Usefulness of Adenosinetriphosphate Bioluminescence Assay (ATPmetry) for Monitoring the Reprocessing of Endoscopes.

OBJECTIVE: To assess the diagnostic value of an adenosinetriphosphate bioluminescence assay (ATPmetry) to monitor the effectiveness of the reprocessing of endoscopes compared with microbiologic sampling. DESIGN: Diagnostic study. SETTING: A 2,200-bed teaching hospital performing 5,000 to 6,000 endoscopic procedures annually. INCLUSION CRITERIA: All samples from bronchial or gastrointestinal endoscopes whatever the context. METHODS: Samples for microbiologic analysis and ATPmetry measurements were taken when each endoscope was inspected following reprocessing. Sampling was performed by flushing each endoscope with 300 mL Neutralizing Pharmacopeia Diluent thiosulfate rinsing solution divided equally between the endoscope channels. For each endoscope a series of 3 ATPmetry measurements were made on a vial containing the first jet from each channel and a second series on the whole sample. RESULTS: Of 165 samples from endoscopes, 11 exceeded the acceptability threshold of 25 colony-forming units/endoscope. In the first jet collected, the median (interquartile range) level of ATPmetry was 30.5 (15.3-37.7) relative light units (RLU) for samples with 25 or fewer colony-forming units compared with 37.0 (34.7-39.3) RLU for samples with more than 25 colony-forming units (P=.008). For the whole sample, the median (interquartile range) level of ATPmetry was 24.8 (14.3-36.3) RLU and 36.3 (36.0-38.3) RLU (P=.006), respectively. After adjusting on the batch of cleansing solution used, no difference in ATPmetry values was found between microbiologically acceptable and unacceptable samples. CONCLUSION: ATPmetry cannot be used as an alternative or complementary approach to microbiologic tests for monitoring the reprocessing of endoscopes in France.

Evaluation of the Quality of Reprocessing of Gastrointestinal Endoscopes.

OBJECTIVES: To evaluate the quality of gastrointestinal endoscope reprocessing and discuss the advantages of microbiological surveillance testing of these endoscopes. METHODS: Retrospective analysis of the results of endoscope sampling performed from October 1, 2006, through December 31, 2014, in a gastrointestinal endoscopy unit of a teaching hospital equipped with 89 endoscopes and 3 automated endoscope reprocessors, with an endoscopy quality assurance program in place. The compliance rate was defined as the proportion of the results classified at target or alert levels according to the French guidelines. A multivariate analysis (logistic regression) was used to identify the parameters influencing compliance. RESULTS: A total of 846 samples were taken. The overall compliance rate was 86% and differed significantly depending on the sampling context (scheduled or not scheduled), the type of endoscope, and the season. No other parameter was associated with compliance. A total of 118 samples carried indicator microorganisms such as Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Enterobacteriaceae, and Candida sp. CONCLUSION: The systematic use of an automated endoscope reprocessor does not provide totally satisfactory compliance. Microbiological surveillance is indispensable to monitor reprocessing, reinforce good practices (endoscopes, reprocessing units), and detect endoscopes requiring early technical maintenance.

Deliberate drug poisoning with slight symptoms on admission: are there predictive factors for intensive care unit referral? A three-year retrospective study.

Deliberate drug poisoning leads to 1% of emergency department (ED) admissions. Even if most patients do not exhibit any significant complication, 5% need to be referred to an intensive care unit (ICU). Emergency physicians should distinguish between low- and high-acuity poisoned patients at an early stage to avoid excess morbidity. Our aim was to identify ICU transfer factors in deliberately self-poisoned patients without life-threatening symptoms on admission. We performed a 3-year retrospective observational study in a university hospital. Patients over 18 years of age with a diagnosis of deliberate drug poisoning were included. Clinical and toxicological data were analysed with univariate tests between groups (ED stay versus ICU transfer). Factors associated with ICU admission were then included in a logistic regression analysis. Two thousand five hundred and sixty-five patients were included. 63.2% were women, and median age was 40 (28-49). 142 patients (5.5%) were transferred to ICU. Cardiac drugs [adjusted OR (aOR) = 19.81; 95% confidence interval (95% CI): 7.93-49.50], neuroleptics (aOR = 2.78; 95% CI: 1.55-4.97) and meprobamate (aOR = 2.71; 95% CI: 1.27-5.81) ingestions were significantly linked to ICU admission. A presumed toxic dose ingestion (aOR = 2.27; 95% CI: 1.28-4.02), number of ingested tablets (aOR = 1.01; 95% CI: 1.01-1.02 for each tablet) and delay between ingestion and ED arrival <2 hr (aOR = 2.85; 95%CI: 1.62-5.03) were also factors for ICU referral. The Glasgow Coma Scale was the only clinical feature associated with ICU admission (aOR = 1.57; 95% CI: 1.44-1.70 for each point loss). These results suggest that emergency physicians should pay particular attention to toxicological data on ED admission to distinguish between low- and high-acuity self-poisoned patients.

