Severe outcomes following pediatric cannabis intoxication: a prospective cohort study of an international toxicology surveillance registry.

INTRODUCTION: An increasing number of jurisdictions have legalized recreational cannabis for adult use. The subsequent availability and marketing of recreational cannabis has led to a parallel increase in rates and severity of pediatric cannabis intoxications. We explored predictors of severe outcomes in pediatric patients who presented to the emergency department with cannabis intoxication. METHODS: In this prospective cohort study, we collected data on all pediatric patients (<18 years) who presented with cannabis intoxication from August 2017 through June 2020 to participating sites in the Toxicology Investigators Consortium. In cases that involved polysubstance exposure, patients were included if cannabis was a significant contributing agent. The primary outcome was a composite severe outcome endpoint, defined as an intensive care unit admission or in-hospital death. Covariates included relevant sociodemographic and exposure characteristics. RESULTS: One hundred and thirty-eight pediatric patients (54% males, median age 14.0 years, interquartile range 3.7-16.0) presented to a participating emergency department with cannabis intoxication. Fifty-two patients (38%) were admitted to an intensive care unit, including one patient who died. In the multivariable logistic regression analysis, polysubstance ingestion (adjusted odds ratio = 16.3; 95% confidence interval: 4.6-58.3; P < 0.001)) and cannabis edibles ingestion (adjusted odds ratio = 5.5; 95% confidence interval: 1.9-15.9; P = 0.001) were strong independent predictors of severe outcome. In an age-stratified regression analysis, in children older than >10 years, only polysubstance abuse remained an independent predictor for the severe outcome (adjusted odds ratio 37.1; 95% confidence interval: 6.2-221.2; P < 0.001). As all children 10 years and younger ingested edibles, a dedicated multivariable analysis could not be performed (unadjusted odds ratio 3.3; 95% confidence interval: 1.6-6.7). CONCLUSIONS: Severe outcomes occurred for different reasons and were largely associated with the patient's age. Young children, all of whom were exposed to edibles, were at higher risk of severe outcomes. Teenagers with severe outcomes were frequently involved in polysubstance exposure, while psychosocial factors may have played a role.

Predictors of severe outcome following opioid intoxication in children.

INTRODUCTION: While the opioid crisis has claimed the lives of nearly 500,000 in the U.S. over the past two decades, and pediatric cases of opioid intoxications are increasing, only sparse data exist regarding risk factors for severe outcome in children following an opioid intoxication. We explore predictors of severe outcome (i.e., intensive care unit [ICU] admission or in-hospital death) in children who presented to the Emergency Department with an opioid intoxication. METHODS: In this prospective cohort study we collected data on all children (0-18 years) who presented with an opioid intoxication to the 50 medical centers in the US and two international centers affiliated with the Toxicology Investigators Consortium (ToxIC) of the American College of Medical Toxicology, from August 2017 through June 2020, and who received a bedside consultation by a medical toxicologist. We collected relevant demographic, clinical, management, disposition, and outcome data, and we conducted a multivariable logistic regression analysis to explore predictors of severe outcome. The primary outcome was a composite severe outcome endpoint, defined as ICU admission or in-hospital death. Covariates included sociodemographic, exposure and clinical characteristics. RESULTS: Of the 165 (87 females, 52.7%) children with an opioid intoxication, 89 (53.9%) were admitted to ICU or died during hospitalization, and 76 did not meet these criteria. Seventy-four (44.8%) children were exposed to opioids prescribed to family members. Fentanyl exposure (adjusted OR [aOR] = 3.6, 95% CI: 1.0-11.6; p = 0.03) and age ≥10 years (aOR = 2.5, 95% CI: 1.2-4.8; p = 0.01) were independent predictors of severe outcome. CONCLUSIONS: Children with an opioid toxicity that have been exposed to fentanyl and those aged ≥10 years had 3.6 and 2.5 higher odds of ICU admission or death, respectively, than those without these characteristics. Prevention efforts should target these risk factors to mitigate poor outcomes in children with an opioid intoxication.

Clinical Pharmacology, Toxicity, and Abuse Potential of Opioids.

