Diagnosis and Management of Amanita Phalloides Toxicity in the Emergency Department Observation Unit: A Case Report.

Introduction: Mushroom toxicity is an important etiology of acute liver injury in a patient with gastrointestinal symptoms. Case Report: We present the case of a male patient presenting to the emergency department (ED) with gastrointestinal distress who was placed under ED observation for elevated liver function tests. During his hospital course, it was revealed he had consumed wild mushrooms believed to be Amanita phalloides. Conclusion: While mushroom ingestion and subsequent toxicity are rare, a high index of suspicion in foraging hobbyists is essential to arriving at the correct diagnosis and directing the patient to the appropriate management.

Tides regulate the flow and density of Antarctic Bottom Water from the western Ross Sea.

Antarctic Bottom Water (AABW) stores heat and gases over decades to centuries after contact with the atmosphere during formation on the Antarctic shelf and subsequent flow into the global deep ocean. Dense water from the western Ross Sea, a primary source of AABW, shows changes in water properties and volume over the last few decades. Here we show, using multiple years of moored observations, that the density and speed of the outflow are consistent with a release from the Drygalski Trough controlled by the density in Terra Nova Bay (the "accelerator") and the tidal mixing (the "brake"). We suggest tides create two peaks in density and flow each year at the equinoxes and could cause changes of ~ 30% in the flow and density over the 18.6-year lunar nodal tide. Based on our dynamic model, we find tides can explain much of the decadal variability in the outflow with longer-term changes likely driven by the density in Terra Nova Bay.

Optimization of antidote stocking, availability, and administration practices for a large multihospital organization.

PURPOSE: Inadequate hospital antidote inventory is a widely documented international issue due to high medication costs, lack of emphasis on antidote importance, variable international standards, hospital size, and drug availability. A large health system underwent process and policy implementation for antidote stocking, availability tracking, and administration strategies to ensure appropriate inventory and improve patient safety. SUMMARY: Process and policy implementation occurred over a 12-month period across the health system's 11 acute care hospitals with emergency department services. Opportunities for optimization were identified following data capture surrounding institution-specific antidote inventory and usage across the health system. Specifically, minimum par levels at each institution were determined from 2018 expert recommendations for both the central pharmacy and automated dispensing machines within the emergency department. These quantities ensured the availability of an antidote within a specific timeframe contingent on the acquisition acuity for at least one 100-kg patient. Entries for order sets, order statements, and smart pump drug libraries were modified or formulated to facilitate standardized practices and minimize safety errors before a system-wide electronic health record transition. CONCLUSION: It is prudent for all institutions, independent or within a health system, to identify areas of improvement for antidote inventory and management. Implementation of a similar process for antidote stocking, sharing, and delivery at other institutions is feasible and necessary to mitigate issues with drug acquisition and timely administration.

Natural cycles in South Pacific Gyre strength and the Southern Annular Mode.

The South Pacific Gyre (SPG) plays a vital role in regulating Southern Hemisphere climate and ecosystems. The SPG has been intensifying since the twentieth century due to changes in large scale wind forcing. These changes result from variability in the Southern Annular Mode (SAM), causing warming along the eastern SPG which affects local ecosystems. However, our understanding of SPG variability on timescales greater than several decades is poor due to limited observations. Marine sediment cores are traditionally used to determine if recent ocean trends are anomalous, but rarely capture centennial variability in the southwest Pacific and limit our understanding of SPG variability. Here we capture centennial SPG dynamics using a novel high-resolution paleocirculation archive: radiocarbon reservoir ages (R) and local reservoir corrections (∆R) in SPG deep-sea black corals. We find black coral R and ∆R correlates with SAM reconstructions over 0-1000 cal BP and 2000-3000 cal BP. We propose this correlation indicates varying transport of well-ventilated subtropical waters resulting from SPG and SAM interactions. We reconstruct several 'spin up' cycles reminiscent of the recent gyre intensification, which has been attributed to anthropogenic causes. This implies gyre strength and SAM show natural co-variability on anthropogenic timescales which should factor into future climate projections.

The role of tides in bottom water export from the western Ross Sea.

