-
ChE shows pesticide exposures.
- ChE looks at exposure over time.
- The test is widely available.
- A blood sample all that is needed.
-
You need a baseline test.
- You need good lab methods.
- The sample must be handled right.
- It matters when the sample is taken.
- The test must be interpreted by a MD.
To understand the basics of ChE and pesticides that inhibit the action of ChE
-
Is present in tiny animals and big.
- Is a very fast enzyme (chemical).
- Is found everywhere in the human body.
- Plays a critical role.
An An “enzyme enzyme” (special kind (special kind of chemical) with a special of chemical) with a special active part. (see the red active part. (see the red spot?)
-
It is produced in tissues and blood.
- It is present in all the nerves in your body, at the
"synapse".
- It turns off a key chemical that is found in the space where one nerve connects with another.
-
Autonomic Nervous System
- Parasympathetic
- Presynaptic Sympathetic
- PNS
- CNS
1.
Is found at the synapse.
2. It turns off the chemical messenger.
3. When affected by pesticide, it decreases.
4. Then, the chemical messenger builds.
5. Overstimulation results.
-
Plasma ChE (PChE)
- Floats freely in plasma
- Made by the liver.
- RBCChE (AChE)
- Bound to red blood cells
- Made when red blood cells are made.
-
Is sensitive to most inhibitor pesticides.
- Recovers rapidly after pesticide
exposure (is made fresh again).
- May be affected by liver disease.
-
Is slower to be affected by Che inhibitor pesticides.
- Is slower to recover after pesticide
exposure.
- May be affected by low red blood cell
count (anemia).
-
Some medicines are like tiny pesticides. They inhibit ChE. Then, the nerves are more
stimulated.
- These medicines are used to treat:
- Alzheimer's Disease
- avis Myasthenia
- Glaucoma
- And to prevent damage from Nerve Gas Attacks
-
Organophosphates
- Inhibit irreversibly.
- ChE must be replaced by the body.
- Carbamates
- Inhibit temporarily.
- Reversal is rapid and related to exposure.
- ChE soon reactivates and is ready to go.
Mild cases: tiredness, weakness, dizziness, nausea and blurred vision
Moderate cases: headache, sweating, tearing, drooling, vomiting, tunnel vision, and twitching
Severe cases: abdominal cramps, urinating, diarrhea, muscular tremors, staggering gait, pinpoint pupils, hypotension (abnormally low blood pressure), slow heartbeat, breathing difficulty, and possibly death
Extoxnet
http://ace.ace.orst.edu/info/extoxnet
Class I and II Carbamates & Organophosphates DANGER or WARNING ON THE LABEL
Threshold: 50 hrs in 30 days
Normal Range of ChE activity
-
Relatively Stable in the Population
- Large difference: upper and lower limits
-
Obtain before exposure.
- 30 days since last handling
- Maintain records for future comparison.
- If it is abnormally low,
- Recheck, average or discard.
- More tests are better than less
- What does "regression to the mean"
mean?
- Retest with the same laboratory, same methods
- Retesting every 30 days
-
When to do follow-up?
- Rules state within 3 days of reaching threshold
- Why are you testing?
- To evaluate work exposure
- To prevent future exposure
- Decrease frequency with experience
-
20% Depression- Evaluate
- 30% AChE- Remove and Evaluate
- 40% PChE- Remove and Evaluate
- If removed,
- when AChE and PChE return to 20% or
less depressed, return to handling
pesticides
-
What else can they do?
- Thinning? Probably not in sprayed orchards*
- Know the operation
- General work
*Engel and Keifer 1998, Keifer, Miller, Fenske 1995
Schnieder et al 1991)
-
Return to regular duty
- When both PChE
- and and AChE get to 20%
or less depressed.
- File a Claim?