Opioids were the most common drug class resulting in overdose deaths in the United States in 2019. Widespread clinical use of prescription opioids for moderate to severe pain contributed to the ongoing opioid epidemic with the subsequent emergence of fentanyl-laced heroin. More potent analogues of fentanyl and structurally diverse opioid receptor agonists such as AH-7921 and MT-45 are fueling an increasingly diverse illicit opioid supply. Overdose from synthetic opioids with high binding affinities may not respond to a typical naloxone dose, thereby rendering autoinjectors less effective, requiring higher antagonist doses or resulting in a confusing clinical picture for health care providers. Nonscheduled opioid drugs such as loperamide and dextromethorphan are associated with dependence and risk of overdose as easier access makes them attractive to opioid users. Despite a common opioid-mediated pathway, several opioids present with unique pharmacodynamic properties leading to acute toxicity and dependence development. Pharmacokinetic considerations involve half-life of the parent opioid and its metabolites as well as resulting toxicity, as is established for tramadol, codeine, and oxycodone. Pharmacokinetic considerations, toxicities, and treatment approaches for notable opioids are reviewed.

Outcomes of a Survey-Based Approach to Determine Factors Contributing to the Shortage of Occupational Medicine Physicians in the United States.

CONTEXT: There is a long-standing shortage of formally trained Occupational & Environmental Medicine (OEM) physicians despite OEM practitioners experiencing high satisfaction and low burnout. OBJECTIVE: To explore the root causes of this shortage and suggest potential remedies. METHODS: Cross-sectional surveys were administered to medical students queried regarding OEM training, practicing OEM physicians queried regarding timing of specialty choice, and OEM Train-in-Place (TIP) program graduates queried regarding satisfaction with training. RESULTS: Of 247 medical student respondents, 70% had heard of OEM, 60% through one lecture. Of the 160 OEM physicians, 17% first became aware of OEM as medical students, and most would have chosen a different path had they heard sooner. Most TIP program trainees reported that they would not have undertaken specialty training without a TIP program (89%). CONCLUSIONS: Strategies to introduce OEM earlier in medical education and TIP programs for mid-career physicians may help overcome persistent shortages of OEM specialists.

Nicotine Content from Cigarettes Submerged in Soda.

INTRODUCTION: Cigarettes and other tobacco products may be extinguished by submersion in liquids in beverage cans or bottles. Cases of nicotine poisoning in children have been reported following ingestion of such liquids. The aim of this study is to analyze the variability of nicotine concentrations with respect to number of cigarettes immersed and the duration of immersion in a soda can METHODS: One unsmoked cigarette was immersed in a cola containing soda can. Three separate samples of the mixture were obtained at different intervals of time post immersion up to 1 week. At the same time, a set of four cola cans were immersed with an increasing number of unsmoked cigarettes and samples obtained. All the samples were then analyzed for nicotine concentrations using liquid chromatography-mass spectrometry. RESULTS: The mean concentration of nicotine measured over the course of 6 hours from one full cigarette in 55 ml of a cola beverage was 0.48 mg/ml. Nicotine concentrations steadily increased in the first 6 hours following submersion, after which, the levels plateaued (r = 0.530, n = 18, p = 0.024). There was a strong positive correlation between nicotine concentrations and the number of cigarettes (r = 0.967, n = 12, p = 3e-7). CONCLUSIONS: The mean concentration of nicotine measured over the course of 6 hours from one immersed cigarette can be potentially toxic especially to children. Nicotine concentrations are positively correlated with the number of cigarettes and time of immersion.

Opioid Toxidrome Following Grapefruit Juice Consumption in the Setting of Methadone Maintenance.

BACKGROUND: Methadone is a synthetic mu-opioid receptor agonist used in the treatment of chronic pain and opioid dependence. Methadone is metabolized by several cytochrome P450 isoenzymes; primarily CYP3A4, CYP2B6, and CYP2D6 before renal and fecal elimination. Exposure to substances like grapefruit juice, that inhibit these isoenzymes may result in increased blood levels of methadone, and thus may manifest clinically as unexpected opioid toxicity. CASE: A 51-year-old male was found unresponsive. He was hypoxic and bradypneic with pinpoint pupils. Multiple boluses followed by infusion of naloxone were required before improvement of respiratory status. Upon awakening, the patient reported participating in an opioid treatment program where he is administered 90 mg of oral methadone daily and denied any other substance use. On further questioning, he admitted to drinking grapefruit juice (estimated to be approximately 500 mL/day) every day for 3 consecutive days before presentation. The patient was discharged home after being counseled to stop drinking grapefruit juice. DISCUSSION: Grapefruit juice is known to be an inhibitor of the CYP3A4 isoenzyme. Various studies demonstrate that through CYP3A4 inhibition, grapefruit juice increases serum levels of opioids, such as methadone, though no clinically significant effects have been reported. CONCLUSIONS: Grapefruit juice inhibits the metabolism of methadone, raising its serum levels. To our knowledge, this is the first reported case in which the interaction between grapefruit juice and methadone was significant enough to cause an opioid toxidrome. It is, therefore, recommended that opioid treatment programs (OTPs) advise patients about this interaction before administering methadone.