Approximately 25% of Antarctic Bottom Water has its origin as dense water exiting the western Ross Sea, but little is known about what controls the release of dense water plumes from the Drygalski Trough. We deployed two moorings on the slope to investigate the water properties of the bottom water exiting the region at Cape Adare. Salinity of the bottom water has increased in 2018 from the previous measurements in 2008-2010, consistent with the observed salinity increase in the Ross Sea. We find High Salinity Shelf Water from the Drygalski Trough contributes to two pulses of dense water at Cape Adare. The timing and magnitude of the pulses is largely explained by an inverse relationship with the tidal velocity in the Ross Sea. We suggest that the diurnal and low frequency tides in the western Ross Sea may control the magnitude and timing of the dense water outflow.

Comparison between carbon monoxide poisoning from hookah smoking versus other sources.

Introduction: Carbon monoxide exposure is a relatively unknown risk of smoking hookah. Dozens of cases of hookah-associated carbon monoxide toxicity have been described over the past decades, but smoking hookah is generally perceived as safe. Only recently have larger series of hookah-associated carbon monoxide toxicity been published. This study evaluates the incidence of hookah-associated carbon monoxide toxicity over 4 years, and compares the exposures from hookah against other carbon monoxide sources.Methods: This is a retrospective cohort study of all patients with carbon monoxide toxicity referred for hyperbaric oxygen therapy at an urban hyperbaric oxygen referral center from January 2015 through December 2018. Cases of hookah-associated carbon monoxide toxicity were compared to patients exposed to other carbon monoxide sources, with an analysis of patient comorbidities, symptomatology, and laboratory evaluation.Results: Over a 48-month period, 376 patients underwent hyperbaric oxygen therapy for carbon monoxide exposure. After exclusions, 265 patients with carbon monoxide toxicity from various sources were analyzed. There were 58 patients with hookah-associated carbon monoxide toxicity (22%). The proportion of hookah-associated carbon monoxide cases increased markedly in the latter years: 2015: 9.5%, 2016: 8.6%, 2017: 24.1%, 2018 41.6%. In the final 2 years analyzed, hookah smoking was the most frequent source of carbon monoxide toxicity referred for therapy. Hookah-associated carbon monoxide patients were younger(28.1 vs. 45.0 years, mean difference 16.8 years, 95% confidence interval: 11.5, 22.1 years, p < 0.001) and more likely to be female (60% vs. 46.6%, p = 0.06) than patients exposed to other carbon monoxide sources. The mean difference in carboxyhemoglobin concentration between hookah associated and those exposed to other carbon monoxide sources was 4.6% (mean 20.1% vs. 24.6%, 95%CI: 1.7, 7.5, p = 0.002).Conclusion: A substantial portion of patients with severe carbon monoxide toxicity was exposed through smoking hookah. The incidence of hookah-related carbon monoxide toxicity appears to be increasing.

Atypical Pharmacodynamic Properties and Metabolic Profile of the Abused Synthetic Cannabinoid AB-PINACA: Potential Contribution to Pronounced Adverse Effects Relative to Δ9-THC.

Recreational use of marijuana is associated with few adverse effects, but abuse of synthetic cannabinoids (SCBs) can result in anxiety, psychosis, chest pain, seizures and death. To potentially explain higher toxicity associated with SCB use, we hypothesized that AB-PINACA, a common second generation SCB, exhibits atypical pharmacodynamic properties at CB1 cannabinoid receptors (CB1Rs) and/or a distinct metabolic profile when compared to Δ9-tetrahydrocannabinol (Δ9-THC), the principal psychoactive cannabinoid present in marijuana. Liquid chromatography tandem mass spectrometry (LC/MS) identified AB-PINACA and monohydroxy metabolite(s) as primary phase I metabolites (4OH-AB-PINACA and/or 5OH-AB-PINACA) in human urine and serum obtained from forensic samples. In vitro experiments demonstrated that when compared to Δ9-THC, AB-PINACA exhibits similar affinity for CB1Rs, but greater efficacy for G-protein activation and higher potency for adenylyl cyclase inhibition. Chronic treatment with AB-PINACA also results in greater desensitization of CB1Rs (e.g., tolerance) than Δ9-THC. Importantly, monohydroxy metabolites of AB-PINACA retain affinity and full agonist activity at CB1Rs. Incubation of 4OH-AB-PINACA and 5OH-AB-PINACA with human liver microsomes (HLMs) results in limited glucuronide formation when compared to that of JWH-018-M2, a major monohydroxylated metabolite of the first generation SCB JWH-018. Finally, AB-PINACA and 4OH-AB-PINACA are active in vivo, producing CB1R-mediated hypothermia in mice. Taken collectively, the atypical pharmacodynamic properties of AB-PINACA at CB1Rs relative to Δ9-THC (e.g., higher potency/efficacy and greater production of desensitization), coupled with an unusual metabolic profile (e.g., production of metabolically stable active phase I metabolites) may contribute to the pronounced adverse effects observed with abuse of this SCB compared to marijuana.

