Embedded weapons-grade tungsten alloy shrapnel rapidly induces metastatic high-grade rhabdomyosarcomas in F344 rats

Early transcriptomic signatures and biomarkers of renal damage due to prolonged exposure to embedded metal

BACKGROUND

Prolonged exposure to toxic heavy metals leads to deleterious health outcomes including kidney injury. Metal exposure occurs through both environmental pathways including contamination of drinking water sources and from occupational hazards, including the military-unique risks from battlefield injuries resulting in retained metal fragments from bullets and blast debris. One of the key challenges to mitigate health effects in these scenarios is to detect early insult to target organs, such as the kidney, before irreversible damage occurs.

METHODS

High-throughput transcriptomics (HTT) has been recently demonstrated to have high sensitivity and specificity as a rapid and cost-effective assay for detecting tissue toxicity. To better understand the molecular signature of early kidney damage, we performed RNA sequencing (RNA-seq) on renal tissue using a rat model of soft tissue-embedded metal exposure. We then performed small RNA-seq analysis on serum samples from the same animals to identify potential miRNA biomarkers of kidney damage.

RESULTS

We found that metals, especially lead and depleted uranium, induce oxidative damage that mainly cause dysregulated mitochondrial gene expression. Utilizing publicly available single-cell RNA-seq datasets, we demonstrate that deep learning-based cell type decomposition effectively identified cells within the kidney that were affected by metal exposure. By combining random forest feature selection and statistical methods, we further identify miRNA-423 as a promising early systemic marker of kidney injury.

CONCLUSION

Our data suggest that combining HTT and deep learning is a promising approach for identifying cell injury in kidney tissue. We propose miRNA-423 as a potential serum biomarker for early detection of kidney injury.

Genotoxicity in the absence of inflammation after tungsten inhalation in mice

Tungsten is used in several applications and human exposure may occur. To assess its pulmonary toxicity, we exposed male mice to nose-only inhalation of tungsten particles at 9, 23 or 132 mg/m³ (Low, Mid and High exposure) (45 min/day, 5 days/week for 2 weeks). Increased genotoxicity (assessed by comet assay) was seen in bronchoalveolar (BAL) fluid cells at Low and High exposure. We measured acellular ROS production, and cannot exclude that ROS contributed to the observed genotoxicity. We saw no effects on body weight gain, pulmonary inflammation, lactate dehydrogenase or protein in BAL fluid, pathology of liver or kidney, or on sperm counts. In conclusion, tungsten showed non-dose dependent genotoxicity in the absence of inflammation and therefore interpreted to be primary genotoxicity. Based on genotoxicity, a Lowest Observed Adverse Effect Concentration (LOAEC) could be set at 9 mg/m³. It was not possible to establish a No Adverse Effect Concentration (NOAEC).

Tungsten toxicity and carcinogenesis

Tungsten is an emerging contaminant in the environment. Research has demonstrated that humans are exposed to high levels of tungsten in certain settings, primarily due to increased use of tungsten in industrial applications. However, our understanding of the potential human health risks of tungsten exposure is still limited. An important point we have learned about the toxicity profile of tungsten is that it is complex because tungsten can often augment the effects of other co-exposures or co-stressors, which could result in greater toxicity or more severe disease. This has shaped the tungsten toxicology field and the types of research questions being investigated. This has particularly been true when evaluating the toxicity profile of tungsten metal alloys in combination with cobalt. In this chapter, the current state of the tungsten toxicology field will be discussed focusing on data investigating tungsten carcinogenicity and other major toxicities including pulmonary, cardiometabolic, bone, and immune endpoints, either alone or in combination with other metals. Environmental and human monitoring data will also be discussed to highlight human populations most at risk of exposure to high concentrations of tungsten, the forms of tungsten present in each setting, and exposure levels in each population.

Serum Indicators of Oxidative Damage from Embedded Metal Fragments in a Rat Model

Injuries suffered in armed conflicts often result in embedded metal fragments. Standard surgical guidance recommends leaving embedded fragments in place except under certain circumstances in an attempt to avoid the potential morbidity that extensive surgery often brings. However, technological advances in weapon systems and insurgent use of improvised explosive devices now mean that practically any metal can be found in these types of wounds. Unfortunately, in many cases, the long-term toxicological properties of embedded metals are not known, further complicating treatment decisions. Because of concerns over embedded metal fragment injuries, the U.S. Departments of Defense and Veterans' Affairs developed a list of “metals of concern” for these types of injuries. In this study, we selected eight of these metals including tungsten, nickel, cobalt, iron, copper, aluminum, lead, and depleted uranium to investigate the long-term health effects using a rodent model developed in our Institute to study embedded fragment injuries. In this report, we show that metals surgically implanted into the gastrocnemius muscle of laboratory rats to simulate a shrapnel wound induce a variety of cytokines including IFN-γ, IL-4, IL-5, IL-6, IL-10, and IL-13. TNF-α and KC/GRO were not affected, and IL-1β was below the limit of detection. Serum levels of C-reactive protein were also affected, increasing with some metals and decreasing with others. The TBARS assay, an assessment of lipid peroxidation, demonstrated that implanted aluminum and lead increased markers of lipid peroxidation in serum. Taken together, the results suggest that serum cytokine levels, as well as other indicators of oxidative damage, may prove useful in identifying potential adverse health effects of embedded metals.

Pulmonary toxicity, genotoxicity, and carcinogenicity evaluation of molybdenum, lithium, and tungsten: A review

Molybdenum, lithium, and tungsten are constituents of many products, and exposure to these elements potentially occurs at work. Therefore it is important to determine at what levels they are toxic, and thus we set out to review their pulmonary toxicity, genotoxicity, and carcinogenicity. After pulmonary exposure, molybdenum and tungsten are increased in multiple tissues; data on the distribution of lithium are limited. Excretion of all three elements is both via faeces and urine. Molybdenum trioxide exerted pulmonary toxicity in a 2-year inhalation study in rats and mice with a lowest-observed-adverse-effect concentration (LOAEC) of 6.6 mg Mo/m³. Lithium chloride had a LOAEC of 1.9 mg Li/m³ after subacute inhalation in rabbits. Tungsten oxide nanoparticles resulted in a no-observed-adverse-effect concentration (NOAEC) of 5 mg/m³ after inhalation in hamsters. In another study, tungsten blue oxide had a LOAEC of 63 mg W/m³ in rats. Concerning genotoxicity, for molybdenum, the in vivo genotoxicity after inhalation remains unknown; however, there was some evidence of carcinogenicity of molybdenum trioxide. The data on the genotoxicity of lithium are equivocal, and one carcinogenicity study was negative. Tungsten seems to have a genotoxic potential, but the data on carcinogenicity are equivocal. In conclusion, for all three elements, dose descriptors for inhalation toxicity were identified, and the potential for genotoxicity and carcinogenicity was assessed.

