sheath diameter compared to ophthalmologist fundoscopic evaluation for papilledema.

OBJECTIVES: The purpose of this study is to determine the sensitivity and specificity of novice emergency physician-performed point-of-care ultrasound diagnosis of papilledema using optic nerve sheath diameter (ONSD) against ophthalmologist-performed dilated fundoscopy. This observational study retrospectively analyzed results of ultrasound-measured ONSD of emergency department (ED) patients with suspected intracranial hypertension from a period spanning June 2014 to October 2017. METHODS: This study concerns a population of ED patients at a large, tertiary-care urban academic medical center from June 2014 to October 2017 over the age of 18 years with primary vision complaints evaluated for papilledema both by an emergency physician-performed ultrasound and an ophthalmologist-performed fundoscopic examination during their ED stay. Sensitivity and specificity of emergency physician-performed ultrasound measurement of optic nerve sheath diameter in the diagnosis of papilledema were primary outcomes for this study. RESULTS: A total of 206 individual patients (male 49%, female 51%; median age 45 years) were included in the study with a total of 212 patient encounters. Calculated sensitivity for the ocular ultrasound examination performed by emergency physicians to diagnose papilledema was 46.9% (95% confidence interval [CI], 32.5% to 61.7%), and specificity was 87.0% (95% CI, 82.8% to 90.5%). Positive predictive value and negative predictive value were calculated to be 35.4% (95% CI, 23.9% to 48.2%) and 91.5% (95% CI, 87.8% to 94.4%), respectively. CONCLUSIONS: Sonographic measurement of ONSD by emergency physicians has low sensitivity but high specificity for detection of papilledema compared to ophthalmologist-conducted fundoscopy.

Impact of hyperthyroidism on in-hospital outcomes of patients with heart failure.

Congestive heart failure (CHF) exacerbations are a frequent cause of hospitalization. Thyroid hormones impact myocardial function; elevated levels of thyroxine, as seen in hyperthyroidism (HT), can worsen CHF symptoms. We retrospectively evaluated the Hospital Corporation of America (HCA) Enterprise Data Warehouse and examined mortality and length of stay (LOS) in patients hospitalized with CHF with and without a diagnosis of HT. 55,031 patients with CHF were identified. The presence of HT was not significantly associated with mortality (p = 0.24) nor LOS (p = 0.32). A significant difference in the distribution of sex (p = 0.001) and age (p = 0.002) was noted, with a higher percentage of females and a lower median age in patients with HT. There was a significant difference in LOS (p = 0.04) for patients with a cardiovascular comorbidity, who had a mean LOS of 6.33 days versus 5.31 days for patient without HT.

Framework for a Community Health Observing System for the Gulf of Mexico Region: Preparing for Future Disasters.

The Gulf of Mexico (GoM) region is prone to disasters, including recurrent oil spills, hurricanes, floods, industrial accidents, harmful algal blooms, and the current COVID-19 pandemic. The GoM and other regions of the U.S. lack sufficient baseline health information to identify, attribute, mitigate, and facilitate prevention of major health effects of disasters. Developing capacity to assess adverse human health consequences of future disasters requires establishment of a comprehensive, sustained community health observing system, similar to the extensive and well-established environmental observing systems. We propose a system that combines six levels of health data domains, beginning with three existing, national surveys and studies plus three new nested, longitudinal cohort studies. The latter are the unique and most important parts of the system and are focused on the coastal regions of the five GoM States. A statistically representative sample of participants is proposed for the new cohort studies, stratified to ensure proportional inclusion of urban and rural populations and with additional recruitment as necessary to enroll participants from particularly vulnerable or under-represented groups. Secondary data sources such as syndromic surveillance systems, electronic health records, national community surveys, environmental exposure databases, social media, and remote sensing will inform and augment the collection of primary data. Primary data sources will include participant-provided information via questionnaires, clinical measures of mental and physical health, acquisition of biological specimens, and wearable health monitoring devices. A suite of biomarkers may be derived from biological specimens for use in health assessments, including calculation of allostatic load, a measure of cumulative stress. The framework also addresses data management and sharing, participant retention, and system governance. The observing system is designed to continue indefinitely to ensure that essential pre-, during-, and post-disaster health data are collected and maintained. It could also provide a model/vehicle for effective health observation related to infectious disease pandemics such as COVID-19. To our knowledge, there is no comprehensive, disaster-focused health observing system such as the one proposed here currently in existence or planned elsewhere. Significant strengths of the GoM Community Health Observing System (CHOS) are its longitudinal cohorts and ability to adapt rapidly as needs arise and new technologies develop.

