Too Much Iron: Iron Overdose

Iron is a mineral that functions primarily as a carrier of oxygen in the body, both as a part of hemoglobin in the blood and of myoglobin in the muscles. The body increases or decreases iron absorption according to need. The presence of vitamin C (ascorbic acid) in a meal increases iron absorption. The body absorbs iron more efficiently when iron stores are low, and during growth spurts or pregnancy.

The most common indication of poor iron status is iron deficiency anemia, a condition in which the size and number of red blood cells are reduced. This condition may result from inadequate intake of iron or from blood loss. 
When there is insufficient iron from dietary sources, or as a result of blood loss in the body, the amount of hemoglobin in the bloodstream is reduced and oxygen cannot be efficiently transported to tissues and organs throughout the body. Iron-deficiency anemia is characterized by fatigue, shortness of breath, pale skin, concentration problems, dizziness, a weakened immune system, and energy loss.

Inadequate intake or iron can cause ill-health but just as important as a cause of illness is consuming too much of Iron. Indeed, Iron excess is a greater risk than iron deficiency for many older Americans. In a study of more than 1,000 white men and women aged 67 to 96 who live at home, 13 percent had too much iron in their blood, but only three percent had too little. 

Healthy people usually absorb about 10 percent of the iron contained in the food they eat to meet the body needs. This is why we need to take iron supplements. But wait a minute. We need to get a few things clear. Let's define anemia: a deficiency of red cells or hemoglobin, or red cells that die too young or are discolored or possess an abnormal shape, or red cells that lack adequate iron. Now defining iron deficiency vary from lab to lab. Most "normal" levels are set too high. Saturation: 12 to 40-45% is reasonable at the present time. Ferritin: 5 to probably 50. Think about it. If "normal" levels are set artificially high, and your levels fall below that "normal," you are "iron deficient."

So how much iron do you really need? Iron is not excreted. The iron you absorb stays and accumulates in storage except that you can lose one milligram a day through hair, finger nails, skin cells and other detritus. That is the amount needed every day to replace the loss. One milligram, that’s all and for women in reproductive years, one and a half milligram. The other way to lose iron, of course, is by blood loss.

The other thing to note is that hemoglobin is not iron! Yes, you are anemic if your hemoglobin is low but that does not necessarily mean your iron is low. Indeed, what might be happening is that the iron is collecting in storage instead of going into hemoglobin. You are actually iron-loaded and need iron removed despite the anemia. The anemia should be treated with B vitamins, especially B12, B6 and folic acid. Many patients with anemia are dying of iron overload, and some are hastened to their death by their physicians who give them more iron.

Even a small amount of excess iron can damage heart and brain and other storage sites in the body and lead to heart attack or stroke. There is exaggerated concern when hemoglobin falls temporarily, following surgery, for example. Blood transfusions are over-used. A study shows that surgery patients who do not receive transfusions survive better than those who do.1 

Before taking iron you must test saturation and ferritin. Ferritin indicates storage iron, which is not essential to maintain life. If both saturation and ferritin are extremely low, you must find out why. Low iron is a signal that iron is being used by cancer cells or is feeding bacteria, or usually it means there is chronic daily blood loss. The bleeding could be from an ulcer or tumor, etc. The source must be found.

Iron is in just about everything. If you are not absorbing the one daily milligram, you are truly on a starvation diet, and low iron is the least of your worries. So, go for iron supplementation only when you need it and be aware of iron's toxic ability to harm you. 

Severe iron overload, which causes liver and heart damage, can occur in people who are genetically susceptible. This is called haemochromatosis. Haemochromatosis, also called iron storage disease, or bronze diabetes is an inborn metabolic defect characterized by an increased absorption of iron, which accumulates in body tissues. The body has no natural way to rid itself of excess iron, so extra iron is stored in body tissues, especially the liver, heart, and pancreas.

