Alvin Bronstein - Academia.edu (original) (raw)

Papers by Alvin Bronstein

Food and Chemical Toxicology, 1982

Introduction and training requirements, Hazardous materials preplanning concerns, Recognition and... more Introduction and training requirements, Hazardous materials preplanning concerns, Recognition and identification of hazardous materials, Chemistry overview, Basic hazardous materials toxicology principles, Emergency response information sources, Medical Surveillance, Personal protective equipment, Air monitoring and detection equipment, EMS/ hazardous materials response practices and scene management, Hazardous materials response team medical support, Heat and cold stress at hazardous materials incidents, Body system response to poisons, Decontamination procedures, Triage and chemical exposure syndromes, Treatment of hazardous materials poisoning, Antidotes for hazardous materials poisoning, Patient transport, Post-incident concerns, Examples of locations/ situations and chemicals involved.

Journal of toxicology, 1995

lEe current principles of toxicology, immunology and allergy do not provide a coherent explanatio... more lEe current principles of toxicology, immunology and allergy do not provide a coherent explanation of a chemical sensitivity lacking reproducible and measurable physiologic or biochemical changes. A new paradigm is needed as a scientific model for multiple chemical sensitivities. {Key Wor&: multiple chemical sensitivities: human: treatment. 1

Journal of toxicology, 2000

To report a massive, 100 g ibuprofen ingestion in an adolescent, with survival. The patient devel... more To report a massive, 100 g ibuprofen ingestion in an adolescent, with survival. The patient developed coma, metabolic acidosis, and mild thrombocytopenia, but improved rapidly with supportive care. Renal function remained normal and no gastrointestinal bleeding occurred. Massive ingestion of ibuprofen may result in a variable picture with some elements of significant toxicity, but supportive care usually results in survival without sequelae.

Online Journal of Public Health Informatics, Apr 9, 2010

Objectives: Real-time surveillance systems are valuable for timely response to public health emer... more Objectives: Real-time surveillance systems are valuable for timely response to public health emergencies. It has been challenging to leverage existing surveillance systems in state and local communities, and, using a centralized architecture, add new data sources and analytical capacity. Because this centralized model has proven to be difficult to maintain and enhance, the US Centers for Disease Control and Prevention (CDC) has been examining the ability to use a federated model based on secure web services architecture, with data stewardship remaining with the data provider. Methods: As a case study for this approach, the American Association of Poison Control Centers and the CDC extended an existing data warehouse via a secure web service, and shared aggregate clinical effects and case counts data by geographic region and time period. To visualize these data, CDC developed a web browser-based interface, Quicksilver, which leveraged the Google Maps API and Flot, a javascript plotting library. Results: Two iterations of the NPDS web service were completed in 12 weeks. The visualization client, Quicksilver, was developed in four months. Discussion: This implementation of web services combined with a visualization client represents incremental positive progress in transitioning national data sources like BioSense and NPDS to a federated data exchange model. Conclusion: Quicksilver effectively demonstrates how the use of secure web services in conjunction with a lightweight, rapidly deployed visualization client can easily integrate isolated data sources for biosurveillance.

Topics in Companion Animal Medicine, Feb 1, 2013

Polyurethane adhesives are found in a large number of household products in the United States and... more Polyurethane adhesives are found in a large number of household products in the United States and are used for a variety of purposes. Several brands of these expanding wood glues (those containing diphenylmethane diisocyanate [MDI]) have the potential to form gastrointestinal (GI) foreign bodies if ingested. The ingested adhesive forms an expanding ball of glue in the esophagus and gastric lumen. This expansion is caused by a polymerization reaction using the heat, water, and gastric acids of the stomach. A firm mass is created that can be 4-8 times its original volume. As little as 2 oz of glue have been reported to develop gastric foreign bodies. The obstructive mass is reported to form within minutes of ingestion of the adhesive. The foreign body can lead to esophageal impaction and obstruction, airway obstruction, gastric outflow obstruction, mucosal hemorrhage, ulceration, laceration, perforation of the esophageal and gastric linings, and death. Clinical signs following ingestion include anorexia, lethargy, vomiting, tachypnea, and abdominal distention and pain, and typically develop within 12 hours. Clinical signs may depend upon the size of the mass. If left untreated, perforation and rupture of the esophagus or stomach can occur. The glue mass does not stick to the GI mucosa and is not always detectable on abdominal palpation. Radiographs are recommended to confirm the presence of the "glue-ball" foreign body, and radiographic evidence of the obstruction may be seen as early as 4-6 hours following ingestion. Emesis is contraindicated owing to the risk of aspiration of the glue into the respiratory tree or the subsequent lodging of the expanding glue mass in the esophagus. Likewise, efforts to dilute the glue and prevent the formation of the foreign body through administration of liquids, activated charcoal, or bulk-forming products to push the foreign body through the GI tract have proven ineffective. Even endoscopy performed to remove the foreign body has been shown to be unreliable. The safest, most effective, and successful therapy is surgical intervention to remove the GI foreign body. If performed early enough, complete recovery of the animal can be expected. Differential diagnoses for polyurethane adhesive ingestion include any potential cause of GI obstruction. The public is largely unaware of the hazards that ingestion of this product may produce. Public education efforts are needed to inform pet owners about the hazards of these glues and the overall importance of providing our companion animals with safe, poison-free environments.

