A. Schaper

Bites and stings by exotic pets in Europe: An 11 year analysis of 404 cases from Northeastern Germany and Southeastern France

Introduction. The presence of exotic, and sometimes venomous, pets in European homes is becoming more common. This phenomenon is the basis of a French-German cooperative evaluation of the species causing the injuries and the circumstances, severity, and treatment of the envenomations Methods. A retrospective, descriptive, cross-sectional, case series of data from 1996 to 2006. The study sample consists of all cases of bites and stings by exotic pets that were registered at four poisons European poisons centers. The inclusion criteria were bites and stings of human beings. Results. From 1996 to 2006 four poisons centers in Europe were consulted on 404 bites and stings by exotic pets. The average age of the patients was 36 (2 to 75) years and 73% of the patients were male. The severity of the envenomations, according to the Poisoning Severity Score, was as follows: 29 severe (7.1%), 55 moderate (14.2%) and 320 minor (78.7%). There were no fatalities in this case series. Exotic snakebites from rattlesnakes, cobras, mambas, and other venomous snakes caused 39% of envenomations, aquatic animals (mostly lionfish of the Pterois genus and stingrays) caused 30% of envenomations and arthropods (tarantulas and scorpions) caused 27% of envenomations. All severe envenomations were caused by venomous snakes. Conclusions. European healthcare professionals may encounter patients bitten or stung by exotic pets. Poisons center consultation can help manage these unusual presentations and help obtain rarely used antivenoms.

Surgical treatment in cocaine body packers and body pushers

ObjectiveBody packers smuggle cocaine by swallowing containers filled with the drugs, whilst body pushers conceal the containers in the rectum or vagina. In a collaborative effort between the Department of General Surgery, two major airports and Poisons Centre, we performed a retrospective study to develop an algorithm for the treatment of ruptured cocaine-filled containers.Materials and methodsThe data of all cocaine body packers and body pushers who were identified at the airports of Frankfurt and Paris from 1985 to 2002 were evaluated concerning incidence, demographics and surgical aspects.ResultsFrom 1985 to 2002, 312 body pushers and 4,660 body packers were identified. The sex ratio was 1:1. Sixty-four “mules” (1.4%) developed life-threatening symptoms of cocaine overdose after the rupture of a container. In 20 patients, an emergency laparotomy was performed and the containers were removed; all of these patients survived. Forty-four body packers died before surgical treatment could be performed. Only one body pusher required medical attention.ConclusionCocaine overdose can be life-threatening. If the cause is the rupture of a container in a body packer, the only possible treatment is immediate laparotomy for the removal of the container.

Iatrogenic intravenous medication errors reported to the PIC Erfurt

Background. We investigated the iatrogenic intravenous medication errors (IIME) reported to the Poisons Information Center (PIC) Erfurt. Methods: All IIME over a ten year period were analyzed retrospectively and categorized into error types, age groups, drugs involved, and estimated risk of toxicity. Results. From 1997 to 2006 the PIC Erfurt registered 132 cases of IIME. They increased from 7 in 1997 to 31 in 2006. Children accounted for 31.1% of the patients affected and adults for 68.9%. The drug classes (ATC classification) involved most frequently were antipsychotics (9.8%) and antihistamines for systemic use (7.5%). The main types of IIME were overdose (53.1%) and incorrect route of administration (29.7%). The estimated risk of toxicity was: 14.4% none, 71.2% risk of toxicity, and 14.4% unpredictable risk. Medical treatment was recommended in 82%. The outcome of 104 of the 132 (78.8%) courses was unknown. In the 28 cases followed to a known outcome, 9 (32%) were asymptomatic and 19 (68%) symptomatic with minor (9 cases), moderate (1 case), and severe features (6 cases) but mostly complete recovery. Two IIME resulted in hypoxia–induced brain damage and one in death despite of resuscitation. Conclusion. Approximately 0.1% of all calls registered by the PIC Erfurt from 1997 to 2006 concerned IIME. Thirty-two percent of IIME followed to a known outcome resulted in severe symptoms. These data show that IIME can be harmful.

Iatrogenic intravenous medication errors reported to the GIZ-Nord Poisons Center Göttingen

BACKGROUND We analyzed the iatrogenic intravenous medication errors (IIME) reported to the GIZ-Nord Poisons Center Göttingen. METHODS IIME over a ten year period were analyzed retrospectively and categorized into error types, age groups, drugs involved, and severity of IIME at registration and after known outcome. RESULTS 265 IIME were registered from 1997 to 2006. They rose from 12 in 1997 to 45 in 2006 corresponding to an increase from 0.058 to 0.148% of all calls of the respective year. Children were affected in (21.1%) and adults in 78.9% of all cases. The drug classes (ATC classification) involved most frequently were antipsychotics (7.9%) and antithrombotic agents (6.0%). The main types of IIME were dosing error (37.7%) and wrong route of administration (28.7%). The severity of IIME at registration was none (33.6%), minor (32.5%), moderate (13.6%), severe (13.6%), fatal (1.5%), and unratable (5.2%). In the 46 cases followed to a known outcome, 15 were asymptomatic and 27 were symptomatic with minor (11 cases), moderate (5 cases) and severe features (11 cases). Four cases of IIME were already fatal at registration and one severe case died in the further course. Dosing error of theophylline was often observed in severe outcomes. CONCLUSION IIME increased from 1997 to 2006. Intravenous use of antipsychotics and theophylline should be restricted to a minimum.

