Epidemiology and Toxicology of Ciguatera Poisoning in the Colombian Caribbean

Ciguatera is a food intoxication caused by the consumption of primarily coral fish; these species exist in large numbers in the seas that surround the Colombian territory. The underreported diagnosis of this clinical entity has been widely highlighted due to multiple factors, such as, among others,...

Full description

Autores:
Navarro Quiroz, Roberto
Herrera-Usuga, Juan Carlos
Osorio-Ospina, Laura Maria
Garcia-Pertuz, Katia Margarita
Navarro Quiroz, Elkin
Tipo de recurso:
Fecha de publicación:
2020
Institución:
Universidad Simón Bolívar
Repositorio:
Repositorio Digital USB
Idioma:
eng
OAI Identifier:
oai:bonga.unisimon.edu.co:20.500.12442/6618
Acceso en línea:
https://hdl.handle.net/20.500.12442/6618
https://www.mdpi.com/1660-3397/18/10/504/pdf
Palabra clave:
Ciguatoxins
Dinoflagellates
Intoxication
Mannitol
Rights
openAccess
License
Attribution-NonCommercial-NoDerivatives 4.0 Internacional
id USIMONBOL2_02bfc7f54298bea1b1a33954e6932d34
oai_identifier_str oai:bonga.unisimon.edu.co:20.500.12442/6618
network_acronym_str USIMONBOL2
network_name_str Repositorio Digital USB
repository_id_str
dc.title.eng.fl_str_mv Epidemiology and Toxicology of Ciguatera Poisoning in the Colombian Caribbean
title Epidemiology and Toxicology of Ciguatera Poisoning in the Colombian Caribbean
spellingShingle Epidemiology and Toxicology of Ciguatera Poisoning in the Colombian Caribbean
Ciguatoxins
Dinoflagellates
Intoxication
Mannitol
title_short Epidemiology and Toxicology of Ciguatera Poisoning in the Colombian Caribbean
title_full Epidemiology and Toxicology of Ciguatera Poisoning in the Colombian Caribbean
title_fullStr Epidemiology and Toxicology of Ciguatera Poisoning in the Colombian Caribbean
title_full_unstemmed Epidemiology and Toxicology of Ciguatera Poisoning in the Colombian Caribbean
title_sort Epidemiology and Toxicology of Ciguatera Poisoning in the Colombian Caribbean
dc.creator.fl_str_mv Navarro Quiroz, Roberto
Herrera-Usuga, Juan Carlos
Osorio-Ospina, Laura Maria
Garcia-Pertuz, Katia Margarita
Navarro Quiroz, Elkin
dc.contributor.author.none.fl_str_mv Navarro Quiroz, Roberto
Herrera-Usuga, Juan Carlos
Osorio-Ospina, Laura Maria
Garcia-Pertuz, Katia Margarita
Navarro Quiroz, Elkin
dc.subject.eng.fl_str_mv Ciguatoxins
Dinoflagellates
Intoxication
Mannitol
topic Ciguatoxins
Dinoflagellates
Intoxication
Mannitol
description Ciguatera is a food intoxication caused by the consumption of primarily coral fish; these species exist in large numbers in the seas that surround the Colombian territory. The underreported diagnosis of this clinical entity has been widely highlighted due to multiple factors, such as, among others, ignorance by the primary care practitioner consulted for this condition as well as clinical similarity to secondary gastroenteric symptoms and common food poisonings of bacterial, parasitic or viral etiology. Eventually, it was found that people a ected by ciguatoxins had trips to coastal areas hours before the onset of symptoms. Thanks to multiple studies over the years, it has been possible to identify the relation between toxigenic dinoflagellates and seagrasses, as well as its incorporation into the food chain, starting by fish primarily inhabiting reef ecosystems and culminating in the intake of these by humans. Identifying the epidemiological link, its cardinal symptoms and a ected systems, such as gastrointestinal, the peripheral nervous system and, fortunately with a low frequency, the cardiovascular system, leads to a purely clinical diagnostic impression without necessitating further complementary studies; in addition, what would also help fight ciguatera poisoning is performing an adequate treatment of the symptoms right from the start, without underestimating or overlooking any associated complications.
