Elevated Blood Lead Levels Associated with Retained Bullet Fragments - United States, 2003-2012

Effect of Lactiplantibacillus plantarum CCFM8661 on serum metabolites and gut microbiota in a lead-exposed population

In this study, we investigated the impact of Lactiplantibacillus plantarum (L. plantarum) CCFM8661 on the gut microbiota, and the serum and fecal metabolomes in lead (Pb)-exposed individuals. The volunteers recruited for this study were divided into two treatment groups, (i) the placebo (control) and (ii) the L. plantarum CCFM8661 treatment groups. The analysis revealed that probiotic intervention reversed some of the changes in Pb exposure-induced intestinal bacterial abundance, including the abundance of Parabacteroides, Bacteroides, Clostridiaceae, and Erysipelotrichaceae. An analysis of the fecal metabolome identified 26 differential metabolites involved in purine metabolism, unsaturated fatty acid metabolism, and other pathways. Serum metabolite analysis showed that L. plantarum CCFM8661 treatment altered the serum metabolite levels of various metabolic pathways, such as the glycerophospholipid, amino acid, and glutathione metabolism pathways. These results suggest that L. plantarum CCFM8661 may have beneficial effects on Pb-exposed populations by modulating the gut microbiota, host serum metabolism, and the metabolism of the gut microbiota.

Succimer chelation does not produce lasting reductions of blood lead levels in a rodent model of retained lead fragments

Retained lead fragments from nonfatal firearm injuries pose a risk of lead poisoning. While chelation is well-established as a lead poisoning treatment, it remains unclear whether chelation mobilizes lead from embedded lead fragments. Here, we tested whether 1) DMSA/succimer or CaNa2EDTA increases mobilization of lead from fragments in vitro, and 2) succimer is efficacious in chelating fragment lead in vivo, using stable lead isotope tracer methods in a rodent model of embedded fragments. DMSA was > 10-times more effective than CaNa2EDTA in mobilizing fragment lead in vitro. In the rodent model, succimer chelation on day 1 produced the greatest blood lead reductions, and fragment lead was not mobilized into blood. However, with continued chelation and over 3-weeks post-chelation, blood lead levels rebounded with mobilization of lead from the fragments. These findings suggest prolonged chelation will increase fragment lead mobilization post-chelation, supporting the need for long-term surveillance in patients with retained fragments.

MiR-130/SNAP-25 axis regulate presynaptic alteration in anterior cingulate cortex involved in lead induced attention deficits

Brain volume decrease in the anterior cingulate cortex (ACC) after lead (Pb) exposure has been linked to persistent impairment of attention behavior. However, the precise structural change and molecular mechanism for the Pb-induced ACC alteration and its contribution to inattention have yet to be fully characterized. The present study determined the role of miRNA regulated synaptic structural and functional impairment in the ACC and its relationship to attention deficit disorder in Pb exposed mice. Results showed that Pb exposure induced presynaptic impairment and structural alterations in the ACC. Furthermore, we screened for critical miRNA targets responsible for the synaptic alteration. We found that miR-130, which regulates presynaptic vesicle releasing protein SNAP-25, was responsible for the presynaptic impairment in the ACC and attention deficits in mice. Blocking miR-130 function reversed the Pb-induced decrease in the expression of its presynaptic target SNAP-25, leading to the redistribution of presynaptic vesicles, as well as improved presynaptic function and attention in Pb exposed mice. We report, for the first time, that miR-130 regulating SNAP-25 mediates Pb-induced presynaptic structural and functional impairment in the ACC along with attention deficit disorder in mice.

Retained bullets and lead toxicity: a systematic review

INTRODUCTION

Lead toxicity secondary to retained bullet(s) (RB) after a penetrating gunshot wound is a rare but likely underdiagnosed condition, given the substantial number of firearm injuries in the United States. There is currently no consensus on the indications for surveillance, chelation, or surgical intervention.

OBJECTIVE

The purpose of our review is to summarize the literature on systemic lead toxicity secondary to RBs to help guide clinicians in the management of these patients.

METHODOLOGY

The primary literature search was conducted in Medline (PubMed), EMBASE, Cochrane, and CENTRAL using the following MESH terms: "chelation" and "lead poisoning" or "lead toxicity" or "lead" and "bullet" or "missile" or "gunshot", or "bullet".