Pulmonary Function Testing in Dentists Versus Controls: A Pilot Study Exploring the Potential Respiratory-Related Occupational Hazards of Dentistry.

OBJECTIVE: Minimal research exists evaluating respiratory-related occupational hazards associated with dentistry in the United States. The purpose of this study was to evaluate the pulmonary function of dentists as compared with controls. METHODS: This is a case-control study evaluating pulmonary function in dentists versus controls. Outcomes included measurements of percent predicted FEV1 (FEV1%), percent of predicted FVC (FVC%), and forced expiratory volume in one second (FEV1)/forced vital capacity (FVC). RESULTS: Our findings indicate that dentists had a statistically significant lower percent predicted FEV1% (P < 0.05) and FVC% (P < 0.05) compared with controls. The prevalence of abnormal FVC% and FEV1% was greater among dentists, but only the increase in abnormal FEV1% approached significance. CONCLUSIONS: Dentists had lower percent predicted values for FVC% and FEV1% versus controls. More research is required to further investigate the association between the dental profession and pulmonary function in dentists.

Hemolytic Crisis following Naphthalene Mothball Ingestion in a 21-Month-Old Patient with Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency.

INTRODUCTION: Naphthalene is an aromatic hydrocarbon that may be found in mothballs and deodorizers. Exposure can occur by ingestion or dermal absorption. We present a case of acute hemolysis requiring blood transfusion in a 21-month-old male with a history of glucose-6-phosphate dehydrogenase (G6PD) deficiency after ingestion of a naphthalene-containing mothball. CASE PRESENTATION: A 21-month-old male with G6PD deficiency presented to the emergency department three hours following an exploratory ingestion of a naphthalene-containing mothball. On arrival, the patient was tachycardic with normal blood pressure, temperature, respiratory rate, and oxygen saturation. Initial laboratory studies showed significant anemia with elevated reticulocyte count, blood urea nitrogen, total bilirubin, and lactate dehydrogenase. Haptoglobin level was low, and the methemoglobin level was unremarkable. The patient was admitted to the pediatric intensive care unit and underwent blood transfusion. DISCUSSION: This case serves as a reminder that mothballs, a ubiquitous household item, can be hazardous when accessible to vulnerable children. Care should be taken to secure these products and prevent ingestion.

Gadolinium Aspiration Following Inadvertent Endotracheal Tube Cuff Injection in a Pediatric Patient.

INTRODUCTION: Gadolinium-based contrast agents (GBCA) are frequently used for MRI contrast studies. We report a case of pulmonary aspiration secondary to inadvertent GBCA injection. CASE REPORT: A 12-year-old female with a past medical history significant for mitochondrial disorder, bronchial asthma, autism, recurrent urinary tract infection, epilepsy, developmental delay, dysautonomia, and thrombocytopenia was scheduled for a contrast-enhanced MRI study using gadoterate meglumine for urinary incontinence. The patient was sedated and intubated in preparation for the study, during which 10 mL of gadoterate meglumine was inadvertently injected into the endotracheal tube cuff pilot line instead of intravenously. The patient remained intubated and was admitted to the intensive care unit with continuous monitoring for signs of pulmonary injury or gadolinium toxicity. She was successfully extubated approximately 24 hours later without complication. DISCUSSION: A variety of adverse effects attributable to parenteral GBCA exposure have been reported ranging from mild irritation to life-threatening anaphylaxis. Gadolinium deposition and storage have been implicated in a number of those adverse effects and multiple treatments modalities have been suggested, but no scientifically guided management exists. CONCLUSION: This case of pulmonary aspiration secondary to inadvertent GBCA injection in a pediatric patient demonstrated no acute  side effects or complications within the first 24 hours. With the wide range of adverse effects attributed to gadolinium use in the medical literature, it is difficult to predict potential future adverse effects.

Neonatal Sepsis.