Sentinels of synthetics - a comparison of phthalate exposure between common bottlenose dolphins (Tursiops truncatus) and human reference populations.

Phthalates are chemical esters used as additives in common consumer goods, such as plastics, household cleaners, and personal care products. Phthalates are not chemically bound to the items to which they are added and can easily leach into the surrounding environment. Anthropogenic drivers, such as coastal plastic pollution and wastewater runoff, increase the exposure potential for coastal marine fauna. Phthalate exposure in free-ranging bottlenose dolphins has been the focus of recent study, with indications of heightened exposure to certain phthalate compounds. The objective of this study was to compare urinary phthalate metabolite concentrations among bottlenose dolphins (Tursiops truncatus) sampled in Sarasota Bay, FL, to levels reported in human samples collected as part of the Centers for Disease Control and Prevention's (CDC) National Health and Nutrition Examination Survey (NHANES). Monoethyl phthalate (MEP) and mono-(2-ethylhexyl) phthalate (MEHP) were the most prevalent metabolites detected in dolphin urine (n = 51; MEP = 29.41%; MEHP = 54.90%). The geometric mean (GM) concentration of MEP was significantly lower for dolphins (GM = 4.51 ng/mL; 95% CI: 2.77-7.34 ng/mL) compared to humans (p<0.05), while dolphin concentrations of MEHP (GM = 4.57 ng/mL; 95% CI: 2.37-8.80 ng/mL) were significantly higher than levels reported in NHANES (p<0.05). Health impacts to bottlenose dolphins resulting from elevated exposure to the MEHP parent compound (diethyl-2-ethylhexyl phthalate, DEHP) are currently unknown. However, given the evidence of endocrine disruption, reproductive impairment, and abnormal development in humans, pursuing investigations of potential health effects in exposed bottlenose dolphins would be warranted.

Presentation Times of Myocardial Infarctions to the Emergency Department: Disappearance of the Morning Predominance.

BACKGROUND: Previous studies show that myocardial infarctions (MIs) occur most frequently in the morning. OBJECTIVES: We hypothesized that there no longer is a morning predominance of MI, and that the timing of ST-elevation myocardial infarction (STEMI) vs. non-ST-elevation myocardial infarction (NSTEMI) presentation differs. METHODS: We reviewed MI, STEMI, and NSTEMI patients (2013-2017) from a multiple-hospital system, identified by diagnostic codes. Daily emergency department arrival times were categorized into variable time intervals for count and proportional analysis, then examined for differences. RESULTS: There were 18,663 MI patients from 12 hospitals included in the analysis. Most MIs occurred between 12:00 pm and 5:59 pm (35.7%), and least between 12:00 am-5:59 am (16.3%). After subdividing all MIs into STEMIs and NSTEMIs, both groups continued to have the greatest presentation between 12:00 pm and 5:59 pm (33.1% and 36.0%, respectively). STEMIs (17.2%) and NSTEMIs (16.2%) were least frequent between 12:00 am and 5:59 am. We found the second most common presentation time for MIs was in the 6 pm-11:59 pm time period, which held true for both subtypes (MI 26.7%, STEMI 26.4%, NSTEMI 26.7%). CONCLUSIONS: These data suggest a potential shift in the circadian pattern of MI, revealing an afternoon predominance for both STEMI and NSTEMI subtypes.

Correction: A characterization of personal care product use among undergraduate female college students in South Carolina, USA.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

A characterization of personal care product use among undergraduate female college students in South Carolina, USA.

Some chemicals used in personal care products (PCPs) are associated with endocrine disruption, developmental abnormalities, and reproductive impairment. Previous studies have evaluated product use among various populations; however, information on college women, a population with a unique lifestyle, is scarce. The proportion and frequency of product use were measured using a self-administered survey among 138 female undergraduates. Respondents were predominately Caucasian (80.4%, reflecting the college's student body), and represented all years of study (freshman: 24.6%; sophomore: 30.4%; junior: 18.8%; senior: 26.1%). All respondents reported use of at least two PCPs within 24 h prior to sampling (maximum = 17; median = 8; IQR = 6-11). Compared with studies of pregnant and postpartum women, adult men, and Latina adolescents, college women surveyed reported significantly higher use of deodorant, conditioner, perfume, liquid soap, hand/body lotion, sunscreen, nail polish, eyeshadow, and lip balm (Chi Square, p < 0.05). More study is needed to understand the magnitude and racial disparities of PCP chemical exposure, but given the potential effects on reproduction and fertility, our findings of abundant and frequent product use among these reproductive-aged women highlight opportunities for intervention and information on endocrine disrupting chemical (EDC)-free alternative products and behaviors.

