Accidental Swallowing of Dental Objects During Pediatric Dental Care in Thailand

AIM

Accidental swallowing of dental objects can occur at any time during dental treatment, especially in child patients. Its severity and sequelae can range from minor to life-threatening. The study aimed to find out the occurrence of accidental swallowing and type of swallowed objects regarding pediatric dental treatment in Thailand.

MATERIALS AND METHODS

A nationwide questionnaire survey was performed among Thai dentists to anonymously report child patients' accidental swallowing throughout their working experience for up to 10 years. Percentage and frequencies of accidental swallowing in child patients, as well as types of dental objects swallowed, were investigated. Association between factors of the respondents and their experiences was assessed by the logistic regression analysis.

RESULTS

Among 408 respondents, 99 respondents [24.26%, 95% confidence interval (CI): 20.10-28.42] had experienced accidental swallowing during pediatric dental treatment. All of them reported ingestion with only one respondent reporting aspiration. Extracted teeth, stainless steel crowns, and rubber cups were top on the list of swallowed items experienced by 11.52%, 8.33%, and 3.92% of respondents, respectively. Dental sharps such as endodontic files and orthodontic wires were reported as well. Dentists with higher educational backgrounds, mostly exposed to more complicated cases, were more likely to experience accidental swallowing (odds ratio of 2.90, 95% CI: 1.61-5.21).

CONCLUSION

Our results indicate that accidental swallowing in child patients appeared to occur more frequently than anticipated. Awareness on patient safety of dental professionals and preventive measures against accidental swallowing when dealing with child patients should be greatly emphasized.

Hazards and Management of Wire Bristle ingestions: A Systematic Review

OBJECTIVE

Inadvertently ingested grill brush bristles can lodge in various locations and lead to a variety of injuries. They can also be difficult to identify and remove. Our primary objective was to perform a systematic review of cases reported in the literature, with analysis of trends in clinical presentation and success of diagnostic modalities and treatment approaches.

DATA SOURCES

Cases of reported grill brush bristle ingestion reported in PubMed, PubMed Central, and Google Scholar databases through April 30, 2021.

REVIEW METHODS

Databases were searched for the following terms: ("ingestion" OR "injury" OR "barbeque" OR "BBQ" OR "grill" OR "foreign body" OR "brush" AND "wire" OR "bristle"). Data were collected on patient demographics, clinical presentation, and treatment course. Statistical analysis was performed on characteristics with low risk of confounding.

RESULTS

An overall 57 studies involving 91 patients were included. Grill brush bristles presented most commonly in the upper aerodigestive tract (48/91), followed by the abdomen (26/91) and deep neck (17/91). Computed tomography was the most accurate imaging modality for initial diagnosis, identifying 92.8% of bristles. Less invasive or adjunctive techniques such as endoscopy, intraoperative imaging, or minimally invasive surgery may be useful particularly for bristles located in the head and neck given the low rate of success of transoral surgery (66.7%).

CONCLUSION

Although this review of retained bristle may be biased toward complex cases, retained grill brush bristles represent an underrecognized and difficult-to-manage hazard. When cases are suspected, clinicians should obtain computed tomography imaging based on presentation and tailor management appropriately.

Endoscopic removal of accidental aspirated and ingested dental foreign bodies: A cross-sectional study

The incidence of accidental ingestion and aspiration of foreign body (FB) is likely to occur. Many FBs are discharged spontaneously, but many dental FBs are often sharp and may remain in the pharynx, esophagus, and stomach, causing serious complications such as hemorrhage, asphyxia, perforation of the digestive tract, mediastinal emphysema, peritonitis, and ileus. We aimed to examine which type of dental foreign bodies can be removed by endoscope.In this study, we enrolled 32 patients who were evaluated at the Emergency and Critical Center between January 2014 and December 2019 and who accidentally ingested or aspirated dental FBs. Medical records were reviewed to determine the patients' sex, age, medical history, time from accidental ingestion of a FB to consultation, cause, location, occurrence status, nature of the FB, location of retained FB, treatment, complications, and outcome.We enrolled 32 patients (14 men, 18 women), with a mean age of 74.5 ± 12.8 years. Accidental ingestion at treatment was common. The most frequent site where the FB was retained was upper gastrointestinal tract (26 cases, 81.3%). In this study, endoscopic removal was indicated for dentures under the size of 43.3 mm, for dental FB (except dentures) more than 13.6 mm. In dentures, between the number of missing teeth, clasp, type, and endoscopic removal was not statistically significant.Dentures under the size of 43.3 mm was likely to be removed by endoscope. Dental FB (except dentures) more than the size of 13.6 mm was likely to be removed by endoscope. There were no indications for endoscopic removal except for size.

