Rita Mrvos

A profile of methylphenidate exposures.

Introduction: Methylphenidate is prescribed commonly for children with attention deficit hyperactivity disorder. An estimated 2.8% of US youths aged 5 to 18 years use it for the management of this disorder. Despite the widespread use of methylphenidate, the demographics and outcome of intentional and unintentional exposures to methylphenidate have not been described. Methods: To profile human exposures to methylphenidate, a retrospective review of all reports to a certified regional poison information center during 1998 was conducted. Data analysis included patient demographics, reason for the exposure, dose ingested, clinical effects, and patient outcome. Results: There were 113 methylphenidate human exposures. The following table summarizes the values for selected parameters that were investigated: Age Group (Years)<66–1213–19>19Mean Age ± SD2.9 ± 1.48.5 ± 2.115.0 ± 1.633.0 ± 10.1Mean Dose ± SD13.6 ± 8.2 mg26.8 ± 18.7 mg106.8 ± 177 mg70.0 ± 73.9 mgUnintentional100%80.8%26.7%44.5%Intentional0%19.2%73.3%54.5%Symptomatic16.0%30.8%50.0%54.5%Number of Patients35263022Conclusions: The majority of exposures in children ≤12 years of age involved unintentional ingestion of a siblings medication, self-administration of an excessive therapeutic dose, or the administration of an inadvertent dose given by a caregiver. Methylphenidate abuse was common among adolescents and adults. Regardless of the reason for the exposure, the amount ingested, or treatment, all exposures had a favorable outcome. Pediatric doses of less than 1 mg/kg were not associated with adverse events.

Friends and foes in the plant world: A profile of plant ingestions and fatalities

Introduction. Plants are beneficial as foodstuffs and many have medicinal properties. However, some plants also have the potential to produce toxicity. The objective of this study was to characterize plant exposures that involve humans and to discuss those that are associated with morbidity and mortality, as well as some that have undeserved bad reputations. Materials and Methods. The American Association of Poison Control Centers (AAPCC) 1983–2009 annual reports were reviewed to identify all plant-related fatalities. The 2000–2009 AAPCC Toxic Exposure Surveillance System and the National Poison Data System databases were queried to identify all plant ingestions. The data were analyzed to identify the specific plants, the age and gender of those who were exposed, the reason for the exposures and patient outcome. Results. During the decade of 2000–2009, 668 111 plant ingestion exposures were reported, 621 109 were single substance exposures with no co-ingestants, and the age was known in 611 708 of the exposures. There has been a steady decline in the number of plant exposures reflected as a percentage of all exposures reported to US poison centers. A total of 8.9% of all exposures involved plants in 1983, 6.0% in 1990, 4.9% in 2000, and 2.4% in 2009. Males accounted for 52.2% of the ingestions and over 60% of the moderate and major outcomes occurred in males. Morbidity was related directly to the reason for the exposure with the most severe outcomes occurring in those who ingested plants intentionally for self-harm or substance abuse. Children ≤5 years of age accounted for 81.2% of plant ingestion exposures. Within this age category, there were 497 002 ingestions over the 10-year period where a known age was recorded and 57.8% occurred in children less than 1 year of age. Only 45 fatalities were recorded between 1983 and 2009. Datura and Cicuta species were responsible for 35.5% of the fatal outcomes. Conclusions. Plant ingestion exposures remain a common call to poison information centers. However, the volume of those calls has decreased steadily over the last three decades. Most plant ingestion exposures occur in children, specifically children ≤5 years of age. Within this age group, there were an inordinate number of exposures in children <1 year of age, a previously unidentified finding with an unknown epidemiological basis. Morbidity and mortality associated with plant ingestion exposures were very low relative to the total number of reported exposures.

Philodendron/Dieffenbachia Ingestions: Are They a Problem?

Ingestions involving the philodendron/dieffenbachia members of the Arum family are allegedly associated with the development of intense irritation of mucous membranes, resulting in swelling of the tongue, lips and palate. Although numerous literature citations promote their toxicity, there are few case reports which substantiate a cause-effect relationship between ingestion and resultant symptomatology. To assess the toxic manifestations associated with the ingestion of these plants, a retrospective review of such cases reported to a Regional Poison Information Center was performed. 188 cases were identified and the integrity of the leaf had been broken in all cases. Philodendrons accounted for 67.5% and dieffenbachias for 32.5% of the cases. 72.8% involved children aged 4-12 months. Only 2.1% (4) of the patients were symptomatic (dieffenbachia-3; philodendron-1). In all cases, the symptoms occurred within 5 minutes of the exposure and were of short duration and the outcome was classified as minor. In this 24 month senses of 188 exposures, severe oral complications and the delayed development of symptoms were not observed.

