[National poisoning registers and toxicovigilance in different countries as models for Germany]. / Vergiftungsregister und Toxikovigilanz in anderen Ländern als Vorbild für Deutschland.

As of 2019, Germany has still not been able to provide a national poisoning register and toxicovigilance for sufficient and reliable information on human exposure for the purpose of identification and assessment of toxic risk to the public. In particular, the USA acts as a special model, but France, the Netherlands, Switzerland, and Sweden also have efficient poisoning registers and toxicovigilance systems that deliver representative human exposure data as early warning systems for risk minimization and prevention. This contribution presents an overview of national poisoning registers and systems of toxicovigilance in different countries and describes the present situation in Germany where, from a public health point of view, insufficient political development in this area has so far been supplied.In Germany, the database for poisoning analysis is still insufficient because poisonings as an important medical entity does not find sufficient medical-statistical correspondence in the ICD Code. Cooperation between the Federal Institute for Risk Assessment (BfR) and the German Poison Centres (GIZ) has already led to significant progress and results in risk minimization, but due to the lack of representative data and the non-implementation of a national monitoring and toxicovigilance system, false estimations of poisoning situations can not be excluded.yIn the future, acute poisoning, and when appropriate chronic poisoning, can be competently assessed via human exposure in the German Poison Centres and through medical reports on poisoning at the BfR. This requires an effective national monitoring and toxicovigilance system supported and financed by government across the borders of the German federal states.

[Poison centres in Germany-history, function, and relevance]. / Giftinformationszentren in Deutschland ­ Historie, Arbeitsweise und Bedeutung.

In 1963 first poison control centres (PCCs) were created in the former Federal Republic of Germany (FRG) as well as in the German Democratic Republic (GDR). In the 1980s, the GDR centralized the toxicological information service in only one centre, whereas the federal structure of the FRG resulted in a foundation of 19 centres. Today only eight German PCCs are established under the responsibility of the German states. Most of them are part of or closely related to university hospitals. In this article, the history, function and relevance of German PCCs are presented.The centres advise on about 255,000 human exposures per annum in a 24/7 service. They provide a very special service in therapeutic emergency management, which is used to a large extent in childhood poisoning. The scientific contributions of German PCCs are well represented at international congresses and two German standard textbooks about the treatment of poisonings in children and adults are published. The worthiness of PCCs in appropriate healthcare and their monetary benefit are as yet unrecognized, although the profit has already been demonstrated through a first systematic assessment in 1991. From public data sources, no sufficient data can be collected for early risk detection in Germany. However, appropriate data could be generated by PCCs and the Federal Institute for Risk Assessment (BfR), but the precondition is the need for better technical equipment and manpower.The existing German political mandate to set up a national monitoring system for poisoning will be ground-breaking for nationwide scientific evaluation and the treatment of cases of human poisoning in the future.

[Health reporting of poisoning in Germany-a scientific investigation into the establishment of national poisoning monitoring in Germany : Background, preliminary work, requirements]. / Gesundheitsberichterstattung über Vergiftungen in Deutschland ­ Wissenschaftliche Untersuchung zur Einrichtung eines nationalen Monitorings von Vergiftungen in Deutschland : Hintergründe, Vorarbeiten, Anforderungen.

As a result of decentralized and non-harmonized documentation of poisoning cases within Germany, in comparison to other countries (e.g. the USA, Switzerland, Sweden, and the Netherlands), there is a substantial lack of harmonized national data, in particular for the early detection and risk assessment at the German Federal Institute for Risk Assessment (BfR).The establishment of a national monitoring system for poisonings in Germany is therefore an important step towards enabling faster and more efficient technical access to consolidated accumulated national poisoning data. Additionally, the monitoring would consolidate the publication of annual reports (modelled on the USA National Poison Data System reports) of the German Poison Information Centres and the BfR. Timely assessment of poisoning cases enables fast recognition and confirmation of acute as well as previously unrecognized poisoning hazards. Also relevant here is the safety of products and the associated protection, especially of children, against poisoning accidents.The continuous monitoring and reporting requirements of such a system necessitate additional and challenging work, suitable human resources and IT infrastructure and an annual budget that must be taken into consideration for overall as well as financial planning.

Alternative drugs go global: possible lead and/ or mercury intoxication from imported natural health products and a need for scientifically evaluated poisoning monitoring from environmental exposures.