A neural circuit integrates pharyngeal sensation to control feeding

Swallowing is an essential step of eating and drinking. However, how the quality of a food bolus is sensed by pharyngeal neurons is largely unknown. Here we find that mechanical receptors along the Drosophila pharynx are required for control of meal size, especially for food of high viscosity. The mechanical force exerted by the bolus passing across the pharynx is detected by neurons expressing the mechanotransduction channel NOMPC (no mechanoreceptor potential C) and is relayed, together with gustatory information, to IN1 neurons in the subesophageal zone (SEZ) of the brain. IN1 (ingestion neurons) neurons act directly upstream of a group of peptidergic neurons that encode satiety. Prolonged activation of IN1 neurons suppresses feeding. IN1 neurons receive inhibition from DSOG1 (descending subesophageal neurons) neurons, a group of GABAergic neurons that non-selectively suppress feeding. Our results reveal the function of pharyngeal mechanoreceptors and their downstream neural circuits in the control of food ingestion.

Antibacterial and anatomical defenses in an oil contaminated, vulnerable seaduck

Oil spills have killed thousands of birds during the last 100 years, but nonlethal effects of oil spills on birds remain poorly studied. We measured phenotype characters in 819 eiders Somateria mollissima (279 whole birds and 540 wings) of which 13.6% were oiled. We tested the hypotheses that (a) the morphology of eiders does not change due to oil contamination; (b) the anatomy of organs reflects the physiological reaction to contamination, for example, increase in metabolic demand, increase in food intake, and counteracting toxic effects of oil; (c) large locomotion apparatus that facilitates locomotion increases the risk of getting oiled; and (d) individual eiders with a higher production of secretions from the uropygial grand were more likely to have oil on their plumage. We tested whether 19 characters differed between oiled and nonoiled individuals, showing a consistent pattern. The final model retained seven predictor variables showing relationships between eiders contaminated with oil and food consumption, flight, and diving abilities. We tested whether these effects were due to differences in body condition, liver mass, empty gizzard mass, or other characters that could have been affected by impaired flight and diving ability. There was no evidence of such negative impact of oiling on eiders. We found that significant exposure to oil was associated with increased diversity of antibacterial defense. Oiled eiders did not constitute a random sample, and superior diving ability as reflected by large foot area was at a selective disadvantage during oil spills. Thus, specific characteristics predispose eiders to oiling, with an adaptation to swimming, diving, and flying being traded against the costs of oiling. In contrast, individuals with a high degree of physiological plasticity may experience an advantage because their uropygial secretions counteract the effects of oil contamination.

Chemical exposures from upholstered furniture with various flame retardant technologies

Upholstered furniture is often manufactured with polyurethane foam (PUF) containing flame retardants (FRs) to prevent the risk of a fire and/or to meet flammability regulations, however, exposure to certain FRs and other chemicals have been linked to adverse health effects. This study developed a new methodology for evaluating volatile organic compound (VOC) and FR exposures to users of upholstered furniture by simulating use of a chair in a controlled exposure chamber and assessing the health significance of measured chemical exposure. Chairs with different fire-resistant technologies were evaluated for VOC and FR exposures via inhalation, ingestion, and dermal contact exposure routes. Data show that VOC exposure levels are lower than threshold levels defined by the US and global indoor air criteria. Brominated FRs were not detected from the studied chairs. The organophosphate FRs added to PUF were released into the surrounding air (0.4 ng/m³ ) and as dust (16 ng/m² ). Exposure modeling showed that adults are exposed to FRs released from upholstered furniture mostly by dermal contact and children are exposed via dermal and ingestion exposure. Children are most susceptible to FR exposure/dose (2 times higher average daily dose than adults) due to their frequent hand to mouth contact.

