Tracking a Medically Important Spider: Climate Change, Ecological Niche Modeling, and the Brown Recluse (Loxosceles reclusa)

Most spiders use venom to paralyze their prey and are commonly feared for their potential to cause injury to humans. In North America, one species in particular, Loxosceles reclusa (brown recluse spider, Sicariidae), causes the majority of necrotic wounds induced by the Araneae. However, its distributional limitations are poorly understood and, as a result, medical professionals routinely misdiagnose brown recluse bites outside endemic areas, confusing putative spider bites for other serious conditions. To address the issue of brown recluse distribution, we employ ecological niche modeling to investigate the present and future distributional potential of this species. We delineate range boundaries and demonstrate that under future climate change scenarios, the spider's distribution may expand northward, invading previously unaffected regions of the USA. At present, the spider's range is centered in the USA, from Kansas east to Kentucky and from southern Iowa south to Louisiana. Newly influenced areas may include parts of Nebraska, Minnesota, Wisconsin, Michigan, South Dakota, Ohio, and Pennsylvania. These results illustrate a potential negative consequence of climate change on humans and will aid medical professionals in proper bite identification/treatment, potentially reducing bite misdiagnoses

Arthroscopic Wafer Procedure for Ulnar Impaction Syndrome

Ulnar impaction syndrome is abutment of the ulna on the lunate and triquetrum that increases stress and load, causing ulnar-sided wrist pain. Typically, ulnar-positive or -neutral variance is seen on a posteroanterior radiograph of the wrist. The management of ulnar impaction syndrome varies from conservative, symptomatic treatment to open procedures to shorten the ulna. Arthroscopic management has become increasingly popular for management of ulnar impaction with ulnar-positive variance of less than 3 mm and concomitant central triangular fibrocartilage complex tears. This method avoids complications associated with open procedures, such as nonunion and symptomatic hardware. The arthroscopic wafer procedure involves debridement of the central triangular fibrocartilage complex tear, along with debridement of the distal pole of the ulna causing the impaction. Debridement of the ulna arthroscopically is taken down to a level at which the patient is ulnar neutral or slightly ulnar negative. Previous studies have shown good results with relief of patient symptoms while avoiding complications seen with open procedures

Efficacy and safety of collagenase clostridium histolyticum for Dupuytren disease nodules: a randomized controlled trial

Abstract Background To determine the safety and efficacy of collagenase clostridium histolyticum (CCH) injection for the treatment of palmar Dupuytren disease nodules. Methods In this 8-week, double-blind trial, palpable palmar nodules on one hand of adults with Dupuytren disease were selected for treatment. Patients were randomly assigned using an interactive web response system to receive a dose of 0.25 mg, 0.40 mg, or 0.60 mg (1:1:1 ratio) and then allocated to active treatment (CCH) or placebo (4:1 ratio). All patients and investigators were blinded to treatment. One injection was made in the selected nodule on Day 1. Caliper measurements of nodule length and width were performed at screening and at Weeks 4 and 8. Investigator-reported nodular consistency and hardness were evaluated at baseline and Weeks 1, 4, and 8. Investigator-rated patient improvement (1 [very much improved] to 7 [very much worse]) and patient satisfaction were assessed at study end. Results In the efficacy population (n = 74), percentage changes in area were significantly greater with CCH 0.40 mg (−80.1%, P = 0.0002) and CCH 0.60 mg (−78.2%, P = 0.0003), but not CCH 0.25 mg (−58.3%, P = 0.079), versus placebo (−42.2%) at post-treatment Week 8. Mean change in nodular consistency and hardness were significantly improved with CCH versus placebo at Weeks 4 and 8 (P ≤ 0.0139 for all). At Week 8, investigator global assessment of improvement was significantly greater with CCH 0.40 mg and 0.60 mg (P ≤ 0.0014) but not statistically significant with CCH 0.25 mg versus placebo (P = 0.13). Most patients were “very satisfied” or “quite satisfied” with CCH 0.40 mg and 0.60 mg. Contusion/bruising (50.0% to 59.1%) was the most common adverse event with CCH treatment. Conclusion In patients with Dupuytren disease, a single CCH injection significantly improved palmar nodule size and hardness. The safety of CCH was similar to that observed previously in patients with Dupuytren contracture. Trial registration ClinicalTrials.gov identifier: NCT02193828 . Date of trial registration: July 2, 2014 to December 5, 201

