Correction: Neonatal blood lead concentration predicts medium term lead-related outcomes in children ≤5 years old with congenital lead poisoning: A retrospective cohort study in Northern Nigeria.

[This corrects the article DOI: 10.1371/journal.pgph.0001644.].

Neonatal blood lead concentration predicts medium term lead-related outcomes in children ≤5 years old with congenital lead poisoning: A retrospective cohort study in Northern Nigeria.

Mother-to-child-transmission of lead via the placenta is known to result in congenital lead toxicity. Between 2010 and 2021, Médecins Sans Frontières and other stakeholders responded to a severe lead poisoning outbreak related to artisanal gold mining in Northern Nigeria. Extensive environmental remediation occurred following outbreak identification; source control efforts are ongoing within the community. We aimed to describe the prevalence of congenital lead poisoning in this cohort and analyse the association between neonatal blood lead concentration (BLC) and medium-term lead-related outcomes during the study period. Children enrolled in the lead poisoning programme between July 2010 and 25 January 2018 who had a screening BLC at ≤4 weeks of age were included. For time-to-event analysis, medium-term outcomes were classified as lead-related (death from lead encephalopathy, and/or met chelation threshold) and non-lead-related (non-lead-related death, on programme no chelation, exit from programme without chelation). Cox regression analysis and ROC analysis were performed. 1468 children were included. All-cause mortality 2.3%; geometric mean neonatal BLC 13.7 µg/dL; 'lead-related death or treatment' 19.3%. For every doubling in neonatal BLC, there was an almost 8-fold increase in adjusted hazard ratio (HR) for the composite lead-related outcome (p<0.001). A neonatal BLC ≥ 15.0 µg/dL had 95% sensitivity for identifying children who went on to have the composite outcome (with specificity 67%; positive likelihood ratio 2.86). Congenital lead poisoning predicts ongoing exposure in this population, even after environmental remediation. This suggests a complex, early, multidisciplinary approach to source control and exposure management is required when elevated neonatal BLC is observed in lead poisoning clusters in low-and-middle-income contexts.

Declining blood lead levels among small-scale miners participating in a safer mining pilot programme in Nigeria.

OBJECTIVES: Our objective was to monitor blood lead levels (BLLs) of miners and ore processors participating in a pilot programme to reduce lead poisoning and take-home exposures from artisanal small-scale gold mining. A medical surveillance programme was established to assess exposures as new methods aimed at reducing lead exposures from ore were introduced in a community in Nigeria where children experienced substantial lead-related morbidity and mortality. METHODS: Extensive outreach and education were offered to miners, and investments were made to adopt wet methods to reduce exposures during mining and processing. We conducted medical surveillance, including a physical exam and repeated blood lead testing, for 61 miners selected from among several hundred who participated in the safer mining pilot programme and consented to testing. Venous blood lead concentrations were analysed using the LeadCare II device at approximately 3-month intervals over a period of 19 months. RESULTS: Overall geometric mean (GM) BLLs decreased by 32% from 31.6 to 21.5 µg/dL during the 19-month project. Women had a somewhat lower reduction in GM BLLs (23%) compared with men (36%). There was a statistically significant reduction in log BLLs from baseline to the final test taken by each participant (p<0.001). CONCLUSIONS: The observed reductions in GM BLLs during the pilot intervention among this representative group of miners and ore processors demonstrated the effectiveness of the safer mining programme in this community. Such measures are feasible, cost-effective and can greatly improve health outcomes in mining communities.

Analytical confirmation of synthetic cannabinoids in a cohort of 179 presentations with acute recreational drug toxicity to an Emergency Department in London, UK in the first half of 2015.

