Yedidia Bentur

The Arum palaestinum plant is one of the 26 species of the Arum genus of the Araceae family. This plant species is found through the Mediterranean region, Western Asia, and Europe. The leaves and seeds of the plant contain needle-shaped oxalate crystals that can irritate the affected tissue (skin, oral cavity, or GI tract) upon exposure. Up to this date, there is no available literature supporting the epidemiology or the clinical manifestations of poisoning by this plant. We retrospectively reviewed all Arum palaestinum exposures to children younger than 18 years of age reported to the Israel National Poison Information Center during 2017 from the IPIC computerized data system. We extracted demographic data and clinical data from those digital files. We reviewed the files of 53 patients’ files and found slight male predominance (58% vs. 42%), and the age of exposure ranged from 9 month to 15 years. The main site of exposure was at home in most cases (47%) followed by outdoor exposure in 40% of the cases. In 66% of the cases, minor clinical manifestations were reported, mainly erythema and mouth irritation, agitation, and drooling. Asymptomatic patients composed 34% of the cases. In 17% of the cases, patients were recommended to visit an ambulatory facility, and other 15% of the cases were referred to the emergency department. There were no cases of severe poisoning, upper airways compromise, or death. Conclusion: Poisoning by Arum palaestinum is one of the most common pediatric plant poisoning in Israel. Our study supports with clinical data for the first time that this poisoning is self-limited, confined to the affected mucosa, and most likely does not necessitate any intervention. What is Known • A. palaestinum poisoning is one of the most common pediatric plant poisoning in Israel. • The leaves and seeds of the plant contain needle-shaped oxalates crystals. What is New • Pediatric exposure to A. palaestinum usually causes only mild and self-limited poisoning. • Expectant observation is the preferred management of such exposure.

Background: The Israel Poison Information Center (IPIC), Rambam Health Care Campus, provides 24-hour telephone consultations on clinical toxicology and drug and reproductive toxicology information. It participates in research, teaching and regulatory activities, and provides laboratory services. In 2014, nurse specialists in poison information joined the IPIC. Objectives: To report the epidemiology of poison exposures in Israel. Methods: We present computerized queries and a descriptive analysis of the medical records database of the IPIC for 2017. Results: A total of 39,928 poison exposure cases were recorded, reflecting increases of 226.3% and 26.7% compared with 1995 and 2012, respectively. Children < 6 years of age were involved in 47.0% of cases; 80.4% of calls were made by the public and 17.8% by physicians; 74.2% of exposures were unintentional and 7.3% intentional. Pharmaceuticals were involved in 51.4% of cases, chemicals in 36.9%, bites and stings in 2.2%, and plants and mushrooms in 1.5%. Substances most frequently involved were analgesics, cleaning products, and antimicrobials. Clinical severity was moderate/major in 3.3%, mainly due to insecticides, drugs of abuse, and corrosives. Three fatalities were recorded (due to colchicine, organophosphates, and volatile substance inhalant abuse). Conclusions: Poison exposures and poisonings have markedly increased in Israel, contributing substantially to morbidity. The IPIC prevented unnecessary referrals to emergency departments. Its database is a valuable national resource for collecting and monitoring poisonings and poison exposure cases. It can be used as a real-time surveillance system for the benefit of public health. It is recommended that reporting to the IPIC become mandatory, and its activities adequately supported by national resources.

Context: Plotosus lineatus is a venomous fish that has migrated from the Indo-Pacific region to the Mediterranean Sea (Lessepsian migrant). Its presence in the Mediterranean Sea was first recorded in 2002 and was observed in growing schools. Its spines contain toxins with lytic, hemolytic and edematous activities. Objective: To characterize the injuries caused by Plotosus lineatus in the Southeastern Mediterranean Sea. Methods: A prospective observational case series of consultations provided by a national Poison Center pertaining to Plotosus lineatus from 2007 to 2016. Demographic and clinical data and method of fish identification were retrieved from the medical toxicological records, and described. Results: Eighty four cases were included; the main findings are: median age 35 (range 3–80) years, 91.7% males, 51.2% fishermen, 78.6% palm injuries, 94% and 4.8% were mildly and moderately injured, respectively. Main local manifestations included pain, puncture wound, swelling, and erythema (90.5%, 70.2%, 33.3%, and 16.7%, respectively). Systemic signs were minor and infrequent (≤7.1%), including hypertension, tachycardia, vomiting, chills, and weakness. Management included wound disinfection, immersion in hot water, tetanus prophylaxis, and analgesics. No patient required hospital admission. The fish was identified mostly by the victim with the aid of the Poison Center (mainly by typical description, and a picture), and some by marine biologists. Conclusions: Plotosus lineatus is a new fish in the Southeastern Mediterranean Sea. It affects fishermen handling fishing nets, and beach hikers stepping on or holding it. Injuries caused by its spines usually result in minor effects; pain may be intense. Treatment includes disinfection, analgesics, and antitetanus and antibiotics as needed. No lethal cases were recorded, unlike exposure of animals to the venom of the Indo-Pacific species; reason is unclear. Our series illustrates the consequences of manmade disruption of ecosystem resulting in invasion of toxic species to a new environment, affecting human health.