Clinical Toxicology, Dec 2, 2022

Journal of Forensic Sciences, Nov 1, 1987

Judging the degree of human alcohol intoxication is an important clinical, social, and medicolega... more Judging the degree of human alcohol intoxication is an important clinical, social, and medicolegal matter. Assessing the degree of intoxication is not always easy by direct patient observation. Observational instruments have been used in forensic science, medical, and social situations in an endeavor to measure alcohol intoxication. The validity of these observational instruments must be questioned. In this study, twenty-one patients with alcohol related complaints presenting to major city emergency departments were studied using one such observational instrument, the Alcohol Symptom Checklist (ASC). Three independent emergency medicine physicians applied the criteria of ASC to the twenty-one patients and obtained a plasma alcohol concentration (PAC) for correlation purposes. Individual correlation coefficients (r = 0.182, r = 0.202, r = 0.200) and a composite correlation coefficient (r = 0.235) demonstrated lack of correlation between PAC and ASC. This lack of correlation is supported by clinical observations of experienced emergency department personnel.

The Journal of emergency medicine, 1985

The optimum therapy for hydrogen sulfide poisoning is unclear. Adjuncts used in the treatment of ... more The optimum therapy for hydrogen sulfide poisoning is unclear. Adjuncts used in the treatment of cyanide poisoning have been advocated because of the shared mechanism of toxicity between hydrogen sulfide and cyanide. Following success in cyanide poisoning, hyperbaric oxygen therapy (HBO) has been suggested for use in treating hydrogen sulfide poisoning. A case of severe hydrogen sulfide poisoning was successfully treated with HBO after standard therapy was apparently ineffective. HBO as a therapeutic adjunct in hydrogen sulfide poisoning and the rationale for its use are discussed.

Annals of Emergency Medicine, Jun 1, 2014

We compare state trends in unintentional pediatric marijuana exposures, as measured by call volum... more We compare state trends in unintentional pediatric marijuana exposures, as measured by call volume to US poison centers, by state marijuana legislation status. Methods: A retrospective review of the American Association of Poison Control Centers National Poison Data System was performed from January 1, 2005, to December 31, 2011. States were classified as nonlegal if they have not passed legislation, transitional if they enacted legislation between 2005 and 2011, and decriminalized if laws passed before 2005. Our hypotheses were that decriminalized and transitional states would experience a significant increase in call volume, with more symptomatic exposures and more health care admissions than nonlegal states. Results: There were 985 unintentional marijuana exposures reported from 2005 through 2011 in children aged 9 years and younger: 496 in nonlegal states, 93 in transitional states, and 396 in decriminalized states. There was a slight male predominance, and the median age ranged from 1.5 to 2.0 years. Clinical effects varied, with neurologic effects the most frequent. More exposures in decriminalized states required health care evaluation and had moderate to major clinical effects and critical care admissions compared with exposures from nonlegal states. The call rate in nonlegal states to poison centers did not change from 2005 to 2011. The call rate in decriminalized states increased by 30.3% calls per year, and transitional states had a trend toward an increase of 11.5% per year. Conclusion: Although the number of pediatric exposures to marijuana reported to the National Poison Data System was low, the rate of exposure increased from 2005 to 2011 in states that had passed marijuana legislation. [

JAMA Pediatrics, Sep 6, 2016

As of 2015, almost half of US states allow medical marijuana, and 4 states allow recreational mar... more As of 2015, almost half of US states allow medical marijuana, and 4 states allow recreational marijuana. To our knowledge, the effect of recreational marijuana on the pediatric population has not been evaluated. OBJECTIVE To compare the incidence of pediatric marijuana exposures evaluated at a children's hospital and regional poison center (RPC) in Colorado before and after recreational marijuana legalization and to compare population rate trends of RPC cases for marijuana exposures with the rest of the United States.