Oxidative damage in metal fragment-embedded Sprague-Dawley rat gastrocnemius muscle

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War often results in shrapnel injuries with metals whose toxicity might be unknown.

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A rodent model was used to study-eight military-relevant metals implanted in muscle.

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Creatine kinase activity, protein oxidation and antioxidant capacity were assessed.

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Data obtained were metal-dependent and not all metals showed identical results.

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Results suggest that subtle damage occurs in muscle surrounding metal shrapnel.

Injuries suffered in armed conflicts often result in wounds with embedded metal fragments. Standard surgical guidance has been to leave fragments in place except under certain circumstances; meaning that individuals may carry these retained fragments for their lifetime. Because of advancements in weapon design and the use of improvised explosive devices, the list of metals that could be found in a wound is extensive. In most cases the toxicological properties of these metals when embedded in the body are not known. To assess the potential damage embedded metals may cause to surrounding tissue, we utilized a rodent model to investigate the effect of a variety of military-relevant metals on markers of oxidative damage. The metals tested included tungsten, nickel, cobalt, iron, copper, aluminum, lead, and depleted uranium. Herein we report our findings on creatine kinase activity, lipid and protein oxidation, total antioxidant capacity, and glutathione levels in gastrocnemius homogenates from Sprague-Dawley rats surgically implanted with metal pellets for periods up to 12 months. Not all embedded metals affected the measured markers equally. However, metal-associated effects were seen at various times for muscle and serum creatinine levels, protein oxidation, total antioxidant capacity, and glutathione levels. No metal-induced effects on lipid peroxidation were observed. Taken together, these data suggest that subtle oxidative damage may be occurring in the muscle surrounding an embedded metal and indicates the need for medical surveillance of those individuals wounded by metal shrapnel.

Protein Expression in the Gastrocnemius Muscle of a Rodent Shrapnel-Injury Model

With shrapnel injuries, the metal fragment is usually left in place to reduce the risk of morbidity extensive surgery might bring. This means the individual may retain those metals for the remainder of their life. Often the long-term health effects of the embedded metal are not known, especially with respect to protein damage and perturbations of muscle repair pathways. In this study, using homogenates of rat gastrocnemius muscle implanted with pellets of military-relevant metals, we investigated expression of iNOS and eNOS, enzymes involved in nitric oxide production, as well as MMP-2 and MMP-9, matrix metalloproteinases associated with muscle repair. In addition, hydroxynonenal-modified proteins were investigated to assess metal-induced oxidative damage and metal levels in the gastrocnemius determined. Metals were implanted for up to 12 months in order to determine the long-term effects on the expression of muscle-associated proteins. With the exception of iron and cobalt at 1-month post-implantation, there were no significant differences in metal levels in the gastrocnemius in any of the cohorts. Protein expression analysis showed significant decreases in iNOS and eNOS in the 6-month and 12-month lead and depleted uranium groups. Hydroxynonenal-modified proteins were also significantly increased in the iron, copper, lead, and depleted uranium groups. These results suggest that some embedded metals can induce long-term oxidative damage, as well as affect enzyme systems involved in signal transduction.

Metal distribution patterns in tissues from implanted Sprague-Dawley rats

Background: Injuries with fragments of embedded metal are a common occurrence in armed conflicts. Unfortunately, the list of metals encountered on the modern battlefield are practically endless while the short- and long-term health effects, especially when embedded as in a shrapnel wound, are not well understood. One of the major concerns with these types of injuries is the solubilization of the embedded metal and the translocation and deposition to various organs of the body. Methods: Using a rodent model system developed in our laboratory to assess the health effects of embedded metal fragments, we surgically implanted metal pellets into the gastrocnemius muscles of male Sprague-Dawley rats. Test metals were chosen from a list promulgated by the U.S. Department of Defense as “metals of concern” with respect to embedded fragment wounds and included tungsten, nickel, cobalt, iron, copper, aluminum, lead, and depleted uranium. Tantalum was used as a control metal. Cohorts of the metal-implanted rats were humanely euthanized at 1, 3, 6, and 12-months post-implantation and a variety of tissues collected and analyzed for metal content using inductively coupled plasma-mass spectrometry. Results: With few exceptions, the embedded metal fragments eventually released solubilized metal ions, with the metals deposited in numerous tissues in the rats. Not all of the embedded metals localized to all tissues at significant levels. Copper, iron, and aluminum were not found in statistically significant levels, versus control, in any of the tissues analyzed. The other metals tested all appeared in elevated levels in the kidney which is not surprising since previous research has shown that they are also excreted in the urine at appreciable amounts. Tungsten and nickel were found in only a small number of tissues, tungsten in spleen, and nickel in liver and testes. Cobalt, lead, and depleted uranium showed the widest distribution with significant levels in liver, spleen, testes, lung, tibia, fibula, and femur. Conclusion: In this study, we showed that embedded metal fragments, such as those suffered in a shrapnel wound, could solubilize and metals become deposited in tissues far from the original site of implantation. Tissue deposition was metal-specific and many of the metals were found to cross the blood-testes barrier and were also found in bone. Since standard surgical guidance recommends leaving embedded fragments in place except for certain circumstances, this report will expand the understanding of tissue deposition of the solubilized metals and will hopefully aid healthcare professionals in developing long-term treatment strategies for dealing with these types of wounds.

Environmental and health hazards of military metal pollution

An increasing body of literature has demonstrated that armed conflicts and military activity may contribute to environmental pollution with metals, although the existing data are inconsistent. Therefore, in this paper, we discuss potential sources of military-related metal emissions, environmental metal contamination, as well as routes of metal exposure and their health hazards in relation to military activities. Emission of metals into the environment upon military activity occurs from weapon residues containing high levels of particles containing lead (Pb; leaded ammunition), copper (Cu; unleaded), and depleted uranium (DU). As a consequence, military activity results in soil contamination with Pb and Cu, as well as other metals including Cd, Sb, Cr, Ni, Zn, with subsequent metal translocation to water, thus increasing the risk of human exposure. Biomonitoring studies have demonstrated increased accumulation of metals in plants, invertebrates, and vertebrate species (fish, birds, mammals). Correspondingly, military activity is associated with human metal exposure that results from inhalation or ingestion of released particles, as well as injuries with subsequent metal release from embedded fragments. It is also notable that local metal accumulation following military injury may occur even without detectable fragments. Nonetheless, data on health effects of military-related metal exposures have yet to be systematized. The existing data demonstrate adverse neurological, cardiovascular, and reproductive outcomes in exposed military personnel. Moreover, military-related metal exposures also result in adverse neurodevelopmental outcome in children living within adulterated territories. Experimental in vivo and in vitro studies also demonstrated toxic effects of specific metals as well as widely used metal alloys, although laboratory data report much wider spectrum of adverse effects as compared to epidemiological studies. Therefore, further epidemiological, biomonitoring and laboratory studies are required to better characterize military-related metal exposures and their underlying mechanisms of their adverse toxic effects.

