Ruben Thanacoody

Position paper update: gastric lavage for gastrointestinal decontamination

Context. The first update of the 1997 gastric lavage position paper was published by the American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists in 2004. This second update summarizes the 2004 content and reviews new data. Methods. A systematic review of the literature from January 2003 to March 2011 yielded few studies directly addressing the utility of gastric lavage in the treatment of poisoned patients. Results. Sixty-nine new papers were reviewed. Recent publications continue to show that gastric lavage may be associated with serious complications. A few clinical studies have recently been published showing beneficial outcomes, however, all have significant methodological flaws. Conclusions. At present there is no evidence showing that gastric lavage should be used routinely in the management of poisonings. Further, the evidence supporting gastric lavage as a beneficial treatment in special situations is weak, as is the evidence to exclude benefit in all cases. Gastric lavage should not be performed routinely, if at all, for the treatment of poisoned patients. In the rare instances in which gastric lavage is indicated, it should only be performed by individuals with proper training and expertise.

Position paper update: ipecac syrup for gastrointestinal decontamination

Context. An update of the first position paper on ipecac syrup from 1997 was published by the American Academy of Clinical Toxicology and the European Association of Poison Centres and Clinical Toxicologists in 2004. The aims of this paper are to briefly summarize the content of the 2004 Position Paper and to present any new data. Methods. A systematic review of the literature from the year 2003 forward. Results. The literature search yielded a limited number of meaningful articles, and there remains no convincing evidence from clinical studies that ipecac improves the outcome of poisoned patients. Furthermore, the availability of ipecac is rapidly diminishing. Conclusions. The routine administration of ipecac at the site of ingestion or in the emergency department should definitely be avoided. Ipecac may delay the administration or reduce the effectiveness of activated charcoal, oral antidotes, and whole bowel irrigation. There is not sufficient evidence to warrant any change in the previous ipecac position papers. There are, however, insufficient data to support or exclude ipecac administration soon after ingestion of some specific poisons in rare situations.

Extracorporeal elimination in acute valproic acid poisoning

Introduction. Valproic acid (VPA) is an antiepileptic drug that is now used for a variety of neurological and psychiatric indications. Clinical manifestations of severe VPA poisoning include central nervous system depression, hypotension, electrolyte and acid–base disturbances, and hyperammonemia. Although extracorporeal methods have been used to enhance VPA elimination, the indications for and effectiveness of these methods have not been fully characterized. Methods. A systematic literature search was performed, which identified 31 reports of the use of extracorporeal elimination in VPA poisoning. Results. VPA has a low molecular weight of 144 Da and a low volume of distribution, but at therapeutic concentrations, it is highly protein bound (85–95%). Protein-binding studies during hemodialysis demonstrate that at high VPA concentrations protein binding is saturated, allowing substantial clearance of the free VPA fraction. Case reports consistently show that during hemodialysis the elimination half-life of VPA can be reduced to around 2 h and the enhanced VPA clearance is often associated with improvement clinically. Hemoperfusion also enhances VPA elimination, but its effectiveness may be limited by column saturation. “In-series” hemodialysis and hemoperfusion have been used, but the combination offers little benefit over hemodialysis alone. Continuous renal replacement techniques are increasingly being used although continuous venovenous hemofiltration and continuous venovenous hemodiafiltration do not appear to be as effective as hemodialysis. No controlled trials are available comparing clinical outcomes with or without extracorporeal elimination in VPA poisoning. Novel techniques such as slow low-efficiency dialysis with filtration and supplementation of the dialysate with albumin are being evaluated. Indications. Extracorporeal methods of elimination should be considered in patients with features of severe VPA poisoning (coma or hemodynamic compromise) and plasma VPA concentration >850 mg/L (coma is more likely to be present at concentrations >850 mg/L), particularly if severe hyperammonemia and electrolyte and acid–base disturbances are present. Conclusions. Based on limited anecdotal evidence, hemodialysis appears to be the extracorporeal method of choice to enhance VPA elimination in acute poisoning. Controlled, randomized trials are required to better characterize the effect of extracorporeal treatment on clinical outcome.

Position paper update: whole bowel irrigation for gastrointestinal decontamination of overdose patients.