Clinical Toxicology, Dec 1, 2010

Background: This is the 27th Annual Report of the American Association of Poison Control Centers'... more Background: This is the 27th Annual Report of the American Association of Poison Control Centers' (AAPCC) National Poison Data System (NPDS). As of July 2009, 60 of the nation's 60 US poison centers (PCs) uploaded case data automatically. The upload time was 19.9 [9.7, 58.7] (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 cases with medical outcomes of death were evaluated by a team of 29 medical and clinical toxicologist reviewers using an ordinal scale of 1-6 to determine Relative Contribution to Fatality (RCF) of the exposure to the death. Results: In 2009, 4,280,391 calls were captured by NPDS: 2,479,355 closed human exposures, 116,408 animal exposures, 1,677,403 information calls, 6,882 human confirmed nonexposures, and 343 animal confirmed nonexposures. The top 5 substance classes most frequently involved in all human exposures were analgesics (11.7%), cosmetics/personal care products (7.7%), household cleaning substances (7.4%), sedatives/hypnotics/antipsychotics (5.8%), and foreign bodies/toys/miscellaneous (4.3%). Analgesic exposures as a class increased the most rapidly (12,494 calls per year) over the last decade. The top 5 most common exposures in children age 5 or less were cosmetics/personal care products (13.0%), analgesics (9.7%), household cleaning substances (9.3%), foreign bodies/toys/miscellaneous (7.0%), and topical preparations (6.8%). Drug identification requests comprised 63.0% of all information calls. NPDS documented 1,544 human exposures resulting in death with 1,158 human fatalities judged related with an RCF of 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory. Conclusions: 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. WARNING: Comparison of exposure or outcome data from previous AAPCC Annual Reports is problematic. In particular, the identification of fatalities (attribution of a death to the exposure) differed from pre-2006 Annual Reports (see Fatality Case Review-Methods). Poison center death cases are described as all cases resulting in death and those determined to be exposure-related fatalities. Likewise, Table 22 (Exposure Cases by Generic Category) since year 2006 restricts the breakdown including deaths to single-substance cases to improve precision and avoid misinterpretation. 982 A.C. Bronstein et al.

Clinical Toxicology, Mar 28, 2017

Context: To date, there are no publicly available schemes designed and evaluated specifically for... more Context: To date, there are no publicly available schemes designed and evaluated specifically for severity assessment of animal poisonings. This poses challenges for the evaluation and comparison of animal poisoning exposure data. Objective: Our objective for this pilot study was to evaluate agreement between raters using the Poisoning Severity Score (PSS) and National Poison Data System (NPDS) medical outcome scheme for severity assessment of canine exposures reported to a multistate poison center (PC) and to identify issues regarding their use for severity assessment of animal poisonings. Agreement between both schemes was also assessed. Methods: The first 196 canine exposures reported to a multistate PC between 1 January and 31 August 2016 were selected and initial inquiry data from exposures was scored by four independent raters. Interrater agreement and agreement between the severity systems was calculated using weighted kappa (K) (Light's kappa). Reported clinical effects were also described. Results: Interrater agreement for both the PSS (K 0.31; 95% CI 0.19, 0.43) and NPDS schemes (K 0.34; 95% CI 0.22, 0.44) was low. Agreement between the schemes was slight (K 0.05; 95% CI À0.08, 0.16) for pooled results from all four raters. For the PSS, 71.7% (n ¼ 281) of ratings were minor, 23.0% (n ¼ 90) moderate, and 5.4% (n ¼ 21) severe. For the NPDS, 69.6% (n ¼ 273) of ratings were minor, 27.0% (n ¼ 106) moderate, and 3.3% (n ¼ 13) severe. The top three reported clinical effects included vomiting (n ¼ 86, 29.9%) drowsiness/lethargy (n ¼ 38, 13.2%), and diarrhea (n ¼ 24, 8.3%). Discussion and conclusions: This study shows considerable variability between raters using either the PSS or NPDS schemes for canine exposures severity assessment. The subjective nature of the schemes, the influence of intra-and interrater variation, and predominance of minor cases on the study findings should be taken into account when interpreting this data. Further evaluation of these schemes is warranted and could help inform their future use for animal poisoning severity assessment.

Emerging Health Threats Journal, Dec 6, 2011

Public Health Reports, Jan 23, 2023

The National Poison Data System (NPDS) comprises self-reported information from people who call U... more The National Poison Data System (NPDS) comprises self-reported information from people who call US poison center hotlines. NPDS data have proven to be important in identifying emerging public health threats. We used NPDS to examine records of people who had self-reported exposure to harmful algal blooms (HABs). Participating poison centers then contacted people who had called their centers from May through October 2019 about their HAB exposure to ask about exposure route, symptoms, health care follow-up, and awareness of possible risks of exposure. Of 55 callers who agreed to participate, 47 (85%) reported exposure to HABs while swimming or bathing in HAB-contaminated water. Nine callers reported health symptoms from being near waters contaminated with HABs, suggesting potential exposure via aerosolized toxins. Symptoms varied by the reported routes of exposure; the most commonly reported symptoms were gastrointestinal and respiratory. More public and health care provider education and outreach are needed to improve the understanding of HAB-related risks, to address ways to prevent HAB-related illnesses, and to describe appropriate support when exposures occur.