[Mesh shrinkage in hernia surgery: data from a prospective randomized double-blinded clinical study].

OBJECTIVES According to an estimated mesh shrinkage following hernia repair of up to 40% a current dogma in hernia surgery requires a mesh overlap of 5 cm around the hernia. However, no valid data addressing this problem of mesh shrinkage are available at present. PATIENTS AND METHODS Within the framework of a prospective randomized double-blinded clinical trial, 50 patients were operated on for a ventral abdominal hernia with the open sublay technique using specially prepared radio-opaque polypropylene (PP) meshes. Of the patients 27 received a conventional heavyweight mesh (P group) and 23 a new lightweight mesh construction (NK group). Follow-up for at least 2 years after mesh repair included conventional abdominal x-rays after 7 days, 3 weeks and 4, 12 and 24 months, as well as computed tomography after 7 days and 4 and 12 months. Main criteria were mesh shrinkage, recurrence and complication rates and quality of life comparing groups P and NK. RESULTS In 46 cases (92%) no mesh shrinkage could be detected and only 4 meshes (8%) showed a moderate shrinkage (1 of 22.2%, 2 of 8% and 1 of 3%) all from the P group. While no hernia recurrences were found, 2 surgical complications occurred with 1 seroma in the P group and 1 hematoma in the NK group. Quality of life showed a linear improvement over time up to the 2 year time point following mesh repair with advantages for the NK group. Pain and mobility scores reached standard values 12 months postoperatively without significant differences between the two groups. CONCLUSIONS In principle PP meshes following an uncomplicated ventral hernia repair do not shrink at all. A moderate shrinkage in isolated cases might occur following heavyweight mesh implantation. Under controlled conditions recurrence as well as complication rates are equal for heavyweight and lightweight PP meshes. Quality of life improves up to 2 years following mesh repair with a trend to a better outcome for lightweight meshes. Pain and mobility scores reached standard values 12 months postoperatively without significant differences between the lightweight and heavyweight meshes.

Netzschrumpfung in der Hernienchirurgie

OBJECTIVES According to an estimated mesh shrinkage following hernia repair of up to 40% a current dogma in hernia surgery requires a mesh overlap of 5 cm around the hernia. However, no valid data addressing this problem of mesh shrinkage are available at present. PATIENTS AND METHODS Within the framework of a prospective randomized double-blinded clinical trial, 50 patients were operated on for a ventral abdominal hernia with the open sublay technique using specially prepared radio-opaque polypropylene (PP) meshes. Of the patients 27 received a conventional heavyweight mesh (P group) and 23 a new lightweight mesh construction (NK group). Follow-up for at least 2 years after mesh repair included conventional abdominal x-rays after 7 days, 3 weeks and 4, 12 and 24 months, as well as computed tomography after 7 days and 4 and 12 months. Main criteria were mesh shrinkage, recurrence and complication rates and quality of life comparing groups P and NK. RESULTS In 46 cases (92%) no mesh shrinkage could be detected and only 4 meshes (8%) showed a moderate shrinkage (1 of 22.2%, 2 of 8% and 1 of 3%) all from the P group. While no hernia recurrences were found, 2 surgical complications occurred with 1 seroma in the P group and 1 hematoma in the NK group. Quality of life showed a linear improvement over time up to the 2 year time point following mesh repair with advantages for the NK group. Pain and mobility scores reached standard values 12 months postoperatively without significant differences between the two groups. CONCLUSIONS In principle PP meshes following an uncomplicated ventral hernia repair do not shrink at all. A moderate shrinkage in isolated cases might occur following heavyweight mesh implantation. Under controlled conditions recurrence as well as complication rates are equal for heavyweight and lightweight PP meshes. Quality of life improves up to 2 years following mesh repair with a trend to a better outcome for lightweight meshes. Pain and mobility scores reached standard values 12 months postoperatively without significant differences between the lightweight and heavyweight meshes.

Intox, detox, antidotes – Evidence based diagnosis and treatment of acute intoxications

BACKGROUND AND AIM Aim of this review is to describe the role of clinical toxicology in the context of acute medicine. A special focus is put on antidotes and important aspects of diagnosis and therapy of acute intoxications. The data of the annual report of GIZ-Nord Poisons Centre is analyzed concerning the following aspects: what intoxications are relevant in acute medicine, are there special aspects in therapy, e.g. antidotes, and what antidotes are relevant? More over intoxication-related fatalities are analyzed. RESULTS AND CONCLUSION In 2015 the poisons centre was consulted in 33,000 cases of acute intoxications. The most important groups are drugs (e.g. antidepressants, beta blockers and calcium channel blockers), chemical products (e.g. products containing surfactant, corrosive substances and toxic alcohols like methanol), plants and recreational drugs. Intoxications are relevant in acute medicine. Some substances can cause fatal intoxications. Important antidotes are naloxone for opiods, acetylcystein for paracetamol, fomepizole and ethanol for toxic alcohols and diazepam for intoxications caused by chloroquine.

