HISTORY
all aspects of life, very extensive
usu no env hx on first visit
3 routes of exposure: dermal, ingestion, inhalation
current known or suspected exposures
work history: all past
work: if exposure consider occup health reporting, worker's comp, class action lawsuit, OSHA
changes in routine, work site
environmental history: all past esp home history
home: materials, carpets, paint, cleaners, body care products, vehicle maintenance
home: location
begin with known exposures, get details, others affected, protective equip use, timing
this is never the whole story: keep going
travel: developing countries
meds
activities: routine, anything abn
sx: timing, location, associations, other people with similar

OCCUPATIONS
tetrachloroethylene (perc) in dry cleaning -->8x risk of hepatocellular carcinoma
nails salon: ethyl methacrylate
welder: manganese

EXPOSURE HX FORMS
give as "homework" to preserve office time
recall mb poor
review in visit to clarify
Examples: CDC, OCFP, Crinnion form is short and good to use in office
QEESI for specific for chemical sensitivities
if use others' forms leave authorship info on there
taking an exposure history: for a very extensive hx
eco-healthy homes booklet is something he uses

SYMPTOMS
occur late in the scheme of things
highly variable rxns

DIAGNOSIS
caution with labeling it psychosomatic: mb partly but rarely total
PE: screening
LABS: CBC for anemia, etc
Urine
Specifics for lead

*Toxic metals with or without essential elements
6 hour urine collection, Doctor's data most used, metametrix
with or without provocative challenge
new pts usu do both unprovoked and provoked
unprovoked = first morning urine
provoked, save all urine for 6 hours
shake container before pouring off sample, record total urine
max 2000mg DMSA, Captomer from Thorne is 100mg or 250mg caps
24 hour has low compliance
instructions: give specific collection deadline, know turnaround time
have patient repeat instructions to you to be sure they get it
repeat challenge each 2-3 months during treatment

HAIR TESTING
represents burden over time
validity questionable, less commonly used
must be uncontaminated hair: dyes, bleaches, chemical curlers, straighteners
only methyl-Hg (fish) not elemental Hg (amalgams) detected
not valid for Cadmium, Lead

FECES TESTING
looks at heavy metal dumping, useful during depuration protocols
values reflect dynamic/depurative rather than static/body burden levels
best used in conjunction with other tests
Doctor's data will do this test

LIPIDS
Bx of adipose used for highly specific/sensitive dx
lipophiles: pesticides, solvents, mercury, POPs, PCBs

DOCTOR'S DATA
http://www.doctorsdata..com
blood, hair and urine tests
urine toxic metals, with or without essential elements
hair and fecal metals
hepatic detox profile
DNA oxidative damage assay
glutathione levels (erythrocyte)

HEPATIC DETOX PROFILE
D-glucaric acid to measure phase I detox
indicates exposure to toxins, induction of p450
concern if elevated

mercapturic acids are indirect marker for phase 2 detox
products of glutathoine, cysteine conjugation
indicates clearing and overall phase 2 function
concern if decreased

DNA OXIDATIVE DAMAGE ASSAY
8-hydroxy-deoxyguanosine (urinary 8-OH-dG)
this is first substance that shows up if damage to DNA

cellular and mito DNA damage
nonspecific marker of oxidation
often result of toxicity

METAMETRIX LABS
metametrix.com
GENERAL (INDIRECT) PROFILES: DNA ox stress marker, organix basic/comprehensive profile (good broad test to do includes nutritional status, see notes on interp), porphyrin profile (for heme)
SPECIFIC TOXICS: BPA profile (urine), chlorinated pesticides, PCBs, Phthalates & Parabens, Toxic metals, volatile solvents

US BIOTEK
http://usbiotek.com/services_environmental-pollutants-panel.php
env pollutants profile

GENOVA
www.gdx.net
Detoxicgenomic profile
looks at snips, CYP, GSTM1 (glutathione-s-transferase), NAT (n-acetyl-transferase), SOD

NMS LABS
WWW.nmslabs.com
first lab to do BPA testing
will do custom orders and special requests
will do any test for environmental toxics, very approachable

LABS
establish good relationship with clinical labs
primary resource for knowing what is what on labs
design custom panels for commonly ordered tests
negotiate prices