Disease Informatics: Living in the toxic world

1. Mathieu Orfila Father of Toxicology Disease Informatics: Living in the toxic world Toxins are component causes of most of the diseases and hence detoxification is usually beneficial “Clean bowled is not the complete cricket”. Similarly, diseases are complex. IT applications can handle disease data complexities and could provide better definition of diseases. Presentation by R.P.Deolankar

2. Earlier lecture on disease informatics • Lecture no. 35791: Disease Informatics: The burden of disease, September 11, 2009 • Lecture no. 34141: Disease Informatics: Brush up the terms describing techniques and resources, February 19, 2009 • Lecture no. 34011: Disease Informatics: Terms and Jargon to begin with, February 1, 2009 • Lecture number -31981: Disease Informatics: ICD-11 at the doorstep, February 26, 2008 • Lecture number-30331: Disease Informatics: Phytates driving from the back-end to Influenza, Encephalitis, Hepatitis, Anemia at the front-end, July 10, 2007 • Lecture number-28921: Disease Informatics: Host factors simplified, February 07, 2007 • Lecture number-25381: DIG for Disease Informatics group; Part-II, November 07, 2006 • Lecture number-25371: DIG for Disease Informatics group; Part-I, November 07, 2006

3. What are toxins? “toxico- “ is a root of a word meaning poison or toxin. • Metals, therapeutic drugs, industrial chemicals, pollutants, pesticides, fuels, herbicides and abused drugs (exogenous) • Bacterial toxins, parasitic products, bile, hormones (endogenous) • Substances that accumulate in the body producing toxicity, even accumulated nutrients and drugs could be toxic (Toxicity depends on dose) • Toxicology: Clinical, Medical, Forensic, Analytical, Chemical, Eco etc • Toxins cause several disorders and are also predisposing factors or component causes of most of the diseases.

4. Adjectives describing toxicity • Acute toxicity is exhibited by short but severe course, usually due to large exposure and reversible effect • Chronic toxicity is persisting or progressing over a long period of time, mostly irreversible • Local toxicity: Toxic effect seen in the restricted area of the body • Systemic toxicity: Affecting the entire body system • Synergistic effect: The working together of two toxic elements that produce an effect greater than the sum of their individual effects

5. Toxic drugs Diclofenac (Voveran) • Non-steroidal anti-inflammatory drug, analgesic, antipyretic, used in arthritis and menstrual pain • Vultures eat the carcasses of livestock that have been administered veterinary diclofenac • Poisonous to vultures, has led to the bird’s near extinction across the India • What can we learn from this incidence? (We don’t have data whether some people die like vultures after taking the medicine) • Vultures are natural scavengers. Loosing the vultures means making the world more toxic.

6. Toxic water: Pollution of lakes, rivers, oceans, and groundwater Endocrine Disrupting substances(Known or suspected) • The viability of commercial and ecologically important marine and freshwater fish stocks may be threatened by the feminisation of male fish • Polluted water bodies: Surface run off of pesticides, fertilizers and plant nutrients, sewage, soil sediments; Mining, Industrial effluents, oil, gasoline, and additives, plastics; Personal Care Products, Household Cleaning Products, and Pharmaceuticals • Endocrine Disrupting Pesticides: atrazine, 2,4-D, DDE, DDT, diazinon, diuron, endosulfan, fenthrothion, glyphosate, lindane, linuron, parathion, permethrin, simazine, TBT, trifluralin, vinclozolin. • Endocrine Disrupting Industrial chemicals or breakdown products: bisphenol A, dioxins, nonylphenol, PCBs, some phthalates

7. Exposure to Endocrine Disruptors Hormones and neurotransmitters keep harmony with each other, body systems and nature’s circadian rhythms. Loss of the harmony causes several disorders. Abnormal neuroendocrine-response leads to • Infectious diseases • Diseases associated with endocrine anomaly like obesity and diabetes • Cancers • Psychiatric diseases • Degenerative diseases etc Protection of enkephalins (neurotransmitters) by enkephalinase inhibitors causes reversal of diarrhea associated with infectious agents like rotavirus. What disrupts function of enkephalins?

