National Poison Center Research Articles

Pesticide-related poison center exposures in children and adolescents aged ≤19 years in Texas, 2000–2013

Context: Although national poison center data show that pesticides were the 8th most commonly reported substance category (3.27%) for children aged ≤5 years in 2014, there is limited information on childhood and adolescent pesticide exposures.Objective: This study assessed pesticide-related poison center exposures in children and adolescents aged ≤19 years from 2000–2013 in Texas to characterize the potential burden of pesticides.Materials and methods: Pesticide-related poison center exposures among children and adolescents aged ≤19 years reported to Texas poison centers were identified. The distribution of exposures was estimated by gender, age category, medical outcome, management site, exposure route, and pesticide category.Results: From 2000 to 2013, there were 61,147 pesticide-related poison center exposures in children and adolescents aged ≤19 years. The prevalence was highest among males at 864.24 per 100,000 population. The prevalence of unintentional exposures was highest among children aged ≤5 years at 2310.69 per 100,000 population, whereas the prevalence of intentional exposures was highest among adolescents aged 13–19 years at 13.82 per 100,000 population. A majority of medical outcomes reported were classified as having no effect (30.24%) and not followed, but minimal clinical effects possible (42.74%). Of all the exposures, 81.24% were managed on site. However, 57% of intentional exposures were referred to or treated at a health-care facility. The most common routes of exposure were ingestion (80.83%) and dermal (17.21%). The most common pesticide categories included rodenticides (30.02%), pyrethrins/pyrethroids (20.69%), and other and unspecified insecticides (18.14%).Discussion: The study found differences in the frequency of exposures by intent for sex and age categories, and identified the most common medical outcomes, management site, exposure route, and pesticide category.Conclusion: Through characterizing pesticide-related poison center exposures, future interventions can be designed to address groups with higher prevalence of exposure.

TOXINZ, the New Zealand Internet poisons information database: The first decade.

The New Zealand National Poisons Centre has, over a number of years, developed an electronic poisons information database. In 2002, this was released as toxinz™ (University of Otago, Dunedin, New Zealand), an Internet accessible version. The objective of this study is to describe New Zealand subscriber utilisation of TOXINZ with an emphasis on pharmaceutical monographs viewed. A retrospective review was conducted of records of New Zealand subscriber access to TOXINZ monographs during the period 1 January 2003 to 31 December 2012. Telephone enquiry data to the New Zealand National Poisons Centre was also obtained for the same time period. Over the decade, 201 255 TOXINZ monographs were accessed, with annual numbers of documents viewed doubling from 13 718 in 2003 to 28 782 in 2012. Pharmaceuticals were the largest group viewed with 132 316 documents accessed (65.7% of all documents), followed by monographs relating to chemicals 46 061 (22.9%), substances of abuse 6698 (3.3%), plants 6563 (3.3%), supportive care 4668 (2.3%), animals 2553 (1.3%), and other 2396 (1.2%). In regard to the pharmaceuticals, high or rapidly increasing levels of enquiries were identified for venlafaxine, quetiapine, paracetamol, zopiclone and tramadol. Investigation of telephone enquiries to the New Zealand National Poisons Centre showed total poisoning calls increased slightly over the 10 year period, whereas telephone enquiries from hospitals halved. The TOXINZ Internet accessible poisons information database has proved to be a well-utilised addition to the New Zealand National Poisons Centre's service.

Practice Trends in the Use of Extracorporeal Treatments for Poisoning in Four Countries.

