Iron poisoning: a literature-based review of epidemiology, diagnosis, and management

Characteristics and outcome of 73 dogs with iron EDTA molluscicide ingestion in Melbourne, Australia (2013-2019)

INTRODUCTION

The objective of this study was to describe the clinical features, treatments and outcomes of dogs with iron ethylenediaminetetraacetate (EDTA) molluscicide ingestion. We aimed to identify potential predictors of serum iron concentration >54 μmol/L; a cut-off recommended for initiating treatment of human iron toxicosis.

METHODS

Medical records across four veterinary hospitals (2013-2019) for dogs with known or suspected iron EDTA molluscicide ingestion were reviewed for signalment, clinical signs, clinicopathological data, treatment regimens and outcomes. Clinical signs of dogs with serum iron concentrations either below or above a cut-off of 54 μmol/L were compared using Fisher's exact test. Association between serum iron and urine discolouration was tested using logistic regression.

RESULTS

Seventy-three dogs were included. The most frequent characteristic was abnormal faeces (n = 47, 64%) as determined by rectal examination, with more dogs that had serum iron >54 μmol/L showing this clinical sign (24/35), compared to dogs with serum iron <54 μmol/L (4/13) (P = 0.025). Clinicopathologic abnormalities included increased base excess (n = 20/49, 20%), hyperglycaemia (n = 13/57, 23%) and hyperlactataemia (n = 12/57, 21%). Fifty-four dogs received deferoxamine chelation (74%), during which 25/42 (60%) dogs had discoloured urine despite all dogs having subsequent iron concentrations <54 μmol/L. Admission serum iron concentration was associated with urine discolouration during hospitalisation (odds ratio 1.046, 95% confidence interval 1.008-1.107, P = 0.011). Sixty-nine dogs (95%) survived to discharge, with 10 dogs (14%) transferred to another veterinarian.

CONCLUSIONS

Iron EDTA molluscicide ingestion caused predominantly gastrointestinal clinical signs, and abnormal faeces, as well as urine discolouration during chelation therapy, which may indicate an elevation of serum iron concentration on presentation. Outcome was excellent.

Oral Ingestion of an Iron-Containing Hand Warmer in a Pediatric Patient

Hand warmer packets are common products used to provide a portable, nonflammable heat source via the exothermic oxidation of iron. We present the first reported case of pediatric hand warmer packet ingestion in a three-year-old male who developed an elevated serum iron concentration (peak 335 ug/dL) and gastrointestinal injury after ingesting the contents of a HOTHANDS hand warmer packet. He was treated with endoscopic gastric foreign body removal and lavage, as well as proton-pump inhibitors and whole bowel irrigation. Hand warmer packs contain reduced elemental iron powder, which has been shown to have a more favorable safety profile when compared to iron salts. The mechanism of toxicity for reduced iron is unknown, though it is thought to be due to conversion to more toxic iron ions in an acidic environment. While the current adult literature suggests that ingestion of a single hand warmer packet is without significant risk, our case demonstrates that even a partial ingestion carries a significant risk of both iron toxicity and direct gastrointestinal caustic injury in a young child. This case demonstrates the need for multidisciplinary care and consideration of urgent endoscopic foreign body removal and gastric lavage followed by whole bowel irrigation to mitigate the potential of severe iron toxicity.

Production of iron enriched Saccharomyces boulardii: impact of process variables

About half of the 1.62 billion cases of anemia are because of poor diet and iron deficiency. Currently, the use of iron-enriched yeasts can be used as the most effective and possible way to prevent and treat anemia due to the ability of biotransformation of mineral compounds into the organic form. In this research, for the first time, Saccharomyces (S.) boulardii was used for iron enrichment with the aim that the probiotic properties of yeast provide a potential iron supplement besides improving the bioavailability of iron. Also, due to its higher resistance than other Saccharomyces strains against stresses, it can protect iron against processing temperatures and stomach acidic-enzymatic conditions. So, the effect of three important variables, including concentration of iron, molasses and KH2PO4 on the growth and biotransformation of yeast was investigated by the Box-Behnken design (BBD). The best conditions occurred in 3 g/l KH2PO4, 20 g/l molasses and 12 mg/l FeSO4 with the highest biotransformation 27 mg Fe/g dry cell weight (DCW) and 6 g/l biomass weight. Such yeast can improve fermented products, provide potential supplement, and restore the lost iron of bread, which is a useful iron source, even for vegetarians-vegans and play an important role in manage with anemia. It is recommended that in future researches, attention should be paid to increasing the iron enrichment of yeast through permeabilizing the membrane and overcoming the structural barrier of the cell wall.

Iron - a background article for the Nordic Nutrition Recommendations 2023

Iron absorption from foods is generally lower than that of most other nutrients and is highly variable depending on individual iron status and iron bioavailability in the meal. Several large population groups in the Nordic and Baltic countries are at risk of iron deficiency, including infants, young children, menstruating females, pregnant women as well as vegetarians. Iron deficiency leads to anemia, fatigue, and limited capacity for physical activity. Of particular concern is that iron deficiency anemia in young children is associated with impaired neurodevelopment. A comprehensive literature search has been performed and summarized. New factorial calculations have been performed considering iron losses, iron absorption and iron requirements in various population groups. Recent data on iron intakes and the prevalence of iron deficiency in the Nordic countries are presented. Average requirements and tentative recommended intakes are presented for 12 different population groups. Pregnant women and those with high menstrual blood losses should consume iron-rich food and undergo screening for iron deficiency. Infants should consume iron-rich complementary foods and cow's milk should be avoided as a drink before 12 months of age and limited to < 500 mL/day in toddlers. Vegetarians should consume a diet including wholegrains, legumes, seeds, and green vegetables together with iron absorption enhancers. There is no evidence that iron intake per se increases the risk of cancer or diabetes. Iron absorption from foods is generally lower than that of most other nutrients and can vary between <2 and 50% depending on individual iron status and iron bioavailability in the meal.

