Raquel Duarte-Davidson

China begins to position for leadership on responsible risk-based global chemicals management.

Section 5 of the Toxic Substances Control Act (TSCA) does not require any toxicity testing as a prerequisite for submission of a Premanufacturing Notice (PMN) for a new chemical. In order to compensate for the lack of actual test data, a process involving structure-activity relationships (SAR) for assessing hazard potential was constructed. The hazard assessment is then coupled with an estimation of potential exposure to determine potential risk. This process involves the use of multiple interdisciplinary teams that work within a 90-day time frame to complete approximately 2000 risk assessments per year.

Characteristics Of Environmental Harm In The Context Of Air Pollution

A framework that allows a simple qualitative assessment of both technical and socio-economic aspects of environmental harm has been developed; that is a framework that captures not only the physical aspects of damage but also how society may feel about it, Technical characteristics of harm include spatial and temporal extent, severity, irreversibility and uniqueness. Social aspects include dread, distrust, equity and imposition, By plotting these on separate axes of a graph it is possible to assess those attributes of greatest concern, draw conclusions as to the nature of the harm, and public perception of it, as well as gaining some insight into appropriate courses of action. The results of applying the methodology to a radioactive release are presented and placed in the context of a range of other air pollution hazards.

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.

The evaluation of standard medical terminology systems to describe symptoms of poisoning, an output of the ASHTII project [Abstract]

Objective:  The UK NPIS are receiving an increasing number of calls about a drug of abuse known as mephedrone or 4-methylmethcathinone, also called ‘bubbles’. It is usually supplied as an off-white crystalline powder with a strong fish-like odour and is either ingested or inhaled. This drug is becoming increasingly popular in the UK as it is currently classed as a legal substance. It is often bought from the Internet as plant food or as a research chemical marked ‘not for human consumption.’  Methods: Enquiries to the UK NPIS for the period 1 January 2008 to 1st January 2009 and also 1st January 2009 to 1st November 2009 involving ‘mephedrone’ or ‘methcathinone’ were retrieved. Each call was examined in detail and all reported symptoms and the results of any investigations noted. Internet websites were also investigated for details of mephedrone exposures to try and compare symptoms experienced by regular users with those reported to the UK NPIS.  Results: No enquiries concerning mephedrone were received by UK NPIS between 1st January 2008 and 1st January 2009 compared with 29 enquiries which were received between 1st January 2009 and 1st November 2009. Of these, the main symptoms reported were agitation/anxiety, headache, sweating, chest pain, mydriasis, loin or back pain and pins and needles. One patient was admitted to ITU with tachycardia, hypotension, rhabdomyolysis and coma following a seizure. The symptoms reported on the Internet (from 13 user information reports) included euphoria, addictive behaviour, dilated pupils, jaw clenching and sweating as well as increased heart rate. There have been some reports of vasoconstriction causing purple extremities and joints. One death has been reported in Sweden although causal links with mephedrone have not yet been confirmed.  Conclusion: Mephedrone is a very new and increasingly popular drug; its legal status in the UK may falsely imply safety. It is, however, a synthetic drug that, from UK NPIS data and Internet reports, causes some potentially dangerous symptoms that are similar to stimulant drugs of abuse. The clinical effects of this chemical need further investigation.Background: Air fresheners have become increasingly popular over recent years with marketing aimed at removing odours, refreshing the air and creating a pleasant ambient mood. Their popularity has resulted in a multi-million pound market with new products continually being released. Air fresheners come in many forms including sprays, plug-ins, gels and candles. Due to their wide use and availability, ingestion of these products is common with hundreds of cases being reported to the National Poisons Information Service (NPIS) annually. Whilst many air-fresheners contain potentially harmful products, they are usually difficult to ingest in large amounts and serious effects are therefore uncommon. Recently however, the NPIS has seen the emergence of a new type of air freshener which has led to concern. Reed diffusers, although available for many years, have seen a massive surge in popularity in 2009. They are usually composed of a bottle filled with approximately 100 - 500 mL of scented liquid delivered to the room by “wicking” reeds made of bamboo or similar. Some also contain decorative items such as beads. The liquid is easily accessible due to the open neck of the bottle and therefore has potential to be ingested in large quantities. The ingredients of reed diffusers vary dramatically. A small sample of different products revealed a contents list which can include 90% essential oils; 85% glycol ethers; 80% ethanol or 78% hydrocarbons.  Case series: From January to November 2009 the NPIS (Cardiff) has received 27 calls involving reed diffusers. These all involved young children aged between 8 months and 4 years with an average age of 21 months. One enquiry involved eye contact, four involved ingestion of beads or pearls from within the unit and 22 involved ingestion of the liquid itself, most of these cases involving unknown amounts.  Conclusion:  These products are of serious concern due to the ease with which young children may ingest significant quantities of potentially life threatening compounds. It is essential that health professionals are aware that the reed diffuser type of air freshener is not as innocuous as those with which we are more familiar and that all cases should be treated as potentially serious.Objective: Intravenous fat emulsion (IFE) has been successfully used as an antidote in cases of local anaesthetic toxicity and the possibility of its usefulness in overdose of other lipid-soluble drugs continues to provoke interest. We report a case of a mixed overdose where IFE was given successfully to treat a haemodynamically compromised patient.  Case report: A 52 year old female was admitted to AE pulse 38, blood pressure 80/50, RR 10, GCS 8/15, and ECG showing complete heart block. Despite receiving conventional treatment - saline, naloxone, atropine, calcium gluconate and sodium bicarbonate she showed no improvement and required admission to the intensive care unit for ventilatory and inotropic support. Awaiting transfer to ITU, 20% intralipid (500 mL) was administered over 30 minutes. Her post-lipid ECG showed sinus rhythm, pulse 79, PR 191, QRS 107 ms, QT/ QTc 407/467 ms. Her blood pressure on admission to ITU was 124/55 mmHg. She subsequently continued to improve requiring no inotropic support and was extubated the following day. A mild aspiration pneumonia was treated successfully with co-amoxiclav and she was discharged after psychiatric assessment without sequelae.  