PURPOSE OF REVIEW: Neonatal sepsis is a diagnosis made in infants less than 28 days of life and consists of a clinical syndrome that may include systemic signs of infection, circulatory shock, and multisystem organ failure. RECENT FINDINGS: Commonly involved bacteria include Staphylococcus aureus and Escherichia coli. Risk factors include central venous catheter use and prolonged hospitalization. Neonates are at significant risk of delayed recognition of sepsis until more ominous clinical findings and vital sign abnormalities develop. Blood culture remains the gold standard for diagnosis. SUMMARY: Neonatal sepsis remains an important diagnosis requiring a high index of suspicion. Immediate treatment with antibiotics is imperative.

Evaluation of a Food and Drug Administration Mandate to Limit Acetaminophen in Prescription Combination Products.

INTRODUCTION: In 2014, the US Food and Drug Administration limited the production of prescription acetaminophen-opioid combination products to 325 mg per dose unit. The goal of this mandate was to decrease the likelihood of unintentional acetaminophen hepatotoxicity. This study was designed to determine if this federal regulation has succeeded in reducing unintentional acetaminophen-induced hepatotoxicity from opioid combination products. METHODS: Using data from the National Poison Data System (NPDS), we analyzed all calls to US Poison Control Centers in the years 2013 and 2015 for acetaminophen-opioid combination product exposures. We then excluded cases that were classified as intentional and those aged 12 years and younger. We used a primary endpoint of N-acetylcysteine administration; secondary endpoints included evidence of hepatotoxicity as aspartate aminotransferase elevation, opioid antagonist administration and severity of overall medical outcome. RESULTS: A total of 18,259 calls between the two yearlong periods met inclusion criteria. 5.16 and 5.01% of calls resulted in N-acetylcysteine administration in 2013 and 2015, respectively. 3.63 and 4.02% received naloxone in 2013 and 2015, respectively, and 0.9% in each year developed hepatotoxicity. Rates of N-acetylcysteine administration, naloxone administration, and hepatotoxicity did not differ significantly between 2013 and 2015. Severity of medical outcome was worse in 2015 as compared to 2013 with more cases being categorized as "major effect" and fewer cases being categorized as "no effect." CONCLUSIONS: The Food and Drug Administration limitation on acetaminophen content per dose unit in opioid combination products did not reduce the occurrence of unintentional acetaminophen-induced hepatotoxicity or N-acetylcysteine administration as reported to NPDS.

The implementation of medical monitoring programs following potentially hazardous exposures: a medico-legal perspective.

CONTEXT: Clinical toxicologists may be called upon to determine the appropriateness of medical monitoring following documented or purported exposures to toxicants in the occupational, environmental, and medical settings. METHODS: We searched the MEDLINE database using the Ovid® search engine for the following terms cross-referenced to the MeSH database: ("occupational exposures" OR "environmental exposures") AND ("physiologic monitoring" OR "population surveillance"). The titles and abstracts of the resulted articles were reviewed for relevance. We expanded our search to include non-peer-reviewed publications and gray literature and resources using the same terms as utilized in the MEDLINE search. There were a total of 48 relevant peer-reviewed and non-peer-reviewed publications. Publications excluded contained no information relevant to medical monitoring following potentially harmful toxicologic exposures, discussed only worker screening/surveillance and/or population biomonitoring, contained redundant information, or were superseded by more recent information. Approaches to medical monitoring: A consensus exists in the peer-reviewed medical literature, legal literature, and government publications that for medical monitoring to be a beneficial public health activity, careful consideration must be given to potential benefits and harms of the program. Characteristics of the exposure, the adverse human health effect, the screening test, and the natural history of the disease are important in determining whether an exposed population will reap a net benefit or harm from a proposed monitoring program. Broader interpretations of medical monitoring: Some have argued that medical monitoring programs should not be limited to exposure-related outcomes but should duplicate general preventive medicine efforts to improve public health outcomes although an overall reduction of morbidity, mortality and disability by modifying correctable risk factors and disease conditions. This broader approach is inconsistent with the targeted approach advocated by the Agency for Toxic Substances and Disease Registry and the United States Preventive Services Task Force and the bulk of the peer-reviewed medical literature. Medical monitoring in legal contexts: Numerous medical monitoring actions have been litigated. Legal rationales for allowing medical monitoring claims often incorporate some of the scientific criteria for the appropriateness of monitoring programs. In the majority of cases in which plaintiffs were awarded medical monitoring relief, plaintiffs were required to demonstrate both that the condition for which medical monitoring was sought could be detected early, and that early detection and treatment will improve morbidity and mortality. However, the treatment of medical monitoring claims varies significantly depending upon jurisdiction. Examples of large-scale, comprehensive medical monitoring programs: Large-scale, comprehensive medical monitoring programs have been implemented, such as the Fernald Medical Monitoring Program and the World Trade Center Health Program, both of which exceeded the scope of medical monitoring typically recommended in the peer-reviewed medical literature and the courts. The Fernald program sought to prevent death and disability due to non-exposure-related conditions in a manner similar to general preventive medicine. The World Trade Center Health Program provides comprehensive medical care for World Trade Center responders and may be viewed as a large-scale, federally--funded research effort, which distinguishes it from medical monitoring in a medico-legal context. Synthesis of public health approaches to medical monitoring: Medical monitoring may be indicated following a hazardous exposure in limited circumstances. General causation for a specific adverse health effect must be either established by scientific consensus through a formal causal analysis using a framework such as the Bradford-Hill criteria. The exposure must be characterized and must be of sufficient severity that the exposed population has a significantly elevated risk of an adverse health effect. Monitoring must result in earlier detection of the condition than would otherwise occur and must confer a benefit in the form of primary, secondary or tertiary prevention. Outcome tables may be of use in describing the potential benefits and harms of a proposed monitoring program. CONCLUSIONS: In the context of litigation, plaintiffs may seek medical monitoring programs after documented or putative exposures. The role of the clinical toxicologist, in this setting, is to evaluate the scientific justifications and medical risks and assist the courts in determining whether monitoring would be expected to result in a net public health benefit.