Lead Toxicity From a Swallowed Fishing Sinker: A Case Report

Lead toxicity is relatively common despite increased public awareness, with lifelong neurologic sequelae. Common sources of exposure include lead paint, contaminated water, curtain weights, and bullets. However, few reports consider management of lead fishing equipment ingestions, such as weights or sinkers. We present a 5-year-old male who swallowed a lead fishing weight and had a high serum lead level despite urgent removal. When managing ingestion of a lead foreign body, if accessible by upper endoscopy, we recommend urgent removal with subsequent monitoring of serum lead levels.

High levels of microplastic ingestion by commercial, planktivorous Alburnus tarichi in Lake Van, Turkey

Microplastic pollution of inland environments has been receiving increased publicity over the last few years. For the first time, this study reports on the presence of microplastics (0.1 mm to <5 mm) in the gastrointestinal tracts of Alburnus tarichi in Lake Van from January to April 2020. In total, 101 fishes were obtained from Citoren, Edremit, Gevas and Dagonu fisheries regions. A total of 3338 pieces of plastic, ranging from 8 to 124 samples per fish with averaging 34 ± 13 MPs/individual, were extracted from gastrointestinal tracts of fish. The majority of the ingested particles consisted of fibres (74%), and blue coloured material was the most consumed microplastic. The polymers identified by Fourier Transform Infrared Spectroscopy (FTIR) were polyethylene and polypropylene. Consequently, this study suggested that the vast majority of A. tarichi were contaminated with microplastics and showed higher abundance in comparison with other worldwide studies so far.

A state-of-the-science review of polychlorinated biphenyl exposures at background levels: relative contributions of exposure routes

Exposure to polychlorinated biphenyls (PCBs) can occur through multiple routes and sources, including dietary intake, inhalation, dermal contact, and ingestion of dust and soils. Dietary exposure to PCBs is often considered the primary exposure route for the general population; however, recent studies suggest an increasing contribution from indoor inhalation exposure. Here, we aim to estimate the relative contribution of different PCB exposure pathways for the general population, as well as for select age groups. We conducted a targeted literature review of PCB concentrations in environmental media, including indoor and outdoor air, indoor dust, and soils, as well as of total dietary intake. Using the average concentrations from the studies identified, we estimated PCB exposure through different routes for the general population. In addition, we assessed exposure via environmental media for select age groups. We identified a total of 70 studies, 64 that provided background PCB concentrations for one or more of the environmental media of interest and 6 studies that provided estimates of dietary intake. Using estimates from studies conducted worldwide, for the general population, dietary intake of PCBs was the major exposure pathway. In general, our review identifies important limitations in the data available to assess population exposures, highlighting the need for more current and population-based estimates of PCB exposure, particularly for indoor air and dietary intake.

Commercial Gilthead Seabream (Sparus aurata L.) from the Mar Menor Coastal Lagoon as Hotspots of Microplastic Accumulation in the Digestive System

This paper presents the results on the presence and characterization of microplastics (MP) in the gastrointestinal tract of gilthead seabream (Sparus aurata L.), a species of commercial interest from the Mar Menor coastal lagoon in Southeast Spain. This is the first time that microplastic ingestion is recorded in any species from this semi-enclosed bay. Stomach and intestine from a total of 17 specimens captured by local fishermen were processed, and microplastic particles and fibers found in all of them were displayed. Overall, 40.32% (279/692) of total isolated microparticles proved to be microplastics; i.e., <5 mm, as identified by FTIR spectroscopy. The average value by fish was 20.11 ± 2.94 MP kg^-1, corresponding to average concentrations of 3912.06 ± 791.24 and 1562.17 ± 402.04 MP by kg stomach and intestine, respectively. Four MP forms were isolated: fiber (71.68%), fragment (21.15%), film (6.81%), and microbead (0.36%), with sizes ranging from 91 µm to 5 mm, an average of 0.83 ± 0.04 mm, and no statistically significant differences between mean sizes in stomach and intestine samples (F-test = 0.004; p = 0.936). Nine polymer types were detected, although most of fibers remained unidentified because of their small size, the presence of polymer additives, or closely adhered pollutants despite the oxidizing digestion carried out to eliminate organic matter. No significant correlation was found between main biological parameters and ingested microplastics, and high-density polyethylene (HDPE), low-density polyethylene (LDPE), polyethylene polypropylene (PEP), and polyvinyl (PV) were identified as the most abundant polymers. The average microplastic ingestion in this study area was higher than those reported in most studies within the Mediterranean Sea, and closely related to microplastic pollution in the surrounding area, although with a predominance of fiber form mainly due to fishery activities.

