Propylene Glycol Poisoning From Excess Whiskey Ingestion: A Case of High Osmolal Gap Metabolic Acidosis

In this report, we describe a case of high anion gap metabolic acidosis with a significant osmolal gap attributed to the ingestion of liquor containing propylene glycol. Recently, several reports have characterized severe lactic acidosis occurring in the setting of iatrogenic unintentional overdosing of medications that use propylene glycol as a diluent, including lorazepam and diazepam. To date, no studies have explored potential effects of excess propylene glycol in the setting of alcohol intoxication. Our patient endorsed drinking large volumes of cinnamon flavored whiskey, which was likely Fireball Cinnamon Whisky. To our knowledge, this is the first case of propylene glycol toxicity from an intentional ingestion of liquor containing propylene glycol.

Threat of plastic pollution to seabirds is global, pervasive, and increasing

Plastic pollution in the ocean is a global concern; concentrations reach 580,000 pieces per km(2) and production is increasing exponentially. Although a large number of empirical studies provide emerging evidence of impacts to wildlife, there has been little systematic assessment of risk. We performed a spatial risk analysis using predicted debris distributions and ranges for 186 seabird species to model debris exposure. We adjusted the model using published data on plastic ingestion by seabirds. Eighty of 135 (59%) species with studies reported in the literature between 1962 and 2012 had ingested plastic, and, within those studies, on average 29% of individuals had plastic in their gut. Standardizing the data for time and species, we estimate the ingestion rate would reach 90% of individuals if these studies were conducted today. Using these results from the literature, we tuned our risk model and were able to capture 71% of the variation in plastic ingestion based on a model including exposure, time, study method, and body size. We used this tuned model to predict risk across seabird species at the global scale. The highest area of expected impact occurs at the Southern Ocean boundary in the Tasman Sea between Australia and New Zealand, which contrasts with previous work identifying this area as having low anthropogenic pressures and concentrations of marine debris. We predict that plastics ingestion is increasing in seabirds, that it will reach 99% of all species by 2050, and that effective waste management can reduce this threat.

Pediatric Toxicology: Emerging Trends

Poisoning represents one of the most common medical emergencies encountered worldwide and is especially problematic for children, who constitute the population that is most vulnerable and at risk for unintentional and preventable poisonings. The scope of toxic substances involved in poisoning is very broad, requiring health care providers to have an extensive knowledge of signs and symptoms of poisoning, as well as specific therapeutic interventions and antidotes. New synthetic and herbal substances have emerged that have resulted in significant poisoning morbidity and mortality in the pediatric population.

Rare-Earth Magnet Ingestion-Related Injuries in the Pediatric Population: A Review

Foreign-body ingestions are common among children and usually resolve with limited, if any, treatment. The ingestion of rare-earth magnets, however, commonly results in serious injury or death. These dangerous high-powered magnets can be found in the United States in a variety of consumer products, including magnetic toy sets designed for children and adults. The ingestion of one of such magnet is unlikely to cause significant harm. However, if multiple magnets are ingested, or if a magnet is ingested along with a metal object, the magnets are powerful enough to attract each other through the walls of the intestine, potentially resulting in significant internal damage. Rare-earth magnet ingestion cases are difficult to diagnose and the symptoms are not easy to differentiate from other causes of gastrointestinal illness or pain. However, delays in medical treatment can lead to serious injury or death. This review article describes the epidemiology of rare-earth magnet ingestion-related injuries and provides recommendations for diagnosis and treatment. Federal regulatory efforts related to rare-earth magnets and other prevention strategies are also discussed.

Extraction of a foreign body in the liver using single incision laparoscopic surgery: a new application for minimally invasive surgical procedures

Ingestion of foreign bodies is a common medical problem frequently observed in children, psychiatric patients and prisoners. Various cases have been found in the medical literature, with different diagnostic and therapeutic approaches. We report a case of a 41-year-old male inmate, hospitalized for right upper quadrant pain of the abdomen due to the ingestion of two syringe needles two weeks previously. We describe the diagnostic procedure and the removal of one of the two needles that had migrated into the liver parenchyma, using a single-incision laparoscopic surgical technique. The operation was carried out safely through a 2.5 cm transverse incision below the umbilicus. The dissection and the removal of the foreign body were easily conducted under direct visualization using a minimally invasive surgical technique. Our case report demonstrates the efficacy and the security of the laparoscopic treatment in such a challenging area, employing a single port access only.

