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Objectives: This study seeks to determine validity evidence for a newly developed multiple-choice examination (MCE) tool to assess retention and application of medical knowledge of students enrolled in a pediatric emergency medicine (PEM) clerkship., Methods: A team of PEM physicians created a 110-item MCE covering the range of clinical topics in PEM relevant for medical students. The researchers determined examination content using the report of Clerkship Directors in Emergency Medicine and PEM Interest Group of the Society for Academic Emergency Medicine (SAEM). The authors administered the MCE to fourth-year medical students at the end of their PEM rotation from May 2020 to April 2023 at four institutions and then analyzed the examination using four of Messick's five sources of validity evidence: content, response process, internal structure, and relation to other variables., Results: A total of 158 students took the test. In academic year (AY)20-21, 47 students took the test and scored, on average, 81%. After revision of poor and indeterminate questions, the 111 medical students who took the revised version of the test in AY21-AY23 scored on average 77.3% with a standard deviation of 5.7% with a normal distribution in scores. The revised questions were rated as excellent (10.0%), good (26.4%), fair (34.5%), poor (24.5%), or indeterminate (4.5%) based on test item discrimination. There was a positive correlation between MCE scores and students' clinical evaluations but no correlation between MCE scores and scores that students received on their clinical notes or patient presentations during case conference., Conclusions: This novel PEM clerkship examination is a reliable test of medical knowledge. Future directions involve evaluating consequences of the MCE and offering the test to medical students in a dedicated PEM rotation at the national level., Competing Interests: The authors declare no conflicts of interest., (© 2024 Society for Academic Emergency Medicine.)

Background: Injuries, the leading cause of death in children 1-17 years old, are often preventable. Injury patterns are impacted by changes in the child's environment, shifts in supervision, and caregiver stressors. The objective of this study was to evaluate the incidence and proportion of injuries, mechanisms, and severity seen in Pediatric Emergency Departments (PEDs) during the COVID-19 pandemic., Methods: This multicenter, cross-sectional study from January 2019 through December 2020 examined visits to 40 PEDs for children < 18 years old. Injury was defined by at least one International Classification of Disease-10th revision (ICD-10) code for bodily injury (S00-T78). The main study outcomes were total and proportion of PED injury-related visits compared to all visits in March through December 2020 and to the same months in 2019. Weekly injury visits as a percentage of total PED visits were calculated for all weeks between January 2019 and December 2020., Results: The study included 741,418 PED visits for injuries pre-COVID-19 pandemic (2019) and during the COVID-19 pandemic (2020). Overall PED visits from all causes decreased 27.4% in March to December 2020 compared to the same time frame in 2019; however, the proportion of injury-related PED visits in 2020 increased by 37.7%. In 2020, injured children were younger (median age 6.31 years vs 7.31 in 2019), more commonly White (54% vs 50%, p < 0.001), non-Hispanic (72% vs 69%, p < 0.001) and had private insurance (35% vs 32%, p < 0.001). Injury hospitalizations increased 2.2% (p < 0.001) and deaths increased 0.03% (p < 0.001) in 2020 compared to 2019. Mean injury severity score increased (2.2 to 2.4, p < 0.001) between 2019 and 2020. Injuries declined for struck by/against (- 4.9%) and overexertion (- 1.2%) mechanisms. Injuries proportionally increased for pedal cycles (2.8%), cut/pierce (1.5%), motor vehicle occupant (0.9%), other transportation (0.6%), fire/burn (0.5%) and firearms (0.3%) compared to all injuries in 2020 versus 2019., Conclusions: The proportion of PED injury-related visits in March through December 2020 increased compared to the same months in 2019. Racial and payor differences were noted. Mechanisms of injury seen in the PED during 2020 changed compared to 2019, and this can inform injury prevention initiatives., (© 2023. The Author(s).)