Conclusion: Animal studies have demonstrated a reduction in morbidity and mortality from lipid-soluble drug cardiotoxicity with IFE, and in humans it has been used to treat local anaesthetic toxicity, as well as bupropion/lamotrigine toxicity. Its exact mode of action is unclear but it may trap lipophilic drugs in an expanded plasma lipid compartment (lipid sink).1 This case demonstrates the successful use of IFE in an overdose involving amitriptyline and diltiazem. Administration of intralipid rapidly reversed ECG changes and improved haemodynamic status without the need for inotrope therapy or extended ITU support. Although data from human poisonings are still limited, we believe there is a role for IFE therapy in managing patients with overdose from lipid-soluble drugs.  References: 1. Sirianni AJ, Osterhoudt KC, Calello DP, et al. Use of lipid emulsion in the resuscitation of a patient with prolonged cardiovascular collapse after overdose of bupropion and lamotrigine. Ann Emerg Med 2008; 51:412–5.Objective: To investigate poisoning with opioid analgesics over a six year period using call data from NPIS (Cardiff), comparing results with prescriptions in the community.  Methods:  Records of all enquiries made to NPIS (Cardiff) between January 2004 and October 2009 were reviewed. Calls related to patients involving opioid analgesics were counted. Prescription rates were obtained from Prescription Cost Analysis Data for England1 and Wales2.  Results: Table 1 shows a summary of results. Call figures are given as percentage of total calls involving opioid analgesics. Calls involving tramadol have increased from 11.7% of total opioid analgesics to 18.8% over the six year period. Coproxamol enquiries have decreased from 18.2% to 0.5% and codeine has increased from 36.2% to 50.7%; oxycodone increased from 0.6% to 1.9% and dihydrocodeine decreased from 22.5% to 14.2%. The number of TOXBASE© hits for tramadol increased from 0.66% of total hits to 1.14%. Conclusion: Both NPIS enquiries and prescriptions for coproxamol have fallen since its withdrawal in 2005. No single opioid appears to have been used as a substitute analgesic. There was a marked increase in calls to NPIS (Cardiff) regarding all other opioids including tramadol with the exception of dihydrocodeine which has decreased steadily since 2004. Use and overdose of tramadol should be monitored closely over coming years due to the potential for significant neurological toxicity.  References: 1. Prescription Cost Analysis 2004–2008. NHS Information Centre 2009. 2. Prescriptions Dispensed in the Community, 2000 to 2008 and Prescription Cost Analysis (PCA) Data. Welsh Assembly Government 2009.Objective: Dextromethorphan is a readily accessible antitussive agent. Recreational abuse has been associated with dissociative effects, and deaths have been reported after ingestion of very large doses.1,2 This study examined the clinical features associated with dextromethorphan ingestion in the United Kingdom.  Methods:  The National Poisons Information Service is commissioned by the Health Protection Agency to provide clinical advice on the management of poisoned patients in the United Kingdom. Enquiries concerning dextromethorphan were examined retrospectively.  Results: Data were available between 2004 to 2007. There were data concerning 354 patients with median age 7 years (95% CI 4 to 14 years) of whom 194 were female (55.0%). Cases involved accidental ingestion in 261 (73.9%), deliberate overdose in 87 (24.6%), and adverse effects of therapeutic dose in 5 (1.4%). Median dose was 45 mg (range 3 to 2750 mg). Commonest co-ingested agents were paracetamol in 147 (41.6%), promethazine in 132 (37.4%), diphenhydramine in 73 (20.7%), pseudoephedrine in 67 (19.0%), triprolidine in 53 (15.0%), and menthol in 32 (9.1%). There were no symptoms or signs of toxicity in 257 patients (72.8%). The dose was higher in patients with symptoms; 120 mg (IQR 50 to 225 mg) versus 30 mg (IQR 8 to 90 mg), p<0.0001 by Mann Whitney test. Dextromethorphan dose was predictive of toxicity; receiver operating characteristic AUC 72.5% (95% CI 67.1 to 77.4%). Clinical features were drowsiness in 50 (14.2%), minor haemodynamic effects in 14 (4.0%), nausea or vomiting in 13 (3.7%), dizziness and ataxia in 10 (2.8%), agitation in 7 (2.0%), non-specific abdominal pain in 4 (1.1%), mydriasis in 3 (0.8%), dry mouth in 3 (0.8%), blurred vision in 2 (0.6%), headache in 2 (0.6%), and tremor in 1 (0.3%). None had features of severe poisoning. Conclusion: Dextromethorphan enquiries to the National Poisons Information Service often concern accidental exposures in children. The majority of patients had no clinical features or only minor symptoms.Objective: To describe the epidemiology of essential oil poisoning reported to the National Poisons Information Service (Cardiff) and to review the toxicity of essential oils.  Methods: Interrogation of the United Kingdom Poisons Information Database (UKPID) and literature review using Medline. Results:  Of 92,731 exposures reported to the NPIS (Cardiff) from Jan 2004 to January 2008, 1518 (1.6%) involved essential oils. Of these cases, 1280 (84%) were ingestions. Most exposures (66.0%) involved patients under the age of 4 years. A review of the literature suggests that certain essential oils (eucalyptus, pennyroyal, turpentine and clove) are more commonly encountered in human exposure. It is not clear whether this is due to greater toxicity or wider use of these particular oils. It is generally regarded that certain oils (pennyroyal, tea tree, turpentine, wintergreen, and wormwood) are too toxic to be used in aromatherapy. Others such as lavender oil are thought to have a much lower toxicity.1 Toxicity from essential oil ingestion (and less commonly dermal contact or intravenous injection) includes gastrointestinal upset, central nervous system depression, aspiration pneumonitis, hepatic and renal failure.2–4 Although the data are limited, it has been suggested that there may be distinct patterns of toxicity for individual oils, e.g. hepatotoxicity with pennyroyal and clove oils. Conclusion:  Although toxicity from essential oil exposure is rarely encountered, severe toxicity has been reported in the medical literature. Essential oils are widely available in many over the counter preparations in the United Kingdom. It is therefore important to remain vigilant to the risks associated with essential oil exposure.  References: 1. Lis-Balchin M. Aromatherapy Science. A guide for healthcare professionals. 1st ed. London, UK: Pharmaceutical Press 2006. 2. Tibballs J. Clinical effects and management of eucalyptus oil ingestion in infants and young children. Med J Aust 1995; 163:177–80. 3. Troulakis G, Tsatsakis AM, Astrakianakis A, et al. Acute intoxication and recovery following massive turpentine ingestion: clinical and toxicological data. Vet Human Toxicol 1997; 39:155–7. 