Metabolic Reliance on Photosynthesis Depends on Both Irradiance and Prey Availability in the Mixotrophic Ciliate, Strombidium cf. basimorphum

Many species of the ciliate genus Strombidium can acquire functional chloroplasts from a wide range of algal prey and are thus classified as generalist non-constitutive mixotrophs. Little, however, is known about the influence of irradiance and prey availability on their ability to exploit the photosynthetic potential of the chloroplasts, and how this may explain their spatial and temporal distribution in nature. In this study, inorganic carbon uptake, growth, and ingestion rates were measured for S. cf. basimorphum under three different irradiances (10, 40, and 120 μmol photons m^–2 s^–1) when acclimated to three different prey densities (5 × 10³, 1 × 10⁴, and 4 × 10⁴ cells mL^–1), as well as when allowed to deplete the prey. After prey depletion, cultures survived without prey longest (∼6 days) at the medium irradiance treatment (40 μmol photons m^–2 s^–1), while ciliate density, inorganic carbon uptake rates, and cellular chl-a content declined fastest at the highest irradiance treatment. This indicates that the ciliates may be unable to maintain the chloroplasts functionally without replacement at high irradiances. Ingestion rates were not shown to be significantly influenced by irradiance. The maximum gross growth efficiency (GGE) in this study (1.1) was measured in cultures exposed to the medium test irradiance and lowest prey density treatment (5 × 10³ cells mL^–1). The relative contribution of inorganic carbon uptake to the ciliate carbon budget was also highest in this treatment (42%). A secondary GGE peak (0.99) occurred when cultures were exposed to the highest test irradiance and the medium prey density. These and other results suggest that S. cf. basimorphum, and other generalist non-constitutive mixotrophs, can flexibly exploit many different environmental conditions across the globe.

Esophageal Retained Lithium Battery in Children Younger than 6 Years: A Prompt Structured Multidisciplinary Approach Is Essential to Reduce Long-Term Consequences

OBJECTIVES

Disk battery esophageal retention in children younger than 6 years represents an increasing endoscopic emergency, followed by a relevant risk of life-threatening late complications. Surgical removal after a failed endoscopic approach is rarely reported in the literature. We describe our experience in this scenario.

METHODS

Two female asymptomatic patients aged 26 and 29 months presented within 4 hours after a witnessed ingestion of a 2-cm, 3-V lithium battery (CR2032) retained in the cervical esophagus. Both patients underwent a prolonged unsuccessful emergent endoscopic removal with a flexible instrument performed by an adult gastroenterologist. Both batteries fused with the esophageal wall were extracted through a longitudinal left cervical esophagotomy combined with minimal resection of necrotic tissues and repaired over a 12F feeding tube.

RESULTS

Patients were extubated after 12 and 72 hours, respectively. Contrast study was performed after 20 and 13 days, respectively, before resuming oral feeding. At endoscopy, the first patient developed a 3-cm-long severe esophageal stenosis (35th day), followed by an asymptomatic tracheoesophageal fistula (60th day), which was conservatively treated. After spontaneous resolution of the tracheoesophageal fistula, esophageal stenosis progressed, partially responsive to esophageal stenting. Short esophagectomy is under evaluation. The second patient developed an asymptomatic limited stenosis, not requiring dilatation.

CONCLUSIONS

The emergent management of lithium battery ingestion needs a structured timely multidisciplinary approach in the emergency department, an experienced pediatric endoscopist, and a simultaneous engagement of pediatric surgical expertise, even in patients who do not show bleeding, to reduce esophageal exposure time to high-voltage current released by batteries, which represents the main factor conditioning tissue damage and prognosis.

2019 Annual Report of the Kansas Poison Control Center at The University of Kansas Health System

Introduction

This is the 2019 Annual Report of the Kansas Poison Control Center (KSPCC) at The University of Kansas Health System. The KSPCC is one of 55 certified poison control centers in the United States and serves the state of Kansas 24-hours a day, 365 days a year with certified specialists in poison information and clinical and medical toxicologists. The KSPCC receives calls from the public, law enforcement, health care professionals, and public health agencies. All calls to the KSPCC are recorded electronically in the Toxicall® data management system and uploaded in near real-time to the National Poison Data System (NPDS) which is the data repository for all poison control centers in the United States.

