Wartime toxicology: the spectre of chemical and radiological warfare in Ukraine.

The unprovoked invasion of Ukraine by the Russian Federation has resulted in the largest humanitarian crisis in Europe since World War II. As fighting intensifies throughout Ukraine, there is an increasing concern that the Russian Federation may consider the direct use of chemical or radiological weapons against military personnel and civilians in Ukraine. Despite prohibition of chemical weapons from the Chemical Weapons Convention of 1997, recent evidence has demonstrated that state actors will continue to use these agents as weapons of war and terror, despite publicly denying their use. We review chemical weapons produced and used by the Russian Federation (or its allies) to identify plausible risks in the Russian war in Ukraine. We also provide rapid assessment and treatment guidelines to recognize and manage these acute exposures.

Impact of maternal body mass index and gestational weight gain on pregnancy complications: an individual participant data meta-analysis of European, North American and Australian cohorts.

OBJECTIVE: To assess the separate and combined associations of maternal pre-pregnancy body mass index (BMI) and gestational weight gain with the risks of pregnancy complications and their population impact. DESIGN: Individual participant data meta-analysis of 39 cohorts. SETTING: Europe, North America, and Oceania. POPULATION: 265 270 births. METHODS: Information on maternal pre-pregnancy BMI, gestational weight gain, and pregnancy complications was obtained. Multilevel binary logistic regression models were used. MAIN OUTCOME MEASURES: Gestational hypertension, pre-eclampsia, gestational diabetes, preterm birth, small and large for gestational age at birth. RESULTS: Higher maternal pre-pregnancy BMI and gestational weight gain were, across their full ranges, associated with higher risks of gestational hypertensive disorders, gestational diabetes, and large for gestational age at birth. Preterm birth risk was higher at lower and higher BMI and weight gain. Compared with normal weight mothers with medium gestational weight gain, obese mothers with high gestational weight gain had the highest risk of any pregnancy complication (odds ratio 2.51, 95% CI 2.31- 2.74). We estimated that 23.9% of any pregnancy complication was attributable to maternal overweight/obesity and 31.6% of large for gestational age infants was attributable to excessive gestational weight gain. CONCLUSIONS: Maternal pre-pregnancy BMI and gestational weight gain are, across their full ranges, associated with risks of pregnancy complications. Obese mothers with high gestational weight gain are at the highest risk of pregnancy complications. Promoting a healthy pre-pregnancy BMI and gestational weight gain may reduce the burden of pregnancy complications and ultimately the risk of maternal and neonatal morbidity. TWEETABLE ABSTRACT: Promoting a healthy body mass index and gestational weight gain might reduce the population burden of pregnancy complications.

Results from a Ukrainian-US collaborative study: prevalence and predictors of respiratory symptoms among Ukrainian coal miners.

BACKGROUND: Underground coal mining is an expanding industry in Ukraine, yet little is known about the burden of respiratory disease among Ukrainian miners. METHODS: A Fogarty International Center-supported collaboration between researchers at the University of Illinois and the Institute of Occupational Health in Kyiv, Ukraine formed to improve capacity for conducting and monitoring medical surveillance among Ukrainian coal miners. A cross-sectional survey among a random sample of working and former miners was conducted; demographic, work, and health information were collected using a standardized questionnaire. Weighted prevalence rates were calculated and predictors of respiratory symptoms explored. RESULTS: Improvements in infrastructure, including spirometry and chest radiography testing, transformed medical surveillance among these miners. Results from the health study included that the prevalence of respiratory symptoms was higher among former compared to current miners (shortness of breath 35.6% vs. 5.1%; chronic bronchitis 18.1% vs. 13.9%, respectively). A statistically significant exposure-response relationship was observed between years mining and respiratory symptoms in former miners and between years mining at the coal face and respiratory symptoms among current miners. Evidence of downward bias from the healthy worker survivor effect was observed. CONCLUSIONS: This successful international collaboration built a sustainable infrastructure for conducting workplace medical surveillance and research. The resulting study was the first in the western literature to report on respiratory symptoms in this population; likely underestimation of disease rates due to selection and measurement biases was demonstrated. Efforts should continue to build this collaboration and to characterize and reduce respiratory illness among Ukrainian coal miners.