RESULTS

The search identified 1,082 articles. After exclusions, a total of 142 articles were included in our final review, the majority of which were case reports. Several factors appear to increase the risk of developing lead toxicity including the location of the RB, the presence of a fracture or recent trauma, number of fragments, hypermetabolic states, and bullet retention duration. Particularly, RBs located within a body fluid compartment like an intra-articular space appear to be at a substantially higher risk of developing lead toxicity. Even though patients with lead toxicity from RBs will have similar symptoms to patients with lead toxicity from other sources, the diagnosis of lead poisoning may occur months or years after a gunshot wound. Symptomatic patients with high blood lead levels (BLLs) tended to improve with a combination of chelation and surgical removal of RBs.

CONCLUSIONS

We suggest surveillance with serial BLLs should be performed. Patients with intra-articular RBs appear to be at increased risk of lead toxicity and if possible, early surgical removal of the RBs is warranted, especially given that signs of toxicity are vague, and patients may not have access to follow-up. Long-term chelation should not be used as a surgical alternative and management should be multidisciplinary.

Exposure Sources Among Veterans With Elevated Blood Lead Levels, United States, 2015‒2021

Objectives. To determine characteristics and sources of exposure in veterans with elevated blood lead levels (BLLs). Methods. We included users of US Veterans Health Administration care aged 18 years or older tested for BLL from October 2015 to September 2021. Prevalence of BLL 10 micrograms per deciliter (µg/dL) or higher and 25 µg/dL or higher was determined within demographic groups. Logistic regression analysis measured association of International Classification of Diseases, Tenth Revision, Clinical Modification‒coded conditions with elevated BLL. Electronic notes were reviewed for exposure sources. Results. Among 1007 unique veterans with BLL 10 µg/dL or higher, prevalence of BLL 10 µg/dL or higher and 25 µg/dL or higher peaked at 4.9 and 1.3 per 100 000 veterans, respectively (fiscal year 2019), and was highest in non-Hispanic White men and those aged 25 to 34 years. Conditions predicted by elevated BLL were attention-deficit/hyperactivity disorder (ADHD) and nausea or vomiting. Firearms represented 70.1% of occupational and 85.9% of nonoccupational exposures. Toxicology consults occurred in 17 of 298 (6%) with BLL 25 µg/dL or higher. Conclusions. Firearms were the largest exposure source among veterans with elevated BLL. Clinicians should be alert for potential conditions (including ADHD and nausea or vomiting in our study) associated with lead exposure. Standardization of care regarding toxicology referral practices is warranted. (Am J Public Health. 2022;112(S7):S670-S678. https://doi.org/10.2105/AJPH.2022.306936).

Low-Cost Forensics Reveal High Rates of Non-lethal Snaring and Shotgun Injuries in Zambia's Large Carnivores

The impact of snaring and human-wildlife conflict (HWC) on large carnivore populations is of growing concern, and yet few empirical data are available. Mortality is the metric most often used, but non-lethal injuries that impact fitness are also important threats. However, because non-lethal injuries to wild carnivores are difficult to detect, they have received little study. Using straightforward forensic examination of the skulls of trophy-hunted lions and leopards from Luangwa Valley (LV) and Greater Kafue Ecosystem (GKE), Zambia, we identified non-lethal injuries consisting of snare damage to teeth and shotgun pellets in skulls. Wire snare entanglement can cause permanent, diagnostic damage to carnivore teeth when individuals bite and pull on the wire. Shotguns are used by poachers, as well as during HWCs to drive off carnivores perceived as threats. Carnivores struck by shotgun pellets can suffer non-lethal, but potentially toxic injuries such as pellets embedded in their skulls. Because poaching and HWC are generally more prevalent near human settlements, we predicted a higher incidence of anthropogenic injuries to carnivores in Luangwa where the human population is larger and more concentrated along protected area edges than Kafue. Contrary to expectation, anthropogenic injuries were more prevalent among lions and leopards in Kafue than Luangwa. Notably, definitive evidence of snare entanglement greatly surpassed previous estimates for these regions. Overall, 37% (41 in 112) of adult male lions (29% in Luangwa, 45% in Kafue) and 22% (10 in 45) of adult male leopards (17% in Luangwa, 26% in Kafue) examined had survived being snared at some point in their lifetime. Among adult male lions, 27% (30 in 112) had old shotgun pellet injuries to their skulls. Our procedure of forensic examination of carnivore skulls and teeth, some of which can be applied to live-captured animals, allows for improved detection of cryptic, non-lethal anthropogenic injuries. Further, our methods represent a consistent and economical way to track changes in the frequency of such injuries over time and between regions, thereby providing a direct measure of the effectiveness of conservation programs that seek to reduce poaching and HWC.

