Toxicological risks on the human health of populations living around the Mediterranean Sea linked to the invasion of non-indigenous marine species from the Red Sea: A review.

The Mediterranean region is, by far, a prime travel destination, having hosted more than 330 million tourists in 2016, mostly for seaside holidays. A greatly increased influx of thermophilic Red Sea species, introduced through the Suez Canal in a process referred to as Lessepsian invasion (in honor of Ferdinand de Lesseps who instigated the building of the Suez Canal), have raised awareness among scientists, medical personnel, and the public, of health risks caused by some venomous and poisonous marine species. The main species of concern are the poisonous Lagocephalus sceleratus, and the venomous Plotosus lineatus, Siganus luridus, Siganus rivulatus, Pterois miles, Synancea verrucosa, Rhopilema nomadica, Macrorhynchia philippina and Diadema setosum. Recognizing that the main factors that drive the introduction and dispersal of Red Sea biota in the Mediterranean, i.e., Suez Canal enlargements and warming seawater, are set to increase, and international tourist arrivals are forecasted to increase as well, to 500 million in 2030, an increase in intoxications and envenomations by alien marine species is to be expected and prepared for.

The role of chest and abdominal computed tomography in assessing the severity of acute corrosive ingestion.

CONTEXT: Corrosive substance ingestion is a toxicological emergency with relatively high mortality requiring rational surgical decisions. OBJECTIVE: Evaluate the role of chest and abdominal computed tomography (CT) in assessing the severity of acute corrosive ingestion. METHODS: A retrospective study of adults admitted due to corrosive ingestion, who underwent gastrointestinal endoscopy and CT within 48 h of admission. Endoscopy findings were graded as 0, 1, 2a, 2b, 3a, and 3b (Zargar's criteria), CT findings were graded as 0, 1, 2, and 3. For each patient endoscopy and CT grades were compared, and sensitivity and specificity for predicting mortality or emergency laparotomy were calculated. RESULTS: Twenty-three patients were included, aged 18-87 years; seven underwent emergency laparotomy, five died. Endoscopy grading was higher than CT grading in 14 patients (66%). The sensitivities of endoscopy grades 2b and 3 to predict mortality and emergency laparotomy were 1 and 0.8, respectively; the specificities were 0.38 and 0.37, respectively. The sensitivities of CT grade 3 to predict mortality and emergency laparotomy were 0.4 and 0.28, respectively; the specificities were 0.94 and 0.93, respectively. Three patients had pulmonary infiltrates on CT but not on chest X-ray. DISCUSSION. CT tends to underestimate the severity of corrosive ingestion compared with endoscopy. It has lower sensitivity and higher specificity than endoscopy in predicting major outcome. CT can provide important information on lung injury, and when endoscopy cannot be completed. CONCLUSION: CT should not be the only basis for surgical decisions during the initial phase of acute corrosive ingestions.

Evaluation of the health effects of occupational exposure of analytic laboratory workers processing illicit drug investigation files.

INTRODUCTION: The Analytic Laboratory of Israel Police processes illicit drug files. In recent years, workers of this laboratory have complained of health problems. Limited information exists on the effect of occupational exposure to illicit drugs; biomonitoring was never done. OBJECTIVE: To assess health effects and systemic absorption of illicit drugs in workers of the Analytic Laboratory occupationally exposed to illicit drugs. METHODS: A prospective cohort study using health and occupational questionnaires, clinical assessments, and monitoring of urinary excretion of illicit drugs was conducted. The study included three blocks of one week each. At each week workers were assessed at the beginning (baseline), and the assessments were repeated at the end of the three working days. Urine specimens were analyzed for illicit drugs in an independent laboratory. Demographic, clinical, occupational, and laboratory data were subjected to descriptive analysis, and paired Student's t-test, chi-square analysis, and repeated measures model. RESULTS: Twenty-seven workers (age, 39.2 ± 8.3 years; 77.8% females) were included, yielding 122 paired samples. The following parameters were reduced at the end of shift compared with baseline: diastolic blood pressure (71.2 ± 11.2 and 77.2 ± 13.6 mmHg, respectively, p < 0.0001), FEV1 (98.3 ± 14.6% and 100.7 ± 12.7%, respectively, p < 0.0001), FVC (101.4 ± 13.7% and 103.7 ± 14.0%, respectively, p = 0.003), and FEF25₋75 (85.7 ± 18.0% and 89.6 ± 18.7%, respectively, p = 0.01). Main health complaints included headache, fatigue, and dry eyes. No illicit drug was detected in the urine specimens. CONCLUSION: It is suggested that the health concerns of the laboratory workers were not related to the absorption of illicit drugs; environmental conditions (e.g. inadequate ventilation and respirable dust) can contribute to these concerns.

