The clinical toxicology of sodium hypochlorite Slaughter, Robin J.; Watts, Martin; Vale, J. Allister ...
Clinical toxicology (Philadelphia, Pa.),
05/2019, Letnik:
57, Številka:
5
Journal Article
Recenzirano
Introduction: Sodium hypochlorite is used as a bleaching and disinfecting agent and is commonly found in household bleach.
Objective: The objective is to review critically the epidemiology, ...mechanisms of toxicity, clinical features, diagnosis, and management of hypochlorite poisoning.
Methods: PubMed was searched from January 1950 to June 2018 using the terms "Hypochlorite", "Sodium Hypochlorite", "Sodium Oxychloride", "Hypochlorous Acid", "Bleach", "Chlorine Bleach", in combination with the keywords "poisoning", "poison", "toxicity", "ingestion", "adverse effects", "overdose", and "intoxication". In addition, bibliographies of identified articles were screened for additional relevant studies including non-indexed reports. Non-peer-reviewed sources were also included. These searches produced 110 citations which were considered relevant.
Epidemiology: There is limited information regarding statistical trends on world-wide poisoning from sodium hypochlorite. In the United States of America, poison control center data have shown that enquiries regarding hypochlorite bleaches have ranged from 43,000 to 46,000 per year over the period 2012-2016.
Mechanisms of toxicity: Hypochlorite's potential to cause toxicity is related to its oxidizing capacity and the pH of the solution. Toxicity arises from its corrosive activity upon contact with mucous membranes and skin.
Features following ingestion: While small accidental ingestions are very unlikely to cause clinically significant toxicity, large ingestions may cause corrosive gastrointestinal injury and systemic effects, including metabolic acidosis, hypernatremia, and hyperchloremia.
Features following dental exposure: Hypochlorite is used extensively by dentists for cleaning root canals and is safe if the solution remains within the root canal. Extrusions into the periapical area can result in severe pain with localized large and diffuse swelling and hemorrhage.
Features following skin exposure: Prolonged or extensive exposure may cause skin irritation and damage to the skin or dermal hypersensitivity. Such exposures can result in either immediate or delayed-type skin reactions. High concentration solutions have caused severe chemical skin burns.
Features following inhalation: Although there are only limited data, inhalation of hypochlorite alone is likely to lead to no more than mild irritation of the upper airways.
Features following ocular exposure: Corneal injuries from ocular exposure are generally mild with burning discomfort and superficial disturbance of the corneal epithelium with recovery within 1 or 2 days. With higher concentration solutions, severe eye irritation can occur.
Diagnosis: The diagnosis can typically be made on the basis of a careful history, including details of the specific product used, its hypochlorite concentration, and the amount involved. As hypochlorite bleach produces a characteristic smell of chlorine, this may provide a diagnostic clue. In severe cases, corrosive injury is suggested on presentation because of hypersalivation, difficulty swallowing, retrosternal pain or hematemesis.
Management: Symptom-directed supportive care is the mainstay of management. Gastrointestinal decontamination is not beneficial. Local corrosive injury is the major focus of treatment in severe cases. Fiberoptic endoscopy and CT thorax/abdomen are complimentary and have been shown to be useful in corrosive injuries in assessing the severity of injury, risk of mortality and risk of subsequent stricture formation and should be performed as soon as possible after ingestion. Dental periapical extrusion injuries should be left open for some minutes to allow bleeding through the tooth and to limit hematoma development in tissue spaces. Once the bleeding has ceased, the canal can be dressed with non-setting calcium hydroxide and sealed coronally.
Conclusions: Accidental ingestion of household bleach is not normally of clinical significance. However, those who ingest a large amount of a dilute formulation or a high concentration preparation can develop severe, and rarely fatal, corrosive injury so prompt supportive care is essential as there is no specific antidote. Treatment primarily consists of symptom-directed supportive care.
Celotno besedilo
Dostopno za:
DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The Offset Dykes of the ∼1.85 Ga ∼200 km-diameter Sudbury impact structure formed by the injection of impact melt from embayment structures in the Sudbury Igneous Complex (SIC) – the ∼3–5 km thick ...impact melt sheet – into the footwall of the crater. Despite having been recognized over a century ago and being the sites for several world-class ore deposits, the timing and emplacement mechanism of the Offset Dykes remains debated. In this contribution we document the geological, geochemical, and mineralogical relationships in the North Range Offset Dykes – the Hess, Trill, Ministic, Cascaden, Pele, Foy, Parkin, Whistle, and Rathbun dykes – and the implications for their injection, crystallization, and differentiation history.