People with haemochromatosis absorb more than the body needs The clinical manifestations include skin pigmentation, diabetes, enlargement of the spleen and liver, heart failure, and general weakness and lassitude. In males, the symptoms are usually noted after 35 years of age, and in females, after menopause, when iron is no longer lost through menstruation and pregnancy. Treatment consists of the removal of blood at regular intervals to decrease the concentration of body iron.

Excess stored iron can lead to atherosclerosis and ischemic heart disease. Phlebotomy, or blood removal, has been used to reduce stored iron in patients with iron overload with some success. Iron chelation with drugs such as desferrioxamine (Desferal) that help patients excrete excess stores of iron can be helpful in treating iron overload caused by multiple blood transfusions.

Anticoagulant rodenticides poisoning

Alternative Names

Rat killer poisoning; Rodenticide poisoning
Definition of Anticoagulant rodenticides poisoning:

Anticoagulant rodenticides are very poisonous products used to kill rats. Rodenticide means rodent killer. Anticoagulant is a blood thinner.

Anticoagulant rodenticide poisoning occurs when someone swallows a product containing these chemicals.

This is for information only and not for use in the treatment or management of an actual poison exposure. If you have an exposure, you should call your local emergency number
Poisonous Ingredient:
2-iso-valeryl-1,3-indandione
2-pivaloyl-1,3-indandione
Brodifacoum
Chlorophacinone
Coumachlor
Difenacoum
Diphacinone
Warfarin

Aspirin

Alternative Names

Acetylsalicylic acid overdose
Definition of Aspirin overdose:

An overdose of aspirin means you have too much aspirin in your body.

This can happen in two ways:

If a person accidentally or intentionally takes a very large dose of aspirin at one time, it's called an acute overdose.

If a normal daily dose of aspirin builds up in the body over time and causes symptoms, it's called a chronic overdose. This may happen if your kidneys do not work correctly or when you are dehydrated. Chronic overdoses are usually seen in older patients during hot weather.

This is for information only and not for use in the treatment or management of an actual poison exposure. If you have an exposure, you should call your local emergency number (such as 911) or the National Poison Control Center at 1-800-222-1222.
Poisonous Ingredient:

Acetylsalicylic acid
Where Found:

Acetylsalicylic acid (aspirin) can be found in many prescription and over-the-counter pain relievers, including:
Alka Seltzer
Anacin
Bayer
Bufferin
Ecotrin
Excedrin
Fiorinal
Percodan
St. Joseph's

Principles of Drug Addiction Treatment

Drug addiction is a complex disorder that can involve virtually every aspect of an individual's functioningÑin the family, at work, and in the community. Because of addiction's complexity and pervasive consequences, drug addiction treatment typically must involve many components. Some of those components focus directly on the individual's drug use. Others, like employment training, focus on restoring the addicted individual to productive membership in the family and society (see Components of Comprehensive Drug Abuse Treatment diagram).

Treatment for drug abuse and addiction is delivered in many different settings, using a variety of behavioral and pharmacological approaches. In the United States, more than 11,000 specialized drug treatment facilities provide rehabilitation, counseling, behavioral therapy, medication, case management, and other types of services to persons with drug use disorders.

Because drug abuse and addiction are major public health problems, a large portion of drug treatment is funded by local, State, and Federal governments. Private and employer-subsidized health plans also may provide coverage for treatment of drug addiction and its medical consequences.

Drug abuse and addiction are treated in specialized treatment facilities and mental health clinics by a variety of providers, including certified drug abuse counselors, physicians, psychologists, nurses, and social workers. Treatment is delivered in outpatient, inpatient, and residential settings. Although specific treatment approaches often are associated with particular treatment settings, a variety of therapeutic interventions or services can be included in any given setting.