Serum glucose and electrolyte levels in alcohol-intoxicated adolescents on admission to the emergency department: an unmatched case-control study.

Aimed at examining serum glucose and electrolytes concentrations in adolescents with acute alcohol intoxication (AAI) on admission to the pediatric Emergency Department (ED), a retrospective unmatched, case-control study was conducted. Two cohorts of adolescents were compared, patients presenting with AAI and patients presenting with non-alcohol intoxication. The study group included ED patients aged 12-18 years with AAI. The control group included ED patients aged 12-18 years who had poisoning from a non-illicit drug. Demographic characteristics and glucose and electrolyte blood levels were extracted from the medical files. The records of patients who were admitted between January 2007 and December 2009 were analyzed. The study group and the control group included 106 subjects and 27 subjects, respectively. The study subjects had serum ethanol levels in the range of 55.6-297 mg/dL. No case of hypoglycemia was recorded. The study subjects had higher glucose levels and lower potassium levels compared to the controls (p < 0.005 and p < 0.0001, respectively). No such difference was found when the levels of sodium and bicarbonate were compared (p = 0.3 and p = 0.14, respectively). In conclusion, the findings of this study suggest that at presentation to the ED adolescents with AAI are at low risk for hypoglycemia.

Determination of urinary hippuric acid in toluene abuse.

BACKGROUND: Volatile substance abuse is practiced mainly by adolescents and young adults. Its effects are central nervous system excitation followed by central nervous system depression, at times accompanied by seizures. It may cause sudden death as a result of ventricular arrhythmias, reflex vagal inhibition, respiratory depression, and anoxia. Chronic toxicity may involve the nervous system, heart, kidney, and liver. Toluene-based adhesives are among the most commonly inhaled substances. CASE REPORT: A 14-year-old female presented with confusion, hallucinations, and intermittent laughing and crying after having inhaled contact glue several times daily in the course of 5 days. Her condition improved within 3 h. Urinary hippuric acid was 93.9 g/g creatinine indicating heavy toluene exposure (biological exposure index, BEI, is 1.6 g/g creatinine). CONCLUSION: In this patient, urinary hippuric acid was a biomarker for her toluene abuse.

Accidental busulfan overdose: enhanced drug clearance with hemodialysis in a child with Wiskott-Aldrich syndrome.

A 4.6 kg infant with Wiskott-Aldrich syndrome received an accidental overdose of busulfan during preparation for allogeneic stem cell transplantation. Pharmacokinetic analysis of plasma busulfan levels alerted staff to the dosing error. Hemodialysis was immediately performed and resulted in accelerated clearance of busulfan. There were no acute neurologic and hepatic side-effects of the busulfan overdose, and despite 2 months of cough accompanied by rales, the patient is now free of pulmonary symptoms. Stable partial donor chimerism occurred after transplantation. At present, the patient is thriving and infection-free 12 months after transplantation, although his platelet count remains at the lower limit of normal.

Ecbalium elaterium (squirting cucumber)--remedy or poison?