8. Toxic air Air pollution • Burning: Smoke from power plant, waste incinerators, furnaces, motor vehicles, marine vessels, aircraft, volcanic activity, , and rocketry • Fumes from paint, hair spray, varnish, aerosol sprays and other solvents, chemicals used in agriculture and forest management, methane from landfills, emitted by ruminants, germs from hospital wastes • Dust from desert land, radioactivity due to nuclear weapons, Radon gas from radioactive decay within the Earth's crust

9. Intoxicating habits Alcohol: Intoxicating ingredient of many common beverages • Fetal Alcohol Syndrome is depicted by retardation of growth, facial malformations, small head and greatly reduced intelligence • CNS Depressant, Depression of inhibitory control, Vasodilation: warm, flushed, reddish skin, Emotional outbursts, Decreased memory & concentration, Poor judgment, Decreased reflexes, Decreased sexual response, Appetite loss • Cirrhosis of liver and Cancer • Lost productivity, impaired performance, cost to society

10. Nicotine • Toxic and addictive • Gum recession, Sores in the mouth, Cancer of the mouth, Increased blood pressure, Heart disease, Ulcers • Chronic nicotine exposure to developing fetus: Decreased birth weight, Attention deficit disorder, Cognitive impairment

11. Slowing down the “Gastrointestinal transit time” (GTT) • The time taken by food to move from mouth to anus is GTT. Indigestible residue of the dinner should be excreted by the morning (GTT< 12 hrs); similarly GTT for breakfast food should not be more than 24 hrs is the common sense • Person is constipated if GTT is > 24 hrs. GTT is associated with low dietary fiber intake, emotional or nervous disturbances, systemic and structural disorders, drug-induced aggravation, and infections. Slow GTT causes flatulence and irregular bowel movements • “Compacted feces is not totally excreted and gets rotten” is considered as quackery assumption by some people. While others link it with colon cancer and several other diseases. This gave rise to the theory of autointoxication.

12. Dysbiotics(Products of dysbiosis) • Injury to the Native microbiota population resulting in dysbiosis is characterized by imbalance in microbial populations; bacteriophages, diet, some host or environmental factors could be associated with dysbiosis • The harmful products produced during dysbiotic state harm locally as well as systemically • Test profiles of urinary compounds associated with microbial overgrowth can include benzoate, hippurate, phenylacetate, phenylpropionate, cresol, hydroxybenzoate, hydroxyphenylacetate, hydroxyphenylpropionate and 3,4-dihydroxyphenylpropionate, indican, tricarballylate, D-lactate, and D-arabinitol • Vaginal dysbiosis is assayed by “Nugent score” method, pH, whiff test

13. Toxic foods Refined white sugar • Could contain traces of chemicals like phosphoric acid and bleaching agents used in the sugar manufacturing process • Consumption of sugar beyond limit affects brain structure and reduces brain function and ability to learn, associated with Alzheimer's disease, Duodenal ulcer, Colorectal cancer, Crohn's disease and Metabolic syndrome X • Increases gastrointestinal transit time, faecal concentration of secondary bile acids and total bile acids, and intestinal fermentation

14. Refined salt • Meager potassium based plant foods and eating salt is mismatch between our genetically determined nutritional requirements and our current diet • Dietary sodium chloride intake independently predicts the degree of hyper-chloremic metabolic acidosis in healthy humans consuming a net acid-producing diet leading to decreased muscle and bone mass in adults, and kidney stone formation and also growth retardation in children • Table salt usually contains substances anti-caking agents such as sodium silicoaluminate or magnesium carbonate

15. Cereal Allergens • Bakers' asthma: chloroform methanol soluble proteins from wheat serve as allergens • Wheat-dependent exercise-induced anaphylaxis (WDEIA): associated with the part of the gluten protein fraction • Gluten in wheat triggers celiac disease (CD) in predisposed individuals • CD, an autoimmune enteropathy, is associated with type 1 diabetes (T1D)