Urine uranium concentrations and renal function in residents of the United States--2001 to 2010.

CONTEXT: Animal model studies have demonstrated that subchronic oral uranium exposure is associated with renal dysfunction. Little is known about the effects of environmental exposure to uranium in humans. OBJECTIVE: To determine whether environmental exposure to uranium is associated with alterations in renal function among residents of the United States. METHODS: We analyzed data from the National Health and Nutrition Examination Survey (NHANES) 2001-2010. Inclusion criteria included the measurement of urine uranium concentration, serum creatinine (sCr), and urine albumin-creatinine ratio. Exclusion criteria included a reported history of diabetes mellitus. Urine uranium concentrations were normalized to urinary creatinine. Respondents with and without detectable urine uranium concentrations were compared using Welch's t-test for urine albumin-creatinine ratio and sCr and using Fisher's exact test for a reported history of renal disease. Regression analysis was performed to assess for an association between urine uranium concentration and urine albumin-creatinine ratio, sCr, or a reported history of renal disease. RESULTS: Uranium was detectable in the urine of 74.1% (n = 9025) of respondents. Urine albumin-creatinine ratio was significantly greater in respondents with detectable urine uranium concentrations (mean 4.84 ± 45.8 mg/g) compared to respondents without detectable urine uranium concentrations (mean 0.77 ± 3.7 mg/g) (p < 0.001). There was no significant difference between the groups with respect to sCr or a reported history of renal disease. Regression analysis did not show a statistically significant association between urine uranium concentration and urine albumin-creatinine ratio (p = 0.45), sCr (p = 0.71), or a reported history of renal disease (p = 0.05). CONCLUSIONS: In this study, a high proportion of the U.S. population had exposure to uranium. We demonstrated an association between detectable urine uranium concentrations and microalbuminuria in residents of the United States but no association with clinical renal disease.

Change in perceived risk associated with marijuana use in the United States from 2002 to 2012.

CONTEXT: The role of a dynamic legal, medical, and social setting in affecting the perceived risk associated with smoking marijuana has not been well studied. We sought to determine whether there has been a change in the perceived risk associated with marijuana use over time. METHODS: A cross-sectional study was conducted using the 2002-2012 National Survey on Drug Use and Health. Respondents were asked to classify the risk of smoking marijuana. Regression analysis and the Mann-Whitney U test were used to analyze the data. RESULTS: A total of 614579 respondents were identified. Between 2002 and 2012, the percent of respondents who characterized regular marijuana use as being associated with "great risk" decreased from 51.3% to 40.3%, while the percent of respondents who characterized it as being associated with "no risk" increased from 5.7% to 11.7%. The percent of respondents who characterized occasional use as "great risk" decreased from 38.2% to 30.7%, while the percent of respondents who characterized it as "no risk" increased from 10% to 16.3%. There was a significant negative temporal trend in the perceived risk for both occasional and regular use of marijuana from 2002 to 2012 after controlling for age and gender (p < 0.001 for both). Increasing age was significantly associated with increased perceived risk for both occasional and regular marijuana use (p < 0.001). Males have a significantly lower perceived risk for regular marijuana use as compared with females (p < 0.001). Individuals who used marijuana during the preceding month reported a lower risk perception in both regular and occasional use. CONCLUSION: Between 2002 and 2012, there was a significant decrease in the perceived risk associated with occasional and regular marijuana use. Younger age, male gender, and past month use were also associated with decreased perceived risk.

