Although recent articles state that jellyfish populations are increasing, most available evidence shows that jellyfish abundances fluctuate with climatic cycles. Reports of increasing prob- lems with jellyfish, especially in East Asia, are too recent to exclude decadal climate cycles. Jellyfish are infamous for their direct negative effects on human enterprise; specifically, they interfere with tourism by stinging swimmers, fishing by clogging nets, aquaculture by killing fish in net-pens and power plants by clogging cooling-water intake screens. They also have indirect effects on fisheries by feeding on zooplankton and ichthyoplankton, and, therefore, are predators and potential competitors of fish. Ironically, many human activities may contribute to increases in jellyfish populations in coastal waters. Increased jellyfish and ctenophore populations often are associated with warming caused by climate changes and possibly power plant thermal effluents. Jellyfish may benefit from eutrophication, which can increase small-zooplankton abundance, turbidity and hypoxia, all conditions that may favor jellyfish over fish. Fishing activities can remove predators of jellyfish and zooplanktivorous fish com- petitors as well as cause large-scale ecosystem changes that improve conditions for jellyfish. Aquacul- ture releases millions of jellyfish into Asian coastal waters yearly to enhance the jellyfish fishery. Aquaculture and other marine structures provide favorable habitat for the benthic stages of jellyfish. Changes in the hydrological regime due to dams and other construction can change the salinity to favor jellyfish. Accidental introductions of non-native gelatinous species into disturbed ecosystems have led to blooms with serious consequences. In many coastal areas, most of these environmental changes occur simultaneously. We summarize cases of problem jellyfish blooms and the evidence for anthropogenic habitat disruptions that may have caused them. Rapid development in East Asia makes that region especially vulnerable to escalating problems. We conclude that human effects on coastal environments are certain to increase, and jellyfish blooms may increase as a consequence.

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Anthropogenic causes of jellyfish blooms and their direct consequences for humans: a review

Objective: To review research into patient satisfaction with teleconsultation, specifically clinical consultations between healthcare providers and patients involving real time interactive video. Design: Systematic review of telemedicine satisfaction studies. Electronic databases searched include Medline, Embase, Science Citation Index, Social Sciences Citation Index, Arts and Humanities Citation Index, and the TIE (Telemedicine Information Exchange) database. Subjects: Studies conducted worldwide and published between 1966 and 1998. Main outcome measures: Quality of evidence about patient satisfaction. Results: 32 studies were identified. Study methods used were simple survey instruments (26 studies), exact methods not specified (5), and qualitative methods (1). Study designs were randomised controlled trial (1 trial); random patient selection (2); case-control (1); and selection criteria not specified or participants represented consecutive referrals, convenience samples, or volunteers (28). Sample sizes were20 (10 trials),100 (14), >100 (7), and not specified (1). All studies reported good levels of patient satisfaction. Qualitative analysis revealed methodological problems with all the published work. Even so, important issues were highlighted that merit further investigation. There is a paucity of data examining patients9 perceptions or the effects of this mode of healthcare delivery on the interaction between providers and clients. Conclusions: Methodological deficiencies (low sample sizes, context, and study designs) of the published research limit the generalisability of the findings. The studies suggest that teleconsultation is acceptable to patients in a variety of circumstances, but issues relating to patient satisfaction require further exploration from the perspective of both clients and providers.

https://www.bmj.com/content/bmj/320/7248/1517.full.pdf

Systematic review of studies of patient satisfaction with telemedicine.

Snake venom variability: methods of study, results and interpretation.

Background It was proposed that Stevens-Johnson syndrome and toxic epidermal necrolysis differed from erythema multiforme majus by the pattern and localization of skin lesions. Objective To evaluate the validity of this clinical separation. Design Case-control study. Settings Active survey from 1989 to 1995 of 1800 hospital departments in Europe. Patients A total of 552 patients and 1720 control subjects. Methods Cases were sorted into 5 groups (erythema multiforme majus, Stevens-Johnson syndrome, Stevens-Johnson syndrome–toxic epidermal necrolysis overlap, toxic epidermal necrolysis, and unclassified erythema multiforme majus or Stevens-Johnson syndrome) by experts blinded as to exposure to drugs and other factors. Etiologic fractions for herpes and drugs obtained from case-control analyses were compared between these groups. Results Erythema multiforme majus significantly differed from Stevens-Johnson syndrome, overlap, and toxic epidermal necrolysis by occurrence in younger males, frequent recurrences, less fever, milder mucosal lesions, and lack of association with collagen vascular diseases, human immunodeficiency virus infection, or cancer. Recent or recurrent herpes was the principal risk factor for erythema multiforme majus (etiologic fractions of 29% and 17%, respectively) and had a role in Stevens-Johnson syndrome (etiologic fractions of 6% and 10%) but not in overlap cases or toxic epidermal necrolysis. Drugs had higher etiologic fractions for Stevens-Johnson syndrome, overlap, or toxic epidermal necrolysis (64%-66%) than for erythema multiforme majus (18%). Unclassified cases mostly behaved clinically like erythema multiforme. Conclusions This large prospective study confirmed that erythema multiforme majus differs from Stevens-Johnson syndrome and toxic epidermal necrolysis not only in severity but also in several demographic characteristics and causes.