16. Exorphins • Endorphins (endogenous + morphines) are “feel good” substances produced by the pituitary and the hypothalamus in response to pain, excitement, orgasm and exercise • Exorphins (neuroactive peptides) are similar to endorphins but are present in proteins of grains and milk and released during digestion, cause increased insulin production and release • Exorphins are associated with cravings and compulsions to increase food ingestion, contribute to the mental disturbances and appetite disorders • Many people with schizophrenia improve if they stop eating wheat and dairy, and worsen if given wheat or gluten and dairy. Variability in normal gut bacteria between individuals may, in part, explain why some people have a problem with exorphins and some don't

17. Aflatoxinsand fungal toxins • Naturally occurring mycotoxins, produced by many species of Aspergillus, aflatoxin contamination is quite common in foods and feeds in India • Crops: cereals (maize, jowar, bajra, rice, wheat), oilseeds (ground nut, soybean, sunflower, cotton), spices (chili peppers, black pepper, coriander, turmeric, ginger), and several tree nuts • Aflatoxin produces an acute hepatic necrosis, resulting later in cirrhosis, and/or carcinoma of the liver • Aflatoxins and hepatitis viruses interact to cause liver cancers • Other immunotoxins of fungal origin are fumonisins, gliotoxin, ochratoxins, patulin, and trichothecenes

18. Toxic environment Aluminiumutensils and acidic water • Aluminium utensils are extensively used to cook acidic foods by people below poverty line and dhaba(Hut)restaurants. Surface water, if acidic, also carries aluminium • Toxicity is linked to Alzheimer's disease, encephalopathy, osteomalacia or aplastic bone disease, proximal myopathy, increased risk of infection, increased left ventricular mass and decreased myocardial function, microcytic anemia, and with very high levels, sudden death

19. Volatile organic compounds (VOC’s) • Benzene gas resulting from cigarette smoke, car exhaust or forest fires is carcinogenic and associated with leukemia. Benzene is component of plastics, synthetic rubbers, dyes, detergents, and some pharmaceuticals and workers in these industries are frequently exposed. • Formaldehyde gas (FG) is used for sterilization and neutralization of equipment. It is both an irritant and a sensitizer (makes prone to allergies) • Hydrocarbons contribute to photochemical smog, some gases are soluble and reach ground water • Outgassing by a new car, new building, paints, carpets etc contribute to sick building syndrome

20. Phthalates in plastics and cosmetics: feminizes males • Phthalates are used as PVC softeners and also help fragrances in cosmetics linger after application • Phthalate containing plastics are commonly used in food packing, soft toys, cosmetics, IV bags etc • Xenoestrogen, increasing the likelihood of small or undeveloped testes, undescended testicles, and low sperm counts in males and premature breast development in females

21. Polychlorinated biphenyl (PCB): Two phenyl rings (C6H5-) chlorinated with several (1 to 10) chlorine atoms • Used in transformers and capacitors and coolants. Used as plasticizers in paints and cements, fire retardant in fabric treatments, heat stabilizing additives for PVC electrical insulation, adhesives etc • Persistent organic pollutant (POP, resistant to environmental degradation through chemical, biological, and photolytic processes) • Fat stored chemical, enters through placenta, breast milk, food, water, inhalation and dermal contact • Growth retardation, nail malformations, delays in cognitive development, and behavioral problems

22. Dioxins (two benzene rings joined by two oxygen bridges) • Persistent organic pollutants, lipophilic and hence stays in body fat, fat from food animals is a source of exposure • Pollution results from industrial emissions, formed as a result of combustion processes such as commercial or municipal waste incineration and from burning fuels • Immunotoxic, exposure enhances susceptibility to viral infections and cancer, reproductive and developmental disorders, chloracne (a severe skin disease with acne-like lesions), skin rashes, skin discoloration, excessive body hair, mild liver damage, diabetes.