Exposure to violence remains a significant issue for children in the United States. The COVID-19 pandemic exacerbated many of these exposures. Violence unequally impacts children of color and lesbian, gay, bisexual, transgender, and questioning youth. Pediatricians can and must continue to advocate and intervene to decrease pediatric violence exposure and its effects., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: To measure the risk of a subsequent assault-related emergency department (ED) visit in assault injured adolescents as compared to those who initially presented for non-assault related injuries., Methods: This was a historical cohort study of youth (ages 10-18 years) seen at two pediatric EDs between 2016 and 2019. Participants were included if their visit had an International Classification of Diseases-10 code for assaultive injury or accidental injury (motor vehicle collisions (MVC) and sports injuries). We calculated the rate of a subsequent ED visit for an assault-related injury, and then used survival analysis to compare time to subsequent ED visit with an assault-related injury between study and comparison groups., Results: A total of 6125 adolescents met inclusion criteria (Assault: n = 2782, 45.4%; MVC: n = 1834, 29.9%; Sports n = 1509, 24.6%). The overall rate per 100 person years of a subsequent assault-related ED visit was 5.6 (n = 344). Patients who initially presented with an assault-related injury had an increased adjusted relative risk (aRR) of return for a subsequent ED visit for an assault-related injury when compared to MVC patients (aRR 17.6 [95% CI: 9.6, 32.2]). Kaplan-Meier time to event analysis found that patients in the assault injury group have a higher probability of a subsequent ED visit for an assault-related injury compared to patients in the MVC injury group (adjusted hazard ratio (aHR): 17.7 [95% CI: 9.67, 32.42])., Discussion: Adolescents injured by assault are more likely to return to the ED for a subsequent assault-related injury compared to adolescents who initially present with non-assault-related injuries., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Several studies show that emergency medicine (EM) physicians are less comfortable caring for pediatric patients than adults. The state of pediatric training has not been comprehensively evaluated since 2000., Objectives: We sought to describe current pediatric education in EM residencies and to evaluate EM Program Director (PD) confidence in graduating trainees' abilities to care for pediatric patients., Methods: We conducted an anonymous, cross-sectional survey study of EM PDs in August 2020. We collected program demographics, clinical rotations, and didactic methods. We used Likert scales to measure PD confidence in graduating residents' competence to care for pediatric and adult patients., Results: We found e-mail addresses for 249 (93%) of 268 EM programs. One hundred nineteen (48%) PDs completed the survey. We include denominators to account for unanswered questions. Sixty-eight (59%) of 116 programs spend 10% to 20% of clinical time seeing pediatric patients. One hundred ten (91%) of 119 require a pediatric emergency medicine (PEM) rotation, 88/119 (83%) require pediatric intensive care, and 34/119 (29%) require neonatal intensive care. Seventy (62%) of 113 have curricula designed by PEM-trained faculty, 96/113 (85%) have PEM attendings teach lectures, and 77/113 (68%) spend 10% to 20% of didactic time on pediatric topics. Twenty-three (23%) of 106 PDs stated not all residents graduate with competence in pediatric resuscitation compared with 2/106 (2%) for adult resuscitation ( P < 0.05)., Conclusions: Program directors report less confidence in graduating residents' competence in caring for pediatric patients compared with adult patients. We propose ideas to strengthen the quality of pediatric education in EM residencies., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Sleep-related infant deaths in the District of Columbia (DC) varies, with rates in certain geographical areas three times higher than DC and seven times higher than the national average. We sought to understand differences in infant sleep knowledge, beliefs, and practices between families in high-risk infant mortality and low-risk infant mortality areas in DC., Methods: Caregivers of infants presenting to the emergency department were surveyed. The associations between location and safe sleep knowledge, beliefs, and practices were analyzed., Results: Two hundred and eighty-four caregivers were surveyed; 105 (37%) were from the high-risk infant mortality area. The majority (68%) of caregivers reported placing their infant to sleep on their backs, sleeping in a crib, bassinet, or pack and play (72%), and were familiar with the phrase "safe sleep" (72%). Caregivers from the high-risk infant mortality area were more likely to report that their infants sleep in homes other than their own (aOR 1.53; 95% CI 1.23, 2.81) and other people took care of their infants while sleeping (aOR 1.76; 95% CI 1.17, 3.19), adjusting for race/ethnicity, education, marital status, and help with childcare. No differences in safe sleep knowledge, beliefs, and practices were present., Conclusions for Practice: Infants from the high-risk infant mortality area were more likely to sleep in homes other than their own and have other caretakers while sleeping. Lack of differences in caregiver awareness of safe sleep recommendation or practices suggests effective safe sleep messaging. Outreach to other caregivers and study of unmet barriers is needed., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: The aims of this study were to assess whether bullying experience among youths is associated with firearm access and to evaluate assault perpetration risk factors between bullied and nonbullied adolescents., Methods: This was a secondary analysis of a cross-sectional survey designed to measure self-reported social determinants of health and behavioral health risks among adolescents (13-21 years) in a pediatric emergency department between July 2017 and August 2019. Participants were included in this subanalysis if they responded to a survey item that assessed bullying. Multivariable logistic regression was used to measure the association of firearm access, weapon carriage, and assault perpetration factors (violence, mental health, substance abuse, and justice involvement) with bullying after adjustment for sex, race/ethnicity, and insurance status., Results: Of the 369 participants meeting inclusion criteria, 147 adolescents (40.5%) reported experiencing bullying. Bullied teenagers had higher odds of a gun in the home (adjusted odds ratio [aOR], 3.0; 95% confidence interval [CI], 1.2-7.8]), weapon carriage (aOR, 5.6; 95% CI, 1.6-18.8), witnessing an assault (aOR, 3.0; 95% CI, 1.6-5.6), negative experience with law enforcement (aOR, 4.5; 95% CI, 2.2-9.2), mental health diagnosis (aOR, 3.9; 95% CI, 2.3-6.7), and marijuana use (aOR, 2.7; 95% CI, 1.1-7.0])., Conclusions: More than 1 in 3 adolescents presenting to the emergency department report having ever experienced bullying. Bullied teenagers have a higher likelihood of firearm access, weapon carriage, and violent injury perpetration risk factors compared with nonbullied youths. Further studies are needed to understand the relationship between bullying and assault perpetration., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Firearm injuries are a leading cause of serious injury and death in childhood. The accuracy of International Classification of Disease (ICD) codes to assign intent is unclear. The objective of this study was to assess the validity of documented ICD codes for firearm injury intent compared with chart review., Methods: We performed a retrospective cohort study of children (<= 18 years) presenting to a tertiary care level 1 pediatric trauma center with firearm injuries between 2006 and 2017. We compared agreement between ICD codes and intent of injury determined by medical record review using Cohen κ. Intent for medical record review was assigned via the injury spectrum of intentionality (suicide attempt, accidental firing, mistaken target, firearm assault and unknown). For comparison with ICD codes, all medical record review cases marked as mistaken target were classified as accidental. A sensitivity analysis was then performed, coding all mistaken targets as assault., Results: There were 122 cases identified over the study period. The most common intent by ICD code was assault (n = 80, 65.6%). Medical record review categorized most injuries as mistaken targets. When mistaken target was categorized as accidental, most firearm injuries were coded as accidental (n = 89, 72.9%) Similar results were seen when mistaken target was categorized as assault, most injuries were categorized as assault (n = 79, 79.5%) Cohen κ was 0.15 when mistaken targets were categorized as accident and 0.30 when categorized as assault., Conclusions: The ICD codes do not fully describe the intent of firearm injury. Revising ICD codes to account for mistaken targets could help to improve the validity of ICD codes for intent., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Drug shortages have been increasing over the past 2 decades. There are limited data on drug shortages and their effect on pediatric emergency and critical care. Our objective was to describe pediatric emergency and critical care drug shortages., Methods: Drug shortage data from January 2001 to December 2015 were obtained from the University of Utah Drug Information Services. Shortages were reviewed, identifying agents used in pediatric emergency and critical care. Shortage data were analyzed for the type of drug, formulation, shortage reason, duration, marketing status (generic vs brand name), or if it was a pediatric-friendly formulation, used for a high-acuity condition, or a single-source product. The availability of a substitute was also described., Results: Of 1883 products on shortage, 779 were used in pediatric emergency or critical care. The annual number of shortages decreased from 2001 to 2004, but then increased, reaching a high in 2011. The median duration for resolved shortages was 7.6 months (interquartile range, 3.0-17.6 months). The most common category affected was infectious disease drugs. High-acuity agents were involved in 27% of shortages and in 11% of pediatric-friendly formulations. An alternative agent was available for 95% of drugs, yet 43% of alternatives were also affected at some time during the study period. The most common reported reason for a shortage was manufacturing problems., Conclusions: From 2001 to 2015, drug shortages affected a substantial number of agents used in pediatric emergency and critical care. This has had implications to the medications available for use and may impact patient outcomes. Providers must be aware of current shortages and implement mitigation strategies to optimize patient care., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