4. Eisen JS, Koren G, Juurlink DN, et al. N-Acetylcysteine for the treatment of clove oil-induced fulminant hepatic failure. J Tox Clin Tox 2004; 42:89–92.Background: The ready availability of so-called natural remedies from Internet websites, together with mostly unsubstantiated claims as to their efficacy in treating various medical conditions, continues to give rise to serious safety concerns. Although the possibility of acute cyanide toxicity from ingestion of large quantities of apricot kernels is well documented, certain websites are still advocating this practice as a ‘natural’ treatment for cancer - even recommending consumption of 50 kernels daily.  Case report: A 48 year-old non-smoking female patient attended the emergency department complaining of nausea, headache, abdominal pain and diarrhoea. She was previously diagnosed with multiple endocrine neoplasia (type IIa) and had undergone a number of neck operations including recent removal of a medullary carcinoma of the thyroid. In an attempt to prevent further recurrence of her disease she had taken advice from a website advocating apricot kernel therapy. Initially she had been ingesting 10 kernels/day but this had been increased to 40/day for the past week. She described having a terrible taste since commencing the therapy and that she now felt very unwell and ‘raw inside’. Examination revealed mild dehydration and an elevated plasma calcium concentration (2.85 mmol/L). Blood cyanide concentration was normal but her serum thiocyanate concentration was 22.6 mg/L (1–4 mg/L in non-smokers), a level consistent with that found in studies of patients ingesting 1500 mg amygdalin (the cyanogenic component of apricot kernels) daily. Following supportive care and intravenous fluids, her symptoms abated and she was discharged.  Discussion:  Analytical data provided by the Food Standards Agency indicate that bitter apricot kernels on sale in health shops in the UK contain on average 0.5 mg of cyanide per kernel. This patient may therefore have been ingesting approximately 330 microgram/kg cyanide daily - uncomfortably close to the lower acute lethal dose limit in humans of 500 microgram/kg and 28 times the TDI (Tolerable Daily Intake) of 12 microgram/kg/day set by the WHO in 2003. Individuals desperately seeking relief from serious and chronic medical conditions are particularly vulnerable to the exaggerated claims of dangerously irresponsible Internet advertisers and may well find themselves in potentially life-threatening situations. Is there a need for regulation?Objective: From 2008 up to now the Poison Information Center (PIC) Erfurt has registered 4 incidents involving:3, 4, 2 (1 fatality) persons with signs of carbon monoxide (CO) poisoining from indoor barbecues (COBIB). To explore if COBIB ist a new phenomenon in Germany, although one which was already described in other countries, we asked 10 German-speaking PICs and the BfR Berlin to send us all their COBIBs from the last ten years.Objective: In the context of compulsory notification ofcases of poisoning, The Federal Institute For RiskAssessment (BfR) received eight reports of fatal casesof carbon monoxdide (CO) poisoning after indoor useof charcoal grills in 2009. Two cases resulted in verysevere neurological damage. CO is odourless, colourlessand non-irritant and therefore, does not produce anywarning effect for humans. The gas is lighter than airand readily absorbed through the lungs, which initiallyremains unnoticed. Insufficient ventilation in indoorenvironments will quickly result in lethal concentrationsof the toxic gas.Methods: The cases were investigatedand documented at BfR, and assessments of individualcases as well as an analysis of cases reported sofar under §16e Chemicals Act were performed. For abetter assessment of exposure, the Institute of the FireDepartment of Saxony-Anhalt (IdF) performed principalmeasurements of CO emissions from charcoal productsinside a fire container in the context of a researchproject of the Federal Land of Saxony-Anhalt.Results: In all cases, charcoal grills had been improperlyoperated indoors and probably also been used forheating. Examinations performed by IdF on thedynamics of the development of O2, CO and CO2 concentrationshave demonstrated the considerable riskposed by open fires in rooms lacking the necessaryventilation. Calculations of the absorbed toxic doseaccording to the Fractional Effective Dose (FED)model [Purser] have confirmed the fatal risk posed byindoor operation of charcoal grills. Very severe andlife-threatening poisoning may occur within 30minutes.Conclusion: Investigations into cases andevaluations of measurements have documented the riskposed by CO formation in indoor environments. Thecluster of fatal cases observed in the first half of 2009has indicated that, obviously, a part of the population isnot aware of the risk posed by indoor open fires. Eventhe use of embers as a source of heat in rooms maycause life-threatening poisoning. Open windows anddoors do not provide safety. In cases of moderate tosevere poisoning, persons affected will mostly exhibit acherry-red healthy skin colour. This may lead to misjudgementof the situation, particularly if alcohol hasbeen consumed.Objective: Risperidone overdose is generally associated with mild and predictable clinical effects, including sedation, tachycardia and dystonia, which are usually resolved within 24 hours of ingestion. We report the management of a case of risperidone overdose in a 28 year old woman who remained asymptomatic for almost 60 hours post-ingestion before the sudden onset of an acute dystonic reaction of the tongue and throat.  Case report: The patient presented following the sudden onset of extremely distressing spasm and swelling of her tongue, neck and side of face, two and a half days after an alleged overdose with 90 mg of a friends risperidone. She was dyspnoeic and could not speak. Examination was unremarkable except for an acute dystonia of her tongue and throat, noisy breathing without true stridor, and sinus tachycardia (HR 150). Neurological examination was normal except for the dystonia. Coagulation, renal and liver function test results were within normal limits. Procyclidine was given as an intravenous bolus of 10 mg. The patient described a reduction in the swelling and spasm of her tongue and throat within 30 minutes of treatment. Serum risperidone concentration at the time of presentation was below the limit of detection for the assay and the concentration of the active metabolite, 9-OH risperidone, was 31 μg/L, which is within the normal range of 10 - 90 μg/L for patients taking risperidone therapeutically. Her heart rate settled following resolution of the dystonia and she was discharged the same day.  Conclusion:  This case report confirms that dystonic reactions can occur some days after an otherwise asymptomatic overdose of risperidone, even in the absence of elevated blood concentrations of the parent drug or its metabolite. Although dystonic reactions are not usually life-threatening, the localisation in this case of the dystonia in the mouth and throat led to severe distress that was treated effectively with procyclidine.

