Toxicology Training Research Articles

Acute Pesticide-Related Illness Among Farmworkers: Barriers to Reporting to Public Health Authorities

ABSTRACTFarmworkers are at high risk of acute occupational pesticide-related illness (AOPI) and AOPI surveillance is vital to preventing these illnesses. Data on such illnesses are collected and analyzed to identify high-risk groups, high-risk pesticides, and root causes. Interventions to address these risks and root causes include farmworker outreach, education, and regulation. Unfortunately, it is well known that AOPI is underreported, meaning that the true burden of this condition remains unknown. This article reviews the barriers to reporting of farmworker AOPI to public health authorities and provides some practical solutions. Information is presented using the social-ecological model spheres of influence. Factors that contribute to farmworker AOPI underreporting include fear of job loss or deportation, limited English proficiency (LEP), limited access to health care, lack of clinician recognition of AOPI, farmworker ineligibility for workers’ compensation (WC) benefits in many states, insufficient resources to conduct AOPI surveillance, and constraints in coordinating AOPI investigations across state agencies. Solutions to address these barriers include: emphasizing that employers encourage farmworkers to report safety concerns; raising farmworker awareness of federally qualified health centers (FQHCs) and increasing the availability of these clinics; improving environmental toxicology training to health-care students and professionals; encouraging government agencies to investigate pesticide complaints and provide easy-to-read reports of investigation findings; fostering public health reporting from electronic medical records, poison control centers (PCCs), and WC; expanding and strengthening AOPI state-based surveillance programs; and developing interagency agreements to outline the roles and responsibilities of each state agency involved with pesticide safety.

Implementing Best Practice in Critically Ill Organophosphate Poisoned Patient Through Simulation-Based Learning Program

Purpose: Despite the clinical and socio-economic impact of acute poisoned patients, many of the treatments are not standardized in Korea. Moreover, no formal training that is specifically focused on clinical toxicology exists. Rather, training and education are conducted case by case in various institutions. This study was conducted to develop a standardized simulation-based clinical toxicology training curriculum for healthcare providers. This program will focus on specific assessment and treatment of critical toxicology patients, specifically those who have been poisoned with organophosphate. Methods: The study was performed using a pre- and post-design to determine the effects of implementation of this program. The study was conducted at eight different urban teaching hospitals in a simulated room in the clinical area. The study was targeted to 19 groups composed of emergency residents and nurses. Simulation-based learning was conducted for each group. Results: All 19 groups achieved the minimum passing score of 75%. Implementation of the program led to improved performance rates for overall management and cooperative moods competency (p<0.01). Inter-rater agreement between the two evaluators was excellent. In general, the participants thought the program was realistic and were able to recognize and improve the competencies needed to care for organophosphate poisoned patients. Conclusion: Simulation-based learning is an effective educational strategy that can be applied to improving and understanding proper care for rare but critical patients. This program was effective at improving team performance and cooperative moods when managing an organophosphate poisoned patient in the Emergency Department.

Impact of online toxicology training on health professionals: the Global Educational Toxicology Uniting Project (GETUP)

Objective: The Global Educational Toxicology Uniting Project (GETUP), supported by the American College of Medical Toxicology, links countries with and without toxicology services via distance education with the aim to improve education. Due to the lack of toxicology services in some countries there is a knowledge gap in the management of poisonings. We describe our experience with the worldwide delivery of an online introductory toxicology curriculum to emergency doctors and other health professionals treating poisoned patients.Methods: We delivered a 15-module introductory Internet-based toxicology curriculum to emergency doctors and health professionals, conducted from August to December 2016. This Internet-based curriculum was adapted from one used to teach emergency residents toxicology in the United States. Modules covered themes such as pharmaceutical (n = 8), toxidromes (n = 2) and agrochemicals (n = 5) poisoning. Participants completed pre-test and post-test multiple choice questions (MCQs) before and after completing the online module, respectively, throughout the course. We collected information on participant demographics, education and training, and perception of relevance of the curriculum. Participants gave feedback on the course and how it affected their practice.Results: One hundred and thirty-six health professionals from 33 countries participated in the course: 98 emergency doctors/medical officers, 25 physicians, eight pharmacists/poisons information specialists, two toxicologists, two medical students and one nurse. Median age of participants was 34 years. Median number of years postgraduate was seven. Ninety (65%) had access to either a poisons information centre over the phone or toxicologist and 48 (35%) did not. All participants expected the course to help improve their knowledge. Overall median pre-module MCQ scores were 56% (95%CI: 38, 75%) compared to post-module MCQ scores median 89% (95% CI: 67, 100%) (p < .0001).Conclusions: Our participants demonstrated an increase in medical knowledge based on performance on MCQs. An online toxicology curriculum is an effective way to deliver education to health professionals treating poisoned patients and can help to bridge the knowledge gap and change practice in developed and developing countries.

