Mashhad University of Medical SciencesAsia Pacific Journal of Medical Toxicology2322-26112220130601An Outbreak of Carbon Monoxide Poisoning in Yamagata Prefecture Following the Great East Japan Earthquake374185710.22038/apjmt.2013.857ENKen IsekiDepartment of Regional Emergency Medicine, Fukushima Medical University School of medicine, Fukushima, Japan.
Department of Emergency and Critical Care Medicine, Yamagata University School of Medicine, Yamagata, Japan.Akiko HayashidaDepartment of Regional Emergency Medicine, Fukushima Medical University School of medicine, Fukushima, Japan.
Department of Emergency and Critical Care Medicine, Yamagata University School of Medicine, Yamagata, Japan.Yukihiro ShikamaDepartment of Neurology, Yamagata Prefectural Kahoku Hospital, Yamagata, JapanKaoru GotoDepartment of Anatomy and Cell Biology, Yamagata University School of Medicine, Yamagata, JapanChoichiro TaseDepartment of Emergency and Critical Care Medicine, Fukushima Medical University School of Medicine, Fukushima, JapanJournal Article20130408<em>Background:</em> In the aftermath of the Great East Japan Earthquake, most of the areas in Yamagata prefecture experienced a serious power failure lasting for approximately 24 hours. A number of households were subsequently poisoned with carbon monoxide (CO) due to various causes. In this study, we conducted a survey of CO poisoning during the disaster. <br/><em>Methods:</em> A questionnaire regarding CO poisoning associated with the disaster was sent to 37 emergency hospitals in Yamagata prefecture. <br/><em>Results:</em> A total of 51 patients were treated for unintentional CO poisoning in 7 hospitals (hyperbaric oxygen chambers were present in 3 of the hospitals). The patients (18 men, 33 women) ranged in age from 0 to 90 years. The source of CO exposure was charcoal briquettes (23 cases; 45%), gasoline-powered electric generators (18 cases; 35%), electric generators together with oil stoves (8 cases; 16%), oil stoves (1 cases; 2%), and automobile exhaust (1 cases; 2%). Blood carboxyhemoglobin levels ranged from 0.5% to 41.6% in 49 cases. Of these, 41 patients were treated by normobaric oxygen therapy, while one was intubated for artificial respiration. Additionally, 5 patients (10%) were treated by hyperbaric oxygen therapy, and 3 patients (6%) experienced delayed neuropsychiatric sequelae. <br/><em>Conclusion:</em> CO sources included gasoline-powered electric generators and charcoal briquettes during the disaster. Storm-related CO poisoning is well recognized as a disaster-associated accident in the United States, but not in Japan. We emphasize that public education is needed to make people aware of the dangers of CO poisoning after a disaster. In addition, a pulse CO-oximeter should be set up in hospitals.Mashhad University of Medical SciencesAsia Pacific Journal of Medical Toxicology2322-26112220130601Estonian Experience on Establishment of a Modern National Poison Information Centre: One-year Profile of Phone Calls in 2012424785810.22038/apjmt.2013.858ENMare OderPoisoning Information Centre, Tallinn, EstoniaKristiina PõldDepartment of Emergency Medicine, North Estonian Medical Centre, Tallinn, EstoniaJournal Article20130616<em><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-font-weight: bold;">Background:</span></em><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-font-weight: bold;"> Initiating a National Poisoning Information Centre (PIC) in Estonia took about 12 years of challenging work on research, training and attracting governmental support and funding. In this study we described the establishment process and the profile of phone calls in the first year which the PIC started to be available full time (24h/day 7days/week).<span style="mso-spacerun: yes;"> </span></span> <br/><em><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-font-weight: bold;">Methods:</span></em><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-font-weight: bold;"> This was a descriptive retrospective study. Relevant documents from 2000-2012 were reviewed. The documents were categorized into 5 main issues against establishment of PIC. Data of all inquiries related to toxic agent exposures regarding patient’s demographic, intention of poisoning and type of toxic substances in 2012 were collected. The data were reported with frequency and percentage.</span> <br/><em><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-font-weight: bold;">Results:</span></em><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-font-weight: bold;"> During establishment process, 386 documents including governmental regulations and contracts, memorandums from meetings, professional e-mails, newspaper articles, interviews, annual reports and </span><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-ansi-language: ET; mso-bidi-font-weight: bold;" lang="ET">program sheets </span><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-font-weight: bold;">of other poison centres and conference presentations were collected. Funding was provided form PHARE and BTox projects (2000-2003), and government of Estonia (2004-2012). Educational programs were held to train specialists in clinical toxicology and poisoning information to direct the PIC. The active phase of establishment started in 2004; however, the services of PIC became available at the beginning of 2008. In 2012, total number of calls was 1118. 