Methods

All encounters reported to the KSPCC from January 1, 2019 through December 31, 2019 were analyzed. Data recorded for each exposure includes caller location, age, weight, gender, exposure substance, nature of exposure, route of exposure, interventions, medical outcome, disposition, and location of care. Encounters were classified as human exposure, animal exposure, confirmed non-exposure, or information call (no exposure reported).

Results

The KSPCC logged 20,589 total encounters in 2019, including 19,406 human exposure cases. The KSPCC received calls from every county in Kansas. A slim majority of human exposure cases (50.5%, n = 9,790) were female. Approximately 61% (n = 11,876) of human exposures involved a child (defined as 19 years of age or less). Most encounters occurred at a residence (91.6%, n = 17,780) and most cases (64.9%, n = 12,599) originated from a residence. The majority of human exposures (85.5%, n = 16,589) were acute cases (exposures occurring over 8 hours or less). Ingestion was the most common route of exposure documented (85.3%, n = 16,548). The most commonly reported substance in pediatric (children ≤ 5) encounters was cosmetics/personal care products (n = 959) followed closely by household cleaning products (n = 943). For adult encounters, analgesics (n = 1,296) and sedative/hypnotics/antipsychotics (n = 1,084) were the most frequently involved substances. Unintentional exposures were the most common reason for exposures (75.4%, n = 14,634). Most encounters (65.9%, n = 12,780) were managed in a non-healthcare facility (i.e., a residence). Among human exposures, 14,591 involved exposures to pharmaceutical agents while 9,439 involved exposure to non-pharmaceuticals. Medical outcomes were 26.4% (n = 5,116) no effect, 18.8% (n = 3,652) minor effect, 9.3% (n = 1,813) moderate effect, and 3.1% (n = 603) major effects. There were 14 deaths in 2019 reported to the KSPCC. Cases from healthcare facilities and cases with moderate or major medical outcomes increased in 2019 compared to 2018. The number of deaths reported to the KSPCC increased in 2019 to 14 from 7 in 2018.

Conclusions

The results of the 2019 Kansas Poison Control Center’s annual report demonstrated that cases were received from the entire state of Kansas totaling over 19,400 human exposures per year. While pediatric exposures remained the most common encounter, there continued a trend of increasing number of cases from healthcare facilities and for cases with serious outcomes. The experience of the KSPCC is comparable to national data. This report supported the continued value of the KSPCC to both public and acute health care in the state of Kansas.

Put your money where your mouth is

Suspicion for battery ingestion should be maintained for any round radiopaque foreign body. Presence of the classic "double ring" sign on plain film should prompt emergent operative removal, although it is not pathognomonic.

Evaluation of potential gastrointestinal carcinogenicity associated with the ingestion of asbestos

The inhalation of asbestos, depending on the fiber type and dose, may be associated with the development of mesothelioma and other asbestos-related diseases. However, little is known about the potential adverse effects associated with the ingestion of asbestos. Evidence of asbestos fibers released from asbestos-cement pipes used in water distribution systems has led to concerns of potentially contaminated drinking water. The purpose of this study is to determine whether ingestion of asbestos fibers may lead to cancerous effects on the gastrointestinal (GI) tract. Data from animal and human studies were analyzed using a weight-of-evidence approach to evaluate the potential risk of GI cancers associated with asbestos ingestion. Seventeen human and 23 animal studies were identified and evaluated in this study. Animal studies were conducted in multiple species with inconsistent dosing protocols. Overall, animal studies reported that the asbestos fibers, irrespective of fiber type and dose, failed to produce any definitive GI carcinogenic effect. The 17 identified human epidemiological studies reported the ingestion of asbestos-contaminated water with concentrations from 1 to 71,350 million fibers per liter (MFL). A majority of the epidemiology studies reported statistically significant increases in multiple GI-specific cancers. However, these findings are confounded due to several critical study limitations including flawed study design, small sample size, selection bias, lack of individual exposure history, lack of adequate latency, and the inability to account for confounders including occupational history, diet, and smoking history. Based on our weight-of-evidence assessment, there is insufficient evidence of causality between the ingestion of asbestos and an increased incidence of GI cancers.