General Categories of Treatment Programs

Research studies on drug addiction treatment have typically classified treatment programs into several general types or modalities, which are described in the following text. Treatment approaches and individual programs continue to evolve, and many programs in existence today do not fit neatly into traditional drug addiction treatment classifications. Examples of specific research-based treatment components are described in the Approaches to Treatment Section

Working With Drug Addicts

Recent survey of more than 1100 personnel administrators concluded that drug and alcohol abuse are more likely to cost a person their job than incompetence. Drug abuse has affected every area of society; the music business is no exception.

Some believe that drug addiction is more pervasive in show business, while others counter that this perception exists only because of the high-profile nature of the industry. The fact that drug addiction crops up everywhere suggests that it is an illness particular to human nature, not a specific industry.

There is little solace in this however, when a musician you know becomes difficult to get along with, unreliable or untrustworthy, incapable of performing, or even violent due to their worsening drug or alcohol problem. It would be wonderful if we lived in a world free of drugs and drug addiction, but until that day arrives musicians may find themselves inadvertently working with others who have become victims of this very serious illness. What follows is some helpful perspective and advice for those who are struggling with this situation, or those who simply wish to know more about it.

There are a myriad of attitudes concerning drug addiction, and drug addicts. (From here on we will refer to persons addicted to drugs and/or alcohol as one group: drug addicts.) Unfortunately, there are still those who believe this condition to be the result of poor judgement, or perhaps a flawed character. The consensus among modern health care professionals, including the American Medical Association (AMA), is that drug addiction is a disease. Theories concerning its origins embody the classic "nature vs. nurture" arguments: Does one become an addict because of genetics, environment and upbringing, or a combination thereof? It may be safely concluded that the origins of drug addiction are many, and complex.

Cultivating an awareness of this issue begins with the realization that drug addicts are not necessarily bad people, but rather victims of their illness. Some people have what is known as an addictive personality - a predisposition to become dependent on a certain lifestyle, or substance. Examples are compulsive eaters or gamblers, those who accumulate excessive debt, and drug addicts, who become addicted to substances. For the drug addict, a simple "just say no" is insufficient. The nature of their illness is such that they have not naturally developed the kind of rational self-control that allows most people to remain free of addiction. Addicts become mired in their habit without realizing that a problem is developing, and they practice denial in order to maintain their increasingly fragile world.
The drug addict will go to great lengths to deny that their use of drugs is the reason for a deteriorating situation. They tend to blame their problems on those around them, including friends, co-workers, and loved ones. Being in a band with such a person is very, very difficult if that person is hostile and blaming, when it's obvious that the drug habit is the real problem. Most groups will tolerate this situation for a while, hoping the problem "solves itself" by merely disappearing, or that the addict will respond to suggestions, or even ultimatums that they "clean up their act." Ultimatums may be temporarily effective, but unless the addict seeks true rehabilitation, problems will invariably recur. Sadly, many addicts lose their jobs and are left alone, denying responsibility, blaming the band member(s) responsible for his or her firing.

When a musician loses his or her job, it's because the other band members have been forced to make a choice. A band is a unique environment: one third team, one third business, one third family. It's very difficult to discharge a member of this "family" when the person is in such obvious trouble and pain. And yet, that person is most likely not contributing fully to the team effort, and may actually be severely damaging to the business effort. A band may have to cancel engagements, or whole tours if a crucial member is unable to perform, and the situation becomes more critical when the other members' livelihoods, including the ability to feed a family, or pay rent or a mortgage are threatened. Every drug addict is an individual, and the demands of every band's situation vary, but there are limits to the number of times band members are able to give the addict the benefit of the doubt, and to the number of broken promises a band is able to endure.