Extracorporeal treatments (ECTRs) such as hemodialysis (HD), enhance the elimination of a small number of toxins. Changes in overdose trends, prescribing practices, antidotes, and dialysis techniques may alter the indications and rates of ECTR use over time. This study analyzed trends in ECTR for poisonings in four countries. A retrospective study of national poison center databases from the United States, Denmark, United Kingdom, and five regional databases within Canada was performed. All cases of patients receiving an ECTR were included. ECTR cases were totalled annually and reported as annual rates per 100,000 exposures with stratification per types of ECTR and toxins. The data collection varied by countries. United States, 1985-2014; United Kingdom, 2011-2013; Denmark, 2005-2014, and regions of Canada as follows: Alberta, 1991-2015; Saskatchewan, 2001-2015; Nova Scotia-PEI, 2006-2015; Quebec, 2008-2014; Ontario-Manitoba, 2009-2015; British Columbia, 2012-2015. During the study period, the total number of ECTRs and rates per 100,000 exposures, respectively, were: United States, 40,258 and 65.7; United Kingdom, 343 and 232.6; Denmark, 616 and 305.5; Canada, 2709 and 177.5; case rates increased over time for the United States, Denmark, and Canada, but decreased in the United Kingdom. Across the United States and Denmark, HD was the preferred modality used. Toxins for which ECTR was most often used were: United States, ethylene glycol; Canada, methanol; United Kingdom, ethylene glycol; Denmark, salicylates. A high number of ECTRs were performed for atypical toxins such as acetaminophen and benzodiazepines. These data demonstrate a growing use of HD for poisoning with significant regional variations in the overall rates and indications.

Jenny Pronczuk de Garbino: a global champion for children's health.

Jenny Pronczuk de Garbino: a global champion for children's health.

Is There An Ideal Prehospital Drug Treatment for Acute Cyanide Poisoning?

Introduction Cyanide, due to its toxicity and prevalence in a variety of industries, is a suitable agent for terrorists or disaffected persons to use as a weapon of terror. New Zealand's National Poisons Centre lists five cyanide antidotes. This review aimed to identify whether there is an ideal pre-hospital drug treatment for acute cyanide poisoning. Methods Literature less than 10 years old was selected after a keyword search. The articles were reviewed for specific positive and negative properties of each antidote. Results Thirty-nine articles were reviewed of which four were excluded. Results varied, with hydroxocobalamin scoring highly on effectiveness, with limited negative effects. It also demonstrated positive haemodynamic effects, suitability in cases involving trauma, carbon monoxide (CO), smoke inhalation casualties and was safe for pre-hospital use. Sodium nitrite, followed by dicobalt edetate had the next highest scores for efficacy. However, both scored negatively for their effects on blood, causing hypotension and toxicity, and they are unsuitable for trauma, CO or smoke inhalation casualties. Sodium thiosulphate, with a moderate level of efficiency, remained most effective when co-administered with other antidotes. 4-dimethylaminophenol and amyl nitrite rated the lowest, with negative effects similar to sodium nitrite. Adrenaline was tested as an antidote in one study where two novel antidotes both demonstrated promising results. Conclusion Hydroxocobalamin had the highest success rate and its safety profile make it the most suitable pre-hospital drug treatment for acute cyanide poisoning.

Toxic Effects of Rhamnus alaternus: A Rare Case Report.

In Tunisia, there are about 478 species of plants commonly used in folk medicine. Medicinal plants and herbal remedies used are responsible for 2% of intoxications listed by Tunisian National Poison Center. Most cases are related to confusion between edible plants and toxic plants lookalikes or to an excessive consumption of therapeutic plants. We report the case of a 58-year-old man admitted to the Emergency Department of the Regional Hospital of Zaghouan (Tunisia), with renal failure and rhabdomyolysis. The patient reported having daily consumption of a homemade tea based on Mediterranean Buckthorn roots, during the last 6 months to treat type 2 diabetes. The aim of this work was to establish an association between the consumption of the herbal remedy and the occurrence of both renal failure and rhabdomyolysis. No similar cases have been reported in recent literature.

