Unintentional ingestion of bupropion in children

Background: The incidence of seizures after unintentional bupropion ingestion in children aged < 6 years has been reported as 0.2%. However, in many poison centers, > 80% of these patients are referred to the Emergency Department (ED) for evaluation. Objective: To evaluate if all unintentional pediatric bupropion ingestions require referral to a health care facility (HCF), or what fraction of these could be managed safely at home. Method: A retrospective chart review was conducted of all bupropion ingestions in children aged < 6 years for 2000–2006 from four regional poison centers. Exclusion criteria were lack of follow-up or multiple drug ingestion. Results: Of 407 patients, 209 (51%) were male. Mean age was 2.2 years (SD ± 1.0). There were 329 patients (81%) seen in a HCF, of which 143 (35%) were hospitalized; 77 patients (19%) were observed at home. Symptoms occurred in 73 patients (18%): sinus tachycardia (n = 50), nausea/vomiting (n = 32), hyperactivity (n = 17), seizure (n = 3), hallucinations (n = 2), and hypertension (n = 2). The mean heart rate of patients with sinus tachycardia (n = 50, 12.3%) was 137 beats/min (SD ± 13), with a range of 112–172 beats/min. Mean dosage of those with tachycardia was 24 mg/kg. In the 2 patients with hypertension, the maximum recorded blood pressures were 145/80 mm Hg (2-year-old boy) and 137/90 mm Hg (2-year-old girl), with heart rates of 122 and 125 beats/min, respectively. Dose ingested and patient weight was known for 218 patients. Mean dosage ingested was 12.2 mg/kg, with a range of 2.6–64 mg/kg. Eighty-eight percent of patients with a known dosage ingested < 20 mg/kg. Discussion: A high percentage of children continue to be seen in a HCF. Concern from the higher incidence of severe effects seen with intentional adult exposures may be one of the reasons for this cautious approach. Conclusion: Unintentional pediatric bupropion ingestions resulted in clinical effects that rarely required any HCF intervention. Isolated unintentional bupropion ingestion of ≤ 10 mg/kg may not require referral to a health care facility.     

Common dietary supplements for weight loss

Over-the-counter dietary supplements to treat obesity appeal to many patients who desire a "magic bullet" for weight loss. Asking overweight patients about their use of weight-loss supplements and understanding the evidence for the efficacy, safety, and quality of these supplements are critical when counseling patients regarding weight loss. A schema for whether physicians should recommend, caution, or discourage use of a particular weight-loss supplement is presented in this article. More than 50 individual dietary supplements and more than 125 commercial combination products are available for weight loss. Currently, no weight-loss supplements meet criteria for recommended use. Although evidence of modest weight loss secondary to ephedra-caffeine ingestion exists, potentially serious adverse effects have led the U.S. Food and Drug Administration to ban the sale of these products. Chromium is a popular weight-loss supplement, but its efficacy and long-term safety are uncertain. Guar gum and chitosan appear to be ineffective; therefore, use of these products should be discouraged. Because of insufficient or conflicting evidence regarding the efficacy of conjugated linoleic acid, ginseng, glucomannan, green tea, hydroxycitric acid, L-carnitine, psyllium, pyruvate, and St. John's wort in weight loss, physicians should caution patients about the use of these supplements and closely monitor those who choose to use these products.     

