How Did That Get There? A Case Series of Adolescent Foreign Bodies

Introduction

Pediatric foreign bodies (FBs) come in many shapes and sizes, and the method by which they enter the body can greatly impact the level of acuity at presentation. Most FBs in children are found in those younger than 5 years old, but the following 3 cases were found in adolescent patients.

Case Presentation

We report on 3 adolescent patients who presented to a single community-based emergency department with the chief complaint of abdominal pain and were found to have complications of abdominal FBs. If undiagnosed, the initial indolent courses of FBs can lead to serious complications, as shown in these examples.

Conclusion

These cases emphasize the need for physicians to maintain a high level of suspicion, to perform detailed histories, and to consider advanced imaging despite reassuring vital signs or physical examination.

Development of skin diseases following systemic exposure: example of dioxins

Most skin manifestations of exposure to toxic compounds are a consequence of a direct contact with the toxicants. However, some toxicants may reach the skin following systemic exposure, and promote skin diseases. Good examples of such chemicals are dioxin-like compounds. This family of lipophilic molecules comprises polychlorinated (dibenzodioxins, dibenzofurans and biphenyls). The most potent member of this family is 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). Following oral ingestion of as little as a few mg TCDD, skin lesions appear in a couple of weeks, starting from the face and diffuse then on the trunk and limbs. This syndrome was historically called "chloracne" and the skin lesions have now been shown to be skin hamartoma induced by TCDD. Sweat glands release their lipid content on the surface of the skin by a holocrine secretion, and so any lost sebocyte should be transmitted to progenitor cells to differentiate and migrate to the sebaceous gland to replace the lost sebocyte. TCDD acts by inducing a switch in this signal and skin hamartoma develop in place of new sebocytes.

Is Zooplankton an Entry Point of Microplastics into the Marine Food Web?

Microplastics (MPs) overlap in size with phytoplankton and can be ingested by zooplankton, transferring them to higher trophic levels. Copepods are the most abundant metazoans among zooplankton and the main link between primary producers and higher trophic levels. Ingestion of MPs has been investigated in the laboratory, but we still know little about the ingestion of MPs by zooplankton in the natural environment. In this study, we determined the concentration and characteristics of MPs down to 10 μm in zooplankton samples, sorted calanoid copepods, and fecal pellets collected in the Kattegat/Skagerrak Sea (Denmark). We found a median concentration of 1.7 × 10-3 MPs ind-1 in the zooplankton samples, 2.9 × 10-3 MPs ind-1 in the sorted-copepods, and 3 × 10-3 MPs per fecal pellet. Most MPs in the zooplankton samples and fecal pellets were fragments smaller than 100 μm, whereas fibers dominated in the sorted copepods. Based on the collected data, we estimated a MP budget for the surface layer (0-18 m), where copepods contained only 3% of the MPs in the water, while 5% of the MPs were packed in fecal pellets. However, the number of MPs exported daily to the pycnocline via fecal pellets was estimated to be 1.4% of the total MPs in the surface layer. Our results indicate that zooplankton are an entry point of small MPs in the food web, but the number of MPs in zooplankton and their fecal pellets was low compared with the number of MPs found in the water column and the occurrence and/or ingestion of MPs reported for nekton. This suggests a low risk of MP transferring to higher trophic levels through zooplankton and a quantitatively low, but ecologically relevant, contribution of fecal pellets to the vertical exportation of MPs in the ocean.

Lack of cholinergic features in healthcare workers caring for a patient with organophosphate poisoning

INTRODUCTION

Controversy exists with regard to risk of secondary exposure of health care workers caring for patients who have ingested an organophosphate insecticide. We aim to report clinical effects of staff members caring for an organophosphate poisoned patient.

INCIDENT

A 76-year-old male presented to the Emergency Department exhibiting a cholinergic toxidrome requiring atropine, intubation and mechanical ventilation.

METHODS

We undertook a retrospective chart review of any Emergency Department presentations for medical assessment in relation to the incident and conducted telephone interviews of any healthcare workers who did not present but were deemed to be closely involved with patient care. We collected data including age, gender, symptoms reported and plasma cholinesterase activity measurement.

RESULTS

We collected data from 13 individuals, of whom nine presented for medical assessment, including the patient's spouse. Five additional staff members were interviewed, having been identified via Emergency Department rostering documentation. The 13 healthcare workers comprised five nurses, four paramedics and four doctors. Dizziness and nausea were reported in two and the patient's spouse reported one episode of vomiting. Of the nine patients who had plasma cholinesterase activity measured, none were below the laboratory reference range, including those who experienced symptoms.