Clinical effect profiles for chemical agentsof concern - role of syndromic surveillanceand rare symptoms [Abstract]

Background: Based on a Federal Institute for RiskAssessment (BfR) detailed analysis (57,093 reports between 1990-2008) of aspiration cases with liquid preparations, the aspiration risk is clearly associated with the ingestion of distinct aliphatic hydrocarbons with a chain length from C8 to C16. These are the main compounds of paraffin-containing lamp oils, grill lighters and kerosene. Based on their typical lowviscosity, low surface tension and low vapour pressure these substances can enter the deep spaces of the lung. More than 320 serious cases and five deaths of children have been documented in the BfR since 1990 with the typical signs of lack of oxygenation, giving strong clinical indications for an oxygen intra-alveolar diffusion barrier effect. To prove this hypothesis, the intraalveolar surface and the oxygen transfer was simulated in an in vitro Alveolar Space Chamber (ASC) experiment. Methods: A gas-tight Plexiglass-measuring chamber (diameter 115 mm, height 115 mm, wallthickness 15 mm) was half-filled with fluorocarbon(FC-43) to generate a liquid-gas surface to simulate the alveolar surface. The oxygen-transport through the surface was measured in the bottom liquid part of the chamber by a Unisense oxygen micro sensor,connected to a high-sensitivity Pico-ammeter. Results:The results of the experiments revealed that the alveolar surfactant can be considered as a strong accelerator to the oxygen transfer into the liquid space of the capillary lung system. In contrast to these findings, generated microfilms of lamp oils reduce the transfer of oxygen through the surface to a high extent (minimum 9-15fold). Transferring these findings to the clinical course of the documented serious lamp oil aspiration, the ASC-experiment could give clear indications of the pathophysiological mechanism. The characteristic physico-chemical properties of ingested lamp oils gives these liquids the capacity to spread deep into the lung, and finally into the alveolar spaces with the effect of building up a persistent diffusion barrier for oxygen.This could explain the severe asphyxia and deathd ocumented in BfR cases. Conclusion: The ASC experiment gives a plausible understanding of the clinical findings in cases of serious lamp oil aspirations.The experiment is currently being extended to find new additional therapeutic tasks in cases of severe aspiration.Background: Based on a Federal Institute for Risk Assessment (BfR) detailed analysis (57,093 reports between 1990-2008) of aspiration cases with liquid preparations, the aspiration risk is clearly associated with the ingestion of distinct aliphatic hydrocarbons with a chain length from C8 to C16. These are the main compounds of paraffin-containing lamp oils, grill-lighters and kerosene. Based on their typical low viscosity, low surface tension and low vapour pressure these substances can enter the deep spaces of the lung. More than 320 serious cases and five deaths of children have been documented in the BfR since 1990 with the typical signs of lack of oxygenation, giving strong clinical indications for an oxygen intra-alveolar diffusion barrier effect. To prove this hypothesis, the intra-alveolar surface and the oxygen transfer was simulated in an in vitro Alveolar Space Chamber (ASC) experiment. Methods: A gas-tight Plexiglass-measuring chamber (diameter 115 mm, height 115 mm, wall thickness 15 mm) was half-filled with fluorocarbon (FC-43) to generate a liquid-gas surface to simulate the alveolar surface. The oxygen-transport through the surface was measured in the bottom liquid part of the chamber by a Unisense oxygen micro sensor, connected to a high-sensitivity Pico-ammeter. Results: The results of the experiments revealed that the alveolar surfactant can be considered as a strong accelerator to the oxygen transfer into the liquid space of the capillary lung system. In contrast to these findings, generated microfilms of lamp oils reduce the transfer of oxygen through the surface to a high extent (minimum 9-15 fold). Transferring these findings to the clinical course of the documented serious lamp oil aspiration, the ASC-experiment could give clear indications of the pathophysiological mechanism. The characteristic physico-chemical properties of ingested lamp oils gives these liquids the capacity to spread deep into the lung, and finally into the alveolar spaces with the effect of building up a persistent diffusion barrier for oxygen. This could explain the severe asphyxia and death documented in BfR cases. Conclusion: The ASC-experiment gives a plausible understanding of the clinical findings in cases of serious lamp oil aspirations. The experiment is currently being extended to find new additional therapeutic tasks in cases of severe aspiration.Abstracts of the 2011 International Congress of the Europeans of the 2011 International Congress of the European Association of Poisons Centres and Clinical Toxicologists, 24–27 May 2011, Dubrovnik, Croatia 1. GHB and its Analogues Knudsen K. Department of Anesthesia and Intensive Care Medicine, Sahlgrenska University Hospital,Background: The Federal Institute for Risk Assessment (BfR) Documentation and Assessment Centre for Poisonings (BfR-Doc Centre) is part of the German toxicological network. German Physicians and Poison Centres (PCs) report human data of poisonings to the BfR. Every case is assessed on the chemical product involved with the distinct formula provided by BfR product database, which contains notifications of the German industry. Data on human poisonings is condensed in a harmonized and standardized data file for analysis. In addition cases of special toxicological and scientific interest (e.g. rare poisonings, high-/low-dose exposures, cases