Pharmacokinetics of vitamin dosage forms: A complete overview

Vitamins are crucial for sustaining life because they play an essential role in numerous physiological processes. Vitamin deficiencies can lead to a wide range of severe health issues. In this context, there is a need to administer vitamin supplements through appropriate routes, such as the oral route, to ensure effective treatment. Therefore, understanding the pharmacokinetics of vitamins provides critical insights into absorption, distribution, and metabolism, all of which are essential for achieving the desired pharmacological response. In this review paper, we present information on vitamin deficiencies and emphasize the significance of understanding vitamin pharmacokinetics for improved clinical research. The pharmacokinetics of several vitamins face various challenges, and thus, this work briefly outlines the current issues and their potential solutions. We also discuss the feasibility of enhanced nanocarrier-based pharmaceutical formulations for delivering vitamins. Recent studies have shown a preference for nanoformulations, which can address major limitations such as stability, solubility, absorption, and toxicity. Ultimately, the pharmacokinetics of pharmaceutical dosage forms containing vitamins can impede the treatment of diseases and disorders related to vitamin deficiency.

Nutritional Aspects of Iron in Health and Disease

Dietary iron assimilation is critical for health and essential to prevent iron-deficient states and related comorbidities, such as anemia. The bioavailability of iron is generally low, while its absorption and metabolism are tightly controlled to satisfy metabolic needs and prevent toxicity of excessive iron accumulation. Iron entry into the bloodstream is limited by hepcidin, the iron regulatory hormone. Hepcidin deficiency due to loss-of-function mutations in upstream gene regulators causes hereditary hemochromatosis, an endocrine disorder of iron overload characterized by chronic hyperabsorption of dietary iron, with deleterious clinical complications if untreated. The impact of high dietary iron intake and elevated body iron stores in the general population is not well understood. Herein, we summarize epidemiological data suggesting that a high intake of heme iron, which is abundant in meat products, poses a risk factor for metabolic syndrome pathologies, cardiovascular diseases, and some cancers. We discuss the clinical relevance and potential limitations of data from cohort studies, as well as the need to establish causality and elucidate molecular mechanisms.

A retrospective analysis of therapeutic drug exposures in New Zealand National Poisons Centre data 2018-2020

OBJECTIVE

The New Zealand National Poisons Centre advises the general public and health professionals on management of exposures to various substances. The epidemiology of medicine exposures was used to characterise inappropriate use of medicines across age groups.

METHODS

Data from contacts in 2018-2020 were analysed: patient demographics (age, gender), number of therapeutic substances, and advice given. The most frequent individual therapeutic substance exposures across age groups and the reasons for these occurring were determined.

RESULTS

A total of 76% of children's (aged 0-12 or unknown child) exposures were exploratory in nature, involving a variety of medicines. Youth (aged 13-19) had frequently engaged in intentional self-poisoning (61% of their exposures), and most commonly by exposure to paracetamol, antidepressants, and quetiapine. Adults (aged 20-64) and older adults (aged 65 and over) were frequently affected by therapeutic errors (50% and 86% of their exposures, respectively). Adults were most frequently exposed to paracetamol, codeine, tramadol, antidepressants, and hypnotics, while older adults were exposed to paracetamol and various cardiac medications.

CONCLUSIONS

Types of inappropriate medicine exposures vary in different age groups.

IMPLICATIONS FOR PUBLIC HEALTH

Poisons centre data add to pharmacovigilance monitoring of potential harm from medicines and inform medication safety policies and interventions.

nZVI-induced iron poisoning aggravated the toxicity of TCEP to earthworm in soil

Tris (2-chloroethyl) phosphate (TCEP) is a newly developed organophosphorus flame retardant that has been increasingly detected in soil as a contaminant. Nanoremediation is a potential solution for the control of TCEP, while the effectiveness and ecological risks are poorly understood. Here, we investigated the physicochemical interactions and joint toxicity of nano zero-valent iron (nZVI) (50-5000 mg/kg) and TCEP (50-5000 μg/kg) at environmental relevant concentrations to earthworms (Eisenia fetida) in soil. During a 28-d exposure, TCEP in soil was neither self-degraded nor removed by nZVI, and the individual toxicity of TCEP on the physiology of earthworms was significantly higher than that of nZVI. Notably, nZVI was found to synergize the toxicity of TCEP to earthworms without showing the classical "Trojan horse effect". Mechanically, TCEP mainly induced a typical neurotoxicity, and indirectly inhibited the food ingestion and growth performance of earthworms; nZVI induced iron poisoning aggravated the intestinal damage and directly inhibited the energy metabolism, therefore exacerbated the TCEP-induced malnutrition. Our findings provide new insights into the toxic mechanisms of nZVI-TCEP co-exposure to soil organisms, and emphasize the necessity of risk assessment and cautious usage of nanoremediation in newly emerged contaminations.

Targeting ferroptosis protects against experimental (multi)organ dysfunction and death

The most common cause of death in the intensive care unit (ICU) is the development of multiorgan dysfunction syndrome (MODS). Besides life-supporting treatments, no cure exists, and its mechanisms are still poorly understood. Catalytic iron is associated with ICU mortality and is known to cause free radical-mediated cellular toxicity. It is thought to induce excessive lipid peroxidation, the main characteristic of an iron-dependent type of cell death conceptualized as ferroptosis. Here we show that the severity of multiorgan dysfunction and the probability of death are indeed associated with plasma catalytic iron and lipid peroxidation. Transgenic approaches underscore the role of ferroptosis in iron-induced multiorgan dysfunction. Blocking lipid peroxidation with our highly soluble ferrostatin-analogue protects mice from injury and death in experimental non-septic multiorgan dysfunction, but not in sepsis-induced multiorgan dysfunction. The limitations of the experimental mice models to mimic the complexity of clinical MODS warrant further preclinical testing. In conclusion, our data suggest ferroptosis targeting as possible treatment option for a stratifiable subset of MODS patients.

Can Nutrients and Dietary Supplements Potentially Improve Cognitive Performance Also in Esports?

