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Treatment of pediatric cerebral radiation necrosis using hyperbaric oxygenation.

Introduction: Cerebral radiation necrosis is rarely encountered in pediatric patients. This case report describes a child with cerebral radiation necrosis who was successfully treated using corticosteroids, bevacizumab, and hyperbaric oxygenation. Case report: A 3-year-old boy developed progressive extremity weakness six months after the completion of radiation therapy for the treatment of a neuroepithelial malignancy. Treatment with corticosteroids and bevacizumab was initiated, but his symptoms did not improve, and he was then referred for hyperbaric oxygen therapy. After completing 60 hyperbaric treatments, he experienced significant improvements in mobility, which remained stable over the next year. Discussion: Cerebral radiation necrosis typically presents in children with symptoms of ataxia or headache. Corticosteroids and bevacizumab are common treatments, but hyperbaric oxygen therapy has also been studied as a therapeutic modality for this condition. When considering the use of hyperbaric oxygenation in pediatric patients, careful attention to treatment planning and patient safety can reduce the risks of adverse events such as middle ear barotrauma and confinement anxiety. Conclusion: In addition to other available pharmacologic therapies, hyperbaric oxygenation should be considered for the treatment of pediatric patients with cerebral radiation necrosis.

Chronic Ciguatera Poisoning: A Case Report.

Ciguatera is a common marine, toxin-borne illness caused by the consumption of fish that contain toxins that activate voltage-sensitive sodium channels. The clinical manifestations of ciguatera are typically self-limited, but chronic symptoms may occur in a minority of patients. This report describes a case of ciguatera poisoning with chronic symptoms, including pruritus and paresthesias. A 40-y-old man was diagnosed with ciguatera poisoning after consuming amberjack while vacationing in the US Virgin Islands. His initial symptoms, including diarrhea, cold allodynia, and extremity paresthesias, evolved into chronic, fluctuating paresthesias and pruritus that became worse after the consumption of alcohol, fish, nuts, and chocolate. After a comprehensive neurologic evaluation failed to reveal another cause for his symptoms, he was diagnosed with chronic ciguatera poisoning. His neuropathic symptoms were treated with duloxetine and pregabalin, and he was counseled to avoid foods that triggered his symptoms. Chronic ciguatera is a clinical diagnosis. Signs and symptoms of chronic ciguatera can include fatigue, myalgias, headache, and pruritus. The pathophysiology of chronic ciguatera is incompletely understood but may involve genetic factors or immune dysregulation. Treatment involves supportive care and avoidance of foods and environmental conditions that may exacerbate symptoms.

Electric shock leading to acute lung injury in a scuba diver.

INTRODUCTION: Electrical injuries are a rarely reported complication of scuba diving. CASE REPORT: A 33-year-old woman wore a 12-volt heated shirt designed for motorcycling, powered by a canister light battery, while scuba diving. A leak in her drysuit allowed water to make contact with an electrified connector from the heated shirt, and she experienced painful electrical shocks. She was able to disconnect the power source and finish the dive, but she developed progressive fevers and dyspnoea several hours later. She was diagnosed with acute lung injury and treated with bronchodilators. Her symptoms resolved over subsequent weeks. DISCUSSION: Acute lung injury is rarely reported after low voltage electrical injury. In this case, the use of a heated shirt that was not intended for underwater activities heightened the patient's risk for electric shock that likely resulted in aspiration of sea water and subsequent acute lung injury. To reduce risk of injury, divers should use equipment that is designed for underwater submersion. Medical professionals who treat the diving population should be aware that divers may use modified equipment that increases the risk of diving-related complications.

Use of hyperbaric oxygen therapy to treat glans penis necrosis after prostatic artery embolization.

We report a case of non-target embolization after PAE, which was treated with topical and systemic therapies including hyperbaric oxygenation. In this case, a 77-year-old man developed distal penile pain, hours after undergoing PAE. Within days, he experienced tissue necrosis involving the glans penis. Treatment with tramadol, tadalafil, topical lidocaine, and hyperbaric oxygenation was initiated, and the necrosis resolved after fifteen days. There are no standard treatments for penile necrosis after PAE. Hyperbaric oxygenation may be effective in reducing ischemia-related tissue loss and may be considered as a treatment option for penile necrosis that occurs as a complication of PAE.