Eucalyptus Oil-Induced Seizures in Children: A Single-Center Prospective Study

Objective

Eucalyptus oil (EO) is known to have proconvulsant properties. EO is present in many over-the-counter preparations and used orally or topically to treat many ailments. In this study, we seek to describe clinical features, neuroimaging, and electroencephalographic findings and follow up outcome in children with eucalyptus oil-induced seizures (EOIS).

Materials and methods

This was a single-center prospective observational study, conducted at a tertiary care hospital from South India over a period of two years. Children (up to 18 years of age) with a first afebrile seizure or breakthrough seizures with preexisting epilepsy and with a recent exposure to EO were included. Data from all the children including demographic data, exposure to EO, mode of exposure, time to onset of seizures in relation to exposure, duration of seizure, type of seizure, investigations, and antiepileptic drug therapy were noted. All the patients were followed up for recurrence of seizures for six to nine months. 

Results

During the study period of two years, a total of 17 children met the inclusion criteria, with a median (range) age of 3.75 years (23 - 150 months) and 10 (59%) were male. Only one patient had breakthrough seizures and all other 16 children had a first episode of seizure. All the children had generalized tonic-clonic seizures with median duration of three minutes (30 sec - 30 minutes). The median (range) interval between EO exposure and the onset of seizures was 20 minutes (10 - 120 minutes). All the children had taken EO drops orally mixed in either water or milk in different amounts. All the patients' brain neuroimaging was normal. All the patients had normal electroencephalography except for four children. Only five patients were treated with antiepileptic drugs for two weeks and one patient with preexisting epilepsy was continued on the same antiepileptic drug. None of the patients had a recurrence of seizures during the follow-up period of six to nine months.

Conclusion 

EOIS is an underrecognized and rare entity of seizures in children. EOIS can occur as first seizures or as breakthrough seizures in preexisting epilepsy patients. Despite the previous case reports in the literature quoting the seizurogenic potential of EO, this awareness is lacking in both clinicians and parents. We also recommend clinicians inquire about exposure to EO while approaching a child with first afebrile seizures or breakthrough seizures, which can prevent unnecessary investigations and long-term antiepileptic drug therapy.

Clinical presentation, diagnosis and management of aerodigestive tract foreign bodies in the paediatric population: Part 2

Children, especially toddlers, because of their behaviour, physiology and anatomical characteristics such as oral exploration of their surroundings, have a tendency to place objects in their mouth. Therefore, ingestion or aspiration of foreign bodies (FBs) in children is a potentially life-threatening and common problem seen across the world. In this second part of our pictorial review on ingested and aspirated FBs, we focus on the paediatric population, reviewing the current literature and examining the epidemiology, clinical presentation, anatomic considerations, appropriate imaging modalities, key imaging characteristics associated with clinically relevant FBs in the emergency department (ED) and current management protocols.

Caustic ingestions over 10 years in Victoria, Australia: High rates in migrants and women

OBJECTIVES

Caustic ingestion is relatively common in developing countries and can result in life-threatening sequelae. There is limited understanding of the epidemiology and incidence in Australia. This statewide 10 year audit aims to investigate this further.

METHOD

A retrospective review was conducted over ten years (2007-2016), including all admissions to hospitals in Victoria. This includes a population of 5.9 million people and 22 hospitals.

RESULTS

384 cases of caustic ingestion were admitted to hospital between January 2007 and December 2016. The overall incidence was 7 cases/million/year. This cohort included 217 females (56.5%), 193 overseas born patients (50.2%) and 196 people (51%) with a history of mental illness. The countries of birth with the highest incidence of caustic ingestion were Ethiopia, 11 patients (227 cases/million/year, RR 31.7, p < 0.0001), Sudan, 11 patients (161 cases/million/year, RR 22.6, p < 0.0001), India, 38 patients (27 cases/million/year, RR 3.9, p < 0.0001). All had a significantly higher incidence than the Australian-born population of only 6.5 cases/million/year (RR 0.4, p < 0.0001). Of those born in India, Sudan and Ethiopia, rates of females were considerably higher than males (72% females). The overall mortality rate in this cohort was 2.3%.