Further development of the alerting system for chemical health threats, phase II (ASHTII) [Abstract]

Objective:  The UK NPIS are receiving an increasing number of calls about a drug of abuse known as mephedrone or 4-methylmethcathinone, also called ‘bubbles’. It is usually supplied as an off-white crystalline powder with a strong fish-like odour and is either ingested or inhaled. This drug is becoming increasingly popular in the UK as it is currently classed as a legal substance. It is often bought from the Internet as plant food or as a research chemical marked ‘not for human consumption.’  Methods: Enquiries to the UK NPIS for the period 1 January 2008 to 1st January 2009 and also 1st January 2009 to 1st November 2009 involving ‘mephedrone’ or ‘methcathinone’ were retrieved. Each call was examined in detail and all reported symptoms and the results of any investigations noted. Internet websites were also investigated for details of mephedrone exposures to try and compare symptoms experienced by regular users with those reported to the UK NPIS.  Results: No enquiries concerning mephedrone were received by UK NPIS between 1st January 2008 and 1st January 2009 compared with 29 enquiries which were received between 1st January 2009 and 1st November 2009. Of these, the main symptoms reported were agitation/anxiety, headache, sweating, chest pain, mydriasis, loin or back pain and pins and needles. One patient was admitted to ITU with tachycardia, hypotension, rhabdomyolysis and coma following a seizure. The symptoms reported on the Internet (from 13 user information reports) included euphoria, addictive behaviour, dilated pupils, jaw clenching and sweating as well as increased heart rate. There have been some reports of vasoconstriction causing purple extremities and joints. One death has been reported in Sweden although causal links with mephedrone have not yet been confirmed.  Conclusion: Mephedrone is a very new and increasingly popular drug; its legal status in the UK may falsely imply safety. It is, however, a synthetic drug that, from UK NPIS data and Internet reports, causes some potentially dangerous symptoms that are similar to stimulant drugs of abuse. The clinical effects of this chemical need further investigation.Background: Air fresheners have become increasingly popular over recent years with marketing aimed at removing odours, refreshing the air and creating a pleasant ambient mood. Their popularity has resulted in a multi-million pound market with new products continually being released. Air fresheners come in many forms including sprays, plug-ins, gels and candles. Due to their wide use and availability, ingestion of these products is common with hundreds of cases being reported to the National Poisons Information Service (NPIS) annually. Whilst many air-fresheners contain potentially harmful products, they are usually difficult to ingest in large amounts and serious effects are therefore uncommon. Recently however, the NPIS has seen the emergence of a new type of air freshener which has led to concern. Reed diffusers, although available for many years, have seen a massive surge in popularity in 2009. They are usually composed of a bottle filled with approximately 100 - 500 mL of scented liquid delivered to the room by “wicking” reeds made of bamboo or similar. Some also contain decorative items such as beads. The liquid is easily accessible due to the open neck of the bottle and therefore has potential to be ingested in large quantities. The ingredients of reed diffusers vary dramatically. A small sample of different products revealed a contents list which can include 90% essential oils; 85% glycol ethers; 80% ethanol or 78% hydrocarbons.  Case series: From January to November 2009 the NPIS (Cardiff) has received 27 calls involving reed diffusers. These all involved young children aged between 8 months and 4 years with an average age of 21 months. One enquiry involved eye contact, four involved ingestion of beads or pearls from within the unit and 22 involved ingestion of the liquid itself, most of these cases involving unknown amounts.  Conclusion:  These products are of serious concern due to the ease with which young children may ingest significant quantities of potentially life threatening compounds. It is essential that health professionals are aware that the reed diffuser type of air freshener is not as innocuous as those with which we are more familiar and that all cases should be treated as potentially serious.Objective: Intravenous fat emulsion (IFE) has been successfully used as an antidote in cases of local anaesthetic toxicity and the possibility of its usefulness in overdose of other lipid-soluble drugs continues to provoke interest. We report a case of a mixed overdose where IFE was given successfully to treat a haemodynamically compromised patient.  Case report: A 52 year old female was admitted to AE pulse 38, blood pressure 80/50, RR 10, GCS 8/15, and ECG showing complete heart block. Despite receiving conventional treatment - saline, naloxone, atropine, calcium gluconate and sodium bicarbonate she showed no improvement and required admission to the intensive care unit for ventilatory and inotropic support. Awaiting transfer to ITU, 20% intralipid (500 mL) was administered over 30 minutes. Her post-lipid ECG showed sinus rhythm, pulse 79, PR 191, QRS 107 ms, QT/ QTc 407/467 ms. Her blood pressure on admission to ITU was 124/55 mmHg. She subsequently continued to improve requiring no inotropic support and was extubated the following day. A mild aspiration pneumonia was treated successfully with co-amoxiclav and she was discharged after psychiatric assessment without sequelae.  Conclusion: Animal studies have demonstrated a reduction in morbidity and mortality from lipid-soluble drug cardiotoxicity with IFE, and in humans it has been used to treat local anaesthetic toxicity, as well as bupropion/lamotrigine toxicity. Its exact mode of action is unclear but it may trap lipophilic drugs in an expanded plasma lipid compartment (lipid sink).1 This case demonstrates the successful use of IFE in an overdose involving amitriptyline and diltiazem. Administration of intralipid rapidly reversed ECG changes and improved haemodynamic status without the need for inotrope therapy or extended ITU support. Although data from human poisonings are still limited, we believe there is a role for IFE therapy in managing patients with overdose from lipid-soluble drugs.  