Button Battery Ingestion in Children (PilBouTox®): A Prospective Study Describing the Clinical Course and Identifying Factors Related to Esophageal Impaction or Severe Cases

In this study, we aimed to identify the factors related to esophageal impaction following button battery (BB) ingestion in children. PilBouTox, a prospective multicentric observational cohort study, was conducted from French Poison Control Centers between June 1, 2016 and May 31, 2018. Children (0-12 years old) with BB ingestion were included. After ingestion, patients were monitored for 21 days or more if they remained symptomatic (maximum 1 year). Causes of ingestion, clinical manifestations, medical management, and the outcomes were recorded. In total, 415 patients were included; among them, 35 had esophageal impaction and 14 had severe complications or died. Seven symptoms were closely related (relative risk (RR) > 30) to esophageal impaction: anorexia, drooling, dyspnea, fever, hemodynamic instability, pallor, and pain. Furthermore, BBs > 15 mm were related to esophageal impaction (RR = 19, CI_95% [4.1; 88]). The absence of initial symptoms was a protective factor for esophageal impaction (RR = 0.013, CI_95% [0.002; 0.1]). Nine symptoms were closely related (RR > 30) to major effects and death: dyspnea, cough, dysphagia, drooling, fever, hemodynamic instability, pain, pallor, and vomiting. Seven symptoms were related to esophageal impaction and their rapid recognition could help to ensure that the patient is taken to a health care facility. Nine factors were related to the major effects of BB ingestion. We recommended an X-ray as soon as possible to determine the position of the BB.Trial Registry: Clinical Trial ID: NCT03708250, https://clinicaltrials.gov/ct2/show/NCT03708250.

Whole-bowel irrigation in cases of poisoning: A retrospective multicentre study of feasibility, tolerability, and effectiveness

BACKGROUND

Whole-bowel irrigation (WBI) is a strategy of gastrointestinal decontamination, recommended by several European and American learned societies, which may be used in the management of the poisoned patients.

OBJECTIVES

The objectives of this study were to describe the feasibility and tolerability of this technique and to compare the clinical outcome of a group of poisoned patients treated with WBI versus that of an untreated group.

METHODS

This was a retrospective and observational study of data recorded by the Angers Poison Control Centre (PCC) between 2012 and 2018. All cases for which the PCC advised WBI were included. The association between outcomes (clinical deterioration after WBI advised by a PCC, length of hospitalisation), WBI treatment, and relevant associated risk factors was determined using univariate and multivariate logistic regression.

RESULTS

A total of 257 patients were included. One hundred forty-one patients were treated with WBI with clearly successful induction of diarrhoea in 47 cases (31%). WBI was not initiated in 89 patients. WBI was initiated but unsuccessful (no diarrhoea) in nine cases. The median age is 46 years (interquartile range: 32-55 years), with a sex ratio (M/F) of 1.3. A total of 27 of 150 patients (18%) who underwent WBI had adverse effects possibly linked to WBI, mainly vomiting (n=23). The patients with clinical deterioration (n=49) were irrigated significantly less often (95% confidence interval: 0.13-0.52; p<0.001). After adjustment for sex, age, time to implementation of WBI, type of substance ingested, and admission to intensive care, patients who were treated with WBI were less likely to deteriorate clinically than patients who were not treated with WBI (p<0.001).

CONCLUSION

Despite a low rate of completion of this procedure, WBI appeared to provide clinical benefits in patients treated in comparison of an untreated group and is associated with an acceptably low risk of direct complications.

A Protocol for the Use of Case Reports/Studies and Case Series in Systematic Reviews for Clinical Toxicology

Introduction: Systematic reviews are routinely used to synthesize current science and evaluate the evidential strength and quality of resulting recommendations. For specific events, such as rare acute poisonings or preliminary reports of new drugs, we posit that case reports/studies and case series (human subjects research with no control group) may provide important evidence for systematic reviews. Our aim, therefore, is to present a protocol that uses rigorous selection criteria, to distinguish high quality case reports/studies and case series for inclusion in systematic reviews.