Urine miRNAs as potential biomarkers for systemic reactions induced by exposure to embedded metal

Aim: Explore the potential of urine microRNAs as biomarkers that may reflect the biological responses to pure metals embedded in skeletal muscle over time. Materials & methods: We tested a panel of military-relevant metals embedded in the gastrocnemius muscles of 3-month-old, male, Sprague-Dawley rats (n = 8/group) for a duration of 1, 3, 6 and 12 months, and performed small RNA-sequencing on the urine samples. Results: Results provide potential tissue targets affected by metal exposure and a list of unique or common urine microRNA biomarkers indicative of exposure to various metals, highlighting a complex systemic response. Conclusion: We have identified a panel of miRNAs as potential urine biomarkers to reflect the complex systemic response to embedded metal exposure.

Inhalation of tungsten metal particulates alters the lung and bone microenvironments following acute exposure

Inhalation of tungsten particulates is a relevant route of exposure in occupational and military settings. Exposure to tungsten alloys is associated with increased incidence of lung pathologies, including interstitial lung disease and cancer. We have demonstrated, oral exposure to soluble tungsten enhances breast cancer metastasis to the lungs through changes in the surrounding microenvironment. However, more research is required to investigate if changes in the lung microenvironment, following tungsten particulate exposure, can drive tumorigenesis or metastasis to the lung niche. This study examined if inhalation to environmentally relevant concentrations of tungsten particulates caused acute damage to the microenvironment in the lungs and/or systemically using a whole-body inhalation system. Twenty-four female BALB/c mice were exposed to Filtered Air, 0.60 mg/m3, or 1.7 mg/m3 tungsten particulates (< 1 µm) for 4 h. Tissue samples were collected at day 1 and 7 post-exposure. Tungsten accumulation in the lungs persisted up to 7 days post-exposure and produced acute changes to the lung microenvironment including increased macrophage and neutrophil infiltration, increased levels of pro-inflammatory cytokines IL-1β and CXCL1, and an increased percentage of activated fibroblasts (α-SMA+). Exposure to tungsten also resulted in systemic effects on the bone, including tungsten deposition and transient increases in gene expression of pro-inflammatory cytokines. Taken together, acute whole-body inhalation of tungsten particulates, at levels commonly observed in occupational and military settings, resulted in changes to the lung and bone microenvironments that may promote tumorigenesis or metastasis and be important molecular drivers of other tungsten-associated lung pathologies such as interstitial lung disease.

Simultaneous removal of harmful anions from geothermal waters using OH- intercalated Mg-Fe-LDH: batch and field column studies

Unlike collectively treatable industrial wastewaters where only one or a few pollutants have concentrations much higher than the relevant standards, geothermal waters, in which multiple harmful constituents coexist, are usually discharged dispersedly, provoking a big challenge for their effective treatment. Here, a Mg/Fe layered double hydroxide with OH^- intercalated (Mg-Fe-OH-LDH) was synthesized in a mechanochemical way and then applied in the treatment of various types of high-temperature geothermal waters in western Yunnan (China) containing a variety of harmful anions (As, Sb, W, and F) and inducing local environmental pollution. Due to the endothermic nature of removal of aqueous As, Sb, W, and F by Mg-Fe-OH-LDH, the original high temperatures of the geothermal waters could promote their sorption effectively. Batch sorption experiments demonstrated that over 94% and 80% of the As and W removal amounts could be reached within the first 10 and 20 min, respectively. On-site column experiments confirmed that the sorbent could remove the targeted harmful constituents from the investigated geothermal waters efficiently. In fact, the performance of the sorbent in the column studies was even better than that in the batch experiments, which can be ascribed to the continuous impetus for sorption caused by the concentration gradient in the flowing sorption system. Specifically, Mg-Fe-OH-LDH displayed the best sorption performance for As(V) among various harmful constituents, and the sorption of As along with W and F was little affected by the coexisting common anions in the geothermal waters, including Cl^-, SO₄^2-, and HCO₃^-/CO₃^2-. In contrast, the removal of Sb(V) from geothermal waters may be impeded to a certain extent by SO₄^2- and CO₃^2-, which possessed stronger electronegativity or smaller ionic radii. This study is the first attempt to apply Mg-Fe-LDH in treatment of geothermal waters with multiple harmful constituents and sheds a light on providing a practical approach for field treatment of geothermal water-derived pollution.

Spectroscopic and Spectrometric Approaches for Assessing the Composition of Embedded Metals in Tissues

Many medical devices contain metals that interface with the body. Additionally, embedded metal fragments from military wounds are typically not removed, to avoid the risk of morbidity associated with invasive surgery. The long-term health consequences of many of these materials are not thoroughly understood. To this end, we have exposed rats for up to one year to implanted single-element metal pellets of any one of Al, Co, Cu, Fe, Ni, Pb, Ta, or W. Various tissues were harvested and flash frozen for analysis of their metal distribution. We discuss approaches to most thoroughly and reliably evaluate the distribution of metal in these tissues. The path to the most appropriate analytical technique took us through extensive examination of the tissues using scanning electron microscopy with energy dispersive X-ray spectroscopy (XPS), X-ray photoelectron spectroscopy (XPS), and laser ablation inductively coupled plasma mass spectrometry (LA-ICP-MS). Though any one of these methods is highly relied upon in surface chemistry analysis, LA-ICP-MS alone showed presence of metal in the tissue. This information will help build robust methods to bridge the gap in our understanding of biosolubility and distribution of embedded metal throughout the body.

Celebrating 60 Years of Accomplishments of the Armed Forces Radiobiology Research Institute1