Journal of Clinical Toxicology, 2012

Objective-Our objective was to characterize the data captured in all animal exposure calls report... more Objective-Our objective was to characterize the data captured in all animal exposure calls reported to the National Poison Data System (NPDS), a national poison center reporting database, from 1 January 2000 through 31 December 2010 and identify Poison Center usage and needs in animal exposure calls. Design-We calculated descriptive statistics characterizing animal type, exposure substance, medical outcome, year and month of call, caller location, and specific state for all animal exposure call data in NPDS from 1 January 2000 to 31 December 2010. SAS version 9.2 was used for the analysis. Results-There were 1,371,095 animal exposure calls out of 28,925,496 (4.7%) total human and animal exposure calls in NPDS during the study period. The majority involved companion animal exposures with 88.0% canine exposures and 10.4% feline exposures. Pesticides were the most common exposure substance (n=360,375; 26.3%), followed by prescription drugs (n=261,543; 18.6%). The most common outcome reported was 'Not followed, judged as nontoxic exposure or minimal clinical effects possible' (n=803,491; 58.6%), followed by 'Not followed, judged potentially toxic exposure' (n=263,153; 19.2%). There were 5,388 deaths reported. Pesticide exposures were responsible for the greatest number of deaths (n=1,643; 30.4%). Conclusions and clinical relevance-Approximately 1 in 20 calls to PCs are regarding potentially toxic exposures to animals, suggesting a need for veterinary expertise and resources at PCs. Pesticides are one of the greatest toxic exposure threats to animals, both in numbers of exposures and severity of clinical outcomes, and is an important area for education, prevention, and treatment. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Topics in Companion Animal Medicine, Feb 1, 2013

Topics in Companion Animal Medicine, Feb 1, 2013

Many antidepressants inhibit serotonin or norepinephrine reuptake or both to achieve their clinic... more Many antidepressants inhibit serotonin or norepinephrine reuptake or both to achieve their clinical effect. The selective serotonin reuptake inhibitor class of antidepressants (SSRIs) includes citalopram, escitalopram (active enantiomer of citalopram), fluoxetine, fluvoxamine, paroxetine, and sertraline. The SSRIs are as effective as tricyclic antidepressants in treatment of major depression with less significant side effects. As a result, they have become the largest class of medications prescribed to humans for depression. They are also used to treat obsessive-compulsive disorder, panic disorders, alcoholism, obesity, migraines, and chronic pain. An SSRI (fluoxetine) has been approved for veterinary use in treatment of canine separation anxiety. SSRIs act specifically on synaptic serotonin concentrations by blocking its reuptake in the presynapse and increasing levels in the presynaptic membrane. Clinical signs of SSRI overdose result from excessive amounts of serotonin in the central nervous system. These signs include nausea, vomiting, mydriasis, hypersalivation, and hyperthermia. Clinical signs are dose dependent and higher dosages may result in the serotonin syndrome that manifests itself as ataxia, tremors, muscle rigidity, hyperthermia, diarrhea, and seizures. Current studies reveal no increase in appearance of any specific clinical signs of serotonin toxicity with regard to any SSRI medication. In people, citalopram has been reported to have an increased risk of electrocardiographic abnormalities. Diagnosis of SSRI poisoning is based on history, clinical signs, and response to therapy. No single clinical test is currently available to confirm SSRI toxicosis. The goals of treatment in this intoxication are to support the animal, prevent further absorption of the drug, support the central nervous system, control hyperthermia, and halt any seizure activity. The relative safety of the SSRIs in overdose despite the occurrence of serotonin syndrome makes them more desirable than other antidepressants. The prognosis in animals that receive treatment is excellent. In one retrospective study, there were no deaths in 313 SSRI-poisoned dogs. No characteristic or classic histopathologic lesions result from SSRI toxicosis. Differential diagnoses for SSRI overdose must include ingestions of other serotonergic medications such as phenylpiperidine opioids (fentanyl and tramadol), mirtazapine, buspirone, amitraz, and chlorpheniramine.

Topics in Companion Animal Medicine, Feb 1, 2013

The New England Journal of Medicine, Jan 23, 2014

Although early reports of exposure to synthetic cannabinoids described a benign course, 1 with li... more Although early reports of exposure to synthetic cannabinoids described a benign course, 1 with little need for emergency care, on August 24, 2013, patients began to present to Denver emergency departments with severe symptoms after exposure to a novel synthetic cannabinoid known locally as "black mamba." The Colorado Department of Public Health and Environment (CDPHE) was notified on September 3. Medical toxicologists and CDPHE epidemiologists developed a case definition and began prospective monitoring with assistance from the Centers for Disease Control and Prevention. Records from poison control centers, care providers in nonhospital settings, and law enforcement were reviewed. A total of 263 cases of possible exposure to the synthetic cannabinoid that met the CDPHE definition were identified statewide for the period August 21 to September 19. Among these cases, only 15 had been identified by the state poison control call-in centers. Among the 263 cases identified, there were 76 patients who presented to the emergency departments at two teaching hospitals in Denver and Aurora. Exposure was confirmed by means of patient history, bedside consultation, or laboratory analyses of products recovered from patients. The majority of cases involved single-agent ingestions; most patients were young men, and symptoms included altered mental status, tachycardia followed by