The genus Helicobacter includes spiral-shaped bacteria in the phylum Proteobacteria, class Epsilonproteobacteria, order Campylobacteriales, that have been associated with disease in animals, including reptiles. Three wild gopher tortoise (Gopherus polyphemus) index cases presented between 2012 and 2019 with nasal discharge, lethargy, and weight loss. Cytological examination of nasal discharge from all 3 tortoises identified marked heterophilic and mild histiocytic rhinitis with abundant extracellular and phagocytized spiral shaped bacteria that stained positive with Warthin-Starry stain. Polymerase chain reaction (PCR) and sequencing of the 16S rRNA gene revealed this to be a novel Helicobacter species. Two tortoises died despite treatment attempts, and the third was moribund and was euthanized. Histological examination of the nasal mucosa (n = 3) showed granulocytic to lymphocytic rhinitis with variable mucosal hyperplasia, erosion, and ulceration; Warthin-Starry staining highlighted the presence of spiral bacteria in the untreated tortoise. Genus-specific primers were designed, and the gyrA and groEL genes were amplified by PCR and sequenced. Phylogenetic analysis shows that this organism and other previously characterized Helicobacter from tortoises form a clade. Development and cross-validation of two qPCR diagnostic assays for the gyrA and groEL genes showed significant correlation of the results of two assays (P < 0.0001). These assays were used to survey nasal wash samples from 31 rehabilitating gopher tortoises. Mortality of tortoises significantly correlated with higher Helicobacter loads detected by qPCR (P = 0.028). Appropriate quarantine protocols for tortoises during rehabilitation should consider this organism. Upper respiratory disease in tortoises may involve complex microbial ecology; factors beyond Mycoplasmopsis (Mycoplasma) agassizii should be taken into account., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Coxiellosis, or Query (Q) fever, a disease caused by the intracellular bacteria Coxiella burnetii , was recently described in a managed breeding herd of white rhinoceros ( Ceratotherium simum ) in the southeastern United States. Clinical disease often results in abortion and could represent a conservation challenge for this species. In addition to the reproductive and herd management consequences, coxiellosis is also a zoonotic disease. Infection or clinical disease in any free-ranging rhinoceros species in a national park setting has not been previously described. In this study, evidence of prior infection was measured by immunofluorescent antibody titers in 89 serum samples collected from white rhinoceros within private reserves and a national park in South Africa. Total seropositivity was 48/89 (53.9% [95% CI, 43.6-63.9%]). Animals on private reserves had a seropositivity of 21/51 (41.1% [95% CI, 27.1-55.2%]), and national park rhinoceros had a higher rate of seropositivity at 71.0% [95% CI, 55.9-86.2%] (27/38; P = 0.004). Adults had a higher seropositivity compared with subadults ( P = 0.03). There was no difference in seropositivity between sexes ( P > 0.05). Results demonstrate that South African white rhinoceros populations are exposed to Coxiella, which could result in underrecognized reproductive consequences. Further studies should investigate potential implications for public health and conservation management of this species.

