Delayed-Onset Portal Venous Thrombosis After Ingestion of 3% Hydrogen Peroxide.

BACKGROUND: Identification of portal venous gas on radiographic imaging is well documented after the ingestion of hydrogen peroxide, as is its resolution after hyperbaric therapy. Although hyperbaric therapy may resolve the gastrointestinal symptoms associated with the presence of portal venous gas, the principle rationale for performing hyperbaric therapy is to prevent subsequent central nervous system oxygen embolization. CASE REPORT: We describe a patient with portal venous gas identified by computed tomography after the ingestion of 3% hydrogen peroxide, managed without hyperbaric therapy, who subsequently developed portal venous thrombosis. We are not aware of this complication being previously described from hydrogen peroxide ingestion. The case is complicated by the coexistence of a self-inflicted stab wound, leading to exploratory laparotomy in a patient predisposed to arterial vascular occlusion. Why Should an EmergencyPhysicianBeAware of This? Emergency physicians will encounter patients after the ingestion of hydrogen peroxide who, despite not having symptoms of central nervous system emboli, have portal venous gas identified on radiographic imaging. Being aware that the principle rationale for prophylactic utilization of hyperbaric therapy is to prevent subsequent central nervous system emboli, and that in at least one case, delayed-onset portal venous thrombosis has occurred without hyperbaric therapy may help contribute to clinical decision-making.

Swipe Right: a Comparison of Accuracy of Plant Identification Apps for Toxic Plants.

INTRODUCTION: Plant identification applications for use on smartphones have been increasing in availability, accuracy, and utilization. We aimed to perform an introductory study to determine if a plant identification application (ID app) used on a smartphone could identify toxic plants, and to compare apps to determine which is most reliable. METHODS: We compared three popular iPhone plant ID apps, PictureThis (PT), PlantSnap (PS), and Pl@ntNet (PN), used to identify 17 commonly encountered toxic plants. Apps were used to photograph the entire plant, leaves, and flowers of ≥ 10 different plants for each species. Two toxicologists performed plant identification with confirmation of identification performed by a botanist, and inter-researcher agreement was confirmed. For each plant species, scores for accuracy of app identification of leaves, flowers, and whole plant were combined to create an overall composite score used to compare accuracy of each app (95% C.I.). RESULTS: PictureThis had the best performance with 10/17 (59% [36 to 78]) plant species identified 100% correctly, as opposed to 8/17 (47% [26 to 69]) for Pl@ntNet and 1/17 for PlantSnap (5.8% [1.1 to 27]). CONCLUSION: A plant identification app may be a useful tool to assist healthcare providers and the public in identifying toxic plants.

Prevalence of Acute Hypersensitivity Reactions in Pediatric Patients Receiving Crotalidae Polyvalent Immune Fab.

INTRODUCTION: Studies of acute hypersensitivity reactions in pediatric populations receiving Crotalidae Polyvalent Immune Fab (CPIF) are complicated by small size, wide age ranges, and diverse definitions of such reactions. METHODS: This is a retrospective chart review of patients aged 13 years or younger treated with CPIF for Crotalid envenomation from November 2006 to 2016. The primary outcome was the presence of an acute hypersensitivity reaction to CPIF and was defined as the development of any of the following symptoms within 3 hours of initiation of CPIF infusion: urticaria, wheezing or respiratory distress, angioedema, hypotension, nausea, and/or vomiting. Demographics, CPIF dose to control and total dose, bite location, level of care, and length of stay were also recorded. RESULTS: Thirty-four patients were ultimately treated with CPIF. Ages ranged from 10 months to 13 years. Twenty-one patients (60%) were male, 24 (70.6%) were admitted to the ICU, and the median length of stay was 2 days with a range of 1-11 days. Zero patients developed an acute hypersensitivity reaction to CPIF. CONCLUSION: Acute hypersensitivity reactions to CPIF did not occur in this cohort. Such reactions are rare with the use of CPIF in pediatric patients.

Death by Copper Ammonium Complex-Containing Fungicide.

ABSTRACT: There is a paucity of published reports of copper ammonium complex ingestion, as most published data describe overdoses of copper sulfate formulations. We report a case of suicide by ingestion of copper ammonium complex-containing fungicide with an elevated postmortem copper level. A 77-year-old woman was found dead at home by her relative after ingesting a fungicide containing 8% copper ammonium complex solution. Turquoise emesis was found at the scene, and on autopsy, turquoise material was found throughout the gastrointestinal tract. Postmortem central blood copper level was 500 µg/dL. Cause of death was determined to be acute copper toxicity.

A fluvoxamine-related fatality: Case report with postmortem concentrations.

Fluvoxamine is a selective serotonin reuptake inhibitor that has been considered relatively safe in overdose. At therapeutic and supratherapeutic concentrations, fluvoxamine affects cardiac conduction, prolongs QTc interval, causes hypotension, obtundation, and can increase propensity for seizures. A man in his 60s was found dead at his home with a postmortem fluvoxamine peripheral blood concentration of 4.9 mg/L, and a liver concentration of 440 mg/kg. His cause of death was determined to be acute fluvoxamine toxicity.

Association of Cardiovascular Comorbidities With Hearing Loss in the Older Old.

