Psilocybine services in Oregon: a call for awareness among clinical toxicologists.

BACKGROUND: In 2023, Oregon enacted laws regulating the manufacture and use of psilocybine products in licensed facilities for supervised sessions with trained facilitators. COMMENTARY: This commentary summarizes the final rules for psilocybine services in Oregon, and provides perspectives from a clinical toxicologist on some of the issues that may arise. These include the scope of practice for non-clinical facilitators, prevention and management of adverse drug reactions, and toxicological uncertainties with regards to dose considerations for people with mental health and other medical conditions. CONCLUSION: This commentary addresses some common misperceptions relating to the program, and provides perspective on some of the challenges that clinical toxicologists may encounter as legislative reform initiatives for psilocybine move forward throughout the United States.

Naltrexone: Not Just for Opioids Anymore.

Naltrexone is a semi-synthetic opioid with competitive antagonist activity at mu opioid receptors. Its efficacy has been demonstrated in the treatment of alcohol and opioid dependence, but adherence to daily dosing has been recognized as a factor limiting long-term effectiveness. Recently, a long-acting injectable formulation of naltrexone has received FDA-approval for treating alcohol and opioid dependence. This article reviews the pharmacology of naltrexone, the current evidence supporting the use of extended-release naltrexone, and the clinical challenges in the induction of patients to this medication.

A Community-Based Approach to Developing a Mobile Device for Measuring Ambient Air Exposure, Location, and Respiratory Health.

In west Eugene (Oregon), community research indicates residents are disproportionately exposed to industrial air pollution and exhibit increased asthma incidence. In Carroll County (Ohio), recent increases in unconventional natural gas drilling sparked air quality concerns. These community concerns led to the development of a prototype mobile device to measure personal chemical exposure, location, and respiratory function. Working directly with the environmental justice (EJ) communities, the prototype was developed to 1) meet the needs of the community and 2) evaluate the use in EJ communities. The prototype was evaluated in three community focus groups (n = 25) to obtain feedback on the prototype and feasibility study design to evaluate the efficacy of the device to address community concerns. Focus groups were recorded and qualitatively analyzed with discrete feedback tabulated for further refinement. The prototype was improved by community feedback resulting in eight alterations/additions to software and instructional materials. Overall, focus group participants were supportive of the device and believed it would be a useful environmental health tool. The use of focus groups ensured that community members were engaged in the research design and development of a novel environmental health tool. We found that community-based research strategies resulted in a refined device as well as relevant research questions, specific to the EJ community needs and concerns.

Determination of parent and hydroxy PAHs in personal PM2.5 and urine samples collected during Native American fish smoking activities.

A method was developed for the measurement of 19 parent PAHs (PAHs) and 34 hydroxylated PAHs (OH-PAHs) in urine and personal air samples of particulate matter less than 2.5 µm in diameter (PM2.5) using GC-MS and validated using NIST SRM 3672 (Organic Contaminants in Smoker's Urine) and SRM 3673 (Organic Contaminants in Nonsmoker's Urine). The method was used to measure PAHs and OH-PAHs in urine and personal PM2.5 samples collected from the operators of two different fish smoking facilities (tipi and smoke shed) burning two different wood types (alder and apple) on the Confederated Tribes of Umatilla Indian Reservation (CTUIR) while they smoked salmon. Urine samples were spiked with ß-glucuronidase/arylsulfatase to hydrolyze the conjugates of OH-PAHs and the PAHs and OH-PAHs were extracted using Plexa and C18 solid phases, in series. The 34 OH-PAHs were derivatized using MTBSTFA, and the mixture was measured by GC-MS. The personal PM2.5 samples were extracted using pressurized liquid extraction, derivatized with MTBSTFA and analyzed by GC-MS for PAHs and OH-PAHs. Fourteen isotopically labeled surrogates were added to accurately quantify PAHs and OH-PAHs in the urine and PM2.5 samples and three isotopically labeled internal standards were used to calculate the recovery of the surrogates. Estimated detection limits in urine ranged from 6.0 to 181 pg/ml for OH-PAHs and from 3.0 to 90 pg/ml for PAHs, and, in PM2.5, they ranged from 5.2 to 155 pg/m(3) for OH-PAHs and from 2.5 to 77 pg/m(3) for PAHs. The results showed an increase in OH-PAH concentrations in urine after 6h of fish smoking and an increase in PAH concentrations in air within each smoking facility. In general, the PAH exposure in the smoke shed was higher than in the tipi and the PAH exposure from burning apple wood was higher than burning alder.