CONCLUSIONS

We found no clinical nor biochemical evidence of toxicity in healthcare workers caring for a critically ill patient with organophosphate ingestion. These findings are consistent with previously published guidelines advocating standard/Level D personal protective equipment. We believe that emergency departments should not be closed as a safety measure.

Pediatric foreign body ingestion in Makkah, Saudi Arabia: A retrospective epidemiological study

OBJECTIVES

To improve the local data and demographics of foreign body (FB) ingestion in the Makkah, Saudi Arabia and to provide basic statistics for future studies in the local community.

METHODS

We carried out a record-based retrospective epidemiological study of 153 pediatric patients with FB ingestion who presented to our center in Makkah, Saudi Arabia, between December 2014 and December 2019. Adult age, impacted FB at other sites, and chemical ingestion were excluded.

RESULTS

Descriptive statistical analyses were performed. There has been an alarming increase in the number of children admitted to hospitals following FB ingestion. Approximately 41.8% of these patients were under the age of 4 years, with boys (63.4%) accounting for the majority. Most of the ingested FB were coins (60.8%), and 96.7% of the patients remained under 24 hours of observation at the hospital. The results showed a highly statistically significant relationship between the FB type, age, length of hospital stay, and esophagoscopic findings.

CONCLUSION

A large number of children presented with ingested FB, especially those younger than 4 years of age, whose clinical presentation varied from asymptomatic to severe complications, and urgent endoscopic intervention might have decreased serious complications. Further preventive measures are necessary within homes in addition to increasing caregivers' awareness of the different circumstances of FB ingestion and the time required for urgent admission.

2021 Annual Report of the Kansas Poison Control Center at The University of Kansas Health System

Introduction

This is the 2021 Annual Report of the Kansas Poison Control Center (KSPCC) at The University of Kansas Health System. The KSPCC serves the state of Kansas 24-hours a day, 365 days a year with certified specialists in poison information and clinical and medical toxicologists.

Methods

Encounters reported to the KSPCC from January 1, 2021 through December 31, 2021 were analyzed. Data recorded includes caller demographics, exposure substance, nature and route of exposure, interventions, medical outcome, disposition, and location of care.

Results

The KSPCC logged 18,253 total encounters in 2021, including calls from every county in Kansas. A majority of human exposure cases (53.6%) were female. Approximately 59.8% were pediatric exposures (defined as 19 years of age or less). Most encounters occurred at a residence (91.7%) and most were managed there (70.5%). Unintentional exposures were the most common reason for exposures (70.5%). The most common reported substance in pediatric encounters was household cleaning products (n = 815) and cosmetics/personal care products (n = 735). For adult encounters, analgesics (n = 1,241) and sedative/ hypnotics/antipsychotics (n = 1,013) were the most frequently reported. Medical outcomes were 26.0% no effect, 22.4% minor effect, 10.7% moderate effect, and 2.7% major effects. There were 22 deaths.

Conclusions

The 2021 KSPCC annual report demonstrated that cases were received from the entire state of Kansas. Pediatric exposures remained most common but cases with serious outcomes continued to increase. This report supported the continued value of the KSPCC to both public and health care providers in the state of Kansas.

Coral Disease and Ingestion: Investigating the Role of Heterotrophy in the Transmission of Pathogenic Vibrio spp. using a Sea Anemone (Exaiptasia pallida) Model System