CONTEXT: Synthetic cannabinoid receptor agonists are the largest group of new psychoactive substances reported in the last decade; in this study we investigated how commonly these drugs are found in patients presenting to the Emergency Department with acute recreational drug toxicity. METHODS: We conducted an observational cohort study enrolling consecutive adult patients presenting to an Emergency Department (ED) in London (UK) January-July 2015 (6 months) with acute recreational drug toxicity. Residual serum obtained from a serum sample taken as part of routine clinical care was analyzed using high-resolution accurate mass-spectrometry with liquid-chromatography (HRAM-LCMSMS). Minimum clinical data were obtained from ED medical records. RESULTS: 18 (10%) of the 179 patient samples were positive for synthetic cannabinoid receptor agonists. The most common was 5F AKB-48 (13 samples, concentration 50-7600 pg/ml), followed by 5F PB-22 (7, 30-400 pg/mL), MDMB-CHMICA (7, 80-8000 pg/mL), AB-CHMINACA (3, 50-1800 pg/mL), Cumyl 5F-PINACA (1, 800 pg/mL) and BB-22 (1, 60 pg/mL). Only 9/18 (50%) in whom synthetic cannabinoid receptor agonists were detected self-reported synthetic cannabinoid receptor agonist use. The most common clinical features were seizures and agitation, both recorded in four (22%) individuals. Fourteen patients (78%) were discharged from the ED, one of the four admitted to hospital was admitted to critical care. CONCLUSIONS: Synthetic cannabinoid receptor agonists were found in 10% of this cohort with acute recreational drug toxicity but self-reported in only half of these. This suggests that presentations to the ED with acute synthetic cannabinoid receptor agonist toxicity may be more common than reported.

Prevalence of Use of Electronic Nicotine Delivery Systems (ENDS) to Vape Recreational Drugs by Club Patrons in South London.

INTRODUCTION: Electronic nicotine delivery systems (ENDS, often called e-cigarettes) are nicotine delivery devices that heat nicotine into vapour that is inhaled, a process called 'vaping'. Use eclipsed nicotine-replacement therapy (NRT) in 2014 but ENDS role in smoking cessation remains controversial. Safety has not been proven and there have been reports to US poison centres regarding potential ENDS-related nicotine toxicity. A further concern is use of ENDS to vape recreational drugs, but there is limited data to substantiate this. The aim of this study was to report on ENDS use to vape recreational drugs in patrons of a South London nightclub where high prevalence of recreational drug use has previously been shown. METHODS: A convenience sample of 101 participants was surveyed in March 2015 as part of a larger survey on drug use. Individuals were asked if they used ENDS to vape nicotine and/or other substances (and if so which substances). RESULTS: Ninety (89.1 %) of respondents were male with median age of 28 years (IQR 23-34). Eighty (79.2 %) currently smoked cigarettes; 20 (19.8 %) currently used ENDS for nicotine. Six (5.9 %) reported using ENDS to take other substances: 2 for 'liquid cannabis' and 4 did not elaborate on the substance(s) used. Of these 6, 3 were using ENDS to vape nicotine and 3 had never used them for nicotine. CONCLUSION: 5.9 % of individuals in this sample reported using ENDS to vape substances other than nicotine. Further work is required in larger populations to determine how common this is, evaluate which agents are being vaped and to inform appropriate public education.

A comparison of recreational drug use amongst sexual health clinic users in London with existing prevalence data.

The objective was to give an overview of self-reported recreational drug use amongst attendees of sexual health clinics in London and compare this to existing datasets. Between December 2013 and March 2014, attendees of two sexual health clinics in London were surveyed. Data collected were: sexual history, smoking and alcohol and recreational drug use. Data were analysed using SPSS (version 21). A total of 1472 respondents were included; 778 (52.9%) men, 676 (45.9%) women and 3 (0.2%) transgender (15 [1.0%] did not answer). Mean age was 30.6 ± 9.0 years. A total of 339 (43.6%) men were men who have sex with men (MSM), and 18 (2.4%) women were women who have sex with women. Lifetime prevalence of use was: alcohol 94.1%; cannabis 48.5%; 'poppers' (volatile nitrites) 28.2%; cocaine 26.8% and 3,4-methylenedioxy-methamphetamine pills 23.2%. Our population had higher current popper, methamphetamine and mephedrone use than the Crime Survey of England and Wales but lower use of cannabis, poppers and Viagra than the European MSM Internet Survey. Global Drug Survey and Part of the Picture respondents' use were higher than our population for all drugs. Drug use in this population had a different pattern to general population surveys and studies involving only MSM.