A systematic review of clinical and laboratory findings of lead poisoning: lessons from case reports

Lead is one of the most toxic heavy metals in the environment. The present review aimed to highlight hazardous pollution sources, management, and review symptoms of lead poisonings in various parts of the world. The present study summarized the information available from case reports and case series studies from 2009 to March 2020 on the lead pollution sources and clinical symptoms. All are along with detoxification methods in infants, children, and adults. Our literature compilation includes results from 126 studies on lead poisoning. We found that traditional medication, occupational exposure, and substance abuse are as common as previously reported sources of lead exposure for children and adults. Ayurvedic medications and gunshot wounds have been identified as the most common source of exposure in the United States. However, opium and occupational exposure to the batteries were primarily seen in Iran and India. Furthermore, neurological, gastrointestinal, and hematological disorders were the most frequently occurring symptoms in lead-poisoned patients. As for therapeutic strategies, our findings confirm the safety and efficacy of chelating agents, even for infants. Our results suggest that treatment with chelating agents combined with the prevention of environmental exposure may be an excellent strategy to reduce the rate of lead poisoning. Besides, more clinical studies and long-term follow-ups are necessary to address all questions about lead poisoning management.

Simultaneous giant adrenocortical and renal cell carcinoma associated with lead exposure from residual gun pellets after shotgun injury: case report

Background

A case of simultaneous adrenocortical and renal cell carcinoma due to long-term lead exposure from residual gun pellets is a rare and relatively unknown topic in the literature.

Case presentation

We present a 43-year-old male patient with a giant retroperitoneal tumor. Thirteen years before he had a shotgun injury of the left upper side of the abdomen and residual gun pellets are present in the abdominal wall. Extirpation of the tumor and the left kidney was performed. Histopathological examination described adrenocortical and renal cell carcinoma.

Conclusion

Continuous and long-term exposure to toxic lead effects from residual gun pellets and traumatic injury represent likely carcinogenic factors in the presented patient.

The impact of retained bullet fragments on outcomes in patients with gunshot wounds

BACKGROUND

Nationally, 115,000 non-fatal firearm injuries occurred in 2017, with many such victims possessing retained bullet fragments (RBFs); however, the impact of RBFs has not been well studied.

METHODS

An institutional trauma database from an urban, level one trauma center was queried for patients presenting with gunshot wounds (GSWs) to the ED in 2017. GSWs were stratified by the presence or absence of RBFs. Groups were compared using t-tests, chi-squared, and logistic regression.

RESULTS

Of 674 patients with GSWs who met inclusion criteria, 394 had RBFs versus 280 with no RBFs. Patients with RBFs were more likely admitted from the ED (57.4% vs. 41.8%, p < 0.001), had significantly higher rates of return to the ED within six months (30.7% vs. 18.6%, p < 0.001), and higher rates of subsequent GSW in the next year (5.1% vs. 1.8%, p = 0.03). On return to ED, 17.6% of those with a RBF had symptoms associated with their RBF.

CONCLUSION

RBFs may represent an unrecognized risk factor for both repeat ED visits and subsequent bullet injury.

Retained bullet fragments after nonfatal gunshot wounds: epidemiology and outcomes

BACKGROUND

With no consensus on the optimal management strategy for asymptomatic retained bullet fragments (RBF), the emerging data on RBF lead toxicity have become an increasingly important issue. There are, however, a paucity of data on the magnitude of this problem. The aim of this study was to address this by characterizing the incidence and distribution of RBF.

METHODS

A trauma registry was used to identify all patients sustaining a gunshot wound (GSW) from July 1, 2015, to June 31, 2016. After excluding deaths during the index admission, clinical demographics, injury characteristics, presence and location of RBF, management, and outcomes, were analyzed.

