Profile of incidental exposures to e-cigarette liquids in Europe, 2018-2019

BACKGROUND

Following the implementation of the European Union Tobacco Product Directive (EU TPD) regulations on e-cigarette products in 2016, we assessed the current profile of e-cigarette liquid exposure incidents and their associated health outcomes.

METHODS

De-identified data were received from poison centers in eight EU Member States (Sweden, the Netherlands, Italy, Hungary Austria, Finland, Spain and Croatia) reporting on e-cigarette liquid exposure incidents between August 2018 to December 2019. Descriptive analysis was conducted to present incident characteristics and health outcomes. Chi-square tests and multivariable logistic regression analysis were used to test associations.

RESULTS

Of the 223 e-liquid exposure incidents recorded by poison centers in multiple EU MS, 64.7% of the cases were unintentional exposures, ranging from 48.4% among adults aged ≥19 years to 100.0% among children aged 0-5 years (p < 0.05). The most frequent route of exposure was ingestion (73.5%) while55.2% experienced any clinical symptoms, including nausea (16.6%), vomiting (11.1%), and dizziness (9.0%). 57.8% of the cases were treated at the residence or on-site.

CONCLUSION

Further monitoring is warranted, using uniform reporting requirements, to ensure the continued compliance to the EU TPD and assess its long-term impact on related incident characteristics.

Characteristics and outcomes of e-cigarette exposure incidents reported to 10 European Poison Centers: a retrospective data analysis

Background

The use of e-cigarettes has increased during the past few years. Exposure to e-cigarette liquids, whether intentional or accidental, may lead to adverse events our aim was to assess factors associated with e-cigarette exposures across European Union Member States (EU MS).

Methods

A retrospective analysis of exposures associated with e-cigarettes reported to national poison centers was performed covering incidents from 2012 to March 2015 from 10 EU MS. De-identified and anonymous raw data was acquired.

Results

In total, 277 incidents were reported. Unintentional exposure was the most frequently cited type of exposure (71.3%), while e-cigarette refill vials were responsible for the majority of the reported incidents (87.3%). Two-thirds of all exposures (67.5%) occurred as ingestion of e-liquids, which was more frequent among children (≤ 5 years, 6–18 years) compared to adults (87.0% vs. 59.3% vs. 57.6%, p < 0.001 respectively), exposure via the respiratory (5.4% vs. 22.2% vs. 22.2%, p < 0.001) were more frequent among paediatric patients while ocular routes (2.2% vs. 3.7% vs. 11.4%, p = 0.021) were more frequent among adults. Logistic regression analyses indicated that paediatric incidents (≤ 5 years) were more likely to be through ingestion (adjusted Odds Ratio [aOR] = 4.36, 95% Confidence Interval [C.I.]: 1.87–10.18), but less likely to have a reported clinical effect (aOR = 0.41, 95% C.I.: 0.21–0.82).

Conclusions

Our study highlighted parameters related to e-cigarette exposure incidents in 10 EU MS, the results of which indicate that consideration should be given to the design features which may mitigate risks, thereby protecting users, non-users and especially children.

Pharmakokinetik von Carvon und Menthol nach Gabe einer Pfefferminzol und Kummelol enthaltenden magensaftresistenten Formulierung1

