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Horn G, Frielingsdorf F, Demel T, Rothmiller S, Worek F, Amend N. Concentration-dependent effects of the nerve agents cyclosarin and VX on cytochrome P450 in a HepaRG cell-based liver model. J Appl Toxicol 2025; 45:222-229. [PMID: 39228234 DOI: 10.1002/jat.4694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 08/06/2024] [Accepted: 08/22/2024] [Indexed: 09/05/2024]
Abstract
The exposure to highly toxic organophosphorus (OP) compounds, including pesticides and nerve agents, is an ongoing medical challenge. OP can induce the uncontrolled overstimulation of the cholinergic system through inhibition of the enzyme acetylcholinesterase (AChE). The cytochrome P450 (CYP) enzymes in the liver play a predominant role in the metabolism of xenobiotics and are involved in the oxidative biotransformation of most clinical drugs. Previous research concerning the interactions between OP and CYP has usually focused on organothiophosphate pesticides that require CYP-mediated bioactivation to their active oxon metabolites to act as inhibitors of AChE. Since there has been little data available concerning the effect of nerve agents on CYP, we performed a study with cyclosarin (GF) and O-ethyl-S-[2-(diisopropylamino)-ethyl]-methylphosphonothioate (VX) by using a well-established, metabolically competent in vitro liver model (HepaRG cells). The inhibitory effect of the nerve agents GF and VX on the CYP3A4 enzyme was investigated showing a low CYP3A4 inhibitory potency. Changes on the transcription level of CYP and associated oxygenases were evaluated by quantitative reverse transcription polymerase chain reaction (qRT-PCR) using the two nerve agent concentrations 250 nM and 250 μM. In conclusion, the results demonstrated various effects on oxygenase-associated genes in dependence of the concentration and the structure of the nerve agent. Such information might be of relevance for potential interactions between nerve agents, antidotes or other clinically administered drugs, which are metabolized by the affected CYP, for example, for the therapy with benzodiazepines, that are used for the symptomatic treatment of OP poisoning and that require CYP-mediated biotransformation.
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Affiliation(s)
- Gabriele Horn
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
| | | | - Tobias Demel
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
| | - Simone Rothmiller
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
| | - Franz Worek
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
| | - Niko Amend
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
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Horn G, Worek F. Suitability of human HepaRG cells and liver spheroids as in vitro model to investigate the bioactivation of the organothiophosphate pesticide parathion. Toxicol In Vitro 2024; 97:105811. [PMID: 38521251 DOI: 10.1016/j.tiv.2024.105811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 03/25/2024]
Abstract
Organophosphorus compounds (OP) constitute a large group of chemicals including pesticides and nerve agents. Organothiophosphate pesticides require cytochrome P450-mediated oxidative desulphuration in the liver to form corresponding oxons, which are potent inhibitors of the enzyme acetylcholinesterase (AChE). Human HepaRG cells are a promising tool to study liver-specific functions and have been shown to maintain drug metabolizing enzymes. This research describes for the first time the in vitro metabolic activation of an organothiophosphate to its active oxon by two different HepaRG cell-based models. Monolayer cultures and liver spheroids were exposed to the model OP parathion and the quantification of the corresponding oxon was performed with an AChE inhibition assay. Our results showed a time- and dose-dependent cytochrome P450 catalyzed bioactivation and a superior metabolism capacity of the monolayer HepaRG model in comparison with the liver spheroids. Finally, HepaRG cells can be assessed as a metabolically competent cell model intermediate between cell-free preparations and intact animals and as suitable to study OP metabolism in the human liver.
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Affiliation(s)
- Gabriele Horn
- Bundeswehr Institute of Pharmacology and Toxicology, Neuherbergstrasse 11, 80937 Munich, Germany.
