Perceptions of the impact of an advanced training programme on the management skills of health professionals in Gauteng, South Africa

Background. South Africa's health sector spans the private and the public sectors. Within the sectors, health managers take on strategic leadership roles without formal training in management or leadership ­ a trend more common in the public sector than the private sector. Health managers are selected based on their clinical skills rather than their leadership or management skills.Objective. To compare self-rated competencies in management and leadership before and after training of the participants; to assess participants' experience of the training programme; and to evaluate the management and leadership skills of the participants after training.Methods. A cross-sectional, descriptive analytical method and 360° interviewing were used in this study. Participants were evaluated ~18 months after completion of the training programme. A 360° evaluation (360° E) of six of the 12 leadership/management competencies was done with the supervisors, colleagues, and subordinates of the participants.Results. All participants rated themselves as improved in 12 managerial and leadership competencies. The 360° E affirmed five of these competencies as improved, with the ability to create and implement a marketing plan rating poorly.Conclusion. Training in management leads to improvement in both leadership and managerial skills of health professionals

Multiple unusual complications in a single patient with combined organophosphate-carbamate pesticide exposure.

Poisoning with organophosphate (OP) or carbamate (CM) pesticides is very common in India. These compounds are powerful inhibitors of acetylcholinesterase, causing accumulation of acetylcholine resulting in muscarinic and nicotinic effects. In addition, there are often direct CNS effects including headache, tremor, delirium, slurred speech, ataxia, and convulsions. Coma supervenes in the later stages. Apart from these, OP poisoning can also induce an “intermediate syndrome” (IMS) characterized by proximal muscle weakness and paralysis; a “delayed syndrome” (organophosphate-induced delayed neuropathy or OPIND) characterized by polyneuropathy and weakness of distal limb muscles; and neuropsychiatric disturbances (chronic organophosphate-induced neuropsychiatric disorder or COPIND). Other disorders have very rarely been reported, such as Guillain-Barre syndrome, Parkin-sonism, transient hepatic dysfunction, pancreatitis, vocal cord paralysis, etc. We report a case of combined organophosphate-carbam-ate poisoning with multiple complications, e.g., intermediate syndrome (IMS), delayed neuropathy (OPIND), and Parkinsonism. These complications are rare, and some of them to the best of our knowledge have not been reported so far.

Five year survey of toxicological testing of clinical body fluid samples at the poison control centre in the Indian State of Kerala.

The Poison Control Centre (PCC) at Amrita Institute of Medical Sciences, Kerala, was established in June 2003, but became fully operational from January 2005. There are only four PCCs in India recognized by the World Health Organization, of which this is one. A five-year (2005 to 2009) review of biological samples analyzed for chemicals, drugs and toxins by the analytical laboratory attached to the PCC is presented to give an indication of the commonest types of poisoning encountered in this region of India, aside from venomous bites and stings. Such data are not adequately available so far, which is also true for other parts of the country. Results of the survey show that there has been a steady rise in the receipt of samples over the entire period from 432 in 2005 to 601 in 2009. Among the samples analyzed, the commonest toxicants are pesticides, pharmaceuticals, heavy metals and alcohols. Of the pesticides, organophosphates accounted for the maximum number, while most of the remaining comprised zinc phosphide, carbamates, pyrethroids, paraquat, phosphorus, and bromadiolone. Aluminium phosphide, which is a common pesticide in some other regions, was virtually non-existent, while zinc phosphide, a rodenticide, is the second highest in incidence. Of the pharmaceuticals, the largest number comprised sedativehypnotics, while antipyretic drugs, especially paracetamol, accounted for a most of the remaining. Of the metals, the commonest was lead, followed by arsenic, mercury, iron, etc. Requests for copper testing were common, but mostly pertained to Wilson‟s disease, and not toxicity. Among the alcohols, ethanol was the commonest. Even though Kerala is rich in flora, plant toxins were low in incidence, because of the difficulty in testing for such toxins, as compared to chemicals. Bites and stings were not included in this study. Therapeutic monitoring of drugs, which accounts for a large number of samples received by the laboratory was also not part of the survey.

Current views on antidotal therapy in managing cases of poisoning and overdose.

While it is an acknowledged dictum that in poisoning or overdose cases, the emphasis must be on general management comprising supportive measures than the use of specific antidotes in the vast majority of cases, it is nevertheless true that there are some instances where the timely use of a specific antidote or antagonist will dramatically reverse or at least halt the progression of toxicity. For this reason, and also because the indications and the exact manner in which antidotes must be used could be controversial or unfamiliar to the physician, an attempt has been made to review the current concepts on antidotal therapy of poisoning. There is enough evidence that the proper use of specific antidotes when combined with general supportive care does reduce the morbidity and mortality associated with severe poisonings. Common antidotes used in a hospital setting have been discussed in some detail.