Urinary Phthalate Metabolites in Common Bottlenose Dolphins (Tursiops truncatus) From Sarasota Bay, FL, USA.

Phthalates are chemical additives to common consumer goods including cleaning products, cosmetics, personal care products, and plastic. Because they are not chemically bound to these products and are widely used, the potential for environmental contamination is significant. Phthalates and their metabolites have been associated with endocrine disruption and reproductive impairment, among other adverse health effects, in laboratory animals and human epidemiologic studies. Common bottlenose dolphins (Tursiops truncatus) are vulnerable to environmental pollutants due to their apex position in the food chain, long life spans, and habitat overlap with developed coastal areas. The objective of this study was to quantify phthalate metabolite concentrations in urine collected from bottlenose dolphins in Sarasota Bay, Florida, during May 2016 (n = 7) and May 2017 (n = 10). Screening of nine phthalate monoester metabolites in bottlenose dolphin urine was performed by liquid chromatography tandem mass spectrometry using methods adapted from those used for analyzing human samples. At least one phthalate metabolite was detected in 71% of the dolphins sampled across both years, with the highest concentrations detected for monoethyl phthalate (MEP; GM = 5.4 ng/ml; 95%CI: 1.3-22.0 ng/ml) and mono-(2-ethylhexyl) phthalate (MEHP; GM = 1.9 ng/ml; 95%CI: 1.1-3.2 ng/ml). These data demonstrate exposure to two of the most commonly used phthalates in commercial manufacturing, diethyl phthalate (DEP) and di-2-ethylhexyl phthalate (DEHP). This study establishes methods for urinary detection of phthalate metabolites in marine mammals and provides baseline data to address a significant and growing, yet poorly understood, health threat to marine wildlife.

Rapid Source-Control Laparotomy: Is There a Mortality Benefit in Septic Shock?

BACKGROUND: In the 1990s, damage control laparotomy (DCL) became a proved approach to treat intra-abdominal injuries caused by trauma. In the ensuing two decades, this approach has been applied to non-traumatic abdominal processes as well. Although the benefits of DCL are clear, the benefit of rapid source-control laparotomy (RSCL) for non-traumatic abdominal diseases is much less clear. However, two recent cohort analyses identified significant increases in the mortality rate with RCSL compared with primary fascial closure (PFC). The purpose of this study was to assess the efficacy of RSCL in patients with septic shock. METHODS: The 2015 National Surgical Quality Improvement Project (NSQIP) database was queried for 11 International Statistical Classifications of Diseases (ICD)-10 codes associated with septic shock. Collected data included age, gender, body mass index (BMI), wound class, American Society of Anesthesiologists (ASA) class, operative time, number of risk factors, and presence or absence of post-operative pneumonia. The risk factors were diabetes mellitus, alcohol or tobacco abuse, blood dyscrasias, disseminated cancer, and cardiac, gastrointestinal, pulmonary, hepatobiliary, or renal dysfunction. The primary outcomes were rate of re-operation, prevalence of post-operative pneumonia, hospital length of stay (LOS), and death by 30 days. RESULTS: The RSCL and PFC cohorts were each comprised of 56 patients matched for propensity scores for ICD-10 code. There were no significant differences in wound or ASA class, BMI, gender, or number of risk factors between the two cohorts. The operative time for RSCL was significantly shorter than for PFC (median 84 vs. 128 min, respectively; p = 0.002). There was no significant difference in re-operation rate, prevalence of post-operative pneumonia, LOS, or mortality rate between the two cohorts. CONCLUSIONS: Although this analysis showed no clear advantage to RSCL in the management of septic shock, it may be a means to salvage certain patients. The best way to assess the relative value of RSCL is a prospective trial.

Rapid Source-Control Laparotomy: Is There a Mortality Benefit?