| | - Franz Worek
- Bundeswehr Institute of Pharmacology and Toxicology, Neuherbergstrasse 11, 80937 Munich, Germany
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Horn G, Demel T, Rothmiller S, Amend N, Worek F. The influence of the model pesticides parathion and paraoxon on human cytochrome P450 and associated oxygenases in HepaRG cells. Clin Toxicol (Phila) 2024; 62:288-295. [PMID: 38874383 DOI: 10.1080/15563650.2024.2361879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/24/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION Intentional and unintentional organophosphorus pesticide exposure is a public health concern. Organothiophosphate compounds require metabolic bioactivation by the cytochrome P450 system to their corresponding oxon analogues to act as potent inhibitors of acetylcholinesterase. It is known that interactions between cytochrome P450 and pesticides include the inhibition of major xenobiotic metabolizing cytochrome P450 enzymes and changes on the genetic level. METHODS In this in vitro study, the influence of the pesticides parathion and paraoxon on human cytochrome P450 and associated oxygenases was investigated with a metabolically competent cell line (HepaRG cells). First, the viability of the cells after exposure to parathion and paraoxon was evaluated. The inhibitory effect of both pesticides on cytochrome P450 3A4, which is a pivotal enzyme in the metabolism of xenobiotics, was examined by determining the dose-response curve. Changes on the transcription level of 92 oxygenase associated genes, including those for important cytochrome P450 enzymes, were evaluated. RESULTS The exposure of HepaRG cells to parathion and paraoxon at concentrations up to 100 µM resulted in a viability of 100 per cent. After exposure for 24 hours, pronounced inhibition of cytochrome P450 3A4 enzyme activity was shown, indicating 50 per cent effective concentrations of 1.2 µM (parathion) and 2.1 µM (paraoxon). The results revealed that cytochrome P450 involved in parathion metabolism were significantly upregulated. DISCUSSION Relevant changes of the cytochrome P450 3A4 enzyme activity and significant alteration of genes associated with cytochrome P450 suggest an interference of pesticide exposure with numerous metabolic processes. The major limitations of the work involve the use of a single pesticide and the in vitro model as surrogate to human hepatocytes. CONCLUSION The data of this study might be of relevance after survival of acute, life-threatening intoxications with organophosphorus compounds, particularly for the co-administration of drugs, which are metabolized by the affected cytochrome P450.
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Affiliation(s)
- Gabriele Horn
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
| | - Tobias Demel
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
| | - Simone Rothmiller
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
| | - Niko Amend
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
| | - Franz Worek
- Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
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Sawicki K, Czajka M, Matysiak-Kucharek M, Kurzepa J, Wojtyła-Buciora P, Zygo K, Kruszewski M, Kapka-Skrzypczak L. Chlorpyrifos alters expression of enzymes involved in vitamin D 3 synthesis in skin cells. PESTICIDE BIOCHEMISTRY AND PHYSIOLOGY 2021; 174:104812. [PMID: 33838712 DOI: 10.1016/j.pestbp.2021.104812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/11/2021] [Accepted: 02/22/2021] [Indexed: 06/12/2023]
Abstract
Skin acts as a mechanical barrier between human body and environment. Epidermal cells are regularly exposed to many physiological and environmental stressors, such as pesticides, like chlorpyrifos (CPS). It is recognised that CPS may affect metabolism of other exo- and endogenous substances by affecting enzyme activity and expression. This study aims to investigate the effect of CPS on expression of CYP27A1, CYP27B1 and CYP24A1, the enzymes involved in synthesis and metabolism of vitamin D3, in human keratinocytes HaCaT and human fibroblasts BJ. Synthesis of vitamin D3 in cells was initiated by irradiating with UVB. Expression of CYP27A1, CYP27B1 and CYP24A1 was evaluated by RT-qPCR and Western blot. Our experiments revealed that expression of all tested cytochrome P450 isoforms in cells exposed to CPS changed significantly. Exposure of HaCaT keratinocytes to CPS decreased CYP27A1 mRNA levels, but increased CYP27B1 and CYP24A1 mRNA levels. This was confirmed at the protein level, except for the CYP27A1 expression. Outcome for the BJ cells was however less conclusive. Though exposure to CPS decreased CYP27A1 and CYP27B1 mRNA levels, at protein level increasing concentration of CPS and UVB intensity induced expression of CYP27A1 and CYP24A1. The expression of CYP27B1 isoform decreased in line with mRNA level. Nevertheless, it can be concluded that CPS may therefore interrupt vitamin D3 metabolism in skin cells, but further studies are required to better understand such mechanisms.
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Affiliation(s)
- Krzysztof Sawicki
- Department of Molecular Biology and Translational Research, Institute of Rural Health, Lublin, Poland.
| | - Magdalena Czajka
- Department of Molecular Biology and Translational Research, Institute of Rural Health, Lublin, Poland
| | | | - Jacek Kurzepa
- Chair and Department of Medical Chemistry, Medical University, Lublin, Poland
| | | | - Karol Zygo
- Department of Public Health, Medical University, Lublin, Poland
| | - Marcin Kruszewski
- Department of Molecular Biology and Translational Research, Institute of Rural Health, Lublin, Poland; Centre for Radiobiology and Biological Dosimetry, Institute of Nuclear Chemistry and Technology, Warsaw, Poland
| | - Lucyna Kapka-Skrzypczak
- Department of Molecular Biology and Translational Research, Institute of Rural Health, Lublin, Poland.