BACKGROUND: Ecbalium elaterium is a plant endemic to the Mediterranean basin. Its roots and cucumber-shaped fruit have been used in folk medicine since antiquity. The alleged uses of the fruit juice are as a potent cathartic, analgesic, and antiinflammatory agent. Cucurbitacin B, a triterpene derivative is the active antiinflammatory principal. PATIENTS: We present a series of 13 patients who were exposed to the juice of Ecbalium elaterium in its natural form. In 3 patients, exposure was intranasal for the treatment of sinusitis or liver cirrhosis. In 3 other cases, children ingested the fruit unwittingly. In 6 patients, exposure was ocular and, in one, dermal. Within minutes of exposure, the patients exhibited irritation of mucous membranes at various degrees of severity manifested as edema of pharynx, dyspnea, drooling, dysphagia, vomiting, conjunctivitis, corneal edema, and erosion, depending on the route of the exposure. Recovery began within several to 24 hours after administration of oxygen, steroids, antihistamines, and beta-2-agonists. Ocular exposures responded to topical steroid and antibiotic eyedrops within a few days. The toddler with the dermal exposure remained asymptomatic. CONCLUSION: Exposure to the juice of Ecbalium elaterium, mainly in its undiluted form, may cause irritation of mucous membranes, supposedly of inflammatory nature. Patients exposed orally or intranasally should be closely followed for upper airway obstruction. Patients exposed ocularly should have their eyes promptly irrigated to prevent corneal and conjunctival injury.

Poison exposure in children before Passover.

BACKGROUND: Extensive cleaning of homes in Israel before Passover may result in increased exposure of children to cleaning substances. OBJECTIVES: To evaluate the potential danger of Passover cleaning to children, and to study the risk factors in order to identify areas for prevention. METHODS: All cases of poison exposure in Jewish and Arab children under the age of 15 years reported to the Israel Poison Information Center during 1990-95 (n = 5,583) were analyzed for the 6 weeks before and 6 weeks after Passover. Poison exposures in Jewish children < 15 years old were studied in seven pediatric emergency rooms for the 2 weeks before and 6 weeks after Passover (n = 123). RESULTS: The IPIC data showed a highly significant 38% increase in the average weekly poison exposure rate for the 2 weeks before Passover compared with the remaining 10 weeks. Data recorded by the pediatric emergency rooms showed a twofold increase in cleaning substance poisoning during the 2 weeks before Passover compared with the following 6 weeks. The rise in exposures to cleaning substances was observed among children from secular, religious and ultra-orthodox families. In these exposures, the substance was found in open containers in 70% of cases. CONCLUSIONS: The extensive cleaning of homes among Jewish families in preparation for Passover poses the danger to young children of cleaning substance poisoning. Increasing public awareness, closer observation of children, and keeping these substances in closed containers should increase children's safety during this annual cleaning.

The efficacy of oral deferiprone in acute iron poisoning.

Due to its high cost and need for parenteral administration, the standard iron chelator deferoxamine is not used in many individuals with acute and chronic iron poisoning worldwide. Deferiprone is the first oral iron chelator to be shown to be effective in chronically iron overloaded thalassemia patients. Its efficacy, by oral administration, in acute iron poisoning has not been tested. Our objective was to determine whether orally administered deferiprone can reduce the mortality of rats following acute, toxic, oral doses of iron. Rats were administered 612 mg/kg elemental iron orally, corresponding to LD50 in the species tested. Two other groups received the same oral dose of iron followed by oral deferiprone: 800 mg/kg and 800 mg/kg, followed by another dose of 800 mg/kg 2 hours later. Coadministration of 800 mg/kg deferiprone with the iron decreased mortality from 30% to 6.6% after 2 hours (P = .02), from 40% to 16.6% after 12 hours (P = .04), and from 53.3% to 20% after 24 hours (P = 0.007). Mortality was also significantly decreased among animals coadministrated 2 repeated doses of deferiprone of 800 mg/kg with iron, to 0%, 9%, and 18%, and 2, 12, and 24 hours postdrug administration, respectively (P = .04, .05, .04, respectively). Histologically, there was a dose-dependent decrease in iron accumulation in the gastrointestinal tract. Orally administered deferiprone can decrease morbidity and mortality caused by acute iron overdose in rats. Oral deferiprone holds promise in the treatment of iron poisoning in humans.