Chartered by the U.S. Congress in 1961, the Armed Forces Radiobiology Research Institute (AFRRI) is a Joint Department of Defense (DoD) entity with the mission of carrying out the Medical Radiological Defense Research Program in support of our military forces around the globe. In the last 60 years, the investigators at AFRRI have conducted exploratory and developmental research with broad application to the field of radiation sciences. As the only DoD facility dedicated to radiation research, AFRRI's Medical Radiobiology Advisory Team provides deployable medical and radiobiological subject matter expertise, advising commanders in the response to a U.S. nuclear weapon incident and other nuclear or radiological material incidents. AFRRI received the DoD Joint Meritorious Unit Award on February 17, 2004, for its exceptionally meritorious achievements from September 11, 2001 to June 20, 2003, in response to acts of terrorism and nuclear/radiological threats at home and abroad. In August 2009, the American Nuclear Society designated the institute a nuclear historic landmark as the U.S.'s primary source of medical nuclear and radiological research, preparedness and training. Since then, research has continued, and core areas of study include prevention, assessment and treatment of radiological injuries that may occur from exposure to a wide range of doses (low to high). AFRRI collaborates with other government entities, academic institutions, civilian laboratories and other countries to research the biological effects of ionizing radiation. Notable early research contributions were the establishment of dose limits for major acute radiation syndromes in primates, applicable to human exposures, followed by the subsequent evolution of radiobiology concepts, particularly the importance of immune collapse and combined injury. In this century, the program has been essential in the development and validation of prophylactic and therapeutic drugs, such as Amifostine, Neupogen®, Neulasta®, Nplate® and Leukine®, all of which are used to prevent and treat radiation injuries. Moreover, AFRRI has helped develop rapid, high-precision, biodosimetry tools ranging from novel assays to software decision support. New drug candidates and biological dose assessment technologies are currently being developed. Such efforts are supported by unique and unmatched radiation sources and generators that allow for comprehensive analyses across the various types and qualities of radiation. These include but are not limited to both 60Co facilities, a TRIGA® reactor providing variable mixed neutron and γ-ray fields, a clinical linear accelerator, and a small animal radiation research platform with low-energy photons. There are five major research areas at AFRRI that encompass the prevention, assessment and treatment of injuries resulting from the effects of ionizing radiation: 1. biodosimetry; 2. low-level and low-dose-rate radiation; 3. internal contamination and metal toxicity; 4. radiation combined injury; and 5. radiation medical countermeasures. These research areas are bolstered by an educational component to broadcast and increase awareness of the medical effects of ionizing radiation, in the mass-casualty scenario after a nuclear detonation or radiological accidents. This work provides a description of the military medical operations as well as the radiation facilities and capabilities present at AFRRI, followed by a review and discussion of each of the research areas.

Effect of embedded metal fragments on urinary metal levels and kidney biomarkers in the Sprague-Dawley rat

BACKGROUND

Wounds with embedded metal fragments are an unfortunate consequence of armed conflicts. In many cases the exact identity of the metal(s) and their long-term health effects, especially on the kidney, are not known.

AIM OF STUDY

The aim of this study was to quantitate the urinary levels of metals solubilized from surgically implanted metal pellets and to assess the effect of these metals on the kidney using a battery of biomarker assays.

MATERIALS AND METHODS

Using a rodent model system developed in our Institute to simulate embedded fragment injuries, eight metals considered likely components of an embedded fragment wound were individually implanted into the gastrocnemius muscle of male Sprague-Dawley rats. The rats were followed for 12 months post-implantation with urine collected prior to surgery then at 1-, 3-, 6-, 9-, and 12-months post-implantation to provide a within-subjects cohort for examination. Urinary metal levels were determined using inductively coupled plasma-mass spectrometry and urinary biomarkers assessed using commercially available kits to determine metal-induced kidney effects.

RESULTS

With few exceptions, most of the implanted metals rapidly solubilized and were found in the urine at significantly higher levels than in control animals as early as 1-month post-implantation. Surprisingly, many of the biomarkers measured were decreased compared to control at 1-month post-implantation before returning to normal at the later time points. However, two metals, iron and depleted uranium, showed increased levels of several markers at later time points, yet these levels also returned to normal as time progressed.

CONCLUSION

This study showed that metal pellets surgically implanted into the leg muscle of Sprague-Dawley rats rapidly solubilized with significant levels of the implanted metal found in the urine. Although kidney biomarker results were inconsistent, the changes observed along with the relatively low amounts of metal implanted, suggest that metal-induced renal effects need to be considered when caring for individuals with embedded metal fragment wounds.

Brain region- and metal-specific effects of embedded metals in a shrapnel wound model in the rat

The health effects of prolonged exposure to embedded metal fragments, such as those found in shrapnel wounds sustained by an increasing number of military personnel, are not well known. As part of a large collaborative effort to expand this knowledge, we use an animal model of shrapnel wounds originally developed to investigate effects of embedded depleted uranium to investigate effects of military-relevant metals tungsten, nickel, cobalt, iron, copper, aluminum, lead, and depleted uranium compared to an inert control, tantalum. Rats are surgically implanted with pellets of one of the metals of interest in the gastrocnemius (leg) muscle and tracked until 1 month, 3 months, 6 months, or 12 months from the time of implant, at which point they are euthanized and multiple organs and tissue samples are collected for inspection. Here we focus on four regions of the brain: frontal cortex, hippocampus, amygdala, and cerebellum. We examined changes in accumulated metal concentration in each region as well as changes in expression of proteins related to blood brain barrier tight junction formation, occludin and ZO-1, and synapse function, PSD95, spinophilin, and synaptotagmin. We report few changes in metal accumulation or blood brain barrier protein expression, but a large number of synapse proteins have reduced expression levels, particularly within the first 6 months of exposure, but there are regional and metal-specific differences in effects.

Cytotoxic and genotoxic assessment of tungsten oxide nanoparticles in Allium cepa cells by Allium ana-telophase and comet assays

Tungsten oxide nanoparticles or nanopowder (WO₃NPs) is commonly used in various industries and also in biomedical applications such as additives, pigments, and biomedical sensors. Non-judicious excessive use of these nanoparticles (NPs) could be a serious human health concern. Therefore, the current study aimed to explore the cytotoxic and genotoxic assessment of WO₃NPs through Allium cepa anaphase-telophase and comet assays. Nanoparticles were characterized through the scanning and transmission electron microscopy (TEM), zetasizer, and energy-dispersive X-ray spectroscopy. The mean size and the average diameter of WO₃NPs were determined as 21.57 ± 2.48 nm and 349.42 ± 80.65 nm using TEM and a Zetasizer measurement system, respectively. Five concentrations (12.5 mg/L, 25 mg/L, 50 mg/L, 75 mg/L, and 100 mg/L) of WO₃NPs were employed on the Allium cepa (A. cepa) roots for 4 h. Significant (p ≤ 0.05) decrease in mitotic index (MI) was shown by WO₃NPs at all concentrations. The increase of chromosomal aberrations (CAs) was also observed in a concentration-dependent manner due to the WO₃NPs exposure. There was a significant increase (p ≤ 0.05) in DNA damage at all concentrations of WO₃NPs on the A. cepa cells. It was concluded that WO₃NPs had cytotoxic and genotoxic effects on A. cepa meristematic cells. Moreover, further cytogenetic effects of WO₃NPs should be investigated at the molecular level to assess its safety margin.

