Abstract
BackgroundToxicology and Emergency medicine textbooks recommend measurement of acetylcholinesterase (AChE) in all symptomatic cases of organophosphorus (OP) poisoning but laboratory facilities are limited in rural Asia. The accuracy of point-of-care (POC) acetylcholinesterase testing has been demonstrated but it remains to be shown whether results would be valued by clinicians. This study aims to assess the effect of seeing AChE POC test results on the knowledge, attitudes and practices of doctors who frequently manage OP poisoning.MethodsWe surveyed 23 clinicians, who had different levels of exposure to seeing AChE levels in OP poisoned patients, on a) knowledge of OP poisoning and biomarker interpretation, b) attitudes towards AChE in guiding poison management, oxime therapy and discharge decisions, and c) practices of ordering AChE in poisoning scenarios.ResultsAn overall high proportion of doctors valued the test (68-89%). However, we paradoxically found that doctors who were more experienced in seeing AChE results valued the test less. Lower proportions valued the test in guidance of acute poisoning management (50%, p = 0.015) and guidance of oxime therapy (25%, p = 0.008), and it was apparent it would not generally be used to facilitate early discharge. The highest proportion of respondents valued it on admission (p < 0.001). A lack of correlation of test results with the clinical picture, and a perception that the test was a waste of money when compared to clinical observation alone were also comments raised by some of the respondents.Greater experience with seeing AChE test results was associated with increased knowledge (p = 0.034). However, a disproportionate lack of knowledge on interpretation of biomarkers and the pharmacology of oxime therapy (12-50%) was noted, when compared with knowledge on the mechanism of OP poisoning and management (78-90%).ConclusionsOur findings suggest an AChE POC test may not be valued by rural doctors. The practical use of AChE in OP poisoning management is complex, and a poor understanding of how to interpret test results may have affected its perceived utility. Future research should evaluate the impact of providing both AChE and training in interpretation on clinicians’ attitudes and practice.
Highlights
Toxicology and Emergency medicine textbooks recommend measurement of acetylcholinesterase (AChE) in all symptomatic cases of organophosphorus (OP) poisoning but laboratory facilities are limited in rural Asia
Their experience of seeing the point-of-care AChE test results ranged from never having seen a test previously in 11 participants, to having seen ‘1-5 tests’ in 7 participants, and ‘5-20 tests’ in 4 participants. Knowledge Those with most experience of AChE test results had the highest knowledge with a significant increase noted in the total score (p = 0.034, see Figure 2)
Attitudes: AChE in OP poisoning management The perception that AChE test was useful in managing OP poisoning was 100% amongst respondents with no AChE test experience (0 tests) and minimal experience (1-5 tests), but was significantly less (50%) in respondents that had the most experience of seeing the most test results (5-20 tests) (p = 0.035, Figure 3a, Table 2)
Summary
Toxicology and Emergency medicine textbooks recommend measurement of acetylcholinesterase (AChE) in all symptomatic cases of organophosphorus (OP) poisoning but laboratory facilities are limited in rural Asia. Toxicology and Emergency medicine textbooks recommend that acetylcholinesterase (AChE) measurement should be performed in all symptomatic cases of OP poisoning where the test is available, as this biomarker may help confirm diagnosis and severity, guide the starting and stopping of oximes by titrating the dose to changing enzyme levels, and may help in guiding patient disposition [2,3,4,5,6]. Recent research has validated the use of a POC acetylcholinesterase testing device (Testmate ChE) for acute OP self-poisoning in rural Sri Lanka, but to date there are no studies to indicate how clinicians would value, and use, such a test should it become available [7]. We were not able to find studies that evaluated the benefit of POC devices in Asian countries, and a deficiency in research surrounding the role of POC testing in a rural hospital setting has been identified by other researchers [8]
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