Severe pulmonary disease in association with Crohn's disease in a 13-year-old girl.

Pulmonary manifestations of Crohn's disease are infrequent in adults and even less common in children. Our literature search found only a few cases of Crohn's disease causing pulmonary manifestations in children. We report on the case of a 13-year-old girl in whom severe pulmonary disease was found four years after the onset of Crohn's disease. Open lung biopsy uncovered bronchiolitis obliterans and granulomatous lung disease. Aggressive treatment has yielded gradual improvement. This case emphasizes the importance of recognizing the association, the differential diagnosis, and treatment implications.

Postmortem digoxin-like immunoreactive substances (DLIS) in patients not treated with digoxin.

Endogenous digoxin-like immunoreactive substances (DLIS) cross-react in immunoassays of digoxin. The postmortem rise in digoxin levels in patients treated with the drug may be due to its redistribution. It is unclear what is the contribution of DLIS to this increase and whether DLIS are present postmortem in patients not treated with digoxin. The objectives of this study were to determine whether DLIS are present after death in patients not treated with digoxin, whether a postmortem increase in DLIS is detectable and whether sampling site can affect DLIS concentrations. DLIS (measured as digoxin, TDx Abott) were determined in blood samples drawn antemortem from ICU patients; postmortem samples from femoral artery and cardiac chambers were taken at least 12 h after the death of these same patients. DLIS concentrations > or = 0.2 ng/ml were measured in 44 and 40% of patients antemortem and postmortem (femoral), respectively. No difference was found in DLIS levels between antemortem and postmortem femoral and cardiac samples. Age, ICU stay and postmortem sampling time did not affect the postmortem increase in DLIS. None of the levels was in the toxic range. DLIS may be present after death and their concentration does not increase postmortem. The interpretation of postmortem digoxin concentrations that fall in the therapeutic range should be done cautiously; such measurable levels do not necessarily indicate misuse or malicious intent even in patients who had not been treated with the drug.

Prolonged elimination half-life of phenol after dermal exposure.

BACKGROUND: Phenol is a general protoplastic poison which has been in use in medicine and industry for decades. It is readily absorbed through the skin causing both local and systemic toxicity. CASE REPORT: A 47-year-old male had 90% phenol spilled over his left foot and shoe (3% of body surface area). After a 4 1/2-hour exposure, manifestations included confusion, vertigo, faintness, hypotension, ventricular premature beats, atrial fibrillation, dark-green urine, and tense swelling, blue-black discoloration, hypalgesia, and hypoesthesia of the affected area. Treatment consisted of irrigation with copious amounts of water, incisions, and supportive measures. RESULTS: Peak serum phenol was 21.6 micrograms/mL, considered in the fatal range. Peak urine phenol plus urine-conjugated phenol was 13,416 mg/g creatinine, indicating a major absorption. Elimination half-life was 13.86 hours, considerably longer than previously reported. CONCLUSIONS: Prolonged skin contact with concentrated phenol in an occlusive environment may result in a major absorption and a long elimination half-life even if the area involved is small. Prolonged elimination may be explained by extensive tissue distribution or by "slow-release reservoir" properties of the skin. Such exposure may be associated with severe systemic and local toxicities. Immediate removal from exposure and aggressive decontamination of the skin are essential to reduce these risks.

Nitric oxide inhalation for paraquat-induced lung injury.

BACKGROUND: When ingested, concentrated paraquat can cause either rapid death from multisystem failure and cardiovascular shock or delayed death from progressive pulmonary fibrosis. Diquat ingestion does not usually cause pulmonary fibrosis, but produces early onset acute renal failure. CASE REPORT: A 52-year-old male ingested approximately 50 mL of a solution containing 13% paraquat and 7% diquat (about 6650 mg of paraquat and 3500 mg of diquat), and subsequently developed adult respiratory distress syndrome and pulmonary fibrosis. Survival prediction employing the criteria of Hart et al. for paraquat plasma levels was 30%. From the probable amount of paraquat ingested, severe toxicity was expected. The clinical course was not consistent with significant diquat toxicity. Treatment included oral Fuller's earth, forced diuresis, hemofiltration, N-acetylcysteine, methylprednisolone, cyclophosphamide, vitamin E, colchicine, and delayed continuous nitric oxide inhalation. The patient recovered and pulmonary function was subsequently normal. CONCLUSION: It is unclear which, if any, of the above treatments contributed to recovery, but the encouraging outcome suggests a possible benefit of nitric oxide inhalation in paraquat poisoning which deserves further study.