with unexpected clinical course, substances of special interest etc) are prepared for standardized case reports. For better retrieval of human toxicological data a bilingual case report database has been implemented. Methods: The cases are documented in a standardized form (accident/situation of poisoning/age/gender/symptoms/signs/exposure data/clinical course/assessment/remarks), indicated by the substance/product involved and supplemented with important references. After co-checks for correctness, completeness and readability, the German text is translated into English and transferred to the database. In addition, selected case reports from literature were transferred as pdf-files to the same database. Results: Since July 2002 more than 500 cases have been selected, prepared and processed with additional data for case reports. The case reports were written down in uniform documents, provided with keywords and additional information, finally assigned to index words. Starting in 2004, the documents were recorded in a prototype database driven by MS-Access, from 2006 onwards the case record database was transferred to an Informix 9.2 database in web-browser technology. At present, the BfR-case database has been provided with additional staff. The BfR is in consultation with specialists in data protection to ask whether the BfR case record database can to be opened in the future for specialists. Conclusion: In the assessment of poisonings and for e-learning there is a great interest in case reports. The BfR intends in future to offer its case reports on poisoning via its Internet portal for subject-specific access.Objective: Information relating to interference in certain biochemistry analyses is readily available in the scientific literature, yet the UK National Poisons Information Service (NPIS) still regularly receives enquiries from clinicians struggling to interpret unexpected results. We report three recent cases that serve to illustrate how erroneous laboratory results can confuse the clinical picture and even lead to misdiagnosis in cases of poisoning. Case series: 1. A 19-year old male presented at hospital claiming a deliberate ingestion of methanol. He appeared clinically well but had a markedly raised serum creatinine - 766 µmol/L. He had been admitted 10 days previously with a paracetamol overdose and it was assumed that the elevated creatinine was a consequence of this and his methanol story was disregarded. An NPIS specialist advised that nitromethane in model engine fuel is known to give falsely high results with certain (Jaffe) creatinine assays. This was confirmed and antidotal treatment was commenced for methanol ingestion. 2. A 35-year old male was admitted with acidosis (pH 6.8) and a raised serum lactate concentration of 24 mmol/L. A preliminary diagnosis of cyanide poisoning was made and antidote considered. An NPIS specialist advised that certain Point of Care blood gas analysers have been reported to provide falsely elevated blood lactate concentrations when ethylene glycol metabolites are present. Blood lactate was measured on a different instrument and shown to be within normal limits. Antidotal therapy was commenced for ethylene glycol ingestion - a diagnosis subsequently confirmed by blood ethylene glycol measurement and a markedly raised osmolar gap. 3. A 3-year old girl was admitted with a 3-day history of vomiting. She was obtunded, acidotic (pH 6.9) and had a serum salicylate concentration of 50 mg/L, although there was no history of aspirin ingestion. Supportive treatment was initiated and a search at home for possible sources of salicylic acid made. A suggestion by NPIS to the clinician that metabolic disorders such as Maple Syrup Urine Disease can cause acidosis and give false positive salicylate results was later confirmed to be the case. Conclusion: The possibility of assay interference should be considered when the figures don’t fit the facts.Objective: To ascertain the toxicity of current UK household products. Methods: Between 1 March 2008 and 30 April 2009 the UK National Poisons Information Service collected prospectively 5939 telephone enquiries relating to household products, approximately 12% of all telephone enquiries. Results: The majority of enquiries (65.5%) concerned children five years of age or less and were received predominantly from hospitals (32.1%), general practitioners (29.8%) and NHS Direct/NHS 24 (28.5%). The majority of exposures occurred at home (97.6%); most exposures were accidental (93.6%). Liquid detergent capsules were most commonly involved (n = 647) followed by bleach (n = 473), multipurpose cleaners (n = 408), descalers (n = 397) and disinfectant/antiseptic/sanitiser liquids (n = 270). Intentional exposures were more likely to involve bleaches, multipurpose cleaners and disinfectant/antiseptic/sanitiser liquids. Exposure to household products occurred mainly as a result of ingestion (75.8%), with eye contact (8.4%), inhalation (6.9%) and skin contact (3.1%) being less common; 5.1% of enquiries involved multiple routes of exposure. The most commonly reported features were vomiting (ingestion), pain (eye contact), dyspnoea (inhalation) and burn (skin contact). In 5840 of 5939 enquiries the Poisoning Severity Score was known at the time of the enquiry. The majority of patients (70.5%) were asymptomatic, 28.0% had developed minor features, 75 patients had developed moderate features and nine patients had developed serious features (PSS 3). Five of these nine patients made a complete recovery, though two developed severe complications and two others died from poisoning with drain cleaner and PVC solvent cleaner; the outcome in two is unknown. Conclusions: Household product exposures are common in the UK, in other parts of Europe1 and in the US2, though they rarely result in severe sequelae.