Karl F. Weyrauch MD MPH
Family Physician
Research Consultant UW PNASH
Member, Western Institutional Review Board
http://depts.washington.edu/bioethx/topics/consent.html
- Both! But mostly a process
(Belmont Report 1979)
- Process is informed by pt's legal
rights and MD's ethical duties
- Information exchange
- Comprehension Comprehension
- Voluntary choice
- Different
- Intent- care decision vs. conflict of interest
- Forms- information dictates short/ “basic ” vs. long/comprehensive
-
appropriate information
- understandable language
-
Both federal and state law apply
- Research Research- 21 CFR Food and Drugs, 45 CFR Public Welfare
- Treatment- RCW 7.70.050 proof
of breach of duty, RCW 7.70.060
contents of consent form
- Understandable language
- Nature and character of the
treatment
- Anticipated results
- Alternative treatments
- Risks and benefits
- Reasonable patient standard - What would the average patient need to know to be an informed need to know to be an informed participant ?
- To do - Provide the best care and respect the patient as a person.
- Vulnerability to coercion= limited autonomy
- By employee status
- By minority status, language,
literacy
Thus, special considerations apply
- Pesticide Handlers Need
- appropriate information
- understandable language
- alternatives, risks and benefits
- not to be pressured to
participate.
http://www11.georgetown.edu/research/gucchd/nccc/
-
Delivers care effectively across cultures
- Identifies unique needs of individuals
- Matches services to these needs
- Determines practice by culturally preferred choices
- Beliefs- “believe”
- Attitudes- “feel”
- Knowledge- “know”
- Language- “speak”
- Traditions- “practice”
- Diversity increasing- 40% nonwhite by 2030 in US population
- Disparities for minorities in health care- increased poverty, cancer, obesity, diabetes; decreased preventive care, immunizations, mental health care
- Outcomes are improved- HgbA1c, patient satisfaction
- Law mandates non-discrimination: legislation, regulation, accreditation
- Malpractice risk-decreased with improved communication
-
appropriate information
- understandable language
- alternatives, risks and benefits
- be pressured to participate not
- a manner that is culturally competent
1. Focus groups to study issues of cultural competence 2. Test-Retest to evaluate product
-
Confidential, in Spanish, with
simultaneous English translation and and
transcription
- Iterative process - "Plan, Do, Study, Act",
each iteration is different
- Test-Retest Ongoing
- Beliefs- law is on their side, employer should care for employees
- Attitude- worry about getting sick from pesticides, fear blood and needles, mistrust unexplained changes, afraid to take time off work to get tested
- Knowledge- very little known about blood tests, ChE test, but know that pesticides are toxic, safety gear is important, employers sometimes scrimp on safety
- Language- English is a barrier to care, many handlers can’t read, recorded information and consent is better
- Tradition- important role of wives and social institutions for decision and making and dissemination of information
-
Requires "Declination Statement" only after receiving training about pesticides and
discussing risks and benefits
with MD or LHCP (WAC 296-307-14820)
-
5th grade reading level
- Incorporates culturally
appropriate knowledge
- Addresses specific attitudes
- Will be available on audiotape
-
Culturally-appropriate format
- Incorporates culturally appropriate beliefs, attitudes, knowledge, language
- Will be available on audiotape
- Circulated to wives, community
-
No job, benefit, seniority loss for
participation
- Testing done on company time
- Information spread to community by radio, church-centered events, strategic information postings e.g. Laundromat
- Pt. reviews Novella, audiotape
- Short Q&A discussion in Spanish
- Pt. signs consent or declination
- Discussion Leader/ Impartial Witness co-signs the form
- Cc: chart and patient. Declination sent to employer
Building Informed Consent For Pesticide Handlers in Washington State Is A Process That Includes:
-
Legal, ethical, cultural components
- Participation by health care team, handler, employer, community
- Specific tools you can use in Spanish
- Please See a Copy of the Consent Form!
Disclaimer and Reproduction Information: Information in
NASD does not represent NIOSH policy. Information included in
NASD appears by permission of the author and/or copyright holder.
More