Hyperbaric oxygen therapy for cutaneous/soft-tissue zygomycosis complicating diabetes mellitus.

A 24-year-old female diabetic patient was hospitalized because of ketoacidosis and a necrotic wound on the hand. Debridement and antibiotic therapy failed to halt the process. After demonstration of Mucor in cultures from the wound, the patient underwent extensive surgery and amphotericin B was administered. When the necrotic process continued despite these measures, adjunctive hyperbaric oxygen (100% O2 at 2.5 ATA for 90 minutes) was administered daily for a total of 21 treatment sessions. She gradually improved, and at 2 months follow-up most of the wound had healed. Although the mortality rate of cutaneous/soft-tissue zygomycosis is markedly lower than that of the rhinocerebral form, morbidity is still considerably high. Successful use of hyperbaric oxygen has been reported in rhinocerebral zygomycosis, and it may have been of benefit in this high-risk patient by preventing local and systemic spreading of the fungus. This report is the first case of the use of hyperbaric oxygen for cutaneous/soft-tissue zygomycosis. It is suggested that hyperbaric oxygen be considered for this indication in diabetic patients as an adjunct to surgery and amphotericin B.

Severe minocycline-induced eosinophilic pneumonia: extrapulmonary manifestations and the use of in vitro immunoassays.

OBJECTIVE: To report a severe and unusual reaction to minocycline and the use of in vitro immunologic assays. CASE SUMMARY: A 46-year-old white man developed severe respiratory distress with pulmonary infiltrates on chest X-ray and eosinophilia in blood, bronchoalveolar lavage fluid, and biopsied lung tissue during exposure to minocycline. Additional manifestations included pleuropericardial effusion, liver function abnormality, and bone marrow eosinophilia. Macrophage inhibition factor and mast cell degranulation assays were positive to minocycline. DISCUSSION: The patient's manifestations were compatible with the diagnosis of eosinophilic pneumonia. After excluding other possible etiologies, minocycline was identified as the offending agent. Generalized damage was suggested by the presence of a combination of extrapulmonary manifestations previously not reported. Results of the in vitro immunologic assays supported the hypersensitivity nature of the disease and confirmed the diagnosis. CONCLUSIONS: Minocycline-induced eosinophilic pneumonia may involve extrapulmonary sites. It is suggested that in vitro immunoassays be used for confirmation of the diagnosis rather than rechallenge or invasive procedures.

The efficacy of calcium gluconate in ocular hydrofluoric acid burns.

1. Although calcium gluconate (CG) is recommended in the treatment of hydrofluoric acid (HF) eye burn its efficacy seems to be controversial, and controlled human or animal studies are limited. The study's objective is to compare the efficacy of 1% CG and normal saline irrigation for the treatment of HF eye injury in animals. 2. 0.05 ml 2% HF was instilled to anesthetized rabbit's eyes. One minute later, four treatment groups were studies: (1) irrigation with normal saline followed by topical antibiotics, corticosteroids and cycloplegics for 48 h (n = 10); (2) irrigation with 1% CG followed by the same topical treatment (n = 9); (3) as group 1 and 1% CG drops over 48 h (n = 10); (4) as group 3, and injection of 1% CG subconjunctivally after irrigation (n = 9). 3. Corneal erosion area, corneal haziness, conjunctival status, vascularization (pannus) and acidity were assessed before injury, immediately after initial treatment and 1, 2, 7 and 14 days thereafter by slit lamp aided by fluorescein staining. 4. Conjunctival pH dropped from 6.0-6.5 to 2.5-3 after injury and increased to 6-6.5 after irrigation. Corneal erosion: smaller in groups 2, 3, significantly so at 2 days, but not different at 14 days. Corneal haziness: more severe in group 4, at 14 days, insignificant. Conjunctival damage: significantly worse in group 4 at 2, 7 and 14 days. Pannus appeared in 2-4 eyes in each group. 5. It seems that for HF injury 1% CG did not have any significant advantage over saline irrigation and topical treatment only. It might have some initial and temporary effect on healing process especially that involving erosion. Given subconjunctivally, 1% CG may be toxic and worsens clinical outcome.

