September 11, 2001 demonstrated dramatic voids in national preparedness, and catalyzed massive efforts to identify and remedy vulnerabilities. Since Part I of this series appeared in August 2002, significant improvements have been achieved especially in bioterrorism and chemical terrorism for first responders and emergency medicine, law enforcement, and public health (surveillance). Such efforts manifested benefits during the SARS outbreaks and monkeypox cases of 2003. Nevertheless, emerging infectious diseases will continue to pose a threat if we do not remain vigilant and continue to invest in training, surveillance, and treatments. As expected, many poison centers and toxicologists have taken leadership roles nationwide. In regions where such leadership existed, preparedness levels are strong and collaborations resulted in the development of valuable response plans and training, including the Advanced Hazardous Life Support (AHLS) and Basic Disaster Life Support (BDLS) courses. Early success notwithstanding, experts suggest that current national preparedness has improved slightly from "1" (9/11) to "3" out of "10". Increasingly it has become evident that the nuclear threat, including radiation terrorism, is significant, against which the US remains inadequately prepared. Arguably the nuclear threat-whether accidental or planned-remains our highest consequence vulnerability, and we must rapidly improve our readiness across disciplines. Special populations including the elderly and children remain marginalized in preparedness protocols. Local vulnerabilities including chemical manufacturing and transportation--not just a risk for terrorism but industrial accidents--continue unabated. Our early success is not an endpoint; much work remains and time is fleeting. This report examines vulnerabilities that must be addressed to enhance preparedness.

Melatonin regulates circadian rhythms, and although widely used in the US, information on the public use of melatonin and patterns of reported adverse effects associated with the substance is limited. To describe the patterns of melatonin calls to poison centers in Texas during 1998-2003, data on all melatonin calls reported to the Texas Poison Center Network were analyzed. During 1998-2003, there were 779 identified human exposures to melatonin identified. Of those patients with a known age, 59.1% were < 6 y. Males accounted for 54.1% of preschool-age patients while more of the older patients were female. Melatonin exposures were unintentional in 99.3% of the cases among children less than 6y and unintentional in < 41% among the older age groups. While 92.4% of exposures involving theyoungest age group were managed outside of a health care facility, 42% or less of the exposures occurring to patients > age 6 years were managed outside of a health care facility. Of those cases with a known outcome, the proportion of cases with at least minor effects rose with increasing age. The majority of melatonin exposures reported to Texas poison centers involved children < 6 y. Younger patients were more likely to be male, have unintentional exposures, have no clinical effect, and to not require management at health care facilities. The observed clinical effects and treatment methods were consistent with the literature.

This study determined the spectrum of deaths due to acute agrochemical poisoning in Turkey. Data was obtained from all autopsy reports performed between 1997 and 2001, compiled by the Institute of Forensic Medicine (which is a department of the Ministry of Justice), and evaluated retrospectively. There were 3990 deaths by intoxication of one form or another. Acute agrochemical/pesticide poisoning caused 843 deaths. Almost half were under 30 yo; 55% were female and 45% were male. Of 205 deaths whose manner of death was determined, 153 (75%) were suicide; the most common substance used was insecticide followed by sulfur, rodenticides, and herbicides. The pattern appeared consistent from 1997 to 2001 with no decline in the number of cases, despite the government having taken measures to educate the public and reduce pesticide use by offering alternates to control pests and insects.

Heightened toxicovigilance since the terrorist actions of 9/11 has raised concerns for malicious use of highly toxic botanicals, as the 3 cases reported illustrate.

The establishment of regulations for genetically modified organisms and the application of environmental risk assessment principles within the European Union are documented.

The use of a powder for poisoning sea fish off Lebanon is reported for the first time. The powder is prepared from the seeds of storax (Styrax officinalis L) and tubers of common cyclamen (Cyclamen persicum Mill.), both species growing wild in Lebanon. References to the properties of these species are provided.

Ingestion of foods containing the sweetener xylitol by dogs results in a significant, and often sustained, insulin-mediated hypoglycemic crisis. The efficacy of activated charcoal for gastrointestinal decontamination following xylitol ingestion is unknown. This screening study examined the effect of pH and incubation time on the in vitro binding of xylitol to activated charcoal. The mean percentage activated charcoal binding ranged between 8 and 23%. Mean percentage binding of xylitol at pH 3 was significantly higher (p < 0.05) than the binding of xylitol at pH 1 or pH 5 following 40 or 60 min of incubation with an aQueous 200 g/L activated charcoal slurry. These results suggest binding of xylitol to activated charcoal is relatively low; however, activated charcoal administration may still be beneficial in some canine acute oral xylitol exposures.

We defined patient demographics, type of the poisoning, distribution according to month, route and reason for exposure, mortality causes and rates from 682 poisonings admitted to University Hospital in Kayseri, Turkey to evaluate whether they follow the pattern of other countries. Poisoning were drugs (54.5%), inhalational poisonings including carbon monoxide (13.7%), food (12.4%), alcohol (7%), pesticides (5.4%) and corrosives (2.1%). In drug ingestions, psychoactive drugs most common; psychoactive, analgesic, and anti-inflammatory drugs were most frequent agents in multiple drug poisonings. Drugs were the most used poison while pesticides, mushrooms, methanol and carbon monoxide caused more deaths. The mortality rate was 2%.