Understanding disease transmission in corals can be complicated given the intricacy of the holobiont and difficulties associated with ex situ coral cultivation. As a result, most of the established transmission pathways for coral disease are associated with perturbance (i.e., damage) rather than evasion of immune defenses. Here, we investigate ingestion as a potential pathway for the transmission of coral pathogens that evades the mucus membrane. Using sea anemones (Exaiptasia pallida) and brine shrimp (Artemia sp.) to model coral feeding, we tracked the acquisition of the putative pathogens, Vibrio alginolyticus, V. harveyi, and V. mediterranei using GFP-tagged strains. Vibrio sp. were provided to anemones using 3 experimental exposures (i) direct water exposure alone, (ii) water exposure in the presence of a food source (non-spiked Artemia), and (iii) through a "spiked" food source (Vibrio-colonized Artemia) created by exposing Artemia cultures to GFP-Vibrio via the ambient water overnight. Following a 3 h feeding/exposure duration, the level of acquired GFP-Vibrio was quantified from anemone tissue homogenate. Ingestion of spiked Artemia resulted in a significantly greater burden of GFP-Vibrio equating to an 830-fold, 3,108-fold, and 435-fold increase in CFU mL^-1 when compared to water exposed trials and a 207-fold, 62-fold, and 27-fold increase in CFU mL^-1 compared to water exposed with food trials for V. alginolyticus, V. harveyi, and V. mediterranei, respectively. These data suggest that ingestion can facilitate delivery of an elevated dose of pathogenic bacteria in cnidarians and may describe an important portal of entry for pathogens in the absence of perturbing conditions. IMPORTANCE The front line of pathogen defense in corals is the mucus membrane. This membrane coats the surface body wall creating a semi-impermeable layer that inhibits pathogen entry from the ambient water both physically and biologically through mutualistic antagonism from resident mucus microbes. To date, much of the coral disease transmission research has been focused on mechanisms associated with perturbance of this membrane such as direct contact, vector lesions (predation/biting), and waterborne exposure through preexisting lesions. The present research describes a potential transmission pathway that evades the defenses provided by this membrane allowing unencumbered entry of bacteria as in association with food. This pathway may explain an important portal of entry for emergence of idiopathic infections in otherwise healthy corals and can be used to improve management practices for coral conservation.

Metal Oxide Nanoparticles in Food Packaging and Their Influence on Human Health

It is a matter of common knowledge in the literature that engineered metal oxide nanoparticles have properties that are efficient for the design of innovative food/beverage packages. Although nanopackages have many benefits, there are circumstances when these materials are able to release nanoparticles into the food/beverage matrix. Once dispersed into food, engineered metal oxide nanoparticles travel through the gastrointestinal tract and subsequently enter human cells, where they display various behaviors influencing human health or wellbeing. This review article provides an insight into the antimicrobial mechanisms of metal oxide nanoparticles as essential for their benefits in food/beverage packaging and provides a discussion on the oral route of these nanoparticles from nanopackages to the human body. This contribution also highlights the potential toxicity of metal oxide nanoparticles for human health. The fact that only a small number of studies address the issue of food packaging based on engineered metal oxide nanoparticles should be particularly noted.

Are antimuscarinic effects common in hydroxyzine overdose? A cohort analysis of antimuscarinic effects in hydroxyzine and diphenhydramine-poisoned patients

INTRODUCTION

Exposures to hydroxyzine, a first-generation H1 antihistamine, have increased rapidly over the last two decades. Many assumptions about hydroxyzine poisoning are based on other antihistamines, like diphenhydramine. However, the receptor affinities of hydroxazine suggest that there should be fewer antimuscarinic findings than diphenhydramine.

METHODS

This was a cohort study that compared hydroxyzine and diphenhydramine exposures reported to the National Poison Data System between January 1, 2000, and December 31, 2020, and the Toxicologic Investigators Consortium Core Registry between January 1, 2010, and December 31, 2020. The primary outcome was to assess for antimuscarinic findings in hydroxyzine-poisoned patients, using diphenhydramine-poisoned patients as a comparison group. The secondary outcomes were to assess for markers of overall toxicity. Inclusion criteria were single-substance exposures with known outcomes. Exclusion criteria for National Poison Data System exposures were chronic exposures, unintentional exposures, and patients younger than 12 years old. There were no exclusion criteria for exposures reported to the Toxicologic Investigators Consortium Core Registry.

RESULTS

There were 17,265 hydroxyzine and 102,354 diphenhydramine exposures reported to the National Poison Data System and 134 hydroxyzine and 1,484 diphenhydramine exposures reported to the Toxicologic Investigators Consortium Core Registry that met inclusion criteria. In both datasets, hydroxyzine-poisoned patients had lower rates and relative risk of developing antimuscarinic findings or receiving physostigmine, with the exception of hyperthermia in the Toxicologic Investigators Consortium Core Registry dataset. Coma/central nervous system depression (major), respiratory depression, seizures, ventricular dysrhythmias, intubation, and benzodiazepine administration were less likely in hydroxyzine-poisoned patients, but central nervous system depression (mild) was more likely in exposures reported to the National Poison Data System. The mortality in hydroxyzine-poisoned patients was rare: 0.02% and 0.8% of exposures reported to the National Poison Data System and Toxicologic Investigators Consortium Core Registry, respectively.

DISCUSSION

The clinical manifestations of hydroxyzine exposures are consistent with the pharmacology of hydroxazine. The clinical effects were consistent across two United States national datasets. Clinicians should not generalize the illness script of diphenhydramine exposures to hydroxyzine exposures.