The Offset Dykes are locally referred to as “quartz diorite” and typically comprise a groundmass of plagioclase, amphibole, and biotite, with varying amounts of pyroxene, quartz, oxides, and sulfides. While it is common for the centre of the dykes to be enriched in sulfides and lithic inclusions (“IQD”) and with inclusion- and sulfide-poor margins (“QD”), the Pele dyke is entirely inclusion-free, and is considerably more evolved and depleted in Ni and Cu relative to the other North Range Offset Dykes. A unit of recrystallized breccia termed “metabreccia” is commonly entrained as inclusions within the QD and IQD, with a greater abundance near the embayment structures and the SIC.
From observations of other impact structures, it is apparent that the base of the impact melt sheet would be laden with clasts early on. Our synthesis thus leads to a model of formation where an injection of clast- and sulfide-rich melt is separated into a clast-rich centre and a clast-poor margin via a process known as flow differentiation. After some differentiation of the melt sheet had occurred, ongoing tectonism in the region opened fracture systems into which chemically evolved clast-poor melt, formed after sulfide saturation of the melt sheet, was emplaced to form the Pele Offset Dyke. We note that the presence of quenched margins along some sections of some Offset Dykes requiring an injection of sulfide-free and clast-free melt is not readily addressed in the model presented here and should be a focus for future investigations. The reason for the major differences between the North Range Offset Dykes discussed here, and their counterparts in the South Range, also remain unanswered.
•A model of emplacement is proposed for the North Range Offset Dykes.•Emplacement could not have occurred during excavation or early crater modification.•Early intrusions are likely clast-rich due to the enrichment of clasts at the base.•One of the dykes was emplaced from a more chemically-evolved melt sheet.•North Range metabreccia is metamorphosed and thermally overprinted footwall breccia.
The AZURE trial is an ongoing phase III, academic, multi-centre, randomised trial designed to evaluate the role of zoledronic acid (ZOL) in the adjuvant therapy of women with stage II/III breast ...cancer. Here, we report the safety and tolerability profile of ZOL in this setting. Eligible patients received (neo)adjuvant chemotherapy and/or endocrine therapy and were randomised to receive neither additional treatment nor intravenous ZOL 4 mg. ZOL was administered after each chemotherapy cycle to exploit potential sequence-dependent synergy. ZOL was continued for 60 months post-randomisation (six doses in the first 6 months, eight doses in the following 24 months and five doses in the final 30 months). Serious (SAE) and non-serious adverse event (AE) data generated during the first 36 months on study were analysed for the safety population. 3,360 patients were recruited to the AZURE trial. The safety population comprised 3,340 patients (ZOL 1,665; control 1,675). The addition of ZOL to standard treatment did not significantly impact on chemotherapy delivery. SAE were similar in both treatment arms. No significant safety differences were seen apart from the occurrence of osteonecrosis of the jaw (ONJ) in the ZOL group (11 confirmed cases; 0.7%; 95% confidence interval 0.3–1.1%). ZOL in the adjuvant setting is well tolerated, and can be safely administered in addition to adjuvant therapy including chemotherapy. The adverse events were consistent with the known safety profile of ZOL, with a low incidence of ONJ.
Background
Single‐centre series of the management of patients with ruptured abdominal aortic aneurysm (AAA) are usually too small to identify clinical factors that could improve patient outcomes.
...Methods
IMPROVE is a pragmatic, multicentre randomized clinical trial in which eligible patients with a clinical diagnosis of ruptured aneurysm were allocated to a strategy of endovascular aneurysm repair (EVAR) or to open repair. The influences of time and manner of hospital presentation, fluid volume status, type of anaesthesia, type of endovascular repair and time to aneurysm repair on 30‐day mortality were investigated according to a prespecified plan, for the subgroup of patients with a proven diagnosis of ruptured or symptomatic AAA. Adjustment was made for potential confounding factors.
Results
Some 558 of 613 randomized patients had a symptomatic or ruptured aneurysm: diagnostic accuracy was 91·0 per cent. Patients randomized outside routine working hours had higher operative mortality (adjusted odds ratio (OR) 1·47, 95 per cent confidence interval 1·00 to 2·17). Mortality rates after primary and secondary presentation were similar. Lowest systolic blood pressure was strongly and independently associated with 30‐day mortality (51 per cent among those with pressure below 70 mmHg). Patients who received EVAR under local anaesthesia alone had greatly reduced 30‐day mortality compared with those who had general anaesthesia (adjusted OR 0·27, 0·10 to 0·70).
Conclusion
These findings suggest that the outcome of ruptured AAA might be improved by wider use of local anaesthesia for EVAR and that a minimum blood pressure of 70 mmHg is too low a threshold for permissive hypotension.