Leucine acts in the brain to suppress food intake but does not function as a physiological signal of low dietary protein.

Intracerebroventricular injections of leucine are sufficient to suppress food intake, but it remains unclear whether brain leucine signaling represents a physiological signal of protein balance. We tested whether variations in dietary and circulating levels of leucine, or all three branched-chain amino acids (BCAAs), contribute to the detection of reduced dietary protein. Of the essential amino acids (EAAs) tested, only intracerebroventricular injection of leucine (10 µg) was sufficient to suppress food intake. Isocaloric low- (9% protein energy; LP) or normal- (18% protein energy) protein diets induced a divergence in food intake, with an increased consumption of LP beginning on day 2 and persisting throughout the study (P < 0.05). Circulating BCAA levels were reduced the day after LP diet exposure, but levels subsequently increased and normalized by day 4, despite persistent hyperphagia. Brain BCAA levels as measured by microdialysis on day 2 of diet exposure were reduced in LP rats, but this effect was most prominent postprandially. Despite these diet-induced changes in BCAA levels, reducing dietary leucine or total BCAAs independently from total protein was neither necessary nor sufficient to induce hyperphagia, while chronic infusion of EAAs into the brain of LP rats failed to consistently block LP-induced hyperphagia. Collectively, these data suggest that circulating BCAAs are transiently reduced by dietary protein restriction, but variations in dietary or brain BCAAs alone do not explain the hyperphagia induced by a low-protein diet.

Development of a real-time PCR assay for identification and quantification of the fish pathogen Francisella noatunensis subsp. orientalis.

Members of the genus Francisella are small Gram-negative facultative intracellular bacteria that cause francisellosis in a wide variety of fish species worldwide. F. noatunensis subsp. orientalis has been recently described as a warm-water pathogen of tilapia Oreochromis spp. In this study, a quantitative real-time polymerase chain reaction (qPCR) TaqMan probe assay was developed to rapidly and accurately detect and quantify F. noatunensis subsp. orientalis from fish tissue. The target region of the assay was the F. tularensis iglC gene homologue previously found in F. noatunensis subsp. orientalis. Probe specificity was confirmed by the lack of signal and cross-reactivity with 12 common fish pathogens, 2 subspecies of F. tularensis, F. noatunensis subsp. noatunensis, and tilapia tissue. The range of linearity was determined to be 50 fg to 1.4 mg, and the lower limit of detection was 50 fg of DNA (equivalent to approximately 25 genome equivalents) per reaction. A similar sensitivity was observed with DNA extracted from a mixture of F. noatunensis subsp. orientalis and fish tissue. The assay was also able to detect and quantify F. noatunensis subsp. orientalis from the spleens of experimentally infected tilapia. No signal was observed in the control groups. In conclusion, we have developed a highly sensitive and specific assay that can be used for the specific identification and quantification of F. noatunensis subsp. orientalis.

Interaction of Francisella asiatica with tilapia (Oreochromis niloticus) innate immunity.