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Correlations Between Clinical Patterns and Causes of Erythema Multiforme Majus, Stevens-Johnson Syndrome, and Toxic Epidermal Necrolysis: Results of an International Prospective Study

An analysis of the findings in 21 patients with the Cowden syndrome or the multiple hamartoma syndrome is presented. The Cowden syndrome is a cancer-associated genodermatosis with characteristic mucocutaneous findings and a wide array of associated abnormalities including a high incidence of breast cancer in female patients. Genetic studies confirmed autosomal dominant inheritance with a high penetrance in both sexes and moderate interfamilial and intrafamilial differences in the expressivity of a number of symptoms. Familial occurrence was present in 4 of the 7 families. There was a strong predominance of female patients (6:1), which may be fortuitous. Mucocutaneous changes were the most constant (100% incidence) and characteristic findings; they almost invariably became manifest in the second decade. Four of our 18 female patients (22%) were treated for breast cancer, a lower incidence than reported previously. No increased incidence of other types of malignancies was found. Craniomegaly (high head circumference) was found to be the most common extracutaneous manifestation (80% incidence); craniomegaly appears to be an important early marker. We also found high incidences of gastrointestinal polyps (approximately 60%) and cutaneous fibromas (76%), while the incidence of thyroid abnormalities, thus far regarded as the most common extracutaneous finding, was similar to that reported previously (62%). G-banded karyotype and preliminary DNA-repair studies revealed no clear abnormalities. No linkage with the loci of HLA, and immunoglobulin haplotypes was found.

The Cowden syndrome: a clinical and genetic study in 21 patients

Cnidarians - animals with endogenous cnidae echinoderms, molluscs and sponges toxic (venomous and poisonous) marine vertebrates further international studies on toxic marine animals special considerations to finish.

Venomous and Poisonous Marine Animals: A Medical and Biological Handbook

Objective To compare physician and patient impressions and interphysician diagnostic agreement between live teledermatology and in-person examinations. Design Paired video and in-person examinations with different dermatologists. Setting An urban Veterans Affairs dermatology clinic. Patients One hundred thirty-nine patients. Main Outcome Measures Satisfaction questionnaires and interphysician diagnostic agreement. Results Patient and physician satisfaction was high. Agreement between video and in-person diagnoses was 80%. Conclusions Physicians and patients were satisfied with teledermatology examinations. Diagnostic agreement between in-person and video dermatologists was high.

https://jamanetwork.com/journals/jamadermatology/articlepdf/189004/dst7045.pdf

Teledermatology and in-person examinations: a comparison of patient and physician perceptions and diagnostic agreement.

Erythema multiforme (EM) is a clinical conundrum the name of which reflects the broad morphological spectrum of the lesions. Molecular and immunologic evidence that herpes simplex virus (HSV) causes a subset of EM lesions [herpes-associated EM (HAEM)] is reviewed, and new data are presented which suggest that autoreactive T-cells triggered by virus infection play an important role in HAEM pathogenesis. Disease development begins with viral DNA fragmentation and the transport of the DNA fragments to distant skin sites by peripheral blood mononuclear cells (PBMCs). HSV genes within DNA fragments deposited on the skin [notably DNA polymerase (Pol)] are expressed, leading to recruitment of HSV-specific CD4+ Th1 cells that respond to viral antigens with production of interferon-gamma (IFN-gamma). This step initiates an inflammatory cascade that includes expression of IFN-gamma induced genes, increased sequestration of circulating leukocytes, monocytes and natural killer (NK) cells, and the recruitment of autoreactive T-cells generated by molecular mimicry or the release of cellular antigens from lysed cells. The PBMCs that pick up the HSV DNA [viz. macrophages or CD34+ Langerhans cells (LC) precursors], their ability to process it, the viral proteins expressed in the skin and the presence of epitopes shared with cellular proteins may determine whether a specific HSV episode is followed by HAEM development. Drug-associated EM (DIEM) is a mechanistically distinct EM subset that involves expression of tumor necrosis factor alpha (TNF-alpha) in lesional skin. It is our thesis that the polymerase chain reaction (PCR) assay for HSV DNA detection in lesional skin and staining with antibodies to IFN-gamma and TNF-alpha, are important criteria for the diagnosis of skin eruptions and improved patient management.

Joseph W. Burnett

Papers

Venomous and Poisonous Marine Animals: A Medical and Biological Handbook

Teledermatology and in-person examinations: a comparison of patient and physician perceptions and diagnostic agreement.

Herpes simplex virus (HSV)-associated erythema multiforme (HAEM): A viral disease with an autoimmune component.

Partial purification of box jellyfish (Chironex fleckeri) nematocyst venom isolated at the beachside.

The chemistry and toxicology of some venomous pelagic coelenterates.