20% of calls were related to general questions about pharmaceuticals and non-toxic agents. 894 calls were related to acute poisoning cases. Most of them (87.9%) were due to accidental poisoning. The most common types of substances responsible for poisoning were pharmaceutical products (30.2%), household products (29.5%) and plant toxins (11.1%).</span> <br/><em><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-font-weight: bold;">Conclusion:</span></em><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-bidi-font-weight: bold;"> To establish a stable PIC, it is crucial to have a wide range data backbone, clear support and direct funding from the government, assistance from collaborative PICs, active international/domestic collaboration and experienced committed specialists in clinical toxicology. A well-established PIC improves public health surveillance and reduces health-care costs. These effects should be investigated in future studies about the National PIC of Estonia.</span>Mashhad University of Medical SciencesAsia Pacific Journal of Medical Toxicology2322-26112220130601Descriptive Analysis of Recorded Phone Calls to Iran Drug and Poison Information Centers during 2011-2012485185910.22038/apjmt.2013.859ENTalat GhaneCentral Division of Iran Drug and Poison Information Centers, Tehran, IranSoheila SaberiAddiction Research Centre, Mashhad University of Medical Sciences, Mashhad, IranMasoomeh DavoodabadiCentral Division of Iran Drug and Poison Information Centers, Tehran, IranJournal Article20130417 <br/><em>Background:</em> Poisoning is one of the main causes of visits to emergency departments and hospitals in Iran. Drug and Poison Information Centers (DPIC) are reliable sources to guide poisoned patients and provide information about pharmaceutical agents. This study was designed to analyze recorded phone calls to Iran DPICs during 2011-2012. <br/><em>Methods:</em> This was a retrospective study on phone calls to DPIC in Tehran between January 2011 and November 2012. Data including demographic features, type of poison (in case of poisoning) and intention of poisoning were collected by reviewing the reported phone calls to central division of Iran DPICs in Tehran. <br/><em>Results:</em> It was found that 98.5% of the phone calls were inquiries about pharmaceutical products and only 1.5% of them were associated with poisoning. 49% of poisonings reported from the DPICs in 2011was intentional, while this rate increased to 67% in 2012. Regarding toxic agents responsible for poisonings, pharmaceuticals were the most common consisting of 68.6% and 70.9% of cases in 2011 and 2012, respectively. <br/><em>Conclusion:</em> Pharmaceutical products are the main causes of poisonings in Iran. Public education on safety and storage issues and also strict terms of sale should be implemented. In addition, the majority of poisonings occurred intentionally while the rate showed an increasing trend. Predisposing factors of this high rate should be studied. <br/><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi;"> </span>Mashhad University of Medical SciencesAsia Pacific Journal of Medical Toxicology2322-26112220130601Investigating Childhood and Adolescence Poisoning Exposures in New Zealand Reported to the National Poisons Centre during 2000-2009525786010.22038/apjmt.2013.860ENAnny YuanFanSchool of Pharmacy, University of Otago, New ZealandArthur HoCheSchool of Pharmacy, University of Otago, New ZealandBenny PanSchool of Pharmacy, University of Otago, New ZealandCindy YangSchool of Pharmacy, University of Otago, New ZealandCarolyn V.CoulterSchool of Pharmacy, University of Otago, New ZealandLucy ShieffelbienNational Poisons Centre, University of Otago, New ZealandWayne TempleNational Poisons Centre, University of Otago, New ZealandRhiannon BraundSchool of Pharmacy, University of Otago, New ZealandJournal Article20130115 <br/><em>Background:</em> Poisoning incidents, in both children and adolescents, are known to occur in New Zealand but little is known about the agents implicated. <br/> <br/><em>Methods:</em> All the calls received over the ten years between 2000 and 2009, by the National Poison Centre in New Zealand, were retrospectively reviewed. Calls related to cases involving those less than 19 years were included. The data were analyzed according to age and gender of cases, the toxic agent implicated in the poisoning and the year of the incident. <br/> <br/><em>Results:</em> Most poisonings occurred in children less than five years of age (86%), with these being further concentrated in children aged one to two years (57%). The most frequently implicated agents were therapeutic agents (39%) and then household products (36%). In adolescents, an increase in drug misuse or abuse was seen from 12 years old – with those aged 13 and 18 years being most frequently exposed to agents with psychotropic properties. <br/> <br/><em>Conclusion:</em> This study showed that accidental (and intentional) ingestion is still an issue for children and adolescents in New Zealand. Specific