Factors influencing brain function and cognitive performance can be critical to athletic performance of esports athletes. This review aims to discuss the potential beneficial effects of micronutrients, i.e., vitamins, minerals and biologically active substances on cognitive functions of e-athletes. Minerals (iodine, zinc, iron, magnesium) and vitamins (B vitamins, vitamins E, D, and C) are significant factors that positively influence cognitive functions. Prevention of deficiencies of the listed ingredients and regular examinations can support cognitive processes. The beneficial effects of caffeine, creatine, and probiotics have been documented so far. There are many plant products, herbal extracts, or phytonutrients that have been shown to affect precognitive activity, but more research is needed. Beetroot juice and nootropics can also be essential nutrients for cognitive performance. For the sake of players’ eyesight, it would be useful to use lutein, which, in addition to improving vision and protecting against eye diseases, can also affect cognitive functions. In supporting the physical and mental abilities of e-athletes the base is a well-balanced diet with adequate hydration. There is a lack of sufficient evidence that has investigated the relationship between dietary effects and improved performance in esports. Therefore, there is a need for randomized controlled trials involving esports players.

Vitamin and mineral supplement exposures: cases reported to Australia's largest Poisons Information Centre, 2014-2015 to 2018-2019

Vitamin and mineral supplements (VMS) are widely available and commonly used. Little is known about patterns of poisoning exposures to VMS in the Australian population. We performed a retrospective study of calls to the New South Wales Poisons Information Centre (NSWPIC), July 2014-June 2019. NSWPIC is Australia's largest PIC, taking approximately 100 000 calls/year (50 % of Australian poisoning calls) from healthcare professionals and members of the public. We conducted additional analyses on Fe exposures due to their high risk of acute toxicity. There were 10 944 VMS exposures reported to NSWPIC during the study period, increasing 9·6 % per annum over a 5-year period (95 % CI, 7·2, 12·1 %). Toddlers (1-4 years) accounted for 41·5 % (4546) of cases. Agents most commonly involved were multivitamins (n 3610), vitamin D (n 2080), Fe (n 1533) and Mg (n 804). In 17·7 % (1934) of cases, the call originated from hospital or the patient was referred to hospital by NSWPIC. Fe exposures increased by 14·0 % per year (95 % CI, 9·5, 18·5 %), and most were associated with high-strength products (> 45 mg elemental Fe per unit dose, n 1036). Fe exposures were hospitalised in 38 % of cases (n 583). We conclude that VMS exposures are increasing in Australia. Although most exposures can be managed at home, many required hospitalisation. Fe exposures are increasing and had higher rates of hospitalisation than other agents. VMS are often considered safe and without the potential for adverse effects, highlighting the importance of public education into the potential risks of misuse of these products.

Nutrition and hair

Healthy hair results from a combination of good generalized health and mindful health care practices. Many nutritional deficiencies lead to poor hair health and include changes to hair structure, texture, and viability. Although the mechanisms by which individual nutrients contribute to hair growth and maintenance have yet to be fully resolved, there are a variety of risk factors that predispose an individual to a nutritional deficiency; age, malnutrition, malabsorption, and medication use are among the most common. A thorough history should be taken in a patient with a hair disturbance to identify risk factors for a nutritional deficiency, which will then guide directed laboratory testing and treatment.

Unintentional paediatric iron poisoning: A retrospective case series

OBJECTIVE

Iron poisoning is a historically important cause of paediatric morbidity and mortality. In recent decades, public health measures have considerably reduced paediatric iron exposures. We investigated unintentional paediatric iron poisoning in children with the aim of developing an assessment approach specific for this group.

METHODS

This was a retrospective observational study of unintentional iron poisoning in children (<7 years old) referred to either a state-wide poisons information service or a tertiary clinical toxicology unit from 1 January 2015 to 16 February 2020. Patients were identified from prospective databases maintained by both services, and data were extracted from these in addition to the medical record.

RESULTS

There were 54 children included in the study (29 [54%] male; median age 2 years (range 8 months to 4 years). The median suspected dose of elemental iron ingested was 72 mg/kg (IQR 41-140 mg/kg). Seventeen (31%) children were symptomatic. There were no cases of severe toxicity. Children symptomatic with gastrointestinal toxicity had a median suspected dose ingested of 60 mg/kg (IQR 38-150 mg/kg) that was similar to asymptomatic children (81 mg/kg [IQR 41-143 mg/kg], P = 0.809). The median peak iron concentration was 49 μmol/L (IQR 13.5-67.5 μmol/L, range 4-75 μmol/L). Symptomatic children had a significantly higher median peak serum iron concentration of 66 μmol/L (IQR 54-68 μmol/L) compared to 12 μmol/L (IQR 9-15 μmol/L) in asymptomatic children (P < 0.001).

CONCLUSION

Unintentional paediatric iron poisoning is uncommon and largely benign. Suspected dose ingested is a poor predictor of toxicity. Targeting investigations and interventions to symptomatic children should reduce unnecessary assessment and management while still safely managing the exposure.

Hard as Iron: A Case of Delayed Presentation of Severe Iron Toxicity With Diagnostic and Treatment Dilemmas

ABSTRACT

Cases of severe iron toxicity have become increasingly rare; most cases are intentional ingestions by late adolescents and adults who present within 12 hours of ingestion. We present a case of an adolescent girl with metabolic acidosis, hypoglycemia, obtundation, and liver and renal failure of undifferentiated etiology who was eventually discovered to have overdosed on ferrous sulfate tablets 4 days before arrival. The diagnosis was made because the patient had an elevated transferrin concentration in the setting of a minimally elevated serum iron concentration and faint radio-opacities on abdominal plain film imaging. This case presents many diagnostic challenges and treatment dilemmas and is a rare report of survival in delayed presentation of severe toxicity.

