Tag Archives: mycotoxin

Sponsored by Agilent

Agilent Introduces New eMethods & Consumables Kits

By Cannabis Industry Journal Staff
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Sponsored by Agilent

Agilent Technologies just announced a new line of products for cannabis testing labs. Their newest tool, Agilent eMethods, are downloadable, plug-and-play instrument methods that “establish reliable efficient protocols with an end-to-end workflow that addresses the different testing needs, and offers guidance on sample preparation, consumables, and supplies.”

Those eMethods give labs a complete analytical system configuration for automating testing, sample prep, separation and detection, along with data processing and reporting abilities. The tool is designed with startup labs in mind, given how tedious developing new testing methodology can be.

According to Monty Benefiel, vice president at Agilent and general manager of the Mass Spectrometry Division, the new tool should give some labs a head start when it comes to method development. “The fledgling market of cannabis and hemp testing has an urgent need for solutions that help ensure efficiency as well as regulatory compliance,” says Benefiel. “Our new tool—Agilent eMethods—along with the Cannabis and Hemp Potency Kit and Cannabis Pesticide and Mycotoxin Kit gives labs a head start in establishing testing procedures, increasing productivity and profitability, and greatly reducing risk.”

In addition to the new eMethods, the company is also rolling out their newest consumables kits: The Cannabis and Hemp Potency Kit and the Cannabis Pesticide and Mycotoxin Kit. These are designed to help labs set up and simplify analyses for complex matrices. They include all the consumables necessary to perform each test and come with step-by-step instructions.

Swetha Kaul, PhD

An Insider’s View: How Labs Conduct Cannabis Mold Testing

By Swetha Kaul, PhD
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Swetha Kaul, PhD

As both recreational and medical cannabis legalization continues to progress across the country, each state is tasked with developing regulatory requirements to ensure that customers and patients receive clean cannabis for consumption. This requires cannabis to undergo laboratory testing that analyzes the presence of microbial impurities including yeast and mold.

Some states, such as Colorado, Nevada, Maine, Illinois and Massachusetts use total yeast and mold count testing (TYMC) and set a maximum yeast and mold count threshold that cultivators must fall below. Other states, such as California, require the detection of species-specific strains of Aspergillus mold (A. fumigatus, A. flavus, A. niger and A. terreus), which requires analyzing the DNA of a cannabis sample through polymerase chain reaction testing, also known as PCR.

Differences in state regulations can lead to different microbiological techniques implemented for testing.Before diving in further, it is important to understand the scientific approach. Laboratory testing requirements for cannabis can be separated into two categories: analytical chemistry methods and microbiological methods.

Analytical chemistry is the science of qualitatively and quantitatively determining the chemical components of a substance, and usually consists of some kind of separation followed by detection. Analytical methods are used to uncover the potency of cannabis, analyze the terpene profile and to detect the presence of pesticides, chemical residues, residuals solvents, heavy metals and mycotoxins. Analytical testing methods are performed first before proceeding to microbiological methods.

Petri dish containing the fungus Aspergillus flavus
Petri dish containing the fungus Aspergillus flavus. It produces carcinogenic aflatoxins, which can contaminate certain foods and cause aspergillosis, an invasive fungal disease.
Photo courtesy of USDA ARS & Peggy Greb.

Microbiological methods dive deeper into cannabis at a cellular level to uncover microbial impurities such as yeast, mold and bacteria. The techniques utilized in microbiological methods are very different from traditional analytical chemistry methods in both the way they are performed and target of the analysis. Differences in state regulations can lead to different microbiological techniques implemented for testing. There are a variety of cell and molecular biology techniques that can be used for detecting microbial impurities, but most can be separated into two categories:

  1. Methods to determine total microbial cell numbers, which typically utilizes cell culture, which involves growing cells in favorable conditions and plating, spreading the sample evenly in a container like a petri dish. The total yeast and mold count (TYMC) test follows this method.
  2. Molecular methods intended to detect specific species of mold, such as harmful aspergillus mold strains, which typically involves testing for the presence of unique DNA sequences such as Polymerase Chain Reaction (PCR).