A cross-sectional study of the association between ventilation of gas stoves and chronic respiratory illness in U.S. children enrolled in NHANESIII.

BACKGROUND: Gas stoves emit pollutants that are respiratory irritants. U.S. children under age 6 who live in homes where gas stoves are used for cooking or heating have an increased risk of asthma, wheeze and reduced lung function. Yet few studies have examined whether using ventilation when operating gas stoves is associated with a decrease in the prevalence of respiratory illnesses in this population. METHODS: The Third National Health and Nutrition Examination Survey was used to identify U.S. children aged 2-16 years with information on respiratory outcomes (asthma, wheeze, and bronchitis) who lived in homes where gas stoves were used in the previous 12 months and whose parents provided information on ventilation. Logistic regression models evaluated the association between prevalent respiratory outcomes and ventilation in homes that used gas stoves for cooking and/or heating. Linear regression models assessed the association between spirometry measurements and ventilation use in children aged 8-16 years. RESULTS: The adjusted odds of asthma (Odds Ratio [OR] = 0.64; 95% confidence intervals [CI]: 0.43, 0.97), wheeze (OR = 0.60, 95% CI: 0.42, 0.86), and bronchitis (OR = 0.60, 95% CI: 0.37, 0.95) were lower among children whose parents reported using ventilation compared to children whose parents reported not using ventilation when operating gas stoves. One-second forced expiratory volume (FEV1) and FEV1/FVC ratio was also higher in girls who lived in households that used gas stoves with ventilation compared to households that used gas stoves without ventilation. CONCLUSIONS: In homes that used gas stoves, children whose parents reported using ventilation when operating their stove had higher lung function and lower odds of asthma, wheeze, and bronchitis compared to homes that never used ventilation or did not have ventilation available after adjusting for other risk factors. Additional research on the efficacy of ventilation as an intervention for ameliorating respiratory symptoms in children with asthma is warranted.

Naphthalene biomarkers and relationship with hemoglobin and hematocrit in White, Black, and Hispanic adults: results from the 2003-2004 National Health and Nutrition Examination Survey.

Naphthalene is an important contaminant in indoor and outdoor air. Acute overexposure can have toxic effects, resulting in hemolysis. There have been no studies evaluating the impact of environmental exposure on red blood cell indices. We examined 1- and 2-hydroxynaphthalene urinary metabolites (NAP1 and NAP2) in non-Hispanic White, non-Hispanic Black, and Mexican-American adults in the USA and their relationship with hemoglobin (Hb) and hematocrit (HCT). Using the 2003-2004 National Health and Nutrition Examination Survey data, weighted generalized linear regression analyses were used to examine the association between Hb (in grams per deciliter) and HCT (in percent) with NAP1 and NAP2 (per 100,000 ng/L). Beta coefficients ± SE are reported. NAP1 and NAP2 were highest in non-Hispanic Blacks, followed by non-Hispanic Whites, and lowest in Mexican-American adults. There was a positive association between NAP1 and Hb (0.39 ± 0.11, p = 0.0034) and HCT (1.14 ± 0.28, p = 0.0009) after adjusting for age, gender, race, education, and smoking. Stratified analysis by smoking showed similar results with the association being stronger for smokers (Hb 0.63 ± 0.23, p = 0.02; HCT 1.43 ± 0.79, p = 0.09) than nonsmokers (Hb 0.34 ± 0.14, p = 0.03; HCT 1.08 ± 0.42, p = 0.02). The association was also stronger for non-Hispanic blacks (Hb 0.54 ± 0.20, p = 0.02; HCT 1.43 ± 0.55, p = 0.02) than for non-Hispanic whites (Hb 0.37 ± 0.18, p = 0.06; HCT 1.20 ± 0.51, p = 0.03) and was not significant for Mexican-Americans (Hb 0.30 ± 1.7, p = 0.10; HCT 0.99 ± 0.52, p = 0.08). NAP2 was not significantly associated with Hb or HCT. The observed disparity in NAP1 and NAP2 levels by race/ethnicity is consistent with published literature. The origin of these differences in exposure is unclear but may reflect differences in environmental exposure as well as genetic susceptibility. The positive association between NAP1 with HCT and Hb is an unexpected finding. Further research is needed to understand the possible biological mechanisms or other explanations for this association.