RESULTS

Overall, 344 patients were admitted for a GSW; of which 298 (86.6%) of these were nonfatal. Of these, 225 (75.5%) had an RBF. During the index admission, 23 (10.2%) had complete RBF removal, 35 (15.6%) had partial, and 167 (74.2%) had no removal. Overall, 202 (89.8%) patients with nonfatal GSW were discharged with an RBF. The primary indication for RBF removal was immediate intraoperative accessibility (n = 39, 67.2%). The most common location for an RBF was in the soft tissue (n = 132, 58.7%). Of the patients discharged with an RBF, mean age was 29.5 years (range, 6.1-62.1 years), 187 (92.6%) were me, with a mean Injury Severity Score of 8.6 (range, 1-75). One hundred sixteen (57.4%) received follow-up, and of these, 13 (11.2%) returned with an RBF-related complication [infection (n = 4), pain (n = 7), fracture nonunion (n = 1), and bone erosion (n = 1)], with a mean time to complication of 130.2 days (range, 11-528 days). Four (3.4%) required RBF removal with a mean time to removal of 146.0 days (range, 10-534 days).

CONCLUSION

Retained bullet fragments are very common after a nonfatal GSW. During the index admission, only a minority are removed. Only a fraction of these are removed during follow-up for complications. As lead toxicity data accumulates, further follow-up studies are warranted.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Surgical Treatment of Upper Extremity Gunshot Injures: An Updated Review

INTRODUCTION

Firearm morbidity and mortality have been increasing in recent years, and with this, the demand for medical personnel firearm injury treatment knowledge. Extremities contribute to a majority of firearm injuries, with these injuries being particularly complex because of neurovascular proximity within a confined space. Knowledge of firearm mechanism of injury and treatment management options is important for any trauma hand surgeon. Many factors play vital roles in the treatment of complex upper extremity (UE) gunshot wounds (GSWs). The aim of our review and case illustrations is to provide hand surgeons with an up-to-date guide for initial emergent management, soft tissue, bony, and nerve repair and reconstruction.

PATIENT AND METHODS

A literature review was conducted in the current management of UE GSW injuries, and 2 specific patient case examples were included. High-energy versus low-energy GSWs were documented and compared, as well as containment injures. Management including soft tissue, bony, and nerve injuries was explored along with patient outcome. Based on these findings, guidelines for GSW management were purposed.

CONCLUSION

Gunshot wounds of the UE encompass a group of highly heterogeneous injuries. High-energy wounds are more extensive, and concomitant injuries to bone, vessel, nerve, muscle, and soft tissue are common. Early treatment with adequate debridement, skeletal fixation, and soft tissue coverage is indicated for complex injuries, and antibiotic treatment in the pre-, peri-, and postoperative period is indicated for operative injuries. Soft tissue coverage options include the entire reconstructive ladder, with pattern of injury and considerations of wound characteristics dictating reconstructive choice. There are arguments to using either external or internal bony fixation techniques for bone fracture management, with choice tailored to the patient. For management of nerve injuries, we advocate earlier nerve repair and a shorter duration of observation before secondary reconstruction in selective cases. If transected nerve endings cannot be brought together, nerve autografts of shorter length are recommended to bridge nerve ending gaps. A significant number of patients with GSW fail to make necessary follow-up appointments, which adds to challenges in treatment.

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.

Imaging Ballistic Injuries

Here in Canada, we often think of gun violence as confined to conflict zones, terrorism, and more of a problem for our southern neighbor. However, in recent years, it has also become a Canadian problem with increased gun violence related to criminal activity presenting in daily practice. Radiologists play a critical role in the evaluation of ballistic trauma and must therefore be familiar with both the common and uncommon patterns of ballistic injury. In this article, we review the mechanisms of ballistic trauma as well as their resultant injury patterns in order to guide image interpretation.

Lead toxicity from retained bullet fragments: A systematic review and meta-analysis

BACKGROUND

Firearm injury remains a public health epidemic in the United States. A large proportion of individuals with gunshot wounds subsequently have retained bullet fragments (RBF). There are no standard medical guidelines regarding bullet removal and the full extent of the consequences of RBF remains unknown.

OBJECTIVE

To determine whether there is an association among RBF, elevated blood lead levels (BLL) and lead toxicity in survivors of firearm injury 16 years and older.

METHODS

PubMed, EMBASE, CINAHL, Scopus, Cochrane Library, and Sociological Abstracts electronic databases were searched for all randomized controlled trials, prospective and retrospective cohort, case-control and cross-sectional studies published in the English language between 1988 and 2018. Quality assessment and risk of bias was evaluated using the Newcastle Ottawa Scale. A meta-analysis was performed using a random-effects model.

