Prenatal Maternal Occupational Exposure and Postnatal Child Exposure to Elemental Mercury.

OBJECTIVES: Young children are highly vulnerable to elemental mercury toxicity, and elementary mercury exposure in young children in China unfortunately occurs regularly because of the wide use of fluorescent lamps, glass thermometers, and other mercury-contained items. This study aimed to summarize such recent cases in a referral clinic and to make recommendations for postexposure treatment and prevention of future exposure. METHODS: Patients were evaluated between January 2007 and December 2009 in environmental health facilities throughout China and were referred to our clinic. A total of 6 children younger than 4 years with significant elemental mercury exposure were included in this case series analysis. The total mercury content in blood and hair (fetal hair if necessary) and average 24-hour urine mercury concentrations were analyzed. Meso-2,3-dimercaptosuccinic acid or surgery was prescribed for the patient if necessary. RESULTS: Young children were found to be exposed in 3 ways as follows: prenatal exposure through maternal occupational contact in compact fluorescent-lamp factories (2 cases), broken thermometers (3 cases), and other causes of accidental inhalation of mercury vapor during the embryonic and lactation periods (1 case). For 3 cases caused by broken thermometers, x-ray images helped to identify the position of mercury residues. Local excision was used to remove mercury from the floor of the mouth in 1 case. One child was prescribed oral meso-2,3-dimercaptosuccinic acid, and a good response was received. CONCLUSIONS: Substitution of mercury-in-glass thermometers and vigilance to prevent women of childbearing age from occupational mercury exposure were suggested. Treatment selection should vary according to patient situations.

Accidental laceration of the vaginal wall by an intravaginal thermometer as a calving detection device in a Japanese black cow.

An intravaginal thermometer was inserted into a 59-month-old Japanese black cow to predict calving. After calving, the thermometer penetrated the vaginal wall and could not be removed by farm staff. Surgery to remove the thermometer was successful. The cow left the animal hospital without hospitalization. In the follow-up, the cow remained healthy on the farm for more than one year and is now pregnant. No symptoms related to damage to the vagina or infection developed. This is the first case report of a vaginal laceration caused by an intravaginal thermometer in a Japanese black cow. Insertional vaginal devices may cause vaginal lacerations in cattle.

Case series of mercury toxicity among children in a hot, closed environment.

Mercury poisoning is much more prevalent in the general population than possibly many physicians realize. We present data on 26 pediatric cases with mercury intoxication from exposure to mercury by inhalation or skin contact as a result of a broken thermometer in a school laboratory. This is the largest pediatric series in Turkey. During a 3-month period, the study team observed the children for clinical symptoms, physical findings, and blood and mercury levels. Of all patients, 21 inhaled, 3 inhaled and touched the element, and 2 took the mercury home. Sixteen children were symptomatic at admission, although blood mercury levels in the symptomatic children were higher than those in asymptomatic children (P = 0.003). The urine mercury levels were not statistically different between the groups at the admission (P > 0.05). The exposure times were 3.5 and 2 hours for symptomatic and asymptomatic children, respectively (P = 0.003). The 2 children who took the mercury home had the highest blood mercury levels and the most prolonged exposure time. N-acetylcysteine and chelation treatments were started in 21 children who had symptoms of mercury intoxication and high mercury levels in their blood or urine. No adverse effects were observed during chelation therapy. Prompt removal of children from contaminated environments and proper decontamination or elimination of devices containing large amounts of mercury from schools are necessary to prevent serious complications caused by exposure to mercury.

Prehospital body temperature measurement in trauma patients: A literature review.