Among states that have legalized some form of cannabis use and put forth regulations, there appears to be a broad consensus that the laboratories should test for potency (cannabinoids concentration), pesticides (or chemical residues) and residual solvents at a minimum. On the other hand, microbial testing requirements, particularly for mold, appear to vary greatly from state to state. Oregon requires random testing for mold and mildew without any details on test type. In Colorado, Nevada, Maine, Illinois and Massachusetts, regulations explicitly state the use of TYMC for the detection of mold. In California, the recently released emergency regulations require testing for specific species of
Aspergillus mold (A. fumigatus, A. flavus, A. niger and A. terreus), which are difficult to differentiate on a plate and would require a DNA-based approach. Since there are differences in costs associated and data produced by these methods, this issue will impact product costs for cultivators, which will affect cannabis prices for consumers.

 

Multi-analyte Configuration for Cannabis Testing Services

Managing Cannabis Testing Lab Workflows using LIMS

By Dr. Susan Audino
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Multi-analyte Configuration for Cannabis Testing Services

With the state led legalization of both adult recreational and medical cannabis, there is a need for comprehensive and reliable analytical testing to ensure consumer safety and drug potency. Cannabis-testing laboratories receive high volumes of test requests from cannabis cultivators for testing quantitative and qualitative aspects of the plant. The testing market is growing as more states bring in stricter enforcement policies on testing. As the number of testing labs grow, it is anticipated that the laboratories that are now servicing other markets, including high throughput contract labs, will cross into cannabis testing as regulations free up. As the volume of tests each lab performs increases, the need for laboratories to make effective use of time and resource management, such as ensuring accurate and quick results, reports, regulatory compliance, quality assurance and many other aspects of data management becomes vital in staying competitive.

Cannabis Testing Workflows

To be commercially competitive, testing labs offer a comprehensive range of testing services. These services are available for both the medical and recreational cannabis markets, including:

  • Detection and quantification of both acid and neutral forms of cannabinoids
  • Screening for pesticide levels
  • Monitoring water activity to indicate the possibility of microbiological contamination
  • Moisture content measurements
  • Terpene profiling
  • Residual solvents and heavy metal testing
  • Fungi, molds, mycotoxin testing and many more

Although the testing workflows differ for each test, here is a basic overview of the operations carried out in a cannabis-testing lab:

  1. Cannabis samples are received.
  2. The samples are processed using techniques such as grinding and homogenization. This may be followed by extraction, filtration and evaporation.
  3. A few samples will be isolated and concentrated by dissolving in solvents, while others may be derivatized using HPLC or GC reagents
  4. The processed samples are then subjected to chromatographic separation using techniques such as HPLC, UHPLC, GC and GC-MS.
  5. The separated components are then analyzed and identified for qualitative and quantitative analysis based on specialized standards and certified reference materials.
  6. The quantified analytical data will be exported from the instruments and compiled with the corresponding sample data.
  7. The test results are organized and reviewed by the lab personnel.
  8. The finalized test results are reported in a compliant format and released to the client.

In order to ensure that cannabis testing laboratories function reliably, they are obliged to follow and execute certain organizational and regulatory protocols throughout the testing process. These involve critical factors that determine the accuracy of testing services of a laboratory.

Factors Critical to a Cannabis Testing Laboratory 

  • Accreditations & Regulatory Compliance: Cannabis testing laboratories are subject to regulatory compliance requirements, accreditation standards, laboratory practices and policies at the state level. A standard that most cannabis testing labs comply to is ISO 17025, which sets the requirements of quality standards in testing laboratories. Accreditation to this standard represents the determination of competence by an independent third party referred to as the “Accreditation Body”. Accreditation ensures that laboratories are adhering to their methods. These testing facilities have mandatory participation in proficiency tests regularly in order to maintain accreditation.
  • Quality Assurance, Standards & Proficiency Testing: Quality assurance is in part achieved by implementing standard test methods that have been thoroughly validated. When standard methods are not available, the laboratory must validate their own methods. In addition to using valid and appropriate methods, accredited laboratories are also required to participate in appropriate and commercially available Proficiency Test Program or Inter-Laboratory Comparison Study. Both PT and ILC Programs provide laboratories with some measure of their analytic performance and compare that performance with other participating laboratories.