High Pressure Injection Injuries: A Serious Occupational Hazard

High pressure injection equipment such as airless paint sprayers, high pressure grease guns, and fuel injection apparatus constitute a serious safety hazard resulting in significant morbidity. These devices are capable of delivering contaminants such as paint, solvents, and grease at pressures ranging from 600-12,000 psi. This allows the substance to penetrate through a minute skin wound and to spread widely through fascial planes and tendon sheaths and to produce significant vascular compression and systemic toxicity. High pressure injection injuries frequently result in amputation. Fifty-five suspected high pressure injection injury cases were evaluated. Twenty were determined to be actual injection injuries from equipment producing pressures in the range of 1,500-12,000 psi. The injected contaminants included latex paint, mineral spirits, and concrete sealer. Fourteen injuries involved digits. Digital amputation was necessary in three patients. Hospital admissions averaged 6.5 days. Successful management of these cases involves awareness of the impending problem and rapid referral of the patient to an emergency department and to a competent orthopedic or plastic surgeon.

Tacrolimus (FK 506) Overdose: A Report of Five Cases

INTRODUCTION Tacrolimus (FK 506), a potent anti-T cell agent, has been shown to be effective in preventing the rejection of transplanted organs. Published research on tacrolimus has focused on effects associated with therapeutic use. Virtually no literature addresses the acute toxicity or the management of tacrolimus overdose. We report five cases of acute overdose with tacrolimus. CASE REPORTS A 2-year-old female with no prior medical history ingested 10 mg of tacrolimus. She remained asymptomatic. A 2-year-old female with a history of multiple visceral organ transplants ingested 11 mg of her tacrolimus. She was admitted to the hospital and activated charcoal was administered. Her renal function was monitored and no changes were noted in a 24 h period. She was discharged. A 29-year-old male renal transplant patient took 150 mg of tacrolimus. He recovered with only a minimal creatinine elevation. A 23-year-old heart and lung transplant patient ingested 375 mg of tacrolimus. She had no effects from the overdose. A 34-year-old female experienced an acute/chronic overdose of 7-9 mg and remained asymptomatic. DISCUSSION Tacrolimus is a neutral macrolide antibiotic that is extracted from the fermentation broth of the soil fungus Streptomyces tsukubaensis. Chronic oral dosing has been associated with numerous side effects. Although these patients ingested significant doses of tacrolimus, they suffered few toxic manifestations associated with tacrolimus. CONCLUSION Little information is available regarding acute tacrolimus overdosage. In this small series of patients, tacrolimus did not produce acute physiologic incapacitation.

Transdermal drug delivery system exposure outcomes

Transdermal drug delivery systems are increasingly popular, yet few data exist regarding medical outcomes after exposures. Using data collected through a Regional Poison Information System, this retrospective study identified 61 cases of transdermal drug delivery system exposures reported over a recent 5-year period. Exposure routes included dermal (48 patients), oral (10 patients), combined oral and dermal (one patient), parenteral use of gel residue (one patient), and combined oral and parenteral (one patient). Forty-four exposures (72%) were managed by home telephone consultation only. Eleven of 17 patients (18%) evaluated in health care facilities were admitted, including eight (13%) to intensive care units. Hospital admission correlated statistically with clonidine and fentanyl exposures, oral exposures, and drug abuse. Clonidine exposure also correlated statistically with intensive care admission. One fatality was recorded, and all other patients recovered uneventfully. Transdermal drug delivery system exposures are infrequently reported to our regional poison information center but are associated with a significant hospital use and admission rate.

Child-Resistant Closures for Mouthwash: Do They Make a Difference?