Predictors of elevated blood lead levels among 3-year-old Ukrainian children: a nested case-control study.

OBJECTIVES: Lead is common in the general population. However, data are lacking for the Ukraine and many other countries from the former Soviet Union (FSU). In this study we evaluate the level of blood lead among 212 Ukrainian children and determine predictors of elevated lead levels. We also describe the health effects associated with elevated blood lead. METHODS: A nested case-control study from a prospective cohort of Ukrainian 3-year-old children was conducted in March 1998. Blood assays were analyzed for lead by labs at the Centers for Disease Control and using portable examination kits. We evaluated predictors of elevated blood lead (blood levels in the upper quartile >4.65 microg/dL) using a multivariable logistic regression model. The model included socioeconomic status, parent occupation, environmental tobacco smoke, hygiene, diet, and health status. RESULTS: The geometric mean lead level was 3.15 microg/dL (range, 0.7--22.7). In our adjusted model, we observed a strong association between lead levels in the upper quartile and children whose fathers worked manual labor jobs in industries associated with lead exposures [adjusted odds ratio (OR)=2.25; P=0.025] and mothers who smoke indoors (adjusted OR=2.87; P=0.047). Daily hygiene and dietary habits were not associated with elevated lead levels. No increased risks of overall morbidity or lead-associated illness were observed (anemia, dental caries, renal disease, cardiovascular diseases, and musculoskeletal complaints). CONCLUSION: This is the first study to describe lead levels and associated variables among Ukrainian children in the peer-reviewed literature. Elevated lead levels in these children were associated with paternal occupation and mothers smoking indoors. At age 3 no adverse health effects were observed. More data are needed to determine the level of heavy metal contamination in children from the Ukraine and many other former Soviet nation-states.

Bioaerosol emissions from a suburban yard waste composting facility.

The purpose of this study was to assess worker and community exposure to bioaerosols emitted from a suburban yard waste composting facility in northern Illinois, USA. Characterization of on- and off-site viable bioaerosols was undertaken through a total of 288 on- and off-site Andersen samples conducted over 10 sampling days. A total of 46 dust samples and 38 Kramer-Collins spore samples were also collected in this period. Evaluation of the impact of the facility on community bioaerosol concentrations was undertaken by comparing on- and off-site measurements by sampling locations, wind direction, and site activity. On-site concentrations of total spores, Aspergillus/Penicillium spores, total bacteria, Gram-positive bacteria, Gram-negative bacteria, actinomycetes, total particulates, endotoxin, and beta-1,3 glucans were higher than off-site concentrations. Total fungal spores averaged 13,451 spores/m3 (range 5,223-26,067) on-site and 8,772 spores/m3 (range 243-18,276) off-site. Viable bacterial airborne concentrations (in cfu/m3) averaged 11,879 on-site (range 480-78,880) and 3,204 off-site (range 160-17,600). Mean levels of endotoxins (in ng/m3) were 1.94 on-site (range 0.12-6.06) and 0.14 off-site (range 0.01-0.41). Mean levels of beta-1,3 glucans (in ng/m3) were 2.17 on-site (range 0.12-14.45) and 0.24 off-site (range 0.01-0.78). Mean total viable fungi, on the other hand, were higher off-site than on-site (8,651 vs 3,068 cfu/m3). On-site concentrations of total bacteria, Gram-positive bacteria, Gram-negative bacteria, and actinomycetes demonstrated a statistically significant pattern of decreasing concentration with distance from pile and higher downwind vs upwind concentrations. Mean on-site concentrations of viable bacteria, viable fungi, and endotoxins were significantly higher during periods of activity compared to periods of no activity. Off-site concentrations of bacteria were also significantly higher during periods of activity compared to no activity. The highest concentrations of total particulates, endotoxin, and beta-1,3-glucans were observed in the personal samplers worn by workers at the facility. One personal sampler measured an Asp f1 exposure of 22.17 ng/m3 during turning activity. Peak exposures to several bioaerosol constituents were sufficiently high to warrant use of respirators by workers during periods of pile activity that lead to dust generation.