23. Pesticides (through foods and sprays) • Carcinogenic (Produce cancer): According to the Environmental Protection Agency (EPA), 60 per cent of herbicides, 90 per cent of fungicides and 30 per cent of insecticides are known to be Carcinogenic, Mutagenic (produce mutants, effects on genetic material that can be inherited), Teratogenic (Produce birth defects) • Neurotoxic, Immunotoxic: causes immunosuppression

24. Other toxicants • Asbestos: associated with parenchymal asbestosis, asbestos-related pleural abnormalities, mesothelioma, certain cancers • Heavy metals: associated with a variety of central, peripheral, or autonomic nervous system injuries • Antinutritional factors present in certain foods requiring processing (Cholinesterase inhibitors, Protease inhibitors, Amylase inhibitors, Tannins, Cyanogenic glycosides, Goitrogens, Lectin proteins (phytohemagglutinins), Lathyrogens, Pyrrolizidine alkaloids in crops contaminated with weeds, Anti-thiamin compounds, Avidin) • Animal and insect venoms • Poisons of herbal or mineral origin

25. How toxins enter the human body • Certain toxic exposures could be unavoidable • Exposure can occur while working, commuting or at residence, accidental or deliberate • Through the skin or injection, mouth or inhalation • Produced in the body itself due to exposure to biological entities e.g. due to dysbiosis or physical entities like radiation or sound

26. Mechanism of action • Producing non-functional analogues of proteins and enzymes e.g. Cyanide and arsenic toxicity • By causing primary damage to the system, mutagenesis, teratogenesis, carcinogenesis, generation of Reactive Oxygen Species (ROS) and accompanying oxidative stress • Secondary: damage to the immunity makes us prone to the infection • Depends on chemical form: Ionic mercury is highly toxic, oral insoluble mercury is non-toxic

27. Clinical specimen for toxicity detection and assay • Blood, saliva and various lavages and smears • Stool, urine, sweat and menstrual fluid, milk, secretions, vomits, enemata • Hair, biopsies, autopsies • In case of experimental animals: dissected tissues

28. Role of organs • Immobilization of toxins in body tissues e.g. Skin, Hair, adipose tissue • Breaking the toxins: Native microbiota, Liver, Immune system, Lungs, Kidneys • Excretory organs: Eyes, Nose, Mouth, Gut, Skin, Urinary system, Reproductive system, Lactation Oxygenation (Cytochrome p450 system) and conjugation (sulfate, glutathione and glucuronic acid, glycine, taurine etc) and methylation are detoxifying functions of liver.

29. Principles of detoxification • Use antidote: inactivate and neutralize toxins e.g. antivenom, activated charcoal, blockers, chelators, hyperbaric oxygen therapy (HBOT), • Reduce exposure: Restore probiosis and cultivate healthy lifestyle • Promote elimination: Extract toxins, metabolically alter it (oxidation and conjugation) to make it more soluble and stimulate excretion Increase in intestinal bacteria producing deconjugating enzymes results in reabsorption of estrogen through enterohepatic circulation. The excess of the hormone could be associated with the disease like breast cancer. Probiotic lactobacillus reduce deconjugating bacteria thereby help in prevention of the cancer.

30. Fat deposits • Starting the raw-vegan diet composed of fresh fruit and vegetables (Prebiotics) nourishes the native microbiota while maintaining the gut movement and permitting the lipolysis • Dysbiosis could be prevented if complete fasting is preceded by a course of raw vegan diet; else, a sudden complete fasting might result in the loss of bowel action • Body fat is used up during fasting and most of the toxins immobilized therein are released for excretion • 5+ a day regimen and Paleolithic type diet could serve as the ideal post-detoxification protocol Indole-3-carbinol, possibly anticarcinogenic, antioxidant, and anti-atherogenic compound, occurs naturally in cruciferous vegetables such as cabbage, broccoli, brussels sprouts, and kale. Limonene present in citrus peels and rind dissolves cholesterol, normalizes peristalsis and reduces heart burn; considered as detoxifying agent.

