Wendy Klein-Schwartz

2004 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System

Toxic Exposure Surveillance System (TESS) data are compiled by the American Association of Poison Control Centers (AAPCC) in cooperation with the majority of US poison centers. These data are used to identify hazards early, focus prevention education, guide clinical research, and direct training. TESS data have prompted product reformulations, repackaging, recalls, and bans; are used to support regulatory actions; and form the basis of postmarketing surveillance of newly released drugs and products. From its inception in 1983, TESS has grown dramatically, with increases in the number of participating poison centers, population served by those centers, and reported human exposures (Table 1). 1-15 The cumulative AAPCC database now contains 24.8 million human poison exposure cases. This report includes 2,241,082 human exposure cases reported by 65 participating poison centers during 1998, an increase of 2.2% compared with 1997 poisoning reports.

2003 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System.

AAPCCs 2003 fatality verification process involved the preparation and review of abstracts on 1,390 fatalities reported to poison centers, some of which were eventually determined to be unrelated to a poison exposure.

1996 Annual report of the American association of poison control centers toxic exposure surveillance system

Toxic Exposure Surveillance System (TESS) data are compiled by the American Association of Poison Control Centers (AAPCC) on behalf of US poison centers. These data are used to identify hazards early, focus prevention education, guide clinical research, and direct training. TESS data have prompted product reformulations, repackaging, recalls, and bans; are used to support regulatory actions; and form the basis of postmarketing surveillance of newly released drugs and products. From its inception in 1983, TESS has grown dramatically, with increases in the number of participating poison centers, population served by those centers, and reported human exposures (Table 1A).1-19 The cumulative AAPCC database now contains 33.8 million human poison exposure cases. This report includes 2,380,028 human exposure cases reported by 64 participating poison centers during 2002, an increase of 4.9% compared to 2001 poisoning reports.

Adverse events associated with dietary supplements: an observational study

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

1995 annual report of the American Association of Poison Control Centers toxic exposure surveillance system

Toxic Exposure Surveillance System (TESS) data are compiled by the American Association of Poison Control Centers (AAPCC) in cooperation with the majority of US poison centers. These data are used to identify hazards early, focus prevention education, guide clinical research, and direct training. TESS data have prompted product reformulations, repackaging, recalls, and bans; are used to support regulatory actions; and form the basis of postmarketing surveillance of newly released drugs and products. From its inception in 1983, TESS has grown dramatically, with increases in the number of participating poison centers, population served by those centers, and reported human exposures (Table 1).1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17 The cumulative AAPCC database now contains nearly 29.2 million human poison exposure cases. This report includes 2,168,248 human exposure cases reported by 63 participating poison centers during 2000, a decrease of 1.5% compared with 1999 poisoning reports.

Acute Beta Blocker Overdose: Factors Associated with the Development of Cardiovascular Morbidity

Objective: To identify factors in exposures to beta blockers (beta-adrenergic receptor antagonists) that are associated with the development of cardiovascular morbidity and contribute to disposition decisions from the emergency department. Methods: Prospective cohort of 280 beta blocker exposures reported to 2 regional poison centers. Multiple logistic regression was used to determine association of various clinical factors and outcome. Results: In this series of beta blocker exposures, 41 (15%) developed cardiovascular morbidity and 4 (1.4%) died. A history of cardioactive coingestant was the only factor significantly associated with the development of cardiovascular morbidity (p <. 05). When cases reporting cardioactive coingestants were excluded, a history of ingesting a beta blocker with membrane stabilizing activity was significantly associated with the development of cardiovascular morbidity (p <. 05). All those in whom the timing of symptoms could be determined, developed symptoms within 6 hours of ingestion. Conclusions: The single most important factor associated with the development of cardiovascular morbidity in beta blocker ingestion is a history of a cardioactive coingestant, primarily calcium channel blockers, cyclic antidepressants, and neuroleptics. In the absence of such co-ingestion, exposure to a beta blocker with membrane stabilizing activity is associated with an increased risk of cardiovascular morbidity. Beta blocker ingestion is unlikely to result in symptoms if the patient remains asymptomatic for 6 hours after the time of ingestion.