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Zhao GP, Yang FW, Li JW, Xing HZ, Ren FZ, Pang GF, Li YX. Toxicities of Neonicotinoid-Containing Pesticide Mixtures on Nontarget Organisms. ENVIRONMENTAL TOXICOLOGY AND CHEMISTRY 2020; 39:1884-1893. [PMID: 32936472 DOI: 10.1002/etc.4842] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/02/2020] [Accepted: 07/31/2020] [Indexed: 06/11/2023]
Abstract
Neonicotinoids are a widely used class of pesticides. Co-exposure to neonicotinoids and other classes of pesticides can exert potentiating or synergistic effects, and these mixtures have been detected in human bodily fluids. The present review summarizes studies into the effects of neonicotinoid-containing pesticide mixtures on humans and other nontarget organisms. Exposure to these mixtures has been reported to result in reproductive and hormonal toxicity, genotoxicity, neurotoxicity, hepatotoxicity, and immunotoxicity in vertebrates. Mortality of pollinators and toxicity in other organisms has also been reported. The underlying mechanism of pesticide mixture toxicity may be associated with impairment of cytochrome 450 enzymes, which are involved in metabolizing pesticides. However, a comprehensive explanation of the adverse effects of neonicotinoid-containing pesticide mixtures is still required so that effective prevention and control measures can be formulated. Environ Toxicol Chem 2020;39:1884-1893. © 2020 SETAC.
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Affiliation(s)
- Guo-Ping Zhao
- Beijing Advanced Innovation Center for Food Nutrition and Human Health, College of Food Science and Nutritional Engineering, China Agricultural University, Beijing, China
| | - Fang-Wei Yang
- Beijing Advanced Innovation Center for Food Nutrition and Human Health, College of Food Science and Nutritional Engineering, China Agricultural University, Beijing, China
| | - Jin-Wang Li
- Beijing Advanced Innovation Center for Food Nutrition and Human Health, College of Food Science and Nutritional Engineering, China Agricultural University, Beijing, China
| | - Han-Zhu Xing
- School of Food Science and Engineering, Qilu University of Technology, Jinan, China
| | - Fa-Zheng Ren
- Beijing Advanced Innovation Center for Food Nutrition and Human Health, College of Food Science and Nutritional Engineering, China Agricultural University, Beijing, China
- Key Laboratory of Functional Dairy, Co-constructed by Ministry of Education and Beijing Government, and Beijing Laboratory of Food Quality and Safety, China Agricultural University, Beijing, China
| | - Guo-Fang Pang
- Beijing Advanced Innovation Center for Food Nutrition and Human Health, College of Food Science and Nutritional Engineering, China Agricultural University, Beijing, China
- Chinese Academy of Inspection and Quarantine, Beijing, China
| | - Yi-Xuan Li
- Beijing Advanced Innovation Center for Food Nutrition and Human Health, College of Food Science and Nutritional Engineering, China Agricultural University, Beijing, China
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Delgado-López F, Zamora-León SP. Breast cancer and environmental contamination: A real connection? COGENT MEDICINE 2018. [DOI: 10.1080/2331205x.2018.1520470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- Fernando Delgado-López
- Facultad de Medicina, Universidad Católica del Maule, Avda. San Miguel 3605, Talca, Chile
| | - S. Pilar Zamora-León
- Facultad de Medicina, Universidad Católica del Maule, Avda. San Miguel 3605, Talca, Chile
- Facultad de Ciencias Básicas, Universidad Católica del Maule, Avda. San Miguel 3605, Talca, Chile
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Thyrotoxic rubber antioxidants, 2-mercaptobenzimidazole and its methyl derivatives, cause both inhibition and induction of drug-metabolizing activity in rat liver microsomes after repeated oral administration. Biochem Biophys Res Commun 2017; 492:116-120. [PMID: 28800917 DOI: 10.1016/j.bbrc.2017.08.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 08/07/2017] [Indexed: 02/03/2023]
Abstract
