Low-velocity, civilian firearm extremity injuries-review and update for radiologists.

Firearm injuries are a preventable epidemic in the USA. Extremities are commonly affected in gunshot injuries. Such injuries may be complex with concomitant osseous, soft tissue, and neurovascular components. The maximum wounding potential of a projectile is determined by its kinetic energy and the proportion of the kinetic energy that is transmitted to the target. Accurate assessment of ballistic injuries is dependent on utilizing the principles of wound ballistics, accurate bullet count, and ballistic trajectory analysis. The goals of this article are to review wound ballistics and the imaging evaluation of extremity civilian firearm injuries in the adult population, with emphasis on ballistic trajectory analysis, specific ballistic fracture patterns, and diffuse, secondary soft tissue ballistic injuries.

Environmental assessment of pediatric Lead exposure in Tehran; a prospective cross-sectional study.

BACKGROUND: Ingestion and inhalation are common routes of exposure for lead in humans. Developing countries still have unacceptably high rates of lead toxicity, especially in children. Studies on probable risk factors of lead poisoning in Iranian children are insufficient. In this study, we aimed to evaluate possible environmental factors in children with high blood lead concentrations living in Tehran and neighboring cities. METHODS: In a prospective cross-sectional study between March 2018 and March 2019 we followed all children referred from two pediatric gastrointestinal clinics with blood lead level (BLL) > 5 µg/dL in metropolitan Tehran to investigate possible environmental risk factors in their home. Household specimens including scratched wall paint, house floor dust, windowsill dust, tap water, and consumed spice were evaluated using atomic absorption method to detect lead concentrations. Epidemiological and environmental data collected through in-depth interviews with parents/guardians. Industrial areas were defined based on municipality maps on industrial places. RESULTS: Thirty of 56 parents/guardians with BLL > 5 µg/dL agreed to be followed through environmental investigation. The only categorical statistically significant risk factor was a history of lead poisoning in the family and living in an industrial zone. There was a positive correlation between BLL and interior windowsills dust lead level, r = 0.46, p = 0.01. Scratched paint lead level and BLL showed a significant positive correlation, r = 0.50, p = 0.005. House floor dust lead level (median = 77.4, p < 0.001) and interior windowsill dust lead level (median = 291, p = 0.011) were both significantly higher than the environmental protection agency (EPA) standards of 40 µg/ft2, 250 µg/ft2. Interior windowsill dust lead concentrations were significantly higher in industrial areas (p = 0.026). CONCLUSION: Children's playing environment should be cleaned more often to reduce dust. Moreover, specific rules may need to be implemented for paint lead concentrations and air pollution, especially in industrial areas.

Lead exposure in common shelduck (Tadorna tadorna): Tracking the success of the Pb shot ban for hunting in Spanish wetlands.

Levels of lead (Pb) were analyzed in tissues of 25 Common shelduck (Tadorna tadorna) from La Albufera Natural Park (NP) in Valencia (Eastern Spain), which were found dead due to a botulism outbreak. The objective was to assess Pb exposure in waterfowl, fourteen years after the implementation of the Real Decreto 581/2001, which banned the use of Pb ammunition for hunting activities in internationally relevant wetlands. For this purpose, this study measured the actual ingestion of lead pellets in Common shelduck from La Albufera de Valencia and provide data on Pb residue concentrations in different tissues of this species breeding in this NP. The Pb distribution pattern in tissues was bone > kidney > liver > brain > muscle, with Pb concentrations of 778.96 ±â€¯998.64, 122.40 ±â€¯89.18, 92.08 ±â€¯57.65, 18.90 ±â€¯16.30 and 15.13 ±â€¯11.85 ng/g (wet weight), respectively. This work presents, as far as we are aware, the first published data on Pb concentrations in Common shelduck. The Pb levels detected were lower than those reported in other studies on Anatid species from Spanish wetlands, which may be explained by this ban. Moreover, lead concentrations found were below those levels for which any observable effect has been described for acute or chronic lead exposure.

Lead concentrations in the blood and eggs of backyard laying hens.

