Patrick E. McKinney

Adverse events associated with dietary supplements: an observational study

BACKGROUNDnAdverse events associated with dietary supplements are difficult to monitor in the USA, because such products are not registered before sale, and there is little information about their content and safety.nnnMETHODSnIn 1998, 11 poison control centres in the USA recorded details of 2332 telephone calls about 1466 ingestions of dietary supplements, in 784 of which patients had symptoms. We used a multitiered review process (kappa 0.42) to select 489 cases for whom we were at least 50% certain that their negative events were associated with dietary supplements. We aimed to assess the effects of multiple ingredients and long-term use, and collated data for patterns of use and information resources.nnnFINDINGSnA third of events were of greater than mild severity. We noted both new and previously reported associations that included myocardial infarction, liver failure, bleeding, seizures, and death. Increased symptom severity was associated with use of several ingredients, long-term use, and age. Paediatric exposures were more often unintentional than were adult ingestions, and treatment of disease was the reason for supplement use in at least 28% of reports. Most products and ingredients were not identified in the information database (Poisindex) used by poison control centres, and specific adverse events were reported variably among five additional sources.nnnINTERPRETATIONnDietary supplements are associated with adverse events that include all levels of severity, organ systems, and age groups. Associations between adverse events and ingredients are difficult to verify if a product has more than one ingredient, and because of incomplete information systems. Research into hazards and risks of dietary supplements should be a priority.

Acute elevation of blood lead levels within hours of Ingestion of large quantities of lead shot

Background: Ingestion of elemental lead foreign bodies is felt to have a low risk of clinically significant lead absorption unless gastrointestinal pathology and/or prolonged transit time are present. We present a case of ingestion of a large quantity of small diameter lead shot accompanied by rapid elevation of blood lead levels. Case Report: A 5½-year-old previously healthy girl was found eating the pellets from an ankle weight. She vomited and complained of abdominal pain. In the emergency department, she had no complaints and normal vital signs. An abdominal X-ray showed thousands of small, round, metallic density objects in the stomach. Her white blood cell count was 14,700/mm3, and the hemoglobin, mean corpuscular volume, free erythrocyte protoporphyrin, zinc protoporphyrin, biochemistry panel 21, and urinalysis were normal. She had no prior lead level for comparison. Whole-bowel irrigation was begun and she passed over 11 stools with pellets as well as other foreign bodies (erasers, bead, etc.) in the first 24 hours. Pellets were still seen on X-ray the following day so she received a high-fiber diet and bisacodyl tablets 10 mg/d. On hospital day 2, her admission blood lead (drawn 13 hours after ingestion) was reported as 57 μg/dL (2.7 μm/L) and chelation was begun with oral 2,3-dimercaptosuccinic acid 10 mg/kg 3x/d for 5 days, then 2x/d for 14 days. Her peak measured lead level was 79 μg/dL approximately 36 hours after ingestion. She excreted 2273 μg lead in the urine during her first 24 hours of chelation. Her blood lead dropped to 14.3 μg/dL by the end of chelation. She did not develop any apparent signs of lead poisoning. Conclusion: Acute elevations of blood lead concentrations may occur rapidly after ingestion of multiple small elemental lead objects.

Elemental mercury in the appendix: an unusual complication of a Mexican-American folk remedy.

BACKGROUNDnIngestion of small amounts of elemental mercury is generally thought to be harmless. However, in 4 previously reported cases, ingested mercury became sequestered in the appendix, causing appendicitis in one. We present a case in which elemental mercury was administered as a Mexican-American folk remedy for abdominal pain and became sequestered in the appendix.nnnCASE REPORTnA 10-year-old Hispanic male presented with 3 days of right-sided abdominal pain, diarrhea, fever, and malaise. On admission, his temperature was 41.5 degrees C and he had right abdominal tenderness. Urinalysis showed 3 WBCs, 9 RBCs, occasional bacteria, and 1+ protein. An abdominal CT scan suggested right focal pyelonephritis, but also showed multiple intraabdominal metallic densities. On further questioning, the family admitted giving him elemental mercury as a remedy for empacho. He was treated with intravenous ampicillin/sulbactam and gentamicin for a focal pyelonephritis. Because of mercury remaining in the gastrointestinal tract, activated charcoal and sorbitol were given. By hospital day 3, mercury filled the appendix as shown by abdominal radiograph. He was placed in the left lateral decubitus position overnight, and by the next morning, the mercury partially emptied from the appendix. By hospital day 8, his symptoms had resolved and mercury was no longer seen in the appendix. There were only minimal increases in urine mercury levels (18 mg/L). At 5-month follow-up, he has remained asymptomatic.

Transdermal Kinetics of A Mercurous Chloride Beauty Cream: An In Vitro Human Skin Analysis

Background: Crema de Belleza-Manning is a popular mercurous chloride-containing beauty cream used to smooth and lighten the complexion and treat acne. Hundreds of people in the Southwestern US border states have been identified with elevated (>20 μg/L) urine mercury levels believed to be secondary to using this cream. The kinetic characteristics of percutaneous mercury absorption are incompletely defined. The objective of this study was to determine the transdermal kinetics of two formulations of mercurous chloride from a beauty cream in an in vitro human skin model. Methods: A proprietary formulation and an aqueous formulation of the beauty cream were studied using modified Franz diffusion cells. Mercury content in the skin samples and the underlying diffusion buffer was determined using atomic absorption spectrophotometry. Results: A rapid initial increase in mercury content both in the skin and the buffer was noted for both formulations. Mercury concentrations in the aqueous samples were significantly (p < 0.05) higher in both the skin and the diffusion buffer compared to parallel samples containing glycerol. Conclusions: Mercury was readily absorbed through the skin in this in vitro human skin model. The aqueous preparation had a markedly increased rate and extent of mercury absorption relative to the proprietary formulation.