Do lodged foreign bodies in the neck need to be removed? No defined criteria in 2020. Fluoroscopy role and review of literature: A case report

Penetrating neck wounds can be fatal and require prompt attention. The trauma literature is flooded with management protocols for penetrating wounds to the neck; however, in the absence of hard signs the definitive management of lodged foreign bodies beyond the platysma is less clear. This report describes a work-related injury of a Caucasian 33-year-old male who arrived in the Emergency Department (ER) with a 1 cm metallic foreign body (FB) lodged in zone II of the neck, 7 mm antero-lateral to the right internal carotid artery. The technical aspects of its retrieval are discussed as well as a literature review of the current management of embedded FBs in the neck. The patient was taken to the operating room and the FB was removed via a 3 cm incision. Fluoroscopy was used for exact localization of and to allow a precise skin incision overlying the FB. The FB was retrieved uneventfully; a fiberoptic esophagoscopy and bronchoscopy showed normal findings. The patient was discharged home the next day. At 15 months follow-up he is doing well without sequela. The use of fluoroscopy is strongly encouraged for FB removal in asymptomatic patients. The management of lodged foreign bodies in the neck should be part of future guidelines.

Time-course analysis of the effect of embedded metal on skeletal muscle gene expression

As a consequence of military operations, many veterans suffer from penetrating wounds and long-term retention of military-grade heavy metal fragments. Fragments vary in size and location, and complete surgical removal may not be feasible or beneficial in all cases. Increasing evidence suggests retention of heavy metal fragments may have serious biological implications, including increased risks for malignant transformation. Previous studies assessed the tumorigenic effects of metal alloys in rats, demonstrating combinations of metals are sufficient to induce tumor formation after prolonged retention in skeletal muscle tissue. In this study, we analyzed transcriptional changes in skeletal muscle tissue in response to eight different military-relevant pure metals over 12 mo. We found that most transcriptional changes occur at 1 and 3 mo after metal pellets are embedded in skeletal muscle and these effects resolve at 6 and 12 mo. We also report significant immunogenic effects of nickel and cobalt and suppressive effects of lead and depleted uranium on gene expression. Overall, skeletal muscle exhibits a remarkable capacity to adapt to and recover from internalized metal fragments; however, the cellular response to chronic exposure may be restricted to the metal-tissue interface. These data suggest that unless affected regions are specifically captured by biopsy, it would be difficult to reliably detect changes in muscle gene expression that would be indicative of long-term adverse health outcomes.

Disturbing medical findings in war-related traumatic amputation patients: a clinical descriptive study from Gaza

OBJECTIVES

The aim of this study was to explore possible long-term negative health effects of injuries sustained by modern weaponry.

SETTING

The study was conducted in Gaza's main hospital, Al-Shifa Hospital.

PARTICIPANTS

During the last 10 to 15 years, thousands of civilian Palestinians in Gaza have survived numerous military incursions, but with war-related traumatic injuries caused by explosive weapons. It is unclear to which extent the injuries sustained by such modern weaponry may increase survivors' risks of negative long-term health effects and serious illness. We have reported mechanisms and severity of injury, demographics and psychosocial status among 254 Palestinian patients in Gaza with war-related extremity amputations. Among the same amputees, subgroups of patients presented a variety of alarming symptoms and findings. 94 patients received further diagnostic clinical exploration, radiology imaging and clinical chemistry laboratory tests at the main clinical centre in Gaza, the Al-Shifa Hospital.

RESULTS

Nine out of ten of the referred patients were young (median 31.5 years) males (88/94, 92.6%). Ultrasound imaging revealed that 19 of 90 patients (20%) had fatty liver infiltration, 3 patients had lung nodules and 10 patients had lung atelectasis on chest CT. Twelve had remaining shrapnel(s) in the chest, five patients had shrapnel(s) in the abdomen and one in the scrotum. We found shrapnel(s) in the amputation stumps of 26 patient's amputated limbs, while 8 patients had shrapnel in the non-amputated limb. Three patients had liver lesions. Nineteen patients had elevated liver enzymes, 32 patients had elevated erythrocyte sedimentation rate and 12 were anaemic. Two patients tested positive for hepatitis C virus and three were positive for hepatitis B virus (HBV). One of the 19 patients with fatty liver tested positive for HBV. Two of the patients with fatty liver infiltration had elevated glycatedhaemoglobin levels and confirmed diabetes mellitus type II.

CONCLUSION

Nearly half (44, 8%) had remaining metal fragments from explosives of unknown composition harboured in various parts of their bodies. All patients identified with lesions and nodules are being followed up locally. As of now, we cannot anticipate the long-term health consequences of living with metal residuals from modern explosive weapons embedded in body organs and tissue.

The management of embedded metal fragment patients and the role of chelation Therapy: A workshop of the Department of Veterans Affairs-Walter Reed National Medical Center

Exposure to retained metal fragments from war-related injuries can result in increased systemic metal concentrations, thereby posing potential health risks to target organs far from the site of injury. Given the large number of veterans who have retained fragments and the lack of clear guidance on how to medically manage these individuals, the Department of Veterans Affairs (VA) convened a meeting of chelation experts and clinicians who care for embedded fragment patients to discuss current practices and provide medical management guidance. Based on this group's clinical expertise and review of published literature, the evidence presented suggests that, at least in the case of lead fragments, short-term chelation therapy may be beneficial for embedded fragment patients experiencing acute symptoms associated with metal toxicity; however, in the absence of clinical symptoms or significantly elevated blood lead concentrations (greater than 80 µg/dL), chelation therapy may offer little to no benefit for individuals with retained fragments and pose greater risks due to remobilization of metals stored in bone and other soft tissues. The combination of periodic biomonitoring to assess metal body burden, longitudinal fragment imaging, and selective fragment removal when metal concentrations approach critical injury thresholds offers a more conservative management approach to caring for patients with embedded fragments.

Retained Shrapnel from a Blast Injury as a Rare Cause of Secondary Osteoarthritis of the Hip Joint: A Case Report and Review of Literature

Background

Complications related to intra-articular retained shrapnel are rare and primarily depend on the anatomical location and the reaction with the surrounding tissue. Retained bodies causing severe osteoarthritis with bone destruction and limb shortening are extremely rare. We describe a rare occurrence of retained shrapnel, possibly iron nails causing a late presentation of grade 4 secondary osteoarthritis of the hip joint with destruction of the femoral head and limb shortening.

Case Presentation

A 74-year-old otherwise healthy Sri Lankan male with a history of blast injury to the right hip 35 years ago presented with an isolated, right sided mild hip pain with a progressive limp for an 8-year duration. He had a true right limb shortening of 3.6 cm and limited range of motion. However, he had minimal functional disability. An X-ray of the pelvis and hip joints showed grade 4 osteoarthritis of the right hip joint with destruction of the right femoral head. There were three retained metallic nails (shrapnel) in the right hip joint of which two were intra-articular. Although he was offered a total hip arthroplasty, he opted for conservative management due to his minimal functional disability. Modified foot wear and simple analgesics were prescribed, and he had no worsening of symptoms at 6 months of follow up.

