Assessment of Children Exposed to Maras Powder Intoxication.

INTRODUCTION: A smokeless tobacco known as Maras powder (MP) is commonly consumed in the southern region of Turkey. To the extent of our knowledge, no previous study in literature has reported acute MP intoxication in children. AIM: Our aim was to determine the clinical effects and treatment strategies of MP poisoning in children.Materials and methods: We retrospectively reviewed the medical records of children <18 years of age with MP intoxication who were followed up in the Intensive Care Unit between January 2016 and April 2018 in our center. RESULTS: Forty-one patients (M/F= 25/16) were included in this study. The mean age was 13.2±22.4 months (age range: 7 to 30 months). The patients presented with vomiting (n=23, 56%), cough (n=17, 41.5%), loss of consciousness (n=11, 26.8%), respiratory distress (n=6, 14.6%), convulsion (n=7, 17%), cyanosis (n=1, 2.4%), and abdominal pain (n=1, 2.4%) following oral ingestion of the substance. On their physical examination all patients with convulsion were in a comatose state. Thirty-two patients (78%) had tachycardia; 15 patients (36.5%) had pharyngeal hyperemia; and three (7.3%) had hiccups. Although the female patients had a lesser rate of symptoms than male patients, the difference was not statistically significant. CONCLUSIONS: Our aim was to inform the doctors about the clinical picture that develops after taking this substance and contribute to the understanding of the treatment approach.

Smokeless tobacco and public health in Bangladesh.

Despite the high prevalence of smokeless tobacco (SLT) use among adults in Bangladesh, SLT was not included in the Tobacco Control Law till 2013. Information on SLT use among Bangladeshi people is inadequate for policymaking and implementing effective control measures. With the aim to identify the prevalence and trends of different SLT products, health and economic impacts, manufacture, and sale of and policies related to SLT in Bangladesh, we carried out a literature review, which involved literature search, data extraction, and synthesis. Evidence suggests that in Bangladesh, SLTs range from unprocessed to processed or manufactured products including Sada Pata, Zarda, Gul, and Khoinee. Over 27% of Bangladeshi adults aged 15 years and older use SLT in one form or other. SLT use is associated with age, sex, education, and socioeconomic status. SLT consumption has reportedly been associated with increased prevalence of heart diseases, stroke, and oral cancer and led to around 320,000 disability adjusted life years lost in Bangladesh in 2010. No cessation service is available for SLT users in public facilities. Compared to cigarettes, taxation on SLT remains low in Bangladesh. The amendment made in Tobacco Control Law in 2013 requires graphic health warnings to cover 50% of SLT packaging, ban on advertisement of SLT products, and restriction to sale to minors. However, implementation of the law is weak. As the use of SLT is culturally accepted in Bangladesh, culturally appropriate public awareness program is required to curb SLT use along with increased tax and cessation services.

[Intoxication by powdered seeds of horse chestnut (Aesculus hippocastanum) used nasally as snuff - a case report]. / Zatrucie sproszkowanymi nasionami kasztanowca zwyczajnego (Aesculus hippocastanum) stosowanymi donosowo w formie tabaki-opis przypadku.

There are only few reports in the medical literature about side effects and toxicity of horse chestnut (Aesculus hippocastanum). We report a 15-year-old woman who was admitted to the hospital because of symptoms including: vomiting, dyspnea, burning in the nose and throat, and syncope, after intranasal snuff of powdered horse chestnut seeds. Laboratory tests showed no abnormalities. After 2 days of hospitalization the female was discharged home with subjective and objective improvement. Preparation and use of snuff is related to the tradition of the kashubian region. The powder formed from horse chestnuts, which is white in color, effects after about 5-10 minutes, and causes severe irritation of the nasal mucous membranes, which results in sneezing. Responsible for side effects is mainly aescin. The most frequently observed aescin intoxication symptoms were gastrointestinal irritation and allergic reactions. Intoxication by powdered seeds of horse chestnut used nasally as snuff may lead, as it was in our case, to sudden and self-limiting clinical symptoms. Supportive therapy and a short hospital observation seems to be sufficient in such cases.

p53 Codon 72 polymorphism in oral exfoliated cells in a Sudanese population.