    Multi-analyte Configuration for Cannabis Testing Services
    CloudLIMS Cannabis Testing LIMS: Multi-analyte Configuration for Cannabis Testing Services
  • Real-time Collaboration: Testing facilities generate metadata such as data derived from cannabis samples and infused products. The testing status and test results are best served for compliance and accessibility when integrated and stored on a centralized platform. This helps in timely data sharing and facilitates informed decision making, effective cooperation and relationships between cannabis testing facilities and growers. This platform is imperative for laboratories that have grown to high volume throughput where opportunities for errors exist. By matching test results to samples, this platform ensures consistent sample tracking and traceability. Finally, the platform is designed to provide immediate, real-time reporting to individual state or other regulatory bodies.
  • Personnel Management: Skilled scientific staff in cannabis-testing laboratories are required to oversee testing activities. Staff should have experience in analytical chromatography instruments such as HPLC and GC-MS. Since samples are often used for multi-analytes such as terpenes, cannabinoids, pesticides etc., the process often involves transferring samples and tests from one person to another within the testing facility. A chain of custody (CoC) is required to ensure traceability and ‘ownership’ for each person involved in the workflow.

LIMS for Laboratory Automation

Gathering, organizing and controlling laboratory-testing data can be time-consuming, labor-intensive and challenging for cannabis testing laboratories. Using spreadsheets and paper methods for this purpose is error-prone, makes data retrieval difficult and does not allow laboratories to easily adhere to regulatory guidelines. Manual systems are cumbersome, costly and lack efficiency. One way to meet this challenge is to switch to automated solutions that eliminate many of the mundane tasks that utilize valuable human resources.. Laboratory automation transforms the data management processes and as a result, improves the quality of services and provides faster turnaround time with significant cost savings. Automating the data management protocol will improve the quality of accountability, improve technical efficiency, and improve fiscal resources.

cloudlims screenshot
Real Time Test Status in CloudLIMS

A Laboratory Information Management System (LIMS) is a software tool for testing labs that aids efficient data management. A LIMS organizes, manages and communicates all laboratory test data and related information, such as sample and associated metadata, tests, Standard Operating Procedures (SOPs), test reports, and invoices. It also enables fully automated data exchange between instruments such as HPLCs, GC-FIDs, etc. to one consolidated location, thereby reducing transcription errors.

How LIMS Helps Cannabis Testing Labs

LIMS are much more capable than spreadsheets and paper-based tools for streamlining the analytical and operational lab activities and enhances the productivity and quality by eliminating manual data entry. Cloud-enabled LIMS systems such as CloudLIMS are often low in the total cost of acquisition, do not require IT staff and are scalable to help meet the ever changing business and regulatory compliance needs. Some of the key benefits of LIMS for automating a cannabis-testing laboratory are illustrated below [Table 1]:

Key Functionality Benefit
Barcode label designing and printing Enables proper labelling of samples and inventory

Follows GLP guidelines

Instant data capture by scanning barcodes Facilitates quick client registration and sample access
3600 data traceability Saves time and resources for locating samples and other records
Inventory and order management Supports proactive planning/budgeting and real time accuracy
Custodian management Promotes overall laboratory organization by assigning custodians for samples and tests

Maintains the Chain-of-custody (CoC)

Test management Accommodates pre-loaded test protocols to quickly assign tests for incoming samples
Accounting for sample and inventory quantity Automatically deducts sample and inventory quantities when consumed in tests
Package & shipment management Manages incoming samples and samples that have been subcontracted to other laboratories
Electronic data import Electronically imports test results and metadata from integrated instruments

Eliminates manual typographical errors

Report management Generates accurate, customizable, meaningful and test reports for clients

Allows user to include signatures and additional sections for professional use

21 CFR Part 11 compliant Authenticates laboratory activities with electronic signatures
ISO 17025 accreditation Provides traceable documentary evidence required to achieve ISO 17025 accreditation
Audit trail capabilities Adheres to regulatory standards by recording comprehensive audit logs for laboratory activities along with the date and time stamp
Centralized data management Stores all the data in a single, secure database facilitating quick data retrieval
Workflow management Promotes better data management and resource allocation
High-configurability Enables modification of screens using graphical configuration tools to mirror testing workflows
State compliance systems Integrates with state-required compliance reporting systems and communicates using API
Adheres to regulatory compliance Creates Certificates of Analysis (CoA) to prove regulatory compliance for each batch as well as batch-by-batch variance analysis and other reports as needed.
Data security & confidentiality Masks sensitive data from unauthorized user access

 

Cloud-based LIMS encrypts data at rest and in-transit while transmission between the client and the server