Conclusion

Late presentation due to shrapnel-induced osteoarthritis with bone destruction and limb shortening is extremely rare. Initial assessment with radiographs is essential following blast injuries to exclude intra-articular or periarticular foreign bodies. Such foreign bodies should be removed to prevent the associated local and systemic complications.

Lead and Other Trace Elements in Danish Birds of Prey

Lead is a widely used and toxic heavy metal that poses a serious hazard to wildlife species and their ecosystems. Lead is used for production of hunting ammunition. Via gunshot or rifle projectiles, it spreads in ecosystems and may end up in predators and scavengers feeding on wounded or dead animals shot with lead-based ammunition. To assess to what degree Danish raptors are subject to lead contamination, we measured the content of lead in liver tissue from Danish birds of prey (n = 137). Additionally, the study included values for 54 other trace elements. In our analysis, emphasis was put on interpretation of lead levels. Levels of cadmium, mercury and selenium were also discussed, while data for the remaining elements were provided for reference purposes. Bismuth was included to assess if lead originated from bismuth gunshot used as an alternative to lead shot. Concentrations of lead, cadmium, mercury and selenium were generally below the levels in similar studies of birds of prey in other northern European countries and none exceeded known and generally accepted threshold values for adverse health effects. As for lead, this is possibly related to the phase out of lead shot for hunting since 1986. The study confirms results from other studies showing that bismuth shot contains traces of lead that is deposited with bismuth in the target animal.

Chemical compositional standards for non-lead hunting ammunition and fishing weights

The chemical composition of non-lead, non-toxic, gunshot used for hunting waterfowl is regulated only in Canada and the USA. No nation regulates the composition of non-lead fishing weights, rifle bullets, and gunshot used for upland game hunting. Compositional criteria for these non-lead products are proposed here, based on established experimental toxicity protocols. Because of the demonstrated acute toxicity of ingested zinc shot to birds, fishing weights and gunshot should never be made of this pure metal. Nickel should be avoided as an incidental component of gunshot because of potential carcinogenicity concerns about such embedded shot in birds and other animals. These compositional criteria could be adopted by all nations undertaking the transition to non-lead fishing weights and hunting ammunition. The listed criteria would facilitate production and international trade in non-lead products, and promote easier enforcement and user compliance with non-lead standards.

Tungsten from typical magmatic hydrothermal systems in China and its environmental transport

Tungsten is of extraordinarily high concentrations in the geothermal waters discharging from several representative Tibetan magmatic hydrothermal systems (up to 1103 μg/L), which are also characterized by exceptionally high W/Mo molar ratios (up to 1182). The geochemical origins of the tungsten in these geothermal waters were investigated, with a comparison to those from Rehai, the sole magmatic hydrothermal system in Yunnan, which is another major part of the Yunnan-Sichuan-Tibet Geothermal Province of China. The results show that the lithology of reservoir host rocks is the primary factor controlling the tungsten concentrations of the geothermal waters, although the contribution of magmatic fluid input cannot be ruled out. In this study, the geothermal waters are generally rich in sulfide, and therefore the molybdenum in the reservoir fluids has been substantially precipitated as the form of molybdenite; in contrast, the reservoir fluids are well undersaturated with respect to tungstenite which is much more soluble than molybdenite. Thus the neutral/alkaline hot springs, i.e. the evolved reservoir fluids, have high W/Mo molar ratios as well. In the hot spring sediments, the distribution pattern of tungsten is quite different. The concentrations of tungsten are the highest in the sediments with high iron concentrations collected from the acid hot spring vents and outflow channels. The adsorption of aqueous tungsten onto iron-bearing minerals, like goethite or pyrite, is favorable at acid pH values and thereby responsible for the very high tungsten concentrations of these acid hot spring sediments. The proportions of thiotungstates in total tungsten are quite low for all the hot springs, as indicated by thermodynamic calculations, suggesting that thiolation of tungstate has little impacts on the environmental transport and fate of geothermal tungsten in the investigated hydrothermal areas. This is the first study to report the tungsten geochemistry of hot springs in mainland China.

Chemical composition and source apportionment of ambient, household, and personal exposures to PM2.5 in communities using biomass stoves in rural China

Fine particulate matter (PM_2.5) has health effects that may depend on its sources and chemical composition. Few studies have quantified the composition of personal and area PM_2.5 in rural settings over the same time period. Yet, this information would shed important light on the sources influencing personal PM_2.5 exposures. This study investigated the sources and chemical composition of 40 personal exposure, 40 household, and 36 ambient PM_2.5 samples collected in the non-heating and heating seasons in rural southwestern China. Chemical analysis included black carbon (BC), water-soluble components (ions, organic carbon), elements, and organic tracers. Source apportionment was conducted using organic tracer concentrations in a Chemical Mass Balance model. Biomass burning was the largest identified PM_2.5 source contributor to household (average, SD: 48 ± 11%) and exposures (31 ± 6%) in both seasons, and ambient PM_2.5 in winter (20 ± 4%). Food cooking also contributed to household and personal PM, reaching approximately half of the biomass contributions. Secondary inorganic aerosol was the major identified source in summertime ambient PM_2.5 (32 ± 14%), but was present in all samples (summer: 10 ± 3% [household], 13 ± 6% [exposures]; winter: 18 ± 2% [ambient], 7 ± 2% [household], 8 ± 2% [exposures]). Dust concentrations and fractional contribution to total PM_2.5 were higher in summer exposure samples (7 ± 4%) than in ambient or household samples (6 ± 1% and 2 ± 1%, respectively). Indoor sources comprised up to one-fifth of ambient PM_2.5, and outdoor sources (vehicles, secondary aerosols) contributed up to 15% of household PM_2.5. While household sources were the main contributors to PM_2.5 exposures in terms of mass, inorganic components of personal exposures differed from household samples. Based on these findings, health-focused initiatives to reduce harmful PM_2.5 exposures may consider a coordinated approach to address both indoor and outdoor PM_2.5 source contributors.

Comparative Assessment of Tungsten Toxicity in the Absence or Presence of Other Metals

Tungsten is a refractory metal that is used in a wide range of applications. It was initially perceived that tungsten was immobile in the environment, supporting tungsten as an alternative for lead and uranium in munition and military applications. Recent studies report movement and detection of tungsten in soil and potable water sources, increasing the risk of human exposure. In addition, experimental research studies observed adverse health effects associated with exposure to tungsten alloys, raising concerns on tungsten toxicity with questions surrounding the safety of exposure to tungsten alone or in mixtures with other metals. Tungsten is commonly used as an alloy with nickel and cobalt in many applications to adjust hardness and thermal and electrical conductivity. This review addresses the current state of knowledge in regard to the mechanisms of toxicity of tungsten in the absence or presence of other metals with a specific focus on mixtures containing nickel and cobalt, the most common components of tungsten alloy.