Trace Metal Element Analysis in Some Seafood in the Coastal Zone of the Red River (Ba Lat Estuary, Vietnam) by Green Sample Preparation and Inductively Coupled Plasma-Mass Spectrometry (ICP-MS)

Fisheries and aquaculture production in the coastal zone of Vietnam contribute significantly to the national economy. However, seafood quality and safety, especially in terms of metal contents, are of increasing concern, for both domestic and international markets. This paper presents the results of an investigation in some trace metal elements (iron (Fe), zinc (Zn), manganese (Mn), copper (Cu), arsenic (As), cadmium (Cd), and mercury (Hg)) concentrations in some fishes, crustaceans, and molluscs in the coastal zone of the Red River (in the Ba Lat estuary in Thai Binh and Nam Dinh provinces) during four sampling campaigns in 2020. All samples were treated by a green sample preparation using microwave digestion and then analyzed by inductively coupled plasma-mass spectrometry (ICP-MS). The results showed that the trace metal element concentrations in fish, crustacean, and mollusc samples decreased in the following order: Fe > Zn > Mn > Cu > As > Cd ∼ Hg. In more details, the ranges of trace metal elements in seafood samples were 13.13-202.73; 7.63-82.71; 0.48-22.73; 0.72-15.58; 0.18-5.12; 0.001-1.114; and 0.001-0.923 mg·kg-1 for Fe, Zn, Mn, Cu, As, Cd, and Hg, respectively. The research results contribute to the dataset of the seafood (both fishery and aquacultural seafood) quality in the Red River coastal zone. Although the mean values of different trace metal elements observed in this study were lower than the allowed values of Vietnam's or European's threshold for food safety, some high concentrations were detected. The survey results suggest the need to expand the monitoring scope (frequency of monitoring, number of samples, and observed variables) for obtaining a fully comprehensive assessment of seafood quality in this region. Our results also indicate that it is necessary to manage water quality in coastal areas, especially where aquaculture activities are carried out.

Electron paramagnetic resonance spectroscopy reveals alterations in the redox state of endogenous copper and iron complexes in photodynamic stress-induced ischemic mouse liver

Divalent copper and iron cations have been acknowledged for their catalytic roles in physiological processes critical for homeostasis maintenance. Being redox-active, these metals act as cofactors in the enzymatic reactions of electron transfer. However, under pathophysiological conditions, owing to their high redox potentials, they may exacerbate stress-induced injury. This could be particularly hazardous to the liver - the main body reservoir of these two metals. Surprisingly, the involvement of Cu and Fe in liver pathology still remains poorly understood. Hypoxic stress in the tissue may act as a stimulus that mobilizes these ions from their hepatic stores, aggravating the systemic injury. Since ischemia poses a serious complication in liver surgery (e.g. transplantation) we aimed to reveal the status of Cu and Fe via spectroscopic analysis of mouse ischemic liver tissue. Herein, we establish a novel non-surgical model of focal liver ischemia, achieved by applying light locally when a photosensitizer is administered systemically. Photodynamic treatment results in clear-cut areas of the ischemic hepatic tissue, as confirmed by ultrasound scans, mean velocity measurements, 3D modelling of vasculature and (immuno)histological analysis. For reference, we assessed the samples collected from the animals which developed transient systemic endotoxemic stress induced by a non-lethal dose of lipopolysaccharide. The electron paramagnetic resonance (EPR) spectra recorded in situ in the liver samples reveal a dramatic increase in the level of Cu adducts solely in the ischemic tissues. In contrast, other typical free radical components of the liver EPR spectra, such as reduced Riske clusters are not detected; these differences are not followed by changes in the blood EPR spectra. Taken together, our results suggest that local ischemic stress affects paramagnetic species containing redox-active metals. Moreover, because in our model hepatic vascular flow is impaired, these effects are only local (confined to the liver) and are not propagated systemically.

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Liver ischemia causes local dyshomeostasis in redox-active transition metal ions.

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Metal ion-reactive species interaction exacerbates injury of the hepatic tissue.

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Copper chelation could aid the removal of reactive species.

Iron Packaging Regulations in the United States and Pediatric Morbidity: A Retrospective Cohort Study

Iron poisoning was a leading cause of pediatric morbidity and mortality. We sought to assess whether the removal of strict iron packaging requirements in 2003 resulted in an increase in iron-related morbidity and mortality in pediatric exposures. We performed a retrospective cohort study utilizing the National Poison Data System from 2000 to 2017. A total of 4110 exposures met inclusion criteria: 847 from before (2000-2003) and 3263 after removal of unit-dose package regulations (2004-2017). The incidence of any marker of severity (7.2% vs 3.8%; odds ratio = 0.51, 95% confidence interval = 0.37-0.69) and frequency of deferoxamine use were both higher in the early time period (2.6% vs 1.0%; odds ratio = 0.38, 95% confidence interval = 0.22-0.66). There was no difference in the frequency of key serious effects (acidosis, elevated transaminases, hypotension). Despite removal of iron packaging regulations in the United States, there continues to be a decrease in the incidence of severe iron exposures in children.

Principal Components and Hierarchical Cluster Analyses of Trace Metals and Total Hydrocarbons in Gills, Intestines and Muscles of Clarias gariepinus (Burchell, 1822)

The aim of the study was to comparatively analyze the interrelationships among iron (Fe), manganese (Mn), zinc (Zn), copper (Cu), lead (Pb), cadmium (Cd), chromium (Cr) and total hydrocarbons (THCs) in the gills, intestines and muscles of Clarias gariepinus collected from Osse River, Nigeria, between the periods of April, 2013 to September, 2014. The trace metals in the fish tissues were analyzed using Atomic Absorption Spectrophotometer (AAS, Philips model PU 9100), while total hydrocarbons were analyzed using High Performance Liquid Chromatograph (HPLC,Prominence Dual brand from HGE) equipped with a detector Shimadzu UV-Visible (UV-Vis Prominence SPD 20 A). The concentrations of trace metals and THCs in the tissues were subjected to principal component analysis (PCA), in conjunction with hierarchical cluster analysis (HCA), backed up by correlation analysis (CA). In the most prioritized component among the hierarchies of contaminants, characterized as principal component 1, results of communality extractions and rotated component matrices revealed the order of contaminants was Mn > Cu > Zn > Fe > Cr in the intestines, Cr > Cu > THCs > Mn > Fe in the muscle, while Pb > Cr > Fe > Mn was the order in the gills of the fish. Iron inhibited accumulation of the other trace metals in the gills, where its threshold of essentiality was maximal. Noteworthy is the fact that Mn and Cu were the most active components in the muscle and concurrently of excess concentrations in the tissue, which is the major edible part of fish, and constitutes its main body weight, hence holds its nutritional and economic values. High level of variability which occurred in the toxicant profile across the tissues of C. gariepinus is a function of uptake route, varied organ functions and specificity of tissue permeability of the compared organs. The study demonstrated variability in organ accumulation capacity and toxicant's competitiveness irrespective of bioavailability. The study provides data useful for future ecotoxicological studies and safety of consumers of the fish.