Enteric coating of peppermint oil/caraway oil capsules avoids subjective discomfort to the patient caused by gastroesophgeal reflux. In order to confirm bioequivalence of an enteric coated formulation containing peppermint oil and caraway oil (Enteroplant) and an immediate release formulation of both oils, the pharmacokinetics of menthol and carvone after oral administration of the two formulations were studied in a randomized, two-period crossover study in 16 healthy male volunteers. The subjects received 180 mg peppermint oil and 100 mg caraway oil, once as 2 enteric coated capsules of the fixed combination preparation Enteroplant containing 90 mg peppermint oil and 50 mg caraway oil each (test) and once in the form of 5 capsules of an immediate release formulation (reference) containing 36 mg peppermint oil and 20 mg caraway oil each. The capsules were taken with 250 ml water after a 10 h fast. Both substances were determined in plasma by GC/MS after extraction. The limit of quantification was 10 ng/ml for menthol and 0.5 ng/ml for carvone. The mean maximum plasma levels for menthol were 1196 ng/ml after administration of the test medication and 1492 ng/ml after administration of the reference medication. The bioavailability with respect to the AUC was comparable after administration of test and reference preparation, the 90% confidence interval was 97 to 105%. As expected, there were considerable differences for Tmax. After application of the enteric coated form the maximum concentration was reached significantly later (3.0 h vs. 1.7 h) compared to the immediate release capsule. Corresponding data were also calculated for carvone. After application of the test medication the maxima of 14 ng/ml for both formulations were reached later (2.5 h vs. 1.3 h). The 90% confidence interval of the AUC for carvone was 79% to 119% and therefore slightly outside the acceptable range for bioequivalence of 80% to 125%. However, this fact should not be relevant, in particular since the dosage of the enteric coated capsule lies at the upper limit of the model text and positive clinical studies, also on the therapeutic equivalence of the two formulations, are available.

Pharmacokinetics of menthol and carvone after administration of an enteric coated formulation containing peppermint oil and caraway oil

Enteric coating of peppermint oil/caraway oil capsules avoids subjective discomfort to the patient caused by gastroesophageal reflux. In order to confirm bioequivalence of an enteric coated formulation containing peppermint oil and caraway oil (CAS 277309-55-4, Enteroplant) and an immediate release formulation of both oils, the pharmacokinetics of menthol and carvone after oral administration of the two formulations were studied in a randomized, two-period cross-over study in 16 healthy male volunteers. The subjects received 180 mg peppermint oil and 100 mg caraway oil, once as 2 enteric coated capsules of the fixed enteric coated combination preparation containing 90 mg peppermint oil (WS 1340) and 50 mg caraway oil (WS 1520) each (test) and once in the form of 5 capsules of an immediate release formulation (reference) containing 36 mg peppermint (WS 1340) oil and 20 mg caraway oil (WS 1520) each. The capsules were taken with 250 ml water after a 10 h fast. Both substances were determined in plasma by GC/MS after extraction. The limit of quantification was 10 ng/ml for menthol and 0.5 ng/ml for carvone. The mean maximum plasma levels for menthol were 1196 ng/ml after administration of the test medication and 1492 ng/ml after administration of the reference medication. The bioavailability with respect to the AUC was comparable after administration of test and reference preparation, the 90% confidence interval was 97 to 105%. As expected, there were considerable differences for Tmax. After application of the enteric coated form the maximum concentration was reached significantly later (3.0 h vs. 1.7 h) compared to the immediate release capsule. Corresponding data were also calculated for carvone. After application of the test medication the maxima of 14 ng/ml for both formulations were reached later (2.5 h vs. 1.3 h). The 90% confidence interval of the AUC for carvone was 79 to 119% and therefore slightly outside the acceptable range for bioequivalence of 80 to 125%. However, this fact should not be relevant, in particular since the dosage of the enteric coated capsule lies at the upper limit of the model text and positive clinical studies, also on the therapeutic equivalence of the two formulations, are available.

Confocal laser scanning microscopy and scanning electron microscopy of tissue Ti-implant interfaces