Age and gender dependent bioavailability of R- and R,S-α-lipoic acid: a pilot study.

Lipoic acid (LA) shows promise as a beneficial micronutrient toward improving elder health. Studies using old rats show that (R)-α-LA (R-LA) significantly increases low molecular weight antioxidants that otherwise decline with age. Despite this rationale for benefiting human health, little is known about age-associated alterations in absorption characteristics of LA, or whether the commercially available racemic mixture of LA (R,S-LA) is equally as bioavailable as the naturally occurring R-enantiomer. To address these discrepancies, a pilot study was performed to establish which form of LA is most effectively absorbed in older subjects relative to young volunteers. Young adults (average age=32 years) and older adults (average age=79 years) each received 500 mg of either R- or R,S-LA. Blood samples were collected for 3h after supplementation. After a washout period they were given the other chiral form of LA not originally ingested. Results showed that 2 out of 6 elder males exhibited greater maximal plasma LA and area under the curve for the R-form of LA versus the racemic mixture. The elder subjects also demonstrated a reduced time to reach maximal plasma LA concentration following R-LA supplementation than for the racemic mixture. In contrast, young males had a tendency for increased bioavailability of R,S-LA. Overall, bioavailability for either LA isoform was much more variable between older subjects compared to young adults. Plasma glutathione levels were not altered during the sampling period. Thus subject age, and potential for varied response, should be considered when determining an LA supplementation regimen.

Dialkyl phosphates as biomarkers of organophosphates: the current divide between epidemiology and clinical toxicology.