publishDate 2020
dc.date.accessioned.none.fl_str_mv 2020-10-01T17:24:28Z
dc.date.available.none.fl_str_mv 2020-10-01T17:24:28Z
dc.date.issued.none.fl_str_mv 2020
dc.type.coarversion.fl_str_mv http://purl.org/coar/version/c_970fb48d4fbd8a85
dc.type.coar.fl_str_mv http://purl.org/coar/resource_type/c_2df8fbb1
dc.type.driver.eng.fl_str_mv info:eu-repo/semantics/article
dc.type.spa.spa.fl_str_mv Artículo científico
dc.identifier.issn.none.fl_str_mv 16603397
dc.identifier.uri.none.fl_str_mv https://hdl.handle.net/20.500.12442/6618
dc.identifier.doi.none.fl_str_mv doi:10.3390/md18100504
dc.identifier.url.none.fl_str_mv https://www.mdpi.com/1660-3397/18/10/504/pdf
identifier_str_mv 16603397
doi:10.3390/md18100504
url https://hdl.handle.net/20.500.12442/6618
https://www.mdpi.com/1660-3397/18/10/504/pdf
dc.language.iso.eng.fl_str_mv eng
language eng
dc.rights.*.fl_str_mv Attribution-NonCommercial-NoDerivatives 4.0 Internacional
dc.rights.coar.fl_str_mv http://purl.org/coar/access_right/c_abf2
dc.rights.uri.*.fl_str_mv http://creativecommons.org/licenses/by-nc-nd/4.0/
dc.rights.accessrights.spa.fl_str_mv info:eu-repo/semantics/openAccess
rights_invalid_str_mv Attribution-NonCommercial-NoDerivatives 4.0 Internacional
http://creativecommons.org/licenses/by-nc-nd/4.0/
http://purl.org/coar/access_right/c_abf2
eu_rights_str_mv openAccess
dc.format.mimetype.spa.fl_str_mv pdf
dc.publisher.eng.fl_str_mv MDPI
dc.source.eng.fl_str_mv Revista Marine drugs. Mar. Drugs
dc.source.none.fl_str_mv Vol. 18, No. 10 (2020)
institution Universidad Simón Bolívar
bitstream.url.fl_str_mv https://bonga.unisimon.edu.co/bitstreams/2ee7159b-a3b1-4e3f-a9d5-880f20f2456c/download
https://bonga.unisimon.edu.co/bitstreams/857ac1f9-2140-4819-8706-36bf2ea435ac/download
https://bonga.unisimon.edu.co/bitstreams/a3939162-9a67-4fa5-bd7f-3de62d0b1b40/download
https://bonga.unisimon.edu.co/bitstreams/97b852c6-c268-45a0-8e47-e7731b578b26/download
https://bonga.unisimon.edu.co/bitstreams/d6b6a3b1-b1fc-4ef6-ac7c-4f3dfd30d575/download
https://bonga.unisimon.edu.co/bitstreams/c38dcbc7-ed81-4e0c-977d-fcc066f17cfc/download
https://bonga.unisimon.edu.co/bitstreams/a66aa1e2-ee6a-400c-adc5-2c300855ff92/download
bitstream.checksum.fl_str_mv b2d7d00a2f5689dfaea265b92fcc608b
4460e5956bc1d1639be9ae6146a50347
733bec43a0bf5ade4d97db708e29b185
a14eb61ec82f34b3017a80f1d30b67f4
eb85d2b3b56708e3afb6a869c0669fcb
5299864d79b6b9e8b9716cd08dc1cc89
74b751a6cd62f32b87fffed84ea66a16
bitstream.checksumAlgorithm.fl_str_mv MD5
MD5
MD5
MD5
MD5
MD5
MD5
repository.name.fl_str_mv Repositorio Digital Universidad Simón Bolívar
repository.mail.fl_str_mv repositorio.digital@unisimon.edu.co
_version_ 1812100532196605952
spelling Navarro Quiroz, Roberto42251988-da73-4d4c-a4f2-981e88bccdabHerrera-Usuga, Juan Carlosddb9a43d-4277-4f6d-9830-b68e678b87b3Osorio-Ospina, Laura Mariab913e415-580e-41b6-b378-95927ea83080Garcia-Pertuz, Katia Margarita12965fc9-9643-4fb2-9e0c-569429ebcc9aNavarro Quiroz, Elkin1ab744b9-f91d-4752-92b3-2a63d62639572020-10-01T17:24:28Z2020-10-01T17:24:28Z202016603397https://hdl.handle.net/20.500.12442/6618doi:10.3390/md18100504https://www.mdpi.com/1660-3397/18/10/504/pdfCiguatera is a food intoxication caused by the consumption of primarily coral fish; these species exist in large numbers in the seas that surround the Colombian territory. The underreported diagnosis of this clinical entity has