CONCLUSIONS

Caustic ingestion remains a significant cause of morbidity and health expenditure in Victoria, particularly amongst vulnerable groups such as recent female migrants from areas in Africa and India. The high frequency of events seen in migrant populations highlights the significant need for awareness of risks in these groups for development of possible prevention strategies which are required. This article is protected by copyright. All rights reserved.

Emerging Mechanisms of Endocytosis in Toxoplasma gondii

Eukaryotes critically rely on endocytosis of autologous and heterologous material to maintain homeostasis and to proliferate. Although mechanisms of endocytosis have been extensively identified in mammalian and plant systems along with model systems including budding yeast, relatively little is known about endocytosis in protozoan parasites including those belonging to the phylum Apicomplexa. Whereas it has been long established that the apicomplexan agents of malaria (Plasmodium spp.) internalize and degrade hemoglobin from infected red blood cells to acquire amino acids for growth, that the related and pervasive parasite Toxoplasma gondii has a functional and active endocytic system was only recently discovered. Here we discuss emerging and hypothesized mechanisms of endocytosis in Toxoplasma gondii with reference to model systems and malaria parasites. Establishing a framework for potential mechanisms of endocytosis in Toxoplasma gondii will help guide future research aimed at defining the molecular basis and biological relevance of endocytosis in this tractable and versatile parasite.

Casein-enhanced uptake and disease-modifying bioactivity of ingested extracellular vesicles

Extracellular vesicles (EVs) from cardiac stromal cells, developed as therapeutic candidates, improve dystrophic muscle function when administered parenterally, but oral delivery remains untested. We find that casein, the dominant protein in breast milk, enhances the uptake and bioactivity of ingested heart‐derived EVs, altering gene expression in blood cells and enhancing muscle function in mdx mice with muscular dystrophy. Thus, EVs, administered orally, are absorbed and exert disease‐modifying bioactivity in vivo. Formulating EVs with casein enhances uptake and markedly expands the range of potential therapeutic applications.

Magnet Ingestion in Children Management Guidelines and Prevention

Purpose: Foreign body ingestion is common in children, and most foreign bodies pass spontaneously without causing serious injuries. Ingestion of multiple high-power magnet pieces is unique and increases the risk of morbidity and mortality. The longer the duration of ingestion, the increased likelihood of complications. Various management options have been reported, and there is no consensus on the ideal management which necessitates the need for a practical algorithm. The incidence of magnet ingestion has been increasing and directly related to the laws and recalls. The aim of this review is to provide an easy and practical pathway for management and to highlight the preventive rules of the legislations and recalls. Methods: PubMed/MEDLINE, the Cochrane Database of Systematic Reviews, and the list of references from all identified complete publications were searched for all publications in English-language for pediatric magnet ingestion. Conclusion: Practical and time-saving management pathways are recommended to minimize the risk of complications. Preventive rules and recalls are important for eliminating the availability of these hazardous magnets. Public awareness about the unique risks posed by these magnets if ingested is important.

Migration of an ingested fishbone to the uterine wall: A case report

This paper reports the first case of the removal of an ingested fishbone from the uterus. A 77-year-old woman presented with a 3-day history of lower abdominal pain. An abscess-like lesion in the posterior wall of the uterus was revealed by transvaginal ultrasonography and pelvic magnetic resonance imaging. Moreover, a curvilinear calcium density in the anterior uterine wall was revealed by abdominal computed tomography. A recto-sigmoidal perforation and uterine abscess were suspected. Thus, hysteroscopic drainage of the abscess was performed. Hysteroscopy revealed a fishbone partially embedded in the myometrium. Its removal resulted in full recovery. This study believed that adhesions between the uterus and rectosigmoid colon after partial gastrectomy for gastric cancer may have limited abdominal symptoms by limiting the leakage of intestinal fluids. Although rare, it should be considered that migration of a fishbone into the uterus could occur.