The past decade has seen increased awareness of and concern for drug addicts, and increased ability to effectively treat their illness. There are full-time self-help groups such as Alcoholics Anonymous (AA), and its first cousin Narcotics Anonymous (NA) dedicated to providing drug addicts with help and support. There are many other public and private organizations with similar goals, including those oriented towards helping "concerned persons" - the family, friends, and co-workers of addicts. One of these groups is an excellent place for band members to go for help with bringing one of their own to rehabilitation. While AA and NA offer free support, private rehabilitation facilities can be very costly. The costs and types of rehabilitation programs vary however, and the addition of substance abuse to the list of illnesses recognized by the AMA has made treatment for drug addiction eligible for coverage under many health insurance policies.
In the health care industry, it's believed that in order for rehabilitation to succeed, an addict must sincerely want to be helped. There is a natural tendency, in observing a person's debilitating addiction, to try to help the addict with a heart-to-heart talk, to try to "bring them to their senses." As well-intentioned as this may be, most addicts feel they don't want help, instead believing they have no problem, or that those outside their situation don't understand. It's also possible for a talk of this nature to backfire, leaving the addict alienated and angry with his or her friends. It may be more helpful to have a recovering (rehabilitated) addict talk to the addict, someone who does understand, someone who has been there and made it back. If you don't know such a person, a call to a local chapter of either AA or NA may prove helpful, as these groups are in touch with successfully rehabilitated addicts who are willing to help with these situations. Frequently however, merely talking to an addict won't inspire any significant change, regardless of who's doing the talking. In order for many addicts to abandon their denial, and want to renounce drugs, they must first hit bottom.

"Hitting bottom" is fairly self explanatory: the person's life must reach a profound level of unhappiness, the previously unlimited reservoir of denial finally gone dry. A person may hit bottom due to a combination of undeniable circumstances, such as failing health, divorce, or arrest for drunken driving or drugs. The fact that these events are referred to as "sobering" is no coincidence. If an addict/musician you know does hit bottom, and asks for help getting straight, it behooves you to give that addict all the help and support you can. It may be difficult to completely forgive and forget all the transgressions that person may have committed as a result of his or her addiction, but remember: they were incapacitated by a very serious illness. Their previously irrational behavior was most likely irrelevant to their true personality, the one finally asking for, and deserving of your help.

Not every drug addict is completely incapacitated by their addiction. In fact, the greatest numbers of addicts in society today are called "functional" drug addicts. They can regulate when they ingest their substance(s) of choice, which enables them to function in an apparently normal fashion. The functional addict can hold a job, make payments on a car or house, even maintain a family life. Amazingly, it's even possible for the addict to keep his or her addiction a secret from a spouse! If you are in a band with such a person, you will notice their regular abuse of the substance, their devotion to it, and a tendency to promote its usage. Functional alcoholics are capable of drinking large quantities without appearing drunk, because of their increased tolerance for alcohol. Ironically, the ability to drink large amounts is viewed by some as a sign of strength, while it is in fact a warning signal of alcoholism - a long-term degenerative illness.

Coexistence with the functional drug addict is somewhat more feasible than with the chronic addict, but there are definite dangers. While the functional drug addict is not completely out of control, he or she is still dependent on their drug, and that dependence is more likely to show itself at times of stress or pressure. In the music business, this can manifest itself at the worst possible times, such as when a group is given an important break, and pressure is at peak level. Remember that the addict's behavior, even the functional addict, is not necessarily based on rational thought. Thus, any working relationship with even a functional addict involves some element of risk. Again, a matter of choice: How much risk is acceptable in order to continue to work with a functional drug addict?

An important part of an addict's denial is the ability to excuse and rationalize his or her behavior. When a band is on the road, an addict will stubbornly maintain that "what I do on my own time is my business." The rationale is that as long as they are not at the gig, they are free to do as they please. This is a flawed, dangerous argument. The road is a twenty-four hour/day work environment; the musician on the road is responsible to the band all of the time. Most top organizations subscribe to this policy, and will not tolerate any drugs at any time while on the road. The reasoning is obvious when one considers the illegal nature of many abused drugs, and that a musician's offstage drug habits can very well affect what happens onstage. It is unlikely that a musician up all night the previous night "partying" will perform up to standards. No top organization can afford to have any member perform below par at any time.