This study evaluated the use of a commercially available, visual enzyme-linked immunosorbent assay (ELISA) for diagnosis of pregnancy in okapi ( Okapia johnstoni ), gerenuk ( Litocranius walleri ), eastern giant eland ( Tragelaphus derbianus spp. gigas ), and dama gazelle ( Nanger dama ). This assay has been validated for use in domestic cattle, sheep, goats, and water buffalo. Unlike other blood-based pregnancy associated glycoprotein (PAG) detection methods, this assay does not require sophisticated laboratory equipment for detection or interpretation and can therefore be utilized in many settings. Banked serum samples from gerenuk ( n = 11), giant eland ( n = 4), dama gazelle ( n = 33) and okapi ( n = 3) were tested, and a pregnant and nonpregnant sample from each individual were included. The ELISA showed 100% sensitivity and specificity in gerenuk and giant eland samples, and 0% sensitivity in dama gazelle and okapi samples. Using this assay, pregnancy was detected by 7-8 wk gestation in gerenuk and 6 wk in giant eland. These results are consistent with previous studies that were able to accurately detect pregnancy in other members of the family Bovidae, but it is possible that PAGs present in okapi and dama gazelle are structurally dissimilar relative to the intended test target, and are therefore unrecognizable using this test. The faint positivity in the dama gazelle assays may be due to cross-reactivity with other proteins in the sample, or due to inconsistent binding with the dama gazelle PAG. This ELISA appears to be an accurate, rapid, and inexpensive method of point-of-care pregnancy diagnosis in gerenuk and giant eland, but not okapi and dama gazelle. Additional studies should be pursued to further characterize the limits of pregnancy detection using this assay in gerenuk and giant eland, and to investigate the validity of this test in other nondomestic ruminant species.

Case Description: A 15-year-old 0.412-kg (0.906-lb) sexually intact male eclectus parrot ( Eclectus roratus ) was evaluated because its owners found it lethargic and dyspneic at the bottom of its cage., Clinical Findings: The parrot was thin and had generalized muscle wasting, diffuse feather loss, pale mucous membranes, and melena. The coelomic cavity was distended and soft on palpation, with coelomic effusion suspected. Results of a CBC indicated leukocytosis with left shift heterophilia, including toxic heterophils, lymphopenia, and anemia. Plasma biochemical analyses revealed severe hyperamylasemia., Treatment and Outcome: Radiography revealed no evidence of a metallic foreign body but severe loss of coelomic detail, suggestive of a coelomic mass, coelomic effusion with coelomitis, or both. Ultrasonography and CT revealed severe accumulation of coelomic fluid; a large, heterogeneous, irregularly marginated, and moderately vascularized mass in the caudal aspect of the coelomic cavity; and multiple hepatic, coelomic, and pulmonary nodules. On the basis of a poor prognosis, the parrot was euthanized. Necropsy results confirmed exocrine pancreatic adenocarcinoma, with disseminated metastases in the liver, gastrointestinal tract, coelomic cavity, and lungs., Clinical Relevance: In birds, pancreatic adenocarcinoma is rarely reported but should be considered a differential diagnosis for hyperamylasemia, coelomic mass, coelomic effusion, or abnormal gastrointestinal signs, alone or in combination. Ultrasonography and CT can be useful in further evaluating such patients and should be considered in the diagnostic plan.