References: 1. Sirianni AJ, Osterhoudt KC, Calello DP, et al. Use of lipid emulsion in the resuscitation of a patient with prolonged cardiovascular collapse after overdose of bupropion and lamotrigine. Ann Emerg Med 2008; 51:412–5.Objective: To investigate poisoning with opioid analgesics over a six year period using call data from NPIS (Cardiff), comparing results with prescriptions in the community.  Methods:  Records of all enquiries made to NPIS (Cardiff) between January 2004 and October 2009 were reviewed. Calls related to patients involving opioid analgesics were counted. Prescription rates were obtained from Prescription Cost Analysis Data for England1 and Wales2.  Results: Table 1 shows a summary of results. Call figures are given as percentage of total calls involving opioid analgesics. Calls involving tramadol have increased from 11.7% of total opioid analgesics to 18.8% over the six year period. Coproxamol enquiries have decreased from 18.2% to 0.5% and codeine has increased from 36.2% to 50.7%; oxycodone increased from 0.6% to 1.9% and dihydrocodeine decreased from 22.5% to 14.2%. The number of TOXBASE© hits for tramadol increased from 0.66% of total hits to 1.14%. Conclusion: Both NPIS enquiries and prescriptions for coproxamol have fallen since its withdrawal in 2005. No single opioid appears to have been used as a substitute analgesic. There was a marked increase in calls to NPIS (Cardiff) regarding all other opioids including tramadol with the exception of dihydrocodeine which has decreased steadily since 2004. Use and overdose of tramadol should be monitored closely over coming years due to the potential for significant neurological toxicity.  References: 1. Prescription Cost Analysis 2004–2008. NHS Information Centre 2009. 2. Prescriptions Dispensed in the Community, 2000 to 2008 and Prescription Cost Analysis (PCA) Data. Welsh Assembly Government 2009.Objective: Dextromethorphan is a readily accessible antitussive agent. Recreational abuse has been associated with dissociative effects, and deaths have been reported after ingestion of very large doses.1,2 This study examined the clinical features associated with dextromethorphan ingestion in the United Kingdom.  Methods:  The National Poisons Information Service is commissioned by the Health Protection Agency to provide clinical advice on the management of poisoned patients in the United Kingdom. Enquiries concerning dextromethorphan were examined retrospectively.  Results: Data were available between 2004 to 2007. There were data concerning 354 patients with median age 7 years (95% CI 4 to 14 years) of whom 194 were female (55.0%). Cases involved accidental ingestion in 261 (73.9%), deliberate overdose in 87 (24.6%), and adverse effects of therapeutic dose in 5 (1.4%). Median dose was 45 mg (range 3 to 2750 mg). Commonest co-ingested agents were paracetamol in 147 (41.6%), promethazine in 132 (37.4%), diphenhydramine in 73 (20.7%), pseudoephedrine in 67 (19.0%), triprolidine in 53 (15.0%), and menthol in 32 (9.1%). There were no symptoms or signs of toxicity in 257 patients (72.8%). The dose was higher in patients with symptoms; 120 mg (IQR 50 to 225 mg) versus 30 mg (IQR 8 to 90 mg), p<0.0001 by Mann Whitney test. Dextromethorphan dose was predictive of toxicity; receiver operating characteristic AUC 72.5% (95% CI 67.1 to 77.4%). Clinical features were drowsiness in 50 (14.2%), minor haemodynamic effects in 14 (4.0%), nausea or vomiting in 13 (3.7%), dizziness and ataxia in 10 (2.8%), agitation in 7 (2.0%), non-specific abdominal pain in 4 (1.1%), mydriasis in 3 (0.8%), dry mouth in 3 (0.8%), blurred vision in 2 (0.6%), headache in 2 (0.6%), and tremor in 1 (0.3%). None had features of severe poisoning. Conclusion: Dextromethorphan enquiries to the National Poisons Information Service often concern accidental exposures in children. The majority of patients had no clinical features or only minor symptoms.Objective: To describe the epidemiology of essential oil poisoning reported to the National Poisons Information Service (Cardiff) and to review the toxicity of essential oils.  Methods: Interrogation of the United Kingdom Poisons Information Database (UKPID) and literature review using Medline. Results:  Of 92,731 exposures reported to the NPIS (Cardiff) from Jan 2004 to January 2008, 1518 (1.6%) involved essential oils. Of these cases, 1280 (84%) were ingestions. Most exposures (66.0%) involved patients under the age of 4 years. A review of the literature suggests that certain essential oils (eucalyptus, pennyroyal, turpentine and clove) are more commonly encountered in human exposure. It is not clear whether this is due to greater toxicity or wider use of these particular oils. It is generally regarded that certain oils (pennyroyal, tea tree, turpentine, wintergreen, and wormwood) are too toxic to be used in aromatherapy. Others such as lavender oil are thought to have a much lower toxicity.1 Toxicity from essential oil ingestion (and less commonly dermal contact or intravenous injection) includes gastrointestinal upset, central nervous system depression, aspiration pneumonitis, hepatic and renal failure.2–4 Although the data are limited, it has been suggested that there may be distinct patterns of toxicity for individual oils, e.g. hepatotoxicity with pennyroyal and clove oils. Conclusion:  Although toxicity from essential oil exposure is rarely encountered, severe toxicity has been reported in the medical literature. Essential oils are widely available in many over the counter preparations in the United Kingdom. It is therefore important to remain vigilant to the risks associated with essential oil exposure.  References: 1. Lis-Balchin M. Aromatherapy Science. A guide for healthcare professionals. 1st ed. London, UK: Pharmaceutical Press 2006. 2. Tibballs J. Clinical effects and management of eucalyptus oil ingestion in infants and young children. Med J Aust 1995; 163:177–80. 3. Troulakis G, Tsatsakis AM, Astrakianakis A, et al. Acute intoxication and recovery following massive turpentine ingestion: clinical and toxicological data. Vet Human Toxicol 1997; 39:155–7. 4. Eisen JS, Koren G, Juurlink DN, et al. N-Acetylcysteine for the treatment of clove oil-induced fulminant hepatic failure. J Tox Clin Tox 2004; 42:89–92.Background: The ready availability of so-called natural remedies from Internet websites, together with mostly unsubstantiated claims as to their efficacy in treating various medical conditions, continues to give rise to serious safety concerns. Although the possibility of acute cyanide toxicity from ingestion of large quantities of apricot kernels is well documented, certain websites are still advocating this practice as a ‘natural’ treatment for cancer - even recommending consumption of 50 kernels daily.  