The freelance musician works in a different context than the band player. Rather than being part of a full-time "family," the freelance works with a variety of faces from gig to gig. The dynamics are quite different than those of a band. Band members depend on one another, and the consequences of any member being in trouble with drugs are deeply felt by all. But the independent musician may not consider an addict on the gig a threat to his or her own career. The freelance may view the addict's dependency on drugs as "someone else's problem," and take comfort in knowing that he or she was not responsible for a bad performance. In a world where individual survival is difficult enough, such an attitude may suffice. More likely the freelance, like the band member, will feel the stress imposed upon the work environment by the drug addict. Attempting to make music with an intoxicated musician is a difficult, sometimes embarrassing experience. It brings a sense of disappointment - even though the freelance can look forward to a different lineup on the next gig, he or she will feel cheated out of the joy derived from playing music. The experience also leaves one feeling sad. The community of professional musicians is a tight-knit group, and one need not work in the family environment of a band in order to feel concern for a friend and fellow musician.

Thankfully, many millions of drug addicts have sought rehabilitation. Upon asking for help, an addict must learn to accept the knowledge that even if they give up drugs forever, they will still be addicted to them, forever. It becomes their goal to live life "one day at a time" by not doing any drugs that day, rather than dwelling on staying clean for their entire lifetime, which may seem an overwhelming task. This is a proven philosophy, and has helped millions of addicts enjoy healthy lifestyles and productive careers. The addict/musician who seeks help is faced with some special challenges, however. A large number of the opportunities to play occur in places where alcohol is not only served, but encouraged. The recovering addict will be regularly surrounded by people consuming alcohol, which can be very unnerving, especially in the first year of rehabilitation. Those helping the addict may recommend that they eliminate their exposure to drugs and alcohol entirely, which poses a very difficult situation for the musician who makes a living playing in nightclubs. There is no single solution to this dilemma; every addict is an individual. Some addicts must severely modify their lifestyle to stay clean, some are able to continue on the club circuit. If an addict must forgo the nightclub scene however, they need not completely retire from playing. There are opportunities to perform in a drug-and-alcohol-free environment, such as the recording studio, rehearsal band, orchestra pit, and of course, the concert stage.

Life on the road may conflict with the recovering addict's attempt to maintain a sense of stability in their new life. One of the ways musician/addicts are able to maintain their sobriety while on the road is by seeking the help and support of other recovering addicts. Alcoholics Anonymous and Narcotics Anonymous hold free meetings on a regular basis at their thousands of local branches. The recovering addict can find strength and support at these meetings, enough to make it through the gig and on to the next town. This is a very viable option for the travelling musician.

It is important to note that it's possible for the recovering addict to suffer a relapse, especially if that person was not truly ready to renounce drugs. A relapse is a very traumatic experience for all concerned persons, and can lead to feelings of hopelessness, and questions of the entire rehabilitation process. During this difficult time, try to remember that drug addiction is an illness, and like many other illnesses, relapse is an unfortunate fact of life. Of the millions of successful recovering addicts in our society, many have had to battle their addiction more than once. Never abandon hope for such a person.

The preceding paragraphs pose a number of very difficult questions about making choices and taking risks. There are no easy answers to these questions; they are left to the individual. Working in a band, or freelance situation with one or more drug addicts can be a frustrating, confusing, even heartbreaking experience. But regardless of how difficult a situation becomes, and how debilitating an addict's illness grows to be, there is always hope. Anyone who has witnessed a drug addict's hitting bottom, and subsequent rehabilitation, will also witness the elation and rejuvenation of that person. Recovering addicts have enormous energy, as well as renewed feelings of clearheadedness and self-worth. It is a great joy to regain a friendship that had been disabled since the person's addiction took over, and to witness the return of artistic prowess that had been buried for so long. In an imperfect world, full of imperfect people, this is the one silver lining found within the cloud of drug addiction.

Drug addiction

You may be hooked emotionally and psychologically. You may have a physical dependence, too. If you have a drug addiction, you have intense cravings for the drug. You want to use it again and again. When you stop taking it, you may have unpleasant physical reactions.

