Richard L. Kingston

Human exposure to insecticide products containing pyrethrins and piperonyl butoxide (2001-2003).

Pyrethrum, used as an insecticide for centuries, is derived from dried and ground flowers of Chrysanthemum cinerariaefolium. Its current major use is in insecticide products to the control insects in the home and food handling establishments. We investigated human incidents reported through the American Association of Poison Control Centers (AAPCC) Toxic Exposure Surveillance System (TESS) associated with regulated insecticides containing pyrethrins and piperonyl butoxide (PY/PBO) from 2001 to 2003. Special attention was paid to dermal and respiratory effects. Although there are limitations associated with TESS data, we observed that In view of their widespread use, the data indicates that PY/PBO products can be used with a relatively low risk of adverse effects. Moreover, the data suggest that they are not likely to cause reactions in people with asthma or allergies.

Clinical Observations and Medical Outcome in 149 Cases of Arsenate ant Killer Ingestion

One hundred forty-nine (149) consecutive cases of arsenate-containing ant killer reported to the Minnesota Regional Poison Center over 4 1/2 months were retrospectively reviewed with a follow-up (1 week to 3 months) completed in 132 (89%) of the population studied. One hundred and forty eight (99%) of the ingestions were accidental. The majority of cases involved children 3 years of age and younger. Only three patients accidentally ingesting the product were symptomatic (mild episodes of vomiting and diarrhea which cleared in all patients within 12 hours). No patient was referred to a medical center for treatment and no patient reached on follow-up reported any additional ill effects as a result of the exposure. In addition to the 149 patients in this series, we describe two representative patients who accidentally ingested similar amounts of sodium arsenate-containing ant killer, resulting in urine arsenic of 3500 micrograms/24 h and 5819 micrograms/24 h. They required no chelation treatment and had no evident sequelae during 4-6 months of medical follow-up. This experience supports poison center directed home management for the majority of single, acute, and accidental ingestions of small quantities (< 5 mL) of arsenate-containing ant killers as a safe alternative to medical center referral and adverse reactions to chelation.

Gastrointestinal decontamination. Which method is best

Why has ipecac syrup become less popular in emergency management of poisoning and overdose? When should gastric lavage, activated charcoal, cathartics, or a combination of methods be used? Which patients are candidates for whole-bowel irrigation with polyethylene glycol-electrolyte solution? Drs Harris and Kingston answer these questions and present their recommendations for each of the available management options.

Isocyanate Exposure Assessment Combining Industrial Hygiene Methods with Biomonitoring for End Users of Orthopedic Casting Products

Previous studies have suggested a potential risk to healthcare workers applying isocyanate-containing casts, but the authors reached their conclusions based on immunological or clinical pulmonology test results alone. We designed a study to assess potential exposure to methylene diphenyl diisocyanate (MDI) among medical personnel applying orthopedic casts using two different application methods. Air, dermal, surface, and glove permeation sampling methods were combined with urinary biomonitoring to assess the overall risk of occupational asthma to workers handling these materials. No MDI was detected in any of the personal and area air samples obtained. No glove permeation of MDI was detected. A small proportion of surface (3/45) and dermal wipe (1/60) samples were positive for MDI, but were all from inexperienced technicians. Urinary metabolites of MDI [methylenedianiline (MDA)] were detected in three of six study participants prior to both a ‘dry’ and ‘wet’ application method, five of six after the dry method, and three of six after the wet method. All MDA results were below levels noted in worker or general populations. Our conclusion is that the risk of MDI exposure is small, but unquantifiable. Because there is some potential risk of dermal exposure, medical personnel are instructed to wear a minimum of 5-mil-thick (5 mil = 0.005 inches) nitrile gloves and avoid contact to unprotected skin. This could include gauntlets, long sleeves, and/or a laboratory coat.

Comment on “An Increase in Dietary Supplement Exposures Reported to US Poison Control Centers”

In the report by Rao et al., the authors’ conclusions raise questions about the safety of dietary supplements (DS); however, there are important study limitations and context that must be considered before drawing conclusions regarding DS safety [1]. The current report purports to review exposures involving the FDA-regulated category of DS products. Yet, several product categories included in the analysis involved products clearly outside the scope of DS, including homeopathic products (representing 36% of the dataset), which are regulated by the US Food and Drug Administration (FDA) as drugs, and beverage versions of energy drinks, which are regulated as foods. Cultural medicines typically include substances that are outside of any regulated category of product. Ma huang products, which accounted for numerous reported exposures, have not been on the market for over a decade and are not relevant to today’s 170million consumers who take DS as part of their wellness efforts [2]. For those calls that involve exposure to properly categorized DS, it must be emphasized that reports of exposure are not synonymous with adverse events. Parents calling for reassurance subsequent to childhood ingestion of non-toxic amounts of these and other household products are routinely represented in the most recent American Association of Poison Control Centers’ (AAPCC) annual report in which 89% of all pediatric (< 6 years) exposures in the database involve no reports of adverse effects following exposure [3]. For the current report, asymptomatic exposures involve as many as 96% of all pediatric exposures and 99.6% when including minor outcomes. There are also concerns with the manner in which medical outcomes were further categorized as Bserious,^ which leads readers to equate those outcomes to life-threatening effects typically requiring life-saving therapeutic interventions, hospitalization, and potential residual disability. Yet, for this report, incidents coded with a moderate outcome were included in the Bserious^ outcome category. Moderate outcomes within the poison center dataset are, by definition, non-life threatening, leave no residual disability, and can include effects such as mild, self-limiting tachycardia, hives, or rash that require no therapeutic intervention. And, even for those serious events included in the PC data that involve allergy and/or anaphylaxis, confirmation that a DS was the cause with confirmatory allergy testing is rare. Removing the moderate outcome incidents from the report’s serious outcome classification leaves only 0.2% as serious incidents as compared to 4.5% reported by the authors. Equally concerning is the inclusion of incidents coded as death without some qualification or further review of the relatively small number of such events (n = 34). As an example, death associated with ginseng is highly suspect and cannot be independently confirmed, especially when fatality abstracts for this and virtually all reported fatalities presented in the dataset are missing both in this report and the corresponding AAPCC annual reports. * Richard L. Kingston rkingston@safetycall.com

Caffeine-Containing Energy Drinks/Shots

Abstract Caffeine-containing energy drinks/shots (CEDS) have become the fastest growing product category within the beverage industry. Coincident to the rapid rise in CEDS consumption, especially among adolescents and young adults, are concerns regarding their efficacy and safety. Much of the controversy surrounding CEDS can be traced to their principal ingredient, caffeine. Caffeine, the worlds most consumed and studied drug, is well known for its central nervous system (CNS) and cardiovascular stimulant effects. While caffeine-containing beverages like coffee and tea have been a mainstay in the human diet for over 500 years, safety concerns for these beverages are minimal, owing in part to their preparation as decoctions with relatively low caffeine content. Safety concerns for CEDS appear to be linked to misuse, individual susceptibilities, and combining these products with alcohol, prescription stimulants, or vigorous exercise. Marketing strategies coupled with higher caffeine content per volume may also contribute to reports of adverse health effects linked to CEDS. However, when consumed in moderation and not combined with alcohol, safety concerns for CEDS appear minimal. This review will address some of the pharmacological and pharmaceutical issues that distinguish CEDS from traditional caffeine-containing beverages. Such distinctions are likely to “energize” the current controversy surrounding these products.