Context: To characterize poison exposures in young Israeli military personnel as reported to the national poison center. Methods: Retrospective poison center chart review over a 14-year period. Cases included were Israeli soldiers aged 18–21 years, the compulsory military service age required by the Israeli law. Results: 1770 records of poison exposures in young military personnel were identified. Most exposed individuals involved males (n = 1268, 71.6%). Main routes of exposure were ingestion (n = 854, 48.3%), inhalation (n = 328, 18.6%) and ocular (n = 211, 11.9%). Accidents or misuse (n = 712, 40.2%) were the most frequently reported circumstances, followed by suicide attempts (370, 20.9%), and bites and stings (161, 9.1%). More than half of the cases involved chemicals (n = 939, 53.1%); hydrocarbons, gases and corrosives were the main causative agents. Pharmaceuticals (mainly analgesics) were involved in 519 (29.3%) cases, venomous animals (mainly scorpions, centipedes, and snakes) in 79 (4.5%). Clinical manifestations were reported in 666 (37.6%) cases, mostly gastrointestinal, neurologic, and respiratory. The vast majority of cases (1634, 92.3%) were asymptomatic or mildly affected; no fatalities were recorded. In 831 (46.9%) cases the clinical toxicologist recommended referral to an emergency department; ambulatory observation was recommended in 563 (31.8%) cases, and hospitalization in 86 (4.9%). Conclusions: Our data show that poison exposures among young soldiers involve mainly males, accidents, misuse and suicides, oral route and chemicals; most exposures were asymptomatic or with mild severity. Repeated evaluations of poison center data pertaining to military personnel is advised for identifying trends in poison exposure and characteristics in this particular population.

Exposure to silica gel, a common desiccant, is considered common and non-toxic although data are limited. To evaluate the characteristics of silica gel ingestion, and to attempt to estimate the associated health care costs. We conducted a one year retrospective review of charts of a national poison information center to characterize ingestions of silica gel and estimate its direct cost to health care services. Cost evaluation was based on emergency department and community clinic tariffs (NIS 807/US$ 213 and NIS 253/US$ 67, respectively). A total of 546 cases were recorded, 2.1% of the annual calls to the poison information center. Most ingestions occurred in children younger than 6 years old (91.4%, 65.2% < 2 years). Median monthly exposure was 42; the peak (74) occurred in April, before the Passover holiday. Sixty calls (11%) came from health care facilities and the rest were reported by the public; 2.7% were symptomatic, mainly mild self-limited mouth and throat discomfort. The direct annual treatment cost of patients who referred themselves to health care facilities without consulting first with the Poison Center (n = 60) was NIS 24,598/US$ 6507 (emergency department and community clinic visit fees). Silica gel ingestion is relatively common, occurring mainly in young children; it is rarely symptomatic but is a source of unnecessary referrals to health care facilities. The potential annual saving by preventing unnecessary referrals due to poison information center advice was estimated at NIS 375,678/US$ 99,383. The availability of poison information center services may prevent unnecessary referrals to health care facilities and thus save costs.

The Israel National Poison Information Center (IPIC), Rambam Health Care Campus, provides 24 hour telephone consultations in clinical toxicology as well as drug and teratogen information. It participates in research, teaching and regulatory activities, and also provides laboratory services. To report data on the epidemiology of poisonings and poison exposures in Israel. We made computerized queries and descriptive analyses of the medical records database of the IPIC during 2012. A total of 31,519 poison exposure cases were recorded, a 157.6% increase compared with 1995. Children < 6 years of age were involved in 43.1% of cases; 74.0% of calls were made by the public and 23.7% by physicians; 74.8% of exposures were unintentional and 9.1% intentional. Chemicals were involved in 35.8% of all cases (single and multiple substances), pharmaceuticals in 48.8%, bites and stings in 3.8%, and plants and mushrooms in 1.6%. Substances most frequently involved were analgesics, cleaning products and antimicrobials. Clinical severity was moderate/major in 3.4%. Substances most frequently involved in moderate/major exposures were corrosives, insecticides and snake venom. Four fatalities were recorded; all were intentional exposures in adults (corrosive, medications, energy drink). Poison exposures and poisonings have increased significantly and have contributed substantially to morbidity and mortality in Israel. The IPIC database is a valuable national resource for the collection and monitoring of poisoning exposure cases. It can be used as a real-time surveillance system for the benefit of public health. It is recommended that reporting to the IPIC become mandatory and its activities be adequately supported by national resources.

Medication errors (ME) are a major concern to healthcare systems. Most studies evaluated ME occurring in healthcare facilities; only few focused on ME outside them. The objective was to characterise ME occurring outside healthcare facilities. A prospective observational follow‐up study evaluating all ME occurring outside healthcare facilities reported to a national poison information centre during a 5‐month period. For each ME case, a detailed questionnaire was filled and a follow‐up call was made within 7 days. The collected data included demographics, circumstances, type of error and outcome. Of 1381 consecutive ME cases were included; 97.8% involved a single incident and 88.3% one drug. The main characteristics of the ME were as follows: children younger than 6 years old (58.9%), parents responsible for 55.6% of cases, wrong dose 34.5% and different medication 30.1%. Analgesics (27.4%) and antimicrobials (12.2%) were the most common pharmaceuticals. The main reasons for the ME were look‐alike packaging (31.4%) and misunderstood instructions (28%). Most followed up patients (97.1%) were asymptomatic or mildly affected; there was one severe case and no mortality. Most ME occurring outside healthcare facilities are single incidents, involving young children who were administered a wrong dose or medication due to look‐alike packaging or misunderstood instructions with asymptomatic or mild outcome. Improved packaging, labelling and patient education are suggested to reduce ME.