Food and Chemical Toxicology, 1982

Introduction and training requirements, Hazardous materials preplanning concerns, Recognition and... more Introduction and training requirements, Hazardous materials preplanning concerns, Recognition and identification of hazardous materials, Chemistry overview, Basic hazardous materials toxicology principles, Emergency response information sources, Medical Surveillance, Personal protective equipment, Air monitoring and detection equipment, EMS/ hazardous materials response practices and scene management, Hazardous materials response team medical support, Heat and cold stress at hazardous materials incidents, Body system response to poisons, Decontamination procedures, Triage and chemical exposure syndromes, Treatment of hazardous materials poisoning, Antidotes for hazardous materials poisoning, Patient transport, Post-incident concerns, Examples of locations/ situations and chemicals involved.

Journal of toxicology, 1995

lEe current principles of toxicology, immunology and allergy do not provide a coherent explanatio... more lEe current principles of toxicology, immunology and allergy do not provide a coherent explanation of a chemical sensitivity lacking reproducible and measurable physiologic or biochemical changes. A new paradigm is needed as a scientific model for multiple chemical sensitivities. {Key Wor&: multiple chemical sensitivities: human: treatment. 1

Journal of toxicology, 2000

To report a massive, 100 g ibuprofen ingestion in an adolescent, with survival. The patient devel... more To report a massive, 100 g ibuprofen ingestion in an adolescent, with survival. The patient developed coma, metabolic acidosis, and mild thrombocytopenia, but improved rapidly with supportive care. Renal function remained normal and no gastrointestinal bleeding occurred. Massive ingestion of ibuprofen may result in a variable picture with some elements of significant toxicity, but supportive care usually results in survival without sequelae.

Online Journal of Public Health Informatics, Apr 9, 2010

Objectives: Real-time surveillance systems are valuable for timely response to public health emer... more Objectives: Real-time surveillance systems are valuable for timely response to public health emergencies. It has been challenging to leverage existing surveillance systems in state and local communities, and, using a centralized architecture, add new data sources and analytical capacity. Because this centralized model has proven to be difficult to maintain and enhance, the US Centers for Disease Control and Prevention (CDC) has been examining the ability to use a federated model based on secure web services architecture, with data stewardship remaining with the data provider. Methods: As a case study for this approach, the American Association of Poison Control Centers and the CDC extended an existing data warehouse via a secure web service, and shared aggregate clinical effects and case counts data by geographic region and time period. To visualize these data, CDC developed a web browser-based interface, Quicksilver, which leveraged the Google Maps API and Flot, a javascript plotting library. Results: Two iterations of the NPDS web service were completed in 12 weeks. The visualization client, Quicksilver, was developed in four months. Discussion: This implementation of web services combined with a visualization client represents incremental positive progress in transitioning national data sources like BioSense and NPDS to a federated data exchange model. Conclusion: Quicksilver effectively demonstrates how the use of secure web services in conjunction with a lightweight, rapidly deployed visualization client can easily integrate isolated data sources for biosurveillance.

Topics in Companion Animal Medicine, Feb 1, 2013

Polyurethane adhesives are found in a large number of household products in the United States and... more Polyurethane adhesives are found in a large number of household products in the United States and are used for a variety of purposes. Several brands of these expanding wood glues (those containing diphenylmethane diisocyanate [MDI]) have the potential to form gastrointestinal (GI) foreign bodies if ingested. The ingested adhesive forms an expanding ball of glue in the esophagus and gastric lumen. This expansion is caused by a polymerization reaction using the heat, water, and gastric acids of the stomach. A firm mass is created that can be 4-8 times its original volume. As little as 2 oz of glue have been reported to develop gastric foreign bodies. The obstructive mass is reported to form within minutes of ingestion of the adhesive. The foreign body can lead to esophageal impaction and obstruction, airway obstruction, gastric outflow obstruction, mucosal hemorrhage, ulceration, laceration, perforation of the esophageal and gastric linings, and death. Clinical signs following ingestion include anorexia, lethargy, vomiting, tachypnea, and abdominal distention and pain, and typically develop within 12 hours. Clinical signs may depend upon the size of the mass. If left untreated, perforation and rupture of the esophagus or stomach can occur. The glue mass does not stick to the GI mucosa and is not always detectable on abdominal palpation. Radiographs are recommended to confirm the presence of the "glue-ball" foreign body, and radiographic evidence of the obstruction may be seen as early as 4-6 hours following ingestion. Emesis is contraindicated owing to the risk of aspiration of the glue into the respiratory tree or the subsequent lodging of the expanding glue mass in the esophagus. Likewise, efforts to dilute the glue and prevent the formation of the foreign body through administration of liquids, activated charcoal, or bulk-forming products to push the foreign body through the GI tract have proven ineffective. Even endoscopy performed to remove the foreign body has been shown to be unreliable. The safest, most effective, and successful therapy is surgical intervention to remove the GI foreign body. If performed early enough, complete recovery of the animal can be expected. Differential diagnoses for polyurethane adhesive ingestion include any potential cause of GI obstruction. The public is largely unaware of the hazards that ingestion of this product may produce. Public education efforts are needed to inform pet owners about the hazards of these glues and the overall importance of providing our companion animals with safe, poison-free environments.