AIMS: To investigate the prevalence of lead exposure in hens and eggs from backyard poultry in a sample of Auckland households, the relationship between concentrations of lead in the blood of the hens and in the shells and yolks of eggs from the same household, and to examine associations with measures of hen health, environment and husbandry factors. METHODS: Thirty households participated in the study from August to November 2016, each providing one adult hen for sampling, an egg from the household if available, and completing a questionnaire on hen husbandry. Concentrations of lead in blood were determined using a portable lead analyser. Eggs were analysed for concentrations of lead in the yolk and shell using inductively coupled plasma mass spectrometry after biological digestion with a mixture of nitric and hydrochloric acid. RESULTS: Twenty three of 30 hens (77%) showed evidence of lead exposure, with median concentrations of lead in blood of 0.77 (min <0.16, max 8.02) µmol/L. All eggs showed evidence of lead exposure, with concentrations of lead in the yolk ranging from 0.003-1.07 mg/kg, and concentrations of lead in the eggshell ranging from <0.1-0.82 mg/kg. A positive correlation existed between concentrations of lead in the blood of a hen and concentrations of lead in egg yolk from the same hen (R2=0.97), and both the yolk (R2=0.58) and shell (R2=0.30) of an egg from her flock. No association was found between concentrations of lead in blood and hen health indices measured in this study. Concentrations of lead in blood were higher in hens from properties with homes built before 1941 than between 1941-1960 (p=0.03), and in hens from properties with weatherboard homes than brick homes (p=0.049). CONCLUSIONS AND CLINICAL RELEVANCE: There was a high prevalence of lead exposure in this sample of Auckland backyard chickens, with the majority of hens being sub-clinically affected. Associations were found between concentrations of lead in the blood of the hens, and properties with homes built before 1941 and clad in weatherboard. Concentrations of lead in over half the egg yolks sampled were at levels sufficient to warrant human health concern. The assessment of concentrations of lead in backyard poultry and eggs intended for human consumption is recommended to protect human and bird health.

An Update on Childhood Lead Poisoning.

Childhood lead poisoning is a multi-faceted, complex condition, which affects not only the child's health and well-being, but also the family's housing security, economic status, job security, and stress level. This review updates the emergency department clinician on the management of childhood lead poisoning. Infants and children are at higher risk than adults for lead exposure due to their smaller size and proportionately larger dose of ingested toxins, their proximity to ground dirt and indoor dust, their energy and curiosity, their oral exploratory and pica behaviors, their proportionately larger daily water and milk intake, and dietary preferences that differ markedly from those of adults. Pediatric health care providers working in the emergency department can provide medical management, as well as preventive counseling and guidance, to parents of children presenting with evidence of acute or chronic lead poisoning.

Retained Lumbar Bullet: A Case Report of Chronic Lead Toxicity and Review of the Literature.

BACKGROUND: Lead toxicity from retained bullet fragments is difficult to both predict and diagnose, but important to treat early, given the potential severity of disease. Blood lead levels > 25 µg/dL and 40 µg/dL are considered toxic in children and adults, respectively. Symptoms may range from nonspecific constitutional symptoms to seizures and coma. Chelation is the mainstay therapy for lead poisoning and levels to treat depend on patient age, blood lead levels, and the presence of symptoms. CASE  REPORT: We present the case of a woman with symptoms of severe lead toxicity from 20-year-old retained bullet fragments. She had been seen by multiple providers for evaluation of each symptom, but a unifying diagnosis had not been found. After identifying this complication, she was treated appropriately and more serious complications were prevented. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of lead toxicity in patients with a seemingly unrelated constellation of symptoms and a history of a previous gunshot wound with retained bullet or bullet fragments.

Choroidal Vasculopathy and Retinal Detachment in a Bald Eagle ( Haliaeetus leucocephalus ) With Lead Toxicosis.

