Inflammatory low back pain with radiculopathy revealing epidural disintegration of a bullet complicated by lead poisoning.

Inflammatory low back pain with radiculopathy is suggestive of cancer, infection or inflammatory diseases. We report a unique case of a 42-year-old patient with an acute inflammatory low back pain with bilateral radiculopathy associated with weight loss and abdominal pain, revealing the disintegration of a lead bullet along the epidural space and the S1 nerve root complicated by lead poisoning. Because of the high blood lead level of intoxication (>10 times over the usual lead levels) and the failure of repeated lead chelator cycles, a surgical treatment to remove bullet fragments was performed. It resulted in a significant decrease of pain and lead intoxication.

[Environmental and occupational risk factors for myelodysplastic syndrome]. / Facteurs de risques environnementaux et professionnels de syndrome myélodysplasique.

Chemotherapy and radiotherapy for a previous cancer can lead to subsequent myelodysplastic syndrome (MDS). However, these therapy-related cases are hypothesized to explain only 5 % of diagnosed MDS cases. Environmental or occupational exposure to chemicals or radiations has also been reported to be associated with higher risk of MDS. The present review analyses those studies evaluating the association of MDS with environmental or occupational risk factors. There is sufficient evidence that environmental or occupational exposure to ionizing radiation or benzene can cause MDS. Tobacco smoking is also a sufficiently documented riskfactor for MDS. A positive association has been reported between exposure to pesticides and MDS. However, there is only limited evidence that this association could be causal.

Human Biomonitoring Initiative (HBM4EU): Human Biomonitoring Guidance Values Derived for Dimethylformamide.

Within the European Joint Program on Human Biomonitoring HBM4EU, human biomonitoring guidance values (HBM-GVs) for the general population (HBM-GVGenPop) or for occupationally exposed adults (HBM-GVWorker) are derived for prioritized substances including dimethylformamide (DMF). The methodology to derive these values that was agreed upon within the HBM4EU project was applied. A large database on DMF exposure from studies conducted at workplaces provided dose-response relationships between biomarker concentrations and health effects. The hepatotoxicity of DMF has been identified as having the most sensitive effect, with increased liver enzyme concentrations serving as biomarkers of the effect. Out of the available biomarkers of DMF exposure studied in this paper, the following were selected to derive HBM-GVWorker: total N-methylformamide (tNMF) (sum of N-hydroxymethyl-N-methylformamide and NMF) and N-acetyl-S-(N-methylcarbamoyl)cysteine (AMCC) in urine. The proposed HBM-GVWorker is 10 mg·L-1 or 10 mg·g-1 creatinine for both biomarkers. Due to their different half-lives, tNMF (representative of the exposure of the day) and AMCC (representative of the preceding days' exposure) are complementary for the biological monitoring of workers exposed to DMF. The levels of confidence for these HBM-GVWorker are set to "high" for tNMF and "medium-low" for AMCC. Therefore, further investigations are required for the consolidation of the health-based HBM-GV for AMCC in urine.

The effect of non-point-of-care haemostasis management protocol implementation in cardiac surgery: A systematic review.

OBJECTIVES: This systematic review aims to outline the evidence on the implementation of a non-point-of-care (non-point-of-care [POC]) haemostasis management protocol compared to experience-based practice in adult cardiac surgery. BACKGROUND: Management of coagulopathy in cardiac surgery is complex and remains highly variable among centres and physicians. Although various guidelines recommend the implementation of a transfusion protocol, the literature on this topic has never been systematically reviewed. METHODS: PubMed, Embase, Cochrane Library, and Web of Science were searched from January 2000 till May 2020. RESULTS: A total of seven studies (one randomised controlled trial [RCT], one prospective cohort study, and five retrospective studies) met the inclusion criteria. Among the six non-randomised, controlled studies, the risk of bias was determined to be serious to critical, and the one RCT was determined to have a high risk of bias. Five studies showed a significant reduction in red blood cells, fresh frozen plasma, and/or platelet transfusion after the implementation of a structural non-POC algorithm, ranging from 2% to 28%, 2% to 19.5%, and 7% to17%, respectively. One study found that fewer patients required transfusion of any blood component in the protocol group. Another study had reported a significantly increased transfusion rate of platelet concentrate in the haemostasis algorithm group. CONCLUSION: Owing to the high heterogeneity and a substantial risk of bias of the included studies, no conclusion can be drawn on the additive value of the implementation of a cardiac-surgery-specific non-POC transfusion and haemostasis management algorithm compared to experience-based practice. To define the exact impact of a transfusion protocol on blood product transfusion, bleeding, and adverse events, well-designed prospective clinical trials are required.