Global accessibility Cloud-based LIMS provides real-time access to laboratory data from anytime anywhere
Real-time collaboration Cloud-based LIMS enhances real-time communication within a laboratory, between a laboratory and its clients, and across a global organization with multiple sites

Table 1. Key functionality and benefits of LIMS for cannabis testing laboratories

Upon mapping the present day challenges faced by cannabis testing laboratories, adopting laboratory automation solutions becomes imperative. Cloud-based LIMS becomes a valuable tool for laboratory data management in cannabis testing laboratories. In addition to reducing manual workloads, and efficient resource management, it helps labs focus on productive lab operations while achieving compliance and regulatory goals with ease.

For more information on this, check out a webinar here: Webinar: How to Meet Cannabis Testing Standards and Regulatory Requirements with LIMS by Stephen Goldman, laboratory director at the State of Colorado certified Cannabis testing facility, PhytaTech.

Microbiology 101 Part One

By Kathy Knutson, Ph.D.
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I have been studying microorganisms for over 35 years, and the elusive critters still fascinate me! Here in Microbiology 101, I write about the foundation of knowledge on which all microbiologists build. You may have a general interest in microbiology or have concerns in your operation. By understanding microbiology, you understand the diversity of microorganisms, their source, control of microorganisms and their importance.

Part 1

The term microbiology covers every living being we cannot see with the naked eye. The smallest microbe is a virus. Next in size are the bacteria, then yeast and mold cells, and the largest microbes are the protozoans. The tiny structure of a virus may be important in the plant pathology of cannabis, but will not grow in concentrates or infused products. A virus is not living, until it storms the gate of a living cell and overtakes the functions within the cell. Viruses are the number one cause of foodborne illness, with the number one virus called Norovirus. Think stomach flu. Think illness on cruise ships. Viruses are a food service problem and can be prevented by requiring employees to report sickness, have good personal hygiene including good hand washing, and, as appropriate, wear gloves. Following Good Manufacturing Practices (GMPs) is critical in preventing the transfer of viruses to a product where the consumer can be infected.

The petri dishes show sterilization effects of negative air ionization on a chamber aerosolized with Salmonella enteritidis. The left sample is untreated; the right, treated. Photo courtesy of USDA ARS & Ken Hammond

The largest microbial cell is the protozoan. They are of concern in natural water sources, but like viruses, will not grow in cannabis products. Control water quality through GMPs, and you control protozoans. Viruses and protozoans will not be further discussed here. Bacteria, yeast and mold are the focus of further discussion. As a food microbiologist, my typical application of this information is in the manufacturing of food. Because Microbiology 101 is a general article on microbiology, you can apply the information to growing, harvesting, drying, manufacture of infused products and dispensing.

It is not possible to have sterile products. Even the canning process of high temperature for an extended time allows the survival of resistant bacterial spores. Astronauts take dehydrated food into space, and soldiers receive MREs; both still contain microbes. Sterility is never the goal. So, what is normal? Even with the highest standards, it is normal to have microbes in your products. Your goal is to eliminate illness-causing microorganisms, i.e. pathogens. Along the way, you will decrease spoilage microbes too, making a product with higher quality.

Petri dish containing the fungus Aspergillus flavus. It produces carcinogenic aflatoxins, which can contaminate foods and cause an invasive fungal disease.
Photo courtesy of USDA ARS & Peggy Greb.

Yeast and mold were discussed on CIJ in a previous article, Total Yeast & Mold Count: What Cultivators & Business Owners Need to Know. Fuzzy mold seen on the top of food left in the refrigerator too long is a quality issue, not a safety issue. Mold growth is a problem on damaged cannabis plants or cuttings and may produce mycotoxin, a toxic chemical hazard. Following Good Agricultural Practices (GAPs) will control mold growth. Once the plant is properly dried, mold will not grow and produce toxin. Proper growing, handling and drying prevents mycotoxins. Like mold, growth of yeast is a quality issue, not a safety issue. As yeast grow, they produce acid, alcohol and carbon dioxide gas. While these fermentation products are unwanted, they are not injurious. I am aware that some states require cannabis-infused products to be alcohol-free, but that is not a safety issue discussed here.

What are the sources of microorganisms?

People. Employees who harvest cannabis may transfer microorganisms to the plant. Later, employees may be the source of microbes at the steps of trimming, drying, transfer or portioning, extract processing, infused product manufacture and packaging.