OBJECTIVES: Accidental hypothermia in trauma patients can contribute to cardiorespiratory dysfunction, acidosis, and coagulopathy, causing increased morbidity and mortality. The early recognition of the clinical signs of hypothermia and the accurate measurement of body temperature by prehospital care providers are essential to avoid deterioration. This review provides an overview of studies that examine the reliability of different core temperature measurement options, with a focus on the prehospital setting. METHODS: A search was performed in PubMed, Embase, Cochrane Library, and CINAHL using combinations of the Medical Subject Headings terms "ambulances," "emergency medical services," "thermometers," "body temperature," "hypothermia," and "body temperature regulation." Studies up to October 2021 were included, and different measurement options were listed and discussed. Eligible studies included those that identified the specific type of thermometer and focused on the out-of-hospital environment. RESULTS: The search strategy yielded 521 studies, five of which met the eligibility criteria. Four studies focused on tympanic temperature measurement, and one focused on temporal artery temperature measurement. Among the noninvasive options, tympanic temperature measurement was most frequently identified as a reliable option for out-of-hospital use. CONCLUSION: A thermistor-based tympanic thermometer that features insulation of the ear and a temperature probe with a cap is likely the most suitable option for prehospital body temperature measurement in trauma patients. These results are based on outdated literature with currently more novel temperature measurement devices available. Future studies are necessary to provide strong recommendations regarding temperature measurement due to emerging technology, the lack of studies, and the heterogeneity of existing studies.

Is current body temperature measurement practice fit-for-purpose?

There has been a marked rise in the number of avoidable deaths in health services around the world. At the same time there has been a growing increase in antibiotic resistant so-called "superbugs." We examine here the potential role of body temperature measurement in these adverse trends. Electronic based thermometers have replaced traditional mercury (and other liquid-in-glass type) thermometers for reasons of safety rather than superiority. Electronic thermometers are in general less robust from a measurement perspective than their predecessors. We illustrate the implications of unreliable temperature measurement on the diagnosis and management of disease, including COVID-19, through statistical calculations. Since a return to mercury thermometers is both undesirable and impractical, we call for better governance in the current practice of clinical thermometry to ensure the traceability and long-term accuracy of electronic thermometers and discuss how this could be achieved.

Entrapment of a nasopharyngeal temperature probe: an unusual complication during an apparently uneventful elective revision laparoscopic Nissen fundoplication.

We report the first case of nasopharyngeal temperature probe entrapment during an apparently uneventful elective revision laparoscopic Nissen fundoplication that precipitated a continuous quality improvement project at our institution. We describe changes in our clinical practice that resulted from this occurrence and envision these modifications will have a positive influence on patient care.

Broken thermometer in foot: a source of mercury poisoning.

A 17-year-old boy was referred after jumping from a ladder onto the ground, crushing a medical thermometer with his right foot. Some days later, he complained of loss of appetite and weakness. A radiograph of the affected foot demonstrated radiopaque densities. Blood and 24-h urine assays for mercury demonstrated toxic levels. Chelation therapy cured the patient dramatically.

Glass thermometer injuries: it is not just about the mercury.

BACKGROUND: Glass mercury thermometers were once used as the criterion standard for measuring core body temperature. Once broken, however, there is the dual hazard of broken glass and exposure to mercury. Previous studies have focused only on the mercury hazard rather than injuries related to thermometer glass. OBJECTIVE: To identify injury patterns from glass thermometers, including glass-related injury and mercury exposure. METHODS: We performed a retrospective cohort study of glass thermometer-related injuries in children evaluated in a pediatric emergency department between October 1995 and October 2007. Case identification was performed using a computer-assisted screening tool followed by a manual chart review. Collected data included age, sex, injury characteristics, physical examination findings, radiologic imaging, interventions, and disposition. To analyze injury rates during these years, we used a multiplicative Poisson model allowing for varying exposures. RESULTS: Thirty-three patients were identified among 627,592 who presented to the emergency department during the study period. Approximately 1 to 6 patients presented every year, including 3 patients in 2007. Decline in injury incidence is less than 9% per year (P = 0.041). Median patient age was 2.4 years (interquartile range, 0.4-3.8 years); 12 patients (36%) were female. Twenty-two patients (66%) underwent radiologic imaging to identify potential foreign body (21 underwent radiography and 1 underwent computed tomographic scanning). There were 15 mouth injuries (45%), 13 anal injuries (39%), and 1 ear injury. Glass was identified by imaging in 5 patients (15%) and by sigmoidoscopic evaluation in 1 patient (3%). Mercury exposure was identified in 14 patients (42%). CONCLUSIONS: Persistent use of glass mercury thermometers has resulted in pediatric injury especially in children younger than 4 years. We reported the different mechanisms of injury with the hope of eliminating its use and reinforcing the use of alternative thermometers.