Mycophilic or mycophobic? Legislation and guidelines on wild mushroom commerce reveal different consumption behaviour in European countries.

Mycophiles forage for and pick vast quantities of a wide variety of wild mushroom species. As a result, mushroom intoxications are comparatively frequent in such countries with mycophiles. Thus, national governments are forced to release guidelines or enact legislation in order to ensure the safe commerce of wild mushrooms due to food safety concerns. It is in these guidelines and laws that one can observe whether a country is indeed mycophobic or mycophilic. Furthermore, these laws and guidelines provide valuable information on mushroom preferences and on the consumption habits of each country. As such we were interested in the questions as to whether mushroom consumption behaviour was different within Europe, and if it was possible to discover the typical or distinctive culinary preferences of Slavic or Romanic speaking people, people from special geographical regions or from different zones. This work is based on the analysis of edible mushroom lists available in specific guidelines or legislation related to the consumption and commerce of mushrooms in 27 European countries. The overall diversity of edible mushrooms authorised to be commercialised in Europe is very high. However, only 60 out of a total 268 fungal species can be cultivated. This highlights the importance of guidelines or legislation for the safe commerce of wild mushrooms. The species richness and composition of the mushrooms listed for commerce is very heterogeneous within Europe. The consumption behaviour is not only language-family-related, but is strongly influenced by geographical location and neighbouring countries. Indicator species were detected for different European regions; most of them are widespread fungi, and thus prove culture-specific preferences for these mushrooms. Our results highlight tradition and external input such as trade and cultural exchange as strong factors shaping mushroom consumption behaviour.

Suicidal poisonings with methadone in France: results of a two year national survey by the Toxicovigilance network.

CONTEXT: Methadone is used in France since March 1995, only for opioid maintenance treatment, in a syrup form. For the launching of a capsule form in April 2008, French health authorities requested a prospective survey of all cases involving exposure to methadone in either of the two available pharmaceutical forms. OBJECTIVE: The aim was to document, in different circumstances and compare the safety of the new capsule form to the syrup. This report presents the findings of one arm of the study, devoted to methadone-related suicide attempts. MATERIALS AND METHOD: From April 15, 2008 to April 15, 2010, all self-injurious methadone poisonings notified to or managed by the French Toxicovigilance Centers network were included. Analysis mainly focused on patients' age and gender, estimated quantity ingested, eventual concomitantly taken substances, distribution of symptoms, and site of treatment. RESULTS: 135 methadone-related suicide attempts were recorded. Analysis showed identical epidemiologic and clinical patient characteristics for the two pharmaceutical forms. Ten deaths occurred. The only discrepancy was a higher incidence of suicide attempts in the capsule group. However, as the number of capsule-treated patients increased during the second year, this difference remained significant but tended to decrease. DISCUSSION: Combining these results with Pharmacovigilance and Addictovigilance arms, health authorities estimated that the benefit/risk balance of this new pharmaceutical form remains positive. They revised their position on requirements for prescribing and dispensing of the capsule form, and made them slightly easier. Following this, this "suicide" arm of Toxicovigilance survey was suspended, whereas the second one, concerning accidental pediatric methadone-related poisonings, has been extended until April 2014. CONCLUSION: In France, suicide attempts were more likely to occur with the capsule formulation. The clinical severity of intoxication was similar between the capsule and liquid forms.

Dysgeusia following consumption of pine nuts: more than 3000 cases in France.

INTRODUCTION: In March 2008, French poison centres (PCs) recorded the first calls reporting persistent bitterness following the ingestion of pine nuts. METHODS: The French toxic exposure surveillance system (French-Tess) was searched and a descriptive analysis of cases was performed on data recorded from 13 March 2008 to 31 January 2010. RESULTS: Some 3111 cases of bitterness were reported to PCs. The number of cases rose sharply from May 2009 to reach a peak in August 2009 with 697 cases. The median time to onset of dysgeusia was 24 hours and it lasted less than 14 days in 95% of cases. Raw as well as cooked or processed pine nuts were implicated. DISCUSSION: The delayed onset and persistence of dysgeusia suggest that the toxin may act via an unknown toxic mechanism on the receptor. The aetiological agent could be an unidentified toxin present in some varieties of non-edible pine nuts. CONCLUSION: The high incidence of the event and the lack of understanding of the nature of the toxin and its pathophysiological mechanism require continued monitoring of poison cases, botanical and biochemical analysis, and experimental studies.