Case report: A 48 year-old non-smoking female patient attended the emergency department complaining of nausea, headache, abdominal pain and diarrhoea. She was previously diagnosed with multiple endocrine neoplasia (type IIa) and had undergone a number of neck operations including recent removal of a medullary carcinoma of the thyroid. In an attempt to prevent further recurrence of her disease she had taken advice from a website advocating apricot kernel therapy. Initially she had been ingesting 10 kernels/day but this had been increased to 40/day for the past week. She described having a terrible taste since commencing the therapy and that she now felt very unwell and ‘raw inside’. Examination revealed mild dehydration and an elevated plasma calcium concentration (2.85 mmol/L). Blood cyanide concentration was normal but her serum thiocyanate concentration was 22.6 mg/L (1–4 mg/L in non-smokers), a level consistent with that found in studies of patients ingesting 1500 mg amygdalin (the cyanogenic component of apricot kernels) daily. Following supportive care and intravenous fluids, her symptoms abated and she was discharged.  Discussion:  Analytical data provided by the Food Standards Agency indicate that bitter apricot kernels on sale in health shops in the UK contain on average 0.5 mg of cyanide per kernel. This patient may therefore have been ingesting approximately 330 microgram/kg cyanide daily - uncomfortably close to the lower acute lethal dose limit in humans of 500 microgram/kg and 28 times the TDI (Tolerable Daily Intake) of 12 microgram/kg/day set by the WHO in 2003. Individuals desperately seeking relief from serious and chronic medical conditions are particularly vulnerable to the exaggerated claims of dangerously irresponsible Internet advertisers and may well find themselves in potentially life-threatening situations. Is there a need for regulation?Objective: From 2008 up to now the Poison Information Center (PIC) Erfurt has registered 4 incidents involving:3, 4, 2 (1 fatality) persons with signs of carbon monoxide (CO) poisoining from indoor barbecues (COBIB). To explore if COBIB ist a new phenomenon in Germany, although one which was already described in other countries, we asked 10 German-speaking PICs and the BfR Berlin to send us all their COBIBs from the last ten years.Objective: In the context of compulsory notification ofcases of poisoning, The Federal Institute For RiskAssessment (BfR) received eight reports of fatal casesof carbon monoxdide (CO) poisoning after indoor useof charcoal grills in 2009. Two cases resulted in verysevere neurological damage. CO is odourless, colourlessand non-irritant and therefore, does not produce anywarning effect for humans. The gas is lighter than airand readily absorbed through the lungs, which initiallyremains unnoticed. Insufficient ventilation in indoorenvironments will quickly result in lethal concentrationsof the toxic gas.Methods: The cases were investigatedand documented at BfR, and assessments of individualcases as well as an analysis of cases reported sofar under §16e Chemicals Act were performed. For abetter assessment of exposure, the Institute of the FireDepartment of Saxony-Anhalt (IdF) performed principalmeasurements of CO emissions from charcoal productsinside a fire container in the context of a researchproject of the Federal Land of Saxony-Anhalt.Results: In all cases, charcoal grills had been improperlyoperated indoors and probably also been used forheating. Examinations performed by IdF on thedynamics of the development of O2, CO and CO2 concentrationshave demonstrated the considerable riskposed by open fires in rooms lacking the necessaryventilation. Calculations of the absorbed toxic doseaccording to the Fractional Effective Dose (FED)model [Purser] have confirmed the fatal risk posed byindoor operation of charcoal grills. Very severe andlife-threatening poisoning may occur within 30minutes.Conclusion: Investigations into cases andevaluations of measurements have documented the riskposed by CO formation in indoor environments. Thecluster of fatal cases observed in the first half of 2009has indicated that, obviously, a part of the population isnot aware of the risk posed by indoor open fires. Eventhe use of embers as a source of heat in rooms maycause life-threatening poisoning. Open windows anddoors do not provide safety. In cases of moderate tosevere poisoning, persons affected will mostly exhibit acherry-red healthy skin colour. This may lead to misjudgementof the situation, particularly if alcohol hasbeen consumed.Objective: Risperidone overdose is generally associated with mild and predictable clinical effects, including sedation, tachycardia and dystonia, which are usually resolved within 24 hours of ingestion. We report the management of a case of risperidone overdose in a 28 year old woman who remained asymptomatic for almost 60 hours post-ingestion before the sudden onset of an acute dystonic reaction of the tongue and throat.  Case report: The patient presented following the sudden onset of extremely distressing spasm and swelling of her tongue, neck and side of face, two and a half days after an alleged overdose with 90 mg of a friends risperidone. She was dyspnoeic and could not speak. Examination was unremarkable except for an acute dystonia of her tongue and throat, noisy breathing without true stridor, and sinus tachycardia (HR 150). Neurological examination was normal except for the dystonia. Coagulation, renal and liver function test results were within normal limits. Procyclidine was given as an intravenous bolus of 10 mg. The patient described a reduction in the swelling and spasm of her tongue and throat within 30 minutes of treatment. Serum risperidone concentration at the time of presentation was below the limit of detection for the assay and the concentration of the active metabolite, 9-OH risperidone, was 31 μg/L, which is within the normal range of 10 - 90 μg/L for patients taking risperidone therapeutically. Her heart rate settled following resolution of the dystonia and she was discharged the same day.  Conclusion:  This case report confirms that dystonic reactions can occur some days after an otherwise asymptomatic overdose of risperidone, even in the absence of elevated blood concentrations of the parent drug or its metabolite. Although dystonic reactions are not usually life-threatening, the localisation in this case of the dystonia in the mouth and throat led to severe distress that was treated effectively with procyclidine.