The Hazardous Level of Heavy Metals in Different Medicinal Plants and Their Decoctions in Water: A Public Health Problem in Brazil

The determination of Cd, Co, Cr, Cu, Fe, Na, Zn, and Pb by inductively coupled plasma-optical emission spectrometry (ICP OES) was performed on dry matter and decoctions of the medicinal plants Cordia salicifolia, Chiococca alba (L.) Hitchc., and Echites peltata used as an appetite suppressant and diuretic in Brazil. The accuracy of the measurements was analyzed by the spike recovery test. Results showed that the concentration of these seven metals (Cd, Co, Cr, Cu, Fe, Na, and Zn) in dry plant samples is below the oral concentration of elemental impurities established by the United States Pharmacopoeia Convention (USP). However, there are no concentration limits for Fe, Na, and Zn established by the USP in drug substances and excipients. Levels higher than the recommended value by the USP were observed for Pb and the lowest for Cd, Co, Cr, and Cu, both in dried plant samples and their decoctions. In the decoctions prepared from these plants were found elements such as Cd, Co, Cr, Cu, Fe, Na, Zn, and Pb. In the decoction prepared from 40 g C. salicifolia leaves and 40 g C. alba wood, the content of Cd is above the oral daily exposure value set by the USP. Hazard index (HI) for decoctions prepared from these plants exceeded the threshold (1). Given the uncertainties associated with the estimates of toxicity values and exposure factors, futures researches should address the possible toxicity in humans. Uncontrolled selling and long-term ingestion of medicinal plants can cause toxicity and interfere with the effect of drugs. Limited knowledge on the interaction potential of medicinal plants poses a challenge and public health problem in Brazil and other countries.

Accumulation of essential and non-essential trace elements in rice grain: Possible health impacts on rice consumers in West Bengal, India

Rice is the major staple food to the population in rural West Bengal, India and Bangladesh. Depletion and excess accumulation of different trace elements, which are essential and non-essential to the human body, in rice can have a detrimental impact on the rice consumer. Therefore, this study has investigated the accumulation of different trace elements in rice consumed in rural households in West Bengal. The mean concentration (mg kg^-1) of essential elements in rice follows the order of Fe (39.4) > Zn (9.79) > Mn (4.40) > Cu (3.26) > Se (0.28) > Co (0.03), while this order for non-essential elements is Pb (1.70) > As (0.34) > Ni (0.22) > Cd (0.04). In general, accumulation in rice is higher for elements that show higher mobility under reducing conditions (e.g. Fe, Mn, As, etc.) compared to elements with lower mobility under such conditions (e.g. Se, Cd, etc.). These orders of accumulation can be attributed to the irrigation practice of continuous flooding of the soil during rice cultivation and the abundance of these elements in the paddy soil itself. By combining these analytical results to the data obtained from questionnaire survey it is estimated that rice consumption can be either enough or a major source to fulfill the daily requirement of Fe, Cu, Se, Mn, and Zn necessary for different physiological functions in the human body for the population in rural Bengal. At the same time, it can be a potential route of As, Cd, Ni, and Pb exposure to develop their non-carcinogenic and carcinogenic health effects among the population. This study highlights that attempts should be made to reduce the accumulation of other non-essential elements together with As in rice grain to ensure the health safety of the people who rarely get a balanced diet and relay on rice consumption to meet the daily calorific intake in rural Bengal.

Risk-based prediction of metal toxicity in sediment and impact on human health due to consumption of seafood (Saccostrea cucullata) found in two highly industrialised coastal estuarine regions of Eastern India: a food safety issue

Estuarine ecosystems of the Bay of Bengal, India, are considered as the most productive environment, which have been persistently threatened by substantial anthropogenic activity. This study aims to investigate the metal contamination in the sediment of two estuaries and possible biomagnifications in the indigenous edible oyster Saccostrea cucullata and related health hazards due to its consumption. The accumulative ecological risks indicated that the sediment is moderate to strongly contaminated with cadmium and lead. The sediment pollution index and pollution load index suggested that the sediment possesses a little ecological stress on the exposed flora and fauna. The statistical interpretation highlights the most metals which have a similar source of origin and are bound to the finer fractions of the sediment, except nickel. Bioaccumulation of sediment-associated Cu and Zn in oyster reflects their potential biomagnifications through aquatic food chain. HPI range was below the critical limit of safe human consumption. The non-carcinogenic (THQ) and carcinogenic (CR) health hazards were estimated from the PTDI provided by USEPA. Except Cr, Hg and Zn, the THQ of all other metals was > 1 suggesting detrimental non-carcinogenic health effects on humans. The TCR of Cr and Cd above safety limit indicates the exposed population might be under severe carcinogenic threat due to those metals.

Lead poisoning due to ingestion of lead-contaminated opium: A diagnostic study on patients' imaging findings

OBJECTIVES

Our study attempts to determine if for patients following ingestion of lead-contaminated opium, radiographs [plain X-ray (KUB)] or unenhanced computed tomography (CT scan) of the abdomen may be predictive of lead poisoning.

METHODS

Our study is concerned with patients of >21 years with elevated lead concentrations, who had undergone KUB or CT. Patients with other toxicities who had undergone similar imaging profiles but who had low blood lead level (BLL) were enrolled as controls.