RESULTS

The search yielded 2,012 articles after removal of duplicates. Twelve were included after full article review. Eleven studies supported an association between elevated BLL and RBF. Bony fractures were associated with increased risk of elevated BLL in three studies. A positive relationship between BLL and the number of RBF was also shown in three studies, with one study demonstrating 25.6% increase in BLL for every natural-log increase in RBF (1-228, p < 0.01). Meta-analysis demonstrated BLL significantly higher in individuals with RBF as compared to controls (5.47 μg/dL, p < 0.01).

CONCLUSION

Patients with bony fractures or multiple RBF, who are at higher risk of elevated BLL, should be monitored for BLL in intervals of 3 months within the first year of injury. For patients who return with BLL above 5 μg/dL, all efforts must be undertaken to remove fragments if there is no potential to worsen the injury.

LEVEL OF EVIDENCE

Systematic review, Meta-analysis, level III.

Characteristics of Pediatric Patients With Retained Bullet Fragments and Need for Follow-Up Blood Lead Monitoring

OBJECTIVES

Multiple case reports of lead toxicity related to retained bullet fragments in pediatric patients sustaining gunshot wound have been published. The purpose of the present study was to determine whether the demographic and clinical characteristics of gunshot wounds (GSWs) could be classified high/low risk and whether routine blood lead monitoring is necessary in these patients.

METHODS

A single-center prospective case series of pediatric GSW patients presenting to the emergency department (ED). The data points that were collected and analyzed included age, sex, race, wound location, disposition, and baseline and follow-up lead levels within 6 months post-injury.

RESULTS

Twenty patients were enrolled in the study and the median age was 7.5 years (interquartile range 5.25-10.75); 75% of the patients were African American. A total of 15 patients (75%) had injuries in either a lower or upper extremity, 9 of whom required admission. Almost all of the injuries involving the head, chest, or abdomen required admission. Of the patients, 65% were admitted and 35% were discharged. All of the patients had an initial blood lead level taken, and follow-up lead levels were determined at 6 months post-injury to be <5 μg/dL. Twelve of 20 patients were lost to follow-up.

CONCLUSIONS

Pediatric GSW is common in male African Americans and these patients had baseline and follow-up lead levels below the reference level. These patients were difficult to follow up. Based on the available data, follow-up lead monitoring may not be indicated.

Risks to human health from ammunition-derived lead in Europe

It has been known for centuries that lead is toxic to humans. Chronic exposure to lead, even at low levels, is associated with an elevated risk of cardiovascular and chronic kidney disease in adults and of impaired neurodevelopment and subsequent cognitive and behavioural development in the foetus and young children. Health agencies throughout the world have moved from assuming that there are tolerable levels of exposure to lead to a recognition that valid 'no-effect' thresholds cannot currently be defined. Formerly, the most important exposure pathways were occupational exposure, water from lead plumbing, paints, petrol additives and foods. Regulation of products and improved health and safety procedures at work have left dietary lead as the main remaining pathway of exposure in European countries. Ammunition-derived lead is now a significant cause of dietary lead exposure in groups of people who eat wild game meat frequently. These are mostly hunters, shoot employees and their families, but also some people who choose to eat game for ethical, health or other reasons, and their children. Extrapolation from surveys conducted in the UK and a review of studies of game consumption in other countries suggest that approximately 5 million people in the EU may be high-level consumers of lead-shot game meat and that tens of thousands of children in the EU may be consuming game contaminated with ammunition-derived lead frequently enough to cause significant effects on their cognitive development.

Effects of lead from ammunition on birds and other wildlife: A review and update

Poisoning of wild birds following ingestion of lead from ammunition has long been recognised and considerable recent research has focused on terrestrial birds, including raptors and scavengers. This paper builds upon previous reviews and finds that both the number of taxa affected and geographical spread of cases has increased. Some lead may also be absorbed from embedded ammunition fragments in injured birds which risk sub-lethal and welfare effects. Some papers suggest inter-specific differences in sensitivity to lead, although it is difficult to disentangle these from other factors that influence effect severity. Sub-lethal effects have been found at lower blood lead concentrations than previously reported, suggesting that previous effect-level 'thresholds' should be abandoned or revised. Lead poisoning is estimated to kill a million wildfowl a year in Europe and cause sub-lethal poisoning in another ≥ 3 million. Modelling and correlative studies have supported the potential for population-level effects of lead poisoning in wildfowl, terrestrial birds, raptors and scavengers.