Development of a Questionnaire for the Search for Occupational Causes in Patients with Non-Hodgkin Lymphoma: The RHELYPRO Study.

Non-Hodgkin lymphoma (NHL), multiple myeloma and chronic lymphocytic leukemia are possibly related to environmental and/or occupational exposure. The primary objective of this study was to develop a questionnaire for screening patients with these blood disorders who might benefit from a specialized consultation for possible recognition of the disease as an occupational disease. The study included 205 subjects (male gender, 67.3%; mean age, 60 years; NHL, 78.5%). The questionnaire performed very satisfactorily in identifying the exposures most frequently retained by experts for their potential involvement in the occurrence of NHL. Its sensitivity and specificity in relation to the final expertise were 96% and 96% for trichloroethylene, 85% and 82% for benzene, 78% and 87% for solvents other than trichloroethylene and dichloromethane, 87% and 95% for pesticides, respectively. Overall, 15% of the subjects were invited to ask National Social Insurance for compensation as occupational disease. These declarations concerned exposure to pesticides (64%), solvents (trichloroethylene: 29%; benzene: 18%; other than chlorinated solvents: 18%) and sometimes multiple exposures. In conclusion, this questionnaire appears as a useful tool to identify NHL patients for a specialized consultation, in order to ask for compensation for occupational disease.

Human biomonitoring initiative (HBM4EU): Human biomonitoring guidance values (HBM-GVs) derived for cadmium and its compounds.

AIMS: The methodology agreed within the framework of the HBM4EU project is used in this work to derive HBM-GVs for the general population (HBM-GVGenPop) and for workers (HBM-GVWorker) exposed to cadmium (Cd) and its compounds. METHODS: For Cd, a significant number of epidemiological studies with dose-response relationships are available, in particular for kidney effects. These effects are described in terms of a relation between urinary Cd (U-Cd) or blood Cd (B-Cd) levels and low molecular weight proteinuria (LMWP) markers like beta-2-microglobulin (ß2M) and retinol-binding protein (RBP). In order to derive HBM-GVs for the general population and workers, an assessment of data from evaluations conducted by national or international organisations was undertaken. In this work, it appeared relevant to select renal effects as the critical effect for the both groups, however, differences between general population (including sensitive people) and workers (considered as an homogenous population of adults who should not be exposed to Cd if they suffer from renal diseases) required the selection of different key studies (i.e. conducted in general population for HBM-GVGenPop and at workplace for HBM-GVWorker). RESULTS AND CONCLUSIONS: For U-Cd, a HBM-GVGenPop of 1 µg/g creatinine (creat) is recommended for adults older than 50 years, based on a robust meta-analysis performed by EFSA (EFSA, 2009a). To take into account the accumulation of Cd in the human body throughout life, threshold or 'alert' values according to age were estimated for U-Cd. At workplace, a HBM-GVWorker of 2 µg/g creat is derived from the study of Chaumont et al., (2011) for U-Cd, and in addition to this recommendation a HBM-GVworker for B-Cd of 5 µg/L is also proposed. The HBM-GVWorker for U-Cd is similar to the biological limit value (BLV) set by the new amendment of the European Carcinogens and Mutagens Directive in June 2019 (2 µg/g creat for U-Cd).

[Biomononitoring of environmental exposure to inorganic arsenic]. / Surveillance biologique de l'exposition environnementale à l'arsenic inorganique.