Ingredients, Supplies and Materials. Anything you purchase may be a source of microorganisms. Procure quality merchandise. Remember the saying, “you get what you pay for.”

Environment. Starting with the outdoors, microbes come from wind, soil, pests, bird droppings and water. When plants are harvested outdoors or indoors, microbes come from the tools and bins. Maintain clean growing and harvesting tools in good working condition to minimize contamination with microbes. For any processing, microbes come from air currents, use of water, and all surfaces in the processing environment from dripping overhead pipes to floor drains and everything in between.

In Part 2 I will continue to discuss the diversity of microorganisms, and future articles will cover Hazard Analysis and Critical Control Points (HACCP) and food safety in more detail. What concerns do you have at each step of operations? Are you confident in your employees and their handling of the product? As each state works to ensure public health, cannabis-infused products will receive the same, if not more, scrutiny as non-cannabis food and beverages. With an understanding and control of pathogens, you can focus on providing your customers with your highest quality product.

Total Yeast & Mold Count: What Cultivators & Business Owners Need to Know

By Parastoo Yaghmaee, PhD
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Editor’s note: This article should serve as a foundation of knowledge for yeast and mold in cannabis. Beginning in January 2018, we will publish a series of articles focused entirely on yeast and mold, discussing topics such as TYMC testing, preventing yeast and mold in cultivation and treatment methods to reduce yeast and mold.


Cannabis stakeholders, including cultivators, extractors, brokers, distributors and consumers, have been active in the shadows for decades. With the legalization of recreational adult use in several states, and more on the way, safety of the distributed product is one of the main concerns for regulators and the public. Currently, Colorado1, Nevada and Canada2 require total yeast and mold count (TYMC) compliance testing to evaluate whether or not cannabis is safe for human consumption. As the cannabis industry matures, it is likely that TYMC or other stringent testing for yeast and mold will be adopted in the increasingly regulated medical and recreational markets.

The goal of this article is to provide general information on yeast and mold, and to explain why TYMC is an important indicator in determining cannabis safety.

Yeast & Mold

Photo credit: Steep Hill- a petri dish of mold growth from tested cannabis

Yeast and mold are members of the fungi family. Fungus, widespread in nature, can be found in the air, water, soil, vegetation and in decaying matter. The types of fungus found in different geographic regions vary based upon humidity, soil and other environmental conditions. In general, fungi can grow in a wide range of pH environments and temperatures, and can survive in harsh conditions that bacteria cannot. They are not able to produce their own food like plants, and survive by breaking down material from their surroundings into nutrients. Mold cannot thrive in an environment with limited oxygen, while yeast is able to grow with or without oxygen. Most molds, if grown for a long enough period, can be detected visually, while yeast growth is usually detected by off-flavor and fermentation.

Due to their versatility, it is rare to find a place or surface that is naturally free of fungi or their spores. Damp conditions, poor air quality and darker areas are inviting environments for yeast and mold growth.

Cannabis plants are grown in both indoor and outdoor conditions. Plants grown outdoors are exposed to wider ranges and larger populations of fungal species compared to indoor plants. However, factors such as improper watering, the type of soil and fertilizer and poor air circulation can all increase the chance of mold growth in indoor environments. Moreover, secondary contamination is a prevalent risk from human handling during harvest and trimming for both indoor and outdoor-grown cannabis. If humidity and temperature levels of drying and curing rooms are not carefully controlled, the final product could also easily develop fungi or their growth by-product.

 What is TYMC?

TYMC, or total yeast and mold count, is the number of colony forming units present per gram of product (CFU/g). A colony forming unit is the scientific means of counting and reporting the population of live bacteria or yeast and mold in a product. To determine the count, the cannabis sample is plated on a petri dish which is then incubated at a specific temperature for three to five days. During this time, the yeast and mold present will grow and reproduce. Each colony, which represents an individual or a group of yeast and mold, produces one spot on the petri dish. Each spot is considered one colony forming unit.

Why is TYMC Measured?

TYMC is an indicator of the overall cleanliness of the product’s life cycle: growing environment, processing conditions, material handling and storage facilities. Mold by itself is not considered “bad,” but having a high mold count, as measured by TYMC, is alarming and could be detrimental to both consumers and cultivators. 