Toxicology Training Unit in Emergency Department Reduces Admission to other Specialties and Hospital Length of Stay

Objective To evaluate the outcome of intoxicated patients presented to Accident and Emergency Department (AED) in Hong Kong with Toxicology Training Unit accreditation and AED without toxicology team. Method A retrospective observational study with data collection from all intoxicated cases reported through Pre-hospital Activated Charcoal Programme, a protocol driven poisoning reporting system, from 1/7/2011 to 30/6/2013 (2 years). Data on basic demographic data (e.g. sex, age), receiving AED, admission rate to other specialty, length of stay in hospital exclude psychiatry ward admission and clinical outcome were collected and analysed. Five AEDs with Toxicology Training Unit (study group) and 7 AEDs without toxicology team (control group) were included. Results A total of 329 intoxicated cases were included in this study. The basic epidemiological data were similar in both groups. There was a significantly lower in hospital admissions in study group (16.9%) than in control group (69.3%; p&lt;0.001) and significant shorter median of hospital stay of 22.1 hours (interquartile range [IQR] 12.8-43.5 hours) in study group compare to 42.7 hours (IQR 20.4-76.1 hours) in control group (p&lt;0.001). Conclusion Our findings show that the establishment of the toxicology training unit can achieve significant reduction in admissions to other specialty and the length of stay in hospital in the management of patients with acute intoxication.

The Importance of Medical Toxicology Training

One of the most common reasons for reference of patients to the emergency department or sending them to high level specialized centers is poisoning. The treatment of these patients requires special scientific and practical skills, that in the absence of skilled staff necessary to perform diagnostic and therapeutic procedures the mortality and morbidity rate of these patients will be greatly increased. This study is a case report of a patient death cases of poisoning after staying in one of the health centers in Iran due to lack of medical staff and unfamiliarity physicians with properly managing the poisoning patients.

The United Kingdom and Ireland Association of Forensic Toxicologists; establishing best practice for professional training & development in forensic toxicology

The current status of forensic toxicology in the United Kingdom is discussed with an emphasis on professional training and development. Best practice is proposed using a blend of modular foundation knowledge training, continuing professional development, academic study, research & development and ongoing analytical practice.The need for establishing a professional career structure is also discussed along with a suggested example of a suitable model.The issues discussed in this paper are intended to provoke discussion within the forensic toxicology community, industry regulators and other government bodies responsible for the administration of justice.

The effect of a targeted clinical toxicology training intervention on the diagnostic accuracy and management of paramedics exposed to clinical simulation: a repeated measures study

John Talbot and James Coulson, 'The effect of a targeted clinical toxicology training intervention on the diagnostic accuracy and management of paramedics exposed to clinical simulation: a repeated measures study', British Paramedic Journal, 2016, Vol. 1 (1): 15-25, © The Author(s) 2016.

Nurses working in poison and toxicovigilance centres

Some nurses have chosen to work The skills acquired through their professional experience in the field, combined with specific training in clinical toxicology, equip them to fulfil their role in innovative missions. Their main activity consists in manning the emergency helpline with additional toxicovigilance missions.

DNA Damage Response Plays Critical Role In Liver Regeneration After Acetaminophen Overdose