While not everyone who uses drugs becomes addicted, many people do. Drug addiction involves compulsively seeking to use a substance, regardless of the potentially negative social, psychological and physical consequences. Certain drugs are more likely to cause physical dependence than are others.

Breaking a drug addiction is difficult, but not impossible. Support from your doctor, family, friends and others who have a drug addiction, as well as inpatient or outpatient drug addiction treatment, may help you beat your drug dependence.

Botulism

Botulism is an acute neurologic disorder that causes potentially life-threatening neuroparalysis due to a neurotoxin produced by Clostridium botulinum. The toxin binds irreversibly to the presynaptic membranes of peripheral neuromuscular and autonomic nerve junctions. Toxin binding blocks acetylcholine release, resulting in weakness, flaccid paralysis, and, often, respiratory arrest. Cure occurs following sprouting of new nerve terminals.

The 3 main clinical presentations of botulism include infant botulism (IB), foodborne botulism (FBB), and wound botulism (WB). Additionally, because of the potency of the toxin, the possibility of botulism as a bioterrorism agent or biological weapon is a great concern.¹ For more information, see CBRNE – Botulism.

Infant botulism is caused by ingested C botulinum spores that germinate in the intestine and produce toxin. These spores typically come from bee honey or the environment. Most infants fully recover with supportive treatment; the attributed infant mortality rate is less than 1%. Improperly canned or home-prepared foods are common sources of the toxin that can result in foodborne botulism. Wound botulism results from contamination of a wound with toxin-producing C botulinum. Foodborne botulism and wound botulism occur predominantly in adults and are the focus of this article.

C botulinum is an anaerobic gram-positive rod that survives in soil and marine sediment by forming spores. Under anaerobic conditions that permit germination, it synthesizes and releases a potent exotoxin. Microbiologically, the organism stains gram-positive in cultures less than 18 hours old. The organism may stain gram-negative after 18 hours of incubation, potentially complicating attempts at diagnosis. On a molecular weight basis, botulinum toxins are the most potent toxins known.

Eight antigenically distinct C botulinum toxins are known, including A, B, C (alpha), C (beta), D, E, F, and G. Each strain of C botulinum can produce only a single toxin type. Types A, B, E, and, rarely, F cause human disease. Toxins A and B are the most potent, and the consumption of small amounts of food contaminated with these types has resulted in full-blown disease. During the last 20 years, toxin A has been the most common cause of foodborne outbreaks; toxins B and E follow in frequency. In 15% of C botulinum infection outbreaks, the toxin type is not determined. Toxins C and D cause disease in various animals. Type G toxin has been associated with sudden death but not with neuroparalytic illness. It was isolated from autopsy material from 5 patients in Switzerland in 1977.

Pathophysiology

The mechanism of action involves toxin-mediated blockade of neuromuscular transmission in cholinergic nerve fibers. This is accomplished by either inhibiting acetylcholine release at the presynaptic clefts of the myoneural junctions or by binding acetylcholine itself. Toxins are absorbed from the stomach and small intestine, where they are not denatured by digestive enzymes. Subsequently, they are hematogenously disseminated and block neuromuscular transmission in cholinergic nerve fibers. The nervous, gastrointestinal, endocrine, and metabolic systems are predominantly affected.

Because the motor end plate responds to acetylcholine, botulinum toxin ingestion results in hypotonia that manifests as descending symmetric flaccid paralysis and is usually associated with gastrointestinal symptoms of nausea, vomiting, and diarrhea. Cranial nerves are affected early in the disease course. Later complications include paralytic ileus, severe constipation, and urinary retention.