Prevalence of asthma and other allergic diseases in an adolescent population: association with gender and race.

OBJECTIVES: To estimate the prevalence and severity of asthma in an adolescent population by sex and race. METHODS: Cross-sectional, population-based survey of school children. SETTING: Midwestern city experiencing damage from the 1993 Mississippi River flood. PARTICIPANTS: 2,693 children attending grades 7 to 12. MEASUREMENTS: Questions from the International Study of Asthma and Allergies in Childhood (ISAAC). RESULTS: Two thousand six hundred ninety-three children were surveyed, for a response rate of 90%. In this population, 16.4% reported having ever been diagnosed with asthma; 25% reported wheezing in the last 12 months; 32% reported symptoms of rhinitis in the last 12 months; and 22% reported ever having hay fever. The prevalence rate for current asthma was 12.6%. Female students had significantly greater prevalence rates for current asthma (16.4% vs 9.0%, OR = 1.85); ever-diagnosed asthma (18.5% vs 14.3%, OR = 1.36); wheezing > or = 4 times in the last 12 months (12.0% vs 5.6%, OR = 1.95); current rhinitis (38.7% vs 25.4%, OR = 1.73); and hay fever (26.4% vs 18.4%, OR = 1.57). All associations with sex remained significant, except ever-diagnosed asthma, after controlling for other known risk factors in logistic regression. African-Americans had higher prevalence rates than other races with differences reaching statistical significance for ever-diagnosed asthma and current asthma; however, these relationships did not remain significant after controlling for other known risk factors in logistic regression. CONCLUSIONS: Our prevalence rates were similar to those reported by other studies that used the ISAAC questionnaire. Female students reported significantly more asthma, wheezing, rhinitis, and hay fever than male students. Female students also reported more severe symptoms and a greater number of emergency room and hospital admissions.

Surveillance for carbon monoxide poisoning using a national media clipping service.

Using a novel method to review carbon monoxide (CO) exposures in the US, the role of CO detectors in prevention of CO-related deaths was studied. Using a national media clipping service, CO poisonings reported in the US were analyzed. The impact of CO detectors was investigated through nonfatal outcomes attributable to the presence of CO detectors and case fatality rate comparison among cities with and without CO detector ordinances. There were 4,564 CO exposures resulting in 406 (8.9%) fatalities. Of the exposures 2,617 (57.3%) occurred in the home, accounting for 374 (92.1%) deaths. Faulty heating systems constituted 2,540 (55.6%) exposures and 186 (45.8%) deaths, with alternate heating sources responsible for 389 (8.5%) exposures and 104 (25.6%) deaths. Cities with CO detector ordinances showed lower case fatality rates as reported in the media than those cities without ordinances (P <.001). There were 1,008 (24.2%) survivors who attributed their survival to the presence of a CO detector. A media clipping service provided insight into CO poisoning demographics. Despite its limitations, this tool may calibrate the positive impact of CO detectors on the prevention of CO-related deaths.

Association of asthma symptoms and severity with indoor bioaerosols.