Can morels (Morchella sp.) induce a toxic neurological syndrome?

INTRODUCTION: Several cases of morel poisoning associated with neurological symptoms have been reported. The objective of this study was to describe this new mushroom poisoning syndrome. MATERIAL AND METHODS: Retrospective study of morel poisonings collected in the French Poison Control Centers from 1976 to 2006. Cases were classified as neurological syndrome (NS; tremor or dizziness/inebriation or unsteadiness/ataxia +/- associated with gastrointestinal symptoms) or isolated gastrointestinal syndrome. RESULTS: 146 patients presented gastrointestinal syndrome (median time to onset: 5 h) and 129 presented NS (12 h) after morel consumption. Gastrointestinal (67%) and other neurological symptoms were also present (mainly ocular/vision disorders: 26%, paresthesia: 7%, drowsiness/confusion: 6%, and muscle disorders: 6%). These patients more frequently ingested a large quantity of morels. Confusion with Gyromitra was ruled out. DISCUSSION: The NS is very different from the common gastrointestinal syndrome occurring after ingestion of poorly cooked morels and is not limited to a cerebellar syndrome.

[Acute acetaminophen overdose]. / Intoxication aiguë par le paracétamol.

Acute ingestion of acetaminophen can induce a dose-dependent hepatotoxicity and lead to death. The management of acute acetaminophen poisoning at the early stage is well codified. A reported amount of ingestion > 200 mg/kg in a child, > 150 mg/kg in an adult (125 mg/kg if risk factors are present) require hospitalisation. Activated charcoal is administered within 1-2 hours of ingestion. AST/ALT levels are measured on admission, 12 hours after, and according to outcome every 12-24 h. N-acetylcysteine (NAC) administration within 8-10 hours protects against acetaminophen-induced hepatotoxicity. The two protocols of NAC administration, intravenous and oral, have a comparable effectiveness. NAC is indicated if the serum acetaminophen level drawn 4 hours after ingestion and plotted on the nomograme falls above the "200 mg/L-4 hours" line. Nomograme is not usable with repeated acute ingestion or repeated supratherapeutic doses; presence of risk factors (enzymatic induction, malnutrition, chronic alcoholism) must be taken into account ("100 mg/L - 4 hours" line). Outcome is favorable with respect to these conditions.

New syndromes in mushroom poisoning.

Several new mushroom poisoning syndromes have been described since the early 1990s. In these syndromes, the onset of symptoms generally occurs >6 hours after ingestion. Treatment is mainly supportive. The syndrome induced by Amanita smithiana/proxima consists of acute tubulopathy, which appears earlier and does not have the same poor prognosis as the orellanine-induced syndrome. It has been described since 1992 in the US and Canada with A. smithiana; in France, Spain and Italy with A. proxima; and in Japan with A. pseudoporphyria. The responsible toxin is probably 2-amino-4,5-hexadienoic acid. The erythromelalgia syndrome has been described as early as the late 19th century in Japan and South Korea with Clitocybe acromelalga, and since 1996 in France and then Italy with C. amoenolens. Responsible toxins are probably acromelic acids identified in both species. Several cases of massive rhabdomyolysis have been reported since 1993 in France and 2001 in Poland after ingestion of large amounts of an edible and, until then, valuable species called Tricholoma equestre. These cases of rhabdomyolysis are associated with respiratory and cardiac (myocarditis) complications leading to death. Rhabdomyolysis with an apparently different mechanism was described in Taiwan in 2001 with Russula subnigricans. Finally, cases of encephalopathy were observed twice after ingestion of Hapalopilus rutilans in Germany in 1992 and Pleurocybella porrigens in Japan in 2004, where a convulsive encephalopathy outbreak was reported in patients with history of chronic renal failure.

Influence of set-up conditions of exposure indicators on the estimate of short-term associations between urban pollution and mortality.

In the past few years many studies on air pollution and health based on time series have been carried out. Yet, this approach does not assess exposure to air pollution at an individual level but it is based on ambient concentrations measured by air quality monitoring networks. Questions on the estimates of exposure to pollutants have been raised, in particular the fact that background measuring stations only have been considered in the set up of pollution indicators. To assess the impact of exposure indicator characteristics on the results of time series analysis, two series (black smoke and sulfur dioxide, respectively) of exposure indicators to urban air pollution were set up taking into account a growing part of proximity measures (industrial sources) available in the studied urban area (Le Havre, France). For each pollutant, indicators distributions were almost similar, especially for black smoke. Whatever the pollutant, the most obvious heterogeneity could be observed between the 100% background indicator and the indicator including the arithmetic mean for all the stations (50% background stations and 50% proximity stations). Then the sensitivity of the associations between mortality and air pollution to these indicators was studied. These indicators did not show statistically significant differences in the estimated excess risk. Yet, confidence intervals were more statistically significant as the contribution of proximity stations was more substantial, in particular for SO2. To conclude, the use of proximity measurements did not influence dramatically on the mean estimates of the association between air pollution and mortality indicators in Le Havre. Therefore it does not seem relevant to include the data provided by the proximity stations in the urban exposure indicators within the context of the epidemiology monitoring system.