Case report: perianal necrotizing fasciitis in a near-term neonate.

Necrotizing fasciitis in the neonatal period is a rare, life-threatening condition. Previous cases of neonatal necrotizing fasciitis in the perianal region were speculated to have been initiated by rectal mucosal trauma secondary to rectal temperature measurements. We observed a case of fatal perianal necrotizing fasciitis in a neonate where the process began as a red ring surrounding the anus and guiac-positive stools, detected after a rectal temperature measurement. We speculate that the perianal necrotizing fasciitis that subsequently developed might have been initiated by a minor rectal mucosal injury, and we investigated the instrument used for the rectal temperature measurement to assess any potential areas on the probe sheath cover that might cause a minor injury. Each probe sheath cover examined had three areas that, in our opinion, could possibly generate a minor mucosal injury.

Intrapelvic migration with long-term retention of a rectal thermometer: a case report.

Rectal perforation is a serious complication of manipulation of the anus and rectum, with catheters and thermometers. Such procedures should be performed with caution. We report a case of a 19-year-old male with retention of an intrapelvic foreign body, a mercury thermometer, which after perforating the rectum migrated into the pelvis and remained there without any symptoms for the next 7 years. A mercury thermometer, broken into 2 fragments, retained in the pelvis was noted accidentally by pelvic roentgenogram examination. An extrinsic thermometer tip over the upper rectal region was palpable by digital rectal examination. On physical examination, no infections or signs of peritonitis were observed. There were no significant abnormal findings by flexible colonoscopy. Computed tomography revealed a foreign body retained in the pelvis. Blood mercury level and a 24-hour urinary measurement of mercury were within normal limits. The patient refused any further treatment since he did not have any discomfort. The patient was in good condition and had not had surgery in the preceding 7 years.

Study between axillary and rectal temperature measurements in children.

We compared axillary and rectal temperatures in 216 patients to assess the reliability of axillary temperature for determining fever in children under 14 years of age. Beyond the neonatal period, the mean rectal temperature was significantly higher than the axillary temperature. The sensitivity of axillary temperature in detecting fever was 87.5% among neonates but only 46% among older children. Axillary temperature correlated well with rectal temperature in neonates but not older children. There was no direct mathematical relationship between axillary and rectal temperature. Axillary temperature should be taken in neonates as it is less hazardous; rectal temperature should be used beyond this age.

Metallic Mercury Injection in the Hand Caused by A Broken Mercury Thermometer: A Case Report.

Incorrect usage of or accidents related to metallic mercury can be hazardous. Herein, we present a case of subcutaneous metallic mercury injection in the hand caused by a broken thermometer and surgical tips for this injury. A 43-year-old female patient visited our hospital due to mercurial injection injury at the left hand suffered 4 weeks previously. On gross findings, the mercury deposition was limited to the subcutaneous layer and enveloped by granulation tissue. The blood mercury level, which had been abnormally elevated, fortunately decreased to within normal levels within five months. Nonetheless, this initial elevation indicates the possibility of systemic complications after local absorption of mercury droplets into the general circulation. In conclusion, we recommend prompt and complete excision of mercury material to prevent local and systemic complications, and excising the granulation tissue in its entirety, while retaining the mercury droplets within, is recommended.

Are tympanic thermometers a source of cross-infection?

AIM: To find out if tympanic thermometers are a source of cross-infection in critical care and whether cleaning is effective. METHOD: An observational study. RESULTS; In most of the inspections the surfaces of the tympanic thermometers looked clean, but three inspections revealed spots of dried fluid and one revealed a dirty base. None of the swabs taken before or after cleaning was positive, but seven of the inspections identified that the lens of the tympanic thermometer was dirty, poSsibly with cerumen (earwax). CONCLUSION: The findings from this study do not support the assumption that tympanic thermometers are a source of cross-infection in critical care, but a potential risk of cross-infection by this route cannot be excluded.

A randomized crossover study of disposable thermometers for prevention of Clostridium difficile and other nosocomial infections.