BACKGROUND: In this study, repeated measurements were made of levels of mold spores, bacteria, and dust-mite allergens over a 7-month period in the homes of asthmatics, and relationships with measures of asthma severity were evaluated. METHODS: A sample of 57 asthmatic individuals, living in 44 homes in East Moline, Illinois, and nearby communities, participated in a panel study. The homes were visited up to nine times during the study to collect air and dust samples. Asthma severity indicators were derived from questionnaire data and from the daily health records from the panel study. Associations between indoor levels of mold spores, bacteria, and dust-mite allergens were tested with several asthma severity indicators. RESULTS: There was evidence of associations between all asthma severity measures and levels of total and gram-negative bacteria, but mold-spore abundance was associated only with emergency room (ER) visits for asthma. No significant associations were found with house-dust-mite allergen and any of the asthma severity indicators, but the levels of dust-mite allergen were low, with median concentrations of 0.18 microg/g dust Der f 1 and 0.19 microg/g dust Der p 1. CONCLUSIONS: Some evidence was found for associations of increased concentrations of gram-negative bacteria and mold spores with asthma severity, particularly with ER visits. No association was found between house-dust-mite allergen and asthma severity indicators; however, the mite-allergen levels in the study homes were generally well below the proposed threshold level of 2 microg/g dust.

Polycyclic aromatic hydrocarbons in placenta.

Concentrations of chrysene, benz [a] anthracene, benzo [a]-pyrene, benzo [b] fluoranthene, indeno [1,2,3-c,d] pyrene, dibenz [a,h] anthracene, and benzo [g,h,i] perylene were measured in placentas from 200 women from two cities in Ukraine, Kyiv and Dniprodzerzhinsk. The participants had no special exposures and were chosen from among subjects in an ongoing study of reproductive health. All seven of the polycyclic aromatic hydrocarbons (PAHs) were found in all placentas, with the sole exception of benzo [a] pyrene in one placenta. Chrysene was present at the highest concentrations, with median 1.38 ng/g dry weight. Dibenz [a,h] anthracene and benzo [g,h,i] perylene had the lowest concentrations; each had median 0.73 ng/g dry weight. Concentrations in Kyiv were slightly higher than those in Dniprodzerzhinsk, but the difference was significant only for dibenz [a,h] anthracene. Dibenz [a,h] anthracene and benzo [g,h,i] perylene increased significantly with maternal body mass index, but other PAHs showed no such pattern. Placentas from deliveries in autumn or winter had slightly but not significantly higher concentrations. Concentrations were not related to maternal age. There were too few smokers in the sample for meaningful evaluation. No associations were seen between any of the placental PAH concentrations and birth weight of the infant.

Polychlorinated dibenzo-p-dioxins, polychlorinated dibenzofurans, and coplanar polychlorinated biphenyls in breast milk from two cities in Ukraine.

Substantial environmental pollution has been alleged in Ukraine, but little information is available to allow an assessment of the possible impact on humans. To help remedy this lack of information, it was of interest to investigate whether certain polychlorinated dibenzo-p-dioxins (PCDDs), polychlorinated dibenzofurans (PCDFs), or coplanar polychlorinated biphenyls (PCBs) were elevated in people from Ukraine. Samples of breast milk were obtained from 200 women from the cities of Kyiv and Dniprodzerzhinsk; Kyiv is the capital and Dniprodzerzhinsk is a highly industrialized city. The samples were combined into four pools by city and age, and analyzed for 7 PCDDs, 10 PCDFs, and 2 coplanar PCBs (126 and 169). The total of the measured PCDDs, expressed as toxic equivalent, ranged from 5.1 to 7.6 pg/g lipid; for PCDFs from 3.6 to 5.2, and for PCBs from 11 to 18 pg/g lipid. Results from the two cities were similar; older women had slightly higher concentrations than did younger women. Levels of these compounds seen in Ukraine were similar to or lower than those seen in other recent studies from European and Asian countries.

Collaborative research and research training through the "Family and Children of Ukraine" research program.