Paraquat: The underestimated lethal pesticide.

Paraquat and diquat are popular herbicides which belong to the bipyridyl group. Paraquat was first synthesized in 1882, but began to be used as a herbicide only since the 1960s. It is available either in granular form or as water soluble concentrate which is an odourless brown liquid. The granular form is available as colourless crystals (dichloride salt) or a yellow solid (bis(methyl sulfate) salt). In India, most of the concentrates of paraquat are available as 10–20% solutions. Paraquat is a rapidly acting herbicide and kills the tissues of green plants mainly by contact action with foliage. Ingestion of paraquat by humans is associated with high mortality, which is a fact that is not widely recognized. Estimated lethal dose is just 10 to 15 ml of the concentrate. Ingestion of 20 to 40 mg of paraquat ion per kg body weight results in death in most cases. It is important to treat all cases of paraquat ingestion as potentially fatal poisonings.

The mis-education of medical students: Righting a wrong

A few years ago, I delivered a talk at one of the annual conferences of the Indian Academy of Forensic Medicine on the terrible curriculum in medical toxicology that is prevalent in India, and in fact coined a new term for the rubbish that we are teaching our medical students - “Toxicomythology”. It is a term that I feel is fully justified, if one looks at some of the appalling notions and pre-historic concepts that are entrenched in the existing curriculum, which are reinforced as authentic by several well known authors of textbooks on the subject. While the situation appears to be improving with a new generation of teachers coming in who are not willing to be bowed down by the burdens of the past, nor by the dictates of their “experienced seniors”, the speed at which this is happening is far from satisfactory. The main reason for this is two-fold: one, forensic practitioners are fond of hiding behind the excuse of overwork with regard to their medicolegal duties, which therefore sadly leaves them with little time for toxicology, and two, an inherent reluctance to update their knowledge not only with regard to toxicology, but also the entire discipline of forensic medicine and toxicology. After all, it is so easy to just carry on with a conventional approach (even if it is grossly outdated), than to take the trouble of finding out where we have gone wrong (and still going wrong) and search for solutions. Recently, at another forum I had asked this very same question to some renowned experts: what real research has gone into forensic medicine in India ever since its inception as a new and independent specialty decades ago? Let us leave toxicology aside for the moment, I said to them; let us talk about forensic pathology. What has been done to make this subject relevant to the Indian scenario (instead of quoting from Western research, which is often not applicable in our country), and to keep updating our knowledge with more and more research initiativcs? Predictably, there was resounding silence. The answer lies in the very textbooks that we refer: information present in the 1970s editions of an average book is not likely to be much different from information present in the current editions. If at all anything is new, it is the addition of more and more material blindly (mostly from Western books!), with no effort at weeding out or pruning the wild foliage of the past. Making excuses for inefficiency is the easiest way out in any sphere of activity; on the other hand, accepting our inadequacies and trying to rectify them requires grit and guts. So, while the Indian Society of Toxicology (IST) can do little by way of rectifying anything in forensic medicine (to which the subject of toxicology has always been attached as an unwanted appendage), we certainly can do a lot in improving the situation with regard to toxicology. And that is precisely the objective of the 4th annual conference of IST (TOXOCON-4): development of an effective curriculum in toxicology for undergraduate and postgraduate medical education, on the basis of which each medical college can re-design the syllabus, thereby giving the existing atrocious scenario a decent burial. The new curriculum will be sent to the Medical Council of India for approval and ratification. We have already coddled together a motley (but eminently dedicated) group of professionals from the fields of forensic medicine, toxicology, pharmacology, and clinical medicine, and we shall chew the rag to bits in January 2008 on the lush backwaters of Kerala, and hopefully come up with a curriculum that will right the wrongs of decades of neglect and apathy.

Detection of Y STR markers of male fetal dna in maternal circulation.

BACKGROUND: Circulating fetal cells and cell free DNA in the maternal blood has been shown to help in prenatal diagnosis of genetic disorders without relying on invasive procedures leading to significant risk of pregnancy loss. AIM: The current study was undertaken to detect the male fetal population using Y STR markers DYS 19, DYS 385 and DYS 392 and also to study the extent of persistence of fetal DNA in the mother following delivery. MATERIALS AND METHODS: Blinded study was conducted on 50 mothers delivering male and female babies. Cellular and cell free DNA was extracted from maternal and fetal cord blood and amplified for Y STR markers by PCR. RESULTS: The amplification sensitivity of Y specific STR, DYS19 was 100% (22/22) in the male fetal DNA samples. The incidence of other STRs, i.e., DYS385 and DYS392 were 91% (20/22) each. Analysis of results revealed that thirteen of the twenty six women had detectable male fetal DNA at the time of delivery. However fetal DNA was not detectable twenty four hours after delivery. CONCLUSION: Preliminary results show that the separation of fetal cell-free DNA in the maternal circulation is a good low-cost approach for the future development of novel strategies to provide non-invasive techniques for early prenatal diagnosis.