E-Cigarette Liquid Nicotine Ingestion in a Child: Case Report and Discussion

Nicotine poisoning is well described in the pediatric population, and even small oral doses may result in toxic effects. The source of nicotine is usually tobacco products and nicotine replacement products such as gum and patches. With the more frequent use of novel products such as e-cigarettes, concern has arisen regarding liquid nicotine. As there are no regulations regarding childproof bottling and packaging, there may be increased potential for unintentional ingestion of these colorfully and appealingly packaged products by children. We present and discuss a case of this nature, as we feel emergency physicians should be aware of this new mode of poisoning, and public health efforts should be made to minimize such exposures.

Chitosan/interfering RNA nanoparticle mediated gene silencing in disease vector mosquito larvae

Vector mosquitoes inflict more human suffering than any other organism-and kill more than one million people each year. The mosquito genome projects facilitated research in new facets of mosquito biology, including functional genetic studies in the primary African malaria vector Anopheles gambiae and the dengue and yellow fever vector Aedes aegypti. RNA interference- (RNAi-) mediated gene silencing has been used to target genes of interest in both of these disease vector mosquito species. Here, we describe a procedure for preparation of chitosan/interfering RNA nanoparticles that are combined with food and ingested by larvae. This technically straightforward, high-throughput, and relatively inexpensive methodology, which is compatible with long double stranded RNA (dsRNA) or small interfering RNA (siRNA) molecules, has been used for the successful knockdown of a number of different genes in A. gambiae and A. aegypti larvae. Following larval feedings, knockdown, which is verified through qRT-PCR or in situ hybridization, can persist at least through the late pupal stage. This methodology may be applicable to a wide variety of mosquito and other insect species, including agricultural pests, as well as other non-model organisms. In addition to its utility in the research laboratory, in the future, chitosan, an inexpensive, non-toxic and biodegradable polymer, could potentially be utilized in the field.

Laundry pack exposures in children 0-5 years evaluated at a single pediatric institution

BACKGROUND

Case reports and poison center series have highlighted increased safety concerns with laundry packs, especially when compared to traditional laundry detergents.

OBJECTIVE

The purpose of this study was to examine the clinical experience with laundry pack exposures at a single institution.

METHODS

A retrospective chart review was performed for exposures to laundry packs seen at a single tertiary care children's hospital medical center. Cases were identified by searching the poison center database for exposures to laundry products from March 2012 to October 2013 in children <5 years old. Medical records were reviewed for all identified cases. Data collected included demographics, treatments, laboratory and radiology data, disposition, and length of stay in the emergency department (ED).

RESULTS

Forty cases were included. Thirty-two were ingestions and eight were ocular exposures. Nine children were admitted, two of which were admitted to a critical care unit. Seven other children were discharged after 1-night admissions; none received any treatments after initial ED treatment. Of these, four children were admitted for the possibility of central nervous system (CNS) depression, but none showed any progression. Twenty-nine children with ingestions were discharged directly from the ED. No children had progression of CNS symptoms. Children discharged from the ED were observed a mean of 189 min.

CONCLUSIONS

Cases of laundry pack exposures seen at our institution were similar to cases described by US poison centers. No child had progression of CNS depression suggesting that prolonged observation is not necessary if the child does not have CNS depression at presentation.

Persistent effects after camphor ingestion: a case report and literature review

BACKGROUND

Camphor is a well-known toxin responsible for thousands of poisonings per year. It can be found in many over-the-counter remedies and illegally imported substances. The toxidrome manifests within minutes and includes gastrointestinal, neurologic, pulmonary, and cardiac effects. Severe ingestions may progress to seizures, apnea, and coma. Most individuals are no longer symptomatic outside the 24-48 h window, but physiologic derangement may persist for far longer in some instances.

CASE REPORT

This is a case report of a 25-year-old Guatemalan woman with no past medical history who ingested a cube of camphor for a facial rash. She presented to the Emergency Department with persistent delirium and headache 6 days after ingestion. She had a protracted recovery but returned to her baseline state of health 19 days after ingestion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Persistent toxic effects of camphor are not well described, and most sources state that the toxidrome resolves in 24-48 h. Given the frequency of camphor poisoning, it is crucial to increase public awareness of camphor toxicity, to understand the biological mechanism of the effects, and to develop more targeted treatments. From the emergency physician's perspective, it is important to realize that toxic effects of camphor poisoning may persist far beyond the 24-48 h window and require attention.