Alpha Spectrometry of Radon Short-Lived Progeny in Drinking Water and Assessment of the Public Effective Dose: Results from the Cilento Area, Province of Salerno, Southern Italy

Radon is a naturally occurring radioactive gas present in the hydrosphere, lithosphere and atmosphere abundantly. Its ionizing radiation provides the largest human internal exposure by inhalation and ingestion to natural sources, constituting a serious health hazard. The contribution to total exposure is mainly due to inhalation, as ingestion by food or drinking water is typically very small. However, because of public health concerns, the contributions from all these sources are limited by regulations and remedial action should be taken in the event that the defined threshold values are overcome. In this paper, the first campaign of measurements to control the radon activity concentration in drinking water from public water supplies in the province of Salerno, south Italy, is described. The results represent a main reference for the area, as it was never investigated before. The purpose of this survey was to contribute to data compilation concerning the presence of radon-222 in groundwater in the Campania region and to determine the associated risk for different age groups. The maximum radon activity concentrations and the related total annual public effective dose turned out to be lower than the threshold values (100 Bq/l and 0.1 mSv/y, respectively) indicated by international guidelines and the national regulation, showing that the health risks for public consumption can be considered negligible.

Risk of toxicity from pediatric topical salicylate ingestions

INTRODUCTION

Suspected pediatric ingestions of greater than or equal to one teaspoon topical salicylate analgesic are recommended by poison control centers to be managed at healthcare facilities. This cutoff is applied for both liquid and non-liquid (cream, ointment, gel) formulations.

METHODS

California poison control cases involving topical salicylate exposures in children less than 6-years-old who were evaluated at a health care facility between 2003 and 2018 were analyzed.

RESULTS

Of 599 patient cases, the majority described no or minor symptoms, with gastrointestinal distress being the most common. Signs of salicylate toxicity (metabolic acidosis, tachypnea) occurred in six cases. Seven patients were hospitalized, six of whom were exposed to liquid preparations.

DISCUSSION

In line with previous research, liquid salicylate preparations were more frequently associated with the signs of salicylate toxicity and hospitalization.

CONCLUSION

There was a low frequency of severe side effects and low hospitalization rates among those referred to a healthcare facility, especially for non-liquid topical salicylate ingestions.

Serotonin Syndrome Associated With Vilazodone Overdose in a 22-Month-Old Treated With Dexmedetomidine

BACKGROUND

Vilazodone was approved by the U.S. Food and Drug Administration in 2011 as a treatment for major depression disorder. Vilazodone is a selective serotonin reuptake inhibitor and 5-HT1A agonist used in the treatment of depression in adults. Vilazodone increases the availability and activity of serotonin and its neural pathways. Vilazodone blocks the serotonin reuptake pump and desensitizes serotonin receptors (especially 5HT1A autoreceptors), therefore increasing serotonergic neurotransmission. Its partial agonist actions at presynaptic somatodendritic 5HT1A autoreceptors theoretically enhance serotonergic activity, contributing to antidepressant actions. There are limited reports exploring its effects in children after unintentional ingestion. Typical adult dosing is titrated from an initial dose of 10 mg up to a maximum dose of 40 mg daily. Serotonin syndrome classically manifests with restlessness, hyperthermia, tachycardia, mydriasis, and increased tone, and is typically treated with benzodiazepines, cyproheptadine, and supportive care. Dexmedetomidine has also been used in case reports to treat serotonin syndrome.

CASE REPORT

We report the case of a toddler with a laboratory-confirmed vilazodone overdose exhibiting symptoms of serotonin syndrome, including restlessness, hyperthermia, mydriasis, dystonia, agitation, seizure-like activity, roving eye movement, tachycardia, and elevated creatine kinase. The patient was admitted and initially treated with supportive care and lorazepam per recommendations of the poison center, which did not recommend cyproheptadine use. On decompensation with suspected serotonin syndrome, the patient was treated with dexmedetomidine. In addition, urine toxicology screening (Amphetamines II assay; Roche, Indianapolis, IN) was positive for amphetamines; however, confirmatory testing (gas chromatography-mass spectrometry) was negative. The patient improved and was discharged after returning to her baseline status at 74 h post ingestion. Importantly, this patient did not require intubation and mechanical intubation, in spite of the large amount of vilazodone ingested. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With increasing prescription of vilazodone, emergency physicians should have a high level of suspicion so as not to miss this toxidrome. The possibility of false-positive amphetamine screenings when an overdose of vilazodone is suspected should be investigated. Finally, systematic evaluation of the use of dexmedetomidine as treatment for serotonin syndrome or vilazodone ingestion should be done to confirm efficacy.