BACKGROUND: The purpose of this study was to determine the influence rapid source-control laparotomy (RSCL) has on the mortality rate in non-trauma patients with intra-abdominal infection. The hypothesis was that RSCL reduces deaths and hospital lengths of stay (LOS) in patients compared with definitive repair and primary fascial closure (PFC). METHODS: The International Classification of Diseases-10 codes for sepsis, gastric and duodenal ulcer perforation or hemorrhage, incisional or ventral hernia with obstruction, intestinal volvulus, ileus with obstruction, diverticulitis with perforation or abscess, vascular disorder of intestine, non-traumatic intestinal perforation, peritoneal abscess, and unspecified peritonitis were used to query the 2015 National Surgical Quality Improvement Project (NSQIP) database for all patients treated with either RSCL or PFC. The two groups of patients were compared on the basis of LOS and deaths. Collected data included age, gender, body mass index (BMI), site classification, American Society of Anesthesiologists (ASA) class, operative time, number of risk factors, and pre-operative septic state. RESULTS: After adjusting for the aforementioned variables, propensity score-matched cohorts (n = 210 in each cohort) were used to evaluate the influence of incision closure type on LOS and mortality rate. The odds of death (31.4% vs. 21.4%) with RSCL was 1.78 (95% confidence interval 1.08-2.95; p = 0.02) times that of PFC. Closure type was not significantly associated with an increased LOS (median 14 vs. 11 days; p = 0.35). CONCLUSIONS: This retrospective cohort analysis demonstrated that RSCL is associated with higher odds of death in general surgical patients with intra-abdominal infection. There is a need for further studies to delineate what, if any, physiologic parameters indicate a need for RSCL.

Adrenal Hormones in Common Bottlenose Dolphins (Tursiops truncatus): Influential Factors and Reference Intervals.

Inshore common bottlenose dolphins (Tursiops truncatus) are exposed to a broad spectrum of natural and anthropogenic stressors. In response to these stressors, the mammalian adrenal gland releases hormones such as cortisol and aldosterone to maintain physiological and biochemical homeostasis. Consequently, adrenal gland dysfunction results in disruption of hormone secretion and an inappropriate stress response. Our objective herein was to develop diagnostic reference intervals (RIs) for adrenal hormones commonly associated with the stress response (i.e., cortisol, aldosterone) that account for the influence of intrinsic (e.g., age, sex) and extrinsic (e.g., time) factors. Ultimately, these reference intervals will be used to gauge an individual's response to chase-capture stress and could indicate adrenal abnormalities. Linear mixed models (LMMs) were used to evaluate demographic and sampling factors contributing to differences in serum cortisol and aldosterone concentrations among bottlenose dolphins sampled in Sarasota Bay, Florida, USA (2000-2012). Serum cortisol concentrations were significantly associated with elapsed time from initial stimulation to sample collection (p<0.05), and RIs were constructed using nonparametric methods based on elapsed sampling time for dolphins sampled in less than 30 minutes following net deployment (95% RI: 0.91-4.21 µg/dL) and following biological sampling aboard a research vessel (95% RI: 2.32-6.68 µg/dL). To examine the applicability of the pre-sampling cortisol RI across multiple estuarine stocks, data from three additional southeast U.S. sites were compared, revealing that all of the dolphins sampled from the other sites (N = 34) had cortisol concentrations within the 95th percentile RI. Significant associations between serum concentrations of aldosterone and variables reported in previous studies (i.e., age, elapsed sampling time) were not observed in the current project (p<0.05). Also, approximately 16% of Sarasota Bay bottlenose dolphin aldosterone concentrations were below the assay's detection limit (11 pg/mL), thus hindering the ability to derive 95th percentile RIs. Serum aldosterone concentrations from animals sampled at the three additional sites were compared to the detection limit, and the proportion of animals with low aldosterone concentrations was not significantly different than an expected prevalence of 16%. Although this study relied upon long-term, free-ranging bottlenose dolphin health data from a single site, the objective RIs can be used for future evaluation of adrenal function among individuals sampled during capture-release health assessments.

Lacaziosis-like disease among bottlenose dolphins Tursiops truncatus photographed in Golfo Dulce, Costa Rica.

Lacaziosis (also known as lobomycosis) is a chronic dermal disease caused by the fungal agent Lacazia loboi, which affects both humans and dolphins. Photographic data have been used to identify lacaziosis-like disease (LLD) among dolphins in the waters of North and South America, and here we report LLD in bottlenose dolphins Tursiops truncatus off the coast of Costa Rica, the first reporting in Central American waters. During the periods of 1991 to 1992 and 2010 to 2011, 3 research teams conducted separate dolphin surveys in the Pacific tropical fiord Golfo Dulce, and each documented skin lesions in the resident population of bottlenose dolphins. Photo-ID records were used to identify LLD-affected bottlenose dolphins and to assess their lesions. Findings showed between 13.2 and 16.1% of the identified dolphins exhibited lesions grossly resembling lacaziosis. By combining efforts and cross-referencing photographic data, the teams explored the presence of LLD in Golfo Dulce over a time gap of approximately 20 yr. Our findings expand the geographical range of the disease and offer insight into its longevity within a given population of dolphins.