BACKGROUND: With increases in globalization, cultural remedies from Chinese, Ayurvedic, Arab and other traditions have become more available to international consumers, offering unfamiliar "Natural Health Products" (NHP), used as alternative medicine or supplementary medicine. Contamination with toxic ingredients including lead, mercury, arsenic, and other toxic elements has been documented in several of these products from various parts of the globe, particularly from some parts of Asia and the Orient. FINDINGS: We have been following this development in the last 6 years and have analyzed n = 20 such products (60 analyses) from patients with intoxication symptoms in a pilot study, showing alarming high concentrations of mercury and/or lead (the first one in "therapeutic" doses). 82 % of the studied NHP contained lead concentrations above the EU limit for dietary supplements. 62 % of the samples exceeded the limit values for mercury. Elevated blood lead and mercury levels in patients along with clinical intoxication symptoms corroborate the causal assumption of intoxication (s). We present one detailed clinical case report of severe lead and mercury intoxications and give an overview about blood concentration related symptoms and signs of n = 41 case reports of mercury intoxications of the German monitoring BfR-DocCenter. CONCLUSIONS: For NHP there is evidence on a distinct toxicological risk with alarming low awareness for a possible intoxication which prevents potentially life-saving diagnostic steps in affected cases. In many cases patients do not communicate the events to their physicians or the local health authority so that case reports (e.g. the BfR-DocCentre) are missing. Thus, there is an urgent need to raise awareness and to initiate more suitable monitory systems (e.g. National Monitoring of Poisonings) and control practice protecting the public.

[Carbon monoxide poisoning from indoor barbecues--incidents reported to the German-speaking Poison Information Centers and the German Federal Institute for Risk Assessment (BfR) in Berlin]. / Kohlenmonoxidvergiftungen durch Grillen in Innenräumen--Mitteilungen an die deutschsprachigen Giftinformationszentren und das Bundesinstitut für Risikobewertung Berlin.

From 2008 to the end of 2009 the Joint Poison Information Center (PIC) in Erfurt observed 7 incidents involving 17 persons (1 fatality) with signs of carbon monoxide poisoning from indoor barbecues (COFIB). To find out whether COFIB is a regional or a general phenomenon in Germany, Austria and Switzerland, all information about COFIBs recorded by the 11 German-speaking Poison Information Centers and the BfR Berlin were retrospectively analyzed for the period 2000 to 2009. In all, 60 COFIBs (accidental: 90.0 %, suicidal: 8.3%, reason unknown: 1.7%) involving 146 individuals were reported. The number of incidents increased from one case with 2 persons in 2000 to 18 cases involving 34 persons in 2009. The 146 victims (female 26.7%, male 27.4%, gender unknown 45.9%; adults 58.2%, children 24.7%, age unknown 17.1%) lived in 15 of the 16 federal states of Germany and in Switzerland. The highest number of victims was found in Bavaria (23), Brandenburg (18), and Baden-Wuerttemberg (18). The symptoms according to the Poisoning Severity Score were none to mild in 60.3%, moderate in 13.7%, severe in 11.6%, fatal in 6.9% and unratable in 7.5%. No clear correlation was found between the carboxyhemoglobin concentration and the severity of the symptoms. As a rising number of COFIBs often involving several individuals was observed from 2000 to 2009, the general public was informed about the risks of indoor barbecues.

Assessment of early acute lung injury in rats exposed to aerosols of consumer products: attempt to disentangle the "Magic Nano" conundrum.

