Mail order weight loss agent-buyer beware!
The paper describes a surveillance study conducted by poisons specialists working at the four National Poisons Information Service (NPIS) centres covering the UK. The service since 2005 has standardised its operating procedures, providing 24-hour toxicological support to healthcare providers via telephone or online TOXBASE® enquiry; moreover, standardising its procedures has allowed information to be stored on a national database which forms the axis for this study.
The study describes data collected from telephone enquiry records and TOXBASE® user sessions concerning the substance 2, 4-Dinitrophenol (DNP) between the periods 1 January 2007 to 31 December 2013. The paper reports age, sex, reported dose, duration of exposure, clinical features and outcome, the latter using a validated poisons severity score (Persson et al, 1998).
The weight-reducing properties of 2, 4-DNP have been well documented. It does, however, have a considerable toxicological profile and was banned by the FDA in 1938; although its effects on French munitions workers were documented much earlier during WWI (Tewari et al, 2009). 2, 4-DNP uncouples oxidative phosphorylation, increasing metabolic rate, heat production and lipolysis, but has a narrow therapeutic index and displays considerable inter-individual variation in dose response. Despite this 2, 4-DNP is readily available via the unregulated mail order sector (Siegmueller and Narasimhaiah, 2010).
In this regard the paper demonstrates the value of a well organised surveillance study, acting as a signal amplifier for toxicological trends; a point made apparent by Figure 2 showing a sharp rise in both telephone and TOXBASE® enquiries from 2012.
Throughout the paper the results are well presented; for example, demonstrating that as enquiries regarding 2, 4-DNP have risen, so has mortality from one fatality in 2012 to three in 2013. Furthermore, a clinical features table allows the reader to establish the main presenting features of 2, 4-DNP toxicity in conjunction with key epidemiological data presented in Table 3 indicating that of the five fatalities from 2, 4-DNP exposure during the study period, four were male and occurred as a result of acute, not chronic toxicity.
‘The paper offers a balanced mix of biochemical, clinical and epidemiological data in a well presented format that is certainly relevant to the out-of-hospital clinician’
A key strength of this paper lies in its methodology insofar as the search criteria are sharply delineated, with only clinical enquiries included in the study while data from educational establishments were excluded. This robustness is further strengthened by virtue of 2, 4-DNP being a substance of interest to NPIS, as such follow-up calls are made to clinical teams involved in the case to gather follow up data; this has certainly enhanced the results section of the paper, in particular Tables 2 (relating to clinical features) and 3 (detailing the reported fatalities).
Although the paper alludes to the incomplete dose information in some of the cases and makes no secret of the reliance on clinical interpretation of symptoms by the healthcare professional making the enquiry, it is consistent with previous reports of 2, 4-DNP toxicity. The paper further indicates that non-educational establishments may use TOXBASE® for purely educational purposes and as such may have contributed to a spike in enquiries; indeed a further contributing factor to this increase may have been the Food Standards Agency's 2, 4-DNP warning issued in 2012, which corresponds with the spike in NPIS enquiries.
This notwithstanding, the paper offers some valuable insight into the role of the NPIS, while alerting the clinician to the potential for toxicity from hitherto unsuspected agents freely available via mail order. The paper offers a balanced mix of biochemical, clinical and epidemiological data in a well presented format that is certainly relevant to the out-of-hospital clinician.
Simply the best…?
Published as a short report, this paper focuses on one element of a large mixed methods study. The authors believe their study was the first controlled trial in the United Kingdom which compared patients’ experiences of being treated by an emergency care practitioner (ECP) with patients’ experiences of being treated by other healthcare providers in a variety of settings. The original study used several methods to explore and evaluate the impact and cost efficacy of the ECP role (Mason et al, 2008).
The content of this paper examines results of a self-completed postal questionnaire that was sent to patients involved in the trial. Five pairs of sites were included in the trial, with each pair having an ‘intervention’ service (care delivered by ECPs) and a ‘control’ service (care delivered by other healthcare professionals who were not ECPs).
The five services included GP out-of-hours, care home, urgent care centre, minor injury unit, and an ambulance service. As a point of note, when referring to the care home sites, the trial was specifically examining differences between patient management provided by a standard paramedic/technician crew dispatched to 999 calls from nursing and residential homes (control), with that of ECPs responding to direct calls from nursing and residential homes (intervention).
Unsurprisingly, due to the nature of a ‘short report’, there is little information given about methodology in the core text of this paper. However, the additional supplementary material (available online) is worth accessing as this explains patient recruitment to the survey questionnaire, and also provides further information about the content of the questionnaire and the subsequent results.
In total, 1 960 patients completed and returned a questionnaire that had been posted to them approximately seven days after using the service. This represented a response rate of only 38.5%.
The survey (predominantly based on a 5-point Likert Scale) included items measuring patients’ experiences and satisfaction with the services. In relation to the section evaluating patients’ levels of satisfaction, the possible answers they could select ranged from ‘strongly agree’ to ‘strongly disagree’. The survey covered a variety of topics, for example: was the clinician polite; were they concerned about the patient as a person; did the clinician spend enough time listening; did they answer all of the patients’ questions; did they conduct a thorough examination; did the patient feel the care could be improved; was the patient satisfied with the care and the advice given?
The results show that in all five pairs of sites, the percentage of patients who were highly satisfied with their overall care was higher in patients who had been treated by ECPs as opposed to non-ECP providers. The difference was statistically significant (confidence interval 99%) in three pairs of services including GP out-of-hours (intervention 78.8%; n=189; control 56.1%; n=147), ambulance service (intervention 84.3%; n=188; control 67.7%; n=113), and care home (intervention 91.9%; n=57; control 40.9%; n=9).
The conclusion from this element of the study is that users of services involving ECPs were more likely to be very satisfied with the overall care that they experienced during this clinical encounter. However, the authors do urge caution when interpreting these findings as there are concerns that the limited response rate might have compromised the representativeness of the respondents.
Nonetheless, this is relevant research, especially given the increasing emphasis on continued development and expansion of scope of practice in several healthcare professions (paramedics included) to meet the increasing demand on healthcare services.
A short paper can only outline the bare bones of any research study, and is designed to stimulate readers to look at the full report. If you have limited access to subscription journals just google the title of the Mason et al (2008) paper below and you will find an open access PDF publication which will provide further information about the research questions, methods, results and findings of this complex study.