Ear, nose and throat foreign bodies: the experience of the Pediatric Hospital of Turin

AIM

Ear, nose and throat (ENT) foreign body (FB) injuries represent an emerging problem in the paediatric population because of their human and social costs. The aim of the study is the site-specific evaluation of FB injuries in the paediatric population referred to the emergency department of the Pediatric Hospital of Turin.

METHODS

This retrospective analysis was carried out sifting medical reports between 2002 and 2011. We collected information about 338 patients' FB characteristics, complications and hospitalisation.

RESULTS

The mean age was 4.2 ± 2.9 years. Nose and ear are the most involved anatomical sites, followed by pharynx, oesophagus and trachea-bronchi. The most common FBs are balls, beads and toys parts (29.6%), followed by fishbones (13.6%). A lower mean age is observed in tracheo-bronchial and oesophageal FBs. The 9.2% of cases reported complications.

CONCLUSIONS

A quick and proper diagnosis followed by an effective treatment of FB injuries and their complication is mandatory. Surveillance registries have a key role in prevention and management of FB injuries; useful information can be obtained also for nurse and ENT specialist training in order to create professionals ready to recognise and manage FB injuries in the most effective way.

Pediatric exposure to laundry detergent pods

OBJECTIVE

Laundry detergent pods are a new product in the US marketplace. This study investigates the epidemiologic characteristics and outcomes of laundry detergent pod exposures among young children in the United States.

METHODS

Using data from the National Poison Data System, exposures to laundry detergent pods among children younger than 6 years of age during 2012-2013 were investigated.

RESULTS

There were 17 230 children younger than 6 years exposed to laundry detergent pods in 2012-2013. From March 2012 to April 2013, the monthly number of exposures increased by 645.3%, followed by a 25.1% decrease from April to December 2013. Children younger than 3 years accounted for 73.5% of cases. The major route of exposure was ingestion, accounting for 79.7% of cases. Among exposed children, 4.4% were hospitalized and 7.5% experienced a moderate or major medical outcome. A spectrum of clinical effects from minor to serious was seen with ingestion and ocular exposures. There were 102 patients (0.6%) exposed to a detergent pod via ingestion, aspiration, or a combination of routes, including ingestion, who required tracheal intubation. There was 1 confirmed death.

CONCLUSIONS

Laundry detergent pods pose a serious poisoning risk to young children. This nationwide study underscores the need for increased efforts to prevent exposure of young children to these products, which may include improvements in product packaging and labeling, development of a voluntary product safety standard, and public education. Product constituent reformulation is another potential strategy to mitigate the severity of clinical effects of laundry detergent pod exposure.

Out-of-hospital medication errors among young children in the United States, 2002-2012

OBJECTIVE

To investigate out-of-hospital medication errors among young children in the United States.

METHODS

Using data from the National Poison Database System, a retrospective analysis of out-of-hospital medication errors among children <6 years old from 2002 through 2012 was conducted.

RESULTS

During 2002-2012, 696,937 children <6 years experienced out-of-hospital medication errors, averaging 63,358 episodes per year, or 1 child every 8 minutes. The average annual rate of medication errors was 26.42 per 10,000 population. Cough and cold medication errors decreased significantly, whereas the number (42.9% increase) and rate (37.2% increase) of all other medication errors rose significantly during the 11-year study period. The number and rate of medication error events decreased with increasing child age, with children <1 year accounting for 25.2% of episodes. Analgesics (25.2%) were most commonly involved in medication errors, followed by cough and cold preparations (24.6%). Ingestion accounted for 96.2% of events, and 27.0% of medication errors were attributed to inadvertently taking or being given medication twice. Most (93.5%) cases were managed outside of a health care facility; 4.4% were treated and released from a health care facility; 0.4% were admitted to a non-critical care unit; 0.3% were admitted to a critical care unit; and 25 children died.