In Germany in 2006 a series of rapidly developing and sometimes severe cases of pulmonary health impairment were observed after normal use of the "Magic Nano Glass & Ceramic" spray and "Magic Nano Bath" spray. In contrast, the previously marketed "Magic Nano" pump spray product (handheld trigger device without propellants) was unobtrusive. Analysis of particles discharged from these products did not reveal stable (solid) nano-sized particles. The precipitous increase of pulmonary health impairment in humans caused by "Magic Nano Sprays" triggered a comparative assessment of the acute inhalation toxicity of "Magic Nano Glass & Ceramic" spray, "Magic Nano Bath" spray, and "Magic Nano" pump spray in rats. The first two test specimens were examined as spray-can aerosols using an intermittent generation principle, whereas the undiluted liquid content of the pump spray was continuously aerosolized. Groups of Wistar rats were nose-only exposed for 4 h. However, due to mortality occurring already during exposure following exposure to Glass & Ceramic spray, the exposure duration was reduced to approximately 2 h in some groups. In addition to endpoints called for by contemporary testing guidelines, respiratory tract injury was also probed by respiratory function measurements during exposure supplemented by analyses in bronchoalveolar lavage (BAL) fluid on the first postexposure day, including lung histopathology in rats exposed to Glass & Ceramic spray. The Glass & Ceramic spray caused mortality at 2269 mg/m(3) and above, the pump spray was in the beginning lethal range at 81222 mg/m(3), while the bath spray was tolerated without mortality up to the maximum tested nominal concentrations of 28100 mg/m(3). The time-adjusted 4-h LC(50) of Glass & Ceramic spray was 5098 mg/m(3). The analysis of respiratory patterns revealed changes indicative of both upper and lower respiratory tract sensory irritation. In addition to clinical signs suggestive of marked lung irritation, especially in the rats exposed to the Glass & Ceramic spray, histopathology revealed lung inflammation, hemorrhages, edema, and focal septal thickening. Lung weights and BAL endpoints (lactate dehydrogenase [LDH], protein, gamma-glutamyltransaminase, and neutrophilic granulocytes) were markedly increased. In summary, this comparative study demonstrates that the conventional OECD 403 protocol is suitable to comparatively assess the potential and potency of these types of consumer products in their end-use configuration. Measurements in BAL were most suitable for the identification of acute lung injury. By contrast, lung function measurements during exposure did not demonstrate any conclusive association with lung injury. It does not appear that the particle size per se is a key determinant in the toxicity of "Magic Nano Glass & Ceramic" spray (approximately 100% mortality occurred at a MMAD of approximately 7 microm; GSD approximately 3). This might suggest that more volatile substances or substances contained in the test articles that co-evaporate with solvents or water may be causative for the findings observed. Hence, the findings of this study support the notion that the assessment of the acute inhalation toxicity of complex end-use products is methodologically challenging and cannot be readily anticipated based on compositional or physical (particle size) data. Accordingly, in the absence of predictive and validated in vitro assays, in vivo inhalation testing of potentially toxic commercialized spray products appears to be indispensable for consumer safety. In order to prevent indiscriminant testing of such products in bioassays, the development of standardized in vitro alternatives should be considered with high priority.

Use of product databases for risk assessment purposes.

Product information databases are important prerequisites for providing data to poison centers (PC) to give adequate advice in cases of poisonings and for preparation of statistics as annual reports. For risk assessment measures, they can help for exposure assessments and for priority setting. A product database is a set of information of product and substance names, compositions, and uses of products. Data are provided due to national regulations as well as to national and international agreements between industry, international associations, e.g. the European Association of Poison Centres and Clinical Toxicologists (EAPCCT), and clinical toxicology institutions. They have different contents, i.e. complete formulations, frame formulations, and material safety data sheets. For definite identification of products, the product name should be readily taken from the labels and must be similar to the names provided by electronic media as databases. Products should be classified according to their use. The first system that has been prepared for that purpose is the ATC classification for pharmaceuticals. For chemicals, several systems e.g. the WHO-IPCS classification code, exist; the EU technical guidance document for risk assessment of chemicals is mentioning use categories, and they are used on national levels as well. For risk assessment purposes, statistics of poisonings and other health hazards are important as well as information about exposure. Linking cases of poisonings with product data enables risk assessors to perform statistical evaluations about health effects due to product use categories which can be compared to product compositions. If products are categorized by their use, information about use characteristics, such as frequencies and durations, can be derived. Hence, product categories can be taken to characterize scenarios and thus help for model estimations of exposure and respective doses.

Detection of cross-transmission of multiresistant Gram-negative bacilli and Staphylococcus aureus in adult intensive care units by routine typing of clinical isolates.

OBJECTIVE: To determine the potential of laboratory services in identifying cross-transmission of multiresistant Gram-negative bacilli (MR GNB) and Staphylococcus aureus in adult intensive care units by routine typing of clinical isolates. METHODS: Over a 12-month period, isolates with indistinguishable PCR fingerprints were traced back to the source patients and their epidemiologic relationships were investigated. Possible episodes of cross-transmission were ascertained, and the validity of antibiograms in identifying the same cluster assessed. RESULTS: Of 3503 specimens received by the microbiological laboratory during 5372 patient days, 1295 cultures showed bacterial growth. Of these, 132 were primary isolates of MR GNB and 92 were primary isolates of S. aureus. Thirty-two MR GNB isolates (24%) shared fingerprints with one or more other isolates. Indistinguishable isolates from epidemiologically related patients suggested 17 episodes of cross-transmission. The positive and negative predictive values of antibiogram-based identification of these episodes were 19% and 72% respectively. S aureus displayed limited genetic diversity. The two most frequent genotypes contained 19 and 16 isolates, of which the majority appeared to be epidemiologically unrelated. CONCLUSIONS: Endemic transmission of MR GNB occurs mainly between two patients and remains unrecognized by conventional laboratory investigation. Rapid genetic typing methods identify patients involved in cross-transmission and give an insight into the population dynamics of MR GNB on adult intensive care units.