been widely highlighted due to multiple factors, such as, among others, ignorance by the primary care practitioner consulted for this condition as well as clinical similarity to secondary gastroenteric symptoms and common food poisonings of bacterial, parasitic or viral etiology. Eventually, it was found that people a ected by ciguatoxins had trips to coastal areas hours before the onset of symptoms. Thanks to multiple studies over the years, it has been possible to identify the relation between toxigenic dinoflagellates and seagrasses, as well as its incorporation into the food chain, starting by fish primarily inhabiting reef ecosystems and culminating in the intake of these by humans. Identifying the epidemiological link, its cardinal symptoms and a ected systems, such as gastrointestinal, the peripheral nervous system and, fortunately with a low frequency, the cardiovascular system, leads to a purely clinical diagnostic impression without necessitating further complementary studies; in addition, what would also help fight ciguatera poisoning is performing an adequate treatment of the symptoms right from the start, without underestimating or overlooking any associated complications.pdfengMDPIAttribution-NonCommercial-NoDerivatives 4.0 Internacionalhttp://creativecommons.org/licenses/by-nc-nd/4.0/info:eu-repo/semantics/openAccesshttp://purl.org/coar/access_right/c_abf2Revista Marine drugs. Mar. DrugsVol. 18, No. 10 (2020)CiguatoxinsDinoflagellatesIntoxicationMannitolEpidemiology and Toxicology of Ciguatera Poisoning in the Colombian Caribbeaninfo:eu-repo/semantics/articleArtículo científicohttp://purl.org/coar/version/c_970fb48d4fbd8a85http://purl.org/coar/resource_type/c_2df8fbb1Friedman, M.A.; Fernández, M.; Backer, L.C.; Dickey, R.W.; Bernstein, J.; Schrank, K.; Kibler, S.; Stephan, W.; Gribble, M.O.; Bienfang, P.; et al. An Updated Review of Ciguatera Fish Poisoning: Clinical, Epidemiological, Environmental, and Public Health Management. Mar. Drugs 2017, 15, 72.Van Dolah, F.M.; Morey, J.S.; Milne, S.; Ung, A.; Anderson, P.E.; Chinain, M. Transcriptomic analysis of polyketide synthases in a highly ciguatoxic dinoflagellate, Gambierdiscus polynesiensis and low toxicity Gambierdiscus pacificus, from French Polynesia. PLoS ONE 2020, 15, e0231400.Gòmez, A.R.; Mancera-Pineda, J.E. Potentially Toxic Dinoflagellates Associated to Seagrass on Isla de Barú, Colombian Caribbean, During El Niño. Acta Biológica Colomb. 2019, 24, 109–117.Scheuer, P.J.; Takahashi, W.; Tsutsumi, J.; Yoshida, T. Ciguatoxin: Isolation and Chemical Nature. Science 1967, 155, 1267–1268.Murata, M.; Legrand, A.M.; Ishibashi, Y.; Yasumoto, T. Structures of ciguatoxin and its congener. J. Am. Chem. Soc. 1989, 111, 8929–8931.Lewis, R.J.; Vernoux, J.-P.; Brereton, I.M. Structure of Caribbean Ciguatoxin Isolated from Caranx latus. J. Am. Chem. Soc. 1998, 120, 5914–5920.Yasumoto, T.; Igarashi, T.; Legrand, A.-M.; Cruchet, P.; Chinain, M.; Fujita, T.; Naoki, H. Structural Elucidation of Ciguatoxin Congeners by Fast-Atom Bombardment Tandem Mass Spectroscopy. J. Am. Chem. Soc. 2000, 122, 4988–4989.Rodriguez, E.A.; Mancera-Pineda, J.E.; Gavio, B. Survey of Benthic dinoflagellatesassociated to beds of Thalassia testudinumin san andrés island, seaflower biosphere reserve, Caribbean Colombia. Acta Biológica Colomb. 