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Table 2 Clinical assessment of toxicant exposures is challenging

From: Expert clinician’s perspectives on environmental medicine and toxicant assessment in clinical practice

Key challenges Clinician Quotes
Lack of clinical guidelines IP It would be great to have a standardized data-collection tool for environmental exposure history. It would make an enormous difference to outcomes.
I’ve got a patient today with high bisphenol and phthalate levels. What do you do about it, besides stopping the exposure? So then, the question is, when they’ve got all these things and they’ve stopped the exposure and they are still very sick people, how do you go about dealing with that?
Limitations of laboratory testing OEP The frustrating thing with EM is actually trying to find the tests which can actually show that what they (the patient) have got is real.
You would counsel (the patient) against over testing and wasting public money.
Most of them you don’t have tests for.
Testing is really difficult. I have a very limited array of tests.
If you’re trying to test for things like benzene exposures and stuff, you really have to catch that at the time they’re exposed because very quickly you don’t get many metabolites left in the system from solvent exposures.
It’s far too expensive for my patients to do that.
I use blood for heavy metals and obviously that only picks up the products that are long-term exposures that bioaccumulate like lead, cadmium, and nickel.
I just don’t feel like I have the tools to do a better job.
IP There’s a lot of rubbish pathology that goes on, where we don’t have good standards, where we accept almost any kind of result as proof of poison and abnormalities and we don’t have good, validated ways of understanding how to measure the toxins. So we don’t have good surrogate markers, because no one can agree on what a marker of a toxic exposure does.
The whole question of the testing… it’s really a mine-field that’s very hard to get your head around. Standard medical labs do not measure anything that are specific to environmental toxins or exposures.
In my area of medicine (CFS/MCS), physical examination is terribly disappointing. It doesn’t really show much at all and that’s part of why people get ignored in this area. They can have neurological and immunological impacts and the physical examination looks and feels just the same as any other person.
Although we wanted to believe that the Australian labs were doing it properly, clearly they weren’t, when they had five-fold differences in one-split sample which they thought were different patients.
I used to use porphyrin tests, but I found that the results were so inconsistent, that I just stopped.
I don’t test for chemicals. I just do the functional liver detoxification profile and get their livers working properly to get rid of the chemicals.
Difficulty in establishing cause and effect OEP In case of punitive or suspected cause, until there’s sufficient scientific evidence supporting, relating the possible cause and the effect... that’s where dose-response relationships are important, whether there’s a plausible biological mechanism that can explain the mechanism from the exposure. It’s important not to create alarm.
It’s hard to quantify these health risks. I think what happens in a lot of companies is you do what you’re regulated to do, and then you just report what you can. There’s a lot of uncertainty in everything we do.
We simply don’t have enough data to make strong conclusions unfortunately.
You need to stick with science as much as possible. But there are a lot of areas where the science isn’t that great.