Free Open Access Medical Education resource knowledge and utilisation amongst Emergency Medicine trainees: A survey in four countries.

Introduction Free Open Access Medical Education encompasses a broad array of free online resources and discussion fora. The aim of this paper was to describe whether Emergency Medicine trainees in different contexts know about Free Open Access Medical Education, whether or not they know about its different platforms, which ones they use, and what the major barriers to regular usage are. Methods A convenience sample was surveyed on awareness and use of Free Open Access Medical Education blogs, podcasts, websites and Twitter at three institutions (in Australia, Botswana and Papua New Guinea) and one deanery (United Kingdom) between June 2013 and June 2014 using an online survey tool or via hand-distributed survey. Results 44 trainees responded: four from Botswana, seven from Papua New Guinea, ten from the United Kingdom and 23 from Australia. 82% were aware of blogs, 80% of websites, 75% of podcasts and 61% of Twitter as resources in Emergency Medicine. Awareness and use of specific resources were lower in Botswana and Papua New Guinea. For blogs, podcasts and websites, trainees who had looked at a resource at least once were neutral or agreed that it was relevant. For Twitter, some trainees found it difficult to navigate or not relevant. Lack of awareness of resources rather than lack of internet access was the main barrier to use. Conclusion The Emergency Medicine trainees in both developed and low resource settings studied were aware that Free Open Access Medical Education resources exist, but trainees in lower income settings were generally less aware of specific resources. Lack of internet and device access was not a barrier to use in this group.

INTRODUCTION: L'enseignement médical gratuit en accès libre englobe un large éventail de ressources et forums de discussion gratuits en ligne. Les objectifs de cette étude sont de décrire si les stagiaires en médecine d'urgence dans différents contextes ont connaissance de l'enseignement médical gratuit en accès libre, s'ils ont ou non ils ont connaissance de ses différentes plateformes, quelles sont celles qu'ils utilisent et quels sont les principaux obstacles à leur utilisation régulière. MÉTHODES: Une enquête a été menée sur un échantillon de commodité sur la sensibilisation aux blogs, podcasts, sites Internet et comptes Twitter sur l'enseignement médical gratuit en accès libre et leur utilisation, dans trois établissements (en Australie, au Botswana et en Papouasie-Nouvelle-Guinée) et un doyenné (Royaume-Uni) entre juin 2013 et juin 2014, en utilisant un outil d'enquête en ligne ou par le biais d'un questionnaire distribué en personne. RÉSULTATS: 44 stagiaires ont répondu: quatre provenant du Botswana, sept de Papouasie-Nouvelle-Guinée, dix du Royaume-Uni et 23 d'Australie. 82% connaissaient les blogs, 80% les sites, 75% les podcasts et 61% les comptes Twitter en tant que ressources en médecine d'urgence. La sensibilisation et l'utilisation de ressources spécifiques étaient plus faibles au Botswana et en Papouasie-Nouvelle-Guinée. Concernant les blogs, les podcasts et les sites Web, les stagiaires qui avaient consulté une ressource au moins une fois en avaient une opinion neutre ou convenaient qu'elle était pertinente. Concernant Twitter, certains stagiaires ont trouvé qu'il était difficile d'y naviguer ou estimaient le service non pertinent. Le principal obstacle à l'utilisation était le manque de sensibilisation aux ressources plutôt que le manque d'accès à Internet. CONCLUSION: Les stagiaires en médecine d'urgence interrogés dans les pays développés comme dans les contextes à faibles ressources étaient conscients de l'existence de ressources en enseignement médical gratuit en accès libre, mais les stagiaires dans les contextes à faible revenu étaient généralement moins conscients des ressources spécifiques. Le manque d'accès à Internet ou à des appareils n'était pas un obstacle à l'utilisation au sein de ce groupe.

Description of 3,180 courses of chelation with dimercaptosuccinic acid in children ≤ 5 y with severe lead poisoning in Zamfara, Northern Nigeria: a retrospective analysis of programme data.