Acetaminophen (APAP) overdose is a leading cause of Acute Liver Failure (ALF). Previous studies have shown that liver regeneration followed by APAP overdose plays a critical role in survival. Here we show that significant DNA double strand break leading to inhibited DNA repair results in prolonged activation of cell cycle checkpoint delaying liver regeneration. We used a novel incremental dose model developed in our laboratory using a regenerating (300 mg/kg, APAP300) and a non‐regenerating (600 mg/kg, APAP600) dose of APAP to identify pathways involved in regeneration after APAP overdose. Marker of liver injury, regeneration and microarray‐based global gene expression changes were studied in male C57BL6 mice over time course of 0 to 72 hr following treatment with either APAP300 or APAP600. The ingenuity pathway analysis of microarray data revealed significant differences in DNA damage, replication and checkpoint related pathways between both doses of APAP. Western blot and immunofluorescence staining of pH2AX Ser139, a hallmark of DNA double strand break, showed prolonged phosphorylation of histone H2AX in mice treated with APAP600 than APAP300. DNA repair proteins involved in Non Homologous End Joining (NHEJ) pathway showed a rapid induction in APAP300 but were significantly suppressed in APAP600, indicating delay or lack of DNA repair. Further, extensive stabilization and activation of p53, the DNA damage Response (DDR) effector protein, was observed in APAP600 as compared to APAP300. p53 stabilization was accompanied by significantly higher and prolonged activation of several p53 target genes such as GADD45α,PAI1, BAX, p21 in APAP600 treated mice as compared to APAP300 treated mice. Furthermore, studies in p53KO mice showed significantly higher injury than WT mice after APAP300 treatment at initial time points. Interestingly, despite the higher injury, p53KO mice recovered similarly as the WT mice due to faster cell cycle resulting in much higher liver regeneration. These data illustrate that lack of prompt DSB repair response after APAP overdose leads to p53‐mediated prolonged growth arrest and replicative senescence. These results suggest that improving DNA repair process to rapidly decrease cell cycle checkpoint alert resulting in faster initiation of liver regeneration following APAP overdose may have therapeutic benefit.Support or Funding InformationThese studies were supported by NIH‐COBRE (P20 RR021940‐03), NIEHS Toxicology Training Grant (T32ES007079‐34) and NIDDK R0198414

Preconception Care: A New Standard of Care within Maternal Health Services.

Emerging research suggests that much pediatric affliction has origins in the vulnerable phase of fetal development. Prenatal factors including deficiency of various nutrients and exposure to assorted toxicants are major etiological determinants of myriad obstetrical complications, pediatric chronic diseases, and perhaps some genetic mutations. With recent recognition that modifiable environmental determinants, rather than genetic predestination, are the etiological source of most chronic illness, modification of environmental factors prior to conception offers the possibility of precluding various mental and physical health conditions. Environmental and lifestyle modification through informed patient choice is possible but evidence confirms that, with little to no training in clinical nutrition, toxicology, or environmental exposures, most clinicians are ill-equipped to counsel patients about this important area. With the totality of available scientific evidence that now exists on the potential to modify disease-causing gestational determinants, failure to take necessary precautionary action may render members of the medical community collectively and individually culpable for preventable illness in children. We advocate for environmental health education of maternity health professionals and the widespread adoption and implementation of preconception care. This will necessitate the translation of emerging knowledge from recent research literature, to health professionals, to reproductive-aged women, and to society at large.

Development of a Medical Toxicology Curriculum in Spanish with Content Informed by a Population Survey for Medical Trainees in the Dominican Republic

Introduction: The aim of this study is to develop a curriculum based on the American Board of Emergency Medicine (ABEM) core content toxicology category with emphasis on exposures prevalent in the Dominican Republic (DR) as informed by a population survey. Methods: A survey was designed to identify common toxicological exposures, practices, and perceptions in community members and medical trainees in Santiago, DR. A toxicology curriculum was taught to medical residents using a curriculum made available online through the Global Educational Toxicology Uniting Project (GETUP). Results: 175 people completed the survey and 34 medical residents completed the course. The average percent of students/residents and community members reported the following, respectively: frequent substance abuse (12.2%, 44.0%), safe storage practices (21.7%, 13.7%), and traditional remedy use (15.2%, 21.8%). Community members answered 44%, medical students answered 61%, and residents answered 73% of the basic knowledge questions correctly. The mean pretest and posttest scores in the medical residents who took the toxicology course were 61% and 83%, respectively. Conclusions: The results suggest this population would benefit from education regarding safe-storage practices, the potential dangers of traditional remedy use, as well as education on the sources and effects of common exposures like lead and pesticide poisoning. Many practice high risk behaviors including substance abuse, unsafe remedy use, as well as the use of products that are either illegal or improperly labeled/handled. The long-term goals of this project are to raise awareness and implement expanded toxicology training in this country.