Microscopic inspection of heterogenous three-dimensional (3D) objects such as oral implants, or implants in general, is conventionally performed either on ground sections of methyl-metacrylate-embedded material, at the cellular level by histologic analysis of the peri-implant tissue by light microscopy (LM), or at the supramolecular level by transmission electron microscopy (TEM). Alternatively, the architecture of the tissue/implant interface is visualized by scanning electron microscopy (SEM). The two approaches exclude each other because of the sample preparation.We elaborate conditions for the non-invasive analysis of tissue/implant interfaces by confocal laser scanning microscopy (CLSM) in buffer, hoping to obtain a 3D view of fluorescently labeled tissue constituents at the tissue implant interface and, through subsequent SEM, of the metal surface. The use of water-immersion objectives, originally developed for high LM under physiological conditions is essential. In an exploratory approach, the tissue/Ti-interfaces of two retrieved dental implants were analyzed. One was a step-cylinder used for orthodontic anchoring and the other was an endosseous step-screw implant retrieved after infection-related loosening prior to load. The adhering tissue fragments were fluorescently triple-labeled for actin, fibronectin, and sm-alpha-actin. Optical sections for fluorescent images and for the laser reflection map were registered concomitantly. This approach allowed the labeled structures to be located on the metal surface. Subsequently, the same implants were prepared for SEM of the tissue/implant interface, and upon removal of the adhering structures, of the underlying metal surface. Thus, specific proteins can be identified and their spatial architecture as well as that of the underlying metal surface can be visualized for one and the same implant. The immediate visualization after fluorescence labeling in buffer by means of water immersion objective lenses proved most critical.

Pharmacokinetics of dexibuprofen administered as 200 mg and 400 mg film-coated tablets in healthy volunteers

The pharmacokinetic properties of 2 film-coated preparations containing 200 mg and 400 mg dexibuprofen were compared in a single-dose, crossover study in 16 healthy, male volunteers. Dexibuprofen was absorbed rapidly (tmax 2.1 - 2.2 hours) reaching maximum concentrations of 12.4 microg/ml (200 mg), respectively 12.0 microg/ml (400 mg dose adjusted). For the characteristics AUC(0-12h) and AUC(0-infinity) arithmetic means of 49.2 (microg) x (h/ml)(200 mg) and 48.2 (microg) x (h/ml)(400 mg dose-adjusted), respectively 50.5 (microg) x (h/ml)(200 mg), and 49.2 (microg) x (h/ml)(400 mg) were calculated. No relevant differences for the pharmacokinetic characteristics terminal half-life, clearance, volume of distribution, and mean residence time were observed. A linear dose-relationship was shown over the investigated dose range. Mean ratios after dosage adjustment of the test preparation using the "2 one-sided t-tests" procedure were calculated. Bioequivalence was assessed for AUC(0-12h) with a mean ratio of 97.7% (90% CI: 92.4 - 103.3%), for AUC(0-infinity) with 97.1% (90% CI: 91.4 - 103.1%), and for Cmax with 97.5% (90% CI: 91.7 - 103.8%). Both dexibuprofen preparations were well tolerated. No changes in hematological and biochemical parameters were detected.

Bacterial leakage into and from prefabricated screw-retained implant-borne crowns in vitro

A mean gap of less than 4 microm following laboratory procedures and continuous loading was demonstrated in prefabricated crowns of the Ha-Ti implant system in earlier studies. The clinical relevance of such high precision in maintaining inflammation free marginal mucosa is yet to be determined. In this present investigation, the complete assembly of Ha-Ti implants including prefabricated screw-retained crowns was tested for bacterial leakage under controlled conditions in vitro. The gaps were shown not to be a barrier for Staphylococcus aureus which were used as test bacteria. Bacterial leakage through these gaps from the environment to the interior of the assembly and vice versa was observed within 24-120 h. The main path of bacterial penetration was possibly found to be through the transversal screw hole and not through the marginal gap of the prefabricated crowns.

New trends in the 3D management of CT data in plastic and reconstructive surgery

Introduction of computer aided tomography in 1972 provided surgeons with multiple 2D maps which they themselves had to conceptualize mentally into a third dimension. The later advent of computerized summation of these data made it possible to display a perspective view of the third dimension on a TV monitor. CT, with the further analytical refinement afforded by software processing (interactive data presentation, contour detection and summation, hypothetical 3D data construction and interactive visualization) now provides the basic information that is needed for the fabrication of an individual model. Such models can be milled from polyurethane. More recently, laser-hardened acrylic resins have proved to be a useful alternative. Both systems are described and their advantages and disadvantages in the planning and performance of plastic and reconstructive surgical procedures discussed in the light of present knowledge.