strategies are needed to be targeted to the 1) products implicated in a high number of poisonings and 2) to children at the different ages.Mashhad University of Medical SciencesAsia Pacific Journal of Medical Toxicology2322-26112220130601Late-onset Radiologic Findings of Respiratory System Following Sulfur Mustard Exposure586286810.22038/apjmt.2013.868ENMahnaz AminiChronic Obstructive Pulmonary Disease Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran0000-0000-0000-0000Zohreh OghabianDepartment of Forensic Medicine and Clinical Toxicology, Kerman University of Medical Sciences, Kerman, Iran0000-0001-7269-4919Journal Article20130414<em><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi;">Background</span></em><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi;">: Sulfur mustard (SM) as a chemical warfare agent, increases permeability</span><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-fareast-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi;"> of bronchial vessels</span><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi;"> and </span><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-fareast-font-family: 'Times New Roman'; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi;">damages airway epithelium</span><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi;">. SM exposure causes debilitating respiratory complications. This study was designed to evaluate clinical respiratory manifestations, and to compare chest X ray (CXR) and high resolution computed tomography (HRCT) scan of chest in SM exposed patients with respiratory complaints. </span> <br/><em><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi;">Methods</span></em><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi;">:All patients with history of SM exposure who visited Imam Reza Specialized Clinic of Respiratory Diseases </span><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-ansi-language: EN-GB;" lang="EN-GB">from September 2001 to March 2011</span><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi;"> were included. Patients with other comorbidities which affect respiratory system were excluded. CXR and chest HRCT scan were performed on the same day and were repeated after 5 years. Clinical and radiologic findings were collected and were compared with each other. </span> <br/><em><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi;">Results</span></em><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi;">: In total, 62 male patients with mean age of 53 (6.9, 41-65) were studied. Dyspnea (61 cases; 100%), dry cough (40 cases; 66%), hemoptysis (21 cases; 35%) and productive cough (20 cases; 33%) were the most common respiratory manifestations. Pulmonary infiltration (51; 83%), pleural thickening (25; 40%) and emphysema (16; 26%) were the most common findings on CXR. According to HRCT scan, pulmonary infiltration (53; 85%), bronchiolitis obliterans (38; 61%) and pleural thickening (36; 58%) were the most common findings (Table 2). Repeated radiologic assessments after 5 years showed a few additional findings in HRCT scan, while in about one fifth of CXRs, new pathologic findings were found.</span> <br/><em><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi;">Conclusion</span></em><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi;">: Patients with SM exposure experience debilitating respiratory disorders in long term. Repeating CXR in patients who present with subjective symptoms may show new findings; however, repeating HRCT scan is probably not necessary.</span>Mashhad University of Medical SciencesAsia Pacific Journal of Medical Toxicology2322-26112220130601Acute Chemical and Pharmaceutical Poisoning Cases Treated in Civil Hospital, Ahmedabad: One year study636786910.22038/apjmt.2013.869ENTejas PrajapatiDepartment of Forensic Medicine and Toxicology, Ahmedabad Municipal Corporation Medical Education Trust, Medical College, Ahmedabad, IndiaKartik PrajapatiDepartment of Forensic Medicine and Toxicology, Ahmedabad Municipal Corporation Medical Education Trust, Medical College, Ahmedabad, IndiaRakesh TandonDepartment of Forensic Medicine and Toxicology, B.J Medical College, Ahmedabad, IndiaSaumil MerchantDepartment of Forensic Medicine and Toxicology, Ahmedabad Municipal Corporation Medical Education Trust, Medical College, Ahmedabad, IndiaJournal Article20130225 <br/><em>Background:</em> To study the pattern of acute chemical and pharmaceutical poisoning in Ahmadabad, Gujarat, India. <br/> <em>Methods:</em> This was a prospective study of patients with chemical and pharmaceutical poisoning who were admitted to the emergency department of Civil Hospital Ahmadabad, from 1st October 2006 to 30th September 2007. Socio-demographic details, intention of poisoning, type of poison, duration of hospitalization and outcome were recorded in a data checklist. <br/> <em>Results:</em> In total, 366 cases were studied over one year. Of these, 70.8% were male. The majority (45.08%) of cases had 21 to 30 years of age. 71.6% of cases lived in rural area and 28.4% of cases lived in urban area. The most common type of poison was pesticides in 33.9% of cases, followed by household chemicals in 26.8% of cases. In 74.6% of cases, intention