CONTEXT: Organophosphate insecticides are widely utilized throughout the world. The cholinergic toxidrome, resulting from cholinesterase inhibition, is the clinically relevant endpoint in organophosphate poisoning. In recent years, urinary dialkyl phosphates (DAPs) have emerged as a common method of assessing exposure to organophosphates in epidemiological investigations. Using dialkyl phosphates as biomarkers of exposure to organophosphates, several recent epidemiological studies have reported associations with adverse health outcomes. The purpose of this article is to review the application and limitations of urinary DAPs as biomarkers of exposure to organophosphate insecticides. METHODS: A literature search was conducted of the PubMed database, using keywords "dialkylphosphate" and "dialkyl phosphate." The scientific literature was reviewed to identify sources of dialkyl phosphate metabolites from in vivo metabolism of organophosphates, and as environmental degradation products. Epidemiological investigations were reviewed to summarize the use of use of DAPs as biomarkers in cross-sectional studies, occupational exposures, acute poisonings, and in health outcome studies. Emphasis was placed on the assessment of DAPs in the context of existing biomarker frameworks, as defined by the National Research Council. Studies were assessed for concurrent use of cholinesterase activity as a biomarker of effect, and whether a dose-response relationship could be determined between DAPs and cholinesterase depression or cholinergic effects. RESULTS: Over 184 publications were identified, describing dialkyl phosphates and their use as biomarkers of exposure. The in vivo metabolism of organophosphates yields different DAPs, depending upon whether they undergo bioactivation or detoxification. The detection of urinary DAPs does not provide specificity with respect to the organophosphate from which they were derived, or their toxicological potency. Several recent studies documented the common presence of DAPs in residential environments and foods. Experimental studies support that DAPs have significant oral bioavailability, and undergo little to no metabolism prior to urinary excretion. Cross-sectional studies in multiple countries confirm that urinary DAPs are commonly detectable in the general population. No occupational studies were identified supporting a dose-response relationship between DAPs and significant cholinesterase inhibition. No occupational studies were identified supporting evidence of a threshold level of DAPs excretion at which clinical cholinergic signs or symptoms have been observed. Recent prospective epidemiological studies using DAPs as biomarkers have not concurrently assessed effects on cholinesterase activity, or conducted analyses that distinguish different DAPs that reflect bioactivation versus detoxification pathways. DISCUSSION: There are numerous limitations to the use of DAPs as biomarkers of exposure. These include a lack of specificity with respect to the organophosphate from which they were derived, and a growing body of evidence that toxicologically irrelevant DAPs are commonly encountered in food and the environment. Substantial intra- and inter-day variability has been reported for dialkyl phosphate excretion in humans, which is problematic for studies that rely on single measurements to assess exposure. The toxicological distinction between different DAPs reflecting biomarkers of activation and detoxification processes has not been considered in some prospective epidemiological studies. A relationship between DAPs as biomarkers of exposure and the critical biomarker of effect, cholinesterase activity, has not been established. CONCLUSIONS: The science of exposure assessment using DAPs as biomarkers is not advancing, and this complicates the interpretation of epidemiological studies. At the current time, DAPs have very limited utility in clinical toxicology or in the risk assessment process for organophosphates. Until these limitations are addressed, the appropriate role of DAPs in the assessment of human health risks from organophosphates is unclear.

Naphthalene Mothballs: Emerging and Recurring Issues and their Relevance to Environmental Health.

Naphthalene is a polycyclic aromatic hydrocarbon that is commonly encountered in indoor and outdoor environments. There is growing awareness of the environmental health risks associated with inhalation exposure to naphthalene in the indoor environment. While there are numerous potential sources of naphthalene indoors, the use of mothballs can be a significant contributor to ambient concentrations. This review article describes recurring and emerging environmental health issues relating to mothballs containing naphthalene. The toxicology and health effects of naphthalene exposure are reviewed, with discussion of high-risk populations and risk mitigation strategies. Environmental health professionals should be aware of mothball use in the home, and recognize risks associated with accidental exposure and misuse.

The spatial epidemiology of cocaine, methamphetamine and 3,4-methylenedioxymethamphetamine (MDMA) use: a demonstration using a population measure of community drug load derived from municipal wastewater.

AIMS: To determine the utility of community-wide drug testing with wastewater samples as a population measure of community drug use and to test the hypothesis that the association with urbanicity would vary for three different stimulant drugs of abuse. DESIGN AND PARTICIPANTS: Single-day samples were obtained from a convenience sample of 96 municipalities representing 65% of the population of the State of Oregon. MEASUREMENTS: Chemical analysis of 24-hour composite influent samples for benzoylecgonine (BZE, a cocaine metabolite), methamphetamine and 3,4-methylenedioxymethamphetamine (MDMA). The distribution of community index drug loads accounting for total wastewater flow (i.e. dilution) and population are reported. FINDINGS: The distribution of wastewater-derived drug index loads was found to correspond with expected epidemiological drug patterns. Index loads of BZE were significantly higher in urban areas and below detection in many rural areas. Conversely, methamphetamine was present in all municipalities, with no significant differences in index loads by urbanicity. MDMA was at quantifiable levels in fewer than half the communities, with a significant trend towards higher index loads in more urban areas. CONCLUSION; This demonstration provides the first evidence of the utility of wastewater-derived community drug loads for spatial analyses. Such data have the potential to improve dramatically the measurement of the true level and distribution of a range of drugs. Drug index load data provide information for all people in a community and are potentially applicable to a much larger proportion of the total population than existing measures.