Objectives: The Poison Prevention and Packaging Act of 1970 mandated that certain potentially hazardous drugs and other products be sold in child-resistant containers (CRCs). The Consumer Product Safety Commission estimates that CRCs for aspirin and oral prescription medicine saved the lives of about 700 children since the requirements went into effect in the 1970s. Under this Act, the Consumer Product Safety Commission issued a rule requiring child-resistant packaging for mouthwashes containing 3 g or more of ethanol per package. The effective date was July 24, 1995, and applied to all applicable products packaged on or after that date. Methods: To determine the effectiveness of this 1995 ruling, all American Association of Poison Control Center Toxic Exposure Surveillance System data involving children younger than 6 years who ingested ethanol-containing mouthwash 10 years before the implementation of this ruling, the transition year, and 10 years after were reviewed. Only single-substance exposures were included. Data reviewed included the total number of exposures per pre and post years and the outcome. Results: A total of 61,185 cases met the criteria. There were 18,275 exposures from 1985 through 1994 prerequirement (0.12% of all exposures); 39,376 from 1996 to 2005 postrequirement years (AR) (0.17% of all exposures); and 3,534 cases reported in 1995 (0.17% of all exposures). Definitive outcomes were coded in 62.6% of the prerequirement group and 42.2% of the AR group. Conclusions: Numerous factors affect these results. However, in those cases where definitive outcomes were coded, the AR group has better outcomes.

Disease surveillance and nonprescription medication sales can predict increases in poison exposure

IntroductionReal-time Outbreak and Disease Surveillance (RODS) is a national real-time syndromic surveillance system that classifies hospital registration chief complaints into one of seven syndromic categories. The National Retail Data Monitor (NRDM) is a public health surveillance tool that is designed to collect and analyze the daily sales of 18 categories of nonprescription medications. The goal of RODS and NRDM is to provide early warning of disease outbreaks, such as biological terrorism. The purpose of this study was to determine whether peak syndromic activity and the consequential purchase of nonprescription medications could predict an increase in poisoning exposures involving NRDM-monitored medications.MethodsData from the RODS and NRDM databases were plotted graphically to portray activity that occurred during 2003. Data from a regional poison information center electronic medical record system that involved all human exposure calls related to NRDM-monitored medications in 2003 were extracted and graphed. Analysis included comparisons between the data sets.ResultsPoison center exposure volume correlated predictably and simultaneously with the peak activity in both the RODS and NRDM databases.DiscussionThere was no delay between the onset of an influenza outbreak in December 2003, the sale of nonprescription palliative mediations, and the increase in poison center exposure call volume. Increased availability of and access to nonprescription medications resulted in more poisoning exposure calls.ConclusionsReal-time surveillance using other databases can help to forecast poison center activity. This knowledge allows the poison center to provide anticipatory guidance to the residents of its region.

A profile of calls to a poison information center regarding older adults.

Objectives: The authors sought to examine the nature of calls to poison information centers by adults ages 50 and over. Methods: The authors used data from the national Toxic Exposure Surveillance System and conducted a retrospective review of all cases reported to an American Association of Poison Control Centers Certified Regional Poison Information Center in 1998 and 1999 (N = 6,365). Results: The results indicated that females’ poison experiences were more likely the result of therapeutic error, adverse drug reactions, ingestions, and the acute-on-chronic class. The authors found that older age was inversely associated with acute class, suspected suicide, food poisoning, and inhalation and dermal exposures. Discussion: Older adults are the greatest consumers of over-the-counter drugs, take multiple medications for various medical conditions, and are experiencing biological changes that affect drug metabolism. Older women may be at especially high risk because of high drug use. Poison prevention education should target older adults.

Regional Pharmaceutical Preparation for Biological and Chemical Terrorism

Background: The United States National Office of Domestic Preparedness has determined that the threat of a biological or chemical attack is very real. As an active participant of a 13-county regional task force, one of the roles of the poison center was to determine the pharmaceutical needs of the community in the event of a terrorist action and develop a financially responsible method of acquisition and storage. Methods: Working with local health officials, an extensive literature review was conducted to identify possible biological and chemical poisons. Treatment recommendations were identified and an estimated amount to treat 5,000 people for 24 hrs was determined. Instead of purchasing the medications, a unique solution utilizing a regional pharmacy wholesaler was used. Discussion: An important element in a biological or chemical terrorist event is the availability of the pharmaceuticals and the capability of delivering them rapidly. The poison center is the ideal agency to help coordinate this endeavor since it is familiar with contemporary therapy and will be aware of the number, location, and status of casualties. Based on the expense involved in the purchase and storage of a large quantity of medications, utilizing a local pharmaceutical distribution company is fiscally responsible. Rotation through normal stock and being readily accessible is another benefit. Conclusion: The poison center serves a number of roles in the surveillance, recognition, and treatment of biological and chemical terrorism. Assisting in the development, implementation, and procurement of a pharmaceutical cache is yet another role.