Family and Children of Ukraine, the Ukrainian component of the European Longitudinal Study of Pregnancy and Childhood, is a prospective, geographically-based study to evaluate pregnancy outcomes in 8,000 women in five cities in Ukraine and follow the cohort of births through 7 years of age. Family and Children in Ukraine has been the major collaborative research project for the University of Illinois' Fogarty-funded program, International Training and Research in Environmental and Occupational Health. This Fogarty program includes graduate training, U.S.-based training of visiting scientists, in-country training, and collaborative in-country research. Factors that have contributed to the success of the collaboration include: 1) its focus on the environmental health of mothers and children, which is a priority goal for both countries; 2) the adoption of an internationally-endorsed research protocol with strict quality-control criteria, specifically designed for international collaboration; 3) the establishment of an in-country data management center; and 4) the investment in a long-term research program rather than a short-term study. The major obstacles have been the difficult economic situation in Ukraine, which limits in-country research investment, and the difficulty in obtaining U.S. funding for an international research program.

A state trauma registry as a tool for occupational injury surveillance.

The goal of occupational surveillance is to identify and determine the magnitude of work-related disease and injury and workplace hazards for the purposes of focusing prevention programs and tracking their effectiveness. There are a number of databases that collect information on pieces of the puzzle of workplace exposure and adverse health outcomes. Other than that for the fatalities, none of these datasets specifically describes the most severe occupational injuries or their attendant disability. The goal of this study was to evaluate the usefulness of the Illinois Trauma Registry (ITR) in the surveillance of occupational injuries. The entire dataset of the ITR was obtained from the Illinois Department of Public Health for the years 1993 and 1994. The occupational injuries were extracted and frequency distributions were determined for all demographic and health variables. Background population, employment, and death-rate data were obtained for the purpose of rate calculation and for comparison of raw data. Mean costs for acute occupational injuries were calculated. There were 5844 occupational cases, comprising 6.7% of the total group. The majority of injuries had occurred in males (86%), in urban settings (81%), and were of the "blunt" injury type. External cause (coded according to the International Classification of Diseases, 9th Revision, External Injury) categories for work-related injuries were "Cut/Struck," 39%; "Falls," 36%; "Transportation," 12%; "Environmental," 6%; "Violence," 3%; and the remainder, 5%. By definition, all cases were admitted to the hospital, with 62% classified as "minor," 28% "moderate," and the remaining 11% "severe" to "life threatening." Surgery was performed in 54%, and admission to a monitored bed or the intensive care unit occurred in 15%. Although 93% were discharged home, only 54% ambulated independently. Seven percent were not independent with regard to self-feeding status. The mean hospital charge was $10,802 (standard deviation, $31,438). A pyramidal model of the place of ITR cases in the universe of occupational injuries is presented. The ITR contains a unique set of variables that broaden our understanding of serious work-related injuries. It is recommended that these variables--"occupation," "type of industry," and "nature of injury"--be added to the ITR so that it may be linked with other databases to check its validity and completeness and to enhance its value in occupational surveillance.

A morbidity study of former pentachlorophenol-production workers.

Pentachlorophenol (PCP) is a pesticide that was once widely used for wood preservation. Commercial PCP contained impurities including higher chlorinated dibenzo-p-dioxins (CDDs) and chlorinated dibenzofurans (CDFs). We investigated the effects of occupational exposure to PCP and its CDD and CDF contaminants on the skin, liver, porphyrin metabolism, and central and peripheral nervous systems. In 1986 we conducted a medical survey of 366 workers who had been engaged in the production of PCP at a single plant between 1938 and 1978. The referent group consisted of 303 workers from the same plant who were not exposed to these or related compounds. Exposure was determined from computerized personnel records. The medical survey included an administered questionnaire, medical record review, physical examination by dermatologists, internists, and neurologists, and analysis of 24-hr urine for quantitative porphyrins among other tests. In this paper we present the results of analyses of the general health, chloracne, and porphyrin metabolism end points. The general health status of PCP workers was similar to unexposed workers, but 17.8% of PCP workers had evidence of current or past chloracne. PCP workers with chloracne had significantly higher mean urinary excretion of coproporphyrins (117. 0 vs. 90.6 microg/24 hr) than unexposed workers after controlling for potential confounders. Workers with chloracne who had worked with both PCP and polychlorinated biphenyls had significantly higher mean urinary excretions of hepta-, penta-, and coproporphyrins than unexposed workers. We conclude that occupational exposure to PCP is associated with chloracne and biochemical abnormalities which may persist years after exposure.

