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Graca M, Sarantopoulos K, Horn DB. Chemical toxic exposures and chronic ocular pain. FRONTIERS IN TOXICOLOGY 2023; 5:1188152. [PMID: 37637478 PMCID: PMC10448520 DOI: 10.3389/ftox.2023.1188152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/18/2023] [Indexed: 08/29/2023] Open
Abstract
Chronic ocular pain is a common, debilitating chronic pain condition with significant morbidity and negative impact in patients' quality of life. Several, diverse types of insults to the ocular surface can lead to acute, and under certain conditions to chronic ocular pain, and these include toxic irritants. Exposure of ocular surface to toxic irritants, in addition to direct tissue injury, carries the capacity to generated intense immune and neuronal responses with hyper-excitability, sensitization and chronic pain. Because, chronic ocular pain subsequent to toxic exposures is relatively unrecognized clinical entity, this brief review highlights pertinent concepts of its epidemiology, pathogenesis/pathophysiology, clinical progression, with recommendations for its clinical management that clinicians may find helpful. Suppression of pain signaling, generating neuronal sensitization, and prevention of chronicity of neuropathic pain is particularly emphasized in this respect.
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Affiliation(s)
- Mateusz Graca
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, United States
| | - Konstantinos Sarantopoulos
- Department of Anesthesiology, Perioperative Medicine and Pain Medicine, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Danielle Bodzin Horn
- Department of Anesthesiology, Perioperative Medicine and Pain Medicine, University of Miami Miller School of Medicine, Miami, FL, United States
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Thors L, Wigenstam E, Qvarnström J, Larsson A, Lindberg S, Öberg L, Rattfelt-Nyholm J, Bucht A. Comparison of skin decontamination strategies in the initial operational response following chemical exposures. Toxicol In Vitro 2023; 87:105539. [PMID: 36539105 DOI: 10.1016/j.tiv.2022.105539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/03/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022]
Abstract
In mass casualty incidents including hazardous chemical skin exposure, decontamination is the primary intervention to avoid systemic uptake of the toxic compound. The protocol needs to be both simple and efficient to enable a rapid response and avoid delay of patient management. In the present study, decontamination strategies included in the initial operational response were evaluated following human skin exposure in vitro to four different contaminants. Results demonstrated that the efficacy of selected decontamination procedures was highly dependent on the chemical contaminant used. Dry removal of the sulfur mustard simulant methyl salicylate prior to wet decontamination was found beneficial compared to wet decontamination alone. Rapidly initiated wet decontamination was more efficient compared to dry and wet removal of the industrial chemical 2-butoxyethanol and the nerve agent tabun. Following VX-exposure, all wet decontamination procedures resulted in increased agent penetration compared to the control. In conclusion, challenges in establishing simple and efficient decontamination procedures for a broad-spectrum of chemicals have been demonstrated. The impact of including a dry removal step during decontamination was evidently agent specific. Despite the variation in efficacy, immediately initiated dry removal may facilitate patient management until wet decontamination resources are available and to reduce the risk of secondary contamination.
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Affiliation(s)
- Lina Thors
- Swedish Defence Research Agency, CBRN Defence and Security, Umeå, Sweden.
| | | | - Johanna Qvarnström
- Swedish Defence Research Agency, CBRN Defence and Security, Umeå, Sweden
| | - Andreas Larsson
- Swedish Defence Research Agency, CBRN Defence and Security, Umeå, Sweden
| | - Sandra Lindberg
- Swedish Defence Research Agency, CBRN Defence and Security, Umeå, Sweden
| | - Linda Öberg
- Swedish Defence Research Agency, CBRN Defence and Security, Umeå, Sweden
| | | | - Anders Bucht
- Swedish Defence Research Agency, CBRN Defence and Security, Umeå, Sweden
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James T, Izon-Cooper L, Collins S, Cole H, Marczylo T. The wash-in effect and its significance for mass casualty decontamination. JOURNAL OF TOXICOLOGY AND ENVIRONMENTAL HEALTH. PART B, CRITICAL REVIEWS 2022; 25:113-134. [PMID: 35220912 PMCID: PMC8903816 DOI: 10.1080/10937404.2022.2042443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Decontamination of skin by washing may increase dermal absorption, a phenomenon known as the wash-in effect. The wash-in effect is frequently discussed in studies investigating casualty decontamination where potentially life-saving interventions may enhance the dermal penetration of toxic chemicals, leading to an increase in incidence of morbidity and rates of mortality. However, the wash-in effect is seldom investigated within the context of mass casualty decontamination and real-life consequences are therefore poorly understood. This paper reviews the existing literature on the wash-in effect to highlight the proposed mechanisms for enhanced absorption and evaluate the wash-in effect within the context of mass casualty chemical decontamination.