Longitudinal trends in organophosphate incidents reported to the National Pesticide Information Center, 1995-2007.

BACKGROUND: Regulatory decisions to phase-out the availability and use of common organophosphate pesticides among the general public were announced in 2000 and continued through 2004. Based on revised risk assessments, chlorpyrifos and diazinon were determined to pose unacceptable risks. To determine the impact of these decisions, organophosphate (OP) exposure incidents reported to the National Pesticide Information Center (NPIC) were analyzed for longitudinal trends. METHODS: Non-occupational human exposure incidents reported to NPIC were grouped into pre- (1995-2000) and post-announcement periods (2001-2007). The number of total OP exposure incidents, as well as reports for chlorpyrifos, diazinon and malathion, were analyzed for significant differences between these two periods. The number of informational inquiries from the general public was analyzed over time as well. RESULTS: The number of average annual OP-related exposure incidents reported to NPIC decreased significantly between the pre- and post-announcement periods (p < 0.001). A significant decrease in the number of chlorpyrifos and diazinon reports was observed over time (p < 0.001). No significant difference in the number of incident reports for malathion was observed (p = 0.4), which was not phased-out of residential use. Similar to exposure incidents, the number of informational inquiries received by NPIC declined over time following the phase-out announcement. CONCLUSION: Consistent with other findings, the number of chlorpyrifos and diazinon exposure incidents reported to NPIC significantly decreased following public announcement and targeted regulatory action.

Regional variation in the severity of pesticide exposure outcomes: applications of geographic information systems and spatial scan statistics.

INTRODUCTION: Geographic information systems and spatial scan statistics have been utilized to assess regional clustering of symptomatic pesticide exposures reported to a state Poison Control Center (PCC) during a single year. In the present study, we analyzed five subsequent years of PCC data to test whether there are significant geographic differences in pesticide exposure incidents resulting in serious (moderate, major, and fatal) medical outcomes. METHODS: A PCC provided the data on unintentional pesticide exposures for the time period 2001-2005. The geographic location of the caller, the location where the exposure occurred, the exposure route, and the medical outcome were abstracted. RESULTS: There were 273 incidents resulting in moderate effects (n = 261), major effects (n = 10), or fatalities (n = 2). Spatial scan statistics identified a geographic area consisting of two adjacent counties (one urban, one rural), where statistically significant clustering of serious outcomes was observed. The relative risk of moderate, major, and fatal outcomes was 2.0 in this spatial cluster (p = 0.0005). CONCLUSIONS: PCC data, geographic information systems, and spatial scan statistics can identify clustering of serious outcomes from human exposure to pesticides. These analyses may be useful for public health officials to target preventive interventions. Further investigation is warranted to understand better the potential explanations for geographical clustering, and to assess whether preventive interventions have an impact on reducing pesticide exposure incidents resulting in serious medical outcomes.

Regional and temporal variation in methamphetamine-related incidents: applications of spatial and temporal scan statistics.

