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Clinical Features of Reported Ethylene Glycol Exposures in the United States.

Jobson MA, Hogan SL, Maxwell CS, Hu Y, Hladik GA, Falk RJ, Beuhler MC, Pendergraft WF - PLoS ONE (2015)

Bottom Line: Toxicity can result in central nervous system dysfunction, cardiovascular compromise, elevated anion gap metabolic acidosis and acute kidney injury.Outcome classification was summed for intentionality and used as a basis for comparison of effect groups.Individuals more likely to experience major effects or death were older, male, and presented with more severe symptoms requiring higher levels of care.

View Article: PubMed Central - PubMed

Affiliation: University of North Carolina (UNC) School of Medicine, Chapel Hill, North Carolina, United States of America.

ABSTRACT

Background: Ethylene glycol is highly toxic and represents an important cause of poisonings worldwide. Toxicity can result in central nervous system dysfunction, cardiovascular compromise, elevated anion gap metabolic acidosis and acute kidney injury. Many states have passed laws requiring addition of the bittering agent, denatonium benzoate, to ethylene glycol solutions to reduce severity of exposures. The objectives of this study were to identify differences between unintentional and intentional exposures and to evaluate the utility of denatonium benzoate as a deterrent.

Methods and findings: Using the National Poison Data System, we performed a retrospective analysis of reported cases of ethylene glycol exposures from January 2006 to December 2013. Outcome classification was summed for intentionality and used as a basis for comparison of effect groups. There were 45,097 cases of ethylene glycol exposures resulting in 154 deaths. Individuals more likely to experience major effects or death were older, male, and presented with more severe symptoms requiring higher levels of care. Latitude and season did not correlate with increased exposures; however, there were more exposures in rural areas. Denatonium benzoate use appeared to have no effect on exposure severity or number.

Conclusion: Deaths due to ethylene glycol exposure were uncommon; however, there were major clinical effects and more exposures in rural areas. Addition of denatonium benzoate was not associated with a reduction in exposures. Alternative means to deter ingestion are needed. These findings suggest the need to consider replacing ethylene glycol with alternative and less toxic agents.

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Related in: MedlinePlus

The effect of addition of bittering agent to ethylene glycol on frequency of oral ingestions in the United States and the District of Columbia.Panels A and B show incidence of intentional (> 11 years old) and pediatric unintentional oral ingestions (≤ 6 years old) per year for all states. In 2012, bitterant was added to commercially sold antifreeze in the United States and the District of Columbia. Panels C-F show no reduction in total, unintentional, intentional (> 11 years old), or pediatric unintentional oral ingestions (≤ 6 years old) of ethylene glycol in states that have added bitterant to ethylene glycol (n = 17) compared to those that have not (n = 34) from 2006–2013. Panels G and H show no reduction in death or major effects in states that have added bitterant compared to those that have not from 2006–2013. Y-axis represents frequency per 100,000 (100 K) humans for all panels; error is SEM; p-values calculated using analysis of variance for panels A and B.
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pone.0143044.g003: The effect of addition of bittering agent to ethylene glycol on frequency of oral ingestions in the United States and the District of Columbia.Panels A and B show incidence of intentional (> 11 years old) and pediatric unintentional oral ingestions (≤ 6 years old) per year for all states. In 2012, bitterant was added to commercially sold antifreeze in the United States and the District of Columbia. Panels C-F show no reduction in total, unintentional, intentional (> 11 years old), or pediatric unintentional oral ingestions (≤ 6 years old) of ethylene glycol in states that have added bitterant to ethylene glycol (n = 17) compared to those that have not (n = 34) from 2006–2013. Panels G and H show no reduction in death or major effects in states that have added bitterant compared to those that have not from 2006–2013. Y-axis represents frequency per 100,000 (100 K) humans for all panels; error is SEM; p-values calculated using analysis of variance for panels A and B.

Mentions: Seventeen states now require addition of the bittering agent, denatonium benzoate, to ethylene glycol preparations as a means to deter individuals from ethylene glycol ingestion (S3 Table). Limiting our analysis to include only oral exposures, we found no significant difference when examining intentional and pediatric ingestions by year (Fig 3A and 3B). We examined the effect of this additive on oral ethylene glycol ingestions in states requiring addition of denatonium benzoate, as compared to states not requiring its addition, and found no significant difference in the total number of ingestions (p = 0.39), unintentional ingestions (p = 0.84), or pediatric ingestions (p = 0.151) (Fig 3C, 3D and 3F). In fact, there was a significant increase in the number of intentional ingestions in states with an enacted law (p = 0.034) (Fig 3E). Furthermore, there were no significant differences in deaths or major effects (Fig 3G and 3H).