of poisoning was self-harm. Case fatality rate among the patients was 18.6% while this index in patients poisoned with household chemicals was the highest (19.9%) followed by pesticides (17.7%). <br/> <em>Conclusion:</em> The prevention and treatment of poisoning with pesticides and household chemicals should merit high priority in the health care of Gujarat population. A specific concern should be raised toward pesticides availability and terms of sale. A national concern should be raised toward providing more laboratory and diagnostic facilities in hospitals in India.Mashhad University of Medical SciencesAsia Pacific Journal of Medical Toxicology2322-26112220130601Low Molecular Weight Heparin Overdose: A 10 Year Case Series687087010.22038/apjmt.2013.870ENAdeline Su-YinNgoDepartment of Emergency Medicine, Alexandra Hospital, Jurong Health Services, Singapore
California Poison Control System, San Francisco Division, San Francisco, USA0000-0003-3288-4595Daryl TanRaffles Cancer Centre, SingaporeKent R.OlsonCalifornia Poison Control System, San Francisco Division, San Francisco, USA
Department of Clinical Pharmacy and Division of Clinical Pharmacology, University of California, San Francisco, USAJournal Article20130509 <br/><em>Background:</em> Low molecular weight heparin (LMWH) is used for the treatment and prevention of coagulative disorders. Few patients receiving therapeutic doses of LMWH develop major hemorrhage. Currently there are few reports in the literature on acute overdose on adults. In this study, clinical profile, treatment and outcome of 21 patients who acutely overdosed enoxaparin are described. <br/> <em>Methods:</em> A retrospective chart review of California Poison Control System (CPCS) database: Visual Dot Lab during 1997 to 2007 was obtained. All patients with a definite reported overdose of subcutaneous injection of LMWH were included. <br/> <em>Results:</em> In total, 21 patients who were all exposed to enoxaparin were studied. The reasons for overdose included medical miscalculation (3 cases, all infants), intentional misuse (2 patients), accidental overdose (7 cases), suicidal attempt (7 cases) and unknown in 2 patients. 7 cases were documented to have overdosed more than 2 times the therapeutic dose. The overdose ranged from 50 mg to 1300mg (0.1-80 times the therapeutic range). No patients were documented to experience bleeding or have thrombocytopenia although complete follow-up was only available for 11 patients. <br/> Reassurance was given to patients with less than 0.14 times the therapeutic dose. The 2 patients who received protamine were overdosed with more than 2.5 times the therapeutic dose of enoxaparin. <br/> <em>Conclusion:</em> Most patients had no complications and were not treated with protamine. This study suggests that a large dosage of LMWH is unlikely to result in any life threatening complications, though further studies are needed to certainly conclude about this. The use of protamine in LMWH overdose seems to remain controversial. <br/><em><span style="font-size: 9.5pt; font-family: 'Times New Roman','serif'; mso-ascii-theme-font: major-bidi; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi;"> </span></em>Mashhad University of Medical SciencesAsia Pacific Journal of Medical Toxicology2322-26112220130601Methamphetamine Related Radiculopathy: Case Series and Review of Literature717589410.22038/apjmt.2013.894ENMohsen ForoughipourDepartment of Neurology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, IranMohammad TaghiFarzadfardDepartment of Neurology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, IranMeisam AghaeeDepartment of Neurology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, IranAli Ghabeli-JuibaryDepartment of Neurology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, IranFariborz RezaietalabDepartment of Neurology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, IranJournal Article20130329<em>Background:</em> Peripheral nervous injury and neuromuscular complications from methamphetamine abuse has not been reported. The mechanism is not yet identified. <br/> <em>Methods:</em> Eight patients with lower extremity weakness following methamphetamine abuse were reported during December 2009 to May 2010. <br/> <em>Results:</em> Patients presented with lower extremity weakness. All patients were co-abusers of methamphetamine and opioids. Other clinical manifestations comprised of distal paresthesia of the lower extremities with progression to proximal portions, with minimal sensory involvement in the distal of the lower extremities. Electrodiagnostic findings were consistent with lumbosacral Radiculopathy. Vital signs were unremarkable and all laboratory tests were within normal limits. Follow-up examination after three months showed improvement of weakness in 3 patients. <br/> <em>Conclusion:</em> For patients with a history of illicit drug abuse and acute neuromuscular weakness, methamphetamine or heroin toxicity should be taken into account. Hence, urine morphine and amphetamine/ methamphetamine tests should be performed and serum lead and thallium levels should be evaluated. In addition, rhabdomyolysis and myoglobinuria should be worked up. <br/><em><span style="font-size: 9.5pt; font-family: 'Times-Roman','serif'; mso-bidi-font-family: Times-Roman;"> </span></em>Mashhad University of Medical SciencesAsia Pacific Journal of Medical Toxicology2322-26112220130601Comment on Editorial; Best Research for Low Income Countries7676100110.22038/apjmt.2013.1001ENAndrew H.DawsonSouth Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka.