2020 webPOISONCONTROL data summary.

INTRODUCTION: Increasing use of the internet for health information has decreased utilization of traditional telephone-based poison centers in the United States. webPOISONCONTROL®, a browser-based tool and app was launched to meet the growing demand for online, personalized recommendations for human poison exposures. This study was conducted to characterize webPOISONCONTROL cases and highlight its potential for real-time monitoring of poisoning. METHODS: Case data for all completed, nonduplicated public cases entered in 2020 were analyzed using a custom Qlik Sense dashboard. RESULTS: Of the 156,202 cases, 52.9% occurred in children younger than 4 years. Most cases (109,057, 69.8%) were initially triaged to home, 28.4% were advised to call Poison Control, and 1.7% were referred to the ED. Follow-up was available for 33.3% of home-triaged cases; 1.7% of those had a change in triage recommendation. Pharmaceuticals were implicated in 41.5% of cases (nonpharmaceuticals in 58.5%). Ingestion was the most common route (88.4%, 138,012). One-time double dose therapeutic error cases were implicated in 17,901 cases (27.6% of pharmaceutical cases). Cosmetics (13.9%) and cleaning substances (12.9%) were the most frequent substance categories. Melatonin was the most frequently implicated generic substance (4.5% of cases). Most (72.0%) cases had no effect (21.4%), a minor effect (3.9%) or were minimally toxic with unknown outcome (46.7%). There were no deaths, 17 major outcomes (0.01%), and 26.7% of cases had potentially toxic exposures with no outcome determination. In 2020, webPOISONCONTROL handled 7.3% as many human poison exposure cases as were reported to U.S. phone-based poison centers. Online cases are skewed towards younger ages (53% in children younger than 4 years vs 37% of phone-based cases) and towards nonpharmaceuticals (58.5% vs 43.5%). Near real-time data visualizations enabled detection of COVID-19-related increases in exposures to hand sanitizers and cleaners, illustrating the public health surveillance and hazard detection capabilities of webPOISONCONTROL. CONCLUSION: The webPOISONCONTROL tool provides a safe, quick and fully-automated alternative to those who are unable or unwilling to use the telephone to call a traditional poison center.

Ivermectin: a mini-review.

Introduction: Avermectins are common antiparasitic drugs, derived from Streptomyces bacteria that exhibit activity against arthropods and nematodes. Ivermectin, an avermectin derivative, is used as a treatment for parasitic infections in humans and domesticated animals.Discussion: Ivermectin's mechanism of action involves binding to ligand-gated ion channel receptors including glutamate, GABA, and glycine, resulting in parasitic paralysis and death. Due to varying expression of these ion channel receptors in vertebrate species, ivermectin toxicity is rarely reported in mammals. Ivermectin is also a substrate for P-glycoprotein, which limits its neurological toxicity in humans. Genetic polymorphisms in P-glycoprotein or coadministration of P-glycoprotein inhibitors may increase the neurotoxicity of ivermectin. Other toxic effects of ivermectin after therapeutic oral use include edema, rash, headache, and ocular complaints. Most of these effects are mild and short in duration. Ivermectin exhibits antiviral effects in-vitro at very high concentrations. This has led to suggestions of ivermectin as a potential treatment for SARS-CoV-2 (COVID-19) infection, although the drug's pharmacokinetic parameters reduce the likelihood that high concentrations of the drug can be achieved in-vivo.Conclusion: Due to concern for adverse events, specifically neurotoxicity, as well as a paucity of supporting evidence, the use of ivermectin as a routine treatment or preventive measure for COVID-19 infection is not recommended at this time.

Bloodless Management of the Anemic Patient in the Emergency Department.

Anemia is a commonly encountered condition in emergency medicine; transfusion of packed red blood cells is commonly performed for anemic patients in the emergency department (ED), but some patients are unable to accept transfusion of blood products due to medical or religious concerns. The unique, acute, and time-sensitive nature of emergency medicine practice requires that physicians maintain an enhanced awareness of bloodless medicine treatment modalities. Identification of bloodless medicine patient preferences in the ED can help guide physicians in the recommendation of acceptable methods of treating anemia in this patient population. A focus on early hemostasis and resuscitation, instead of attempts to convince the patient to accept blood transfusion, can be lifesaving in patients with acute bleeding. Treatment strategies including the use of methods to reduce unnecessary blood loss, enhance red blood cell production, and increase the oxygen-carrying capacity of blood should also be considered early in patient presentation. Timely involvement of the Hospital Liaison Committee can help facilitate successful interpersonal communication and shared decisionmaking between emergency physicians and bloodless medicine patients. By embracing an understanding of bloodless medicine patient needs as well as available treatment strategies, ED physicians can contribute to optimal overall outcomes for anemic bloodless medicine patients.