2010, 15, 229–246.Kibler, S.R.; Davenport, E.D.; Tester, P.A.; Hardison, D.R.; Holland, W.C.; Litaker, R.W. Gambierdiscus and Fukuyoa species in the greater Caribbean: Regional growth projections for ciguatera-associated dinoflagellates. Ecol. Model. 2017, 360, 204–218.Rhodes, L.L.; Smith, K.F.; Murray, J.S.; Nishimura, T.; Finch, S.C. Ciguatera Fish Poisoning: The Risk from an Aotearoa/New Zealand Perspective. Toxins 2020, 12, 50.Yan, M.; Mak, M.Y.L.; Cheng, J.; Li, J.; Gu, J.R.; Leung, P.T.Y.; Lam, P.K.S. E ects of dietary exposure to ciguatoxin P-CTX-1 on the reproductive performance in marine medaka (Oryzias melastigma). Mar. Pollut. Bull. 2020, 152, 110837.Soliño, L.; Costa, P.R. Global impact of ciguatoxins and ciguatera fish poisoning on fish, fisheries and consumers. Environ. Res. 2020, 182, 109111.Sanchez-Henao, J.A.; García-Álvarez, N.; Fernández, A.; Saavedra, P.; Silva Sergent, F.; Padilla, D.; Acosta-Hernández, B.; Martel Suárez, M.; Diogène, J.; Real, F. Predictive score and probability of CTX-like toxicity in fish samples from the o cial control of ciguatera in the Canary Islands. Sci. Total Environ. 2019, 673, 576–584.Meyer, L.; Capper, A.; Carter, S.; Simpfendorfer, C. An investigation into ciguatoxin bioaccumulation in sharks. Toxicon O . J. Int. Soc. Toxinol. 2016, 119, 234–243.Magalhães, V.F.; Marinho, M.M.; Domingos, P.; Oliveira, A.C.; Costa, S.M.; Azevedo, L.O.; Azevedo, S.M.F.O. Microcystins (cyanobacteria hepatotoxins) bioaccumulation in fish and crustaceans from Sepetiba Bay (Brasil, RJ). Toxicon 2003, 42, 289–295.Alavarado, D.A.; Vera, J.M.R. Dynamics of the bioaccumulation of ciguatoxins in a food chain. Rev. Cuba. Investig. Biomed. 2013, 32, 271–283.Palafox, N.A.; Buenconsejo-Lum, L.E. Ciguatera Fish Poisoning: Review of Clinical Manifestations. J. Toxicol. Toxin Rev. 2001, 20, 141–160.Clinical Observations on 3,009 Cases of Ciguatera (Fish Poisoning) in the South Pacific—PubMed. Available online: https://pubmed.ncbi.nlm.nih.gov/574366/ (accessed on 15 June 2020).Skinner, M.P.; Brewer, T.D.; Johnstone, R.; Fleming, L.E.; Lewis, R.J. Ciguatera Fish Poisoning in the Pacific Islands (1998 to 2008). PLoS Negl. Trop. Dis. 2011, 5.Sims, J.K. A theoretical discourse on the pharmacology of toxic marine ingestions. Ann. Emerg. Med. 1987, 16, 1006–1015.Edwards, A.; Zammit, A.; Farrell, H. Four recent ciguatera fish poisoning incidents in New South Wales, Australia linked to imported fish. Commun. Dis. Intell. 2019, 43.Friedemann, M. Ciguatera fish poisoning outbreaks from 2012 to 2017 in Germany caused by snappers from India, Indonesia, and Vietnam. J. Consum. Prot. Food Saf. 2019, 14, 71–80.Neves Junior, C.K.; Goldani, L.Z.; Neves Junior, C.K.; Goldani, L.Z. Ciguatera fish poisoning in Brazilian traveler to Caribbean. Braz. J. Infect. Dis. 2019, 23, 200–202.Raman, R.; Coppes, S.; Hellingman, T.; Laclé, C. Junctional bradycardia caused by ciguatera intoxication. BMJ Case Rep. 2019, 12, e229354.Chinain, M.; Gatti, C.M.; Roué, M.; Darius, H.T. Ciguatera poisoning in French Polynesia: Insights into the novel trends of an ancient disease. New Microbes New Infect. 