Pharmacokinetics and bioequivalence of the main metabolites of selegiline: desmethylselegiline, methamphetamine and amphetamine after oral administration of selegiline

A bioavailability study of 2 different selegiline preparations were conducted in 20 healthy volunteers to test the bioequivalence. Almost no bioavailability study of selegiline has been published. As plasma levels of selegiline are very low and the elimination half-life is very short being about 9 minutes, therefore, a very sensitive and selective method for determining the 3 main metabolites desmethylselegiline (DMS), methamphetamine (MA) and amphetamine (A) was developed. After application of a single oral dose of 5 mg selegiline the Cmax values of DMS reached 5-6 ng/ml, of MA 6-7 ng/ml and of A about 2 ng/ml. The AUC infinity values were with DMS about 11 ng/ml x h +/- 4.5, with MA about 130 g/ml x h +/- 50 and with A about 50 ng/ml x h +/- 15. The 90% confidence interval was with logarithmic transformed AUC infinity values 92-107% with DMS, 89-107% with MA, and 84-104% with A. The logarithmic transformed Cmax values showed a 90% confidence interval of 92-127% with DMS, 91-101% with MA, and 90-103% with A. All relevant pharmacokinetic parameters showed bioequivalence with all 3 metabolites (DMS, MA, and A).

Comparison of the bioavailability of dexibuprofen administered alone or as part of racemic ibuprofen

Two bioavailability studies of S(+)-ibuprofen (dexibuprofen) were conducted in healthy volunteers to define the relationship between the bioavailability of the drug after administration of dexibuprofen alone or as part of ibuprofen racemate. Enantioselective plasma drug analysis was used throughout. In the first study, the bioavailability of dexibuprofen from a 400 mg tablet formulation was compared with that from 400 mg in aqueous solution. The tablet formulation did not influence the bioavailability of the drug and dexibuprofen was well absorbed from the gastro-intestinal tract. The second study was divided into three identical parts. Bioavailability of dexibuprofen 200, 400 and 600 mg was compared with its bioavailability from ibuprofen racemate 400, 800 and 1200 mg. The second study showed that the mean relative bioavailability of dexibuprofen to ibuprofen racemate was 0.66, thus enabling the estimation of clinically useful dexibuprofen doses from the usual doses of the racemate. The 95% confidence interval limits did not include 0.5, leading to the conclusion that administering half of the racemate dose would not provide patients with an adequate amount of therapeutically active drug.

Individual model fabrication in maxillofacial radiology

Oral and maxillofacial surgery has long needed a methodology for accurate definition of the third dimension. The introduction of computer-aided tomography in the 1970s provided surgeons with multiple 2-D maps which they themselves had to conceptualize into a third dimension. The later advent of computerized summation of these data made it possible to display a perspective view of the third dimension on a TV monitor. CT, and more recently MRI, with the further analytical refinement afforded by software processing (interactive data presentation, contour detection and summation, hypothetical 3-D construction and interactive visualization) now provide the basic information that is needed for the fabrication of an individual model. Such models can be milled from a variety of materials. More recently, laser-hardened acrylic resins have been shown to be a useful alternative. Both systems are described and their advantages and disadvantages in the planning and performance of oral and maxillofacial surgical procedures are discussed.

Seven-year follow-up of vanishing bone disease in a 14-year-old girl

A review of the literature revealed 91 cases of massive osteolysis since the first report by Jackson in 1838, including 31 in the maxillofacial region meeting the Heffez criteria. In seven cases, early irradiation was performed, after which no further progression of bone lysis was observed. The young female patient reported here has been followed up clinically and radiologically for 7 years after radiotherapy, during which time she has remained stable, with no progression of the osteolysis. Our experience with this patient appears to confirm that early radiotherapy with a dose of 30-40 Gy prevents further progression of the disease and can even lead to recalcification. On this basis, and provided the patient remains symptom-free, reconstructive surgery appears a viable treatment option.