Useful lessons learned
The 1.85 Ga Sudbury impact structure is considered a remnant of a peak-ring or multi-ring basin with an estimated original diameter of 150 to 200 km. The Offset Dikes are radial and concentric dikes ...around the Sudbury Igneous Complex (SIC) and are composed of the so-called inclusion-rich Quartz Diorite (IQD) and inclusion-poor Quartz Diorite (QD), and in some Offset Dikes, Metabreccia (MTBX). We carried out a detailed field and analytical investigation of MTBX from the Parkin Offset Dike in the North Range of the Sudbury structure. Our observations suggest that MTBX represents impact breccia that originally formed underneath the Main Mass of the SIC and that was subsequently contact-metamorphosed and entrained during the emplacement of the Parkin Offset Dike. The MTBX bears no resemblance to the QD and IQD in which it is hosted, but it does share many similarities with Footwall Breccia (FWBX), suggesting that the two shared a similar initial origin. A genetic relationship between MTBX and FWBX is also supported by whole rock geochemical analyses.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Anaesthetic medication administration errors are a significant threat to patient safety. In 2002, we began collecting data about the rate and nature of anaesthetic medication errors and implemented a ...variety of measures to reduce errors.
Facilitated self-reporting of errors was carried out in 2002–2003. Subsequently, a medication safety bundle including ‘smart’ infusion pumps were implemented. During 2014 facilitated self-reporting commenced again. A barcode-based medication safety system was then implemented and the facilitated self-reporting was continued through 2015.
During 2002–2003, a total of 11 709 paper forms were returned. There were 73 reports of errors (0.62% of anaesthetics) and 27 reports of intercepted errors (0.23%). During 2014, 14 572 computerised forms were completed. There were 57 reports of errors (0.39%) and 11 reports of intercepted errors (0.075%). Errors associated with medication infusions were reduced in comparison with those recorded in 2002–2003 (P<0.001). The rate of syringe swap error was also reduced (P=0.001). The reduction in error rate between 2002–2003 and 2014 was statistically significant (P=0.0076 and P=0.001 for errors and intercepted errors, respectively). From December 2014 through December 2015, 24 264 computerised forms were completed after implementation of a barcode-based medication safety system. There were 56 reports of errors (0.23%) and six reports of intercepted errors (0.025%). Vial swap errors in 2014–2015 were significantly reduced compared with those in 2014 (P=0.004). The reduction in error rate after implementation of the barcode-based medication safety system was statistically significant (P=0.0045 and P=0.021 for errors and intercepted errors, respectively).
Reforms intended to reduce medication errors were associated with substantial improvement.
Uncomplicated acute appendicitis can be managed with non-operative (antibiotic) treatment, but laparoscopic appendicectomy remains the first-line management in the UK. During the COVID-19 pandemic ...the practice altered, with more patients offered antibiotics as treatment. A large-scale observational study was designed comparing operative and non-operative management of appendicitis. The aim of this study was to evaluate 90-day follow-up.
A prospective, cohort study at 97 sites in the UK and Republic of Ireland included adult patients with a clinical or radiological diagnosis of appendicitis that either had surgery or non-operative management. Propensity score matching was conducted using age, sex, BMI, frailty, co-morbidity, Adult Appendicitis Score and C-reactive protein. Outcomes were 90-day treatment failure in the non-operative group, and in the matched groups 30-day complications, length of hospital stay (LOS) and total healthcare costs associated with each treatment.
A total of 3420 patients were recorded: 1402 (41 per cent) had initial antibiotic management and 2018 (59 per cent) had appendicectomy. At 90-day follow-up, antibiotics were successful in 80 per cent (1116) of cases. After propensity score matching (2444 patients), fewer overall complications (OR 0.36 (95 per cent c.i. 0.26 to 0.50)) and a shorter median LOS (2.5 versus 3 days, P < 0.001) were noted in the antibiotic management group. Accounting for interval appendicectomy rates, the mean total cost was €1034 lower per patient managed without surgery.
This study found that antibiotics is an alternative first-line treatment for adult acute appendicitis and can lead to cost reductions.