OBJECTIVE: To test the hypothesis that use of disposable thermometers would result in lower rates of nosocomial Clostridium difficile diarrhea and of total nosocomial infections, compared with electronic thermometers. DESIGN: Prospective randomized crossover trial. SETTING: A 700-bed university hospital providing primary and tertiary care. PATIENTS: All patients admitted to a group of 20 inpatient nursing units. INTERVENTIONS: 20 nursing units were randomized into two groups. One group randomly was assigned exclusive use of single-use disposable thermometers for patient temperature measurement, and the other group was assigned exclusive use of electronic thermometers. After 6 months, the assignments were reversed. MAIN OUTCOME MEASURES: Rates of C difficile infections, total nosocomial diarrheal episodes, and total nosocomial infections were prospectively followed in each study unit over 11 months. RESULTS: 26,350 patients were admitted to the study units and hospitalized for 120,529 patient days. There were 947 nosocomial infections (7.86 per 1,000 patient days). Nosocomial C difficile-associated diarrhea defined by positivity to both toxin B (titer > or = 1:10) and toxin A was detected in 32 patients (3.4% of all nosocomial infections). A significantly lower rate of nosocomial C difficile-associated diarrhea was observed with disposable thermometer use (0.16 per 1,000 patient days) compared with electronic thermometer use (0.37 per 1,000 patient days, relative risk [RR] = 0.44; 95% confidence interval [CI95], 0.21-0.93, P = .026). There was no difference in overall rates of nosocomial infection between the disposable and electronic groups (8.03 and 7.68 infections per 1,000 patient days, respectively; RR, 1.04; CI95, 0.92-1.19; P = .52) or in the overall rate of nosocomial diarrhea (3.34 and 3.40 per 1,000 patient days, respectively; RR, .98; CI95, 0.81-1.19; P = .87). CONCLUSIONS: The incidence of nosocomial C difficile diarrhea was reduced significantly by using single-use, disposable thermometers as compared with electronic thermometers, but there was no effect on either the overall rate of nosocomial diarrhea or the rate of total nosocomial infections.

A cluster of atypical skin lesions in well-baby nurseries and a neonatal intensive care unit.

We describe an epidemiologic investigation that elucidated the cause of vesicular and bullous skin lesions of the hands and feet that occurred in three otherwise well neonates during a 24-hour period. The investigation encompassed two well-baby nurseries of 28 and 17 beds and one level III neonatal intensive care unit (NICU) of 31 beds located in a 440-bed university-affiliated community hospital. Work-up for infectious causes of the skin lesions in the initial three cases had negative results. Expanded case surveillance disclosed seven additional cases that had occurred within the previous 2 weeks in the NICU. Analysis of risk factors focused attention on the insertion technique for peripheral intravenous catheters. This led to the discovery of a defective transillumination device, the tip of which reached a temperature of 88 degrees C within 20 seconds, causing thermal burns. The cause of the malfunction was the failure to install an infrared filter during the manufacture of the device. No additional cases were observed after the defective unit was removed from service. In summary, a defective transilluminating device caused a cluster of thermal burns in a newborn nursery and NICU. Epidemiologic investigation of the cluster allowed the investigators to focus on techniques of intravenous catheter insertion, which thus led to the identification of the cause of the injuries. With the increasing emphasis on health outcomes measurement, hospital epidemiologists will likely have an expanding role in investigating clusters of noninfectious adverse events.

Assessment of masseter spasm complicated by a faulty temperature probe.

During palatoplasty on a 9-year-old girl with no personal or familial history of malignant hyperthermia, the temperature monitor reported an increase in temperature. Additionally, the surgeon thought the patient's jaw muscle was in spasm. While preparations were made for treatment of malignant hyperthermia, the temperature probe was tested and found to be defective. When it was replaced, the patient's temperature was within normal range. When the temperature probe was tested 6 days later, it was working properly. The cause of the problem may have been moisture in the connection between the probe and the exterior cable, which eventually evaporated. Decision algorithms can assist in such situations to distinguish between a medical problem and a mechanical problem with the monitor.