Night of the sirens: analysis of carbon monoxide-detector experience in suburban Chicago.

STUDY OBJECTIVE: To determine the pattern and environmental causes of carbon monoxide (CO)-detector alarms. METHODS: Data including time, location, detector manufacturer, CO measurements in the home, reported illness, cause, and actions taken were collected between July 15, 1994, and January 26, 1995, on all calls to 17 suburban Chicago fire departments for CO-detector alarms. We used univariate time-series analysis involving joint estimation of model parameters and outlier effects to analyze data and compared data on ambient CO levels from the Illinois Environmental Protection Agency to the number of calls per day. RESULTS: During the study period, 777 calls for sounding CO detectors were made to the fire departments in question. The median number of calls per day was three. Our univariate time series identified 3 days with a significant excess of calls (December 12, 29 calls; December 21, 69; December 22, 128; P < .001). The average ambient CO readings on these days were 0.99, 3.25, and 3.89 ppm, respectively, compared with an overall mean of 8.8 ppm. In-home CO levels among all 828 measurements taken from the 777 domestic calls ranged from 0 to 425 ppm, 0 in 249 (30%), 1 to 10 in 340 (41%), 11 to 50 in 149 (18%), 51 to 100 in 22 (9%), and more than 100 in 11 (1.3%). No measurement was taken in six cases. Cause of alarm was listed as furnace in 25 cases, auto exhaust in 24, stove/oven in 22, poor location of detector in 14, water heater in 11, outside sources in 7, and multiple sources in 7. Other sources accounted for fewer than 1% each. The participating fire departments considered 242 cases (31%) to be false alarms. Cause was not determined in 400 calls (51%). In 37 calls (4.8%), people reported illness. CONCLUSION: Above-average ambient CO levels coincided with a significant increase in the number of calls and may have contributed to the triggering of CO alarms.

Dust-mite-allergen concentrations in asthmatics' bedrooms in the Quad Cities (Illinois, USA) after the Mississippi River floods of 1993.

This study aimed to measure allergens from Dermatophagoides farinae and D. pteronyssinus and to examine possible relationships of these mite allergens with flooding and other housing factors. A total of 313 dust samples were collected from the bedrooms of 57 asthmatics in 45 homes in the Quad Cities (Illinois, USA) and analyzed by ELISA for the presence of the D. farinae and D. pteronyssinus allergens. Twenty of these homes had some flooding in the last 12 months due to the Mississippi River floods of 1993 and/or other factors. The log-transformed least-squares means of allergens collected were 28 ng/m2 for the D. farinae allergen and 26 ng/m2 for the D. pteronyssinus allergen. D. farinae allergen levels were significantly higher in homes located in the valley, in homes during the summer months, in homes with furred or feathered pets, in homes which had not been flooded in the last year, and in homes where rugs had been steam-cleaned in the last 12 months. D. pteronyssinus allergen levels were significantly higher in homes located in the valley, in homes during April and July-September, in homes with furred or feathered pets, and in homes with no dehumidifier.

Chloral hydrate toxicity from oral and intravenous administration.

BACKGROUND: Overdose from enteric chloral hydrate results in cardiovascular and central nervous system symptoms. CASE REPORTS: This case series compares and contrasts two cases of oral chloral hydrate overdose with two cases of accidental i.v. administration. Whereas ingestion of 219 mg/kg of chloral hydrate resulted in transient bigeminy, ingestion of up to 960 mg/kg caused torsades de pointes and ventricular fibrillation which were effectively treated with defibrillation and a beta blocker. I.V. administration in humans does not appear previously documented. Two cases of i.v. administration of a therapeutic chloral hydrate dose resulted in central nervous system depression and minimal local effects at the injection site. CONCLUSIONS: Given the high bioavailability of oral chloral hydrate the major determinant of cardiotoxicity may be the dose rather than the route of administration. Cardiac arrhythmias due to chloral hydrate appear to be responsive to beta blocker therapy.