Does transportation by ambulance decrease time to gastrointestinal decontamination after overdose

STUDY OBJECTIVEnBecause the ability of gastrointestinal decontamination to alter drug absorption varies inversely with time, we compared the time from arrival in the emergency department to gastrointestinal decontamination (gastric lavage or activated charcoal) for patients transported by ambulance with patients transported by other means after overdose.nnnMETHODSnA retrospective chart review was conducted in an academic university ED with an annual volume of 56,000 visits. Consecutive cases of oral overdose treated by gastrointestinal decontamination between December 1, 1995, and May 31, 1996, were identified from International Classification of Diseases, ninth revision, billing codes. ED charts were reviewed to determine the patients age, sex, mode of transportation, disposition, and time interval to gastrointestinal decontamination with either gastric lavage or activated charcoal.nnnRESULTSnTwo hundred eighty-one patient visits were identified. Complete data were available for 173 visits. Six patients were excluded because the diagnosis of overdose was not made on presentation, leaving 167 cases for analysis. The median age for all patients was 27 years; 95 (57%) were female. Overdose patients were transported by ambulance in 105 (67%) cases. Admission rates were similar for patients transported by ambulance and those who arrived by other means. The median interval from arrival to any gastrointestinal decontamination (lavage or charcoal) for patients transported by ambulance was shorter than patients who arrived by other means at 55 and 73 minutes, respectively (95% confidence interval for difference 2.5 to 30.5 minutes, P =.03). Subgroup analysis showed this difference was largely the result of gastric lavage.nnnCONCLUSIONnOverdose patients transported by ambulance have a shorter time interval from ED arrival to gastrointestinal decontamination than patients arriving by other means. This difference was largely related to more rapid gastric lavage.

Butoxyethanol ingestion with prolonged hyperchloremic metabolic acidosis treated with ethanol therapy.

Background: Severe toxic ingestions of butoxyethanol (CAS No. 111-76-2) are rare despite the prevalence of this glycol ether in products such as glass and surface cleaners. Manifestations of acute butoxyethanol toxicity include metabolic acidosis, hemolysis, hepatorenal dysfunction, and coma, but vary widely in reported cases. Furthermore, the optimal therapeutic approach is not yet established. Much of the toxicity of butoxyethanol has been ascribed to its aldehyde and acid metabolites which are similar to those produced by oxidative metabolism of methanol and ethylene glycol. Although the roles of alcohol dehydrogenase inhibition with ethanol or fomepizole and hemodialysis are clear in the case of toxic ingestions of methanol and ethylene glycol, they remain poorly defined for butoxyethanol poisoning. Case Report: We report the case of a 51-year-old female who ingested up to 8 ounces of Sanford Expo White Board Cleaner® (butoxyethanol and isopropanol). She developed prolonged hyperchloremic metabolic acidosis and mental status depression and was treated with ethanol therapy but not hemodialysis. This patient recovered without apparent sequelae. The kinetics of butoxyethanol metabolism in this case are described and the potential therapeutic options are discussed.

Do Poison Center Triage Guidelines Affect Healthcare Facility Referrals

Background: The purpose of this study was to determine the extent to which poison center triage guidelines influence healthcare facility referral rates for acute, unintentional acetaminophen-only poisoning and acute, unintentional adult formulation iron poisoning. Methods: Managers of US poison centers were interviewed by telephone to determine their centers triage threshold value (mg/kg) for acute iron and acute acetaminophen poisoning in 1997. Triage threshold values and healthcare facility referral rates were fit to a univariate logistic regression model for acetaminophen and iron using maximum likelihood estimation. Results: Triage threshold values ranged from 120–201 mg/kg (acetaminophen) and 16–61 mg/kg (iron). Referral rates ranged from 3.1% to 24% (acetaminophen) and 3.7% to 46.7% (iron). There was a statistically significant inverse relationship between the triage value and the referral rate for acetaminophen (p < 0.001) and iron (p = 0.0013). The model explained 31.7% of the referral variation for acetaminophen but only 4.1% of the variation for iron. Conclusion: There is great variability in poison center triage values and referral rates for iron and acetaminophen poisoning. Guidelines can account for a meaningful proportion of referral variation. Their influence appears to be substance dependent. These data suggest that efforts to determine and utilize the highest, safe, triage threshold value could substantially decrease healthcare costs for poisonings as long as patient medical outcomes are not compromised.

Do poison center guidelines adversely affect patient outcomes as triage referral values increase

Abstract Background.u2002The purpose of this study was to determine whether patient outcomes were adversely affected as healthcare referral values increased for two common poisonings: acute, unintentional acetaminophen (APAP) poisonings and acute, unintentional iron (Fe) poisonings. We hypothesized that symptom rates would increase with high referral values. Methods.u2002Qualifying 1997 exposures were separated by substance (APAP or Fe) and then further stratified into three healthcare referral value ranges. Symptomatic and asymptomatic patients were totaled for each stratum. Expected vs. observed distributions of symptomatic and asymptomatic patients across triage referral strata for a given substance and treatment location were compared using chi‐square test for independence. The Wilcoxon–Mann–Whitney test was used to compare the distribution of patients across referral strata for home vs. healthcare facility locations for a specific substance. Results.u2002There were no statistically significant differences in the distribution of symptomatic patients within referral value strata for APAP or for Fe. There was also no difference in distribution of symptomatic patients across strata when comparing home vs. healthcare facility for APAP and Fe. Conclusion.u2002Referral values as high as 201 mg/kg for APAP and 61 mg/kg for Fe do not appear to adversely affect patient outcomes.