The majority of exposures to e-cigarette devices and components occurred in children of 5 years or below due to accidental exposure. Based on the available data, the reported exposures have resulted in minimal toxicity. Calls to Poison Centers regarding these products have rapidly increased since 2010, and continued surveillance may show changes in the epidemiological trends surrounding e-cigarette exposures.

Introduction Phosgene is a rare exposure with strong clinical implications. We report a phosgene exposure that resulted in the patient's death. Case Report A 58 year-old man arrived to the emergency department 1 hour after exposure to phosgene with complaints of a sore throat. Initial vital signs were blood pressure 175/118 mmHg, heart rate 98/min, respirations 12/min, and oxygen saturation of 93% on room air. Physical exam revealed few scattered rhonchi, without signs of distress. Initial arterial blood gases (ABG's) revealed pH 7.42, pCO2 43 mmHg, pO2 68 mmHg, HCO3 27 meq/L, and oxygen saturation of 93% on room air. Initial chest x-ray 2 hours after the exposure demonstrated clear lung fields. Approximately 2.5 hours after the exposure, he began complaining of dyspnea, restlessness and his oxygen saturation dropped below 90%.He received nebulized albuterol, 1 gram intravenous methylprednisolone, and 100 % oxygen via face mask. Minimal improvement was noted and he was intubated. The post intubation chest x-ray, 3.5 hours after the exposure, revealed diffuse alveolar infiltrates. Acetylcysteine, terbutaline, and IV steroids were administered without improvement. The patient died 30 hours after exposure. Discussion There are many misunderstandings concerning phosgene due to its rare presentation. Traditional treatment modalities are often unproven in human trials and were unsuccessful in this case. Conclusion This case highlights the significant toxicity that results from phosgene exposure and the challenges of the limited treatment modalities. There is concern for the use of this agent in chemical terrorism.

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Johnson FK, Ciric S, Boudriau S, et al., Effects of alcohol on the pharmacokinetics of morphine sulfate and naltrexone hydrochloride extended release capsules. J Clin Pharmacol 2012; 52:747-756. Background: The coingestion of ethanol and opioids can lead to potentially life-threatening effects. Prior studies of hydromorphone extended release preparations showed that ethanol altered extended release characteristics, leading to product withdrawal. Research Question: Does coadministration of ethanol affect the bioavailability or kinetics of morphine or naltrexone from a morphine sulfate/naltrexone (MS-sNT) extended release capsule?Methods: An open-label, randomized, single-dose, fourway crossover, four sequence pharmacokinetic drug interaction study between MS-sNT (EMBEDA) 60 mg capsules and ethanol was conducted. MS-sNT 60 mg was given with 4, 20, and 40 % ethanol or water. Serial blood samples for ethanol, morphine, naltrexone, and 6-β-naltrexol concentration were obtained and used to determine standard kinetic descriptors. Results: A total of 32 participants enrolled in the study and 31 completed all four study arms. Peak ethanol concentrations occurred within 1 h post-ingestion in all three ethanol treatment groups. MS-sNT administration with 4 and 20 % ethanol displayed profiles similar to MS-sNT with water, while MS-sNT administered with 40 % ethanol resulted in an increased rate of morphine absorption and a twofold increase in peak plasma morphine concentrations. Bioavailability of morphine across all three ethanol groups was similar to the reference arm. Naltrexone was largely undetectable in the majority of samples. Thus, kinetics were not determined. Conclusion: Administration of MS-sNT with 4 or 20 % ethanol did not significantly alter the pharmacokinetics of the morphine dose. The administration of MS-sNT with 40 % ethanol (equivalent to more than five 1.5 oz shots of hard liquor) resulted in a modified extended release profile of morphine that was different from that of immediaterelease morphine solution. Ethanol coingestion does not appear to alter naltrexone sequestration. Thus, the risk of opioid withdrawal following coingestion of ethanol and MS-sNT with alcohol may be low. Critique: This generally well-conducted study specifically examined the single-dose kinetics of morphine and naltrexone when intact MS-sNT (EMBEDA) was coadministered with ethanol under fasting conditions. There are two methodological questions from the report. First, it is not clear how many data points were excluded in patients that experienced vomiting. Second, the subjects in this study did not receive regular release morphine, so comparing results from the current study to a prior study may not be valid. We agree with the authors that it is not feasible to extrapolate the study results to instances in which the MS-sNT is deliberately tampered with and coingested with ethanol. Unfortunately, in a majority of coingestions, it is exceedingly difficult to estimate the amount of ethanol consumed with any degree of accuracy. This...

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