RESULTS

We evaluated a total of 79 cases and 79 controls with median [IQR] BLLs of 126 [97.4, 160] μg/dL and 8.7 [5.5, 15] μg/dL. All cases and eleven controls (13.9%) were addicted to oral opium, and of these cases, anemia (94.9%) and abdominal pain (92.4%) were the two most common clinical manifestations. Two radiologists reviewed the X-ray and non-contrast CTs. Fifty (63.3%) and 53 (67.1%) cases and controls underwent CT scanning with 34 (68%) vs. 6 (11.3%) positive CTs (P < 0.001) while 43 (54.4%) and 39 (43.3%) underwent X-rays with 21 (48.8%) vs. 4 (11.8%) positive X-rays, respectively (P < 0.001). Positive CT is associated with BLL between 10 and 45 μg/dL with a specificity of 96.9%, 88.7% and positive predictive value of 97.5% and 85% respectively.

CONCLUSIONS

In suspected cases of lead exposure due to ingested opium, and if BLL is not readily available, a positive imaging result may guide radiologists and physicians to consider lead poisoning.

Optimization of transdermal deferoxamine leads to enhanced efficacy in healing skin wounds

Chronic wounds remain a significant burden to both the healthcare system and individual patients, indicating an urgent need for new interventions. Deferoxamine (DFO), an iron-chelating agent clinically used to treat iron toxicity, has been shown to reduce oxidative stress and increase hypoxia-inducible factor-1 alpha (HIF-1α) activation, thereby promoting neovascularization and enhancing regeneration in chronic wounds. However due to its short half-life and adverse side effects associated with systemic absorption, there is a pressing need for targeted DFO delivery. We recently published a preclinical proof of concept drug delivery system (TDDS) which showed that transdermally applied DFO is effective in improving chronic wound healing. Here we present an enhanced TDDS (eTDDS) comprised exclusively of FDA-compliant constituents to optimize drug release and expedite clinical translation. We evaluate the eTDDS to the original TDDS and compare this with other commonly used delivery methods including DFO drip-on and polymer spray applications. The eTDDS displayed excellent physicochemical characteristics and markedly improved DFO delivery into human skin when compared to other topical application techniques. We demonstrate an accelerated wound healing response with the eTDDS treatment resulting in significantly increased wound vascularity, dermal thickness, collagen deposition and tensile strength. Together, these findings highlight the immediate clinical potential of DFO eTDDS to treating diabetic wounds. Further, the topical drug delivery platform has important implications for targeted pharmacologic therapy of a wide range of cutaneous diseases.

Discovery of Novel, Drug-Like Ferroptosis Inhibitors with in Vivo Efficacy

Ferroptosis is an iron-catalyzed, nonapoptotic form of regulated necrosis that results in oxidative lipid damage in cell membranes that can be inhibited by the radical-trapping antioxidant Ferrostatin-1 (Fer-1). Novel inhibitors derived from the Fer-1 scaffold inhibited ferroptosis potently but suffered from solubility issues. In this paper, we report the synthesis of a more stable and readily soluble series of Fer-1 analogues that potently inhibit ferroptosis. The most promising compounds (37, 38, and 39) showed an improved protection compared to Fer-1 against multiorgan injury in mice. No toxicity was observed in mice after daily injection of 39 (UAMC-3203) for 4 weeks. UAMC-3203 inserts rapidly in a phospholipid bilayer in silico, which aligns with the current understanding of the mechanism of action of these compounds. In conclusion, these analogues have superior properties compared to Fer-1, show in vivo efficacy, and represent novel lead compounds with therapeutic potential in relevant ferroptosis-driven disease models.

Concentration of heavy metals in seafood (fishes, shrimp, lobster and crabs) and human health assessment in Saint Martin Island, Bangladesh

A contaminated aquatic environment may end up in the food chain and pose risks to tourist health in a tourist destination. To assess the health risk for tourists that visit St. Martine Island, which is a popular domestic and foreign tourist destination in Bangladesh, a study is undertaken to analyse the level of heavy metal contamination from chromium (Cr), manganese (Mn), copper (Cu), zinc (Zn), arsenic (As), cadmium (Cd), lead (Pb), mercury (Hg) and iron (Fe) in six of the most consumed fish (L. fasciatus, R. kanagurta, H. nigrescens, P. cuneatus, P. annularis and S. rubrum) and five crustacean species, which consist of a shrimp (P. sculptilis), a lobster (P. versicolor) and three crabs (P. sanguinolentus, T. crenata and M. victor) captured. The samples were analysed for trace metals using atomic absorption spectrometer, and the concentrations of the metals were interpreted using the United State Environmental Protection Agency (USEPA) health risk model. The muscle and carapace/exoskeleton of shrimp, lobster and crabs were analysed and contained various concentrations of Pb, Hg, As, Cr, Cd, Fe, Cu, Zn and Mn. The hierarchy of the heavy metal in marine fish is Fe > Cd > Zn > Pb > Cu > Cr > Mn > Hg. The concentrations of Pb in the species R. kanagurta, H. nigresceus and S. rubrum were above the food safety guideline by Australia, New Zealand and other legislations in most marine fish and crustaceans. Crabs showed higher mean heavy metal concentrations than shrimp and lobster. Acceptable carcinogen ranges were observed in three fish species (R. kanagurata, H. nigresceus and S. rubrum) and one crustacean species (P. sculptilis) samples.

Myeloperoxidase deficiency attenuates systemic and dietary iron-induced adverse effects

Iron deficiency is routinely treated with oral or systemic iron supplements, which are highly reactive and could induce oxidative stress via augmenting the activity of proinflammatory enzyme myeloperoxidase (MPO). To investigate the extent to which MPO is involved in iron-induced toxicity, acute (24 h) iron toxicity was induced by intraperitoneal administration of FeSO₄ (25 mg/kg body weight) to MPO-deficient (MpoKO) mice and their wild-type (WT) littermates. Acute iron toxicity was also assessed in WT mice pretreated with an MPO inhibitor, 4-aminobenzoic acid hydrazide. Systemic iron administration up-regulated circulating MPO and neutrophil elastase and elevated systemic inflammatory and organ damage markers in WT mice. However, genetic deletion of MPO or its inhibition significantly reduced iron-induced organ damage and systemic inflammatory responses. In contrast to the acute model, 8 weeks of 2% carbonyl iron diet feeding to WT mice did not change the levels of circulating MPO and neutrophil elastase but promoted their accumulation in the liver. Even though both MpoKO and WT mice displayed similar levels of diet-induced hyperferremia, MpoKO mice showed significantly reduced inflammatory response and oxidative stress than the WT mice. In addition, WT bone-marrow-derived neutrophils (BMDN) generated more reactive oxygen species than MPO-deficient BMDN upon iron stimulation. Altogether, genetic deficiency or pharmacologic inhibition of MPO substantially attenuated acute and chronic iron-induced toxicity. Our results suggest that targeting MPO during iron supplementation is a promising approach to reduce iron-induced toxicity/side effects in vulnerable population.