CONCLUSIONS

This is the first comprehensive study to evaluate the epidemiologic characteristics of out-of-hospital medication errors among children <6 years of age on a national level. Increased efforts are needed to prevent medication errors, especially those involving non-cough and cold preparations, among young children.

Ingestion of hyaluronans (molecular weights 800 k and 300 k) improves dry skin conditions: a randomized, double blind, controlled study

Hyaluronan (HA) has been increasingly used as a dietary supplement to improve the skin. However, the effect of ingested HA may depend on its molecular weight (MW) because its physiological activities in the body vary with its MW. In this study, we examined the effects of ingested HA with varying MW on the skin. In this randomized, double blind, placebo controlled study, 61 subjects with dry skin received oral HA (120 mg/day), of MWs 800 k and 300 k or placebo, for 6 weeks. The skin moisture contents of the first two groups increased more than those of the placebo group during the ingestion period. In addition, group HA 300 k exhibited significant improvements in skin moisture content 2 weeks after ingestion ended compared with the placebo group. A questionnaire survey about subjective facial aging symptoms showed that the HA treated groups exhibited significantly improved the skin condition compared with the placebo treated group. Furthermore, dermatologists objectively evaluated the clinical symptoms of the facial and whole body skin, showing that no adverse events were related to daily ingestion of HA. This study shows that both of ingesting HAs (MWs 800 k and 300 k) improved the skin condition by increasing the moisture content.

Is it safe to use a toothbrush?

AIM

To systemically collect and summarize the literature on case reports concerning adverse events associated with the oral use of a toothbrush.

MATERIALS AND METHODS

Two electronic databases were searched for articles published up to October 2013 to identify appropriate studies using focused search terms and 'case reports' as a filter. Results. A comprehensive search identified 419 unique titles and abstracts. Ninety-four studies met the eligibility criteria. In total, 118 subjects (age range = 1-60 years) presented adverse events related to the oral use of a toothbrush. Events could be summarized in five categories, of which ingestion was the most reported problem among the individuals (50 cases). This was followed by impaction of a toothbrush (27 cases). Reports more frequently involved females and children were more likely to have injuries compared to males and adults. Most of the cases that presented with adverse events of the oral use of a toothbrush were referred for treatment to a physician.

CONCLUSIONS

The combined evidence related to serious adverse events as presented in case reports showed that the oral use of a toothbrush can be associated with ingestion, impaction, instant trauma, gingival traumatic injury and seizures. Given the incidence of reporting, important recommendations are that a toothbrush should not be used to induce vomiting, nor should people walk or run with this device in their mouths, especially children.

Chronic cervical esophageal foreign bodies in children: surgical approach after unsuccessful endoscopic management

OBJECTIVES

We reviewed the surgical management of chronic cervical esophageal foreign bodies (CCEFBs) in a pediatric population after failed endoscopic retrieval.

METHODS

A descriptive analysis via a retrospective chart review of patients with CCEFBs who failed initial endoscopic management was performed between 2008 and 2013. Details were recorded regarding presenting symptoms, time from symptom onset to diagnosis of the CCEFB, surgical approach, and complications.

RESULTS

Three patients with CCEFBs unsuccessfully managed with endoscopy were identified. The range of ages at diagnosis was 14 months to 4.5 years. The foreign bodies (FBs) were present for at least 1 month before diagnosis (range, 1 to 10 months). Respiratory symptoms were predominant in all cases. Neck exploration with removal of the FB was performed in each case. Complications included esophageal stricture necessitating serial dilations (patient 1), left true vocal fold paresis that resolved spontaneously (patient 3), and tracheoesophageal fistula with successful endoscopic closure (patient 3). No long-term sequelae were experienced.

CONCLUSIONS

A high index of suspicion is required to recognize CCEFBs in children with respiratory distress. Although endoscopic management remains the first-line treatment, it may fail or may not be possible because of transmural FB migration. In this setting, neck exploration with FB removal is a safe and effective alternative.

Self-ingested intraduodenal foreign bodies--expectancy or surgical sanction?

Self-harm is a frequent pathology amongst psychiatric patients and in the penitentiary environment. Multiple self-aggression types are described, but, by far, the practice most frequently met inside the Romanian penitentiary environment is foreign body (FB) ingestion. The paper aims to show aspects pertaining to the presence of intraduodenal foreign bodies, both in simple cases and in cases that ended with a perforation, using a number of 47 cases registered between 2003 and 2010 in "Rahova" Penitentiary Hospital. The paper also focused on particular aspects linked to intraduodenal foreign body surgical accessibility.