Intentional and unintentional nonadherence to antihypertensive medication

BACKGROUND: Hypertension is poorly controlled in the US due to medication nonadherence. Recent evidence suggests that nonadherence can be classified as intentional or unintentional and different patient characteristics, such as the experience of adverse effects, may be associated with each. OBJECTIVE: To examine associations between patient characteristics, including reported adverse effects, and both intentional and unintentional nonadherence among 588 hypertensive patients. METHODS: Baseline data from a clinical trial, the Veterans' Study To Improve the Control of Hypertension, were examined. Intentional and unintentional nonadherence were assessed using a self-report measure. Participants were presented with a list of adverse effects commonly associated with antihypertensive medication and asked to indicate which symptoms they had experienced. Logistic regression analyses were used to examine adjusted associations between patient characteristics and type of nonadherence. RESULTS: Approximately 31% of patients reported unintentional nonadherence and 9% reported intentional nonadherence. Non-white participants, individuals without diabetes mellitus, and individuals reporting > or = 5 adverse effects were more likely to report intentional nonadherence than their counterparts. Individuals with less than a 10th-grade education and non-white participants were more likely to report unintentional nonadherence than their counterparts. When symptoms of increased urination and wheezing/shortness of breath were reported, patients were more likely to report intentional and unintentional nonadherence compared with those who were adherent. Unintentional nonadherence was also associated with reports of dizziness and rapid pulse. CONCLUSIONS: Both intentional and unintentional nonadherence are common and related to perceived adverse effects. Furthermore, different interventions may be necessary to improve adherence in unintentionally and intentionally nonadherent patients.     

A critical evaluation of Internet marketing of products that contain ephedra

OBJECTIVE: To evaluate information contained within Internet sites that advertise and market dietary supplements containing ephedra. MATERIAL AND METHODS: We conducted an Internet search to identify Web sites advertising weight-loss supplements that contained ephedra. Between July 7 and July 18, 2002, 4 search engines were used by entering the term herbal weight loss. Outcome measures included disclosure of potential adverse effects of or contraindications to ephedra-containing supplements, disclosure of ephedra alkaloid dosage, and presence of misleading or incorrect information. RESULTS: Thirty-two products and advertisements were identified and systematically evaluated for deviance from truth-in-advertising standards. Of the 32 Web sites analyzed, 13 (41%) failed to disclose potential adverse effects or contraindications to supplement use. Seventeen (53%) did not reveal the dosage of ephedra alkaloids that was recommended. More importantly, 11 sites (34%) contained incorrect or misleading statements, some of which could directly result in serious harm to consumers. CONCLUSION: If dietary supplements containing ephedra are to continue to be marketed freely, substantial reform in advertising regulation and enforcement is warranted.     

Outcomes after supratherapeutic escitalopram ingestions

Escitalopram (ESC) is a new selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. There are limited data regarding accidental and intentional ESC exposure. We conducted a retrospective chart review of isolated ESC ingestions reported to our regional poison center during 2003-2004. Twenty-eight patients met inclusion criteria. The average patient age was 28.1 years (range 2-75 years) and the average amount of ESC ingested was 62.5 mg (range 5-300 mg from 19 cases). The most common formulation ingested was the 20-mg tablet. There were eight accidental ingestions and 20 intentional overdoses. Six of the eight accidental ingestions were observed at home with follow-up in 24 h, and no adverse outcomes were reported. The other two accidental overdoses were observed in the Emergency Department (ED) and discharged home with no adverse events reported. Nineteen of the intentional overdoses were observed in the ED for approximately 4-6 h and discharged home or to an inpatient psychiatry ward. One of the intentional overdose patients was admitted for persistent lethargy, but had a good outcome. ESC toxicity can theoretically be life threatening, but no patients in our series had adverse sequealae after accidental or intentional overdose.     

Toxic Ingestions in Pregnancy: Abortifacient Use in a Case Series of Pregnant Overdose Patients

Objectives : To profile young, pregnant patients with an overdose reported to an urban poison center; and to characterize the ingestions and short-term outcomes of these overdose patients.
Methods : A prospective, observational study of female overdose patients was performed from November 1, 1994, through March 31, 1995. Consecutive cases were identified from all calls to the regional poison center (annual call volume = 70,000) regarding intentional overdose in women between the ages of 12 and 30 years. Pregnancy tests were recommended by the poison center during the study period in female patients aged 12—30 years who presented to a health care facility (usually an urban ED) with an intentional overdose. Pregnant patients were then followed during their hospitalizations, and the results of toxicology studies and maternal and short-term fetal outcomes were recorded.
Results : Pregnancy tests were obtained for 371 (32%) of 1,142 eligible patients. Of patients with pregnancy tests, 43 (11.6%) were pregnant. Although most cases were comparable to general adult intentional ingestions, 5 of the 43 pregnant patients ingested known abortifacients. Most pregnant patients (35/43, 81%) had toxicity at or below American Association of Poison Control Centers (AAPCC) criteria for minimal toxicity, and all patients recovered completely.
Conclusion : Pregnancy was a common finding in this sample of young, female, intentional overdose patients reported to our regional poison control center. Frequent use of abortifacients for toxic ingestions has not been previously reported. A pregnancy test should be obtained for all female patients of childbearing age with an intentional ingestion to address the potential association of the ingestion with an unanticipated or undesired pregnancy.     