A subadult male bald eagle ( Haliaeetus leucocephalus ) was presented for severe depression and weakness. Physical examination findings included depressed mentation, dehydration, sternal recumbency, poor body condition, and bilateral, whole-head, horizontal nystagmus. A heavy-metal panel was performed, and blood lead levels were 6.1 ppm. Treatment for lead poisoning was initiated, including subcutaneous fluids and parenteral calcium-disodium ethylenediaminetetraacetic acid, ceftiofur, and meloxicam. Ophthalmic examination findings included absent menace response, absent dazzle reflex, slow and incomplete direct pupillary light reflex, mild anterior uveitis, incipient cataracts, multifocal retinal tears, and retinal separation in both eyes. Because of poor prognosis for vision and release to the wild, the eagle was euthanatized. No lesions were observed on gross postmortem examination. Histologically, extensive myocardial necrosis and multisystemic arteriolar vasculopathy were identified. The eyes were examined after tissue processing, and the vasculopathy extended into the choriocapillaris and was associated with a secondary, bilateral, exudative, retinal detachment. This is the first report in avian species characterizing the histopathologic ocular lesions of lead poisoning.

CHRONICALLY EMBEDDED LEAD PROJECTILES IN WILDLIFE: A CASE SERIES INVESTIGATING THE POTENTIAL FOR LEAD TOXICOSIS.

Research has demonstrated that intramuscularly embedded lead in humans and rats may cause direct plumbism, albeit rarely, and has identified risk factors to this end. To the authors' knowledge, this has not been investigated in wildlife, despite a high incidence of embedded lead in these animals secondary to cynegetic activities. Fourteen wildlife cases submitted to the National Fish and Wildlife Forensics Laboratory for cause-of-death determination had chronically embedded lead projectiles that were unrelated to the cause of death. Tissue lead levels were measured in all cases and revealed clinically significant hepatic lead levels in two cases. The results corroborate comparative literature and suggest that embedded lead fragments carry a low risk for direct plumbism, even in the face of risk factors such as fractures, inflammation, and projectile fragmentation. Wildlife morbidity and mortality from embedded lead is more commonly realized secondary to incidental ingestion and ballistic trauma rather than by direct toxicity.

Radiological changes in lead poisoning.

INTRODUCTION: Lead poisoning in childhood remains an important public health concern. We highlight the radiological findings in a patient with a high blood lead concentration. CASE SUMMARY: A 7-year-old girl presented to hospital with abdominal pain, nausea, and asthenia. Laboratory tests showed severe hypochromic microcytic anemia, punctate basophilic stippling of erythrocytes, and a blood lead concentration of 880 µg/L (4.3 µmol/L). IMAGES: Radiographs of the femur, tibia, and fibula demonstrated dense metaphyseal bands ("lead lines"). On cranial computed tomography, we observed multiple speck-like and curvilinear hyperdensities involving subcortical regions, putamen, and left cerebellar hemisphere. CONCLUSION: In patients with lead poisoning, imaging of the brain and bones may show characteristic features. These imaging findings may point to the diagnosis of lead toxicity when these radiographic findings are discovered during the evaluation of vague complaints such as abdominal pain or mental status changes or when a blood lead concentration is not readily available.

Take the lead.

A 23-year-old previously healthy woman presented with headache, generalized seizures, ataxia, encephalopathy, abdominal pain, nausea, and vomiting culminating in a 40-pound weight loss. A contrasted magnetic resonance imaging scan of the brain showed T2/FLAIR hyperintensities in the sulci of the occipital and parietal lobes, a punctate focus of restricted diffusion along the inferior aspect of the left caudate head and an empty sella. A lumbar puncture showed an opening pressure of 55 cm H2O, and kidney, ureter, and bladder X ray showed a radiopaque particle in the colon. Serum lead level was 85 mcg/dL (<3.5). Blood smear showed foreign bodies identified as lead particles in the blood with basophilic stippling of RBCs. She was treated with chelation therapy and bowel irrigation and eventually recovered. Further investigation indicated that she was being slowly poisoned by her husband, a chiropractor who had access to lead.

Understanding Ballistic Injuries.

