Spotlight on Research


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.

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