Effect of sub-chronic ferrous sulfate treatment on motor skills, hematological and biochemical parameters in rats

This study investigated the effects of ferrous sulfate (FeSO4) on motor skills, hematological and biochemical parameters in rats. Adult rats were treated with dose of iron (280 mg/L, per os) for 15 consecutive days in drinking water. No significant difference was noticed for the motor skills in the stationary beam (p = 0.23) and suspended string tests (p = 0.48) between control and iron-treated rats. However, iron-treated rats showed a significant increase in white blood cells count (p = 0.01), mean corpuscular volume values (p = 0.02) and decrease in frequency of peristaltic contractions of the fragment of the intestine (in vitro) compared to control rats (p = 0.01). No significant difference in plasma iron level (p = 0.89) and transferrin amount were observed after iron treatment (p = 0.65). The findings indicate that iron treatment at 280 mg/L, per os for 15 consecutive days in adult rats induced increase of hematological parameters (sign of a potential inflammation), but not motor skills deficit.

Pediatric liver transplantation for fulminant hepatic failure secondary to intentional iron overdose

Acute iron poisoning may lead to life-threatening hepatotoxicity. We present the cases of two pediatric patients with hepatotoxicity following intentional iron ingestion that progressed rapidly to fulminant hepatic failure despite treatment with deferoxamine. Liver transplantation was lifesaving in both patients. These cases emphasize the need for a high index of suspicion for iron ingestion, close monitoring for liver toxicity, and timely consideration for liver transplantation.

Neurocognitive Function Is Associated With Serum Iron Status in Early Adolescents

OBJECTIVE

The association between iron and neurocognition remains underexplored in adolescents, and the neurocognitive effects of low and high iron levels have yet to be established. The aim of this study was to investigate the relationships of low and high iron levels with neurocognitive domains in early adolescents.

METHOD

The sample comprised 428 adolescents (12.0 ± 0.4 years) from Jintan, China. Serum iron concentrations were analyzed from venous blood samples and classified into low, normal, and high levels according to the clinical reference range 75-175 μg/dl. Neurocognition was measured by the Penn Computerized Neurocognitive Battery and Wechsler Intelligence Scale. Generalized linear regression was used to analyze relationships.

RESULTS

Prevalence rates of iron deficiency, normal iron, and high iron were 13.8%, 76.4%, and 9.8%, respectively. Compared with normal levels, iron deficiency was associated with slower performance in tasks that measured abstraction and mental flexibility (β = 107.5, p = .03) and spatial processing ability (β = 917.2, p = .04). High serum iron was associated with less accuracy in the spatial processing ability task (β = -2.2, p = .03) and a longer reaction time in the task assessing abstraction and mental flexibility (β = 702.8, p = .046) compared to normal levels.

CONCLUSION

Both iron deficiency and high iron levels contribute to reduced neurocognitive performance in a domain-specific manner in early adolescents. The dual burden of iron under- and overnutrition should be incorporated into future interventions for improving brain development and cognitive function in adolescents, especially in a Chinese context.

Iron mediated toxicity and programmed cell death: A review and a re-examination of existing paradigms

Iron is an essential micronutrient that is problematic for biological systems since it is toxic as it generates free radicals by interconverting between ferrous (Fe²⁺) and ferric (Fe³⁺) forms. Additionally, even though iron is abundant, it is largely insoluble so cells must treat biologically available iron as a valuable commodity. Thus elaborate mechanisms have evolved to absorb, re-cycle and store iron while minimizing toxicity. Focusing on rarely encountered situations, most of the existing literature suggests that iron toxicity is common. A more nuanced examination clearly demonstrates that existing regulatory processes are more than adequate to limit the toxicity of iron even in response to iron overload. Only under pathological or artificially harsh situations of exposure to excess iron does it become problematic. Here we review iron metabolism and its toxicity as well as the literature demonstrating that intracellular iron is not toxic but a stress responsive programmed cell death-inducing second messenger.

New developments and controversies in iron metabolism and iron chelation therapy

Iron is essential for all organisms including microbial, cancer and human cells. More than a quarter of the human population is affected by abnormalities of iron metabolism, mainly from iron deficiency and iron overload. Iron also plays an important role in free radical pathology and oxidative damage which is observed in almost all major diseases, cancer and ageing. New developments include the complete treatment of iron overload and reduction of morbidity and mortality in thalassaemia using deferiprone and selected deferiprone/deferoxamine combinations and also the use of the maltol iron complex in the treatment of iron deficiency anaemia. There is also a prospect of using deferiprone as a universal antioxidant in non iron overloaded diseases such as neurodegenerative, cardiovascular, renal, infectious diseases and cancer. New regulatory molecules of iron metabolism such as endogenous and dietary chelating molecules, hepcidin, mitochondrial ferritin and their role in health and disease is under evaluation. Similarly, new mechanisms of iron deposition, removal, distribution and toxicity have been identified using new techniques such as magnetic resonance imaging increasing our understanding of iron metabolic processes and the targeted treatment of related diseases. The uniform distribution of iron in iron overload between organs and within each organ is no longer valid. Several other controversies such as the toxicity impact of non transferrin bound iron vs injected iron, the excess levels of iron in tissues causing toxicity and the role of chelation on iron absorption need further investigation. Commercial interests of pharmaceutical companies and connections to leading journals are playing a crucial role in shaping worldwide medical opinion on drug sales and use but also patients' therapeutic outcome and safety. Major controversies include the selection criteria and risk/benefit assessment in the use of deferasirox in thalassaemia and more so in idiopathic haemochromatosis, thalassaemia intermedia and ex-thalassaemia transplanted patients who are safely treated with venesection. Iron chelating drugs can override normal regulatory pathways, correct iron imbalance and minimise iron toxicity. The use of iron chelating drugs as main, alternative or adjuvant therapy is in progress in many conditions, especially those with non established or effective therapies.