Members of the genus Francisella are facultative intracellular bacteria that cause important diseases in a wide variety of animals worldwide, including humans and fish. Several genes that are important for intramacrophage survival have been identified, including the iglC gene, which is found in the iglABCD operon in the Francisella sp. pathogenicity island (FPI). In the present study, we examined the interaction of wild-type Francisella asiatica and a Delta iglC mutant strain with fish serum and head kidney-derived macrophages (HKDM). Both the wild-type and the mutant strains were resistant to killing by normal and heat-inactivated sera. The wild-type F. asiatica is able to invade tilapia head kidney-derived macrophages and replicate vigorously within them, causing apoptosis and cytotoxicity in the macrophages at 24 and 36 h postinfection. The Delta iglC mutant, however, is defective for survival, replication, and the ability to cause cytotoxicity in HKDM, but the ability is restored when the mutant is complemented with the iglC gene. Uptake by the HKDM was mediated partially by complement and partially by macrophage mannose receptors, as demonstrated by in vitro assays. Light and electron microscopy analysis of the infected macrophages revealed intracellular bacteria present in a tight vacuole at 2 h postinoculation and the presence of numerous bacteria in spacious vacuoles at 12 h postinfection, with some bacteria free in the cytoplasm.

Attenuation of the fish pathogen Francisella sp. by mutation of the iglC* gene.

Fish francisellosis is an emergent disease caused by gram-negative facultative intracellular bacteria of the genus Francisella. Different strains of the bacterium have caused high mortalities in warmwater and coldwater fish species. Francisella sp. isolates from fish have been found to share more than 97% identity to the human pathogen Francisella tularensis upon 16S ribosomal RNA sequence comparison. Homologue genes of the F. tularensis intracellular growth locus (iglA*, iglB*, iglC*, and iglD*) were identified from LADL 07-285A, a clinical isolate obtained from diseased Nile tilapia Oreochromis niloticus. The iglABCD operon DNA sequence comparison revealed that Francisella LADL 07-285A had 94% identity with F. philomiragia subsp. philomiragia and 83% identity with F. tularensis subsp. novicida U112. The functions of the conserved proteins corresponding to the genes are elusive but appear to be essential for the ability of Francisella sp. to survive within macrophages and cause disease. An insertion mutation was made in the iglC* gene of LADL 07-285A by allelic exchange, and the iglC* mutant was found to be attenuated after intraperitoneal and immersion challenges in Nile tilapia. Laboratory challenge methods for inducing francisellosis in Nile tilapia were evaluated by intraperitoneal injection and immersion with serial dilutions of Francisella LADL 07-285A. The dose lethal to 50% of test fish at 40 d postchallenge was 10(-5.3) (about 1.2 X 10(3) colony-forming units/fish) by intraperitoneal injection and was 10(-1) (2.3 X 10(7) colony-forming units/mL of tank water) by immersion.

Signature-tagged mutagenesis of Edwardsiella ictaluri identifies virulence-related genes, including a salmonella pathogenicity island 2 class of type III secretion systems.

Edwardsiella ictaluri is the leading cause of mortality in channel catfish culture, but little is known about its pathogenesis. The use of signature-tagged mutagenesis in a waterborne infection model resulted in the identification of 50 mutants that were unable to infect/survive in catfish. Nineteen had minitransposon insertions in miscellaneous genes in the chromosome, 10 were in genes that matched to hypothetical proteins, and 13 were in genes that had no significant matches in the NCBI databases. Eight insertions were in genes encoding proteins associated with virulence in other pathogens, including three in genes involved in lipopolysaccharide biosynthesis, three in genes involved in type III secretion systems (TTSS), and two in genes involved in urease activity. With the use of a sequence from a lambda clone carrying several TTSS genes, Blastn analysis of the partially completed E. ictaluri genome identified a 26,135-bp pathogenicity island containing 33 genes of a TTSS with similarity to the Salmonella pathogenicity island 2 class of TTSS. The characterization of a TTSS apparatus mutant indicated that it retained its ability to invade catfish cell lines and macrophages but was defective in intracellular replication. The mutant also invaded catfish tissues in numbers equal to those of invading wild-type E. ictaluri bacteria but replicated poorly and was slowly cleared from the tissues, while the wild type increased in number.