2013 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 31st Annual Report

ABSTRACTBackground: This is the 31st Annual Report of the American Association of Poison Control Centers’ (AAPCC) National Poison Data System (NPDS). As of January 1, 2013, 57 of the nation's poison centers (PCs) uploaded case data automatically to NPDS. The upload interval was 8.08 [7.10, 11.63] (median [25%, 75%]) minutes, creating a near real-time national exposure and information database and surveillance system.Methodology: We analyzed the case data tabulating specific indices from NPDS. The methodology was similar to that of previous years. Where changes were introduced, the differences are identified. Poison center (PC) cases with medical outcomes of death were evaluated by a team of 38 medical and clinical toxicologist reviewers using an ordinal scale of 1–6 to assess the Relative Contribution to Fatality (RCF) of the exposure to the death.Results: In 2013, 3,060,122 closed encounters were logged by NPDS: 2,188,013 human exposures, 59,496 animal exposures, 806,347 information calls, 6,116 human-confirmed nonexposures, and 150 animal-confirmed nonexposures. Total encounters showed a 9.3% decline from 2012, while health care facility human exposure calls were essentially flat, decreasing by 0.1%.All information calls decreased 21.4% and health care facility (HCF) information calls decreased 8.5%, medication identification requests (drug ID) decreased 26.8%, and human exposures reported to US PCs decreased 3.8%. Human exposures with less serious outcomes have decreased 3.7% per year since 2008 while those with more serious outcomes (moderate, major or death) have increased by 4.7% per year since 2000.The top five substance classes most frequently involved in all human exposures were analgesics (11.5%), cosmetics/personal care products (7.7%), household cleaning substances (7.6%), sedatives/hypnotics/antipsychotics (5.9%), and antidepressants (4.2%). Sedative/hypnotics/antipsychotics exposures as a class increased most rapidly (2,559 calls/year) over the last 13 years for cases showing more serious outcomes. The top five most common exposures in children of 5 years or less were cosmetics/personal care products (13.8%), household cleaning substances (10.4%), analgesics (9.8%), foreign bodies/toys/miscellaneous (6.9%), and topical preparations (6.1%). Drug identification requests comprised 50.7% of all information calls. NPDS documented 2,477 human exposures resulting in death with 2,113 human fatalities judged related (RCF of 1, undoubtedly responsible; 2, probably responsible; or 3, contributory).Conclusions: These data support the continued value of PC expertise and need for specialized medical toxicology information to manage the more severe exposures, despite a decrease in calls involving less severe exposures. Unintentional and intentional exposures continue to be a significant cause of morbidity and mortality in the United States. The near real-time, always current status of NPDS represents a national public health resource to collect and monitor US exposure cases and information calls. The continuing mission of NPDS is to provide a nationwide infrastructure for public health surveillance for all types of exposures, public health event identification, resilience response and situational awareness tracking. NPDS is a model system for the nation and global public health.

A model to improve the accuracy of US Poison Center data collection

Context. Over 2 million human exposure calls are reported annually to United States regional poison information centers. All exposures are documented electronically and submitted to the American Association of Poison Control Center's National Poison Data System. This database represents the largest data source available on the epidemiology of pharmaceutical and non-pharmaceutical poisoning exposures. The accuracy of these data is critical; however, research has demonstrated that inconsistencies and inaccuracies exist. Objective. This study outlines the methods and results of a training program that was developed and implemented to enhance the quality of data collection using acetaminophen exposures as a model. Methods. Eleven poison centers were assigned randomly to receive either passive or interactive education to improve medical record documentation. A task force provided recommendations on educational and training strategies and the development of a quality-measurement scorecard to serve as a data collection tool to assess poison center data quality. Poison centers were recruited to participate in the study. Clinical researchers scored the documentation of each exposure record for accuracy. Results. Two thousand two hundred cases were reviewed and assessed for accuracy of data collection. After training, the overall mean quality scores were higher for both the passive (95.3%; + 1.6% change) and interactive intervention groups (95.3%; + 0.9% change). Data collection accuracy improved modestly for the overall accuracy score and significantly for the substance identification component. There was little difference in accuracy measures between the different training methods. Conclusion. Despite the diversity of poison centers, data accuracy, specifically substance identification data fields, can be improved by developing a standardized, systematic, targeted, and mandatory training process. This process should be considered for training on other important topics, thus enhancing the value of these data in relation to public health safety.