Understanding the pathophysiology of a disease allows physicians to make a diagnosis, alter its natural course, and develop and implement appropriate preventative and management strategies. With ballistic injuries, an understanding of how the mechanism of injury translates to the injuries observed makes it possible to make sense of what can, at times be a complex imaging appearance and mitigate against the long-term complications of gunshot wounds. In this article, the authors describe the different types of ballistic projectiles, their mechanism of injury as well as the injury patterns they cause. In addition, both lead arthropathy and MR imaging safety in patients with retained ballistic debris are discussed.

Lead toxicity due to retained intracranial bullet fragments: illustrative case.

BACKGROUND: Lead toxicity (plumbism) secondary to retained lead bullet fragments is a rare complication in patients with gunshot wounds. To the authors' knowledge, there has been no definitive case reported of lead toxicity due to retained intracranial bullet fragments. OBSERVATIONS: The authors reported the case of a 23-year-old man who presented after being found down. Computed tomography scanning of the head revealed bullet fragments within the calvaria adjacent to the left transverse sinus. During follow-up, he developed symptoms of plumbism with paresthesias in his bilateral hands and thighs, abdominal cramping, labile mood, and intermittent psychosis. Plumbism was confirmed with sequentially elevated blood lead levels (BLLs). The patient opted for surgical removal of the bullet fragments, which led to reduction in BLLs and resolution of his symptoms. LESSONS: Although rare, lead toxicity from retained intracranial bullet fragments should be considered in patients who have suffered a gunshot wound to the head and have symptoms of lead toxicity with elevated BLLs. For safe and accessible intracranial bullet fragments in patients with plumbism, surgical intervention may be indicated.

Public health implications of lead poisoning in backyard chickens and cattle: four cases.

Lead intoxication in livestock has historically been associated with cattle turned out to pasture and accidental ingestion of lead from drinking crankcase oil, licking grease from machinery, chewing on plumbing or batteries, or drinking water contaminated from leaching materials. Even with the decrease in manufactured items produced with lead, contaminants persist in the landscape and may enter the food supply through animal products. Changing patterns of open range herds moving to new pasture and the increased popularity of urban/suburban backyard chickens or other livestock necessitates public awareness about the clinical signs of lead intoxication, the potential for subclinical animals, public health concerns, particularly for exposure in children, and testing options available. Cases of lead intoxication in livestock demand a thorough case work-up to identify all sources of lead, address subclinical cases, evaluate risk to consumers, and make management suggestions for future prevention. We discuss four recent cases of confirmed lead poisoning in backyard chickens and open range cattle and assess the public health implications therein. Taken as a whole and considering the potential of the remaining herd or flock to be affected without necessarily showing signs, public health officials and veterinarians should be prepared to advise clients on case work-up and management and prevention considerations. Backyard chickens and cattle may not present for suspected lead poisoning as in several of the cases discussed herein yet may still contain concerning tissue or blood levels. The authors believe increased surveillance through heavy metal screens is crucial to adequately protect public health.

Successful treatment of a delayed presentation of a gunshot injury to the femoral neck in an elderly man: a case report.

Gunshot wounds involving major joints can be lethal as a result of the disruption to major neurovascular tracts. We report on a high-energy ballistic injury resulting in a comminuted femoral neck fracture in an elderly patient with a surgical delay exceeding 20 h. The patient underwent bipolar hemiarthroplasty and led a functional, satisfactory life after surgery. Lead intoxication was also identified, and the blood lead concentration was almost two times the positive diagnostic value (25 µg/dL). The rebound in lead concentration suggested delayed lead toxicity. The patient did not have symptoms of plumbism at the last follow-up 4 years after the injury.