Iron-induced gastric ulceration with radiological and endoscopic appearance of carcinoma

Erosive injury of the upper gastrointestinal tract resulting from therapeutic oral iron supplements is an uncommon phenomenon. We present a case of a large gastric ulcer with clinical, endoscopic and radiological features suggestive of malignancy, which resolved completely on cessation of iron therapy.

Serum ferritin is an important inflammatory disease marker, as it is mainly a leakage product from damaged cells

"Serum ferritin" presents a paradox, as the iron storage protein ferritin is not synthesised in serum yet is to be found there. Serum ferritin is also a well known inflammatory marker, but it is unclear whether serum ferritin reflects or causes inflammation, or whether it is involved in an inflammatory cycle. We argue here that serum ferritin arises from damaged cells, and is thus a marker of cellular damage. The protein in serum ferritin is considered benign, but it has lost (i.e. dumped) most of its normal complement of iron which when unliganded is highly toxic. The facts that serum ferritin levels can correlate with both disease and with body iron stores are thus expected on simple chemical kinetic grounds. Serum ferritin levels also correlate with other phenotypic readouts such as erythrocyte morphology. Overall, this systems approach serves to explain a number of apparent paradoxes of serum ferritin, including (i) why it correlates with biomarkers of cell damage, (ii) why it correlates with biomarkers of hydroxyl radical formation (and oxidative stress) and (iii) therefore why it correlates with the presence and/or severity of numerous diseases. This leads to suggestions for how one might exploit the corollaries of the recognition that serum ferritin levels mainly represent a consequence of cell stress and damage.

Unusual clotting dynamics of plasma supplemented with iron(III)

Iron salts are used in the treatment of iron deficiency anemia. Diabetic patients are frequently anemic and treatment includes administration of iron. Anemic patients on hemodialysis are at an increased risk of thromboembolic coronary events associated with the formation of dense fibrin clots resistant to fibrinolysis. Moreover, in chronic kidney disease patients, high labile plasma iron levels associated with iron supplementation are involved in complications found in dialyzed patients such as myocardial infarction. The aim of the present study was to investigate whether iron treatment is involved in the formation of the fibrin clots. Clotting of citrated plasma supplemented with Fe(3+) was investigated by thromboelastometry and electron microscopy. The results revealed that iron modifies coagulation in a complex manner. FeCl(3) stock solution underwent gradual chemical modification during storage and altered the coagulation profile over 29 days, suggesting that Fe(3+) interacts with both proteins of the coagulation cascade as well as the hydrolytic Fe(3+) species. Iron extends clotting of plasma by interacting with proteins of the coagulation cascade. Fe(3+) and/or its hydrolytic species interact with fibrinogen and/or fibrin changing their morphology and properties. In general FeCl(3) weakens the fibrin clot while at the same time precipitating plasma proteins immediately after application. Fe(3+) or its derivatives induced the formation of insoluble coagulums in non-enzymatic reactions including albumin and transferrin. Iron plays a role in coagulation and can precipitate plasma proteins. The formation of coagulums resistant to lysis in non‑enzymatic reactions can increase the risk of thrombosis, and extending clotting of plasma can prolong bleeding.

Mathematical calculations of iron complex stoichiometry by direct UV-Vis spectrophotometry

The effects of iron-chelating agents on miscellaneous pathologies are currently largely tested. Due to various indications, different properties for chelators are required. A stoichiometry of the complex in relation to pH is one of the crucial factors. Moreover, the published data on the stoichiometry, especially concerning flavonoids, are equivocal. In this study, a new complementary approach was employed for the determination of stoichiometry in 10 iron-chelating agents, including clinically used drugs, by UV-Vis spectrophotometry at relevant pH conditions and compared with the standard Job's method. This study showed that the simple approach based on absorbance at the wavelength of complex absorption maximum was sufficient when the difference between absorption maximum of substance and complex was high. However, in majority of substances this difference was much lower (9-73 nm). The novel complementary approach was able to determine the stoichiometry in all tested cases. The major benefit of this method compared to the standard Job's approach seems to be its capability to reveal a reaction stoichiometry in chelators with moderate affinity to iron. In conclusion, using this complementary method may explain several previous contradictory data and lead to a better understanding of the underlying mechanisms of chelator's action.

Iron autointoxication in a 16-year-old girl: a protective role for hepcidin?

Intentional iron overdose appears to be an increasingly common form of attempted suicide. We present a case of iron overdose in a 16-year-old girl who was found unconscious in her bed and brought to our emergency department. The most remarkable diagnostic findings were the patient's comatose condition, divergent eye position and positive Babinski foot pad reflexes. Laboratory tests showed hyperglycaemia and mild metabolic acidosis. A computed tomography scan of the cerebrum showed no signs of intracerebral haemorrhage or elevated intracerebral pressure. Toxicology screening showed no use of acetaminophen, ethanol or drugs of abuse. The patient was stabilized and monitored on the intensive care ward. When she woke up, she confessed to having taken Fero-Gradumet(®). Retrospectively analysed, the serum iron concentration in the first blood sample (seven hours after ingestion) was 62 μmol/L which corresponds with moderate iron intoxication. The patient received whole bowel irrigation with 2 L polyethyleneglycol solution and de-ironing treatment with intravenous deferoxamine 20 mg/kg in eight hours. She was discharged from the hospital after three days in a good clinical condition. Retrospectively, serum hepcidin concentrations were determined and evaluated in conjunction with serum iron concentrations and the installed treatment. Before medical de-ironing interventions were started, we saw that the serum iron concentration in our patient was already declining. At the same time, we observed a sharp increase in the serum hepcidin concentration. After normalization of serum iron concentrations, hepcidin normalized as well.