Language independent description ofpoisoning symptoms in RAS-CHEM usingMedDRA terminology [Abstract]

Background: Based on a Federal Institute for RiskAssessment (BfR) detailed analysis (57,093 reports between 1990-2008) of aspiration cases with liquid preparations, the aspiration risk is clearly associated with the ingestion of distinct aliphatic hydrocarbons with a chain length from C8 to C16. These are the main compounds of paraffin-containing lamp oils, grill lighters and kerosene. Based on their typical lowviscosity, low surface tension and low vapour pressure these substances can enter the deep spaces of the lung. More than 320 serious cases and five deaths of children have been documented in the BfR since 1990 with the typical signs of lack of oxygenation, giving strong clinical indications for an oxygen intra-alveolar diffusion barrier effect. To prove this hypothesis, the intraalveolar surface and the oxygen transfer was simulated in an in vitro Alveolar Space Chamber (ASC) experiment. Methods: A gas-tight Plexiglass-measuring chamber (diameter 115 mm, height 115 mm, wallthickness 15 mm) was half-filled with fluorocarbon(FC-43) to generate a liquid-gas surface to simulate the alveolar surface. The oxygen-transport through the surface was measured in the bottom liquid part of the chamber by a Unisense oxygen micro sensor,connected to a high-sensitivity Pico-ammeter. Results:The results of the experiments revealed that the alveolar surfactant can be considered as a strong accelerator to the oxygen transfer into the liquid space of the capillary lung system. In contrast to these findings, generated microfilms of lamp oils reduce the transfer of oxygen through the surface to a high extent (minimum 9-15fold). Transferring these findings to the clinical course of the documented serious lamp oil aspiration, the ASC-experiment could give clear indications of the pathophysiological mechanism. The characteristic physico-chemical properties of ingested lamp oils gives these liquids the capacity to spread deep into the lung, and finally into the alveolar spaces with the effect of building up a persistent diffusion barrier for oxygen.This could explain the severe asphyxia and deathd ocumented in BfR cases. Conclusion: The ASC experiment gives a plausible understanding of the clinical findings in cases of serious lamp oil aspirations.The experiment is currently being extended to find new additional therapeutic tasks in cases of severe aspiration.Background: Based on a Federal Institute for Risk Assessment (BfR) detailed analysis (57,093 reports between 1990-2008) of aspiration cases with liquid preparations, the aspiration risk is clearly associated with the ingestion of distinct aliphatic hydrocarbons with a chain length from C8 to C16. These are the main compounds of paraffin-containing lamp oils, grill-lighters and kerosene. Based on their typical low viscosity, low surface tension and low vapour pressure these substances can enter the deep spaces of the lung. More than 320 serious cases and five deaths of children have been documented in the BfR since 1990 with the typical signs of lack of oxygenation, giving strong clinical indications for an oxygen intra-alveolar diffusion barrier effect. To prove this hypothesis, the intra-alveolar surface and the oxygen transfer was simulated in an in vitro Alveolar Space Chamber (ASC) experiment. Methods: A gas-tight Plexiglass-measuring chamber (diameter 115 mm, height 115 mm, wall thickness 15 mm) was half-filled with fluorocarbon (FC-43) to generate a liquid-gas surface to simulate the alveolar surface. The oxygen-transport through the surface was measured in the bottom liquid part of the chamber by a Unisense oxygen micro sensor, connected to a high-sensitivity Pico-ammeter. Results: The results of the experiments revealed that the alveolar surfactant can be considered as a strong accelerator to the oxygen transfer into the liquid space of the capillary lung system. In contrast to these findings, generated microfilms of lamp oils reduce the transfer of oxygen through the surface to a high extent (minimum 9-15 fold). Transferring these findings to the clinical course of the documented serious lamp oil aspiration, the ASC-experiment could give clear indications of the pathophysiological mechanism. The characteristic physico-chemical properties of ingested lamp oils gives these liquids the capacity to spread deep into the lung, and finally into the alveolar spaces with the effect of building up a persistent diffusion barrier for oxygen. This could explain the severe asphyxia and death documented in BfR cases. Conclusion: The ASC-experiment gives a plausible understanding of the clinical findings in cases of serious lamp oil aspirations. The experiment is currently being extended to find new additional therapeutic tasks in cases of severe aspiration.Abstracts of the 2011 International Congress of the Europeans of the 2011 International Congress of the European Association of Poisons Centres and Clinical Toxicologists, 24–27 May 2011, Dubrovnik, Croatia 1. GHB and its Analogues Knudsen K. Department of Anesthesia and Intensive Care Medicine, Sahlgrenska University Hospital,Background: The Federal Institute for Risk Assessment (BfR) Documentation and Assessment Centre for Poisonings (BfR-Doc Centre) is part of the German toxicological network. German Physicians and Poison Centres (PCs) report human data of poisonings to the BfR. Every case is assessed on the chemical product involved with the distinct formula provided by BfR product database, which contains notifications of the German industry. Data on human poisonings is condensed in a harmonized and standardized data file for analysis. In addition cases of special toxicological and scientific interest (e.g. rare poisonings, high-/low-dose exposures, cases with