Cytotoxicity and in Vitro Degradation Kinetics of Foundry-Compatible Semiconductor Nanomembranes and Electronic Microcomponents

Foundry-compatible materials and processing approaches serve as the foundations for advanced, active implantable microsystems that can dissolve in biofluids into biocompatible reaction products, with broad potential applications in biomedicine. The results reported here include in vitro studies of the dissolution kinetics and nanoscale bioresorption behaviors of device-grade thin films of Si, SiN _x, SiO₂, and W in the presence of dynamic cell cultures via atomic force microscopy and X-ray photoemission spectroscopy. In situ investigations of cell-extracellular mechanotransduction induced by cellular traction provide insights into the cytotoxicity of these same materials and of microcomponents formed with them using foundry-compatible processes, indicating potential cytotoxicity elicited by W at concentrations greater than 6 mM. The findings are of central relevance to the biocompatibility of modern Si-based electronics technologies as active, bioresorbable microsystems that interface with living tissues.

Tungsten: an Emerging Toxicant, Alone or in Combination

PURPOSE OF REVIEW

Tungsten is an emerging environmental toxicant, yet our understanding of the potential risks of exposure on human health is still limited.

RECENT FINDINGS

In this review, we will discuss populations most at risk of exposure to high concentrations of tungsten. In addition, we will highlight what is known about the toxicity profile of tungsten compounds, based on epidemiological, in vitro, and in vivo studies, focusing on bone, immune, pulmonary, and cancer outcomes. Of note, emerging evidence indicates that tungsten can augment the effects of other stimulants, stressors, and toxicants. Of particular importance may be tungsten-cobalt mixtures that seem to be more toxic than either metal alone. This is important because it means that we cannot just evaluate the toxicity of tungsten in isolation. Finally, we still have limited information of how many of the in vitro and in vivo findings translate to human populations, so it will be important to conduct epidemiology studies in highly exposed populations to adequately address the potential risks of tungsten exposure on human health. Together, we discuss recent findings that support further investigation into the toxicities of tungsten alone and in combination with other metals.

Tungsten doped hydroxyapatite processed at different temperatures: dielectric behaviour and anti-microbial properties

Electrical and antibacterial activities of bio-compatible W/HAp synthesizedviachemical precipitation followed by annealing at different temperature.

Hydrophobic Sand Is a Non-Toxic Method of Urine Collection, Appropriate for Urinary Metal Analysis in the Rat

Hydrophobic sand is a relatively new method of urine collection in the rodent, comparable to the established method using a metabolic cage. Urine samples are often used in rodent research, especially for biomarkers of health changes after internal contamination from embedded metals, such as in a model of a military shrapnel wound. However, little research has been done on the potential interference of hydrophobic sand with urine metal concentrations either by contamination from the sand particulate, or adsorption of metals from the urine. We compare urine collected from rats using the metabolic cage method and the hydrophobic sand method for differences in metal concentration of common urinary metals, and examine physical properties of the sand material for potential sources of contamination. We found minimal risk of internal contamination of the rat by hydrophobic sand, and no interference of the sand with several common metals of interest (cobalt, strontium, copper, and manganese), although we advise caution in studies of aluminum in urine.

Soft-Tissue Sarcoma following Traumatic Injury: Case Report and Review of the Literature

Soft-tissue sarcomas (STSs) are a heterogeneous group of tumors, which accounts for 1–2% of adult cancers worldwide. Despite quite a few reports on traumatic events followed by STS formation, the link between the two events remains a point of controversy. In this paper, we present the case of a young patient who had a rhabdomyosarcoma in the lower extremity, which had developed in the same location where the patient was wounded by a gunshot 9 years earlier. X-ray and CT scans clearly showed metal fragments in the area of sarcoma formation. The patient underwent neoadjuvant chemotherapy treatment, to which the tumor was, unfortunately, unresponsive. Therefore, the patient was referred to below-knee amputation of the injured leg. There are several possible etiological factors for sarcoma development in this patient, including tissue damage and inflammation, as well as the presence of metal fragments in the tissue and the limb’s exposure to radiation during multiple imaging tests. Here, we will discuss the potential influence wielded by the injury itself, as well as its complications and its medical management on the formation of the sarcoma, in light of the current literature.

High-resolution measurement and mapping of tungstate in waters, soils and sediments using the low-disturbance DGT sampling technique

Increasing tungsten (W) use for industrial and military applications has resulted in greater W discharge into natural waters, soils and sediments. Risk modeling of W transport and fate in the environment relies on measurement of the release/mobilization flux of W in the bulk media and the interfaces between matrix compartments. Diffusive gradients in thin-films (DGT) is a promising passive sampling technique to acquire such information. DGT devices equipped with the newly developed high-resolution binding gels (precipitated zirconia, PZ, or ferrihydrite, PF, gels) or classic/conventional ferrihydrite slurry gel were comprehensively assessed for measuring W in waters. (Ferrihydrite)DGT can measure W at various ionic strengths (0.001-0.5molL(-1) NaNO3) and pH (4-8), while (PZ)DGT can operate across slightly wider environmental conditions. The three DGT configurations gave comparable results for soil W measurement, showing that typically W resupply is relatively poorly sustained. 1D and 2D high-resolution W profiling across sediment-water and hotspot-bulk media interfaces from Lake Taihu were obtained using (PZ)DGT coupled with laser ablation ICP-MS measurement, and the apparent diffusion fluxes across the interfaces were calculated using a numerical model.

ATSDR evaluation of health effects of tungsten and relevance to public health

The Agency for Toxic Substances and Disease Registry prepares toxicological profiles, as part of its mandate, on hazardous chemicals found at Comprehensive Environmental Response, Compensation, and Liability Act National Priorities List sites that have the greatest public health impact. These profiles comprehensively summarize toxicological and environmental information. This article constitutes the release of portions of the Toxicological Profile for tungsten. The primary purpose of this article is to provide public health officials, physicians, toxicologists and other interested individuals and groups with an overall perspective on the toxicology of tungsten. It contains descriptions and evaluations of toxicological studies and epidemiological investigations and provides conclusions, where possible, on the relevance of toxicity and toxicokinetic data to public health. Toxicology and Industrial Health 2007; 23: 347—387

Biological and environmental interactions of emerging two-dimensional nanomaterials

Two-dimensional materials have become a major focus in materials chemistry research worldwide with substantial efforts centered on synthesis, property characterization, and technological application. These high-aspect ratio sheet-like solids come in a wide array of chemical compositions, crystal phases, and physical forms, and are anticipated to enable a host of future technologies in areas that include electronics, sensors, coatings, barriers, energy storage and conversion, and biomedicine. A parallel effort has begun to understand the biological and environmental interactions of synthetic nanosheets, both to enable the biomedical developments and to ensure human health and safety for all application fields. This review covers the most recent literature on the biological responses to 2D materials and also draws from older literature on natural lamellar minerals to provide additional insight into the essential chemical behaviors. The article proposes a framework for more systematic investigation of biological behavior in the future, rooted in fundamental materials chemistry and physics. That framework considers three fundamental interaction modes: (i) chemical interactions and phase transformations, (ii) electronic and surface redox interactions, and (iii) physical and mechanical interactions that are unique to near-atomically-thin, high-aspect-ratio solids. Two-dimensional materials are shown to exhibit a wide range of behaviors, which reflect the diversity in their chemical compositions, and many are expected to undergo reactive dissolution processes that will be key to understanding their behaviors and interpreting biological response data. The review concludes with a series of recommendations for high-priority research subtopics at the "bio-nanosheet" interface that we hope will enable safe and successful development of technologies related to two-dimensional nanomaterials.