Abstract Context. A position paper on the use of whole bowel irrigation (WBI) was first published in 1997 by the American Academy of Clinical Toxicology (AACT) and the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) and updated in 2004. The aims of this paper are to briefly summarize the content of the 2004 Position Paper and to present any new data and recommendations. Methods. A systematic review of the literature from January 2003 to February 28, 2013 was conducted using multiple online databases for articles concerning WBI for gastrointestinal decontamination. An evidence table was created for applicable articles. The authors produced the initial draft that was reviewed by AACT and EAPCCT. Results. The literature search produced 60 articles with the possibility of applicable human data. Based mainly on volunteer studies, WBI can be considered for potentially toxic ingestions of sustained-release or enteric-coated drugs particularly for those patients presenting later than 2 h after drug ingestion when activated charcoal is less effective. WBI can be considered for patients who have ingested substantial amounts of iron, lithium, or potassium as the morbidity is high and there is a lack of other potentially effective options for gastrointestinal decontamination. WBI can be considered for removal of ingested packets of illicit drugs in “body packers.” However, controlled data documenting improvement in clinical outcome after WBI are lacking. WBI is contraindicated in patients with bowel obstruction, perforation, or ileus, and in patients with hemodynamic instability or compromised unprotected airways. WBI should be used cautiously in debilitated patients and in patients with medical conditions that might be further compromised by its use. The concurrent administration of activated charcoal and WBI might decrease the effectiveness of the charcoal. The clinical relevance of this interaction is uncertain. Conclusion. WBI can facilitate removal of select toxicants from the gastrointestinal tract in some patients, but there is no convincing evidence from clinical studies that it improves the outcome of poisoned patients. There is no new evidence that would require a major revision of the conclusions of the 2004 position statement.

National audit of antidote stocking in acute hospitals in the UK

Background Inadequate stocking of essential antidotes in hospitals for the treatment of poisoned patients has been reported worldwide. Joint National Poisons Information Service (NPIS)/College of Emergency Medicine (CEM) guidelines for antidote stocking in UK emergency departments and acute hospitals were published in 2008. Aim To determine the impact of these guidelines by surveying the availability of antidotes in acute hospitals in the UK. Methods A two-page questionnaire consisting of antidote stocking information was distributed in 2010 to the Chief Pharmacist in all acute hospitals in the UK. The availability of 28 antidotes in the NPIS/CEM antidote guidelines as well as that of Intralipid was surveyed. Results Surveys were completed for 196 of the 224 (87.5%) hospitals. Over 90% of hospitals had acetylcysteine, activated charcoal, dantrolene, desferrioxamine, naloxone, flumazenil and vitamin K available within the recommended time period. Pralidoxime was reported to be held in only 33% of hospitals, though pralidoxime is supplied by the Department of Health to 95 hospitals in the UK that act as holding centres. Cyproheptadine and viper venom antiserum were held in around 50% of acute hospitals. For the treatment of cyanide and toxic alcohol poisoning, more than one antidote is available. For cyanide poisoning, most hospitals held at least one antidote (usually dicobalt edetate) but 9 (5%) held none of the four antidotes. For toxic alcohol and glycol poisoning, most hospitals held ethanol for intravenous use but not fomepizole and 30 (15%) did not stock any antidote for toxic alcohol poisoning. Conclusion Stocking of less commonly used antidotes is inconsistent. This is likely to result in delayed access to treatment and worse patient outcomes.

Patterns of presentation and clinical features of toxicity after reported use of ([2-aminopropyl]-2,3-dihydrobenzofurans), the 'benzofuran' compounds. A report from the United Kingdom National Poisons Information Service.

Abstract Objective. To characterise the patterns of presentation and clinical features of toxicity following reported recreational use of benzofuran compounds ((2-aminopropyl)-2,3-dihydrobenzofurans) in the UK, as reported to the National Poisons Information Service (NPIS), and to compare clinical features of toxicity with those after reported mephedrone use. Methods. NPIS patient-specific telephone enquiries and user sessions for TOXBASE®, the NPIS online information database, related to (2-aminopropyl)-2,3-dihydrobenzofurans and associated synonyms were reviewed from March 2009 to August 2013. These data were compared with those of mephedrone, the recreational substance most frequently reported to NPIS, collected over the same period. Results. There were 63 telephone enquiries concerning 66 patients and 806 TOXBASE® user sessions regarding benzofuran compounds during the period of study. The first telephone enquiry was made in July 2010 and the highest numbers of enquiries were received in August 2010 (33 calls, 112 TOXBASE® sessions). Patients were predominantly male (82%) with a median age of 29 years; 9 reported co-ingestion of other substances. Comparing the 57 patients who reported ingesting benzofuran compounds alone with 315 patients ingesting mephedrone alone, benzofurans were more often associated with stimulant features, including tachycardia, hypertension, mydriasis, palpitation, fever, increased sweating, and tremor, (72% vs. 38%, odds ratio [OR] 4.2, 95% confidence interval [CI] 2.27–7.85, P < 0.0001) and mental health disturbances (58% vs. 38%, OR 2.3, 95% CI 1.29–4.07, P = 0.006). Other features reported after benzofuran compound ingestion included gastrointestinal symptoms (16%), reduced level of consciousness (9%), chest pain (7%), and creatinine kinase elevation (5%). Conclusions. Reported ingestion of benzofuran compounds is associated with similar toxic effects to those of amphetamines and cathinones. Mental health disturbances and stimulant features were reported more frequently following reported ingestion of benzofuran compounds than after ingestion of mephedrone.