Clinical Toxicology, Dec 2, 2022

Journal of Forensic Sciences, Nov 1, 1987

Judging the degree of human alcohol intoxication is an important clinical, social, and medicolega... more Judging the degree of human alcohol intoxication is an important clinical, social, and medicolegal matter. Assessing the degree of intoxication is not always easy by direct patient observation. Observational instruments have been used in forensic science, medical, and social situations in an endeavor to measure alcohol intoxication. The validity of these observational instruments must be questioned. In this study, twenty-one patients with alcohol related complaints presenting to major city emergency departments were studied using one such observational instrument, the Alcohol Symptom Checklist (ASC). Three independent emergency medicine physicians applied the criteria of ASC to the twenty-one patients and obtained a plasma alcohol concentration (PAC) for correlation purposes. Individual correlation coefficients (r = 0.182, r = 0.202, r = 0.200) and a composite correlation coefficient (r = 0.235) demonstrated lack of correlation between PAC and ASC. This lack of correlation is supported by clinical observations of experienced emergency department personnel.

The Journal of emergency medicine, 1985

The optimum therapy for hydrogen sulfide poisoning is unclear. Adjuncts used in the treatment of ... more The optimum therapy for hydrogen sulfide poisoning is unclear. Adjuncts used in the treatment of cyanide poisoning have been advocated because of the shared mechanism of toxicity between hydrogen sulfide and cyanide. Following success in cyanide poisoning, hyperbaric oxygen therapy (HBO) has been suggested for use in treating hydrogen sulfide poisoning. A case of severe hydrogen sulfide poisoning was successfully treated with HBO after standard therapy was apparently ineffective. HBO as a therapeutic adjunct in hydrogen sulfide poisoning and the rationale for its use are discussed.

Annals of Emergency Medicine, Jun 1, 2014

We compare state trends in unintentional pediatric marijuana exposures, as measured by call volum... more We compare state trends in unintentional pediatric marijuana exposures, as measured by call volume to US poison centers, by state marijuana legislation status. Methods: A retrospective review of the American Association of Poison Control Centers National Poison Data System was performed from January 1, 2005, to December 31, 2011. States were classified as nonlegal if they have not passed legislation, transitional if they enacted legislation between 2005 and 2011, and decriminalized if laws passed before 2005. Our hypotheses were that decriminalized and transitional states would experience a significant increase in call volume, with more symptomatic exposures and more health care admissions than nonlegal states. Results: There were 985 unintentional marijuana exposures reported from 2005 through 2011 in children aged 9 years and younger: 496 in nonlegal states, 93 in transitional states, and 396 in decriminalized states. There was a slight male predominance, and the median age ranged from 1.5 to 2.0 years. Clinical effects varied, with neurologic effects the most frequent. More exposures in decriminalized states required health care evaluation and had moderate to major clinical effects and critical care admissions compared with exposures from nonlegal states. The call rate in nonlegal states to poison centers did not change from 2005 to 2011. The call rate in decriminalized states increased by 30.3% calls per year, and transitional states had a trend toward an increase of 11.5% per year. Conclusion: Although the number of pediatric exposures to marijuana reported to the National Poison Data System was low, the rate of exposure increased from 2005 to 2011 in states that had passed marijuana legislation. [

JAMA Pediatrics, Sep 6, 2016

As of 2015, almost half of US states allow medical marijuana, and 4 states allow recreational mar... more As of 2015, almost half of US states allow medical marijuana, and 4 states allow recreational marijuana. To our knowledge, the effect of recreational marijuana on the pediatric population has not been evaluated. OBJECTIVE To compare the incidence of pediatric marijuana exposures evaluated at a children's hospital and regional poison center (RPC) in Colorado before and after recreational marijuana legalization and to compare population rate trends of RPC cases for marijuana exposures with the rest of the United States.