Clinical guidelines for imaging and reporting ingested foreign bodies

OBJECTIVE

The purpose of this article is to familiarize radiologists with the specific characteristics of foreign bodies, obtained from image interpretation, to guide further management. Details of object morphologic characteristics and location in the body gained through imaging form the backbone of the classification used in the treatment of ingested foreign bodies.

CONCLUSION

The characteristics of foreign bodies and predisposing bowel abnormalities affect the decision to follow ingested objects radiographically, perform additional imaging, or proceed with endoscopic or surgical removal.

Activation of lateral hypothalamus-projecting parabrachial neurons by intraorally delivered gustatory stimuli

The present study investigated a subpopulation of neurons in the mouse parabrachial nucleus (PbN), a gustatory and visceral relay area in the brainstem, that project to the lateral hypothalamus (LH). We made injections of the retrograde tracer Fluorogold (FG) into LH, resulting in fluorescent labeling of neurons located in different regions of the PbN. Mice were stimulated through an intraoral cannula with one of seven different taste stimuli, and PbN sections were processed for immunohistochemical detection of the immediate early gene c-Fos, which labels activated neurons. LH projection neurons were found in all PbN subnuclei, but in greater concentration in lateral subnuclei, including the dorsal lateral subnucleus (dl). Fos-like immunoreactivity (FLI) was observed in the PbN in a stimulus-dependent pattern, with the greatest differentiation between intraoral stimulation with sweet (0.5 M sucrose) and bitter (0.003 M quinine) compounds. In particular, sweet and umami-tasting stimuli evoked robust FLI in cells in the dl, whereas quinine evoked almost no FLI in cells in this subnucleus. Double-labeled cells were also found in the greatest quantity in the dl. Overall, these results support the hypothesis that the dl contains direct a projection to the LH that is activated preferentially by appetitive compounds; this projection may be mediated by taste and/or postingestive mechanisms.

Self harm through foreign bodies ingestion - rare cause of digestive perforation

Self-harm is a rare pathology, often seen in psychiatric patients but more frequently in the penitentiary environment. Of the many possible forms of self-harm, foreign bodies (FB) ingestion is by far the most usual in the Romanian prison environment. The paper aims to present the diagnostic and therapeutic aspects arising as a consequence of the digestive tract perforations consequent upon foreign bodies ingestion; a number of 45 cases which occurred over a 7-year period (2003-2010) in "Rahova" Penitentiary Hospital, were analyzed. We also examined the surgical particularities of case resolution.

Self harm through foreign bodies ingestion - a rare cause of digestive perforation

Self-harm is a rare pathology, often seen in psychiatric patients but more frequently in the penitentiary environment. Of the many possible forms of self-harm, foreign bodies (FB) ingestion is by far the most usual in the Romanian prison environment. Our paper aims to present the diagnostic and therapeutic aspects arising as a consequence of digestive tract perforations consequent upon foreign bodies ingestion; we analyze a number of 45 cases which occurred over a 7-year period (2003-2010) in Rahova Penitentiary Hospital. We also examined the surgical particularities of case resolution.

ABBREVIATIONS

FB - foreign bodies, EEA - end-to-end anastomosis.

Acid resistance in Francisella tularensis

Francisella tularensis, the etiologic agent of tularemia, can survive under acidic conditions. Tularemia can be acquired by several routes, including by ingestion of contaminated food or water. While acid resistance is usually associated with a low oral infective dose (ID), the ID for gastrointestinal illness is quite high. In this study, four strains of F. tularensis ssp. tularensis (type A) and four strains of F. tularensis ssp. holarctica (type B) were examined for innate acid resistance and the ability to survive in synthetic gastric fluid (SGF) under in vitro conditions similar to passage through the human stomach. Survival for all strains was significantly less in pH 2.5 SGF than in pH 2.5 phosphate-buffered saline and pH 4.0 SGF. Attenuated strains were consistently less resistant. Type B strains are most often associated with waterborne outbreaks and were examined after storage in natural water. Low-nutrient preadaptation resulted in increased resistance. Although F. tularensis can persist under certain acidic conditions, it is sensitive to conditions replicating the fasting human stomach. This may help explain the high ID required for gastrointestinal infections.