Under the Weather with Ciguatera Fish Poisoning: Climate Variables Associated with Increases in Suspected Cases

Ciguatera fish poisoning (CFP), the most common nonbacterial illness linked with eating fish, arises from the ciguatoxin produced by Gambierdiscus algae in tropical and subtropical areas of the Pacific, Western Atlantic, and Indian oceans.1 In this issue of EHP investigators assess the relationship between climate variability and reports of CFP, concluding that incidence of CFP is likely to increase with rises in sea-surface temperature and tropical storm frequency.1 Ciguatoxin bioaccumulates up the food chain as herbivorous fish eat the algae and are themselves eaten by carnivorous fish.2 The odorless, tasteless toxin withstands freezing and cooking, and people who ingest it begin experiencing gastrointestinal, neurological, and sometimes cardiovascular symptoms within hours of exposure. The symptoms usually resolve after a few days but may linger for months or years, or return after apparent recovery; death is rare. An estimated 50,000–500,000 cases of CFP occur annually worldwide.3 CFP is thought to be a widely unreported illness.4 Gambierdiscus algae (inset) produce a toxin that contaminates reef fish such as red snapper, triggerfish, and mackerel. Climate change is predicted to increase sea-surface temperatures in some areas, which could allow harmful marine algae to become more prolific over a wider territory.4,5,6 In the current study, the researchers hypothesized that CFP incidence increases in conjunction with warmer sea-surface temperatures and increased tropical storm activity. “What we were interested in is the extension of ciguatera into the mainland United States, either from fish importing or through expansion of the endemic area up the sea coast,” says Daniel Gingold, who led the study at Emory University. “It’s possible that the biggest change [in incidence] that would happen due to climate change is not actually in places where it’s already endemic—it may occur in places that used to not be able to support ciguatera but now do.” Information on possible CFP cases during 2001–2011 came from the National Poison Data System; the data comprised 1,102 calls to poison control centers in the continental United States, Puerto Rico, and the U.S. Virgin Islands. Cases were grouped by month and analyzed with monthly sea-surface temperatures and severe tropical storm activity in the Caribbean during 1999–2011. The model incorporated lag times of 0, 3, 6, 12, 18, and 24 months between weather events and reported CFP cases. Lyndon Llewellyn, research manager at the Australian Institute of Marine Science, characterized these lag times as an important aspect. “There will often be a delay between the initiation of ciguatera flowing through the ecosystem before human poisonings are observed,” he says. Llewellyn was not involved in the study. Based on their analysis, the investigators estimated that each additional storm in a month was associated with an 11% increase in CFP-related calls 18 months later, and that each 1°C increase in maximum sea-surface temperature during the month of August was associated with a 62% increase in calls after a lag of 5–16 months.1 These results were then considered in light of predictions about climate change. Assuming a 2.5°C increase in maximum Caribbean sea-surface temperature and a 10% increase in storm frequency, the researchers estimated an additional 239 CFP-related calls per year. The maximum estimated increase was 461 calls.1 There are numerous caveats to the findings. “The sea-surface temperature projections in the tropical Atlantic by our climate models are really bad,” says Vasu Misra, an associate professor of meteorology at the Center for Ocean-Atmospheric Prediction Studies, The Florida State University, who was not involved with the study. “So, attribution of climate to CFP incidence is a very difficult task.” Misra also notes a growing consensus that overall Atlantic storm frequency may go down in the future climate, although more intense storms may become slightly more frequent. Additionally, it was impossible to confirm CFP cases, fish origin, and location of exposure, and factors such as tourism and changes in fish consumption over time were not controlled.1 “We are missing a lot of information about this whole question,” says Gingold. “It’s been hypothesized for a long time that ciguatera would be affected by climate. But we really don’t have enough data to answer this question yet—we don’t have enough years of data, and we don’t have a very good surveillance system for identifying the toxin in commercial fish or for confirming actual cases.” Whether as an emerging disease in nonendemic areas or a neglected tropical disease in endemic areas, ciguatera and Gambierdiscus algae both warrant scrutiny.2 The limitations in this study generally pervade ciguatera research, says Llewellyn, who adds, “This paper is a good example of what is needed—biomedical professionals, especially epidemiologists, focusing on ciguatera.”