Poisonous plants: An ongoing problem

Abstract Introduction A medical visit for plant ingestion is rare in the paediatric emergency services but may involve a high toxicity. The botanical toxicology training of health staff is often very limited, and it can be difficult to make a diagnosis or decide on the appropriate treatment. Objective To study the epidemiological and clinical characteristics of poisoning due to plant ingestion in order to increase the knowledge of the health professional. Material and methods A descriptive retrospective study was conducted on patients seen in a paediatric emergency department after the ingestion of plant substances from January 2008 to December 2012. Results During the period of study, 18 patients had ingested possible toxic plants. In 14 cases, it was considered to be potentially toxic: broom, oleander, mistletoe, butcher's broom, and vulgar bean (2), Jerusalem tomato, castor (2), Jimson weed, potus, marijuana, and mushrooms with digestive toxicity (2). Among the potentially toxic cases, the ingestion was accidental in 10 patients, 2 cases were classed as child abuse, 1 case had recreational intention, and another one suicidal intentions. The ingestion of oleander, castor and Jimson weed had major toxicity. Conclusions The potential gravity of the ingestion of plant substances and the variety of the exposure mechanism requires the paediatrician to bear in mind this possibility, and to be prepared for its diagnosis and management. Specific preventive information measures need to be designed for the families and for the regulation of toxic plants in playgrounds.

The Current State of Poison Control Centers in Pakistan and the Need for Capacity Building.

Chemical exposure is a major health problem globally. Poison control centers (PCCs) play a leading role both in developed and developing countries in the prevention and control of poisonous chemical exposures. In this study, we aimed to assess the current state of PCCs in Pakistan and highlight capacity building needs in these centers. A cross-sectional survey of the two registered PCCs was done during August - December 2011. Necessary services of the PCCs were evaluated and the data were recorded on a predesigned checklist. Both PCCs are affiliated to a tertiary care hospital. Clinical services to poisoned patients were available 24 hours a day / 7 days a week. Information on common local products was available to poison center staff. Both centers were involved in undergraduate and post graduate teaching. Telephone poison information service was not available in either of centers. There was a limited capacity for qualitative and analytical toxicology. Common antidotes were available. There were limited surveillance activities to capture toxic risks existing in the community and also a deficiency was observed in chemical disaster planning. PCCs in Pakistan need capacity building for specialized training in toxicology, toxicovigilance, chemical disaster planning, analytical laboratory tests and telephone service for consultation in poisoning cases.

Tóxicos vegetales: un problema aún vigente

IntroductionA medical visit for plant ingestion is rare in the pediatric emergency services but may involve a high toxicity. The botanical toxicology training of health staff is often very limited, and it can be difficult to make a diagnosis or decide on the appropriate treatment. ObjectiveTo study the epidemiological and clinical characteristics of poisoning due to plant ingestion in order to increase the knowledge of the health professional. Material and methodsA descriptive retrospective study was conducted on patients seen in a pediatric emergency department after the ingestion of plant substances from January 2008 to December 2012. ResultsDuring the period of study, 18 patients had ingested possible toxic plants. In 14 cases, it was considered to be potentially toxic: broom, oleander, mistletoe, butcher's-broom, and vulgar bean (2), Jerusalem tomato, castor (2), Jimson weed, potus, marijuana, and mushrooms with digestive toxicity (2). Among the potentially toxic cases, the ingestion was accidental in 10 patients, 2 cases were classed as infantile mistreatment, 1 case had recreational intention, and another one suicidal intentions. The ingestion of oleander, castor and Jimson weed had major toxicity. ConclusionsThe potential gravity of the ingestion of plant substances and the variety of the exposure mechanism requires the pediatrician to bear in mind this possibility, and to be prepared for its diagnosis and management. Specific preventive information measures need to be designed for the families and for the regulation of toxic plants in playgrounds.

Preclinical tests in Brazil

Preclinical tests in Brazil

Editorial introductions

Editorial introductions

A Comparison of Simulation-Based Education versus Lecture-Based Instruction for Toxicology Training in Emergency Medicine Residents

A Comparison of Simulation-Based Education versus Lecture-Based Instruction for Toxicology Training in Emergency Medicine Residents

A click chemistry‐mediated approach to understanding survivin:caspase‐9 protein‐protein interactions