Management of poisoning with ethylene glycol and methanol in the UK: a prospective study conducted by the National Poisons Information Service (NPIS).

Abstract Background: Poisoning with methanol and ethylene glycol can cause serious morbidity and mortality. Specific treatment involves the use of antidotes (fomepizole or ethanol) with or without extracorporeal elimination techniques. Methods: A prospective audit of patients with methanol or ethylene glycol poisoning reported by telephone to the National Poisons Information Service (NPIS) in the UK was conducted during the 2010 calendar year and repeated during the 2012 calendar year. The study was conducted to determine the frequency of clinically significant systemic toxicity and requirement for antidote use and to compare outcomes and rates of adverse reaction and other problems in use between ethanol and fomepizole. Results: The NPIS received 1315 enquiries involving methanol or ethylene glycol, relating to 1070 individual exposures over the 2-year period. Of the 548 enquiries originating from hospitals, 329 involved systemic exposures (enteral or parenteral as opposed to topical exposure), of which 216 (66%) received an antidote (204 for ethylene glycol and 12 for methanol), and 90 (27%) extracorporeal treatment (86 for ethylene glycol and 4 for methanol). Comparing ethanol with fomepizole, adverse reactions (16/131 vs. 2/125, p < 0.001) and administration errors, lack of monitoring, or inappropriate use (45/131 vs. 6/125, p < 0.0001) were reported more commonly, whereas non-availability and inadequate stocks were reported less commonly (6/125 vs. 33/131, p < 0.0001). Eight fatalities and complications or sequelae occurred in 21 patients. Poor outcome (death, complications, or sequelae) was significantly associated with older age, higher poisoning severity scores, and lower pH on admission (p < 0.001). Conclusions: Systemic poisoning with ethylene glycol or methanol results in hospitalisation at least 2–3 times per week on average in the UK. No difference in outcome was detected between ethanol and fomepizole-treated patients, but ethanol was associated with more frequent adverse reactions.

Mathematical modelling of the effect of late administration of a novel acetylcysteine regimen based on the SNAP trial on hepatic glutathione regeneration and hepatocyte death following simulated acetaminophen overdose