31. Mucosal deposits • Mucosa provides lining to the digestive tract, the respiratory tract and the reproductive tract and becomes dirty due to the pollutants and pathogens • Fats could be used to remove fat soluble mucosal deposits. Oral fat administration helps in excretion of bile. Ayurvedprotocols snehana(oleation), basti(enema / douche), virechana(purgation)and nasya (nasal applications) make use of fats and oil • Water or water based solutions are extensively used in traditional yoga protocols viz. Shankhaprakshalana(cleaning the conch i.e. gut), Vamana(vomiting)and Kunjal(elephant style cleaning), Jalaneti(nasal irrigation) and Jalabasti(enema)

32. Max Gerson explains action of saltless diet • Saltless diets eliminate the retained sodium, chlorine and H2O together with toxins and poisons from the tissues all over the body and also help to restore mineral balance • Infiltration of sodium chloride and water into the cells of anodic organs replacing potassium and other positive ions is reversed by saltless diet

33. Spa therapies Cleaning through gut • Colon irrigation, Basti (Enema), Virechana (Purgation), Vamana (Vomiting), Triphala (A herbal mixture), Shankhaprakshalana (Yoga method of gut washing), Jala neti (Irrigation), Sutra neti (Cleaning internally using cotton / cloth) • Econutrition/ immunonutrition: Fiber, Prebiotics, Probiotics, Synbiotics • Abdominal exercises and massage • Natural fresh food: fruits and salads

34. Cleaning through respiratory system • Promenade along the beach, hills, gardens and parks, open spaces • Aerobic exercises, Dancing, Sports, Pranayama (breath control) and breathing exercises • Nasya and neti and other yogic kriyas • Ozone therapy

35. Flushing by boosting urination • Drinking liquids, water, fruit and vegetable juices • Herbal diuretics • Chelation therapy; Heavy metal chelators: EDTA, dimercaprol [BAL], Alpha lipoic acid [ALA], Aminophenoxyethane-tetraacetic acid [BAPTA], Deferasirox, Deferiprone, Deferoxamine, Diethylenetriaminepentaacetic acid [DTPA], Dimercaprol [BAL], Dimercapto-propane sulfonate [DMPS], Dimercaptosuccinic acid [DMSA], Ethylenediaminetetraacetic acid [calcium disodium versante, CaNa2-EDTA], Ethylene glycol tetraacetic acid [EGTA], D-penicillamine

36. Sweating and bathing • Sunbath, Sauna (steam bath), Infrared sauna • Foot bath, Hot and cold packs, Herbal packs • Ron Hubbard method: jogging, oil ingestion, sauna, and high doses of vitamins, particularly niacin • Natural bath (open air) as suggested by Adolph Just

37. Expelling through uterus • Could be used by traditional healers to treat chronic ailments like migraine, oligomenorrhea, dysmenorrhea • Induction of contractions in uterus is usually the strategy; manual, herbal or sexual • Manual: Acupressure/ acupuncture and massage, uttar-basti (Ayurveda) • Herbal: Ergotamine, castor oil, pineapple (raw) • Sexual: Stimulation of organs by partner/ therapist Clothing, particularly tight undergarments, obstruct lymph movement and detoxification process

38. Tools for study Toxicological signatures • Signature is a distinctive characteristic or set of characteristics by which a biological structure or medical condition is recognized. It indicates the presence of a substance or the occurrence of a physical process or event. • Microarray studies of livers of laboratory animals treated with different chemicals (xenobiotics and drugs) provide signatures for pharmacological and toxicological endpoints. • Union of genes present in the signatures characterise liver fibrosis • The approach of using the whole genome and a diverse set of compounds allows a comprehensive view of most pharmacological and toxicological questions and is applicable to other situations such as disease and development.