Objectives: Nonoperative management of hemodynamically stable liver lacerations in pediatric trauma patients is a safe and effective management strategy for pediatric patients; approximately 90% will be successfully managed nonoperatively. No study has specifically identified risk criteria for the need for intervention versus observation alone. Our objective for this study was to determine risk factors from the physical examination, computed tomography scan, and laboratory results associated with intervention for liver laceration., Methods: We performed a retrospective cohort study using data from the Pediatric Emergency Care Applied Research Network Intra-abdominal Injuries Study public use data set. Data were collected prospectively at the time of enrollment; a limited data set was released for public use in 2014. Patients were included if they were diagnosed with a liver laceration by computed tomography scan. We used bivariable and multivariable analyses to determine associations of specific risk factors with intervention, defined as laparotomy, angiographic embolization, blood transfusion, death, or return to emergency department for any reason within 30 days., Results: Of the 12,044 patients in the Intra-abdominal Injuries Study, 282 were diagnosed with a liver laceration. All patients were hospitalized, and 99 (35.1%) underwent an intervention. Variables were then eliminated if more than 10% of cases were missing data. Multivariable logistic regression identified the following independent risk factors for intervention: white blood cell count greater than 15 K/mcl (adjusted odds ratio [adjOR], 2.83; 95% confidence interval [CI], 1.43-5.63), pelvic fracture (adjOR, 2.50; 95% CI, 1.02-6.10), liver injury greater than grade 2 (adjOR, 2.16; 95% CI, 1.06-4.40), Glasgow Coma Scale score less than 15 (adjOR, 4.77; 95% CI, 2.27-7.63), and hematocrit less than 32% (adjOR, 4.79; 95% CI, 2.00-11.46)., Conclusions: We identified 5 high-risk criteria associated with intervention for traumatic liver laceration in pediatric patients. Prospective studies are necessary to validate these results before using them to determine disposition of pediatric patients with traumatic liver injuries.

Introduction: Firearm injuries and motor vehicle injuries are 2 leading causes of fatal injury in the U.S., each accounting for approximately 35,000 deaths annually. Research on firearm injuries is under-represented compared with research on motor vehicle collisions. This study seeks to identify perceived barriers to firearm injury research versus motor vehicle injury research., Methods: This was a mixed-methods survey of corresponding authors of a minimum of 1 study, archived in PubMed, related to firearm injury or motor vehicle injury between 2014 and 2018. Analyses were performed in 2019. Electronic surveys included both closed- and open-ended questions to assess barriers to research. Bivariable and multivariable logistic regression was performed to identify differences in perceptions to barriers between the 2 groups. Qualitative analysis of free-text responses was performed through inductive derivation of themes., Results: Surveys were distributed to 113 firearm injury researchers (42% response rate) and 241 motor vehicle injury researchers (31.5% response rate). After adjustment, firearm injury researchers were less likely to cite institutional support (AOR=0.3, 95% CI=0.1, 0.8) as a factor contributing to their success, than motor vehicle injury researchers. Firearm injury researchers were more likely to report fear of personal threats (AOR=10.4, 95% CI=2.4, 44.4) and experiencing personal threats (AOR=16.1, 95% CI=1.6, 165.4). Thematic analysis revealed 4 themes: career, political, funding, and harassment., Conclusions: When compared with motor vehicle injury researchers, firearm injury researchers are significantly more likely to report limited support and threats to personal safety as barriers to research. Further research to understand the impact of these barriers and methods to overcome them is needed., (Copyright © 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Firearms remain a common cause of injury in children. Advocacy is a tool that can be useful in effecting systemic change. Yet for firearm injury prevention, traditional methods of effecting change face unique barriers not experienced in other areas of pediatric injury prevention. As pediatric emergency medicine physicians, we are on the front lines, and as part of the receiving end of the trauma inflicted on our communities by firearms, ours is a powerful voice well suited to overcome these barriers. Current firearm advocacy efforts include raising awareness via social media or editorials, organizing larger advocacy groups for support, challenging legislation, and implementing hospital-based violence intervention programs. Future advocacy directions should include collaborating with unique partners, teleadvocacy, direct action, and finding common ground with gun regulation opposition. Physician advocacy is essential to firearm injury prevention. Continuing to innovate around our advocacy efforts will be vital to the health and safety of our patients., (© 2020 Elsevier Inc. All rights reserved.)