CONCLUSIONS

Hydroxyzine-poisoned patients were less likely to develop antimuscarinic findings than diphenhydramine-poisoned patients. Hydroxyzine-poisoned patients were more likely to have mild central nervous system depression than an antimuscarinic toxidrome.

Varied Manifestations of Sharp Penetrating Foreign Bodies in the Aerodigestive Tract: Our Experience

Introduction Foreign body ingestion or aspiration is an emergency dealt by otorhinolaryngologists. It is most common among children and the geriatric population. It paves the way for critical morbidity when prompt treatment is not initiated. Therefore, in the absence of strong evidence to guide decision-making, all suspicious presentations of the ingested sharp foreign body need to be kept in mind while making a diagnosis. Hence, our study is aimed to document the varied manifestations of sharp penetrating foreign bodies in the aerodigestive tract. Materials and methods The medical records of 40 patients who presented with sharp foreign body ingestion/aspiration in the department of otorhinolaryngology in our centre from September 2012 to September 2022 were reviewed retrospectively. Results In all 40 patients, we were able to retrieve the foreign body as such without crushing or breaking it. In our study, the most common foreign body retrieved among middle-aged and elderly were chicken bone (22.5%) or fish bone (25%), and the most common foreign body following accidental ingestion in children were stapler pins (20%). Conclusion The findings of our study concluded that relevant clinical history, atypical presentation, and radiological imaging of sharp penetrating foreign bodies in the neck should be addressed with the utmost caution, as foreign bodies migrate to deep neck space and bronchus and can result in untoward complications. Hence, we need to be suspicious of the varied manifestation of aerodigestive tract foreign bodies for early diagnosis and prompt treatment.

Intentional Ingestion of Foreign Bodies: A Physician's Agony

Intentional foreign body ingestion is the phenomenon wherein one swallows a non-digestible object with the intent to cause self-injury. It is intentional in adult patients with a positive psychiatric history and can be a recurrent issue. Although the incidence of this condition is increasing, there are few existing articles on the subject that highlight its importance. This case report aims to present a unique patient encounter to emphasize the multispecialty approach required for management and provide an overview of the literature available on the subject regarding types of objects swallowed, selection of appropriate imaging modalities, and plans of management.

Consumption of trematode parasite infectious stages: from conceptual synthesis to future research agenda

Given their sheer cumulative biomass and ubiquitous presence, parasites are increasingly recognized as essential components of most food webs. Beyond their influence as consumers of host tissue, many parasites also have free-living infectious stages that may be ingested by non-host organisms, with implications for energy and nutrient transfer, as well as for pathogen transmission and infectious disease dynamics. This has been particularly well-documented for the cercaria free-living stage of digenean trematode parasites within the Phylum Platyhelminthes. Here, we aim to synthesize the current state of knowledge regarding cercariae consumption by examining: (a) approaches for studying cercariae consumption; (b) the range of consumers and trematode prey documented thus far; (c) factors influencing the likelihood of cercariae consumption; (d) consequences of cercariae consumption for individual predators (e.g. their viability as a food source); and (e) implications of cercariae consumption for entire communities and ecosystems (e.g. transmission, nutrient cycling and influences on other prey). We detected 121 unique consumer-by-cercaria combinations that spanned 60 species of consumer and 35 trematode species. Meaningful reductions in transmission were seen for 31 of 36 combinations that considered this; however, separate studies with the same cercaria and consumer sometimes showed different results. Along with addressing knowledge gaps and suggesting future research directions, we highlight how the conceptual and empirical approaches discussed here for consumption of cercariae are relevant for the infectious stages of other parasites and pathogens, illustrating the use of cercariae as a model system to help advance our knowledge regarding the general importance of parasite consumption.