INTRODUCTION: This investigation utilized spatial scan statistics, geographic information systems, and multiple data sources to assess spatial clustering of statewide methamphetamine-related incidents. Temporal and spatial associations with regulatory interventions to reduce access to precursor chemicals (pseudoephedrine) were also explored. METHODS: Four statewide data sources were utilized including regional poison control center statistics, fatality incidents, methamphetamine laboratory seizures, and hazardous substance releases involving methamphetamine laboratories. Spatial clustering of methamphetamine incidents was assessed using SaTScan. SaTScan was also utilized to assess space-time clustering of methamphetamine laboratory incidents, in relation to the enactment of regulations to reduce access to pseudoephedrine. RESULTS: Five counties with a significantly higher relative risk of methamphetamine-related incidents were identified. The county identified as the most likely cluster had a significantly elevated relative risk of methamphetamine laboratories (RR = 11.5), hazardous substance releases (RR = 8.3), and fatalities relating to methamphetamine (RR = 1.4). A significant increase in relative risk of methamphetamine laboratory incidents was apparent in this same geographic area (RR = 20.7) during the time period when regulations were enacted in 2004 and 2005, restricting access to pseudoephedrine. Subsequent to the enactment of these regulations, a significantly lower rate of incidents (RR = 0.111, p = 0.0001) was observed over a large geographic area of the state, including regions that previously had significantly higher rates. CONCLUSIONS: Spatial and temporal scan statistics can be effectively applied to multiple data sources to assess regional variation in methamphetamine-related incidents, and explore the impact of preventive regulatory interventions.

Toxigenic fungi and mycotoxins in outdoor, recreational environments.

INTRODUCTION: Some epidemiological studies of damp buildings have focused on health risks from indoor exposure to toxigenic fungi and mycotoxins. Most of these studies have not considered assessment of these hazards in outdoor environments. The purpose of this investigation was to assess for toxigenic fungal species in outdoor recreational environments through the microbial analysis of locations representing opportunities for human exposure. A screening assessment was also conducted using commercially available ELISA kits to assess for trichothecene mycotoxins in outdoor samples. METHODS: Ten swab and tape-lift samples were obtained from a city park. Swabs were cultured and identified by a trained mycologist. Bulk samples of grasses were screened for deoxynivalenol using a commercial ELISA assay. A pilot study of 6 bulk samples was screened for macrocyclic trichothecenes using a commercial ELISA assay. RESULTS: Tape-lift samples contained trace to moderate spores. Penicillium and Aspergillus-like spores were identified in 50% of tape-lift samples. 50% of swab samples contained potentially toxigenic species of Penicillium (P. citrinum, P. brevicompactum, P. chrysogenum). None of the bulk samples tested positive for deoxynivalenol. 3 of 6 (50%) bulk samples were positive for macrocyclic trichothecenes (> 0.2 ppb), however both negative control samples also tested positive. CONCLUSIONS: Potentially toxigenic fungi were commonly encountered in an outdoor, recreational environment. Future epidemiological studies need to consider outdoor activities in hazard and exposure assessment. Further work is needed to define the accuracy of commercially developed ELISA kits that are being used for the detection of mycotoxins in environmental samples.

Pyrethrin and pyrethroid exposures in the United States: a longitudinal analysis of incidents reported to poison centers.

INTRODUCTION: Citing the Food Quality Protection Act, the US Environmental Protection Agency (EPA) decided to phase out and eliminate organophosphate insecticide use in residential environments. The phase out process spanned from 2000 to 2005, and it may have resulted in increased consumer use of insecticides containing other active ingredients. This study utilized data from the national Poison Control Center to assess possible changes in exposure incidents involving pyrethrin and pyrethroid insecticides during the phase out of organophosphates from residential uses. METHODS: We extracted pyrethrin and pyrethroid insecticide exposure data from the American Association of Poison Control Centers Toxic Exposure Surveillance System (TESS) annual reports from 2000 to 2005. We examined pyrethrin and pyrethroid incidents by total exposures for each year, and we stratified exposures by age range, reason, number of cases treated in a health care facility, and medical outcome. Cases were examined as a proportion of all insecticide exposures. We calculated the annual incidence rates for exposures involving pyrethrin and pyrethroid insecticides of the population served. RESULTS: Pyrethrin and pyrethroid exposures increased annually in number and as a percentage of all insecticide exposure incidents. The increase in cases was observed for all age categories and exposure reasons. A statistically significant correlation was observed between advancing years (2000-2005) and the number of pyrethrin and pyrethroid incidents (p<.01). While the number of incidents treated in a health care facility increased annually during the study period, the proportion was constant (0.185 +/- 0.012) over the six year period. During the study period, the incidence rate for pyrethrin and pyrethroid exposures increased each year. 44% of all medical outcomes data was recorded, and the majority of outcomes resulted in no symptoms (37%) or minor symptoms (53%). CONCLUSION: TESS data showed a clear increase in cases involving pyrethrins and pyrethroids. The increase was temporally associated with the phase out of organophosphates from residential uses. In the future, medical toxicologists and poison control center personnel should be prepared to respond to an increasing number of pyrethrin and pyrethroid insecticide exposures.