Wound botulism results when wounds are contaminated with C botulinum spores. Wound botulism has developed following traumatic injury that involved soil contamination, among injection drug users (particularly those who use black-tar heroin²), and after cesarean delivery. The wound may appear deceptively benign. Traumatized and devitalized tissue provides an anaerobic medium for the spores to germinate into vegetative organisms and to produce neurotoxin, which then disseminates hematogenously. The nervous, endocrine, and metabolic systems are predominantly affected. Symptoms develop after an incubation period of 4-14 days, with a mean of 10 days. The clinical symptoms of wound botulism are similar to those of foodborne botulism except that gastrointestinal symptoms (including nausea, vomiting, diarrhea) are uncommon.

Frequency

United States

In the United States, approximately 154 cases of botulism are reported annually to the Centers for Disease Control and Prevention (CDC). Infant botulism accounts for nearly 75% of all botulism cases.

The incidence of foodborne botulism is approximately 24 cases per year. The incidence of wound botulism is 3 cases per year. The incidence of infant botulism is 71 cases per year, with a mean age of 3 months.

Toxin A is found predominantly west of the Mississippi River. Toxin B is found most commonly in the eastern United States. Toxin E is found in northern latitudes, such as the Pacific Northwest, the Great Lakes region, and Alaska. The frequency of botulism in native Alaskans is among the highest in the world.³ Toxin E outbreaks are frequently associated with fish products.

International

Human botulism is found worldwide. Spores from C botulinum strains that produce type A or B toxins are distributed widely in the soil and have been found throughout the world. Toxin type B is commonly found in Europe. Toxin G was originally isolated in Switzerland.

Mortality/Morbidity

• Mortality rates vary based on the age of the patient and the type of botulism. Foodborne botulism carries an overall mortality rate of 5-10%. Wound botulism carries a mortality rate that ranges from 15-17%. The risk of death due to infant botulism is usually less than 1%.
• The recovery period from botulism is often prolonged (30-100 d). Some patients demonstrate residual weakness or autonomic dysfunction for 1 year after the onset of the illness. However, most patients achieve full neurologic recovery. Permanent deficits may occur in those who sustain significant hypoxic insults.

Sex

Wound botulism is more common in males. Foodborne botulism has no sexual predilection.

Age

Foodborne botulism and wound botulism predominately occur in adults. The mean age of infant botulism is 3 months.

Clinical

History

Following the onset of symptoms, botulism quickly progresses over several days. The magnitude of the neuromuscular impairment can advance hourly. Persons who survive this phase eventually stabilize and then recover over a period of days to months. The mechanism of recovery is not fully understood but requires the generation of new presynaptic axons and the formation of new synapses, as the original synapses are permanently affected. As with tetanus, recovery from botulism does not confer long-term immunity. Rare reports have described a second episode in the same patient.

• Foodborne botulism
  • Foodborne botulism should be suspected in patients who present with an acute gastrointestinal illness associated with neurologic symptoms. Symptoms usually appear within 12-36 hours following consumption of contaminated food products. The severity of the illness varies from mild to severe, but death can occur within 24 hours.
  • The incubation period is usually 18-36 hours. Depending on toxin dose, the incubation period ranges from 2 hours to 8 days. The onset of symptoms can be abrupt or can evolve over several days.
• Wound botulism
  • Patients with wound botulism typically have a history of traumatic injury with wounds that are contaminated with soil.
  • Since 1994, the number of patients with wound botulism who have a history of chronic intravenous drug abuse has increased dramatically. In most cases, black-tar heroin has been the implicated vehicle.
  • Rare cases of wound botulism after cesarean delivery have been documented.
  • Aside from a longer incubation period, wound botulism is similar to foodborne botulism. The incubation period of wound botulism ranges from 4-14 days, with a mean of 10 days. Unlike foodborne botulism, wound botulism causes no gastrointestinal symptoms. Patients may be febrile, but this is more likely due to the wound infection rather than the wound botulism. In many cases, the wound appears benign.

Physical

More than 90% of patients with botulism have 3-5 of the following signs or symptoms: nausea, vomiting, dysphagia, diplopia, dilated/fixed pupils, and an extremely dry mouth unrelieved by drinking fluids.