Use of Antibiotics in Poisonous Ingestions of Corrosives and Organophosphates: A Retrospective Cohort Study

The use of antibiotics following oral poisoning by corrosives and organophosphates is controversial. We assessed the clinical outcomes of using antibiotics in acute poisonous ingestion involving corrosives or organophosphates by conducting a retrospective cohort study of patients presenting to the emergency department following ingestion of corrosives or organophosphates who received either antibiotics or supportive care. The endpoints included clinical stability, length of stay (LOS), and mortality. Of 95 patients, 40 received antibiotics and 55 received supportive care. The median age was 2.1 and 2.7 years, respectively (p = 0.053). Bacterial growth was shown in only 2 of 28 cultures (both were respiratory), but with hospital-acquired organisms as it was shown ≥4 days post-admission. Clinical stability rates were 60% and 89.1% in the antibiotic and supportive care groups, respectively (p < 0.001). Median LOS was 3 vs. 0 days (p < 0.001), and no mortality was recorded. NG/G-tube placement was the only factor associated with clinical failure (OR, 20.97; 95% CI, 2.36-186.13). Antibiotic use was not associated with higher chances of clinical stability, which may suggest that their use was unnecessary. Clinicians are encouraged to use antibiotics wisely, and only in the presence of a clear indication of an infection. This study provides a basis for future prospective studies to confirm its findings.

Equid nutritional physiology and behavior: an evolutionary perspective

Like other members of the even-toed ungulates (the perissodactyls), equids once had a higher species diversity in the fossil record than they have today. This is generally explained in comparison to the enormous diversity of bovid ruminants. Theories on putative competitive disadvantages of equids include the use of a single toe as opposed to two toes per leg, the lack of a specific brain cooling (and hence water-saving) mechanism, longer gestation periods that delay reproductive output, and in particular digestive physiology. To date, there is no empirical support for the theory that equids fare better on low-quality forage than ruminants. In contrast to the traditional juxtaposition of hindgut and foregut fermenters, we suggest that it is more insightful to sketch the evolution of equid and ruminant digestive physiology as a case of convergence: both evolved a particularly high chewing efficacy in their respective groups, which facilitates comparatively high feed and hence energy intakes. But because the ruminant system, less based on tooth anatomy but more on a forestomach sorting mechanism, is more effective, equids depend more on high feed intakes than ruminants and may well be more susceptible to feed shortages. Arguably, the most under-emphasized characteristic of equids may be that in contrast to many other herbivores including ruminants and coprophageous hindgut fermenters, equids do not use the microbial biomass growing in their gastrointestinal tract. Equids display behavioral and morphophysiological adaptations to high feed intakes, and their cranial anatomy that facilitates the cropping of forage while performing grinding chewing at the same time might be unique. Rather than looking for explanations how equids are better adapted to their present niches than other organisms, considering them remnants of a different morphophysiological solution may be more appropriate.

Individual differences in digesta retention and their relation to chewing in cattle-A pilot investigation

While information on individual differences in digesta mean retention time (MRT) might be interesting when selecting phenotypes for digestive efficiency, MRT measurements are prohibitively labour-intensive for large-scale application. Therefore, more easily measured proxies of MRT might be helpful. We used the opportunity of an experiment applying saliva stimulant in cattle to investigate the effect of different individual chewing behaviour on fluid and particle MRT with a consistent diet. Four non-lactating cattle (670-850 kg body mass [BM]) were used in a 4 × 4 Latin square design, treated with the saliva stimulant pilocarpine in dosages of 0, 1, 2.5 and 5 mg/kg BM per day. The cattle were fed hay with dry matter intake (DMI) assigned according to their metabolic body weight. MRT in the whole gastrointestinal tract (GIT), the reticulorumen (RR) and the distal tract were measured using Co-EDTA, Cr-mordanted fibre and La-mordanted fibre as markers representing fluid, small particles (2 mm) and large particles (1 cm), respectively. The chewing behaviour was measured via noseband pressure sensor and expressed as chewing frequency (chews per time) and chewing intensity (chews per DMI), both for total chewing (ingestion plus rumination) and rumination chewing alone. The animals differed considerably in chewing behaviour and MRT measures. BM did not show a significant effect on chewing behaviour and MRT measures, though it tended to negatively correlated to total chewing intensity. Chewing intensity exerted a significant negative influence on MRT of fluid and particles in the RR, which was not the case for chewing frequency. Chewing frequency showed a significant relationship with MRT of large particles in the GIT. We suggest that chewing behaviour could influence MRT in two ways: (i) by affecting saliva production via the masticatory-salivary reflex and subsequently, the fluid inflow to the RR; (ii) by contributing to particle size reduction. Should the link between chewing behaviour and MRT be corroborated in larger studies, chewing measures, with their large interindividual variation, could emerge as an easy-to-measure proxy for MRT characteristics.