Earlier studies have investigated the tumor suppressor gene p53 as a co-factor in the development of oral squamous cell carcinoma (OSCC). Our previous studies have indicated that chronic use of Sudanese snuff (toombak) and the presence of human papilloma virus (HPV) may be involved in the high prevalence of OSCC in Sudan. This study investigated the prevalence of p53 codon 72 polymorphism in brush biopsies obtained from a Sudanese population. A total of 174 individuals were included in the study; chronic toombak users (n=152) and non-users (n=22). DNA was extracted from all the samples and genotyped for the codon 72 polymorphism by polymerase chain reaction/restriction fragment length polymorphism. The Arg/Pro genotype was found in 53% of the 174 study participants, compared to 21% found with Arg/Arg and 26% found with Pro/Pro. Stratifying by toombak use, 28 (18%), 45 (29%) and 79 (52%) of the 152 samples from toombak users had Arg/Arg, Pro/Pro and Arg/Pro respectively, compared to 9 (41%), 0 (0%) and 13 (59%) found in the 22 samples from non users. The differences between the samples from toombak users and non users in Arg/Arg and Pro/Pro codon 72 polymorphism and HPV infection were statistically significant (p<0.05). Our study indicated that a high prevalence of the genotype Arg/Pro at the p53 codon 72 may contribute to susceptibility to OSCC, especially in combination with the use of carcinogenic tobacco-specific nitrosamine (TSNA)-rich toombak. Our observations warrant an in-depth study for understanding the role of p53 polymorphism in human oral cancers.

A case of life-threatening rectal administration of moist snuff.

CASE REPORT: We report a case of self-administration of 75 sachets of moist snuff rectally in a previously healthy, 42-year-old man. He presented with symptoms of nausea, discomfort, and dizziness. He had dry and warm skin, a pulse rate of 53 bpm, a mean arterial blood pressure of 135 mmHg and fluctuations in consciousness. The patient was treated with mechanical ventilation because of respiratory insufficiency. No specific anti-nicotinergic treatment was given. Plasma levels of the nicotine metabolite cotinine were 8,691 µg/L 7 h after admittance and 9,814 µg/L after 12 h. Levels of cotinine in the urine were above >50,000 µg/L. The patient developed a mild pneumonia, but he was uneventfully extubated after 12 h of mechanical ventilation. All physiological parameters were restored and he was discharged from hospital after 36 h. CONCLUSION: Excessive rectal administration of moist snuff may be life threatening. Patients may require intensive care. Long-term sequelae were not seen in this case.

Unintentional child poisonings through ingestion of conventional and novel tobacco products.

OBJECTIVE: This study examines child poisonings resulting from ingestion of tobacco products throughout the nation and assesses the potential toxicity of novel smokeless tobacco products, which are of concern with their discreet form, candy-like appearance, and added flavorings that may be attractive to young children. METHODS: Data representing all single-substance, accidental poisonings resulting from ingestion of tobacco products by children <6 years of age, reported to poison control centers, were examined. Age association with ingestion of smokeless tobacco versus other tobacco products was tested through logistic regression. Total nicotine content, pH, and un-ionized nicotine level were determined, and the latter was compared with values for moist snuff and cigarettes. RESULTS: A total of 13,705 tobacco product ingestion cases were reported, >70% of which involved infants <1 year of age. Smokeless tobacco products were the second most common tobacco products ingested by children, after cigarettes, and represented an increasing proportion of tobacco ingestions with each year of age from 0 to 5 years (odds ratio: 1.94 [95% confidence interval: 1.86-2.03]). A novel, dissolvable, smokeless tobacco product with discreet form, candy-like appearance, and added flavorings was found to contain an average of 0.83 mg of nicotine per pellet, with an average pH of 7.9, which resulted in an average of 42% of the nicotine in the un-ionized form. CONCLUSION: In light of the novelty and potential harm of dissolvable nicotine products, public health authorities are advised to study these products to determine the appropriate regulatory approach.