Randomized trial of two mind-body interventions for weight-loss maintenance

OBJECTIVE: Regain of weight after initial weight loss constitutes a major factor contributing to the escalating obesity epidemic. The objective of this study was to determine the feasibility and clinical impact of two mind-body interventions for weight-loss maintenance. DESIGN: Randomized, balanced, controlled trial. SETTING: Large-group model health maintenance organization. PARTICIPANTS: Overweight and obese adults were recruited to a 12-week behavioral weight-loss program. Participants meeting threshold weight loss and attendance requirements were eligible for randomization. INTERVENTIONS: The three weight-loss maintenance interventions were qigong (QI), Tapas Acupressure Technique (TAT (registered trademark of Tapas Fleming, L.Ac.), and a self-directed support (SDS) group as an attention control. OUTCOMES: The main outcome measure was weight loss maintenance at 24 weeks postrandomization. Patient interviews explored additional benefits of the interventions, as well as barriers and facilitators to compliance. RESULTS: Eighty-eight percent (88%) of randomized patients completed the study. There were no significant study-related adverse events. At 24 weeks, the TAT group maintained 1.2 kg more weight loss than the SDS group did (p = 0.09), and 2.8 kg more weight loss than the QI group did (p = 0.00), only regaining 0.1 kg. A separation test (0.05 level, 0.95 power) indicated that TAT merits further study. A secondary analysis revealed that participants reporting a previous history of recurrent unsuccessful weight loss were more likely to regain weight if assigned to the SDS arm, but this effect was suppressed in both the QI and TAT groups (p = 0.03). Although QI participants reported important general health benefits, the instruction sequence was too brief, given the complexity of the intervention. CONCLUSIONS: TAT warrants further research for weight-loss maintenance. Any further research on qigong should use a modification of our protocol.     

Evaluation of internet websites marketing herbal weight-loss supplements to consumers

OBJECTIVE: The aim of this study was to evaluate the quality and quantity of drug information available to consumers on Internet websites marketing herbal weight-loss dietary supplements in the United States. METHODS: We conducted an Internet search using the search engines Yahoo and Google and the keywords "herbal weight loss." Website content was evaluated for the presence of active/inactive ingredient names and strengths and other Food and Drug Administration (FDA) labeling requirements. Information related to drug safety for the most common herbal ingredients in the products evaluated was compared against standard herbal drug information references. RESULTS: Thirty-two (32) websites were evaluated for labeling requirements and safety information. All sites listed an FDA disclaimer statement and most sites (84.4%) listed active ingredients, although few listed strengths or inactive ingredients. Based on the drug information for the most common ingredients found in the weight-loss dietary supplements evaluated, potential contraindications for cardiovascular conditions, pregnancy/nursing, and high blood pressure were listed most frequently (73%, 65.5%, and 37%, respectively), whereas few websites listed potential drug interactions or adverse reactions. CONCLUSIONS: Potential hazards posed by dietary supplements may not be accurately, if at all, represented on Internet websites selling these products. Since consumers may not approach their physicians or pharmacists for information regarding use of dietary supplements in weight loss, it becomes necessary for health care providers to actively engage their patients in open discussion regarding the use, benefits, and hazards of dietary supplements.     