Evaluation of Quetiapine Abuse and Misuse Reported to Poison Centers

There are case reports of abuse of quetiapine, but no studies address quetiapine abuse or misuse. Most literature on the population that abuses quetiapine describes an older age group with previous substance abuse history, many of whom are in jail. The objective of this study was to evaluate national poison center data on misuse/abuse of quetiapine. A retrospective study of American Association of Poison Control Centers National Poison Data System data from 2005 to 2011 on single substance quetiapine exposures coded as intentional misuse or abuse and followed to known outcome was performed. Data were evaluated for age, toxicity, management sites, treatments, and medical outcomes. There were 3116 cases meeting inclusion criteria; reason was misuse in 1948 cases and abuse in 1168 cases. The median age was 23 years. Misuse was reported most often in adults, whereas abuse occurred most frequently in adolescents. The male-to-female ratio was 1.7 for abuse and 1.0 for misuse. There were no deaths. Moderate or major toxicity occurred in 23.7% and 27.1% of misuse and abuse cases, respectively. Seventy-six percent were treated in the emergency department and/or received medical admission. Misuse was more common than abuse, except in adolescents for whom abuse was more frequent. Although outcomes were generally good, significant toxicity occurred in 25% of cases and more than 75% of the patients were treated in the emergency department and/or received medical admission. The consequences of nonmedical use of quetiapine are serious in some patients.

Ciguatera Fish Poisoning and Climate Change: Analysis of National Poison Center Data in the United States, 2001–2011

Background: Warm sea surface temperatures (SSTs) are positively related to incidence of ciguatera fish poisoning (CFP). Increased severe storm frequency may create more habitat for ciguatoxic organisms. Although climate change could expand the endemic range of CFP, the relationship between CFP incidence and specific environmental conditions is unknown.Objectives: We estimated associations between monthly CFP incidence in the contiguous United States and SST and storm frequency in the Caribbean basin.Methods: We obtained information on 1,102 CFP-related calls to U.S. poison control centers during 2001–2011 from the National Poison Data System. We performed a time-series analysis using Poisson regression to relate monthly CFP call incidence to SST and tropical storms. We investigated associations across a range of plausible lag structures.Results: Results showed associations between monthly CFP calls and both warmer SSTs and increased tropical storm frequency. The SST variable with the strongest association linked current monthly CFP calls to the peak August SST of the previous year. The lag period with the strongest association for storms was 18 months. If climate change increases SST in the Caribbean 2.5–3.5°C over the coming century as projected, this model implies that CFP incidence in the United States is likely to increase 200–400%.Conclusions: Using CFP calls as a marker of CFP incidence, these results clarify associations between climate variability and CFP incidence and suggest that, all other things equal, climate change could increase the burden of CFP. These findings have implications for disease prediction, surveillance, and public health preparedness for climate change.Citation: Gingold DB, Strickland MJ, Hess JJ. 2014. Ciguatera fish poisoning and climate change: analysis of National Poison Center data in the United States, 2001–2011. Environ Health Perspect 122:580–586; http://dx.doi.org/10.1289/ehp.1307196

Toxicity and clinical outcomes of paliperidone exposures reported to U.S. Poison Centers

Context. Paliperidone is an atypical antipsychotic that was approved in the U.S. in 2006, and is also available in Canada, Australia, New Zealand, Europe, and Asia. Information regarding paliperidone overdoses is limited to case reports. Serious toxicity has yet to be reported. Objective. To evaluate the toxicity of paliperidone exposures using a national poison center database. Methods. A retrospective, observational case series of single-substance paliperidone cases reported to the National Poison Data System from 2007 to 2012 was conducted. Cases were evaluated for demographics, reason for exposure, clinical effects, treatments, disposition, and coded medical outcomes. For cases with major effects the text fields in poison center charts were evaluated to verify accuracy of coded outcome. The relationship between dose and severity of medical outcome was analyzed for acute exposure cases. Results. There were 801 paliperidone cases that met inclusion criteria that included 592 persons of 13 years or greater, 67 children of 6–12 years, 140 children of less than 6 years, and 2 unknown ages. Most common reasons for exposure included: suicide attempt (39.6%), unintentional general (21.1%), therapeutic error (15.7%), and adverse drug reaction (11.9%). The most commonly observed clinical effects were drowsiness/lethargy (28.7%), tachycardia (23.3%), and dystonia (14.2%). Most patients were managed in the emergency department (40.3%) or were admitted to a health care facility (HCF) (42.7%). In 564 cases treated in a HCF, treatments included activated charcoal (25.7%), antihistamines (21.1%), and benzodiazepines (9.4%). Medical outcomes were no effect (35.0%), minor (30.8%), moderate (33.7%), and major effect (0.5%). There were no deaths. Of 491 acute exposures, dose was coded for 74.3% of exposures. There was a significant difference in the reported median dose between those with no effect (6 mg) and either minor effect (12 mg; p = 0.047) or moderate effect cases (12 mg; p = 0.020) in 91 children less than 6 years. Conclusions. The majority of patients experienced no or minor toxicity and were not admitted for medical care. Although a higher dose was associated with a more serious outcome in children less than 6 years, the data do not provide clear-cut triage guidelines.