Helium and oxygen treatment of severe air-diving-induced neurologic decompression sickness.

BACKGROUND: The use of helium and oxygen recompression treatment of neurologic decompression sickness (DCS) has several theoretical advantages over the traditionally used air and oxygen recompression tables that have been confirmed by findings from recent animal experiments. OBJECTIVES: To evaluate the outcome of patients with neurologic DCS who had been treated with a helium-oxygen protocol and to compare it with that of a retrospective control group that was treated with air-oxygen tables. DESIGN: The study and control groups included 16 and 17 diving casualties, respectively. The severity of neurologic DCS was estimated according to a 9-point scale weighting motor, sensory, and sphincter control functions. The study group was treated with a helium-oxygen decompression protocol, and the control group was treated with the US Navy air-oxygen Table 6 or 6A. Persistent residual dysfunction was treated in both groups with daily hyperbaric oxygen sessions, at 2.5 absolute atmospheres for 90 minutes, until no further clinical improvement was noted. SETTING: The Israel Naval Medical Institute (Israel's national hyperbaric referral center), Haifa. RESULTS: Significant clinical score increments were found for both the helium-oxygen- and air-oxygen-treated groups: 2.8 +/- 2.4 (mean +/- SD) and 7.4 +/- 1.1 at presentation vs 7.6 +/- 2.1 and 8.1 +/- 1.5 at discharge, respectively (P < .001 and P = .005, respectively). Although the score at presentation was significantly lower for the helium-oxygen-treated group (P < .001), no difference was found between the groups' average outcome scores. While most of the improvement in the patients in the study group could be attributed to the helium-oxygen treatment and not to the supplemental hyperbaric oxygen, in the control group, no significant difference could be demonstrated between the scores at presentation and at completion of the air-oxygen recompression table. In 5 patients who were treated with the use of the air-oxygen tables, deterioration was observed after recompression. No deterioration or neurologic DCS relapse occurred in the helium-oxygen-treated group. CONCLUSION: The results suggest an advantage of helium-oxygen recompression therapy over air-oxygen tables in the treatment of neurologic DCS.

[Hyperbaric oxygen for carbon monoxide poisoning].

Severe cases of carbon monoxide (CO) poisoning from all over Israel are treated at the Israel Naval Medical Institute with hyperbaric oxygen (HBO). Between 1.11.94 and 15.2.95. 24 cases of CO poisoning were treated. Poisoning was usually due to domestic gas-fired heating systems, CO being the only toxin involved. Since delay between termination of CO exposure and arrival at the emergency department averaged 55 minutes, the level of carboxyhemoglobin measured on presentation did not always reflect the true severity of the poisoning. Poisoning was defined as severe and requiring HBO treatment when 1 or more of the following indications was present: evidence of neurological involvement, cardiographic signs of acute ischemic injury, metabolic acidosis, carboxyhemoglobin level greater than 25%, and pregnancy. 20 (84%) recovered consciousness during the course of 1 session (90 min.) of HBO treatment (pO2 2.8 ATA) or immediately thereafter, with resolution of other signs of CO poisoning. 3 required a second treatment session before their symptoms resolved. A patient who arrived in deep coma with severe cerebral edema died. HBO is an important element in the combined treatment of severe CO poisoning. There should be greater awareness of the danger of CO poisoning and the means of preventing it, both among medical staff and the population as a whole, mainly in areas in which cold weather requires use of heating systems, which may be gas-fired.