The non life-threatening results of a bite from a grass snake in a 17-y-old patient are described, their significance evaluated, and the hazard of such bites discussed.

Antimony is a poisonous element with toxic properties that mimic those of arsenic. Numerous reports describe gastrointestinal complications of vomiting, diarrhea and stomatitis associated with antimony exposure. However, antimony toxicity from the use of tartar emetic as a treatment for alcohol abuse has never been described previously. A 19-y-o man with a history of alcohol abuse ingested a 10 mL bottle of "Soluto Vital" (tartar emetic, 50 mg/mL), produced in Guatemala for treatment of alcohol abuse. He presented 60 min after ingestion with severe vomiting, abdominal cramps, diarrhea, weakness and orthostasis. Initial laboratory evaluations were remarkable for creatinine of 2.5 mg/dL, potassium 6.1 mEq/L, and 60% hematocrit. He was given activated charcoal, iv saline and antiemetics. Over the next 48 h his creatinine normalized to 1.1 mg/dL and the hematocrit returned to 53%; urine had an antimony concentration of 1200 mcg/L (normal = < 10 mcg/L). It is important to recognize that foreign alcohol therapies aversive therapy other than disulfiram may be used, the contents of such a foreign product should be identified.

Gamma hydroxybutyrate (GHB) is widey used as a sexual enhancement drug, a euphoriant, muscle building agent, a sleep aid, a weight loss agent, and as a date rapeagent. Precursor ingredients such as gammabutyrolactone (GBL) and GHB recipes are available, especially via the Internet. This is a report of an organic inkjet cleaner containing a GHB precursor 1,4-butanediol and butylenegycol. A 26-y-o male fell unconscious during work being unresponsive, with constricted pupils, and convulsing, he did not respond to naloxone. A bottle labeled "Hurricane" was found in his pocket. Five h later the patient awoke and was subsequently discharged with all vitals normal. The patient had recently purchased "Hurricane" as a sleep aid and to treat his panic attacks. It is an organic product with active ingredients similar to ink jet cleaner, the key ingredient being 1,4butanediol, which is metabolized to GHB. In spite of legislative changes restricting GHB, the precursors remain available and continue a public health threat.

Lead poisoning is described in a herd of 120 Nelore cows of which 35 were affected. All affected cows died after a clinical course of 2-7 d with clinical signs related to cortical neurological disturbances. The source of Pb was fumes from a car battery recycling plant which has had a failure in its filtering system. Lead concentrations in liver and kidneys of 2 cows, in soil; and in grass where the cows were held were respectively 39 to 431 ppm, 147 to 431 ppm, and 245 ppm. No significant gross changes were observed. Histopathology revealed of neuronal necrosis, vacuolation of the neuropil and hypertrophy of the vascular endothelium in the cerebral cortices, degeneration of the epithelial cells of renal proximal tubules, and hemosiderosis of kidney, spleen and liver.

Veterinary anesthestics have gained popularity as drugs of abuse. A case of multiple drug abuse by a 36-y-old veterinarian involved the injection of xylazine-ketamine, resulting in gastrointestinal, cardiovascular and central nervous system effects, and unexpected hypertension, tachycardia and electrocardiogram changes.

Acute ingestion of copper sulfate has been reported to cause gastrointestinal injury, hemolysis, methemoglobinemia, hepatorenal failure, shock; or even death. The toxicity of organocopper compounds, however, remains largely unknown. A 40-y-old man attempted suicide by ingesting some 50 ml of Sesamine fungicide. He immediately developed headache, vomiting and abdominal pain, followed by progressive dyspnea, cyanosis, dark urine and diarrhea. Severe methemoglobinemia and hemolysis were documented, and treatment with ascorbic acid and hydration was commenced. He was referred to our service 3 d later for methylene blue treatment. Despite the above treatment, his symptomatology persisted and it was not until 5 d post-ingestion that the implicated fungicide was identified as copper-8-hydroxyquinolate. BAL therapy and plasma exchange were instituted, which decreased his plasma hemoglobin from 1,300 mg/dL to 29.1 mg/dL, and lowered his methemoglobin level from 20.9% to 1.1%. His serum and urine copper concentration dropped from 238 microg/dL to 96 microg/dL and from 112 microg/dL to 16 microg/dL, respectively. He was discharged uneventfully 18 d post-ingestion. Pre-existing glucose-6-phosphate dehydrogenase (G6PD) deficiency as well as copper-induced inhibition of G6PD activity was documented during hospitalization. Organocopper compounds may cause prolonged hemolysis and methemoglobinemia through oxidative stress, especially among patients with G6PD deficiency. Antidotal therapy with methylene blue is not likely to be effective in this setting: treatment with intensive supportive measures and other therapeutic options, such as plasma exchange, should be sought.