Central Clinical School, Royal Prince Alfred Hospital, Sydney, AustraliaJournal Article20130428<span style="font-size: small; font-family: tahoma,arial,helvetica,sans-serif;">Achieving a practical and productive balance in collaborative research between partners from high and lower income countries (North-South Collaborations) requires seeking win-win solutions. This issue requires time to engage each other and to understand each participant’s research priorities and to identify areas of mutual interest. In SACTRC’s experience, key elements include; building research capacity that is closely linked to the research being conducted by the partners, establishing a clear research identity for the group that facilitates further funding and publishing in accessible (open access) high impact journals (1).</span> <br/><span style="font-size: small; font-family: tahoma,arial,helvetica,sans-serif;">The preparation of any research paper requires a significant effort and time. Publishing in high impact journals allows both young researchers to be more competitive in career advancement and established researchers to be able to get further funding to support collaborative research. The challenge for any new journal such as the APJMT is to build a reputation that will impress both readers and funders (2). While the flaws of publication metrics such as h-index and journal impact factors are recognised, they remain important factors when seeking competitive grants. Although the importance of translational research is increasingly recognised by granting bodies in funding decisions, the metrics for measuring this are not well defined (3).</span>Mashhad University of Medical SciencesAsia Pacific Journal of Medical Toxicology2322-26112220130601Knowledge, Not Funding is the Most Important Research Resource7777100210.22038/apjmt.2013.1002ENRobert J.HoffmanAlbert Einstein College of Medicine, Bronx, New YorkJournal Article20130430<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">In the last issue of the Asia Pacific Journal of Medical Toxicology, Dr. Reza Afshari raised the question of what are the best scientific areas of focus of toxicology for “low income countries and how such research might be achieved (1). South-south collaboration, in which developing countries share resources, was one of the proposed solutions.</span>
<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">Rather than limit discussion to “low income” countries, the issue of research agenda might be better framed within the perspective of “developed” and “developing” countries. Two of the largest Asia Pacific Association of Medical Toxicology member countries, Iran and India lay almost within visual distance of the United Arab Emirates. Despite its wealth, the United Arab Emirates has a general lack of high-quality medical research, and toxicology research is virtually non-existent. In contrast, Iran and India, with far less economic strength, have a vast network of highly trained and expert clinicians in medical toxicology and most other medical specialties. This is helpful to consider, and to understand that high income does not equal quality in research.</span>
<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">Outstanding medical research, applicable to both developing and developed countries, may be conducted in resource-poor settings. An example of collaborative research that comes to mind is the World Health Organization (WHO) Pediatric Hydrocarbon Study Group clinical decision rule for young children with possible hydrocarbon aspiration (2). The results of this research, that was supported by the WHO, conducted in Egypt, and led by an American toxicologist, have clinical applicability and utility in developing and developed countries. Conducting this study in a developed country, such as the USA, would have been extraordinarily difficult or impossible.</span>
<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">In addition to South-South collaborations, tapping research expertise of other countries, developed or developing, is another key factor for facilitating relevant and translatable research in countries that historically lack such. Finding mutually relevant research questions that are shared by developed and developing countries can also avail research opportunities. </span>
<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">Lastly, developing a culture of research led by clinicians and persons with expertise in biostatistics and epidemiology, who may be based in clinical sciences or academia, is an important key to having a sustained productive research effort in any country.</span>