unexpected clinical course, substances of special interest etc) are prepared for standardized case reports. For better retrieval of human toxicological data a bilingual case report database has been implemented. Methods: The cases are documented in a standardized form (accident/situation of poisoning/age/gender/symptoms/signs/exposure data/clinical course/assessment/remarks), indicated by the substance/product involved and supplemented with important references. After co-checks for correctness, completeness and readability, the German text is translated into English and transferred to the database. In addition, selected case reports from literature were transferred as pdf-files to the same database. Results: Since July 2002 more than 500 cases have been selected, prepared and processed with additional data for case reports. The case reports were written down in uniform documents, provided with keywords and additional information, finally assigned to index words. Starting in 2004, the documents were recorded in a prototype database driven by MS-Access, from 2006 onwards the case record database was transferred to an Informix 9.2 database in web-browser technology. At present, the BfR-case database has been provided with additional staff. The BfR is in consultation with specialists in data protection to ask whether the BfR case record database can to be opened in the future for specialists. Conclusion: In the assessment of poisonings and for e-learning there is a great interest in case reports. The BfR intends in future to offer its case reports on poisoning via its Internet portal for subject-specific access.Objective: Information relating to interference in certain biochemistry analyses is readily available in the scientific literature, yet the UK National Poisons Information Service (NPIS) still regularly receives enquiries from clinicians struggling to interpret unexpected results. We report three recent cases that serve to illustrate how erroneous laboratory results can confuse the clinical picture and even lead to misdiagnosis in cases of poisoning. Case series: 1. A 19-year old male presented at hospital claiming a deliberate ingestion of methanol. He appeared clinically well but had a markedly raised serum creatinine - 766 µmol/L. He had been admitted 10 days previously with a paracetamol overdose and it was assumed that the elevated creatinine was a consequence of this and his methanol story was disregarded. An NPIS specialist advised that nitromethane in model engine fuel is known to give falsely high results with certain (Jaffe) creatinine assays. This was confirmed and antidotal treatment was commenced for methanol ingestion. 2. A 35-year old male was admitted with acidosis (pH 6.8) and a raised serum lactate concentration of 24 mmol/L. A preliminary diagnosis of cyanide poisoning was made and antidote considered. An NPIS specialist advised that certain Point of Care blood gas analysers have been reported to provide falsely elevated blood lactate concentrations when ethylene glycol metabolites are present. Blood lactate was measured on a different instrument and shown to be within normal limits. Antidotal therapy was commenced for ethylene glycol ingestion - a diagnosis subsequently confirmed by blood ethylene glycol measurement and a markedly raised osmolar gap. 3. A 3-year old girl was admitted with a 3-day history of vomiting. She was obtunded, acidotic (pH 6.9) and had a serum salicylate concentration of 50 mg/L, although there was no history of aspirin ingestion. Supportive treatment was initiated and a search at home for possible sources of salicylic acid made. A suggestion by NPIS to the clinician that metabolic disorders such as Maple Syrup Urine Disease can cause acidosis and give false positive salicylate results was later confirmed to be the case. Conclusion: The possibility of assay interference should be considered when the figures don’t fit the facts.Objective: To ascertain the toxicity of current UK household products. Methods: Between 1 March 2008 and 30 April 2009 the UK National Poisons Information Service collected prospectively 5939 telephone enquiries relating to household products, approximately 12% of all telephone enquiries. Results: The majority of enquiries (65.5%) concerned children five years of age or less and were received predominantly from hospitals (32.1%), general practitioners (29.8%) and NHS Direct/NHS 24 (28.5%). The majority of exposures occurred at home (97.6%); most exposures were accidental (93.6%). Liquid detergent capsules were most commonly involved (n = 647) followed by bleach (n = 473), multipurpose cleaners (n = 408), descalers (n = 397) and disinfectant/antiseptic/sanitiser liquids (n = 270). Intentional exposures were more likely to involve bleaches, multipurpose cleaners and disinfectant/antiseptic/sanitiser liquids. Exposure to household products occurred mainly as a result of ingestion (75.8%), with eye contact (8.4%), inhalation (6.9%) and skin contact (3.1%) being less common; 5.1% of enquiries involved multiple routes of exposure. The most commonly reported features were vomiting (ingestion), pain (eye contact), dyspnoea (inhalation) and burn (skin contact). In 5840 of 5939 enquiries the Poisoning Severity Score was known at the time of the enquiry. The majority of patients (70.5%) were asymptomatic, 28.0% had developed minor features, 75 patients had developed moderate features and nine patients had developed serious features (PSS 3). Five of these nine patients made a complete recovery, though two developed severe complications and two others died from poisoning with drain cleaner and PVC solvent cleaner; the outcome in two is unknown. Conclusions: Household product exposures are common in the UK, in other parts of Europe1 and in the US2, though they rarely result in severe sequelae.