Food-Grade Metal Oxide Nanoparticles Exposure Alters Intestinal Microbial Populations, Brush Border Membrane Functionality and Morphology, In Vivo (Gallus gallus)

Among food additive metal oxide nanoparticles (NP), titanium dioxide (TiO₂) and silicon dioxide (SiO₂) are commonly used as food coloring or anti-caking agents, while zinc oxide (ZnO) and iron oxide (Fe₂O₃) are added as antimicrobials and coloring agents, respectively, and can be used as micronutrient supplements. To elucidate potential perturbations associated with NP consumption on gastrointestinal health and development, this in vivo study utilized the Gallus gallus (broiler chicken) intraamniotic administration to assess the effects of physiologically relevant concentrations of food-grade metal oxide NP on brush border membrane (BBM) functionality, intestinal morphology and intestinal microbial populations in vivo. Six groups with 1 mL injection of the following treatments were utilized: non-injected, 18 MΩ DI H₂O; 1.4 × 10^-6 mg TiO₂ NP/mL, 2.0 × 10^-5 mg SiO₂ NP/mL, 9.7 × 10^-6 mg ZnO NP/mL, and 3.8 × 10^-4 mg Fe₂O₃ NP/mL (n = 10 per group). Upon hatch, blood, cecum, and duodenum were collected to assess mineral (iron and zinc) metabolism, BBM functional, and pro-inflammatory-related protein gene expression, BBM morphometric analysis, and the relative abundance of intestinal microflora. Food additive NP altered mineral transporter, BBM functionality, and pro-inflammatory cytokine gene expression, affected intestinal BBM development and led to compositional shifts in intestinal bacterial populations. Our results suggest that food-grade TiO₂ and SiO₂ NP have the potential to negatively affect intestinal functionality; food-grade ZnO NP exposure effects were associated with supporting intestinal development or compensatory mechanisms due to intestinal damage, and food-grade Fe₂O₃ NP was found to be a possible option for iron fortification, though with potential alterations in intestinal functionality and health.

Ingested Chicken Bone (Xiphoid Process) in the Anal Canal: A Case Report and Literature Review

Accidental foreign body (FB) ingestion is common in the elderly, particularly edentulous and denture wearers. The most commonly ingested FBs are food-related, including fish and chicken bones. While small FBs can pass through the gastrointestinal tract without any complications, large or irregular-shaped FBs usually cause complications. These complications include choking, ulceration, perforation, fistula, abscess formation, or even death. Ingestion of a large chicken bone that reaches the anal canal without causing injury is extremely rare. We present a rare case of accidental chicken bone (xiphoid process) ingestion that manifested itself by projecting from the anus while defecating. Interestingly, the patient did not experience any food choking or abdominal pain, nor did she have any type of dementia. However, the patient could not grind food properly due to the loss of her upper molar teeth, which made her develop a habit of rapid swallowing. On examination, the chicken bone was seen within the anus with a sharp edge embedded in the mucosal wall. While a plain pelvic X-ray failed to display the FB, a pelvic CT scan with a 3D illustration showed its dimensions (5.0 x 2.5 x 3 cm). A plain pelvic CT scan confirmed the presence of the bone-contrast FB within the anal canal without injuring the surrounding anatomical structures. The FB was gently manipulated and successfully extracted after administering 5 ml of lidocaine gel enema. The patient was counseled regarding proper chewing habits, and she was referred to a dental clinic for a professional assessment. Seven days later, the patient was seen again at the clinic for a follow-up and was found to have an uneventful recovery. Maintaining good dental health and proper eating habits, as well as increasing awareness among edentulous individuals and denture wearers, are required to prevent accidental FB ingestions.

Microplastics in Commercial Fishes and By-Catch from Selected FAO Major Fishing Areas of the Southern Baltic Sea

According to recent world wide studies, microplastics (MPs) have been found in many fish species; however, the majority of research has focused only on the gastrointestinal tract, neglecting edible organs. This study aimed to assess the presence of microplastics in the non-edible (gills, digestive tract) and edible organs (liver) of three commercial fish species and twoby-catch species from the southern Baltic Sea. Fish (Clupea harengus, Gadus morhua, Platichthy sflesus, Taurulus baublis, Cyclopterus lumpus) were caught in 108 and 103 FAO Fishing Zones belonging to the Polish fishing zone. The abundanceof MPs ranged from 1 to 12 items per fish, with an average of 4.09 items. MPs were observed in different organs, such as the liver, gills, and digestive tract of all five tested species. MPs recognized as fibers were the most abundant. Other shapes of polymers found in fish organs were pellets and particles of larger plastic pieces. The dominant color of the MPs was blue, but there were also red, black, transparent, yellow, green, and white items found. According to dimensions, dominant MPs were between 0.1 and 0.5 mm in size. The chemical characterization of polymers accomplished by the use of Fourier Transform Infrared (FT-IR) Spectroscopy demonstrated the abundance of cellophane, polyamide, polyethylene, polypropylene, polyethylene terephthalate, polyvinyl propionate, polyacrylonitrile, and polyester.