Importance: In the United States, the population of individuals older than 80 years is expected to double in the next 40 years. Cardiovascular comorbidities are prevalent in this older old population, and their relationship with hearing loss has not been well characterized. Objective: To investigate the association of cardiovascular disease (CVD)-related risk factors with auditory function among the older old (>80 years). Design, Setting, and Participants: Audiological data and medical records from 2001 through 2014 of 433 patients aged 80 to 106 years at an academic medical center were analyzed in 2017. Main Outcomes and Measures: The degree of low- and high-frequency hearing loss of participants with coronary artery disease, diabetes, hypertension, history of cerebrovascular accident, and smoking status was compared with that of disease-free individuals. Rate of hearing loss was also determined. Results: Among the 433 patients (67% female; mean [SD] age, 89 [5.8] years), the presence of at least 1 cardiovascular morbidity was associated with elevated mean (SD) low-frequency pure-tone average (LFPTA) of 42.4 (1.6) vs 36.9 (3.5) decibels hearing loss (dB HL), a difference of 5.47 (95% CI, 4.15-9.49) dB HL. Among the 96 patients with 2 audiograms performed at age 80 years or older from which the rate of hearing loss could be calculated, 32 patients had CVD or related risk factors and 64 were healthy controls. Those with at least 1 disease had accelerated hearing loss. Patients with cardiovascular morbidity experienced a faster mean (SD) decline in LFPTA of 1.90 (0.27) vs 1.18 (0.42) dB HL/y, a difference of 0.72 (95% CI, 0.08-1.36) dB HL/y. Of the conditions studied, coronary artery disease had the highest association with audiometric thresholds and was associated with hearing loss at all frequencies tested and with poor word recognition score. Hearing loss was more strongly associated with CVD risk factors in men than in women. Conclusions and Relevance: In this study of the older old, cardiovascular risk factors and disease were associated with worse hearing and a greater rate of hearing deterioration. Hearing loss in women was less associated with the presence of CVD, possibly owing to the cardioprotective effects of estrogen. The association of hearing with CVD severity and management remains to be determined.

Sulfur Mustard Exposure from Dredged Artillery Shell in a Commercial Clammer.

A 40-year-old commercial fisherman presented with a blistering second degree burn to the right arm after handling a dredged and undetonated World War I-era sulfur mustard artillery shell. He sustained isolated second degree cutaneous injury requiring wound care and skin grafting. Sulfur mustard, or dichlorethylsulphide, is a vesicant chemical warfare agent that causes significant cutaneous chemical burn and is managed with burn wound care. Long-term effects include cosmetic disfigurement and increased risk of developing cancer. Sulfur mustard exposure is a rare but devastating injury when discarded artillery shells are encountered in coastal waters.

Aortic Thrombus Causing a Hypertensive Emergency.

Thoracic aorta thrombi are a rare condition typically presenting as a source for distal embolization in elderly patients with atherosclerotic risk factors. However, young patients with a variety of presentations resulting from such thrombi have rarely been reported. We describe a case of a young patient with refractory hypertensive emergency caused by a large thoracic aorta thrombus. Investigation was guided by abnormal physical exam findings.

Increases in the Rate of Age-Related Hearing Loss in the Older Old.

Importance: There is a critical disparity in knowledge regarding the rate and nature of hearing loss in the older old (80 years and older). Objective: To determine if the rate of age-related hearing loss is constant in the older old. Design, Setting, and Participants: We performed a retrospective review that began on August 1, 2014, with audiometric evaluations at an academic medical center of 647 patients aged between 80 and 106 years, of whom 141 had multiple audiograms. Main Outcomes and Measures: From a population perspective, the degree of hearing loss was compared across the following age brackets: 80 to 84 years, 85 to 89 years, 90 to 94 years, and 95 years and older. From an individual perspective, the rate of hearing decrease between 2 audiograms was compared with age. Results: Changes in hearing among age brackets were higher during the 10th decade of life than the 9th decade at all frequencies (5.4-11.9 dB hearing level [dB HL]) for the 647 patients (mean [SD] age, 90 [5.5] years). Correspondingly, the annual rate of low-frequency hearing loss was faster during the 10th decade by the 3.8 dB HL per year at 0.25 kHz, 3.8 dB HL per year at 0.5 kHz, and 3.2 dB HL per year at 1 kHz. Despite the universal presence of hearing loss in our sample, 382 patients (59%) used hearing aids. Conclusions and Relevance: There is a significant increase in the rate of hearing loss in patients during the 10th decade of life compared with the 9th decade that represents a fundamental change in the mechanistic process of presbycusis. Despite the potential benefit of hearing aids, they remain underused in the older old. Use may be improved by changing the method of hearing rehabilitation counseling from a patient-initiated model to a chronic disease example.

Hearing Aid Use is Associated with Better Mini-Mental State Exam Performance.

OBJECTIVE: Hearing loss is associated with cognitive decline in the elderly. However, it is unknown if the use of hearing aids (HAs) is associated with enhanced cognitive function. METHODS: In a cross-sectional study at an academic medical center, participants underwent audiometric evaluation, the Mini-Mental State Exam (MMSE), and the Trail Making Test, Part B (TMT-B). The impact of use versus disuse of HAs was assessed. Performance on cognitive tests was then compared with unaided hearing levels. RESULTS: HA users performed better on the MMSE (1.9 points; rank-sum, p = 0.008) despite having worse hearing at both high frequencies (15.3-dB hearing level; t test, p < 0.001) and low frequencies (15.7-dB hearing level; t test p < 0.001). HA use had no effect TMT-B performance. Better performance on the MMSE was correlated with both low frequency (ρ = -0.28, p = 0.021) and high frequency (ρ = -0.21, p = 0.038) hearing level, but there was no correlation between performance on the TMT-B and hearing at any frequency. CONCLUSION: Despite having poorer hearing, HA users performed better on the MMSE. Better performance on cognitive tests with auditory stimuli (MMSE) but not visual stimuli (TMT-B) suggests that hearing loss is associated with sensory-specific cognitive decline rather than global cognitive impairment. Because hearing loss is nearly universal in those older than 80 years, HAs should be strongly recommended to minimize cognitive impairment in the elderly.