2019, 31.Asaeda, G. The transport of ciguatoxin: A case report11Selected Topics: Toxicology is coordinated by Kenneth Kulig, MD, of Denver, Colorado. J. Emerg. Med. 2001, 20, 263–265.Farrell, H.; Zammit, A.; Manning, J.; Shadbolt, C.; Szabo, L.; Harwood, D.T.; McNabb, P.; Turahui, J.A.; van den Berg, D.J. Clinical diagnosis and chemical confirmation of ciguatera fish poisoning in New South Wales, Australia. Commun. Dis. Intell. Q. Rep. 2016, 40, E1–E6.Milaciu, M.V.; Ciumarnean, L.; Oras, an, O.H.; Para, I.; Alexescu, T.; Negrean, V. Semiology of food poisoning. HVM Bioflux 2016, 8, 108–113.Caillaud, A.; de la Iglesia, P.; Darius, H.T.; Pauillac, S.; Aligizaki, K.; Fraga, S.; Chinain, M.; Diogène, J. Update on Methodologies Available for Ciguatoxin Determination: Perspectives to Confront the Onset of Ciguatera Fish Poisoning in Europe. Mar. Drugs 2010, 8, 1838–1907.Satake, M.; Fukui, M.; Legrand, A.-M.; Cruchet, P.; Yasumoto, T. Isolation and structures of new ciguatoxin analogs, 2,3-dihydroxyCTX3C and 51-hydroxyCTX3C, accumulated in tropical reef fish. Tetrahedron Lett. 1998, 39, 1197–1198.Tsumuraya, T.; Hirama, M. Rationally Designed Synthetic Haptens to Generate Anti-Ciguatoxin Monoclonal Antibodies, and Development of a Practical Sandwich ELISA to Detect Ciguatoxins. Toxins 2019, 11, 533.Bodero, M.; Gerssen, A.; Portier, L.; Klijnstra, M.D.; Hoogenboom, R.L.A.P.; Guzmán, L.; Hendriksen, P.J.M.; Bovee, T.F.H. A Strategy to Replace the Mouse Bioassay for Detecting and Identifying Lipophilic Marine Biotoxins by Combining the Neuro-2a Bioassay and LC-MS/MS Analysis. Mar. Drugs 2018, 16, 501.Humpage, A.; Magalhaes, V.; Froscio, S. Comparison of analytical tools and biological assays for detection of paralytic shellfish poisoning toxins. Anal. Bioanal. Chem. 2010, 397, 1655–1671.Raikhlin-Eisenkraft, B.; Bentur, Y. Rabbitfish (“aras”): An unusual source of ciguatera poisoning. Isr. Med. Assoc. J. Imaj. 2002, 4, 28–30.Saraya, A.; Sintunawa, C.;Wacharapluesadee, S.; Swangpun, K.; Dumrongchua, S.;Wilde, H.; Hemachudha, T. Marine Fish Toxins in Thailand: Report of 6 Suspected Ciguatera Cases. Case Rep. Clin. Med. 2014, 2014.Gillespie, N.C.; Lewis, R.J.; Holmes, M.J.; Bourke, J.B.; Pearn, J.H.; Bourke, A.T.C.; Shields, W.J. Ciguatera in Australia: Occurrence, clinical features, pathophysiology and management. Med. J. Aust. 1986, 145, 584–590.Friedman, M.A.; Fleming, L.E.; Fernandez, M.; Bienfang, P.; Schrank, K.; Dickey, R.; Bottein, M.-Y.; Backer, L.; Ayyar, R.;Weisman, R.; et al. Ciguatera Fish Poisoning: Treatment, Prevention and Management. Mar. Drugs 2008, 6, 456–479.Palafox, N.A.; Jain, L.G.; Pinano, A.Z.; Gulick, T.M.; Williams, R.K.; Schatz, I.J. Successful Treatment of Ciguatera Fish Poisoning With Intravenous Mannitol. JAMA 1988, 259, 2740–2742.Pearn, J.H.; Lewis, R.J.; Ru , T.; Tait, M.; Quinn, J.; Murtha,W.; King, G.; Mallett, A.; Gillespie, N.C. Ciguatera and Mannitol: Experience with a New Treatment Regimen. Available online: https://pubmed.ncbi.nlm.nih. gov/2500582/ (accessed on 18 September 2020).Bourdy, G.; Cabalion, P.; Amade, P.; Laurent, D. Traditional remedies used in the Western Pacific for the treatment of ciguatera poisoning. J. Ethnopharmacol. 1992, 36, 163–174.Chan, T.Y.K. Severe bradycardia and prolonged hypotension in ciguatera. Singap. Med. J. 2013, 54, e120–e122.Chateau-Degat, M.-L.; Huin-Blondey, M.-O.; Chinain, M.; Darius, T.; Legrand, A.