A non- albicans Candida species was identified in 6 birds exhibiting clinical signs associated with gastrointestinal disease. The clinical disease signs noted in these 6 birds included diarrhea, regurgitation, and melena, and were considered concurrent or identified secondary to other comorbidities. Candida glabrata was identified in a yellow-naped Amazon parrot ( Amazona auropalliata ), a ring-necked dove ( Streptopelia capicola ), a blue-and-gold macaw ( Ara ararauna ), and 2 cockatiels ( Nymphicus hollandicus ). Candida krusei was identified in a white-crowned parrot ( Pionus senilis ). Fungal culture and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry identification was correlated with results of fecal and/or crop Gram's stains, and DNA sequencing was used in one case. Three cases resolved after treatment, 2 birds died, and 1 was lost to follow-up. Non- albicans Candida infections are an emerging issue in human health care and are known to have an increased resistance to antifungal drugs. Similar to Candida albicans, these non- albicans Candida species are often identified in patients that have a history of prior antibiotic exposure. Recent data in human medicine describe a shift in species distribution away from C albicans dominance and toward other species, including C glabrata and C krusei . Both species are considered normal flora within the human and bird mycobiota and may emerge to cause disease, especially when the normal gastrointestinal environment has been disrupted.

Whole blood transfusions are an essential treatment modality during rehabilitation of stranded sea turtles, however, standardized protocols for transfusions are not available in reptile medicine. The objective of this study was to optimize a cross-matching protocol for sea turtle blood transfusions. Fresh venous blood samples from 15 turtles ( n = 14 green turtles, Chelonia mydas [Cm]; n = 1 loggerhead sea turtle, Caretta caretta [Cc]) were tested using a temperature-appropriate (i.e., reflecting body temperature), time-sensitive protocol in 26 reactions using two procedures for cross-match evaluation at 30 and 60 min at ambient air and water bath temperature. There were no significant differences between both protocols at 30- and 60-min incubation times or between microscopic evaluations at 2 or 5 min. The major cross-match identified 7/22 incompatible Cm-Cm reactions as observed by microscopic erythrocyte agglutination. Minor cross-matches resulted in 6/22 incompatible Cm-Cm reactions. About half of all Cm-Cm reactions (12/22) were compatible by major and minor cross-match. All Cc-Cm reactions (4/4) were incompatible. A higher than expected proportion of incompatible Cm cross-matching reactions suggests preexisting antibodies to nonself erythrocyte antigens in this species, or other factors promoting erythrocyte aggregation or agglutination. Preliminary data across Cm and Cc suggests cross-species incompatibility. These results indicate that sea turtles may react to donor erythrocytes even at the first transfusion. Concurrent major and minor cross-matching using the proposed protocol at 30-min incubation at room temperature should be considered a necessary and effective way to test for patient and donor incompatibilities in sea turtles., (Copyright 2019 by American Association of Zoo Veterinarians.)

Fibropapillomatosis of sea turtles is traditionally treated with surgical debulking techniques that are often associated with prolonged healing and tumor recurrence. Electrochemotherapy was recently described for green turtles Chelonia mydas and can be an alternative to surgery and even general anesthesia. The objectives of this study were to replicate an electrochemotherapy protocol from a previous report and add plasma bleomycin analysis to the treatment. After bleomycin injection into similarly sized tumors of two green turtles and immediate electroporation at two time points, plasma bleomycin reached detectable concentrations that were considerably lower than those found in human studies. At 3 months posttherapy, no healing complications or recurrences were encountered and only scar tissue remained. This study adds further support that electrochemotherapy with bleomycin has the potential to be used as an effective alternative treatment for this complex disease., (© 2019 American Fisheries Society.)