[Acute higher funghi mushroom poisoning and its treatment]. / Intoxications aiguës par les champignons supérieurs et leur traitement.

PRINCIPLE: The various mushroom poisoning syndromes are summarised together with elements underlining uncertainty and lack of knowledge. For each of the classical syndromes concerned, classified in delays inferior or superior to 6 hours, the toxins and their mechanisms of action, the main mushrooms responsible, the symptoms and their treatment are all presented. EARLY SYNDROMES: Characterised by early onset within 6 hours, these represent the majority of intoxications. There are 6 syndromes: gastro-intestinal (resinoid), muscarine (sudorien, cholinergic), pantherine (myco-atropine, anticholinergic), coprine (similar to the antabuse syndrome), narcotine (psilocybin, hallucinatory) and paxillus syndrome (exceptional). LATE SYNDROMES: Characterised by an onset after six hours, they regroup the phalloid syndrome that is responsible for 90 to 95% of deaths due to higher funghi mushrooms, the orellanine and gyromitrin syndrome and new syndromes identified over the past decade concerning acute renal failure with shorter onset than during the orellanine syndrome (Amanita proxima), erythermalgia (Clitocybe amoenolens), rhabdomyolysis (Tricholoma equestre) and central nervous system failure (Hapalopilus rutilans).

Carbon monoxide poisoning monitoring network: a five-year experience of household poisonings in two French regions.

BACKGROUND: In France, the epidemiological situation of acute carbon monoxide (CO) poisoning is only partially known. The purpose of this study was to assess the epidemiological situation of household poisonings in two French regions where a regional toxicovigilance network was active. METHODS: During five years, we studied, by means of a standardized data collection form, cases of acute CO poisoning admitted to regional hospitals and notified by hospital physicians. RESULTS: From 1997 to 2001, 1,458 people were involved in 489 places. Household poisonings represented the first circumstance of CO poisoning with 811 people involved in 293 places. So, analysis was performed only for household poisonings. The mean age was 33.3 years. Twenty patients died (2.6%), 16 patients were in coma (2.1%), and 11 patients had an initial isolated loss of consciousness (14.4%). Responsible appliances in household poisonings were identified in 84% of places. The appliances most often involved were vented heating systems (46.4%), mobile heaters (13.2%), and thermal motors (8.7%). In 63% of the 293 places, investigation showed that poisoning occurred because of a faulty installation. Vented gas heaters and mobile heaters were responsible for half of the severe household CO poisonings. CONCLUSION: In the countries of Rhône-Alpes and Auvergne, most of household CO poisonings are no longer caused by waterheaters but by gas heating systems. Poisonings caused by mobile heaters more frequently led to coma and death and thermal motors played a large part in moderate poisonings. These recently emerging trends justify the efforts focused on ongoing monitoring and the introduction of preventive measures.

Short-term effects of air pollution on mortality in nine French cities: a quantitative summary.

Between 1990 and 1995, 9 French cities provided data on daily air pollution, total mortality, cardiovascular mortality, and respiratory mortality. Personnel in individual cities performed Poisson regressions, controlling for trends in seasons, calendar effects, influenza epidemics, temperature, and humidity, to assess the short-term effects of air pollution. The authors describe results obtained from the quantitative pooling of these local analyses. When no heterogeneity could be detected, a fixed-effect model was used; otherwise, a random-effect model was used. Significant and positive associations were found between total daily deaths in these cities and the 4 air pollution indicators studied: (1) Black Smoke, (2) sulfur dioxide, (3) nitrogen dioxide, and (4) ozone. A 50-microg/m3 increase in Black Smoke (24 hr), sulfur dioxide (24 hr), nitrogen dioxide (24 hr), or ozone (8 hr) was associated with increases in total mortality of 2.9% (95% confidence interval [CI]) = 1.3, 4.4), 3.6% (95% CI = 2.1, 5.2), 3.8% (95% CI = 2.0, 5.5), and 2.7% (95% CI = 1.3, 4.1), respectively. Similar results were obtained for cardiovascular mortality. Except for sulfur dioxide, positive--but not significant--associations were found with respiratory mortality. The internal consistency among the cities studied, as well as consistency with previously published results, favors a causal interpretation of these associations.