To be continued: the ASHT II project [Abstract]

Objective: To compare the tools, terminologies and systems used by poisons centres’ (PCs) to record information about exposures to chemical consumer products, to compare the information collected when documenting enquiries, and to assess the extent to which PCs collect information that is useful for industry and risk management. This study was carried out as part of Subcomponent 3 of the research project ‘Description of the Nature of Accidental Misuse of Chemicals and Chemical Products (DeNaMiC). Methods: A questionnaire was sent to European PCs and other institutions. The questionnaire was structured in six parts: Contact data; General information (tasks, customers and workload in terms of poisons enquiries); Documentation system (Documentation and further processing); Product information (sources, updates, handling); Documented cases (kind of information); Toxicovigilance Activity. Results: 26 replies were received from PCs and hospitals that give poisons advice in 19 countries. The product/chemical information system and the case documentation depend on national regulations and number and type of enquiries. Self-created, electronic databases for case records and for product information are common in European PCs even when product databases are provided by a governmental agency. PCs collect the same basic data set about cases (patient data, amount and physical state of chemical, exposure route). The circumstances of poisoning (location, use/ storage by the consumer, efficiency of Risk Management Measures (RMMs)) are not documented routinely in all PCs. A number of PCs use the INTOX definition to classify the “circumstances of exposure”. Conclusion: To gather Europe-wide data about poisonings e.g. for root cause analysis, to check the efficiency of RMMs, PCs need support from industry to maintain their knowledge about products. The classification of products needs improvement and harmonisation. Case documentation would need to be expanded to include some exposure factors, using standardised terminology.Objective: To analyse the number of calls and symptoms observed in enquiries regarding liquitabs to the UK National Poisons Information Service (NPIS). Discussion: Liquitabs are liquid detergent sachets that are added to your washing machine. There are several types of detergent including cationic, anionic and non-ionic. These liquid detergent sachets are classed as irritant (Xi, R36) according to the EU directive 1999/45/EC. The following table (Table 1) lists the surfactants contained in various types of liquitabs. Methods: UK national data was extracted and analysed for the year end of October 2007 to the end of October 2008. Results: There were 472 enquiries nationally on liquitab exposures with 10 cases (2.1%) exhibiting central nervous system (CNS) features. The age range of those patients exhibiting CNS features were age ≤2yrs. Of these patients the main features listed were drowsiness, hypo-responsiveness, lethargy and falling Glasgow Coma Scale (GCS). Conclusion: The NPIS currently classes these products as low systemic toxicity. In view of the symptoms reported in 10 cases this year, further investigation may be warranted regarding the potential systemic toxicity of these detergents and whether those at the extremes of age are more susceptible to developing CNS effects.Objective: To report a case of symptomatic varenicline overdose in an adult. Case report: Varenicline is a new drug for smoking cessation. It is both a partial agonist and antagonist to the nicotine receptor. Trials have shown safety and efficacy at doses of 1 mg BD.1 Adverse effects have included nausea, vomiting, headache, fatigue and drowsiness.2 There are few reports of overdoses involving varenicline. A 14 year old female developed lethargy after ingesting 21 milligrams.3 Hypotension, tachycardia and coma have occurred when varenicline has been ingested in combination with unknown amounts of valproic acid and quetiapine.4 We report the case of a 48 year old male who ingested 12.5 milligrams of varenicline. Alcohol was co-ingested. The patient presented to hospital four hours after ingestion. On admission he was drowsy, hypotensive and experiencing hyperhidrosis. In accordance with TOXBASE (the primary clinical toxicology database of the National Poisons Information Service), the management plan for the patient included monitoring blood pressure, pulse, respiratory rate and temperature. A twelve lead ECG was recommended. Subsequently the patient become bradycardic and was given atropine and ephedrine. IV fluids were administered. Over a six hour period his condition improved and he made a complete recovery. Conclusion: Varenicline is a new drug and very little is known about its effects in overdose. This case suggests that toxicity may be seen at a dose which is relatively small compared to previously reported cases. References: 1. Faessel HM, Gibbs MA, Clark DJ, et al. Multiple-dose pharmacokinetics of the selective nicotinic receptor partial agonist, varenicline, in healthy smokers. J Clin Pharmacol 2006; 46:1439–1448. 2. SPC for Champix, Pfizer Limited. From http://emc. medicines.org.uk. Cited 10th November 2008. 3. Feng S, Goto CS, Velez LI, et al. Varenicline (Chantix) overdose in an adolescent female (abstract). Clin Toxicol 2008; 46:362. 4. Goto CS, Feng S, Velez LI, et al. Spectrum of toxicity due to varenicline (Chantix) exposure (abstract). Clin Toxicol 2008; 46:365.Objective: Within the European Union there is a mesh of rapid alert systems (RAS) for different hazards, e.g. food and feed (RASFF), dangerous consumer products (RAPEX) and communicable diseases (EWRS = early warning and response system). The abbreviation RAPEX stands for the rapid alert system for all dangerous consumer products, with the exception of food, pharmaceutical and medical devices. These systems link national and European public health authorities. Although the rapid alert system for biological and chemical attacks (RAS-BICHAT) connects national focal points in case of confirmed terror attacks with chemicals, there is still a gap for chemical hazards in cases of mere suspicion: in the future poisons centres and the EAPCCT will play an important role in the process of exchanging warnings concerning these hazards within the European Union. The ASHT research project prepares tools for these important new functions. The scope of the ASHT I projects was the creation of an EUwide alerting system to detect covert release of chemicals with a criminal or terrorist intent. The acronym “ASHT” stands for “Alerting System and Development of a Health Surveillance System for the Deliberate