The objectives of this study were to describe a minimally invasive coelomic fluid sampling technique in elasmobranchs, to characterize the coelomic fluid composition in clinically normal and abnormal animals, and to compare findings from wild and managed populations. Fluid was collected via the coelomic pore in 89 individuals from 16 species spanning clinically normal and abnormal patients within a managed population (n = 54), a semi-managed open-lagoon population (n = 18), and a wild population (n = 17). Biochemical and cytological fluid analyses were performed on all samples, and bacterial and fungal culture, protein electrophoresis, and cholesterol electrophoresis were performed on a subset of samples. The presence of a variable volume of colorless to white and clear to slightly turbid coelomic fluid was consistent with a normal finding; however, the cytological and chemical makeup of coelomic fluid was found to provide additional clinically relevant information. The coelomic fluid from some of the abnormal samples (n = 37) contained white blood cells (n = 15) and concurrent bacteria (n = 7), the latter suggestive of bacterial coelomitis. Yolk was identified in both clinically normal and abnormal females. Of the biochemical parameters tested, calcium, chloride, cholesterol, osmolality, phosphorus, salinity, sodium, specific gravity, total protein, and urea nitrogen have clinical utility. Abnormal samples were mostly associated with reproductive disease, but to a lesser extent with coelomitis and hemocoelom. The wild and semi-managed groups had biochemical differences presumably reflective of the higher salinity of ocean water compared with that in the managed habitat. Aerobic bacteria were identified in normal (n = 7) and abnormal (n = 11) animals. Positive bacterial culture without inflammation may be normal. This study contributes to a further understanding of elasmobranch coelomic fluid analysis and its use as a diagnostic modality for the evaluation of elasmobranch health., (© 2019 American Fisheries Society.)

A 25-year-old female yellow-naped Amazon parrot ( Amazona auropalliata) was presented for an acute onset of lethargy, ptyalism, and regurgitation. Results of hematologic testing and plasma biochemical analysis revealed severe leukopenia and heteropenia with toxic heterophils and marked hyperamylasemia and hypoproteinemia, consistent with gastrointestinal dysfunction. Survey radiograph findings were suggestive of coelomic effusion. Results of a contrast-enhanced computed tomography (CT) scan revealed a tubular, irregularly marginated structure along the medial aspect of the duodenum, consistent with an inflamed pancreas. The bird died soon after CT imaging, and acute necrotizing pancreatitis and pancreatic coagulative necrosis were observed at necropsy. This report describes the use of a less-invasive modality such as CT to aid in the antemortem diagnosis of acute pancreatitis in a psittacine bird. Pancreatitis should be considered a differential diagnosis in birds with gastrointestinal signs and coelomic effusion visualized on radiography, and the observation of an enlarged inflamed pancreas in the absence of a defined pancreatic mass on CT.

Objective: To describe contemporary drug shortages affecting general ambulatory pediatrics., Study Design: Data from January 2001 to December 2015 were obtained from the University of Utah Drug Information Service. Two pediatricians reviewed drug shortages and identified agents used in ambulatory pediatrics. Shortage data were analyzed by the type of drug, formulation, reason for shortage, duration, marketing status, if a pediatric friendly-formulation was available, or if it was a single-source product. The availability of an alternative, and whether that alternative was affected by a shortage, also was noted., Results: Of 1883 products in shortage during the study period, 314 were determined to be used in ambulatory pediatrics. The annual number of new pediatric shortages decreased initially but then increased to a high of 38 in 2011. Of the 314 pediatric shortages, 3.8% were unresolved at the end of the study. The median duration of resolved shortages was 7.6 months. The longest shortage was for ciprofloxacin 500-mg tablets. The most common class involved was infectious disease drugs. Pediatric-friendly dosage forms were affected in 19.1% of shortages. An alternative agent was available for 86% drugs; however, 29% of these also were affected. The most common reason for shortage was manufacturing problems., Conclusions: Drug shortages affected a substantial number of agents used in general ambulatory pediatrics. Shortages for single-source products are a concern if a suitable alternative is unavailable. Providers working in the ambulatory setting must be aware of current shortages and implement mitigation strategies to optimize patient care., (Copyright © 2018 Elsevier Inc. All rights reserved.)

In the years following the abolition of the English National Board for Nursing, Midwifery and Health Visiting in 2002, concerns were raised within the Critical Care nursing community about a lack of consistency in post-registration education programmes. In response to this, the Critical Care Network National Nurse Leads (CC3N) formed a sub-group, the Critical Care Nurse Education Review Forum (CCNERF) to address these concerns. A review of UK course provision confirmed marked inconsistency in the length, content and associated academic award. The CCNERF commenced a two-phase project, first developing national standards for critical care nurse education such as length of course and academic credit level, followed by the development of a national competency framework. Following significant review and revision, version two of the National Competency Framework for Registered Nurses in Adult Critical Care was published by CC3N in 2015. This paper introduces the National Competency Framework and provides an overview of its background, development and implementation. It then considers the future direction of UK post-registration Critical Care nurse education.