Fractional mercury levels in Brazilian gold refiners and miners.

A field study survey of individuals residing in the region of Para, Brazil, was conducted to determine fractional mercury levels in individuals at risk for exposure in the Brazilian Amazon region. Subjects with a history of exposure to mercury either in the gold mining or refining industry, or exposure to these processes through proximity were included. Three groups were identified as either having recent (less than 2 d since last exposure), intermediate (less than 60 d), or remote (greater than 60 d) exposure to mercury vapors. Fractional blood and urinary mercury levels were assessed for these groups. Group I (recent) had the highest geometric mean blood 24.8 (SD 44.1, range 7.6-158.8) micrograms/L and urine 75.6 (SD 213.4, range 6.5-735.9) micrograms/g-cr (microgram mercury per gram of creatinine) mercury; intermediate (group II) geometric mean blood 7.6 (SD 5.5, range 2.2-19.4) micrograms/L and urine levels 23.8 (SD 84.0, range 7.8-297.0) micrograms/g-cr; the lowest levels in remote exposure (group III): geometric mean blood 5.6 (SD 3.3, range 3.1-14.3) micrograms/L and urine 7.0 (SD 9.8, range 3.1 to 32.9) micrograms/g-cr. The fraction of organic was lowest in group I (32.4%), higher in group II (65.7%), and highest in group III (72.2%). While the frequency of symptoms was comparable in the recent and intermediate groups (2.6 mean, SD 2.3, range 0-8, and 3.1 mean, SD 1.9, range 0-7, symptoms per patient), those with remote exposure demonstrated the highest rate of reporting (6.4 mean, SD 4.1, range 0-11, symptoms per patient). There is significant exposure to mercury for those working in or living near the mining and refining industry. Blood and urine levels are a better marker of recent than remote exposure. The fraction of organic mercury increases with time since exposure. Symptoms may be persistent and low levels of blood and urine mercury do not exclude remote or cumulative toxicity.

Acute bone marrow toxicity and pancytopenia following exposure to lead chromate, xylene, and ethylbenzene in a degloving injury.

A case of unique acute bone marrow toxicity and pancytopenia following subcutaneous exposure to lead chromate, xylene, and ethylbenzene in a previously healthy patient is reported. The patient sustained an extensive degloving injury to his lower extremity. The wound was contaminated with traffic paint containing lead chromate pigment along with a large volume of xylene and ethylbenzene solvent. Consequences of the patient's clinical course and management of degloving injuries are discussed.

Constraints on the enhancement of elimination of drugs with activated charcoal.

Both extracorporeal hemoperfusion through charcoal-containing columns and repeated oral administration of charcoal can accelerate clearance of some drugs or toxins from the systemic circulation. The efficacy of these 2 interventions is limited by a variety of factors, and the complex kinetic equations describing charcoal-induced clearance provide little practical clinical guidance about the potential efficacy of charcoal in accelerating clearance of a specific drug or toxin without previous empiric data. We derive here simple rules that place an upper limit on the maximal fraction of an absorbed dose of drug that can be removed (FRmax) by charcoal in terms of the volume of distribution (Vd), a parameter which is known for most drugs. For 4 h of hemoperfusion, a theoretical upper limit of FRmax is (1/Vd), where Vd is expressed in L/kg of body weight, and actual fractional removal (FR) will not exceed [1/(2 x Vd)]. Drug removal by 24 h of repeated po administration of charcoal exhibits similar relationships between FRmax and Vd, when charcoal-induced clearance derives primarily from removal of drug from blood perfusing in gastrointestinal mucosa. These relationships offer a simple means to evaluate the potential efficacy of acceleration of drug clearance by activated charcoal for drugs with a known value for Vd, and the relationships indicate that such interventions are impractical for drugs with very large values for Vd, such as tricyclic antidepressants.