Organophosphate exposures in the United States: a longitudinal analysis of incidents reported to poison centers.

The implementation of the Food Quality Protection Act of 1996 resulted in a decision by the U.S. Environmental Protection Agency to phase out and eliminate the use of organophosphate insecticides in residential environments. The phase-out and cancellation process began in the year 2000 and was complete in 2005. The purpose of this investigation was to utilize national Poison Control Center data to assess whether the risk mitigation decision had an impact on the number of incident cases involving organophosphates in the United States. Organophosphate exposure incident data were extracted from Annual Reports of the American Association of Poison Control Centers Toxic Exposure Surveillance System (TESS) for the years 1995 to 2004. The number of organophosphate exposure incidents peaked at 20,135 in 1997, and declined in each subsequent year. A statistically significant decrease was observed in the average annual number of organophosphate exposure incidents when comparing data from the time periods before (1995-1999) and after (2000-2004) the commencement of the phase-out process. The decrease in organophosphate incident cases was observed for all age categories, as well as for the circumstances surrounding the exposure (unintentional and intentional exposure incidents). TESS data showed a significant decrease in incident cases involving organophosphates in association with the phase-out from residential uses. The results of this investigation are consistent with other studies that have reported that regulatory restriction of access to pesticide formulations may have a significant impact on the number of human exposure incidents.

Fatality after a single dermal application of lindane lotion.

Lindane lotion, approved by the US Food and Drug Administration (FDA) for treatment of scabies and lice, poses risks of serious adverse effects on the nervous system. In 2003, the FDA issued a public health advisory for lindane products, emphasizing the importance of compliance with labeling instructions. The author presents a case in which a fatal outcome followed a single dermal application of lindane. The product was not applied according to the labeling instructions, and the 66-year-old man rapidly developed hypoxemia, seizures, respiratory acidosis, and hypotension. The final diagnosis at autopsy was hypoxic ischemic encephalopathy from lindane. This case is consistent with other reports of severe neurological outcomes from pharmaceutical use of lindane. These factors suggest a need for the FDA to reassess whether the risks of lindane have been effectively communicated to healthcare providers.

Pyrethroid insecticides: advances and challenges in biomonitoring.

Pyrethroid insecticides have a wide variety of applications throughout the world. They are structurally diverse chemicals that are synthetically derived from naturally occurring pyrethrin insecticides. Significant advances in analytical chemistry have led to the development of biomarkers of exposure to pyrethroids, and these methods are currently being applied to study exposure in the general population. This article reviews the chemistry and toxicology of pyrethroid insecticides, with an emphasis on the development of biomarkers to assess environmental exposure. Future challenges in the application of these biomarkers in epidemiological studies are explored, as is a need for improved understanding of the toxicokinetics of pyrethroids in humans.

Pesticides and electronic resources for health care providers.

Agricultural workers are at higher risk of occupational injuries, including pesticide exposures. There is general agreement that the training of health care providers to recognize and manage such exposures is limited and in need of improvement. While the Internet presents opportunities for health care providers to access information and continue their medical education, it can be difficult to identify relevant resources in a timely manner. This case report presents a realistic scenario of a suspected pesticide exposure among symptomatic agricultural workers. The discussion that follows presents Web-based resources that health care providers can rely upon in recognizing, managing, and preventing pesticide-related illness.