The American College of Radiology (ACR) Computed Tomography (CT) Accreditation Program requires submission of phantom scans acquired with the ACR accreditation phantom. There is a known issue with some wide-beam scanners in which the Hounsfield unit (HU) value of water may be correct when using the scanner manufacturer's phantom, but will be out of range in some scan modes when scanning the accreditation phantom. The phantom manufacturer has developed a product known as Extension Plates to eliminate the water HU value issue. The purpose of this technical note is to evaluate the effectiveness of the Extension Plates in alleviating the water HU issue. The ACR phantom was scanned on nine different CT scanners representing four CT manufacturers at eight different facilities. Scanner models included 16- and 64-channel geometries from each manufacturer. All scanners passed routine daily water HU testing per the manufacturer's instructions. The accreditation phantom was scanned in helical and axial modes both with and without the Extension Plates present. Regions of interest were placed on the linearity test objects as well as the water HU test object in Module 1 of the phantom. Mean values were recorded and compared with the acceptable ranges specified by the ACR accreditation phantom testing instructions. Water HU values failed for one scanner model when scanned in helical mode using the widest collimation available and the Extension Plates were not present. All other scanner models passed the water HU linearity test with or without the Extension Plates in both axial and helical scan modes. Three of the four manufacturers tested failed the linearity test for different materials. The presence of the Extension Plates only affected the HU measurement for the water test object.

Vertical product information flow is important with regard to consumers' perceptions of the meat which they buy. When research and analysis of traceability is carried out it is often found that critical points where information is systematically lost are encountered in the transformations of the resources. This study describes how lamb meat can be both tracked and traced through a lamb meat producer (company A). At company A 60% of the resource transformations were shown to be additions, mixing and splitting, these are considered to be those which produce the most critical traceability points. After an analysis of the current traceability system at company A suggested improvements were made. With regard to granularity of traceability they cannot trace individual animals during production, but rather a set of animals. The smallest traceable resource unit (TRU) company A can trace back to be a set of (identifiable) animals from one specific farm.

Gulf of Mexico hypoxia has received considerable scientific and policy attention because of its potential ecological and economic impacts and implications for agriculture within its massive watershed. A 2000 assessment concluded that increased nitrate load to the Gulf since the 1950s was the primary cause of large-scale hypoxia areas. More recently, models have suggested that large-scale hypoxia did not start untilthe mid-1970s, and that a 40-45% nitrogen load reduction may be needed to reach the hypoxia area goal of the Hypoxia Action Plan. Recently, USGS revised nutrient load estimates to the Gulf, and the Action Plan reassessment has questioned the role of phosphorus versus nitrogen in controlling hypoxia. In this paper, we re-evaluate model simulations, hindcasts, and forecasts using revised nitrogen loads, and testthe ability of a phosphorus-driven version of the model to reproduce hypoxia trends. Our analysis suggests that, if phosphorus is limiting now, it became so because of relative increases in nitrogen loads during the 1970s and 1980s. While our model suggests nitrogen load reductions of 37-45% or phosphorus load reductions of 40-50% below the 1980-1996 average are needed, we caution that a phosphorus-only strategy is potentially dangerous, and suggest it would be prudent to reduce both.

A backward masking paradigm was employed to investigate temporal resolution capabilities in normal-hearing subjects of increasing chronological age. Results have documented: (1) a 2-, 4-, 8-, and 11-fold decibel magnitude difference for averaged psychoacoustic functions when comparing data obtained from young adults to those of elderly listeners; (2) that backward masking function slopes become significantly steeper with age, especially at very short interstimulus intervals; (3) a significant interaction between age and target frequency; (4) a linear age-associated decrement in presumed temporal resolution abilities, and (5) no significant target frequency difference nor any ear differences existed. Both end organ and central nervous system mechanisms were considered in explaining these findings.

A 14-year-old white girl with mild dysostosis multiplex, odontoid hypoplasia, short stature, cloudy corneas, keratansulfaturia, but without detectable central nervous system abnormalities was referred with the diagnosis of Morquio syndrome. Clinical and roentgenographic findings were minimal compared to those of typical patients with the Morquio syndrome, MPS IV. Beta-Galactosidase activity in extracts of the patient's cultured fibroblasts was deficient, while that of galactosamine-6-sulfate sulfatase was normal. Conjunctival biopsy revealed intracytoplasmic vacuoles typical of lysosomal storage diseases. It is postulated that in this patient the deficiency of a beta-galactosidase is responsible for inadequate degradation of keratan sulfate and the appearance of a mild form of the Morquio syndrome (MPS IVB).

A compound, isolated from acid hydrolysates of urine samples from normal children, characterized as 3,6-anhydroglucosamine by chromatography on a cation exchange resin and by gas-liquid chromatography, could not be detected in hydrolyses of urine from Morquio patients.