-M.; Nguyen, N.L.; Laudon, F.; Chansin, R.; Dewailly, E. Prevalence of Chronic Symptoms of Ciguatera Disease in French Polynesian Adults. Am. J. Trop. Med. Hyg. 2007, 77, 842–846.Celis, J.S.; Pineda, J.E.M. Análisis Histórico de la Incidencia de Ciguatera en las Islas del Caribe Durante 31 Años: 1980–2010. Bull. Mar. Coast. Res. 2016, 44, 44.Alvarez, R. Primer caso de ciguatera en el caribe colombiano por Seriola zonata (Mitchill, 181 5) (Pisces: Carangidae). Biomédica 1997, 17, 67.Mancera-Pineda, J.E.; Montalvo-Talaigua, M.; Gavio, B. Dinoflagelados potencialmente tóxicos asociados a material orgánico flotante (drift) en San Andrés Isla, Reserva Internacional de la Biosfera-Seaflower: Potentially toxic dinoflagellates associated to drift in San Andrés Island, International Biosphere Reservation-Seaflower. Caldasia 2014, 36, 139–156.Espitia, J.D.G. Ictiotoxismo por consumo de barracuda (Sphyraena barracuda) y morena manchada (Gymnothorax moringa) en la comunidad de pescadores artesanales de Tasajera, Caribe colombiano. Duazary 2007, 4, 160–167.Ramos, B.; Edith, M. Asociación entre la Temperatura Ambiental y Temperatura Superficial del Mar sobre la Aparición de Casos de Ciguatera en el Departamento de San Andrés y Providencia. Master’s Thesis, Francisco José de Caldas District University, Bogotá, Colombia, 2015.Uribe, A.G.; Martínez, M.L.O.; Quijada, H.; Durán, M.E.M. Perfil epidemiológico de las intoxicaciones por sustancias químicas en Colombia. Inf. Quinc. Epidemiológico Nac. 2013, 22, 24.Lawrence, D.N. Ciguatera Fish Poisoning in Miami. JAMA J. Am. Med. Assoc. 1980, 244, 254.Ortega Chavarría, M.J.; Alcocer Delgado, D.; Diaz Greene, E.J.; Rodríguez Weber, F.L. Ciguatera poisoning: Infectious cause neuropathy. Acta Médica Grupo Ángeles 2019, 17, 268–271.Álvarez Rivero, V.; Cervantes Zorrilla, R.; Lorea Cárdenas-Hernández, M.; González-Chávez, M.A. Scombroidosis. Acta Médica Grupo Ángeles 2018, 16, 63–65.ORIGINALPDF.pdfPDF.pdfPDFapplication/pdf491558https://bonga.unisimon.edu.co/bitstreams/2ee7159b-a3b1-4e3f-a9d5-880f20f2456c/downloadb2d7d00a2f5689dfaea265b92fcc608bMD51CC-LICENSElicense_rdflicense_rdfapplication/rdf+xml; charset=utf-8805https://bonga.unisimon.edu.co/bitstreams/857ac1f9-2140-4819-8706-36bf2ea435ac/download4460e5956bc1d1639be9ae6146a50347MD52LICENSElicense.txtlicense.txttext/plain; charset=utf-8381https://bonga.unisimon.edu.co/bitstreams/a3939162-9a67-4fa5-bd7f-3de62d0b1b40/download733bec43a0bf5ade4d97db708e29b185MD53TEXTEpidemiology_Toxicology.pdf.txtEpidemiology_Toxicology.pdf.txtExtracted texttext/plain39001https://bonga.unisimon.edu.co/bitstreams/97b852c6-c268-45a0-8e47-e7731b578b26/downloada14eb61ec82f34b3017a80f1d30b67f4MD54PDF.pdf.txtPDF.pdf.txtExtracted texttext/plain41980https://bonga.unisimon.edu.co/bitstreams/d6b6a3b1-b1fc-4ef6-ac7c-4f3dfd30d575/downloadeb85d2b3b56708e3afb6a869c0669fcbMD56THUMBNAILEpidemiology_Toxicology.pdf.jpgEpidemiology_Toxicology.pdf.jpgGenerated Thumbnailimage/jpeg1632https://bonga.unisimon.edu.co/bitstreams/c38dcbc7-ed81-4e0c-977d-fcc066f17cfc/download5299864d79b6b9e8b9716cd08dc1cc89MD55PDF.pdf.jpgPDF.pdf.jpgGenerated Thumbnailimage/jpeg5381https://bonga.unisimon.edu.co/bitstreams/a66aa1e2-ee6a-400c-adc5-2c300855ff92/download74b751a6cd62f32b87fffed84ea66a16MD5720.500.12442/6618oai:bonga.unisimon.edu.co:20.500.12442/66182024-08-14 21:54:48.427http://creativecommons.org/licenses/by-nc-nd/4.0/Attribution-NonCommercial-NoDerivatives 4.0 Internacionalopen.accesshttps://bonga.unisimon.edu.coRepositorio Digital Universidad Simón Bolívarrepositorio.digital@unisimon.edu.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