Metal fume fever and polymer fume fever.

INTRODUCTION: Inhalational exposure to metal-containing fumes generated by welding and related processes may result in the development of the clinical syndrome known as "metal fume fever." Polymer fume fever is a separate and distinct but related disorder that has been associated with inhalational exposure to specific fluorinated polymer products, such as polytetrafluoroethylene or Teflon(®). We undertook a review of the peer-reviewed medical literature as it relates to these two disease entities in order to describe their epidemiology, pathophysiology, clinical presentation, diagnosis, treatment, prevention, and prognosis. METHODOLOGY: We performed a search of the PubMed ( www.pubmed.com ) and Ovid MEDLINE (ovidsp.tx.ovid.com) databases for keywords "metal fume fever," "polymer fume fever," and "fume fever," covering the period 1946 to September 2014, which resulted in a total of 141 citations. Limiting the search to articles published in the English language yielded 115 citations. These 115 articles were manually reviewed for relevance. In addition, the reference lists in each article retrieved were reviewed for additional relevant references. This left 48 relevant citations. EPIDEMIOLOGY: Metal fume fever occurs most commonly as an occupational disease in individuals who perform welding and other metal-joining activities for a living. It is estimated that 1,500-2,500 cases of metal fume fever occur annually in the United States. Polymer fume fever was initially identified as an occupational disease but increased regulations have resulted in decreased incidence in the occupational setting. Overheating of Teflon(®)-coated cookware is one of the more common mechanisms for exposure. PATHOPHYSIOLOGY: While the precise pathophysiology associated with the development of metal fume fever is yet to be elucidated, suggested pathophysiologic mechanisms include pro-inflammatory cytokine release, neutrophil activation, and oxygen radical formation. The pathophysiologic mechanism for polymer fume fever has not been definitively elucidated but may involve similar mechanisms to those proposed for metal fume fever. CLINICAL PRESENTATION: Metal fume fever typically presents with generally non-specific complaints including influenza-like symptoms, fever, shaking chills, arthalgias, myalgias, headache, and malaise. Onset of symptoms typically occurs 4-10 h following the exposure to metal-containing fumes. While metal fume fever is typically benign and self-limited, severe cases of the disease have been reported. In patients with ongoing metal fume exposure over the course of a workweek, tachyphylaxis occurs resulting in improvement in symptoms over the course of the workweek and maximal symptoms occurring after an exposure-free period such as a weekend. The clinical presentation of polymer fume fever is indistinguishable from metal fume fever, with an exposure history being necessary to distinguish the two entities. DIAGNOSIS: Chest radiographs are typically normal in cases of metal fume fever and polymer fume fever; however, mild vascular congestion may be demonstrated and severe cases may feature diffuse patchy infiltrates. Laboratory studies are typically not necessary but may demonstrate leukocytosis with leftward shift or an elevated erythrocyte sedimentation rate. TREATMENT: The primary treatment for both metal fume fever and polymer fume fever is supportive and directed at symptom relief. Oral hydration, rest, and the use of antipyretics and anti-inflammatory medications (e.g., non-steroidal anti-inflammatory drugs and aspirin) are recommended. A careful workplace exposure assessment analysis conducted by an occupational medicine specialist or clinical toxicologist in concert with a qualified industrial hygienist should be performed. PREVENTION: A careful workplace exposure assessment including measurement of ambient zinc and other metal (e.g., chrome, nickel, copper and manganese) fume concentrations or concentrations of fluorocarbon polymer decomposition products at different locations within the workplace should be performed. PROGNOSIS: Metal fume fever is typically a benign and self-limited disease entity that resolves over 12-48 h following cessation of exposure. CONCLUSIONS: Metal and polymer fume fevers generally follow a benign course with spontaneous resolution of symptoms, though both have the potential to be serious, especially in those with significant preexisting cardiorespiratory disease.