BACKGROUND AND OBJECTIVES: The French national authority for health (Haute autorité de santé: HAS) and the French clinical toxicology society (Société de toxicologie clinique: STC) received a formal request from the French ministry for heath to elaborate recommendations for the screening of environmental overexposure to inorganic arsenic (iAs), for the medical management of overexposed patients and for the medical surveillance of exposed population. To allow these recommendations, preliminary literature retrieval and analysis were performed for identifying validated indicators of both exposure and early effects of iAs and their levels in the general population living in France. METHODS: Evaluations of inorganic arsenic toxicity conducted by national or international health agencies during the last 3 decades were all examined and analyzed. These evaluations were completed by literature retrieval through Medline and Scopus from January 2016 to December 2019. RESULTS AND CONCLUSIONS: The best biomonitoring indicator for iAs exposure is the sum of urine iAs, monmomethylarsonic acid (MMA) and dimethylarsinic acid (DMA) concentrations (SAs). The upper limit of confidence interval of the 95th percentile of the distribution of this parameter in the general adult population living in France is 10 µg/g of creatinine, and is recommended as the limit value for the definition of overexposure. In less than 12 year-old children specific limit values are required, but not yet available. In their absence, SAs should exceed both 10 µg/g creatinine and 11 µg/L to be considered as indicating a probable overexposure to iAs. There are no useful biological indicators of iAs early effects. Non carcinogenic skin effects of inorganic arsenic (hyperpigmentation and keratosis) should be considered as the earliest deleterious effects of repeated environmental iAs exposure.

Increased severity associated with tallowamine in acute glyphosate poisoning.

Context: During the re-approval process of glyphosate in Europe, it was mentioned that glyphosate-based products (GBF) were more toxic than glyphosate alone. This phenomenon was attributed to the surfactants and among them, polyethoxylated tallowamine (POEA) has been suspected to significantly contribute to the toxicity of glyphosate products. In animal data acute oral toxicity of POEA has been suggested to be greater than glyphosate toxicity in animal studies. There are no data, however, comparing the clinical signs and severity of acute human poisoning with tallowamine-containing GBF (TA) and non-tallowamine-containing GBF (NTA). The aim of this study was to compare the severity of oral poisoning between TA and NTA cases, reported to the French Poison Control Centres (PCC) over 7 years.Methods: This is a retrospective study of cases of oral exposure to GBF reported to French PCCs between January 1st, 2008 and December 12th, 2014. The formulation of every GBF was reviewed using the PCC national database of products and compositions, to identify cases involving TA, NTA, or GBF with unknown co-formulants.Results: Between 2008 and 2014, 1362 cases of GBF ingestion were registered in the PCC national database of poisoning cases. Among them, 429 were symptomatic acute cases of ingestion of GBF. There were 235 exposures to TA, 105 to NTA, and 89 to unknown GBF. There were more severe cases in the TA group than in the NTA group (p = 0.037).Discussion: The present study shows that POEA rather than other co-formulants leads to more severe symptoms in those patients ingesting GBF. The acute toxicity of POEA might be explained by its irritating properties; in experimental studies, it caused skin irritation and severe eye and mucous membranes irritation.Conclusion: In this study, severe respiratory symptoms were also more frequently reported in the TA group. The surfactant properties of POEA are likely to cause aspiration pneumonitis which is a plausible explanation for the respiratory failure complicating severe GBF poisoning cases.

Severity of manchineel fruit (Hippomane mancinella) poisoning: A retrospective case series of 97 patients from French Poison Control Centers.

In this retrospective series of 97 cases of manchineel fruit ingestion reported to French Poison Control Centers between 2009 and 2017, we investigated cases of poisoning due to manchineel fruit (from the Hippomane mancinella tree). This fruit is known to be responsible for oropharyngeal and gastrointestinal tract lesions and possibly hypotension and bradycardia (previously attributed to the presence of physostigmine). The most commonly observed clinical signs were oropharyngeal pain, abdominal pain, diarrhea and oropharyngeal irritation. No major gastrointestinal tract lesions were observed in the five cases in which upper gastrointestinal (GI) endoscopy was performed. One case of laryngeal edema and one case of bradycardia were observed, but analysis of the harvested fruits did not confirm the presence of physostigmine. Ingestion of manchineel fruit can cause mild abdominal pain and digestive irritation, requiring medical attention. Rarely, when several fruits have been ingested, severe oropharyngeal injury or hemodynamic disorders may require otorhinolaryngological consultation or cardiac monitoring for several hours, respectively.

A comparative study of edetate calcium disodium and dimercaptosuccinic acid in the treatment of lead poisoning in adults.