We examined the effects of thyrotoxic rubber antioxidants, 2-mercaptobenzimidazole (MBI, 0.3 mmol/kg/day) and its methyl derivatives, methyl-MBIs [4-methyl-MBI (4-MeMBI, 0.6 mmol/kg/day), 5-methyl-MBI (5-MeMBI, 0.6 mmol/kg/day), and 4(or 5)-methyl-MBI (4(5)-MeMBI, 0.6 or 1.2 mmol/kg/day)], on the drug-metabolizing activity in male rat liver microsomes by 8-day repeated oral administration. The weight of liver and thyroid were increased by all the test chemicals; MBI was most potent, and there was no additive or synergistic effect between 4-MeMBI and 5-MeMBI. MBI decreased the cytochrome P450 (CYP) content, NADPH-cytochrome P450 reductase (POR) activity, 7-ethoxycoumarin O-deethylation (ECOD) activity, and flavin-containing monooxygenase (FMO) activity, but increased the 7-pentoxyresorufin O-depentylation (PROD) activity, suggesting inhibition of the drug-metabolizing activity on the whole but induce some activities such as the CYP2B activity. On the contrary, all the methyl-MBIs increased the CYP content, CYB5 content, ECOD activity, 7-ethoxyresorufin O-deethylation (EROD) activity, and PROD activity, indicating that they are mostly inducible of the CYP activity. However, the methyl-MBIs decreased the FMO activity, and 5-MeMBI and 4(5)-MeMBI appeared inhibitory for CYPs 2C11 and 2C13. Between 4-MeMBI and 5-MeMBI, there was no additive or synergistic effect on the drug-metabolizing activity, but was counteraction. It was concluded that MBI and methyl-MBIs had both inhibitory and inducible effects on the drug-metabolizing activity in rat liver microsomes at thyrotoxic doses. The effects of 4(5)-MeMBI indicated that the increased liver weight alone can be a hepatotoxic sign but not an adaptive no-adverse response in toxicity studies. The present results were related to the toxicokinetic profiles of MBI and 4(5)-MeMBI in the repeated toxicity studies.
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D'Agostino J, Zhang H, Kenaan C, Hollenberg PF. Mechanism-Based Inactivation of Human Cytochrome P450 2B6 by Chlorpyrifos. Chem Res Toxicol 2015; 28:1484-95. [PMID: 26075493 DOI: 10.1021/acs.chemrestox.5b00156] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Chlorpyrifos (CPS) is a commonly used pesticide which is metabolized by P450s into the toxic metabolite chlorpyrifos-oxon (CPO). Metabolism also results in the release of sulfur, which has been suggested to be involved in mechanism-based inactivation (MBI) of P450s. CYP2B6 was previously determined to have the greatest catalytic efficiency for CPO formation in vitro. Therefore, we characterized the MBI of CYP2B6 by CPS. CPS inactivated CYP2B6 in a time- and concentration-dependent manner with a kinact of 1.97 min(-1), a KI of 0.47 μM, and a partition ratio of 17.7. We further evaluated the ability of other organophosphate pesticides including chorpyrifos-methyl, diazinon, parathion-methyl, and azinophos-methyl to inactivate CYP2B6. These organophosphate pesticides were also potent MBIs of CYP2B6 characterized by similar kinact and KI values. The inactivation of CYP2B6 by CPS was accompanied by the loss of P450 detectable in the CO reduced spectrum and loss of detectable heme. High molecular weight aggregates were observed when inactivated CYP2B6 was run on SDS-PAGE gels indicating protein aggregation. Interestingly, we found that the rat homologue of CYP2B6, CYP2B1, was not inactivated by CPS despite forming CPO to a similar extent. On the basis of the locations of the Cys residues in the two proteins which could react with released sulfur during the metabolism of CPS, we investigated whether the C475 in CYP2B6, which is not conserved in CYP2B1, was the critical residue for inactivation by mutating it to a Ser. CYP2B6 C475S was inactivated to a similar extent as wild type CYP2B6 indicating that C475 is not likely the key difference between CYP2B1 and CYP2B6 with respect to inactivation. These results indicate that CPS and other organophosphate pesticides are potent MBIs of CYP2B6 which may have implications for the toxicity of these pesticides as well as the potential for pesticide-drug interactions.