Clinical Features of Reported Ethylene Glycol Exposures in the United States.

Jobson MA, Hogan SL, Maxwell CS, Hu Y, Hladik GA, Falk RJ, Beuhler MC, Pendergraft WF - PLoS ONE (2015)

The effect of addition of bittering agent to ethylene glycol on frequency of oral ingestions in the United States and the District of Columbia.Panels A and B show incidence of intentional (> 11 years old) and pediatric unintentional oral ingestions (≤ 6 years old) per year for all states. In 2012, bitterant was added to commercially sold antifreeze in the United States and the District of Columbia. Panels C-F show no reduction in total, unintentional, intentional (> 11 years old), or pediatric unintentional oral ingestions (≤ 6 years old) of ethylene glycol in states that have added bitterant to ethylene glycol (n = 17) compared to those that have not (n = 34) from 2006–2013. Panels G and H show no reduction in death or major effects in states that have added bitterant compared to those that have not from 2006–2013. Y-axis represents frequency per 100,000 (100 K) humans for all panels; error is SEM; p-values calculated using analysis of variance for panels A and B.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4643878&req=5

pone.0143044.g003: The effect of addition of bittering agent to ethylene glycol on frequency of oral ingestions in the United States and the District of Columbia.Panels A and B show incidence of intentional (> 11 years old) and pediatric unintentional oral ingestions (≤ 6 years old) per year for all states. In 2012, bitterant was added to commercially sold antifreeze in the United States and the District of Columbia. Panels C-F show no reduction in total, unintentional, intentional (> 11 years old), or pediatric unintentional oral ingestions (≤ 6 years old) of ethylene glycol in states that have added bitterant to ethylene glycol (n = 17) compared to those that have not (n = 34) from 2006–2013. Panels G and H show no reduction in death or major effects in states that have added bitterant compared to those that have not from 2006–2013. Y-axis represents frequency per 100,000 (100 K) humans for all panels; error is SEM; p-values calculated using analysis of variance for panels A and B.
Mentions: Seventeen states now require addition of the bittering agent, denatonium benzoate, to ethylene glycol preparations as a means to deter individuals from ethylene glycol ingestion (S3 Table). Limiting our analysis to include only oral exposures, we found no significant difference when examining intentional and pediatric ingestions by year (Fig 3A and 3B). We examined the effect of this additive on oral ethylene glycol ingestions in states requiring addition of denatonium benzoate, as compared to states not requiring its addition, and found no significant difference in the total number of ingestions (p = 0.39), unintentional ingestions (p = 0.84), or pediatric ingestions (p = 0.151) (Fig 3C, 3D and 3F). In fact, there was a significant increase in the number of intentional ingestions in states with an enacted law (p = 0.034) (Fig 3E). Furthermore, there were no significant differences in deaths or major effects (Fig 3G and 3H).

Bottom Line: Toxicity can result in central nervous system dysfunction, cardiovascular compromise, elevated anion gap metabolic acidosis and acute kidney injury.Outcome classification was summed for intentionality and used as a basis for comparison of effect groups.Individuals more likely to experience major effects or death were older, male, and presented with more severe symptoms requiring higher levels of care.

View Article: PubMed Central - PubMed

Affiliation: University of North Carolina (UNC) School of Medicine, Chapel Hill, North Carolina, United States of America.

ABSTRACT

Background: Ethylene glycol is highly toxic and represents an important cause of poisonings worldwide. Toxicity can result in central nervous system dysfunction, cardiovascular compromise, elevated anion gap metabolic acidosis and acute kidney injury. Many states have passed laws requiring addition of the bittering agent, denatonium benzoate, to ethylene glycol solutions to reduce severity of exposures. The objectives of this study were to identify differences between unintentional and intentional exposures and to evaluate the utility of denatonium benzoate as a deterrent.

Methods and findings: Using the National Poison Data System, we performed a retrospective analysis of reported cases of ethylene glycol exposures from January 2006 to December 2013. Outcome classification was summed for intentionality and used as a basis for comparison of effect groups. There were 45,097 cases of ethylene glycol exposures resulting in 154 deaths. Individuals more likely to experience major effects or death were older, male, and presented with more severe symptoms requiring higher levels of care. Latitude and season did not correlate with increased exposures; however, there were more exposures in rural areas. Denatonium benzoate use appeared to have no effect on exposure severity or number.

Conclusion: Deaths due to ethylene glycol exposure were uncommon; however, there were major clinical effects and more exposures in rural areas. Addition of denatonium benzoate was not associated with a reduction in exposures. Alternative means to deter ingestion are needed. These findings suggest the need to consider replacing ethylene glycol with alternative and less toxic agents.

Show MeSH
Related in: MedlinePlus