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Affiliation(s)
- Thomas James
- Radiation, Chemical and Environmental Hazards, UK Health Security Agency, Chilton, UK
| | - Lydia Izon-Cooper
- Radiation, Chemical and Environmental Hazards, UK Health Security Agency, Chilton, UK
| | - Samuel Collins
- Radiation, Chemical and Environmental Hazards, UK Health Security Agency, Chilton, UK
- Global Operations, UK Health Security Agency, London, UK
| | - Haydn Cole
- Radiation, Chemical and Environmental Hazards, UK Health Security Agency, Chilton, UK
| | - Tim Marczylo
- Radiation, Chemical and Environmental Hazards, UK Health Security Agency, Chilton, UK
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James T, Collins S, Marczylo T. Identification of Novel Simulants for Toxic Industrial Chemicals and Chemical Warfare Agents for Human Decontamination Studies: A Systematic Review and Categorisation of Physicochemical Characteristics. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:8681. [PMID: 34444429 PMCID: PMC8391658 DOI: 10.3390/ijerph18168681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/13/2021] [Accepted: 08/15/2021] [Indexed: 11/16/2022]
Abstract
Chemical simulants have long been used in human trials of mass decontamination to determine the efficacy of decontamination interventions against more toxic agents. Until now, reliance has mostly been on individual chemicals as surrogates to specific agents (e.g., methyl salicylate for sulphur mustard). A literature review was conducted to identify chemicals that had been previously tested on human volunteers and that represent diverse physicochemical characteristics in order to create a repository for chemical simulants. Of the 171 unique chemicals identified, 78 were discounted for the risk they could pose to human volunteers, 39 were deemed suitable for use, and a further 54 were considered to be possible simulants but would require further research. Suitable simulants included both solid and liquid chemicals spanning a wide range of physicochemical properties including molecular weight, octanol/water partition coefficient, vapour pressure, and solubility. This review identifies an array of potential simulants suitable for use in human volunteer decontamination studies and is of relevance to future studies on systemic absorption and surface decontamination.
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Affiliation(s)
- Thomas James
- Centre for Radiation, Chemicals and Environmental Hazards (CRCE), Public Health England, Chilton OX11 0RQ, UK; (S.C.); (T.M.)
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Collins S, Williams N, Southworth F, James T, Davidson L, Orchard E, Marczylo T, Amlôt R. Evaluating the impact of decontamination interventions performed in sequence for mass casualty chemical incidents. Sci Rep 2021; 11:14995. [PMID: 34294861 PMCID: PMC8298482 DOI: 10.1038/s41598-021-94644-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/12/2021] [Indexed: 11/23/2022] Open
Abstract
The Initial Operational Response (IOR) to chemical incidents is a suite of rapid strategies including evacuation, disrobe and improvised and interim decontamination. IOR and Specialist Operational Response (SOR) decontamination protocols involving mass decontamination units would be conducted in sequence by UK emergency services following a chemical incident, to allow for safe onward transfer of casualties. As part of a series of human volunteer studies, we examined for the first time, the effectiveness of UK IOR and SOR decontamination procedures alone and in sequence. Specifically, we evaluated the additional contribution of SOR, when following improvised and interim decontamination. Two simulants, methyl salicylate (MeS) with vegetable oil and benzyl salicylate (BeS), were applied to participants’ skin. Participants underwent improvised dry, improvised wet, interim wet, specialist decontamination and a no decontamination control. Skin analysis and UV photography indicated significantly lower levels of both simulants remaining following decontamination compared to controls. There were no significant differences in MeS levels recovered between decontamination conditions. Analysis of BeS, a more persistent simulant than MeS, showed that recovery from skin was significantly reduced following combined IOR with SOR than IOR alone. These results show modest additional benefits of decontamination interventions conducted in sequence, particularly for persistent chemicals, supporting current UK operational procedures.