Clinical manifestations of toxicity in a series of 784 boric acid ingestions

A retrospective chart review was conducted at two regional poison centers to determine the clinical outcome of boric acid ingestions and to assess the relationship between serum boric acid levels and clinical presentation. A total of 784 cases were studied; all but 2 were acute ingestions. No patients developed severe manifestations of toxicity, and 88.3% were entirely asymptomatic. The most common symptoms were vomiting, abdominal pain, and diarrhea. Lethargy, headache, lightheadedness, and atypical rash were seen less frequently. Boric acid levels were obtained in 51 patients and ranged from 0 to 340 micrograms/mL. Blood levels were 70 micrograms/mL or more in 7 patients; 4 remained asymptomatic, whereas the other 3 had nausea or vomiting. Dialysis was performed in 4 of these 7 patients, only 1 of whom had symptoms (vomiting). On the basis of data from 9 patients, the mean half-life of boric acid was determined to be 13.4 hours (range, 4.0 to 27.8). Hemodialysis in 3 patients significantly shortened the half-life compared with pre- and postdialysis half-lives. Our results suggest that acute boric acid ingestions produce minimal or no toxicity and that aggressive treatment is not necessary in most patients.

Initial symptoms as predictors of esophageal injury in alkaline corrosive ingestions

The predictive value of initial clinical evaluation in the management of alkaline corrosive ingestion remains unclear. This multicenter study was designed to determine if specific clinical signs and symptoms following ingestion of alkaline corrosives could predict significant esophageal injury. Alkaline corrosives were defined by a pH greater than or equal to 12. Signs and symptoms previously suggested as predictive of significant esophageal injury were documented on a standardized data form. Esophagoscopy reports were reviewed blinded to initial symptoms. Three hundred thirty-six alkaline-corrosive ingestions were analyzed. The mean number of symptoms reported in patients who did not have esophagoscopy was 1.2, in patients who had esophagoscopy was 3.0, and in patients that had visualized second or third degree esophageal burns was 4.8. Of 88 patients who had esophagoscopy, 63 (72%) had both the esophagoscopy report and initial symptom assessment available. Esophagoscopy was positive, defined as second or third degree esophageal burns, in 18 of 63 cases (29%). All patients with significant burns were symptomatic. No single or group of initially reported signs and symptoms could identify all patients with potentially serious esophageal burns.

Poison Centers’ Experience With Methylphenidate Abuse in Pre-Teens and Adolescents

OBJECTIVE To evaluate trends and toxicity of methylphenidate abuse in pre-teens and adolescents reported to poison centers. METHOD The 1993-1999 American Association of Poison Control Centers Toxic Exposure Surveillance System was queried for methylphenidate abuse cases in children aged 10 through 19 years that were followed to known outcome. Main outcome measures included number of cases annually, toxicity, management site, and coded medical outcome. RESULTS Of 759 cases, 42.7% involved 10-through 14-year-olds. For the 530 (70.0%) cases involving methylphenidate only, the frequency increased sevenfold from 1993 to 1999. Of 570 patients (75.1%) managed in a health care facility, 398 were discharged from the emergency department and 172 were admitted. Symptoms occurred more commonly in exposures involving coingestants (84.3%) than in methylphenidate-only exposures (71.1%). The most common symptoms in adolescents with methylphenidate only were tachycardia (31.7%), agitation/irritability (25.7%), and hypertension (11.5%). Outcomes were no effect in 189 cases (24.9%) and mild, moderate, and severe in 318 (41.9%), 245 (32.3%), and 7 (0.9%) patients, respectively. CONCLUSIONS Poison center data demonstrate increasing frequency of methylphenidate abuse. While the majority of adolescents experienced clinical effects and were managed in a health care facility, outcomes were good, especially in cases involving methylphenidate only.

Relative toxicity of cyclic antidepressants

To compare the relative central nervous system and cardiac toxicity of amoxapine, maprotiline, and trazodone with the older tricyclic antidepressants, a three-year (1981 through 1983) retrospective review was performed on 1,313 cases involving cyclic antidepressant exposures reported to the Maryland Poison Center. Seizures were more common in the amoxapine (24.5%) and maprotiline (12.2%) groups, compared with either the tricyclic antidepressants (3.0%) or trazodone (0%) (P less than .01). A higher incidence of seizures also was observed in desipramine ingestors (17.9%) compared with other tricyclic antidepressants. No significant differences in the incidence of central nervous system depression or cardiotoxicity was found between the groups. These findings support reports of an increased incidence of seizures in overdoses of amoxapine and maprotiline, but do not substantiate claims of less cardiotoxicity.