Chumbo e anemia / Lead and anemia

O plumbismo é um problema de saúde pública, afetando o desenvolvimento das crianças. O sistema hematológico é um alvo importante da toxicidade do chumbo, comprometendo a síntese do heme e consequentemente causando anemia. Os efeitos sobre o ácido δ-amino levulínico de hidratase (ALAD)são mais marcantes provocando o acúmulo de ácido δ-amino levulínico (ALA) e o aumento do ácido gama aminobutírico (GABA) no sistema nervoso central. A intoxicação do chumbo afeta também a síntese das cadeias globulínicas α e β, o que contribui para o desenvolvimento da anemia. A anemia não é uma manifestação precoce do plumbismo, sendo evidente quando os níveis de chumbo estão elevados por períodos prolongados. A anemia geralmente é anemia hipocrômica normocítica, embora microcitose seja comumente observada, com presença de pontilhado basófilo nos eritrócitos. Recentemente, foi observada maior susceptibilidade ao plumbismo em crianças com deficiência de ferro, sendo sugerido que o ferro é capaz de competir com o chumbo inibindo sua ligação com a proteína transportadora DMT1 (Divalent Metal Transporter1). Na coexistência de deficiência de ferro e intoxicação por chumbo, a anemia é mais severa, com acentuado grau de microcitose e hipocromia, sendo recomendado suplementação de ferro para crianças com risco de intoxicação por chumbo.

The plumbism is a public health problem, affecting the development the children. The hematologic system is a target important from lead poisoning, engaging the heme synthesis causing anemia. The effects above the δ-aminolevulinate acid dehidrathase (ALAD) are very marking causing the accumulationof δ-aminolevulinic acid (ALA) and the increase of γ-acid aminobutyric (GABA) in the nervous system central. The exacerbate lead toxicity demonstrated affect also the synthesis the globulins chains α and β, the one to contributory about to the development from anemia. The anemia isn’t a manifestation precocious of the plumbism, being clear when the levels of lead elevated for prolonged periods. The anemia generally is hypochromic normocytic, the microcytosis may be commonly observed, with presence of basophilic stippling in the erythocytes. Recently, was observed greater susceptibility the plumbism in the children with iron deficiency, being suggested by what the iron is capable of competed with the lead, inhibiting the binding with the transport protein DMT1 (Divalent Metal Transporter 1). In the co-existence of iron deficiency and lead poisoning, the anemia is very severe, with accented degree of microcytosis and hypochromia, being recommended iron supplementation to children with risk of lead poisoning.

Plumbemia em trabalhadores da indústria de reciclagem de baterias automotivas da Grande Porto Alegre, RS / Blood lead levels in the battery recycling industry of the metropolitan region of Porto Alegre, RS

A reciclagem de baterias pode contaminar o ar, o solo e a água, não só no lugar de processamento, mas também nas regiões circunvizinhas, sendo que os resíduos permanecem no local mesmo após o término da atividade. No presente artigo descrevemos os resultados da avaliação da plumbemia em 53 operários que trabalhavam com reciclagem de baterias automotivas e em 53 indivíduos sem história de exposição. Os dados obtidos foram comparados e discutidos em relação às normas do Ministério do Trabalho (MT) e da Occupational Safety and Health Administration (OSHA). A plumbemia no sangue do grupo controle foi de 2,44±1,15 µg/dl e, no grupo exposto, de 59,43±28,34 µg/dl, sendo que 79,2 por cento dos indivíduos mostraram níveis acima do valor de referência (até 40 µg/dl). Estudos recentes recomendam estratégias para prevenir a intoxicação com chumbo: identificação, eliminação ou controle da fonte, monitoração da exposição e respectivos danos e um programa de recompra de baterias usadas das por parte da indústria de origem.

Battery recycling may contaminate soil, air and water not only at the processing site but also in the neighboring areas, inasmuch as the residues remain at the site even after the end of the activity. In the present article, we describe the results of plumbism evaluation in 53 individuals that work with car battery recycling and 53 individuals without history of lead exposure. The obtained data were compared and discussed according to the regulations of Brazilian Ministry of Labor and OSHA (Occupational Safety and Health Administration). Blood lead levels in the control group were 2.44 ± 1.15 µg/dl and 59.43 ± 28.34 µg/dl in the exposed group. 79.2 percent of the individuals presented levels above the reference value (40 µg/dl). Recent studies recommend strategies to prevent lead intoxication: source identification, control or elimination, monitoring of environmental exposure and hazards and a buy-back program of used batteries by the industry of origin.