AN EXCELLENT PRIMER ON TOXICOLOGY
Toxicology Secrets, 1st Edition by Louis J. Ling, Richard F. Clark, Timothy B. Erickson and John H. Trestrail III
Hanley & Belfus, Medical Publishers, 210 South 13th Street, Philadelphia, PA 19107; xvi + 303 pages: ISBN 1-56053-410-9. Publication Date December 2000: Price, $39.95 (US), $44.95 (Foreign).
This is yet another great book from Hanley and Belfus in their now famous Secrets series. Like their previous book on Trauma, this one is also in a "question - answer" form, making it very easy for the students to answer their exam questions, or questions asked in their clinical rounds.
Written by four toxicology experts, this book is divided into 64 chapters spread over fifteen sections. Almost all conceivable topics in toxicology have been covered. The sections are (i) General principles (ii) Over-the-counter drugs (iii) Prescription medications (iv) Antibiotics (v) Cardiac drugs (vi) Psychopharmacologic medications (vii) Drugs of abuse (viii) Metals (ix) Chemicals (x) Pesticides (xi) Gases (xii) Food poisoning (xiii) Botanicals (xiv) Envenomations, and (xv) Toxic Terrorist threats.
A quick look at the questions tell us that they are quite interesting and useful. Sample these questions: (i) We all know about toxidromes, but what is a packidrome? (page 12, chapter 3 entitled "Toxidromes and vital signs"); (ii) What is "crack dancing"? (page 123, chapter 30 entitled "Cocaine"); and (iii) What are POPs? (page 242, chapter 56 entitled "Air and water pollution").
What I found extremely interesting in this book were questions which were marked as "Extra Credit" questions. These are basically interesting trivia, which very few people know of. Professors of toxicology and medicine would find these trivia very valuable to spice up their lectures. I certainly am going to use them in my own toxicology lectures. In almost every chapter these questions appear. Sample these, and try to answer if possible: (i) The untimely death from bulimia of what famous singer almost jeopardized the nonprescription sales of syrup of ipecac? (page 8, chapter 2 entitled "General Management of Poisonings"); (ii) In October 1982, there was a national panic when seven people died in Chicago from cyanide-laced acetaminophen capsules. Who was eventually found to be responsible for this tampering incident? (page 24, chapter 6 entitled "Acetaminophen"); (iii) The name warfarin is actually an acronym of the name of the patent holder plus the suffix from the word coumarin. Who is the patent holder of this anticoagulant? (page 54, chapter 13 entitled "Anticoagulants"); (iv) The condition known as "orange-picker's flu" is caused by low-level chronic exposure to what type of pesticides? (page 189, chapter 45 entitled "Insecticides: Organophosphates and carbamates"); and (v) In a famous hotel fire in 1980, 79 people died despite being far from the actual flames. Their deaths were due to inhalation of toxic smoke and fumes. What was the name of the hotel that burned? (page 213, chapter 51 entitled "Smoke inhalation");
Mnemonics are cleverly used at several places. What is the differential diagnosis of metabolic acidosis with an increased anion gap? The answer is given in the form of a mnemonic, A MUDPILES (page 31). It expands like this: Alcohol, Methanol, Uremia, Diabetic ketoacidosis, Paraldehyde, Isoniazid and Iron, Lactic acidosis, Ethylene glycol, Salicylic acid, and Starvation.
The book is well-endowed with a number of tables and bulleted lists wherever necessary. Three tables appear just in one chapter on caffeine. The question asked is,"How much caffeine is dangerous" (page 34)? The answer is fortified with the help of a table, which gives age, dose in grams and blood levels in micrograms per ml. Similarly as the answer to another question, the authors give a table (page 35) telling us how much caffeine is there in various commonly consumed drinks such as brewed coffee, instant coffee, Decaffeinated coffee, tea, chocolate milk and so on. I found these table particularly helpful, as they tend to give a lot of useful information in a capsule form.
Bulleted lists appear at several places. In the chapter on Arsenic, the question asked is,"What is arsenic and where is it found? (page 153)". The answer appears in the form of a bulleted list. In the chapter on "Marine envenomations", the question asked is, "What are the do's and don'ts of jellyfish sting management (page 277)"? The answer to this question too appears as a bulleted list. The students are especially going to like this approach, as it tends to summarize the information in a way they can easily remember and recall at the time of written or oral exams.
Several questions are in "True-False" format. For instance on page 158, the authors ask this question, "True or false: The reduction in blood lead levels seen in the United States is the result of extensive screening". The answer is "False". Reduction in blood lead levels have actually occurred as a result of removal of the most important sources of environmental lead such as leaded gasoline and lead abatement of contaminated homes.
Answers to the questions above? (i)Well, packidrome is an unofficial term that describes the mixed toxidromes apparent in patients with multi-ingredient drug ingestions. This is seen commonly with cold and flu preparations that contain antihistamines, analgesics, antipyretics, and decongestants in one package. (ii)"Crack dancing" is the name given to choreoathetoid movements associated with cocaine use. The patient exhibits movements like lip-smacking, repetitive eye blinking, choreoathetoid movements of the extremities etc. The symptoms start minutes to hours after cocaine use and may last for several days. It is thought that these movements could be due to super sensitivity to dopamine. Symptoms are not life-threatening, and resolve on their own. Another name for this syndrome is boca torcida or "twisted mouth", and (iii) POPs are Persistent Organic Pollutants.
Answers to Extra Credit questions? (i) For the syrup of ipecac question, the answer is Karen Carpenter. (ii) the perpetrator was never found. (iii) The acronym warfarin comes from Wisconsin Alumni Research Foundation. (iv) Organophosphates. (v) The name of the hotel was "The MGM Grand Hotel".
I believe clinical toxicologists, forensic toxicologists, and clinicians would find this book very useful. Forensic professionals like me are also going to admire this book, because in our day-to-day practice, we deal with a number of poisoned patients having medico legal implications. But I think students of medicine - both at undergraduate and postgraduate level - are going to love this book most. It is after all for them, this series is intended. I would fully recommend this book to all of these and any one else who is interested in the science of poisons in general.
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