Smokeless tobacco and head and neck cancer: there is risk even without fire.

The use of smokeless tobacco (primarily moist chewing tobacco) is currently on the rise in the USA. Smokeless tobacco contains many carcinogens. Multiple large-scale epidemiologic studies have been completed to evaluate the risk of cancer associated with use of smokeless tobacco. This article will review the current knowledge of the mechanisms of carcinogenesis and the relative risk these products impart to the users.

De minimus non curat lex--virtual thresholds for cancer initiation by tobacco specific nitrosamines--prospects for harm reduction by smokeless tobacco.

Whereas the impact of tobacco specific nitrosamines in smokers is obscured by the presence of numerous other carcinogens and promoters, for smokeless tobacco virtually all the carcinogenic potential is associated with 4-(nitrosomethylamino)-1-(3-pyridyl)-1-butanone (NNK) and N'-nitrosonornicotine (NNN). In some countries exposure to smokeless tobacco with extremely high nitrosamine concentrations have been found to induce cancers in the head-neck region, whereas three recent large epidemiological studies failed to detect any such risk with respect to Swedish low-nitrosamine snuff. This review deals with quantitative aspects of DNA adduct formation from NNN and NNK in relation to the background levels ubiquitously found in healthy humans without known exposures to either tobacco or alkylating agents. The lack of significant increases of pro-mutagenic O6-methylations and DNA pyridyloxobutylations seen in smokers, as well as the negative outcome of the Swedish epidemiological studies, can be expected on basis of extrapolation of the dose response relationships found in rodents to actual exposures to NNK and NNN in Swedish snuff or from smoking. Sweden has the lowest prevalence of male smokers and smoking related diseases in the Western World, which has been ascribed to the fact that more than 20% of the grown up male population uses snuff. Smokeless tobacco represents an inexpensive and effective alternative to nicotine delivering products like nicotine patch, spray or gum. Considering that all other tobacco products are freely marketed, the ban on low-nitrosamine snuff in all countries in EU except Sweden is difficult to defend on either medical or ethical grounds.

Swedish moist snuff and myocardial infarction among men.

BACKGROUND: Previous studies have provided inconsistent results on possible increased risk of cardiovascular disease with the use of smokeless tobacco. The aim of this study was to assess whether long-term use of Swedish moist snuff (widely used among Swedish men) increases the risk of acute myocardial infarction. METHODS: This case-control study was conducted in 2 Swedish counties. We identified 1760 men, age 45-70 years, who had a myocardial infarction in 1992-1994. We randomly selected male controls from the study base after stratification for age and hospital catchment area. Information about snuff consumption, smoking history, hypertension, and other factors was obtained by mailed questionnaire and medical examination. The participation rate was 77% among cases and 78% among controls, with tobacco use data available for 1432 cases and 1810 controls. RESULTS: After adjustment for age, hospital catchment area, and smoking, the relative risk of first acute myocardial infarction was 1.1 (95% confidence interval=0.8-1.5) for former snuff users and 1.0 (0.8-1.3) for current snuff users. Analyses limited to either nonfatal or fatal cases did not change the results. Among the controls, the consumption of smokeless tobacco was strongly associated with certain risk factors for myocardial infarction such as smoking, hypertension, and high body mass index. CONCLUSION: The hypothesis that smokeless tobacco increases the risk for myocardial infarction is not supported in the present study.

Genotoxicity of 'gudakhu', a tobacco preparation. II. In habitual users.

The genotoxic potential of 'gudakhu', a paste-like tobacco preparation that is used widely in Orissa, India, was evaluated using the micronucleus test in exfoliated cells of the buccal mucosa. Cells from 120 habitual users and from 102 non-users were examined. The incidence of micronuclei (MN) was increased in the mucosa cells of users, and the increase was significant in those who had used gudakhu for more than 5 yr. The increased incidence of MN was significantly correlated with the period of use of gudakhu, as well as with the frequency of daily use. There were no significant differences between the results for men and women.