Aspergillus species niger
Photo: Carlos de Paz, Flickr

The vast majority of mold and yeast present in the environment are indeed harmless, and even useful to humans. Some fungi are used commercially in production of fermented food, industrial alcohol, biodegradation of waste material and the production of antibiotics and enzymes, such as penicillin and proteases. However, certain fungi cause food spoilage and the production of mycotoxin, a fungal growth by-product that is toxic to humans and animals. Humans absorb mycotoxins through inhalation, skin contact and ingestion. Unfortunately, mycotoxins are very stable and withstand both freezing and cooking temperatures. One way to reduce mycotoxin levels in a product is to have a low TYMC.

Aspergillus flavus on culture.
Photo: Iqbal Osman, Flickr

Yeast and mold have been found to be prevalent in cannabis in both current and previous case studies. In a 2017 UC Davis study, 20 marijuana samples obtained from Northern California dispensaries were found to contain several yeast and mold species, including Cryptococcus, Mucor, Aspergillus fumigatus, Aspergillus niger, and Aspergillus flavus.3 The same results were reported in 1983, when marijuana samples collected from 14 cannabis smokers were analyzed. All of the above mold species in the 2017 study were present in 13 out of 14 marijuana samples.4

Aspergillus species niger, flavus, and fumigatus are known for aflatoxin production, a type of dangerous mycotoxin that can be lethal.5 Once a patient smokes and/or ingests cannabis with mold, the toxins and/or spores can thrive inside the lungs and body.6, 7 There are documented fatalities and complications in immunocompromised patients smoking cannabis with mold, including patients with HIV and other autoimmune diseases, as well as the elderly.8, 9, 10, 11

For this reason, regulations exist to limit the allowable TYMC counts for purposes of protecting consumer safety. At the time of writing this article, the acceptable limit for TYMC in cannabis plant material in Colorado, Nevada and Canada is ≤10,000 CFU/g. Washington state requires a mycotoxin test.12 California is looking into testing for specific Aspergillus species as a part of their requirement. As the cannabis industry continues to grow and advance, it is likely that additional states will adopt some form of TYMC testing into their regulatory testing requirements.

References:

  1. https://www.colorado.gov/pacific/sites/default/files/Complete%20Retail%20Marijuana%20Rules%20as%20of%20April%2014%202017.pdf
  2. http://laws-lois.justice.gc.ca/eng/acts/f-27/
  3. https://www.ucdmc.ucdavis.edu/publish/news/newsroom/11791
  4. Kagen SL, Kurup VP, Sohnle PG, Fink JN. 1983. Marijuana smoking and fungal sensitization. Journal of Allergy & Clinical Immunology. 71(4): 389-393.
  5. Centre for Disease control and prevention. 2004 Outbreak of Aflatoxin Poisoning – Eastern and central provinces, Kenya, Jan – July 2004. Morbidity and mortality weekly report.. Sep 3, 2004: 53(34): 790-793
  6. Cescon DW, Page AV, Richardson S, Moore MJ, Boerner S, Gold WL. 2008. Invasive pulmonary Aspergillosis associated with marijuana use in a man with colorectal cancer. Diagnosis in Oncology. 26(13): 2214-2215.
  7. Szyper-Kravits M, Lang R, Manor Y, Lahav M. 2001 Early invasive pulmonary aspergillosis in a leukemia patient linked to aspergillus contaminated marijuana smoking. Leukemia Lymphoma 42(6): 1433 – 1437.
  8. Verweii PE, Kerremans JJ, Voss A, F.G. Meis M. 2000. Fungal contamination of Tobacco and Marijuana. JAMA 2000 284(22): 2875.
  9. Ruchlemer R, Amit-Kohn M, Raveh D, Hanus L. 2015. Inhaled medicinal cannabis and the immunocompromised patient. Support Care Cancer. 23(3):819-822.
  10. McPartland JM, Pruitt PL. 1997. Medical Marijuana and its use by the immunocompromised. Alternative Therapies in Health and Medicine. 3 (3): 39-45.
  11. Hamadeh R, Ardehali A, Locksley RM, York MK. 1983. Fatal aspergillosis associated with smoking contaminated marijuana, in a marrow transplant recipient. Chest. 94(2): 432-433.
  12. http://apps.leg.wa.gov/wac/default.aspx?cite=314-55-102