Alterations of pharmacokinetic properties of gentamicin, penicillin G and two cephalosporins in septicaemic rabbits

The pharmacokinetics of gentamicin, penicillin G, latamoxef and CPW 86-363, a novel third generation cephalosporin, were studied in healthy and septicaemic rabbits. Elevation of body temperature in infected animals was paralleled by statistically significant decreases in serum drug levels during the early stages of the distribution phase for penicillin G, latamoxef and CPW 86-363 whereas gentamicin showed increased serum drug levels during the early period. No significant differences were seen in tissue fluid levels (STIF) or normal and septicaemic rabbits for the four antibiotics used. Haemodynamic alterations and an increased permeability of blood vessel walls are presumed to contribute to changes in distribution properties of various drugs during experimental septicaemia. The qualitative differences among the antibiotics tested seem to be related to their physico-chemical characteristics.

Comparative pharmacokinetic analysis of latamoxef and CPW 86-363, a novel carboxy-pyrazol-cephalosporin and formation of N-methyl-thiotetrazole

The pharmacokinetics of latamoxef and CPW 86-363, a novel carboxy-pyrazol-cephalosporin, were evaluated in healthy volunteers after intravenous bolus injection of 1 g. Based on concentration-time courses in serum both cephalosporins showed similar distribution properties, although CPW 86-363 was eliminated significantly faster. The route of elimination of latamoxef was mainly via the urine, whereas CPW 86-363 was also excreted into the bile. N-methylthiotetrazole, which is the common side chain in position 3 of both cephalosporins, was found in the serum as well as in the urine. Its rate and extent of formation was higher for latamoxef than for CPW 86-363 and depends rather on the instability of the parent compound than on metabolic transformation. This is supported by studies on the in vitro degradation of both derivatives. The relevance of these findings are discussed in view of secondary coagulopathies, which are associated with cephalosporins having a N-methylthiotetrazole side chain.

[New aspects of causal therapy of hearing and speech development disorders caused by cleft palate]

Seromucous effusions were found in the tympanum in 91% of 208 cases of cleft palate. The incidence of recurrent mucosal effusions after paracentesis alone, in addition to drainage of the middle ear and poor speech results after veloplasty alone (according to Schweckendieck), led to the realization that hearing and speech disturbances in patients with cleft palates must be treated with a combination of morphologically correct veloplasty and tympanic drainage. Taking into consideration the fact that the auditory canal reaches maturation at the end of the first year of life, this procedure should be performed before the patient is 12 months old.

The utility of diffusion chambers as models for the description of drug disposition

Tissue cages were employed to explore the diffusion processes of several cephalosporins into extravascular fluids. Concentrations of cefotaxime in serum and in subcutaneous chambers increased proportionally to the amount of the drug injected. Administration of single equal doses of cephalothin, cephaloridine and cefotaxime resulted in different concentration-time courses in the serum and in diffusion chambers. These observations suggest that diffusion chambers are linked to the tissue at the implantation site. None of the classical compartmental approaches can be applied to evaluate the kinetics of drug diffusion into tissue cages. Correlations of total or non-protein bound drug concentrations in tissue cages to those in the peripheral compartment assumed concentration and time dependent diffusion processes. No specific diffusion constant based on the law of Fick could be derived for the diffusion chambers used in this study. Concentration-time courses in serum and interstitial fluid can be simultaneously evaluated according to pharmacokinetic-pharmacodynamic models. Based on the equation describing the effect site this model can be used to simulate drug concentrations in tissue cages by varying the dose size or the dose interval.

Influence of endotoxin on the distribution of cephalosporins in rabbits

The concentration: time courses of six different cephalosporins were studied in serum and interstitial fluid from issue cages after intravenous injection in normal and endotoxaemic rabbits. Circulatory and metabolic changes induced by endotoxin were similar to the altered organ function observed in patients with septicaemia. A significant shift of drug fractions, increase in the volume of distribution and prolonged mean residence times were observed in this model with ceftazidime, ceftriaxone and CPW 86-363, and were the result of specific changes in the peripheral compartment. The opposite findings were observed with cefotaxime, while latamoxef and cefoperazone resulted in no changes.