Terror-Related Trauma

In our current era, terrorist attacks have become a part of our daily life experience almost worldwide. New terrorist groups are emerging and the number of terrorist attacks is constantly rising.

The Role of the Component Metals in the Toxicity of Military-Grade Tungsten Alloy

Tungsten-based composites have been recommended as a suitable replacement for depleted uranium. Unfortunately, one of these mixtures composed of tungsten (W), nickel (Ni) and cobalt (Co) induced rhabdomyosarcomas when implanted into the leg muscle of laboratory rats and mice to simulate a shrapnel wound. The question arose as to whether the neoplastic effect of the mixture could be solely attributed to one or more of the metal components. To investigate this possibility, pellets with one or two of the component metals replaced with an identical amount of the biologically-inert metal tantalum (Ta) were manufactured and implanted into the quadriceps of B6C3F₁ mice. The mice were followed for two years to assess potential adverse health effects. Implantation with WTa, CoTa or WNiTa resulted in decreased survival, but not to the level reported for WNiCo. Sarcomas in the implanted muscle were found in 20% of the CoTa-implanted mice and 5% of the WTa- and WCoTa-implanted rats and mice, far below the 80% reported for WNiCo-implanted mice. The data obtained from this study suggested that no single metal is solely responsible for the neoplastic effects of WNiCo and that a synergistic effect of the three metals in tumor development was likely.

Toxic and transcriptional responses of PC12 cells to soluble tungsten alloy surrogates

There is increasing evidence that metals have a role in the etiology of diverse neurological diseases. This study used PC12 cells as an in vitro model to examine the toxicity of tungsten alloys that have important military applications. Initially, the relative concentrations of tungsten (W), nickel (Ni), and cobalt (Co) mobilized from pellets of a weapons-grade tungsten alloy incubated in physiologically relevant solutions were determined. Dosing solutions of soluble metal salts that were equivalent in ratio to those mobilized from these alloy pellets were used to treat nerve growth factor (NGF) differentiated PC12 cells. Treatments consisted of single (W, Ni or Co), paired (W/Ni, W/Co or Ni/Co) or complete (W/Ni/Co) metal exposures for 24 h followed by measurement of cytotoxicity, viability, and microarray analysis to examine their impact on survival and viability, global gene expression, and biological processes. Gene expression changed dramatically with addition of NGF. Addition of Ni or Co either singly or in combination further impacted gene expression. An observed additive effect of Ni and Co on gene expression was unaffected by the addition of W. The work showed that tungsten, as found in this tungsten alloy, had minimal relative toxicity as compared to the other alloy components when used either alone or in combination.

Primary diffuse pleural rhabdomyosarcoma in an adult patient

Rhabdomyosarcoma is an aggressive malignant tumor of childhood, originating from immature cells that are destinated to form striated skeletal muscle. It usually arises in the head and neck or the extremities. Primary diffuse pleural rhabdomyosarcoma is exceptionally rare. Herein we report a case of primary diffuse pleural rhabdomyosarcoma in a 48-year-old man. The diagnosis was confirmed by percutaneous pleural biopsy. Chemotherapy (cisplatin, ifosfamide, adriamycin, vincristine) was initiated due to the large volume of the tumor. After 3 months, computed tomography of the thorax showed stable radiological findings.

An update to the toxicological profile for water-soluble and sparingly soluble tungsten substances

Tungsten is a relatively rare metal with numerous applications, most notably in machine tools, catalysts, and superalloys. In 2003, tungsten was nominated for study under the National Toxicology Program, and in 2011, it was nominated for human health assessment under the US Environmental Protection Agency's (EPA) Integrated Risk Information System. In 2005, the Agency for Toxic Substances and Disease Registry (ATSDR) issued a toxicological profile for tungsten, identifying several data gaps in the hazard assessment of tungsten. By filling the data gaps identified by the ATSDR, this review serves as an update to the toxicological profile for tungsten and tungsten substances. A PubMed literature search was conducted to identify reports published during the period 2004-2014, in order to gather relevant information related to tungsten toxicity. Additional information was also obtained directly from unpublished studies from within the tungsten industry. A systematic approach to evaluate the quality of data was conducted according to published criteria. This comprehensive review has gathered new toxicokinetic information and summarizes the details of acute and repeated-exposure studies that include reproductive, developmental, neurotoxicological, and immunotoxicological endpoints. Such new evidence involves several relevant studies that must be considered when regulators estimate and propose a tungsten reference or concentration dose.

Combat-related intradural gunshot wound to the thoracic spine: significant improvement and neurologic recovery following bullet removal

The vast majority of combat-related penetrating spinal injuries from gunshot wounds result in severe or complete neurological deficit. Treatment is based on neurological status, the presence of cerebrospinal fluid (CSF) fistulas, and local effects of any retained fragment(s). We present a case of a 46-year-old male who sustained a spinal gunshot injury from a 7.62-mm AK-47 round that became lodged within the subarachnoid space at T9-T10. He immediately suffered complete motor and sensory loss. By 24-48 hours post-injury, he had recovered lower extremity motor function fully but continued to have severe sensory loss (posterior cord syndrome). On post-injury day 2, he was evacuated from the combat theater and underwent a T9 laminectomy, extraction of the bullet, and dural laceration repair. At surgery, the traumatic durotomy was widened and the bullet, which was laying on the dorsal surface of the spinal cord, was removed. The dura was closed in a water-tight fashion and fibrin glue was applied. Postoperatively, the patient made a significant but incomplete neurological recovery. His stocking-pattern numbness and sub-umbilical searing dysthesia improved. The spinal canal was clear of the foreign body and he had no persistent CSF leak. Postoperative magnetic resonance imaging of the spine revealed contusion of the spinal cord at the T9 level. Early removal of an intra-canicular bullet in the setting of an incomplete spinal cord injury can lead to significant neurological recovery following even high-velocity and/or high-caliber gunshot wounds. However, this case does not speak to, and prior experience does not demonstrate, significant neurological benefit in the setting of a complete injury.