Hyperbaric oxygen therapy for systemic gas embolism after hydrogen peroxide ingestion

BACKGROUND

Hydrogen peroxide is a commonly available product and its ingestion has been demonstrated to produce in vivo gas bubbles, which can embolize to devastating effect.

OBJECTIVE

We report two cases of hydrogen peroxide ingestion with resultant gas embolization, one to the portal system and one cerebral embolus, which were successfully treated with hyperbaric oxygen therapy (HBO), and review the literature.

CASE REPORT

Two individuals presented to our center after unintentional ingestion of concentrated hydrogen peroxide solutions. Symptoms were consistent with portal gas emboli (Patient A) and cerebral gas emboli (Patient B), which were demonstrated on imaging. They were successfully treated with HBO and recovered without event.

CONCLUSIONS

As demonstrated by both our experience as well as the current literature, HBO has been used to successfully treat gas emboli associated with hydrogen peroxide ingestion. We recommend consideration of HBO in any cases of significant hydrogen peroxide ingestion with a clinical picture compatible with gas emboli.

Intentional overdose of azathioprine in a patient with systemic lupus erythematosus

A 14-year-old girl with systemic lupus erythematosus presented with a mixed overdose of paracetamol, ibuprofen and azathioprine (1500 mg) following a deliberate self-harm attempt. The patient was admitted and monitored. No adverse effects were observed. A review of the literature showed very few reported azathioprine overdoses. Lupus patients are at risk of developing low mood and depression (and related self-harm including overdose of medication). This can be as a consequence of the disease process itself or in reaction to the stresses of living with a chronic disease, which are perhaps particularly acute in some adolescents with the disease. An intentional overdose in a patient with lupus is clearly a cry for help and should be appropriately managed. Counselling of young people and their parents about possible mood disorders is an important part of the management of this chronic disease. Despite the theoretical risk of significant myelosuppression as well as other potential adverse effects, azathioprine in acute overdose seems to be generally well tolerated.

Rare-earth magnet ingestion-related injuries among children, 2000-2012

This study describes the epidemiology of rare-earth magnet ingestion by children by retrospectively analyzing 72 cases of magnet ingestion collected from Saferproducts.gov and the US Consumer Product Safety Commission from 2000 through 2012. The mean child age was 6.4 years. Patients ingested between 1 and 40 magnets, most often 1 to 4 magnets. Unique circumstances of ingestion included faux piercing (19.4%) and mistaking magnets for candy (6.9%). Surgery was required in 69.7% of cases where treatment was reported. Fifty-three patients were hospitalized (73.6%), and the length of hospital stay was reported in 58.5% of those cases, ranging from 1 to 54 days. Approximately half (50.7%) of the magnets causing injury were products intended for use by adults. Study findings demonstrate that pediatric ingestion of rare-earth magnets can cause serious gastrointestinal injury. Establishing a performance standard that limits the attraction force of these magnets offers the best prevention solution to this important pediatric public health problem.

Boric acid ingestion clinically mimicking toxic epidermal necrolysis

The ingestion of large amounts of boric acid, a component of household insecticides, is a rare occurrence, characterized by a diffuse desquamative skin eruption, neutropenia, thrombocytopenia, delirium, acute renal failure and prolonged ileus. A 56-year-old male with a history of multiple previous suicide attempts was witnessed ingesting household roach killer and 4 days later presented to the hospital with lethargy, stiffness and a diffuse erythematous and desquamative eruption with bullous formation. He subsequently developed erythema of both palms as well as alopecia totalis. Histopathology from a right arm shave biopsy revealed a mostly intact epidermis with subtle vacuolar alteration of the basal layer, scattered intraepidermal apoptotic keratinocytes, parakeratosis with alternating layers of orthokeratosis and considerable superficial exfoliation; accompanying dermal changes included vasodilatation and mild perivascular inflammation. This report describes the cutaneous and systemic complications in a rare case of boric acid ingestion. There is little published material on the symptoms and histopathology following boric acid ingestion, but knowledge of this entity is important, both to differentiate it from other causes of desquamative skin rashes and to allow the initiation of appropriate clinical care.