<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">This letter can be easily summarized: “The most important resource for quality research is not funding, it is knowledge”.</span>Mashhad University of Medical SciencesAsia Pacific Journal of Medical Toxicology2322-26112220130601Research Priorities for Medical Toxicology in Low and Middle Income Countries7878100310.22038/apjmt.2013.1003ENSurjit SinghDepartment of internal medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, IndiaJournal Article20130318<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">In the editorial by Dr. Reza Afshari “What is the best research for low income countries” (1), some important issues have been raised, highly relevant to developing countries. In most developing countries including India, emergency medicine is not well established and clinical toxicology is even further a low priority in view of both research and clinical management. The number of poison control and treatment centers is few and if they exist, they are mainly in metro cities. Moreover, we are faced with lack of required resources for such research.</span>
<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">Dr. Afshari’s suggestion about the need for epidemiological studies should be regarded as highly important (1). These studies should be prospective and community-based rather than hospital or poison centre based. Unless we know the pattern of poisonings, it will not be possible to formulate the guidelines for treatment and research as poisonings vary in different countries and in different areas of a country (2). Depending on pattern, the treatment and research guidelines can be devised and scarce resources can be allocated. The acute poisonings in developing countries are very often due to toxic chemicals. This is because there is a lack of control on availability of chemicals as laws do exist but implementation is lacking (2). Although specific antidote is available for majority of them, mortality remains high because treatment is often delayed due to non-availability of proper centres and lack of antidotes. Therefore, it is necessary to train health care professionals and to provide better awareness in general public regarding risks of poisonings. Furthermore, not only resources are lacking, western textbooks or literature is only available for management of poisonings and local guidelines are limited. In high income countries, both knowledge and money are available but poisoned patients are in limited number while in developing countries it is other way round. </span>
<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">We must pay the most careful attention to the role of gastric lavage which due to legal reasons in some countries such as India, it is mandatory (3). </span>
<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">It is also crucial to carefully investigate the venomous snakes where more species are required to be identified and antivenoms should be developed. There is a great need to develop low-priced diagnostic kits and cheaper analytic methods for poisons.</span>
<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">More access to information in developing world and South-South collaboration is a highly welcomed idea. We need a standardized format to record, uniform protocols to manage poisonings and low cost healthcare technologies such as self-inflating bag in saving patients with respiratory arrest following snakebite or OPC poisoning or where short term ventilation is required.</span>Mashhad University of Medical SciencesAsia Pacific Journal of Medical Toxicology2322-26112220130601Changing the Insight of Scientists in High Income Countries: A Solution for Collaborative Research with Lower Income Countries7979100410.22038/apjmt.2013.1004ENHamid SharifiFaculty of Veterinary Medicine, Shahid Bahonar University of Kerman, Kerman, IranAli AkbarHaghdoostResearch Center for Modeling in Health, Institute of Futures Studies in Health, Kerman University of Medical Sciences, Kerman, IranJournal Article20130430<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">The recent issue of Asia Pacific Journal of Medical Toxicology made an important and interesting theme “What is the Best Research for Low Income Countries?” (1). We enjoyed reading the paper; nevertheless we hope to find a chance to share our idea.</span>
<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">It was mentioned that some, for sure not all, researchers from the developed countries might not have enough motivation to contribute to the scientific production in the developing countries. Sadly, we agree with this idea and in practice most of the researchers in the less developed countries face these barriers. But the question is why such subtle discrimination exists in the scientific environment of the world despite its dominant moral concepts?</span>
<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">Usually, scientists are working very hard to progress in their fields. Many indicators including H-index have been developed to measure the scientific level of experts. However, all of these indicators have their own limitations (2). Dr. Afshari mentioned in his paper that some scientists from north countries might not contribute since these contributions decelerate their progress. However, we did not find any strong logic for such explanation. There are many opportunities in the developing countries for scientific progress. Some of these opportunities are lower competition in scientific fields, more available International resources, many crucial questions for research, and the hospitality of the developing countries (including researchers, universities, and journals) to scientists of developed countries.</span>