BACKGROUND: We evaluated the efficacy of two antidotes, edetate calcium disodium (CaNa2EDTA) and dimercaptosuccinic acid (DMSA), for the treatment of lead poisoning in adults. METHODS: Thirty-seven patients with blood lead concentrations >40 µg/dL and positive CaNa2EDTA lead mobilization were randomized to receive 1050 mg/m2/day of oral DMSA (n = 21) or 500 mg/m2/day of intravenous CaNa2EDTA (n = 16) over two five-day courses separated by a 10-day rest period. Efficacy of treatment was evaluated by blood lead assays on the first day of the two courses and 14 days after the end of treatment and baseline CaNa2EDTA lead mobilization test and 14 days after the end of treatment. RESULTS AND CONCLUSION: Both treatments significantly reduced the prevalence of clinical symptoms, blood lead levels and CaNa2EDTA lead mobilization and were well tolerated. DMSA had a greater impact on reducing blood lead concentrations (p = .005) and CaNa2EDTA on lead mobilization (p = .04). Comparison of equimolar doses showed that CaNa2EDTA was more effective than DMSA (p < .001).

Incidence and clinical characteristics of ciguatera fish poisoning in Guadeloupe (French West Indies) between 2013 and 2016: a retrospective cases-series.

This retrospective case study analysed the incidence and symptoms of ciguatera fish poisoning (ciguatera) in Guadeloupe (French West Indies) between 2013 and 2016. Cases attending the emergency departments of the two public hospitals and the reports received by the regional health authority in charge of monitoring (ARS) were compiled. Two hundred and thirty-four cases of poisoning were observed, with a mean annual incidence of 1.47/10,000 (95% CI): 1.29-1.66), i.e 5 times higher than the previously reported incidence (1996-2006). The main species described as being responsible for poisoning were fish from the Carangidae family (n = 47) (jack), followed by fish from the Lutjanidae family (n = 27) (snapper), Serranidae family (n = 15) (grouper), Sphyraenidae family (n = 12) (barracuda), and Mullidae family (n = 12) (goatfish). One case of lionfish ciguatera was observed. 93.9% of patients experienced gastrointestinal symptoms, 76.0% presented neurological signs (mainly paresthesia, dysesthesia and pruritus) and 40.3% presented cardiovascular symptoms (bradycardia and/or hypotension). A high frequency (61.4%) of hypothermia (body temperature <36.5 °C) was observed. This study reports for the first time the relatively high frequency of cardiac symptoms and low body temperature. The monitoring of ciguatera poisoning throughout the Caribbean region must be improved, notably after reef disturbance due to Irma and Maria major cyclones.

Hair concentration of trace elements and growth in homeless children aged <6years: Results from the ENFAMS study.

BACKGROUND: Growth is an important indicator of health in early childhood. This is a critical developmental period, during which a number of factors, including exposure to metals, might play a role in later physical and metabolic functions. OBJECTIVE: To study the association between exposure to arsenic (As), cadmium (Cd), mercury (Hg), lead (Pb) and selenium (Se), and physical growth of children from homeless families aged <6years. METHODS: This study was based on data of the cross-sectional survey (ENFAMS), which was conducted by the Observatoire du Samu Social on a random sample of homeless sheltered families in the Paris region during winter 2013. Families with children under 6years (N=324) were interviewed in 17 languages using face-to-face questionnaires. A nurse took anthropometric measures and collected hair samples where As, Cd, Hg, Pb and Se levels were measured. We calculated weight-for-age Z-score (WAZ), height-for-age Z-score (HAZ) and BMI-for-age Z-score (BMIZ) of children, using the 2006 WHO Child Growth Standards as a reference. Associations between ln-transformed metal exposures and growth outcomes were tested by multivariable linear regression models with adjustment for potential confounders (including maternal anthropometrical and socio-demographical characteristics, gestational age, child birthweight, breastfeeding, food insecurity of the child). Due to missing data (1.6% to 14.2% depending on the variables), we used multiple imputation by chained equations. RESULTS: A strong positive correlation was found between Pb and Cd levels (r=0.65; p<0.001). Positive associations between Se level and HAZ (ß=0.61; p=0.05) and between Cd and BMIZ (ß=0.21; p=0.03) and negative associations between As and HAZ (ß=-0.18; p=0.05) were no more significant after multiple imputation. A weak negative trend was observed between Cd and HAZ (ß=-0.14; p=0.14), while positive trends were found between Se and both WAZ (ß=0.55; p=0.10) and HAZ (ß=0.51; p=0.06) after multiple imputation. CONCLUSION: Overall, our results found no strong association between exposure to metals and physical growth of homeless children but we observed some trends that were consistent with previous studies. More research is required studying these associations longitudinally, along with higher sample sizes, for better understanding the sources of exposure in homeless population and the potential effects on growth.

