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.

Solid sodium hydroxide compounds are used to unclog drains. In Turkey, these agents are easily available and commonly used by housewives. They are sold in weak bags and usually stored within these bags. We present the case of an elderly woman with dementia who developed severe alkaline tongue burn and edema after unintentional short contact with solid sodium hydroxide drain cleaner. Official legislation for safety packing in Turkey will lead to reduction in the incidence of accidental caustic injuries.

An outbreak of footrot occurred in a flock of Corriedale sheep; 27 animals were treated with antibiotic and footbathed in a 5% copper sulfate solution. Being deprived of water for > 17 h, many sheep drank the footbath solution. After 6 h 16 sheep became ill with acute copper poisoning, 10 animals died within 10 h; 6 were severely ill and were sent to Veterinary Hospital, and 4 had mild signs and recovered without treatment. The sick sheep had anorexia, dullness, grinding teeth, moaning, rumen atony, dehydration, dark blue-green diarrheic feces and congested membranes. They were treated with 3.4 mg tetrathiomolybdate/kg body weight and lactated Ringer's solution iv, oral molybdate, sulfate, kaolin and pectin, and drenched with antacids. Two of the 6 sheep died during hospitalization. The ingestion of copper solution caused an intense gastrointestinal injury that resulted in ulcers, petechial and echymotic hemorrhages in the mucosa, mild hemolysis detected by microscopic hemoglobinuria and a lowered packed cell volume, severe hepatic injury that raised the AST and gammaGT blood values, and moderate kidney lesions with increasing serum blood urea and nitrogen creatinine levels.

We investigated a cluster of canine poisonings around the 4th of July weekend in 2003 in dogs that visited a local park. Medical records review and personal interviews were performed on 17 suspect cases; 14 dogs met the case definition criteria. The 13/14 dogs were allowed off-leash at some point during their visit to the park; 7 owners noted their dog had either eaten something at the park or vomited up meat-like material within 1 h after their walk. Eleven of the 14 dogs died or were euthanized. Urine samples from 4 dogs were positive for trace amounts of paraquat and 1 vomitus sample tested positive. Tachypnea was a significant risk factor for death of the dogs. Oral or gastrointestinal ulcers were significantly correlated with recovery.

The Vietnamese centipede (Scolopendra subspinipes) is one of the largest and most aggressive tropical centipedes. It has become a popular pet among arthropod enthusiasts and the general public. Despite their reputation, few well-documented cases of envenomation are reported in the medical literature. A 53-yo man developed severe pain, swelling and erythema of his left hand and forearm after being bitten on the hand by his pet Vietnamese centipede. The neurological and vascular examination of the arm was normal. He was admitted to the hospital, treated with arm elevation, analgesics and parenteral antibiotics. His symptoms gradually resolved and he was discharged after 4 d with no neurological or cosmetic sequelae.

A spontaneous outbreak of neurological disease in swine caused by the ingestion of Aeschynomene indica seeds and reproduction of the disease in the same specie are reported. In the natural outbreak the morbidity, mortality and lethality rates were respectively 25%-40%, 8.5%-20%, and 25%-66%. Clinical signs were variable degrees of incoordination of gait, falls, sternal recumbency with wide base stance of the hind limbs, lateral recumbency and death. For experimental reproduction of the intoxication, 5 (A-E) pigs were fed a ration containing 10% (PigA), 15% (Pig B) and 20% (Pigs C-E) of A. indica seeds. Pigs A and B were euthanatized and Pigs C-E died of acute disease respectively 16, 21 and 24 hours after the start of the experiment. Clinical signs were similar to those observed in pigs from the spontaneous outbreak. Histopathological findings in the brain of pigs fed rations with 20% A. indica seeds (C-E) were congestion, edema and hemorrhage and swollen capillary endothelia in nuclei and in the telencephalic cortex. Pigs fed 10% and 15% A. indica had histopathological changes in the brain of discrete focal symmetrical areas of malacia. These findings indicate that one or more toxic principles in A. indica seeds are responsible for this neurological condition and that clinical outcome and pathological changes are dose-dependent. The symmetrical malacic foci from the ingestion of A. indica seeds in pigs affected vestibular and cerebellar nuclei, putamen, and the mesencephalic substantia nigra, oculomotor, and red nucleus; thus, focal symmetrical encephalomalacia is suggested as a better name for the disease.

We report the first case from Turkey of a dermonecrotic wound associated with possible Loxosceles spider bite and offer the complete clinical course that resulted in a permanent scar. Emergency physicians in western Turkey should be aware of Loxosceles spider bites as a cause of necrotizing wounds.

Fourteen pigs, fed during the last 5 mo of rearing on fumonisin B1 naturally contaminated feed, were evaluated for hematological and biochemical effects. After slaughtering of the animals, the liver and 1 kidney underwent histopathological examination; the other kidney was tested by HPLC for fumonisin B1 residues. With feed contamination of 2 and 22 mg fumonisin B1/kg, the calculated daily intake of fumonisin B1 was approximately 50 microg/kg bw before the first blood sampling and approximately 500 microg/kg bw before the second blood sampling and slaughter. No hematological changes were observed, while moderate adverse effects on liver function (ALT and cholesterol) and hepatocyte integritywere found. No histopathological alterations nor fumonisin residues were detected (LOD 5 microg/kg) in the kidneys. The levels of contamination had slight but observed effects on swine health. The lack of fumonisin B1 carry-over to edible swine tissues was confirmed and under the studied conditions, no consumer risk from the pork products was expected.