Release of Chemicals by Terrorists”. In ASHT II this task expands to all chemical incidents. Methods: Description of political, financial, toxicological and technical aspects of the project. Results: In the first phase of the project, ASHT I, two major tasks were accomplished: the feasibility of both a rapid alert system for chemicals (RAS-CHEM) by creating DEV RAS-CHEM, a preliminary “developmental” version, and a European surveillance system between poisons centres. Like ASHT I the second phase of the project is funded by the European Commission, the EAPCCT and the other project members. The duration of the project is 36 months. In ASHT II several tasks will have to be accomplished. Firstly, the DEV RAS-CHEM draft version must be converted into an EU-wide operating rapid alert system for chemicals (RAS-CHEM). The data base must be accessible via the internet. The data base shall carry out the delivery of “chemical event” alerting. The member states’ public health surveillance authorities are to be integrated in the process. On the other hand the ‘EU PC Forum’ as a means of emergency communication between European poisons centres is to be created. This includes the testing of a prototype toxicosurveillance tool using automated data sampling in poisons centres. Toxicological aspects include the refinement of lists of chemicals, symptoms or toxidromes as important bases for mutual data exchange. Concerning the information technology level, several requirements are to be taken into consideration: for the creation of an event and for retrieval functions an appropriate relational data base structure is essential. National Public Health Authorities of the member states of the European Union and the WHO are integrated into the project as associate partners. Conclusion: The early warning system for chemicals (RAS-CHEM) will be integrated into the suite of other pre-existing EU early warning systems in the near future. There is a chance that poisons centres and the EAPCCT could upgrade their role for chemical alertness in Europe.Objective: To determine the availability of information from poisons centres and other sources that would characterise the nature of accidental exposure to household chemical products to improve risk management. The DeNaMiC project was funded by European Chemical Industry Council (CEFIC) and was carried out by the poisons centres in Gottingen, Lille, London and Prague, the German Federal Institute for Risk Assessment, the World Health Organization and the Health Protection Agency (UK). Method: The project involved developing an analytical tool to compare data on accidental poisoning obtained from the published literature, poisons centre annual reports and official mortality and morbidity statistics, and comparing and mapping the data collection and product classification schemes used by three poisons centres (Gottingen, Lille and London). A retrospective analysis of 3 years of enquiry data from Gottingen and Lille was also carried out to determine routinely available data on circumstances of exposure. European poisons centres were surveyed to determine the availability of data useful for product risk assessment. In addition, an analysis of published literature on toxicovigilance and a survey of toxicovigilance activities of European poisons centres was carried out. Finally, the project explored the feasibility of using poisons centres to obtain additional information about circumstances of exposure through a prospective followup study. Results: A range of publicly available data on accidental exposures was found; however, this provided little on the circumstances of exposure and could only be compared qualitatively. The product classification schemes used by three poisons centres showed some degree of comparability for household products. European poisons centres collected the same base data set but varied in collecting data relevant for risk assessment. European poisons centres varied in their understanding of ‘toxicovigilance’ but most stated that they perform it. It was possible to collect additional prospective data on exposures to household products relevant for risk assessment and management. Conclusions: Poisons centres are an important potential source of data useful for product risk assessment and management. In most cases, however, this requires additional work that needs to be resourced. Cooperation between poisons centres and industry can contribute to improving product safety.Objective: The European commission has proposed a directive amendment to restrict the sales of mercury in all clinical thermometers and in other, new, measuring devices to the general public. This is anticipated to reduce the impact on the environment and therefore reduce toxicity to humans and wildlife both acutely and in the long-term. In the UK this will come into effect on 3rd April 2009 as an amendment to the Controls on Dangerous Substances and Preparations Regulations. In light of this, a retrospective study to determine the percentage of mercury related calls due to these measuring devices was undertaken. Methods: Calls to the National Poisons Information Service (NPIS) from 1 January 2007 to 31st December 2007 concerning mercury were examined and the percentage of calls relating to thermometer, sphygmomanometer and barometer analysed as well as other calls concerning mercury. The calls were also assessed to determine 1) how many of these calls needed advice on disposal indicating that a spill had occurred or 2) how many needed referral to hospital. Results: There were 132 calls involving mercury; the majority of calls were regarding thermometers, 87 (67%). Barometers accounted for 6 (5%) and sphygmomanometers 4 (3%) of calls, therefore calls concerning all mercury-containing measuring devices implicated in the directive change accounted for 97 (75%) mercury calls. 48 (50%) of calls regarding measuring devices required advice on clean-up due to spillage. Only one call regarding a thermometer resulted in advice to attend A&E because of respiratory symptoms after inhalation. Conclusion: Calls regarding measuring devices containing mercury accounted for the vast majority of all mercury calls with clinical thermometers being the principal enquiry. Half of these calls needed advice on clean-up of a spillage, indicating potential loss of mercury into the environment. The proposed directive may decrease public exposure from elemental mercury, decrease public exposure and environmental impact and decrease enquiries to the NPIS. References: Directive 2007/51/EEC of the European parliament, 2007. Controls on Dangerous Substances and Preparations Regulations (S.I.2006 No. 3311) Schedule I, 2006.