Notification and reporting health threatscaused by chemical events through RASCHEM: policy and mechanism forcoordinating public health measures at EUlevel [Abstract]

Background: Based on a Federal Institute for RiskAssessment (BfR) detailed analysis (57,093 reports between 1990-2008) of aspiration cases with liquid preparations, the aspiration risk is clearly associated with the ingestion of distinct aliphatic hydrocarbons with a chain length from C8 to C16. These are the main compounds of paraffin-containing lamp oils, grill lighters and kerosene. Based on their typical lowviscosity, low surface tension and low vapour pressure these substances can enter the deep spaces of the lung. More than 320 serious cases and five deaths of children have been documented in the BfR since 1990 with the typical signs of lack of oxygenation, giving strong clinical indications for an oxygen intra-alveolar diffusion barrier effect. To prove this hypothesis, the intraalveolar surface and the oxygen transfer was simulated in an in vitro Alveolar Space Chamber (ASC) experiment. Methods: A gas-tight Plexiglass-measuring chamber (diameter 115 mm, height 115 mm, wallthickness 15 mm) was half-filled with fluorocarbon(FC-43) to generate a liquid-gas surface to simulate the alveolar surface. The oxygen-transport through the surface was measured in the bottom liquid part of the chamber by a Unisense oxygen micro sensor,connected to a high-sensitivity Pico-ammeter. Results:The results of the experiments revealed that the alveolar surfactant can be considered as a strong accelerator to the oxygen transfer into the liquid space of the capillary lung system. In contrast to these findings, generated microfilms of lamp oils reduce the transfer of oxygen through the surface to a high extent (minimum 9-15fold). Transferring these findings to the clinical course of the documented serious lamp oil aspiration, the ASC-experiment could give clear indications of the pathophysiological mechanism. The characteristic physico-chemical properties of ingested lamp oils gives these liquids the capacity to spread deep into the lung, and finally into the alveolar spaces with the effect of building up a persistent diffusion barrier for oxygen.This could explain the severe asphyxia and deathd ocumented in BfR cases. Conclusion: The ASC experiment gives a plausible understanding of the clinical findings in cases of serious lamp oil aspirations.The experiment is currently being extended to find new additional therapeutic tasks in cases of severe aspiration.Background: Based on a Federal Institute for Risk Assessment (BfR) detailed analysis (57,093 reports between 1990-2008) of aspiration cases with liquid preparations, the aspiration risk is clearly associated with the ingestion of distinct aliphatic hydrocarbons with a chain length from C8 to C16. These are the main compounds of paraffin-containing lamp oils, grill-lighters and kerosene. Based on their typical low viscosity, low surface tension and low vapour pressure these substances can enter the deep spaces of the lung. More than 320 serious cases and five deaths of children have been documented in the BfR since 1990 with the typical signs of lack of oxygenation, giving strong clinical indications for an oxygen intra-alveolar diffusion barrier effect. To prove this hypothesis, the intra-alveolar surface and the oxygen transfer was simulated in an in vitro Alveolar Space Chamber (ASC) experiment. Methods: A gas-tight Plexiglass-measuring chamber (diameter 115 mm, height 115 mm, wall thickness 15 mm) was half-filled with fluorocarbon (FC-43) to generate a liquid-gas surface to simulate the alveolar surface. The oxygen-transport through the surface was measured in the bottom liquid part of the chamber by a Unisense oxygen micro sensor, connected to a high-sensitivity Pico-ammeter. Results: The results of the experiments revealed that the alveolar surfactant can be considered as a strong accelerator to the oxygen transfer into the liquid space of the capillary lung system. In contrast to these findings, generated microfilms of lamp oils reduce the transfer of oxygen through the surface to a high extent (minimum 9-15 fold). Transferring these findings to the clinical course of the documented serious lamp oil aspiration, the ASC-experiment could give clear indications of the pathophysiological mechanism. The characteristic physico-chemical properties of ingested lamp oils gives these liquids the capacity to spread deep into the lung, and finally into the alveolar spaces with the effect of building up a persistent diffusion barrier for oxygen. This could explain the severe asphyxia and death documented in BfR cases. Conclusion: The ASC-experiment gives a plausible understanding of the clinical findings in cases of serious lamp oil aspirations. The experiment is currently being extended to find new additional therapeutic tasks in cases of severe aspiration.Abstracts of the 2011 International Congress of the Europeans of the 2011 International Congress of the European Association of Poisons Centres and Clinical Toxicologists, 24–27 May 2011, Dubrovnik, Croatia 1. GHB and its Analogues Knudsen K. Department of Anesthesia and Intensive Care Medicine, Sahlgrenska University Hospital,Background: The Federal Institute for Risk Assessment (BfR) Documentation and Assessment Centre for Poisonings (BfR-Doc Centre) is part of the German toxicological network. German Physicians and Poison Centres (PCs) report human data of poisonings to the BfR. Every case is assessed on the chemical product involved with the distinct formula provided by BfR product database, which contains notifications of the German industry. Data on human poisonings is condensed in a harmonized and standardized data file for analysis. In addition cases of special toxicological and scientific interest (e.g. rare poisonings, high-/low-dose