Castor bean seed ingestions: A state-wide poison control system's experience

Context. Ingestions of the seed of the castor bean plant (Ricinus communis) carries the risk of toxicity from ricin, a potent inhibitor of protein synthesis. Objective. We sought to describe characteristics of castor bean seed exposures reported to a state-wide poison control system. Methods. This was an observational case series. A state-wide poison control system's database was reviewed for exposures to castor bean plant seeds from 2001 to 2011. Case notes were reviewed and data collected, when available, included age, gender, circumstances surrounding exposure, number of castor beans consumed, whether beans were chewed or crushed, symptoms described, laboratory values (aspartate aminotransferase [AST], alanine aminotransferase [ALT], prothrombin time [PT] and international normalized ratio [INR]), duration of follow-up, treatment, and patient outcomes. Results. Eighty-four cases were identified. Ingestions were unintentional in 50 cases (59%) cases and intentional in 34 (40%) cases. A median of 10 seeds (range: 1–20) were ingested in intentional cases versus 1 seed (range: 1–40) in unintentional cases. In 49 (58%) of cases the seeds were reported to have been chewed or crushed. Gastrointestinal symptoms were the most commonly reported symptoms. Vomiting (n = 39), nausea (n = 24), diarrhea (n = 17), and abdominal pain (n = 16) predominated. One patient developed hematochezia and vomiting after reportedly ingesting and intravenously injecting castor bean seeds. Laboratory values were documented in 17 (20%) cases. Only one abnormality was noted; an asymptomatic patient one week following ingestion had AST/ALT of 93 U/L and 164 U/L, respectively. Ricinine was confirmed in the urine of two patients. Twenty-three (27%) cases received activated charcoal. Seventy-two (86%) of cases were calls from health care facilities or referred to health care facilities by the poison control center. Twenty-two (26%) cases were admitted for a median of 2 days (range: 1–10). Admitted cases ingested a median of 8.5 seeds (range: 1–20). Intentional ingestions were followed for median of 37.5 h (range: 0.5–285.5) while unintentional cases were followed for 14 h (range: 1–182). No delayed symptoms, serious outcomes, or deaths were reported. Discussion. Due to the presence of ricin, there is concern for serious outcomes after ingestions of the seeds of the castor bean plant. In this study GI symptoms were most commonly reported but serious morbidity or mortality was not present. The true risk of castor bean plant seed ingestions should continue to be re-evaluated. Conclusion. In this retrospective review, gastrointestinal symptoms were the most common symptoms described after reported exposures to castor bean seeds. These exposures were not associated with serious morbidity, mortality, or delayed symptoms.     

Zolpidem (Ambien): A Pediatric Case Series

Abstract

Background: In 1993, the nonbenzodiazepine sedative-hypnotic zolpidem tartrate (Ambien®) was approved for use in the US. Zolpidem has an imidazopyridine structure and possesses a rapid onset of action and a short half-life. The toxic threshold and profile have not been well established in the pediatric population. Methods: All pediatric zolpidem exposures reported to a regional poison information center over 24 months were reviewed retrospectively from the American Association of Poison Control Centers Toxic Exposure Surveillance System data collection forms. Results: Twelve pediatric zolpidem exposures were reported. Seven were unintentional (ages 20 mon-5 y) and five were intentional misuse/suicide (ages 12–16 y). The regional poison information center was contacted within 1 h in ten cases with onset of symptoms within 10 to 60 min (mean 31.6 min). One child had no effect with 2.5 mg. As little as 5 mg caused symptoms with minor outcome in six unintentional ingestions (5–30 mg). Minor to moderate symptoms were reported 1–4 h after intentional ingestions (12.5–150 mg). The duration of symptoms in the unintentional cases ranged from less than 60 min up to 4 h(mean 2.4 h) and 6–10 h (mean 7.5 h) in the intentional exposures. Treatment consisted of observation (4), syrup of ipecac (l), lavage and activated charcoal (l), activated charcoal alone (5), and unknown (1). Conclusion: Due to the very rapid onset of central nervous system symptoms in children, emesis is not a treatment option. Supportive care, activated charcoal in large ingestions, and observation until symptoms resolve may be sufficient in most pediatric cases.     