Acute Thiopurine Overdose: Analysis of Reports to a National Poison Centre 1995–2013

Literature regarding acute human toxicity of thiopurines is limited to a handful of case reports. Our objectives were to describe all cases of overdose with thiopurines reported to the Swiss Toxicological Information Centre between 1995–2013. A retrospective analysis was performed to determine circumstances, magnitude, management and outcome of overdose with these substances. A total of 40 cases (14 paediatric) were reported (azathioprine, n = 35; 6-mercaptopurine, n = 5). Of these, 25 were with suicidal intent, 12 were accidental and 3 were iatrogenic errors. The magnitude of overdose ranged from 1.5 to 43 (median 8) times the usual dose in adults. Twelve cases (30%) had attributable symptoms. The majority of these were minor and included gastrointestinal complaints and liver function test and blood count abnormalities. Symptoms were experienced by patients who took at least 1.5-times their usual daily thiopurine dose. Overdoses over two or more consecutive days, even if of modest size, were less well tolerated. One case of azathioprine and allopurinol co-ingestion over consecutive days led to agranulocytosis. Decontamination measures were undertaken in 11 cases (10 activated charcoal, 1 gastric lavage) and these developed fewer symptoms than untreated patients. This study shows that acute overdoses with thiopurines have a favourable outcome in the majority of cases and provides preliminary evidence that gastrointestinal decontamination with activated charcoal may reduce symptom development after overdose of these substances if patients present to medical services soon after ingestion.

On the Role of Poison Centers in Radiation Emergency Preparedness and Response Activities: Findings of the “Radiation Emergencies Public Health Roundtable” (Atlanta, GA—August 2012)

After the earthquake and tsunami that struck Japan on 11 March 2011, the ensuing Japanese nuclear power plant emergency renewed concerns among officials and citizens of the USA about contamination with radioactive material and the need for medical countermeasures (MCMs) to protect the public's health. The nation's poison centers (PCs), particularly those on the West Coast, received 400 calls requesting information about protective actions for contamination with radioactive material and exposure to ionizing radiation. Centers for Disease Control and Prevention (CDC) experts analyzed PC call data through the National Poison Data System (NPDS) in order to target communication messages effectively [1]. Poison centers are already used extensively by medical facilities, individual clinicians, and the general public to assess, triage, manage, and monitor known or suspected toxic exposures. Collectively, PCs receive more than four million exposure and information calls annually [2]. All calls are electronically reported to NPDS, a near real-time surveillance system maintained by the American Association of Poison Control Centers (AAPCC) and CDC. As noted by CDC speakers at a March 2010 Public Health Grand Rounds session, there is a lack of sufficient radiation subject matter expertise, as well as a lack of education and training, in this topic within the public health community [3]. These shortcomings also apply to PC staff. Calls about radiation are not as frequent as calls about other topics; therefore, PC staff may lack sufficient knowledge of such topics as ionizing radiation, the health effects of radiation exposure, contamination with radioactive materials, and appropriate MCMs to treat each type of incident. The Health Studies Branch and Radiation Studies Branch are located within CDC's National Center for Environmental Health in Atlanta, Georgia. Staff from these two branches proposed to identify and discuss the existing knowledge gaps in radiation emergency preparedness and response among PC staff by organizing an educational session for PC professionals, followed by a roundtable discussion. Organizers envisioned the roundtable as a means of initiating a continuing dialogue between PCs and other public health entities about the current and potential roles that PCs can play during a radiation public health emergency. This paper briefly summarizes the roundtable and its main findings; a full report is available online at CDC's radiation emergencies Web portal.1

Medication Errors Outside Healthcare Facilities: A National Poison Centre Perspective