Survivin, a 16.5 kDa mammalian cytosolic protein, is upregulated in multiple cancers and is a promising therapeutic target. As its name implies, survivin facilitates cell survival by inhibiting apoptosis. Survivin is thought to inhibit the apoptotic initiator caspase‐9, however, the specific mechanisms of and amino acids involved in caspase‐9 inhibition have yet to be fully elucidated. Identifying the amino acid residues involved in the interaction between survivin and caspase‐9 will facilitate the rational design of small molecule protein‐protein interaction inhibitors. Click chemistry provides a facile approach to covalently link disparate azide‐ and terminal alkyne‐ containing molecules, thereby allowing for site‐specific incorporation of a fluorescent tag into a polypeptide sequence. Using site‐directed mutagenesis with the unnatural amino acid para‐azidophenylalanine (paF), we synthesized an azide‐containing mutant survivin protein. We then used copper‐free click chemistry to covalently modify the mutant survivin azide with an alkyne‐containing fluorophore dibenzylcyclooctyne‐488 (DBCO488) to generate a triazole‐containing cycloadducted product. Using western blotting, UV illumination, and Coomassie blue staining, we demonstrated the ability to site‐specifically cycloadduct the para‐azidophenylalanine in the survivin protein to the fluorescent cyclooctyne, DBCO488. This technology will now enable us to perform fluorescence analyses of the survivin:caspase‐9 complex in order to identify the specific amino acid residues involved in this interaction. This novel approach to monitor protein‐protein interactions holds untapped potential to improve rational drug design for survivin:caspase‐9‐targeted anticancer therapeutic agents.Funding: Environmental Toxicology Training Program 5T32ES007079–32 (SCB), COBRE P20 RR021940‐06 (JNL), R01 GM099959‐01 (PI, Collaborator John Karanicolas)

Breadth of Emergency Medical Training in Pakistan

Emergency medical care in Pakistan has not been a priority of medical education and training because of the country's need to address its lack of primary care. Resources and trained personnel are scarce. Despite these challenges, the value of emergency medical care is gaining attention. The objective of this study was to explore the breadth of Emergency Medicine training in Pakistan through an analysis of an Emergency Medicine residency in a teaching hospital. The Aga Khan University Hospital in Karachi is a teaching institution with the only Emergency Medicine residency program in the region. It was started in 2000, led by US-trained physicians, and it laid the foundation for Emergency Medicine in the country. The study was conducted over a four-week period in January of 2009. Data collection consisted of three components: (1) a survey of the Emergency Department and hospital services; (2) a survey of the Emergency Medicine training curriculum; and (3) a retrospective chart review of every tenth patient seen in the Aga Khan Emergency Department from December 1-14, 2008. The training program is similar to that of the US models. Of the 153 patients selected for the chart review, the majority presented with GI complaints. Of these, 51 (33%) were admitted to the hospital; 20% (n = 15) left against medical advice; the remaining 57% (n = 87) were discharged. The hospital admitted patients with complaints that were expected in the region. Although Aga Khan University Hospital is a pioneer in establishing Emergency Medicine as an official medical discipline in the region, the hospital's obstetrics and gynecology, trauma, toxicology and prehospital services training do not meet current curriculum standards set forth by the Society of Academic Emergency Medicine and the Council of Emergency Medicine Residency Directors. Nevertheless, the review provides a snapshot of the development of Emergency Medical Services in a developing nation. This information may assist other nations that are interested in developing such programs.

Practice or Perish: Why Bedside Toxicology is Essential to the Survival of Our Specialty

One of the medical toxicologists in our group was recently asked a shocking question. She was providing recommendations via telephone to a rather upset and flustered emergency physician, when the caller interrupted her by asking, “Excuse me, are you even a clinician?” Working on a toxicology service that admits and consults on more than 1,200 patients per year, my colleague was understandably taken aback. Hearing the story later, I was dismayed but not surprised. Based on the current practice of many toxicologists, how can we fault the emergency physician for asking such a question? Medical toxicology has become a specialty in which the telephone has largely replaced the stethoscope as the primary tool of our trade. This is in no way meant to diminish the importance of poison control centers. Not only was the establishment of poison centers instrumental in the development of medical toxicology as a subspecialty [1], there is no doubt as to the public health benefit and system-wide cost savings engendered by poison centers [2–7]. My concern is the role played by toxicologists in our healthcare system. Presumably, fellowship training in medical toxicology allows us to make clinical recommendations and advise caregivers at a level beyond that of the emergency physician and poison information specialist. If this is true, how many patients does the medical toxicologist have to treat at the bedside to ensure the validity of our advice? What happens when the emergency physician on the other end of the telephone has laid hands on more poisoned patients in the preceding week than the toxicologist has in the preceding year? If we do not examine patients, treat them at bedside, and learn from our experience, what is it that distinguishes us from Poisindex™ or a poison information specialist?