<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">Despite the above positive points, there are some barriers as well. The scientific gaps in some fields, less effective organizations, political, and financial obstacles are some examples. However, we would like to highlight one more important issue; a considerable portion of scientists in the developed countries do not have a deep and comprehensive view about the real situation in the developing countries. Honestly, we think they might have a distorted view about the capacities and the level of works in less developed countries. As a result of such a view, it would be difficult to establish a real scientific communication and collaboration between them.</span>
<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">Therefore, it seems that a multi-dimensional strategy has to be taken by the scientific organizations in the developing countries with the following components:</span>
<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">Improving their capacities in order to minimize their gaps with the developed countries.</span>
<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">Working as a network and support each other efficiently by creating south-south links.</span>
<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">Changing the attitude of scientists in the developed countries and change their insight about the existing capacities in the developing countries.</span>Mashhad University of Medical SciencesAsia Pacific Journal of Medical Toxicology2322-26112220130601What Is the Best Research Globally?8080100510.22038/apjmt.2013.1005ENDarryl MaciasDepartment of Emergency Medicine, University of New Mexico, Albuquerque, USAJournal Article20130414<span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">Dr. Afshari’s editorial gives insight on human nature (1). Collaborative willingness usually occurs when different sides perceive personal benefit, or when institutions mandate collaboration. This is not unique between higher and lower income countries; many working in global emergency medicine (EM) observe this within wealthier countries. It exists among collaborators in low resource settings. Yes, pride and status are globally universal. Convincing others to engage altruistically is challenging.</span> <br/><span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;"> Camaraderie and “brotherhood” is created from shared experiences. Many global health practitioners work for extended times overseas, returning to their own countries with new perspectives and gratitude, if the experience was positive. As mentors, we must identify young physicians and investigators with these attributes, and create positive outcomes. Then, it is imperative to continue the relationship. Commitment is therefore needed. The Global Network of Emergency Medicine had its second meeting in Dubai in May 2013, in order to promote this idea, without making one country adhere to the system of EM of another country-in other words, EM and research is set according to autochthonous needs (2).</span> <br/><span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">Project funding remains difficult. In the US, the National Institutes of Health grant 5% of their budget to EM research. Yet the NIH will claim that 23% of their funding goes to emergency medicine research. Why the disparity? Occasionally, primary investigators from other specialties use our departments as their “laboratories”, leaving EM specialists outside of a given large, prospective, randomized study (much of the cardiology literature published in the New England Journal of Medicine has few of our specialists included) (3,4). Furthermore, our research methodology may be lacking, since the majority of designs are case controlled, and fewer studies overlooked by powerful funding agencies. Many funding agencies don’t understand EM priorities. Donors may be non EM trained philanthropists, or bureaucrats. Decision maker physicians are also rarely EM (5), let alone toxicology trained. Either change funding demographics, or look southward.</span> <br/><span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">In Mexico, PACE (http://www.pace-medspanish.org) monies come from those personally affected by emergencies or from governments wishing to improve health statistics (example: decreasing infant-maternal mortality). These community-based programs help funders reach their goals, and fund us to spread EM rurally. A Latin-American “southern” alliance exists, with the “brotherhood” of US EM organizations (ACEP).</span> <br/><span style="font-family: tahoma,arial,helvetica,sans-serif; font-size: small;">With global economic uncertainty looming, well-developed regions can benefit from programs originating from limited resource settings. Many of us believe altruism, a communal bond or desperate needs, is able to link the North and South together.</span>