Methods: This protocol will adapt the existing Navigation Guide methodology for specific inclusion of case studies. The usual procedure for systematic reviews will be followed. Case reports/studies and case series will be specified in the search strategy and included in separate sections. Data from these sources will be extracted and where possible, quantitatively synthesized. Criteria for integrating cases reports/studies and case series into the overall body of evidence are that these studies will need to be well-documented, scientifically rigorous, and follow ethical practices. The instructions and standards for evaluating risk of bias will be based on the Navigation Guide. The risk of bias, quality of evidence and the strength of recommendations will be assessed by two independent review teams that are blinded to each other.

Conclusion: This is a protocol specified for systematic reviews that use case reports/studies and case series to evaluate the quality of evidence and strength of recommendations in disciplines like clinical toxicology, where case reports/studies are the norm.

Mise au point sur les intoxications au baclofène et son syndrome de sevrage

Le baclofène, initialement utilisé comme traitement antispastique, est depuis plusieurs années prescrit chez les patients alcoolodépendants pour favoriser le sevrage alcoolique. La France présente la spécificité d’avoir autorisé la mise sur le marché du baclofène dans cette indication depuis 2018. Les patients alcoolodépendants présentent un risque accru de tentative de suicide, notamment par intoxication volontaire.  L’incidence des intoxications volontaires au baclofène s’est majoré sur la dernière décennie. Comparativement aux autres intoxications, celle-ci présente un recours fréquent à la ventilation mécanique (50% des cas) et une léthalité significative (plus de 2% des cas). Le toxidrome de l’intoxication aiguë au baclofène se résume principalement à une dépression du système nerveux central, pouvant aller de la sédation jusqu’au coma, et nécessitant une surveillance continue pour des doses suspectées ingérées supérieures à 200 mg. Le dosage plasmatique du baclofène permet de confirmer le diagnostic et de suivre l’évolution de l’élimination de la molécule. La principale voie d’élimination est rénale, motivant une surveillance accrue de la fonction rénale dans ce contexte. L’épuration extrarénale pourra se discuter dans les intoxications les plus sévères associées à une insuffisance rénale aiguë. Le reste de la prise en charge reste symptomatique, sans antidote existant. Le syndrome de sevrage au baclofène se rencontre lors d’un arrêt brutal du traitement, et peut être composé des symptômes suivants : spasticité, hyperthermie, agitation, rhabdomyolyse. Il peut compliquer l’hospitalisation de patients traités au long cours admis pour une intoxication aiguë. Son traitement nécessite une réintroduction précautionneuse du baclofène.

Identification of the origin of infantile saturnism based on lead isotopic and elemental ratios

BACKGROUND

In France, the prevalence of childhood lead poisoning is becoming rare since the avoidance of lead in paints in 1949 and the gradual replacement of water pipes. Chronic lead toxicity is well known and is well correlated to blood lead concentration.

AIM

Here we report a case of severe lead poisoning occurring in a young female child with a pica behavior.

METHODS

A blood sample and four environmental samples were analyzed using inductively coupled plasma- mass spectrometry (ICP-MS). Lead concentration, lead isotopes and elemental ratios were compared.

RESULTS

The determination of ²⁰⁸Pb/²⁰⁶Pb, ²⁰⁶Pb/²⁰⁷Pb and Cd/Pb has allowed us to identify the origin of lead poisoning.

DISCUSSION-CONCLUSION

The source of contamination was eliminated and the child benefited from a psychological and medical follow up. Her outcome was positive. This case illustrated the potential interest of the use of elemental and isotopic ratios for clinical practice as the ICP-MS measurement has allowed a quick response and a rapid eviction of the contamination's source.

[Promoting access to health care among deaf and hard of hearing youth: the example of the internet training workshops]

Social inequalities in health remain a major problem in France despite recent efforts to improve access to prevention and care. In France, the reduction of inequalities involves many actors, including the Instances régionales d'education et de promotion de la santé (IREPS, the Regional Authorities for Health Education and Promotion). This paper focuses on health education for deaf and hard of hearing youth. The educational team responsible for providing health education among this population has highlighted the dangers of internet use among deaf and hard of hearing youth. The overall objective is to "promote the critical and responsible use of the Internet", focusing in particular on social and technical skills. The project is a long-term intervention based on the active involvement of the educational team and the participating youth. Another objective of the project is to enable participants to contribute to online resources. This has involved using QR codes to create digital resources. The study found high levels of satisfaction among all the participants. These findings provide further evidence of the importance of providing health education to deaf and hard of hearing people.