Organizational Issues, Structure, and Processes of Care in 257 ICUs in Latin America: A Study From the Latin America Intensive Care Network

Objective: Latin America bears an important burden of critical care disease, yet the information about it is scarce. Our objective was to describe structure, organization, processes of care, and research activities in Latin-American ICUs. Design: Web-based survey submitted to ICU directors. Settings: ICUs located in nine Latin-American countries. Subjects: Individual ICUs. Interventions: None. Measurements and Main Results: Two hundred fifty-seven of 498 (52%) of submitted surveys responded: 51% from Brazil, 17% Chile, 13% Argentina, 6% Ecuador, 5% Uruguay, 3% Colombia, and 5% between Mexico, Peru, and Paraguay. Seventy-nine percent of participating hospitals had less than 500 bedsmost were public (59%) and academic (66%). ICUs were mainly medical-surgical (75%)number of beds was evenly distributed in the entire cohort77% had 24/7 intensivists46% had a physician-to-patient ratio between 1: 4 and 7and 69% had a nurse-to-patient ratio of 1 >= 2.1. The 24/7 presence of other specialists was deficient. Protocols in use averaged 9 +/- 3. Brazil (vs the rest) had larger hospitals and ICUs and more quality, surveillance, and prevention committees, but fewer 24/7 intensivists and poorer nurse-to-patient ratio. Although standard monitoring, laboratory, and imaging practices were almost universal, more complex measurements and treatments and portable equipment were scarce after standard working hours, and in public hospitals. Mortality was 17.8%, without differences between countries. Conclusions: This multinational study shows major concerns in the delivery of critical care across Latin America, particularly in human resources. Technology was suboptimal, especially in public hospitals. A 24/7 availability of supporting specialists and of key procedures was inadequate. Mortality was high in comparison to high-income countries.Hosp Interzonal Agudos Gen San Martin de La Plata, Serv Terapia Intens, Buenos Aires, DF, ArgentinaPontificia Univ Catolica Chile, Fac Med, Dept Med Intens, Santiago, ChileClin Bazterr, Buenos Aires, DF, ArgentinaClin Santa Isabel, Buenos Aires, DF, ArgentinaUniv Fed Rio Grande do Sul, Fac Med, Dept Med Interna, Porto Alegre, RS, BrazilHosp Clin Porto Alegre, Porto Alegre, RS, BrazilHosp Espanol, Montevideo, UruguayANII, Montevideo, UruguayHosp Eugenio Espejo, Unidad Cuidados Intens, Quito, EcuadorUniv Int Ecuador, Escuela Med, Quito, EcuadorUniv ICESI, Fdn Valle Lili, Dept Intens Care Med, Cali, ColombiaHosp Alejandro Posadas, Serv Terapia Intens, Buenos Aires, DF, ArgentinaUniv Fed São Paulo, Anesthesiol Pain & Intens Care Dept, São Paulo, BrazilHosp Coracao, Res Inst HCor, São Paulo, BrazilSanat Otamendi & Miroli, Serv Terapia Intens, Buenos Aires, DF, ArgentinaUniv Nacl La Plata, Fac Ciencias Med, Catedra Farmacol Aplicada, Buenos Aires, DF, ArgentinaHosp Espanol, ASSE, Montevideo, UruguayUniv Republica, Sch Med, Dept Pathophysiol, Montevideo, UruguayUdelaR, Hosp Clin, Catedra Med Intens, Area Invest Resp, Montevideo, UruguayUniv Chile, Hosp Clin, Unidad Pacientes Crit, Santiago, ChileColumbia Univ, Med Ctr, Div Pulm Allergy & Crit Care Med, New York, NY USASt Georges Univ Hosp NHS Fdn Trust, London, EnglandHosp Sirio Libanes, São Paulo, BrazilUniv São Paulo, Dept Emergency Med, São Paulo, BrazilUniv Fed São Paulo, Anesthesiol Pain & Intens Care Dept, São Paulo, BrazilWeb of Scienc