BACKGROUND: In 2010, Médecins Sans Frontières (MSF) discovered extensive lead poisoning impacting several thousand children in rural northern Nigeria. An estimated 400 fatalities had occurred over 3 mo. The US Centers for Disease Control and Prevention (CDC) confirmed widespread contamination from lead-rich ore being processed for gold, and environmental management was begun. MSF commenced a medical management programme that included treatment with the oral chelating agent 2,3-dimercaptosuccinic acid (DMSA, succimer). Here we describe and evaluate the changes in venous blood lead level (VBLL) associated with DMSA treatment in the largest cohort of children ≤ 5 y of age with severe paediatric lead intoxication reported to date to our knowledge. METHODS AND FINDINGS: In a retrospective analysis of programme data, we describe change in VBLL after DMSA treatment courses in a cohort of 1,156 children ≤ 5 y of age who underwent between one and 15 courses of chelation treatment. Courses of DMSA of 19 or 28 d duration administered to children with VBLL ≥ 45 µg/dl were included. Impact of DMSA was calculated as end-course VBLL as a percentage of pre-course VBLL (ECP). Mixed model regression with nested random effects was used to evaluate the relative associations of covariates with ECP. Of 3,180 treatment courses administered, 36% and 6% of courses commenced with VBLL ≥ 80 µg/dl and ≥ 120 µg/dl, respectively. Overall mean ECP was 74.5% (95% CI 69.7%-79.7%); among 159 inpatient courses, ECP was 47.7% (95% CI 39.7%-57.3%). ECP after 19-d courses (n = 2,262) was lower in older children, first-ever courses, courses with a longer interval since a previous course, courses with more directly observed doses, and courses with higher pre-course VBLLs. Low haemoglobin was associated with higher ECP. Twenty children aged ≤ 5 y who commenced chelation died during the period studied, with lead poisoning a primary factor in six deaths. Monitoring of alanine transaminase (ALT), creatinine, and full blood count revealed moderate ALT elevation in <2.5% of courses. No clinically severe adverse drug effects were observed, and no laboratory findings required discontinuation of treatment. Limitations include that this was a retrospective analysis of clinical data, and unmeasured variables related to environmental exposures could not be accounted for. CONCLUSIONS: Oral DMSA was a pharmacodynamically effective chelating agent for the treatment of severe childhood lead poisoning in a resource-limited setting. Re-exposure to lead, despite efforts to remediate the environment, and non-adherence may have influenced the impact of outpatient treatment. Please see later in the article for the Editors' Summary.

Association of blood lead level with neurological features in 972 children affected by an acute severe lead poisoning outbreak in Zamfara State, northern Nigeria.

BACKGROUND: In 2010, Médecins Sans Frontières (MSF) investigated reports of high mortality in young children in Zamfara State, Nigeria, leading to confirmation of villages with widespread acute severe lead poisoning. In a retrospective analysis, we aimed to determine venous blood lead level (VBLL) thresholds and risk factors for encephalopathy using MSF programmatic data from the first year of the outbreak response. METHODS AND FINDINGS: We included children aged ≤5 years with VBLL ≥45 µg/dL before any chelation and recorded neurological status. Odds ratios (OR) for neurological features were estimated; the final model was adjusted for age and baseline VBLL, using random effects for village of residence. 972 children met inclusion criteria: 885 (91%) had no neurological features; 34 (4%) had severe features; 47 (5%) had reported recent seizures; and six (1%) had other neurological abnormalities. The geometric mean VBLLs for all groups with neurological features were >100 µg/dL vs 65.9 µg/dL for those without neurological features. The adjusted OR for neurological features increased with increasing VBLL: from 2.75, 95%CI 1.27-5.98 (80-99.9 µg/dL) to 22.95, 95%CI 10.54-49.96 (≥120 µg/dL). Neurological features were associated with younger age (OR 4.77 [95% CI 2.50-9.11] for 1-<2 years and 2.69 [95%CI 1.15-6.26] for 2-<3 years, both vs 3-5 years). Severe neurological features were seen at VBLL <105 µg/dL only in those with malaria. INTERPRETATION: Increasing VBLL (from ≥80 µg/dL) and age 1-<3 years were strongly associated with neurological features; in those tested for malaria, a positive test was also strongly associated. These factors will help clinicians managing children with lead poisoning in prioritising therapy and developing chelation protocols.