The Behavior of Planktonic Copepods Minimizes the Entry of Microplastics in Marine Food Webs

The entry of microplastics (MPs) into marine food webs is a major environmental concern. We investigated how the behavior of planktonic copepods influences the risk of MPs to enter marine food webs by applying a trait-based approach and by combining experiments (bottle incubations and video observations) with biogeographical analyses. We aimed to evaluate which type of feeding behavior is most risky in terms of MP ingestion and which marine geographical areas are more susceptible to MP ingestion by planktonic copepods. We used different species as models of the main foraging behaviors in planktonic copepods: feeding-current, cruising, ambush, and mixed behavior feeding. All behaviors showed a similarly low risk of MP ingestion, up to 1 order of magnitude lower than for similar-sized microalgae. We did not observe any influence of the prey type or MP size (8 and 20 μm) on MP ingestion for any of the behaviors. By mapping the global distribution of feeding behaviors, we showed that feeding-current feeding is the most common behavior, but the risk of MP ingestion remains equally low across the global ocean, independently of the predominant behavior. Overall, our results suggest a low risk of MP ingestion by planktonic copepods and therefore a minimal risk of trophic transfer of MPs via marine pelagic copepods in marine ecosystems.

The clinical assessment of foreign body ingestions: Experience in a developing country

Foreign body (FB) ingestion is an important emergency in low- to middle-income countries. Our study sought to identify which clinical and radiological findings best predict upper gastrointestinal FB impaction. Amongst 149 adolescents and adults presenting to two Jamaican hospitals between 2018 and 2020, FB's were found at 31% of telescopic laryngoscopies and 60% of rigid oesophagoscopies. Commonest sites of impaction were the tonsils at laryngoscopy (15/46) and proximal oesophagus at oesophagoscopy (17/22). Odds of pharyngeal impaction were higher with fish bone ingestion, persistent discomfort, perceived location of discomfort above the cricoid cartilage and symptoms noted during a meal. Persistent discomfort and FB shadow on X-ray imaging produced higher odds of oesophageal impaction. Simple clinical and radiological assessments are useful in predicting FB impaction in resource-limited settings.

Timing of embolic phenomena after hydrogen peroxide exposure - a systematic review

INTRODUCTION

Hydrogen peroxide ingestions cause significant morbidity and mortality due to oxygen gas emboli and are treatable with hyperbaric oxygen therapy. Recommendations for observation are based on small case series.

OBJECTIVES

The aim of this systematic review is to define the time of onset of embolic phenomena after hydrogen peroxide exposure and to describe the proportion of patients who received hyperbaric oxygen therapy.

METHODS

Cases from a systematic literature search were combined with those from a prior study that used data derived from the American Association of Poison Control Centers National Poison Data System. Air-gas emboli were defined as embolic phenomena (stroke, myocardial infarction, obstructive shock) potentially reversed with hyperbaric oxygen therapy. Simple counts, mean, and interquartile range were used for description and comparisons.

RESULTS

A total of 766 records were identified in the literature search. Three-hundred and eighty-three duplicate records were identified and removed. Of the 383 remaining records, 156 met inclusion criteria; 88 were excluded based on predetermined criteria yielding 68 records with 85 unique cases. Forty-one cases were extracted from the 2017 National Poison Data System study resulting in a total of 126 cases for analysis. Case descriptions: We analyzed these 126 cases and documented 213 discrete clinical events, excluding deaths. There were 108 high-concentration exposures, 10 low-concentration exposures, and 8 were unknown. Thirty-five cases were intentional ingestions but not for self-harm, and 84 were unintentional or accidental. Only 4 cases were for self-harm, and there were 23 pediatric cases. There were 99 air-gas emboli reported in 78 patients. Time to onset: The time to onset of air-gas embolic was documented in 70/78. Time to symptom onset ranged from immediate to 72 h after hydrogen peroxide exposure. Over 90% of embolic symptoms occurred within 10 h of ingestion. Hyperbaric oxygen therapy: A total of 54/126 cases received hyperbaric oxygen therapy. Of those 54 cases, 31 had primary portal venous gas while the remaining 23 had air-gas emboli. Of the 23 air-gas emboli cases treated with hyperbaric oxygen therapy, 13 made full recoveries while 10 had residual symptoms or died. Mean time from air-gas emboli symptom onset to hyperbaric oxygen therapy in the full recovery group was 9 h compared to 18.2 h in the partial recovery/death group. Portal venous gas: There were 63 total reported cases of portal venous gas. Forty-nine of these cases were primary portal venous gas, 13 were secondary findings in patients with air-gas emboli and one case was secondary to non-air-gas emboli symptoms. Twenty-seven of 49 patients with portal venous gas (55%) as the primary finding had gastrointestinal bleeding. Thirty of the 63 cases received hyperbaric oxygen therapy for portal venous gas without any documented air-gas emboli. Deaths: Seventeen deaths occurred in the combined cohort. Of these, 13 were associated with high-concentration exposures. All deaths with reported time to symptom onset had symptoms within 1 h of exposure.