Ethnic differences in herb and vitamin/mineral use in the elderly

BACKGROUND: Little information exists on herb and vitamin-mineral supplement use in very old people and whether use varies by ethnicity. OBJECTIVE: To examine the prevalence and predictors of herb and vitamin-mineral supplement use in a tri-ethnic sample of adults aged > or = 77 years. METHODS: In-home interviews in 1997-1998 assessed medications use and sociodemographic and health factors in community-dwelling elderly non-Hispanic white (n = 125), black (n = 112), and Hispanic (n = 128) adults. RESULTS: Of the 365 subjects (71.5% > or = 80 y old, 52.6% female), 172 reported using at least one of the preparations (vitamin-mineral supplements 132, herbs alone 21, both herbs and vitamin-mineral supplements 19). Herbal use varied by ethnicity: 12.8% in non-Hispanic whites, 16.1% in blacks, and 4.7% in Hispanics. The most commonly used herbs were garlic, Ginkgo biloba, saw palmetto, and vinegar. Use of vitamin-mineral supplements, alone or combined with herbs, also varied by ethnicity: 54.4% in non-Hispanic whites, 31.3% in blacks, and 37.5% in Hispanics. In the fully adjusted multivariate model with white ethnicity as reference, the odds ratio of vitamin-mineral supplements use for blacks was 0.37 (95% CI 0.21 to 0.65) and for Hispanics was 0.56 (95% CI 0.30 to 1.03). In bivariate analyses, female gender, black ethnicity, being born in the US, and having coronary artery disease were significantly associated with herbal use (p < 0.05); however, in the fully adjusted multivariate model, only the female gender remained significantly associated with herbal use (OR 2.14; 95% CI 1.00 to 4.59). CONCLUSIONS: Use of herbs or vitamin-mineral supplements is common in very old people and varies by ethnicity.     

Ramelteon ingestions reported to Texas poison centers, 2005-2009

Background

The only data that currently exist on ramelteon (Rozerem^®; Takeda Pharmaceuticals North America, Inc., Deerfield, IL) ingestions is from clinical trials. To fill this gap, data on ramelteon ingestions reported to Texas poison centers during 2005–2009 were collected and analyzed.

Objectives

The objective of this study was to describe how reported ramelteon ingestions were handled by Texas poison center staff and when known, the patient’s final medical outcome. In cases where the dosage was significant enough to refer the patient to a health care facility, adverse clinical reactions and treatments are also described.

Methods

Cases were analyzed for selected demographic and clinical factors. Of 222 total patients, 67.6% were women and 73.9% were over the age of 19 years. Cases were analyzed by motivating factors (e.g., unintentional, intentional), management site, adverse reactions, and final medical outcome.

Results

Of the ramelteon ingestions reported to Texas poison centers, 67.6% involved adult women and were suspected attempted suicides; 75% of ramelteon ingestions not involving other substances were managed at a health care facility. However, 88.3% of these ingestions resulted in no significant clinical effect.

Conclusion

The management strategies used by Texas poison centers for the 56 cases reported in this study were adequate.     

Ischemic colitis associated with use of a bitter orange-containing dietary weight-loss supplement

Since the US Food and Drug Administration banned the use of dietary supplements containing ephedra in February 2004, numerous "ephedra-free" weight-loss products have appeared on the market. Many of these supplements contain compounds such as bitter orange that are similar in structure and action to ephedra. We describe a patient in whom ischemic colitis developed 1 week after initiation of a bitter orange-containing weight-loss supplement. The patient had no other predisposing factors, and discontinuation of the supplement led to immediate improvement and ultimate resolution of her symptoms. Both consumers and health care professionals should be aware of the potential harm that bitter orange-containing dietary supplements can cause and report such adverse events to the US Food and Drug Administration.     

Use of dosage as a triage guideline for unintentional cyclic antidepressant (UCA) ingestions in children

Triage guidelines for unintentional cyclic antidepressant (UCA) ingestions vary widely, with limited supportive evidence. All records of UCA ingestion reported to 4 certified regional poison centers were evaluated for the years 1998 through 2000. Inclusion criteria included age 5 mg/kg. The majority of UCA ingestions produced limited or no symptomatology. In this series, all children with ingestions of <5 mg/kg developed no or minor effects. Home monitoring might be appropriate in such cases.