Surveillance and Analysis of Occupational Carbon Monoxide Poisoning in the Paris Region.

OBJECTIVES: Acute carbon monoxide poisoning is common and often severe. Domestic causes have been extensively documented, while occupational exposures have been reported less frequently. We analyse occupational carbon monoxide poisonings from the available data of the carbon monoxide poisoning surveillance network for Paris and its region, and identify predictive factors of severity for occupational poisoning in order to identify priority prevention actions. METHODS: We retrospectively reviewed all events of acute accidental carbon monoxide exposures which occurred in the Paris region, at the work place, and notified to the surveillance network from 1 January 2005 to 31 December 2011. RESULTS: Over the 7-year study period, 362 exposed workers were identified, representing 8.15% of all cases of carbon monoxide exposures. The largest number of events occurred in the building sector and most commonly affected occupations were craft and related trades workers. The most common sources of exposure were internal combustion engine equipment that was involved in almost half of cases. Minor severity was observed in 86% of cases, and 13% were moderate or more. We identify that the use of internal combustion engine equipment was significantly associated with increased severity. CONCLUSIONS: Occupational carbon monoxide poisoning is reported less frequently than domestic poisoning and has different and more numerous causes. It can be potentially severe, especially when it is caused by internal combustion engine equipment. Information about risks, compliance with instructions and cleaning rules, and establishment of collective and individual protective equipment would significantly reduce the frequency and severity of carbon monoxide poisoning.

[Outbreak of carbon monoxide poisoning in the Ile-de-France region during the 2016 Seine flooding]. / Épidémie d'intoxications oxycarbonées lors de la crue de la Seine au printemps 2016.

INTRODUCTION: Heavy rainfall in May 2016 caused large-scale flooding of the Seine and its tributaries. Analysis of this unusual event showed that it could recur on an even larger scale. The sanitary consequences were less frequently assessed in this analysis, particularly the risk of accidental collective carbon monoxide (CO) poisoning caused by the use of combustion engine drainage pumps. METHODS: We retrospectively reviewed all cases of acute accidental carbon monoxide exposure observed in the Ile-de-France region, related to the use of drainage pumps in spring and summer 2016 and notified to the Ile-de-France CO poisoning surveillance network. RESULTS: Five events were identified, including 45 people exposed to carbon monoxide. Thirty-four of these people were poisoned, 5 were not poisoned and insufficient data were available for 6 people. Three people showed signs of severity and 2 were treated by hyperbaric oxygen therapy. The other poisoned individuals were managed in hospital and treated by oxygen therapy. All were cured. DISCUSSION: Collective CO poisonings are common sanitary events during flooding and can be potentially severe. They can occur during the event or over the following days. Preventive measures may help to reduce the risk of CO poisoning, such as increased awareness among professionals, better information of individuals who rent these types of devices or even the use of CO detectors during their use.

Evaluation of oxaliplatin exposure of healthcare workers during heated intraperitoneal perioperative chemotherapy (HIPEC).

The aim of this study was to evaluate air and surface contaminations, and internal contamination of healthcare workers during open-abdomen HIPEC using oxaliplatin. Platinum (Pt) was measured in urine of exposed workers and in multiple air and surface samples. Three successive HIPEC procedures were investigated in each of the two hospitals participating in the study. Analysis of air samples did not detect any oxaliplatin contamination. Heavy contamination of the operating table, the floor at the surgeon's feet, and the surgeon's overshoes were observed. Hand contamination was observed in surgeons using double gloves for intra-abdominal chemotherapy administration, but not in those using three sets of gloves. Pt was not detected in urine samples obtained after HIPEC (<5 ng/L). The main risk of HIPEC is related to direct or indirect skin exposure and can be prevented by correct use of adapted protective equipment.