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Affiliation(s)
- Jaime D'Agostino
- Department of Pharmacology, University of Michigan, 2220C MSRB III, 1150 W. Medical Center Drive, Ann Arbor, Michigan 48109-5632, United States
| | - Haoming Zhang
- Department of Pharmacology, University of Michigan, 2220C MSRB III, 1150 W. Medical Center Drive, Ann Arbor, Michigan 48109-5632, United States
| | - Cesar Kenaan
- Department of Pharmacology, University of Michigan, 2220C MSRB III, 1150 W. Medical Center Drive, Ann Arbor, Michigan 48109-5632, United States
| | - Paul F Hollenberg
- Department of Pharmacology, University of Michigan, 2220C MSRB III, 1150 W. Medical Center Drive, Ann Arbor, Michigan 48109-5632, United States
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Yoshigae Y, Sridar C, Kent UM, Hollenberg PF. The inactivation of human CYP2E1 by phenethyl isothiocyanate, a naturally occurring chemopreventive agent, and its oxidative bioactivation. Drug Metab Dispos 2013; 41:858-69. [PMID: 23371965 PMCID: PMC3608457 DOI: 10.1124/dmd.112.050609] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 01/31/2013] [Indexed: 11/22/2022] Open
Abstract
Phenethylisothiocyanate (PEITC), a naturally occurring isothiocyanate and potent cancer chemopreventive agent, works by multiple mechanisms, including the inhibition of cytochrome P450 (P450) enzymes, such as CYP2E1, that are involved in the bioactivation of carcinogens. PEITC has been reported to be a mechanism-based inactivator of some P450s. We describe here the possible mechanism for the inactivation of human CYP2E1 by PEITC, as well as the putative intermediate that might be involved in the bioactivation of PEITC. PEITC inactivated recombinant CYP2E1 with a partition ratio of 12, and the inactivation was not inhibited in the presence of glutathione (GSH) and not fully recovered by dialysis. The inactivation of CYP2E1 by PEITC is due to both heme destruction and protein modification, with the latter being the major pathway for inactivation. GSH-adducts of phenethyl isocyanate (PIC) and phenethylamine were detected during the metabolism by CYP2E1, indicating formation of PIC as a reactive intermediate following P450-catalyzed desulfurization of PEITC. Surprisingly, PIC bound covalently to CYP2E1 to form protein adducts but did not inactivate the enzyme. Liquid chromatography mass spectroscopy analysis of the inactivated CYP2E1 apo-protein suggests that a reactive sulfur atom generated during desulfurization of PEITC is involved in the inactivation of CYP2E1. Our data suggest that the metabolism of PEITC by CYP2E1 that results in the inactivation of CYP2E1 may occur by a mechanism similar to that observed with other sulfur-containing compounds, such as parathion. Digestion of the inactivated enzyme and analysis by SEQUEST showed that Cys 268 may be the residue modified by PIC.
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Affiliation(s)
- Yasushi Yoshigae
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI, USA
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Hernández AF, Parrón T, Tsatsakis AM, Requena M, Alarcón R, López-Guarnido O. Toxic effects of pesticide mixtures at a molecular level: their relevance to human health. Toxicology 2012; 307:136-45. [PMID: 22728724 DOI: 10.1016/j.tox.2012.06.009] [Citation(s) in RCA: 369] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2012] [Revised: 06/13/2012] [Accepted: 06/13/2012] [Indexed: 11/18/2022]
Abstract
Pesticides almost always occur in mixtures with other ones. The toxicological effects of low-dose pesticide mixtures on the human health are largely unknown, although there are growing concerns about their safety. The combined toxicological effects of two or more components of a pesticide mixture can take one of three forms: independent, dose addition or interaction. Not all mixtures of pesticides with similar chemical structures produce additive effects; thus, if they act on multiple sites their mixtures may produce different toxic effects. The additive approach also fails when evaluating mixtures that involve a secondary chemical that changes the toxicokinetics of the pesticide as a result of its increased activation or decreased detoxification, which is followed by an enhanced or reduced toxicity, respectively. This review addresses a number of toxicological interactions of pesticide mixtures at a molecular level. Examples of such interactions include the postulated mechanisms for the potentiation of pyrethroid, carbaryl and triazine herbicides toxicity by organophosphates; how the toxicity of some organophosphates can be potentiated by other organophosphates or by previous exposure to organochlorines; the synergism between pyrethroid and carbamate compounds and the antagonism between triazine herbicides and prochloraz. Particular interactions are also addressed, such as those of pesticides acting as endocrine disruptors, the cumulative toxicity of organophosphates and organochlorines resulting in estrogenic effects and the promotion of organophosphate-induced delayed polyneuropathy.
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Affiliation(s)
- Antonio F Hernández
- Department of Legal Medicine and Toxicology, University of Granada School of Medicine, Granada, Spain.
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