39. Detoxification is underestimated •  Molecular signatures converge in disease like cancer • Such phenomenon is yet to be seen in several other diseases • Toxicities are associated with several disorders and diseases and prevention of toxic exposures / detoxification is well justified • Research councils need to take special initiative in toxicology and detoxification

40. Organizations and databases OECD • The Organisation for Economic Co-operation and Development • An international organisation of 30 countries that accept the principles of representative democracy and free-market economy • Guidelines for the Testing of Chemicals: a collection of the most relevant internationally agreed testing methods used by government, industry and independent laboratories to assess the safety of chemical products

41. OECD special initiative on (Q)SARs • (Q)SARs: (Quantitative) Structure-Activity Relationships • Methods for estimating properties of a chemical from its molecular structure and have the potential to provide information on hazards of chemicals, while reducing time, monetary cost and animal testing currently needed

42. OECD special initiative on endocrine disruptors • Providing information and co-ordinating activities • Developing new and revised existing Test Guidelines to detect endocrine disrupters; and • Harmonising hazard and risk characterisation approaches

43. OECD special initiative on toxicogenomics Toxicogenomics: A study of the response of a genome to hazardous substances, using “omics” technologies Providing tools for: • Improving the understanding of mechanisms of toxicity • Identifying biomarkers of toxicity and exposure • Reducing uncertainty in grouping of chemicals for assessments, (Q)SARs, inter-species extrapolation, effects on susceptible populations, etc.; and • Providing alternative methods for chemical screening, hazard identification and characterisation

44. Toxnet • Toxicology data network provided by National Library of Medicine, USA • Databases on toxicology, hazardous chemicals, environmental health, and toxic releases • Web interface is designed as an easy way to search databases of varying formats and content • Toxicology literature • Chemical information

45. IPCS • The International Programme on Chemical Safety • Joint venture of the United Nations Environment Programme, the International Labour Organisation, and the World Health Organization

46. IPCS activities • To carry out and disseminate evaluations of the effects of chemicals on human health and the quality of the environment • To carry out and disseminate evaluations of the effects of chemicals on human health and the quality of the environment • Development of know-how for coping with chemical accidents, coordination of laboratory testing and epidemiological studies, and promotion of research on the mechanisms of the biological action of chemicals

47. Pharmacopoeias • Pharmacopoeia is an authoritative publication designating the properties, action, use, dosage, and standards of strength and purity of drugs • Pharmacopeia provides standards for the quality of all pharmaceuticals, biologics, dietary supplements, and other health care products • Regulatory toxicology: All prescription and over-the-counter drugs marketed meet pharmacopoeia standards for toxicity testing • Animal tests are common in serial batches of drugs, biologics, and/or biological products and to assess the toxic potential of plastics or leachable components of implanted medical devices

48. ToxInt • The Toxic Intensities Database • Produced by the World Bank's Economics of Industrial Pollution research team, in collaboration with the Center for Economic Studies of the U.S. Census Bureau • The dataset provides pollution intensities and the corresponding toxic risks for 246 chemicals in the U.S. EPA’s Toxic Release Inventory (TRI)

49. Environment regulatory and other important knowledge organizations • Environmental protection agency in US • Pollution control boards and departments • National Environment Protection Authority (NEPA) in India • Ministries imposing environment policies and act • Society of Toxicology, India, Founded by Prof. P. K. Gupta for exchange of ideas, information and knowledge • Mission of International Union of Toxicology (IUTOX) is to improve human health through the science and practice of toxicology world-wide

50. The lecture series is being prepared for IT specialists and health workers who would team up to solve the disease problems. Thank you Agada Tantra of Ancient Indian medicine is Toxicology • Presentation is encouraged by: • KishoriApte • National Toxicology Center, Pune • JayantMandlik • Little India Foundation, Dapoli • RavindraNisal • Nisargopchar Ashram, UruliKanchan • KishorSaraf • SiddakalaAyurvedMahavidyalaya, Sangamner