The Use of Hyperbaric Oxygen Therapy in the Management of Severe Radiation-Induced Hemorrhagic Gastritis in a Pediatric Patient.

Radiation-induced hemorrhagic gastritis is a serious and rare complication of radiation therapy. Optimal therapies in the pediatric population are not well established. We report a 2-year-old female diagnosed with rhabdomyosarcoma who developed hemorrhagic gastritis following chemotherapy and radiation therapy. The patient presented with acute onset anemia, hematemesis, and melena. Endoscopies revealed circumferential ulceration at the pylorus with spontaneous oozing that failed to respond effectively with multimodal medical and endoscopic therapies. Following hemodynamic stabilization, the patient was treated with hyperbaric oxygen therapy with excellent clinical response of the bleeding. Further research on the benefit of hyperbaric oxygen therapy is warranted to determine if this treatment can reduce the incidence of gastrointestinal complications in patients who have received radiation therapy.

Effective Decontamination and Remediation After Elemental Mercury Exposure: A Case Report in the United States.

Elemental mercury exposure can result in significant toxicity. Source decontamination and remediation are often required after larger elemental mercury exposures, but the details of these processes are infrequently reported. In the case described herein, a 64-year-old woman and her husband were exposed to elemental mercury in their home after the husband purchased it online for the purpose of recreational barometer calibration. After the mercury reportedly spilled during the calibration process, a vacuum cleaner was used to decontaminate the affected surface; this led to extensive mercury contamination of the home. The couple was relocated from the home while remediation occurred over the course of several weeks. Vacuum cleaning of an elemental mercury spill can lead to extensive volatilization and recirculation of mercury vapor. For smaller mercury spills, careful removal of visible mercury beads by using an eyedropper, cardboard, and masking tape is recommended. Larger spills require professional decontamination and remediation and may necessitate involvement of governmental resources. Vacuum cleaning should not be used as an initial method of decontamination after elemental mercury exposure. Careful attention to source decontamination can reduce the emotional and financial costs associated with extensive remediation after elemental mercury exposure.

Hyperbaric oxygen therapy for paediatric patients: an unintended consequence of the COVID-19 pandemic.

OBJECTIVE: Hyperbaric oxygen therapy (HBOT) is a useful adjunctive treatment for selected complicated wounds, including severe diabetic lower extremity ulcerations and compromised skin grafts or flaps. The Sars-CoV-2 (COVID-19) pandemic has disrupted healthcare delivery, with its effects extending to delivery of HBOT. During the pandemic, paediatric patients in our geographic region who were referred for HBOT faced challenges as centres temporarily closed or were unprepared to treat younger patients. Our monoplace HBOT centre modified existing practices to allow for treatment of these patients. This study aims to outline the steps necessary to adapting a pre-existing HBOT centre for the safe treatment of paediatric patients. METHOD: A retrospective review was performed to identify patients 18 years of age or younger referred for HBOT during 2020. Patient characteristics, referral indications and HBOT complications were collected. Changes implemented to the HBOT centre to accommodate the treatment of paediatric patients were documented. RESULTS: A total of seven paediatric patients were evaluated for HBOT and six were treated. The mean patient age was four years (range: 1-11 years). Referral diagnoses included sudden sensorineural hearing loss, skin flap or graft compromise, and radiation-induced soft tissue necrosis. All patients tolerated HBOT treatment in monoplace chambers without significant complications noted. Enhancements made to our clinical practice to facilitate the safe and effective treatment of paediatric patients included ensuring the availability of acceptable garments for paediatric patients, maintaining uninterrupted patient grounding (in relation to fire safety), and enhancing social support for anxiety reduction. CONCLUSION: The results of our review show that paediatric patients can be safely treated within the monoplace hyperbaric environment.