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Affiliation(s)
- Samuel Collins
- Chemicals and Environmental Effects Department, Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Didcot, Oxfordshire, UK.
| | - Natalie Williams
- Behavioural Science Team, Emergency Response Department Science and Technology, Health Protection Directorate, Public Health England, Porton Down, UK
| | - Felicity Southworth
- Behavioural Science Team, Emergency Response Department Science and Technology, Health Protection Directorate, Public Health England, Porton Down, UK
| | - Thomas James
- Chemicals and Environmental Effects Department, Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Didcot, Oxfordshire, UK
| | - Louise Davidson
- Behavioural Science Team, Emergency Response Department Science and Technology, Health Protection Directorate, Public Health England, Porton Down, UK
| | - Emily Orchard
- Behavioural Science Team, Emergency Response Department Science and Technology, Health Protection Directorate, Public Health England, Porton Down, UK
| | - Tim Marczylo
- Toxicology Department, Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Didcot, Oxfordshire, UK
| | - Richard Amlôt
- Behavioural Science Team, Emergency Response Department Science and Technology, Health Protection Directorate, Public Health England, Porton Down, UK.,Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Collins S, James T, Carter H, Symons C, Southworth F, Foxall K, Marczylo T, Amlôt R. Mass Casualty Decontamination for Chemical Incidents: Research Outcomes and Future Priorities. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:3079. [PMID: 33802722 PMCID: PMC8002470 DOI: 10.3390/ijerph18063079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/09/2021] [Accepted: 03/13/2021] [Indexed: 01/22/2023]
Abstract
Planning for major incidents involving the release of hazardous chemicals has been informed by a multi-disciplinary research agenda which has sought to inform all aspects of emergency response, but with a focus in recent years on mass casualty decontamination. In vitro and human volunteer studies have established the relative effectiveness of different decontamination protocols for a range of chemical agents. In parallel, a programme of research has focused on communicating with and managing large numbers of contaminated casualties at the scene of an incident. We present an accessible overview of the evidence underpinning current casualty decontamination strategies. We highlight where research outcomes can directly inform response planning, including the critical importance of beginning the decontamination process as soon as possible, the benefits of early removal of contaminated clothing, the evidence under-pinning dry and wet decontamination and how effective communication is essential to any decontamination response. We identify a range of priority areas for future research including establishing the significance of the 'wash-in' effect and developing effective strategies for the decontamination of hair. We also highlight several areas of future methodological development, such as the need for novel chemical simulants. Whilst considerable progress has been made towards incorporating research outcomes into operational policy and practice, we outline how this developing evidence-base might be used to inform future iterations of mass casualty decontamination guidance.
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Affiliation(s)
- Samuel Collins
- Chemicals and Environmental Effects Department, Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Didcot OX11 0RQ, UK;
| | - Thomas James
- Chemicals and Environmental Effects Department, Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Didcot OX11 0RQ, UK;
| | - Holly Carter
- COVID-19 Behavioural Science and Insights Unit, Public Health England, Public Health England, London SE1 8UG, UK; (H.C.); (C.S.); (R.A.)
| | - Charles Symons
- COVID-19 Behavioural Science and Insights Unit, Public Health England, Public Health England, London SE1 8UG, UK; (H.C.); (C.S.); (R.A.)
| | - Felicity Southworth
- Behavioural Science, Emergency Response Department Science & Technology, Health Protection Directorate, Public Health England, Porton SP4 0JG, UK;
| | - Kerry Foxall
- Toxicology Department, Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Didcot OX11 0RQ, UK; (K.F.); (T.M.)
| | - Tim Marczylo
- Toxicology Department, Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Didcot OX11 0RQ, UK; (K.F.); (T.M.)
| | - Richard Amlôt
- COVID-19 Behavioural Science and Insights Unit, Public Health England, Public Health England, London SE1 8UG, UK; (H.C.); (C.S.); (R.A.)
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London SE1 1UL, UK
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