Clinical Toxicology, Dec 1, 2010

Background: This is the 27th Annual Report of the American Association of Poison Control Centers'... more Background: This is the 27th Annual Report of the American Association of Poison Control Centers' (AAPCC) National Poison Data System (NPDS). As of July 2009, 60 of the nation's 60 US poison centers (PCs) uploaded case data automatically. The upload time was 19.9 [9.7, 58.7] (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 cases with medical outcomes of death were evaluated by a team of 29 medical and clinical toxicologist reviewers using an ordinal scale of 1-6 to determine Relative Contribution to Fatality (RCF) of the exposure to the death. Results: In 2009, 4,280,391 calls were captured by NPDS: 2,479,355 closed human exposures, 116,408 animal exposures, 1,677,403 information calls, 6,882 human confirmed nonexposures, and 343 animal confirmed nonexposures. The top 5 substance classes most frequently involved in all human exposures were analgesics (11.7%), cosmetics/personal care products (7.7%), household cleaning substances (7.4%), sedatives/hypnotics/antipsychotics (5.8%), and foreign bodies/toys/miscellaneous (4.3%). Analgesic exposures as a class increased the most rapidly (12,494 calls per year) over the last decade. The top 5 most common exposures in children age 5 or less were cosmetics/personal care products (13.0%), analgesics (9.7%), household cleaning substances (9.3%), foreign bodies/toys/miscellaneous (7.0%), and topical preparations (6.8%). Drug identification requests comprised 63.0% of all information calls. NPDS documented 1,544 human exposures resulting in death with 1,158 human fatalities judged related with an RCF of 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory. Conclusions: 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. WARNING: Comparison of exposure or outcome data from previous AAPCC Annual Reports is problematic. In particular, the identification of fatalities (attribution of a death to the exposure) differed from pre-2006 Annual Reports (see Fatality Case Review-Methods). Poison center death cases are described as all cases resulting in death and those determined to be exposure-related fatalities. Likewise, Table 22 (Exposure Cases by Generic Category) since year 2006 restricts the breakdown including deaths to single-substance cases to improve precision and avoid misinterpretation. 982 A.C. Bronstein et al.

Clinical Toxicology, Mar 28, 2017

Context: To date, there are no publicly available schemes designed and evaluated specifically for... more Context: To date, there are no publicly available schemes designed and evaluated specifically for severity assessment of animal poisonings. This poses challenges for the evaluation and comparison of animal poisoning exposure data. Objective: Our objective for this pilot study was to evaluate agreement between raters using the Poisoning Severity Score (PSS) and National Poison Data System (NPDS) medical outcome scheme for severity assessment of canine exposures reported to a multistate poison center (PC) and to identify issues regarding their use for severity assessment of animal poisonings. Agreement between both schemes was also assessed. Methods: The first 196 canine exposures reported to a multistate PC between 1 January and 31 August 2016 were selected and initial inquiry data from exposures was scored by four independent raters. Interrater agreement and agreement between the severity systems was calculated using weighted kappa (K) (Light's kappa). Reported clinical effects were also described. Results: Interrater agreement for both the PSS (K 0.31; 95% CI 0.19, 0.43) and NPDS schemes (K 0.34; 95% CI 0.22, 0.44) was low. Agreement between the schemes was slight (K 0.05; 95% CI À0.08, 0.16) for pooled results from all four raters. For the PSS, 71.7% (n ¼ 281) of ratings were minor, 23.0% (n ¼ 90) moderate, and 5.4% (n ¼ 21) severe. For the NPDS, 69.6% (n ¼ 273) of ratings were minor, 27.0% (n ¼ 106) moderate, and 3.3% (n ¼ 13) severe. The top three reported clinical effects included vomiting (n ¼ 86, 29.9%) drowsiness/lethargy (n ¼ 38, 13.2%), and diarrhea (n ¼ 24, 8.3%). Discussion and conclusions: This study shows considerable variability between raters using either the PSS or NPDS schemes for canine exposures severity assessment. The subjective nature of the schemes, the influence of intra-and interrater variation, and predominance of minor cases on the study findings should be taken into account when interpreting this data. Further evaluation of these schemes is warranted and could help inform their future use for animal poisoning severity assessment.

Emerging Health Threats Journal, Dec 6, 2011

Public Health Reports, Jan 23, 2023

The National Poison Data System (NPDS) comprises self-reported information from people who call U... more The National Poison Data System (NPDS) comprises self-reported information from people who call US poison center hotlines. NPDS data have proven to be important in identifying emerging public health threats. We used NPDS to examine records of people who had self-reported exposure to harmful algal blooms (HABs). Participating poison centers then contacted people who had called their centers from May through October 2019 about their HAB exposure to ask about exposure route, symptoms, health care follow-up, and awareness of possible risks of exposure. Of 55 callers who agreed to participate, 47 (85%) reported exposure to HABs while swimming or bathing in HAB-contaminated water. Nine callers reported health symptoms from being near waters contaminated with HABs, suggesting potential exposure via aerosolized toxins. Symptoms varied by the reported routes of exposure; the most commonly reported symptoms were gastrointestinal and respiratory. More public and health care provider education and outreach are needed to improve the understanding of HAB-related risks, to address ways to prevent HAB-related illnesses, and to describe appropriate support when exposures occur.