Yew (Taxus baccata) foliage was co-incubated with rumen fluid (RF) taken from fistulated cattle (Bos taurus), anesthetized white-tailed deer (Odocoileus virginianus) and O. virginianus killed by bow hunters. The first trial with live deer resulted in statistically significant 59% reduction of taxine A by deer RF and no reduction by cattle RF. The second intubation trial, in which half the samples were stopped after 12 h, resulted in slightly less taxine A reduction by deer (46%) and 12% reduction by cattle RF. RF obtained by hunters eQuipped with thermos bottles and trained to collect RF immediatey upon field dressing their deer caused the most (88-96%) taxine A destruction: cattle RF reduced 68-88% the toxin. Obtaining RF from freshly killed deer was less expensive and more consistently successful than taking RF by intubation of anesthetized deer. The greater ability of white-tailed deer RF to detoxify yew taxines may not entirely explain the advantage white-tailed deer have over cattle to surviveyew ingestions without toxic effects.

This study compared CYP-mediated activation and toxicity of chlorpyrifos (CPF) in male and female rats, since gender difference in CPF toxicity in rats has been reported. A dose of 50 mg/kg of CPF in corn oil was administered ip to 2 groups of male and female rats while the respective control groups received the vehicle alone. Measurement of cholinesterase activity in brain showed no difference in cholinesterase inhibition between male and female rats 3 h following CPF administration. In contrast, inhibition of plasma cholinesterase was significantly greater in females than males. The activities of microsomal CYP 1A1, 2B1, 2E1 and 3AV 2 determined whether CPF, a suicide substrate of cytochrome P450 enzymes, was metabolized by the liver CYP enzymes. The CYP 1A1 and 2B1 activities were significantly decreased in both male and female rats, with the CYP 1A1 decrease in females markedly greater than that in males. CPF produced a significant inhibition of only CYP 3A1/2 activity, but not CYP 2E1 activity, irrespective of gender effect. These results demonstrated that CYP 1A1, 2B1 and 3A1/2 were differentially involved in the metabolism of CPF to CPF-oxon in both genders and the extent of plasma cholinesterase inhibition was significantly greater in female than male rats.

This study covers 1975 to 2003 with measurements of lead in soil (n = 24), hay (n = 259), silage (n = 35) and blood of cows (n = 1279) from farms (n = 1 to 14) situated 1 to 10 km around a lead smelter. Until 1978, when protective filters were installed in the plant chimneys, the farms had been exposed to heavy industrial-metallurgic effluent. Early measurments (1968 to 1975) high lead (> 600.0 mg lead/kg) in the topsoil, and continuing measurements (1981 to 2003) showed no significantly decreased lead after the installation of filters; however, mean lead in hay samples gradually decreased. In 1975 lead concentrations in 4 samples of hay were 227.0 to 953.0 mg/kg DM. In 2002 (n = 12) mean lead concentrations were about 100-fold lower (5.6 +/- 3.3 mg lead/kg DM). A similar trend of decreasing lead concentrations occurred also in the blood of cows. In 1975 (n = 9) average lead concentration was 1.2 +/- 0.6 mg/kg whole blood, while in 2002 (n = 58) it was about 20-times lower (0.07 +/- 0.005 mg/kg). This significant decrease in lead concentration may be attributed to sanitation of the major source of industrial emission of lead gasses and dust by installation of bag filters to the plant chimneys in 1978. After 1982 mean cow lead blood concentrations were within normal reference values (< 0.250 mg of lead/kg). However, during the last 10y mean lead concentrations have still been 1- to 2-fold above the values measured in blood (n = 32) from 3 control areas in Slovenia. Cattle blood levels proved a good bioindicator of environmental contamination. Monitoring lead in the blood of animals on farms near the smelter should continue because the persistence of lead in topsoil is the main problem in this area.

An education program was implemented at a regional poison center to increase use of a new nationwide 800 number (800/222-1222) in counties in our region that had low rates of utilization. We identified 10 counties with the lowest utilization rates and provided textbook covers to the elementary and secondary schools in these areas. The covers contained the poison help logo and information about what to do if a poisoning occurs. Changes in utilization rate for these counties were compared to similar counties over the course of a year. Utilization rates increased in both sets of counties over the study period, but there was no significant difference (p = 0.84) between the 2 groups. Use of textbook covers to increase awareness and utilization made little impact beyond our normal efforts and was not cost-effective.

Isopropyl alcohol (IPA) is widely used in industrial and home-cleaning products, easily available to general public and inexpensive: intoxications can occur unintentionally, in suicide attempts or by alcohol abusers as a substitute for ethanol. Symptoms involve the gastrointestinal tract, central nervous system and at high doses cardiovascular manifestations may appear. Ketonemia, ketonuria without hyperglicemia or acidosis and elevated osmol gap are common laboratory findings. Mortality and morbidity is low, but some fatal cases have been reported in patients in deep coma and especially those with hypotension. We present a life-threatening intoxication, with deep coma and hypotension, treated successfully with hemodialysis. Whether hemodialysis must always be performed is a controversial question. Our opinion is hemodialysis is not needed, even in life-threatening situations. Arguments about this opinion are presented.

Despite the well-founded reputation of plants of the genus Taxus as being amongst the most toxic plants for domestic livestock in the US, there are surprisingly few published case reports of yew poisoning in horses. This report documents 2 acute fatalities in horses in the central Willamette Valley, OR associated with the consumption of Taxus sp. The predominant features of the intoxication were peracute death, with no signs of struggling or convulsions, in otherwise fit and well managed adult horses. The most significant gross necropsy findings were limited to pulmonary congestion and hemorrhage, suggestive of acute circulatory disturbance. A diagnosis of Taxus sp poisoning was confirmed on the basis of a history of potential exposure, by the identification of yew leaves in the gastric contents of the horses, and by the subsequent identification of yew clippings in the pasture. The literature relevant to Taxus sp poisoning in horses is reviewed.