exposures, cases with unexpected clinical course, substances of special interest etc) are prepared for standardized case reports. For better retrieval of human toxicological data a bilingual case report database has been implemented. Methods: The cases are documented in a standardized form (accident/situation of poisoning/age/gender/symptoms/signs/exposure data/clinical course/assessment/remarks), indicated by the substance/product involved and supplemented with important references. After co-checks for correctness, completeness and readability, the German text is translated into English and transferred to the database. In addition, selected case reports from literature were transferred as pdf-files to the same database. Results: Since July 2002 more than 500 cases have been selected, prepared and processed with additional data for case reports. The case reports were written down in uniform documents, provided with keywords and additional information, finally assigned to index words. Starting in 2004, the documents were recorded in a prototype database driven by MS-Access, from 2006 onwards the case record database was transferred to an Informix 9.2 database in web-browser technology. At present, the BfR-case database has been provided with additional staff. The BfR is in consultation with specialists in data protection to ask whether the BfR case record database can to be opened in the future for specialists. Conclusion: In the assessment of poisonings and for e-learning there is a great interest in case reports. The BfR intends in future to offer its case reports on poisoning via its Internet portal for subject-specific access.Objective: Information relating to interference in certain biochemistry analyses is readily available in the scientific literature, yet the UK National Poisons Information Service (NPIS) still regularly receives enquiries from clinicians struggling to interpret unexpected results. We report three recent cases that serve to illustrate how erroneous laboratory results can confuse the clinical picture and even lead to misdiagnosis in cases of poisoning. Case series: 1. A 19-year old male presented at hospital claiming a deliberate ingestion of methanol. He appeared clinically well but had a markedly raised serum creatinine - 766 µmol/L. He had been admitted 10 days previously with a paracetamol overdose and it was assumed that the elevated creatinine was a consequence of this and his methanol story was disregarded. An NPIS specialist advised that nitromethane in model engine fuel is known to give falsely high results with certain (Jaffe) creatinine assays. This was confirmed and antidotal treatment was commenced for methanol ingestion. 2. A 35-year old male was admitted with acidosis (pH 6.8) and a raised serum lactate concentration of 24 mmol/L. A preliminary diagnosis of cyanide poisoning was made and antidote considered. An NPIS specialist advised that certain Point of Care blood gas analysers have been reported to provide falsely elevated blood lactate concentrations when ethylene glycol metabolites are present. Blood lactate was measured on a different instrument and shown to be within normal limits. Antidotal therapy was commenced for ethylene glycol ingestion - a diagnosis subsequently confirmed by blood ethylene glycol measurement and a markedly raised osmolar gap. 3. A 3-year old girl was admitted with a 3-day history of vomiting. She was obtunded, acidotic (pH 6.9) and had a serum salicylate concentration of 50 mg/L, although there was no history of aspirin ingestion. Supportive treatment was initiated and a search at home for possible sources of salicylic acid made. A suggestion by NPIS to the clinician that metabolic disorders such as Maple Syrup Urine Disease can cause acidosis and give false positive salicylate results was later confirmed to be the case. Conclusion: The possibility of assay interference should be considered when the figures don’t fit the facts.Objective: To ascertain the toxicity of current UK household products. Methods: Between 1 March 2008 and 30 April 2009 the UK National Poisons Information Service collected prospectively 5939 telephone enquiries relating to household products, approximately 12% of all telephone enquiries. Results: The majority of enquiries (65.5%) concerned children five years of age or less and were received predominantly from hospitals (32.1%), general practitioners (29.8%) and NHS Direct/NHS 24 (28.5%). The majority of exposures occurred at home (97.6%); most exposures were accidental (93.6%). Liquid detergent capsules were most commonly involved (n = 647) followed by bleach (n = 473), multipurpose cleaners (n = 408), descalers (n = 397) and disinfectant/antiseptic/sanitiser liquids (n = 270). Intentional exposures were more likely to involve bleaches, multipurpose cleaners and disinfectant/antiseptic/sanitiser liquids. Exposure to household products occurred mainly as a result of ingestion (75.8%), with eye contact (8.4%), inhalation (6.9%) and skin contact (3.1%) being less common; 5.1% of enquiries involved multiple routes of exposure. The most commonly reported features were vomiting (ingestion), pain (eye contact), dyspnoea (inhalation) and burn (skin contact). In 5840 of 5939 enquiries the Poisoning Severity Score was known at the time of the enquiry. The majority of patients (70.5%) were asymptomatic, 28.0% had developed minor features, 75 patients had developed moderate features and nine patients had developed serious features (PSS 3). Five of these nine patients made a complete recovery, though two developed severe complications and two others died from poisoning with drain cleaner and PVC solvent cleaner; the outcome in two is unknown. Conclusions: Household product exposures are common in the UK, in other parts of Europe1 and in the US2, though they rarely result in severe sequelae.