Background: Cardiovascular medication overdose causes significant morbidity and mortality in the US. In 2015, the National Poison Data System responded to over 2.1 million exposures, 103,339 related to cardiovascular drugs. Cardiovascular drugs were the seventh most frequently involved substance and rated as the fourth category with the greatest rate of increase in exposure. Despite maximal supportive pharmacologic therapy (including vasopressor administration, high-dose insulin therapy, lipid emulsion therapy, and extracorporeal life support), there are still cases of refractory shock leading to death. In vitro studies on canine arteries exposed to amlodipine have shown that it stimulates release of nitric oxide (NO) leading to peripheral vasodilation. Amlodipine overdose could therefore be managed by scavenging NO. Methylene blue (MB) inhibits NO directly but also inhibits NO production by inhibiting guanylyl cyclase and endothelial NO synthase activity. We developed a porcine model of amlodipine toxicity and compared the effects of MB versus traditional vasopressor therapy with norepinephrine (NE), with time to death as the primary outcome. Methods: Animals were anesthetized and instrumented with monitoring devices according to previous protocols in our institution and a pilot study was first completed to establish a lethal model of amlodipine toxicity. Each of the two groups of animals received a toxic dose of amlodipine. A continuous infusion of amlodipine with accelerating doses was given to mimic overdose and continuing gastrointestinal absorption. After 70 min of amlodipine infusion, each group was resuscitated with 20 mL/kg of normal saline. Animals in each group were then randomized to receive either MB or NE therapy. Hemodynamic parameters, including mean arterial pressure, cardiac output, were measured every 10 min. Results: The primary outcome was time to death. Survival times were compared using a Kaplan–Meier analysis, and the two groups were compared with the log-rank test. The study was powered at 80% to detect a hazard ratio of 0.2 (MB versus NE), assuming a two-sided log-rank test with alpha1⁄4 0.05. Nine animals per group were required for adequate power. An interim analysis was conducted after 15 of the initially planned 18 animals were completed (seven MB and eight NE). This revealed that, for the primary outcome, MB was clearly not superior to NE. Furthermore, it would be impossible to achieve a statistically significant effect for the MB hazard ratio with the addition of three pigs, regardless of the outcome. Therefore, the study was ended prematurely. Overall, one of the seven (14%) animals in the MB group survived to 300 min compared with two of the eight animals (25%) in the NE group. Median survival time was 100 min for the MB group and 177 min for the NE group. Survival time did not differ by group (log-rank test, p1⁄4 .29) but there was a nonsignificant trend toward longer survival in the NE group. Conclusions: In this newly developed porcine model of amlodipine toxicity, MB did not lead to increased time to death as compared with NE poisoned animals. Whether MB is beneficial in combatting distributive shock in amlodipine toxicity remains unclear and requires further study.

Mathematical modelling of the effect different acetylcysteine regimens on hepatic glutathione regeneration and hepatocyte death following simulated acetaminophen overdose

Background: Cardiovascular medication overdose causes significant morbidity and mortality in the US. In 2015, the National Poison Data System responded to over 2.1 million exposures, 103,339 related to cardiovascular drugs. Cardiovascular drugs were the seventh most frequently involved substance and rated as the fourth category with the greatest rate of increase in exposure. Despite maximal supportive pharmacologic therapy (including vasopressor administration, high-dose insulin therapy, lipid emulsion therapy, and extracorporeal life support), there are still cases of refractory shock leading to death. In vitro studies on canine arteries exposed to amlodipine have shown that it stimulates release of nitric oxide (NO) leading to peripheral vasodilation. Amlodipine overdose could therefore be managed by scavenging NO. Methylene blue (MB) inhibits NO directly but also inhibits NO production by inhibiting guanylyl cyclase and endothelial NO synthase activity. We developed a porcine model of amlodipine toxicity and compared the effects of MB versus traditional vasopressor therapy with norepinephrine (NE), with time to death as the primary outcome. Methods: Animals were anesthetized and instrumented with monitoring devices according to previous protocols in our institution and a pilot study was first completed to establish a lethal model of amlodipine toxicity. Each of the two groups of animals received a toxic dose of amlodipine. A continuous infusion of amlodipine with accelerating doses was given to mimic overdose and continuing gastrointestinal absorption. After 70 min of amlodipine infusion, each group was resuscitated with 20 mL/kg of normal saline. Animals in each group were then randomized to receive either MB or NE therapy. Hemodynamic parameters, including mean arterial pressure, cardiac output, were measured every 10 min. Results: The primary outcome was time to death. Survival times were compared using a Kaplan–Meier analysis, and the two groups were compared with the log-rank test. The study was powered at 80% to detect a hazard ratio of 0.2 (MB versus NE), assuming a two-sided log-rank test with alpha1⁄4 0.05. Nine animals per group were required for adequate power. An interim analysis was conducted after 15 of the initially planned 18 animals were completed (seven MB and eight NE). This revealed that, for the primary outcome, MB was clearly not superior to NE. Furthermore, it would be impossible to achieve a statistically significant effect for the MB hazard ratio with the addition of three pigs, regardless of the outcome. Therefore, the study was ended prematurely. Overall, one of the seven (14%) animals in the MB group survived to 300 min compared with two of the eight animals (25%) in the NE group. Median survival time was 100 min for the MB group and 177 min for the NE group. Survival time did not differ by group (log-rank test, p1⁄4 .29) but there was a nonsignificant trend toward longer survival in the NE group. Conclusions: In this newly developed porcine model of amlodipine toxicity, MB did not lead to increased time to death as compared with NE poisoned animals. Whether MB is beneficial in combatting distributive shock in amlodipine toxicity remains unclear and requires further study.

Characteristics of Toxic Alcohol and Glycol Poisoning in the UK

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.