• Generally, botulism progresses as follows:
• Preceding or following the onset of paralysis are nonspecific findings such as nausea, vomiting, abdominal pain, malaise, dizziness, dry mouth, dry throat, and, occasionally, sore throat. Except for nerves I and II, the cranial nerves are affected first.
• Cranial nerve paralysis manifests as blurred vision, diplopia, ptosis, extraocular muscle weakness or paresis, fixed/dilated pupils, dysarthria, dysphagia, and/or suppressed gag reflex. Additional neurologic manifestations include symmetric descending paralysis or weakness of motor and autonomic nerves.
• Respiratory muscle weakness may be subtle or progressive, advancing rapidly to respiratory failure. Progressive muscle weakness occurs and often involves the muscles of the head and neck, as well as intercostal diaphragmatic muscles and those of the extremities.
• The autonomic nervous system is also involved. Manifestations of this include the following:
• Paralytic ileus advancing to severe constipation
• Gastric dilatation
• Bladder distention advancing to urinary retention
• Orthostatic hypotension
• Reduced salivation
• Reduced lacrimation
• Other neurologic findings include the following:
• Changes in deep tendon reflexes, which may be either intact or diminished
• Incoordination due to muscle weakness
• Absence of pathologic reflexes and normal findings on sensory and gait examinations
• Normal results on mental status examination
• Many patients with foodborne botulism and wound botulism are afebrile.

Causes

• Causes of wound botulism have been associated with traumatic injury involving contamination with soil, chronic abuse of intravenous drugs (eg, black-tar heroin), and cesarean delivery. Wound botulism illness can occur even after antibiotics are administered to prevent wound infection.
• Foodborne botulism results from the ingestion of preformed neurotoxins; A, B, and E are the most common. On average, 24 cases of foodborne botulism are reported annually.
  • High-risk foods include home-canned or home-processed low-acid fruits and vegetables; fish and fish products; and condiments, such as relish and chili peppers.
  • Commercially processed foods and improperly handled fresh foods are occasionally associated with botulism outbreaks.
  • Outbreaks of foodborne botulism in restaurants, schools, and private homes have been traced to uncommon sources, such as commercial pot-pies, baked potatoes,⁴ beef stew, turkey loaf, sautéed onions, chopped garlic in oil,⁵ and cheese sauce.

References

Contents
Overview:	Botulism
Differential Diagnoses & Workup:	Botulism
Treatment & Medication:	Botulism
Follow-up:	Botulism
Multimedia:	Botulism

Cannabis and crime

Andy Coghlan correctly identified minimising the harms caused by cannabis use as the focus for the Beckley Foundation Cannabis Commission's report "Moving beyond stalemate" (3 January, p 6). It is important to stress that the legalisation option mentioned in the article is only one of many alternatives to prohibition put forward in our report for governments to consider.

Under a decriminalisation regime, cannabis use and possession remain illegal but those who break the law are not subjected to arrest and prosecution, thereby alleviating some of the social harms that can result from treating users as criminals.

By contrast, legalisation would allow a legitimate cannabis market to be established. The authors do suggest that in looking beyond decriminalisation governments should consider a regulated cannabis market as one option, for the reasons Coghlan highlighted. They point out, however, that it is not known what the consequences of such a market would be for levels of cannabis use and the resulting harms, because it has never been tried. They accordingly recommended that if this policy were introduced it would have to be subject to an ongoing process of review and evaluation.

The evidence from the Dutch experience - an imperfect example of such a market, as cannabis production there is still illegal and therefore unregulated - is mixed, although it does not appear to be associated with higher levels of use and harm than other European countries.

The commissioners of the Beckley report are world-renowned experts in drugs and drugs policy. Their report recognises that the UN convention governing cannabis control is almost 50 years old and long overdue for reform. The Beckley Foundation and the commission support an evidence-based, evolutionary process to changing cannabis law.