CONCLUSION

This review of hydrogen peroxide exposure cases suggests that clinically significant embolic phenomena occur within 10 h of exposure, although delayed air-gas emboli do happen and should considered when deciding duration of observation. It remains equivocal whether hyperbaric oxygen therapy is beneficial in cases of primary portal venous gas without systemic involvement.

Case Report of Tetrodotoxin Poisoning from Lagocephalus sceleratus in Lebanon

The Indo-Pacific pufferfish Lagocephalus sceleratus is a tetrodotoxin-containing species believed to have entered the Mediterranean Sea through the Suez Canal. Tetrodotoxin (TTX) is primarily found in the liver, intestine, and ovaries of L. sceleratus. We report a case of a patient with TTX poisoning from L. sceleratus consumption in Lebanon. History of ingestion, clinical presentation, and exam findings were obtained during phone-based consultation with the patient and intensive care physician. A 46-year-old male presented to a hospital in Lebanon with perioral and extremity numbness as well as dizziness 1 h after ingestion of an L. sceleratus fish. He had caught and prepared the fish himself and had eaten a skinless piece of flesh. Over the following 6 h he also developed ataxia and generalized body numbness. His treatment included systemic hydrocortisone, antihistamine, activated charcoal, and fluids. He was admitted to the intensive care unit, where he developed self-limited, stable sinus bradycardia. He was discharged home on hospital day 5 with residual lightheadedness that improved over several days. This is one of the first reported cases of tetrodotoxin poisoning due to L. sceleratus in Lebanon. Public awareness regarding the toxicity of this species after any ingestion is essential to prevent toxicity and death.

Hypertension and Severe Hypokalemia Associated With Oral Ingestion of Topical Hydrocortisone Cream

Background

Topical use of corticosteroids causes systemic effects, but systemic toxicity by ingesting topical corticosteroid cream has not been reported. We describe a patient admitted with ingestion of over-the-counter (OTC) hydrocortisone cream.

Case Report

A 64-year-old woman presented with 2-weeks of generalized weakness. She had a history of hypertension, anxiety, depression, and chronic fatigue syndrome, but medical records were unavailable and she was not on any medications. She reported taking prednisone 7.5 mg daily for several years, which was discontinued 5 months ago. Due to worsening symptoms, she started ingesting OTC topical hydrocortisone as replacement and admitted to consuming 2 squirts of 1% hydrocortisone cream twice daily over the previous month leading up to hospitalization. Her pulse rate was 77/min, blood pressure was 232/110 mmHg. There was no pedal edema, elevated jugular venous pressure, hirsutism, muscle wasting, or purplish skin striae. Labs revealed potassium 1.5 mg/dL (3.6-5.4), serum cortisol 61.5 μg/dL (2.3-19.4), Creatine Kinase 1864 IU/L (24-173), undetectable adrenocorticotropic hormone. She received potassium, labetalol, and intravenous fluids. Her serum cortisol level decreased to 11 μg/dL and potassium to 4.1 mg/dL within 24 hours. She left the hospital against medical advice on Day 2.

Discussion

Although both prednisone and hydrocortisone have glucocorticoid properties, only hydrocortisone has mineralocorticoid properties. Hydrocortisone 20 mg provides a mineralocorticoid effect equivalent to 0.1 mg fludrocortisone.

Conclusion

Hydrocortisone cream was confirmed as the source of exogenous corticosteroid by an undetectable adrenocorticotropic hormone and rapid decrease in cortisol following discontinuation. Incorrect use of OTC medications can lead to life-threatening side effects.