Journal of Clinical Toxicology, 2012

Objective-Our objective was to characterize the data captured in all animal exposure calls report... more Objective-Our objective was to characterize the data captured in all animal exposure calls reported to the National Poison Data System (NPDS), a national poison center reporting database, from 1 January 2000 through 31 December 2010 and identify Poison Center usage and needs in animal exposure calls. Design-We calculated descriptive statistics characterizing animal type, exposure substance, medical outcome, year and month of call, caller location, and specific state for all animal exposure call data in NPDS from 1 January 2000 to 31 December 2010. SAS version 9.2 was used for the analysis. Results-There were 1,371,095 animal exposure calls out of 28,925,496 (4.7%) total human and animal exposure calls in NPDS during the study period. The majority involved companion animal exposures with 88.0% canine exposures and 10.4% feline exposures. Pesticides were the most common exposure substance (n=360,375; 26.3%), followed by prescription drugs (n=261,543; 18.6%). The most common outcome reported was 'Not followed, judged as nontoxic exposure or minimal clinical effects possible' (n=803,491; 58.6%), followed by 'Not followed, judged potentially toxic exposure' (n=263,153; 19.2%). There were 5,388 deaths reported. Pesticide exposures were responsible for the greatest number of deaths (n=1,643; 30.4%). Conclusions and clinical relevance-Approximately 1 in 20 calls to PCs are regarding potentially toxic exposures to animals, suggesting a need for veterinary expertise and resources at PCs. Pesticides are one of the greatest toxic exposure threats to animals, both in numbers of exposures and severity of clinical outcomes, and is an important area for education, prevention, and treatment. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Topics in Companion Animal Medicine, Feb 1, 2013

Topics in Companion Animal Medicine, Feb 1, 2013

Many antidepressants inhibit serotonin or norepinephrine reuptake or both to achieve their clinic... more Many antidepressants inhibit serotonin or norepinephrine reuptake or both to achieve their clinical effect. The selective serotonin reuptake inhibitor class of antidepressants (SSRIs) includes citalopram, escitalopram (active enantiomer of citalopram), fluoxetine, fluvoxamine, paroxetine, and sertraline. The SSRIs are as effective as tricyclic antidepressants in treatment of major depression with less significant side effects. As a result, they have become the largest class of medications prescribed to humans for depression. They are also used to treat obsessive-compulsive disorder, panic disorders, alcoholism, obesity, migraines, and chronic pain. An SSRI (fluoxetine) has been approved for veterinary use in treatment of canine separation anxiety. SSRIs act specifically on synaptic serotonin concentrations by blocking its reuptake in the presynapse and increasing levels in the presynaptic membrane. Clinical signs of SSRI overdose result from excessive amounts of serotonin in the central nervous system. These signs include nausea, vomiting, mydriasis, hypersalivation, and hyperthermia. Clinical signs are dose dependent and higher dosages may result in the serotonin syndrome that manifests itself as ataxia, tremors, muscle rigidity, hyperthermia, diarrhea, and seizures. Current studies reveal no increase in appearance of any specific clinical signs of serotonin toxicity with regard to any SSRI medication. In people, citalopram has been reported to have an increased risk of electrocardiographic abnormalities. Diagnosis of SSRI poisoning is based on history, clinical signs, and response to therapy. No single clinical test is currently available to confirm SSRI toxicosis. The goals of treatment in this intoxication are to support the animal, prevent further absorption of the drug, support the central nervous system, control hyperthermia, and halt any seizure activity. The relative safety of the SSRIs in overdose despite the occurrence of serotonin syndrome makes them more desirable than other antidepressants. The prognosis in animals that receive treatment is excellent. In one retrospective study, there were no deaths in 313 SSRI-poisoned dogs. No characteristic or classic histopathologic lesions result from SSRI toxicosis. Differential diagnoses for SSRI overdose must include ingestions of other serotonergic medications such as phenylpiperidine opioids (fentanyl and tramadol), mirtazapine, buspirone, amitraz, and chlorpheniramine.

Topics in Companion Animal Medicine, Feb 1, 2013

The New England Journal of Medicine, Jan 23, 2014

Although early reports of exposure to synthetic cannabinoids described a benign course, 1 with li... more Although early reports of exposure to synthetic cannabinoids described a benign course, 1 with little need for emergency care, on August 24, 2013, patients began to present to Denver emergency departments with severe symptoms after exposure to a novel synthetic cannabinoid known locally as "black mamba." The Colorado Department of Public Health and Environment (CDPHE) was notified on September 3. Medical toxicologists and CDPHE epidemiologists developed a case definition and began prospective monitoring with assistance from the Centers for Disease Control and Prevention. Records from poison control centers, care providers in nonhospital settings, and law enforcement were reviewed. A total of 263 cases of possible exposure to the synthetic cannabinoid that met the CDPHE definition were identified statewide for the period August 21 to September 19. Among these cases, only 15 had been identified by the state poison control call-in centers. Among the 263 cases identified, there were 76 patients who presented to the emergency departments at two teaching hospitals in Denver and Aurora. Exposure was confirmed by means of patient history, bedside consultation, or laboratory analyses of products recovered from patients. The majority of cases involved single-agent ingestions; most patients were young men, and symptoms included altered mental status, tachycardia followed by