Medication errors (ME) are a major concern to healthcare systems. Most studies evaluated ME occurring in healthcare facilities; only few focused on ME outside them. The objective was to characterise ME occurring outside healthcare facilities. A prospective observational follow-up study evaluating all ME occurring outside healthcare facilities reported to a national poison information centre during a 5-month period. For each ME case, a detailed questionnaire was filled and a follow-up call was made within 7 days. The collected data included demographics, circumstances, type of error and outcome. Of 1381 consecutive ME cases were included; 97.8% involved a single incident and 88.3% one drug. The main characteristics of the ME were as follows: children younger than 6 years old (58.9%), parents responsible for 55.6% of cases, wrong dose 34.5% and different medication 30.1%. Analgesics (27.4%) and antimicrobials (12.2%) were the most common pharmaceuticals. The main reasons for the ME were look-alike packaging (31.4%) and misunderstood instructions (28%). Most followed up patients (97.1%) were asymptomatic or mildly affected; there was one severe case and no mortality. Most ME occurring outside healthcare facilities are single incidents, involving young children who were administered a wrong dose or medication due to look-alike packaging or misunderstood instructions with asymptomatic or mild outcome. Improved packaging, labelling and patient education are suggested to reduce ME.

2012 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 30th Annual Report

Background: This is the 30th Annual Report of the American Association of Poison Control Centers’ (AAPCC) National Poison Data System (NPDS). As of July 1, 2012, 57 of the nation's poison centers (PCs) uploaded case data automatically to NPDS. The upload interval was 7.58 [6.30, 11.22] (median [25%, 75%]) min, creating a near real-time national exposure and information database and surveillance system.Methodology: We analyzed the case data tabulating specific indices from NPDS. The methodology was similar to that of previous years. Where changes were introduced, the differences are identified. Poison center cases with medical outcomes of death were evaluated by a team of 34 medical and clinical toxicologist reviewers using an ordinal scale of 1–6 to assess the Relative Contribution to Fatality (RCF) of the exposure to the death.Results: In 2012, 3,373,025 closed encounters were logged by NPDS: 2,275,141 human exposures, 66,440 animal exposures, 1,025,547 information calls, 5,679 human confirmed nonexposures, and 218 animal confirmed nonexposures. Total encounters showed a 6.9% decline from 2011, while healthcare facility (HCF) exposure calls increased by 1.2%. All information calls decreased by 14.8% and HCF information calls decreased by 1.7%, medication identification requests (Drug ID) decreased by 22.0%, and human exposures reported to US PCs decreased by 2.5%. Human exposures with less serious outcomes have decreased by 3.7% per year since 2008, while those with more serious outcomes (moderate, major, or death) have increased by 4.6% per year since 2000.The top five substance classes most frequently involved in all human exposures were analgesics (11.6%), cosmetics/personal care products (7.9%), household cleaning substances (7.2%), sedatives/hypnotics/antipsychotics (6.1%), and foreign bodies/toys/miscellaneous (4.1%). Analgesic exposures as a class increased the most rapidly (8,780 calls/year) over the last 12 years. The top five most common exposures in children aged 5 years or less were cosmetics/ personal care products (13.9%), analgesics (9.9%), household cleaning substances (9.7%), foreign bodies/toys/ miscellaneous (7.0%), and topical preparations (6.3%). Drug identification requests comprised 54.4% of all information calls. NPDS documented 2,937 human exposures resulting in death with 2,576 human fatalities judged related (RCF of 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory).Conclusions: These data support the continued value of PC expertise and need for specialized medical toxicology information to manage the more severe exposures, despite a decrease in calls involving less severe exposures. Unintentional and intentional exposures continue to be a significant cause of morbidity and mortality in the US. The near real-time, always current status of NPDS represents a national public health resource to collect and monitor US exposure cases and information calls. The continuing mission of NPDS is to provide a nationwide infrastructure for public health surveillance for all types of exposures, public health event identification, resilience response, and situational awareness tracking. NPDS is a model system for the nation and global public health.