There is little evidence on the cost effectiveness of different brands of hip prostheses. We compared lifetime cost effectiveness of frequently used brands within types of prosthesis including ...cemented (Exeter V40 Contemporary, Exeter V40 Duration and Exeter V40 Elite Plus Ogee), cementless (Corail Pinnacle, Accolade Trident, and Taperloc Exceed) and hybrid (Exeter V40 Trilogy, Exeter V40 Trident, and CPT Trilogy). We used data from three linked English national databases to estimate the lifetime risk of revision, quality-adjusted life years (QALYs) and cost. For women with osteoarthritis aged 70 years, the Exeter V40 Elite Plus Ogee had the lowest risk of revision (5.9% revision risk, 9.0 QALYs) and the CPT Trilogy had the highest QALYs (10.9% revision risk, 9.3 QALYs). Compared with the Corail Pinnacle (9.3% revision risk, 9.22 QALYs), the most commonly used brand, and assuming a willingness-to-pay of £20,000 per QALY gain, the CPT Trilogy is most cost effective, with an incremental net monetary benefit of £876. Differences in cost effectiveness between the hybrid CPT Trilogy and Exeter V40 Trident and the cementless Corail Pinnacle and Taperloc Exceed were small, and a cautious interpretation is required, given the limitations of the available information. However, it is unlikely that cemented brands are among the most cost effective. Similar patterns of results were observed for men and other ages. The gain in quality of life after total hip arthroplasty, rather than the risk of revision, was the main driver of cost effectiveness. Cite this article: Bone Joint J 2015;97-B:762-70.
Summary
The effectiveness of emergency surgery vs. non‐emergency surgery strategies for emergency admissions with acute appendicitis, gallstone disease, diverticular disease, abdominal wall hernia or ...intestinal obstruction is unknown. Data on emergency admissions for adult patients from 2010 to 2019 at 175 acute National Health Service hospitals in England were extracted from the Hospital Episode Statistics database. Cohort sizes were: 268,144 (appendicitis); 240,977 (gallstone disease); 138,869 (diverticular disease); 106,432 (hernia); and 133,073 (intestinal obstruction). The primary outcome was number of days alive and out of hospital at 90 days. The effectiveness of emergency surgery vs. non‐emergency surgery strategies was estimated using an instrumental variable design and is reported for the cohort and pre‐specified sub‐groups (age, sex, number of comorbidities and frailty level). Average days alive and out of hospital at 90 days for all five cohorts were similar, with the following mean differences (95%CI) for emergency surgery minus non‐emergency surgery after adjusting for confounding: −0.73 days (−2.10–0.64) for appendicitis; 0.60 (−0.10–1.30) for gallstone disease; −2.66 (−15.7–10.4) for diverticular disease; −0.07 (−2.40–2.25) for hernia; and 3.32 (−3.13–9.76) for intestinal obstruction. For patients with ‘severe frailty’, mean differences (95%CI) in days alive and out of hospital for emergency surgery were lower than for non‐emergency surgery strategies: −21.0 (−27.4 to −14.6) for appendicitis; −5.72 (−11.3 to −0.2) for gallstone disease, −38.9 (−63.3 to −14.6) for diverticular disease; −19.5 (−26.6 to −12.3) for hernia; and − 34.5 (−46.7 to −22.4) for intestinal obstruction. For patients without frailty, the mean differences (95%CI) in days alive and out of hospital were: −0.18 (−1.56–1.20) for appendicitis; 0.93 (0.48–1.39) for gallstone disease; 5.35 (−2.56–13.28) for diverticular disease; 2.26 (0.37–4.15) for hernia; and 18.2 (14.8–22.47) for intestinal obstruction. Emergency surgery and non‐emergency surgery strategies led to similar average days alive and out of hospital at 90 days for five acute conditions. The comparative effectiveness of emergency surgery and non‐emergency surgery strategies for these conditions may be modified by patient factors.
Large impact structures have complex morphologies, with zones of structural uplift that can be expressed topographically as central peaks and/or peak rings internal to the crater rim. The formation ...of these structures requires transient strength reduction in the target material and one of the proposed mechanisms to explain this behavior is acoustic fluidization. Here, samples of shock‐metamorphosed quartz‐bearing lithologies at the West Clearwater Lake impact structure, Canada, are used to estimate the maximum recorded shock pressures in three dimensions across the crater. These measurements demonstrate that the currently observed distribution of shock metamorphism is strongly controlled by the formation of the structural uplift. The distribution of peak shock pressures, together with apparent crater morphology and geological observations, is compared with numerical impact simulations to constrain parameters used in the block‐model implementation of acoustic fluidization. The numerical simulations produce craters that are consistent with morphological and geological observations. The results show that the regeneration of acoustic energy must be an important feature of acoustic fluidization in crater collapse, and should be included in future implementations. Based on the comparison between observational data and impact simulations, we conclude that the West Clearwater Lake structure had an original rim (final crater) diameter of 35–40 km and has since experienced up to ~2 km of differential erosion.
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