Identification of active principles of manihot esculenta and cerbera odallum by thin layer chromatography: The potential for misinterpretation in forensic cases.

The main aim of this study was to perform thin layer chromatography on plant extracts of Cerbera odallum and Manihot esculenta, and ascertain as to whether similar patterns are obtained in the results. Most forensic science laboratories in India perform TLC assays for detecting active principles of Cerbera odallum, which is a common suicidal agent in some parts of the country. There have been instances where a positive report for Cerbera odallum was furnished, where no such history of ingestion was available. In some of these cases there was history of ingestion of cassava (Manihot esculenta), which is a staple food in some communities. The suspicion naturally arose as to whether the active principles of these two plants (one edible, the other poisonous) exhibit similar TLC profiles leading to the confusion. In this study the TLC patterns of the glycosides present in Cerbera odallum and Manihot esculenta were studied, which revealed that this was indeed the case. This makes it imperative that alternative methods must be used in suspected poisoning with Cerbera odallum, in order to avoid confusion in medicolegal cases. It is clear that the glycosides present in both odallum and cassava cross-react with each other giving similar TLC results.

Death due to antbite: A case report.

A case is reported of a young child being bitten by multiple fire ants, and succumbing. This is one of the rarest cases reported in literature.

Perfect takeoff.

When we first decided to start a professional society exclusively (and yet comprehensively) devoted to the field of toxicology about a year ago, little did we anticipate that it would grow so quickly, or that it would become so popular among a wide range of professionals, that we can now boast of a membership spanning the entire gamut of toxicology: clinical, forensic, pharmaceutical, occupational, you name it, and we have some member or the other who represents that area. In less than a year, the Indian Society of Toxicology has grown almost to a 200-member strong contingent that is continuing to record its precocious growth even as this editorial is being written, so much so that the figures being mentioned would undoubtedly have changed by the time this issue of the journal reaches the hands of its subscribers (your hands). While it took a premier national society devoted to forensic medicine (of which the editor is a life member) decades to cross the 500 member mark, at the rate at which 1ST is growing currently, it will not be surprising if that milestone is crossed in less than 5 years (touchwood!). What is even more heartening is that nearly half the existing members are life members, the long haulers in contrast to transient wayfarers, who actually dictate in the long run as to whether a Society is going to be able to achieve its goals. And there are so many goals to achieve, so many miles to go before we sleep! This brings us to the Inaugural Conference of the Society, which will hopefully be the forerunner for regular annual conferences in the years to come. Holding regular conferences, symposia, and workshops in various areas of toxicology is one of the most important objectives of the Society, since that is the principal manner by which we can highlight the importance of the subject to our scientific brethren, and even the lay public at large, besides serving as a forum where we can interact with each other and learn from each other. By the time you get to read this issue, the Inaugural Conference (TOXOCON-1) should be well under way, since the release of the former has been designed to coincide with the date of the Conference (28 November 2005). The next issue of this journal (JIST), i.e., the Jan-June 2006 issue will carry a detailed report of TOXOCON-1, including full text versions of invited lectures and award winning papers presented at the Conference, as well as abstracts of all other papers. So, if you are just an annual (2005) member, or your subscription runs out by the year end, you would do well to renew the membership/subscription, or better still become a life member of 1ST and receive all future issues without break in continuity. Coming to this issue of JIST, a look at the contents will indicate the range and depth of the articles published, as well as the international nature of the journal. We have articles not only from various parts of India, but also from other countries such as Malaysia, Cameroon, and Turkey. And the waiting list of articles to be published keeps growing inexorably. What better indicator of the success of a professional journal can there be than the length of its waiting list of prospective authors! The hugely popular features (Toxiquiz and Toxicology Snippets) of course find a place in this issue as in the previous one, and in fact will be made permanent fixtures. In future issues, it is proposed to add more innovative features that will be specifically designed with a view to make them useful and interesting. After all it is our avowed aim to make JIST the gold standard for professional journals published on the subject from India.

Poisoning due to white seed variety of Abrus precatorius.

We report an unusual case of poisoning involving the white seed variety of Abrus precatorius that caused serious manifestations in a middle-aged male who had consumed the seeds on the advice of a folk medicine practitioner. He recovered after a prolonged duration of hospital treatment without any subsequent complications or sequelae. The case is being reported on account of its rarity.