Buprenorphine: an emerging hazard for children

Buprenorphine, a partial agonist of the muopioid receptor, has been used for about a decade in the treatment of adults with opioid addiction. Although considered safe and effective for this condition, there have been some reports of serious complications from unintended consumption of the medication by children. In this issue of The Journal, Lavonas et al from Denver report 29 months of cases submitted to a national poison center database. There were 2380 exposures in this study, with complications ranging in severity (up to 4 deaths). The investigators undertook root cause analyses of these exposures, in an effort to identify preventive strategies. Not surprisingly, storage and packaging deficiencies were identified in many cases. The authors also remind us that buprenorphine is not detected by most standard opioid drug screens, so the diagnosis often relies on an accurate history of the availability of the drug to the patient. Article page 1377▶ Root Causes, Clinical Effects, and Outcomes of Unintentional Exposures to Buprenorphine by Young ChildrenThe Journal of PediatricsVol. 163Issue 5PreviewTo characterize the rates, root causes, and clinical effects of unintentional exposures to buprenorphine sublingual formulations among young children and to determine whether exposure characteristics differ between formulations. Full-Text PDF Open Access

PP231—Acute human toxicity of thiopurines, mycophenolate and sirolimus

Literature regarding acute human toxicity of thiopurines and mycophenolate (MMF) is limited to a handful of case reports. There are no published reports of sirolimus (SIR) overdose. The aim of this study was to investigate the circumstances and outcomes of overdoses (ODs) with thiopurines, MMF, and SIR using data reported to a single national poison center.

Fire Eater's Lung: Retrospective Analysis of 123 Cases Reported to a National Poison Center

Background: Fire eater's lung (FEL) is a distinct form of acute chemical toxic pneumonitis, which is caused by aspiration of flammable petrochemical derivatives used by street performers for ‘fire eating'. The optimal management of this condition has not yet been determined. Objective: The aim of this study was to investigate patient characteristics, clinical features, treatment, and outcome of FEL. Methods: A single-center retrospective review of consecutive cases of FEL in children and adults reported to a national poison center (the Swiss Toxicological Information Center) between 1995 and 2012. Results: 123 cases (83.7% males, mean age 21.9 years) were included. The most frequently reported symptom was cough (50.4%), followed by chest pain (45.5%), and fever (35.8%). Dyspnea was reported by 23.6%. Cough (p = 0.002) and chest pain (p = 0.02) were significantly more prevalent in subjects reporting to have aspirated the fuel compared to those who have swallowed it or who did not perceive poison exposure. A pulmonary infiltrate was detected in 83% of the cases in whom chest X-ray was performed. Overall, 22% were treated with an antibiotic agent for a mean duration of 10.4 days. Corticosteroids were administered in 4.9%. All showed complete recovery irrespective of the therapeutic management. Conclusion: The combination of intense pleuritic chest pain, cough, dyspnea, and fever, or any of these symptoms after ‘fire eating' or erroneous swallowing of a petroleum distillate should alert the clinician to the diagnosis of FEL. Early antibiotic treatment of severe cases seems justified, considering that clinical, laboratory, and radiologic findings of FEL are overlapping with bacterial superinfection.

INVESTIGATING CHILDHOOD AND ADOLESCENCE POISONING EXPOSURES IN NEW ZEALAND REPORTED TO THE NATIONAL POISONS CENTRE DURING 2000-2009

Background: Poisoning incidents, in both children and adolescents, are known to occur in New Zealand but little is known about the agents implicated. Methods: All the calls received over the ten years between 2000 and 2009, by the National Poison Centre in New Zealand, were retrospectively reviewed. Calls related to cases involving those less than 19 years were included. The data were analyzed according to age and gender of cases, the toxic agent implicated in the poisoning and the year of the incident. Results: Most poisonings occurred in children less than five years of age (86%), with these being further concentrated in children aged one to two years (57%). The most frequently implicated agents were therapeutic agents (39%) and then household products (36%). In adolescents, an increase in drug misuse or abuse was seen from 12 years old – with those aged 13 and 18 years being most frequently exposed to agents with psychotropic properties. Conclusion: This study showed that accidental (and intentional) ingestion is still an issue for children and adolescents in New Zealand. Specific strategies are needed to be targeted to the 1) products implicated in a high number of poisonings and 2) to children at the different ages.