Time to Onset of Paresthesia Among Community Members Exposed to the World Trade Center Disaster

We examined whether time to onset of paresthesia was associated with indicators of severity of World Trade Center (WTC) exposure. We analyzed data from 3411 patients from the Bellevue Hospital—WTC Environmental Health Center. Paresthesia was defined as present if the symptom occurred in the lower extremities with frequency “often” or “almost continuous.” We plotted hazard functions and used the log-rank test to compare time to onset of paresthesia between different exposure groups. We also used Cox regression analysis to examine risk factors for time-to-paresthesia after 9/11/2001 and calculate hazard ratios adjusted for potential confounders. We found significantly elevated hazard ratios for paresthesia for (a) working in a job that required cleaning of WTC dust in the workplace; and (b) being heavily exposed to WTC dust on September 11, 2001, after adjusting for age, race/ethnicity, depression, anxiety, post-traumatic stress disorder, and body mass index. These observational data are consistent with the hypothesis that exposure to WTC dust or some other aspect of cleaning WTC dust in the workplace, is associated with neuropathy and paresthesia. Further neurological evaluations of this and other WTC-exposed populations is warranted.

Gunshot Wounds to the Upper Extremity

Upper extremity gunshot wounds result in notable morbidity for the orthopaedic trauma patient. Critical neurovascular structures are particularly at risk. The fractures are often comminuted and may be associated with a variable degree of soft-tissue injury. The literature lacks consensus regarding antibiotic selection and duration, and indications for surgical débridement. Bullets and/or bullet fragments should be removed in cases of plumbism, intra-articular location, nerve impingement, location within a vessel, and location in a subcutaneous position within the hand and/or wrist. Gunshot fractures generally do not follow common fracture patterns seen in blunt injuries, and the complexity of certain gunshot fractures can often be a challenge for the treating orthopaedic surgeon. Common plate and screw constructs may not adequately stabilize these injuries, and innovative fixation techniques may be required. The treatment for bone defects varies by location and severity of injury, and typically requires staged treatment. Nerve injuries after gunshot wounds are common, but spontaneous nerve recovery is expected in most cases.

Plasma and saliva levels of three metals in waterpipe smokers: a case control study

In this case-control study, the influence of waterpipe tobacco smoking on the plasma and saliva levels of cadmium, lead and zinc was examined in participants who were waterpipe tobacco smokers (WS) or never-smokers (NS). The concentration of metals was higher in WS relative to NS. The mean (SEM) cadmium concentration in plasma was 3.3 (0.18) µg/dL in WS versus 0.82 (0.09) µg/L in NS (p < .001) and in saliva was 5.1 (0.36) µg/L in WS versus 0.64 (0.2) µg/L in NS (p < .001). The mean (SEM) lead concentration in plasma was 5.2 (0.25) µg/dL in WS versus 3.4 (0.41) µg/dL in NS (p < .01) and in saliva was 4.8 (0.58) µg/L in WS versus 2.8 (0.27) µg/L in NS (p < .05). Similarly, a significant difference in zinc concentration was observed, with a mean of 2.0 (0.17) µg/mL in WS plasma versus 1.49 (0.16) µg/mL in NS (p < .05) and a mean 0.94 (0.07) µg/mL in WS saliva versus 0.45 (0.06) µg/mL in NS (p < .01). In conclusion, waterpipe tobacco smoking is associated with elevated levels of metals in body fluids. These results provide another demonstration of how waterpipe tobacco smoking exposes smokers to harmful toxicants.

Severe lead toxicity attributed to bullet fragments retained in soft tissue

A man aged 30 years presented to an emergency department with a 1 month history of severe abdominal pain, jaundice, constipation, lower extremity weakness and weight loss. A peripheral blood smear was performed that showed basophilic stippling of erythrocytes prompting a blood lead level (BLL) evaluation. The patient had a BLL of >200 µg/dL. Retained bullet fragments were identified in the left lower extremity from a previous gunshot wound 10 years prior. Lead from the excised bullet fragment was consistent with the patient's blood lead by isotope ratio analysis. This case is a rare example of a severely elevated BLL attributed to bullet fragments in soft tissue. Bullets retained in soft tissue are not often considered a risk factor for a markedly elevated BLL because they become encapsulated within the tissue over time.