Views of diverse primary care patients on the roles of healthcare providers and staff and the influence of other variables in their weight management.

The prevalence of overweight/obesity is disproportionately higher among racial/ethnic minority and low-income patients. The purpose of this study was to survey racially diverse, low-income patients regarding their experiences with and desires regarding their providers' involvement in weight management. Adult patients (N = 529), including mostly African American (42.7%), White (44.6%) and low-income (55.5% with incomes <$30 000) patients from 7 Patient-Centered Medical Homes voluntarily completed a brief anonymous survey while waiting to see their providers. Only 19.8% of the patients said that their primary care provider frequently or very frequently talked with them about their weight. Older patients as compared to younger patients, as well as males compared to females, were more likely to have their primary care provider talk to them about their diet and physical activity during the last year. It was also found that 56.9% of the patients were interested in getting help from their doctor to connect with resources for weight management in their community. African American patients, as compared to White patients, were more interested in getting such help. These results suggest that there is a need to establish healthcare policies and training in primary care settings that are designed to ensure that primary care providers routinely talk with all of their patients, including their female and older patients, about their weight and weight management services. Additionally, primary care administrators need to play an increased role in identifying, developing, and advocating for affordable weight management services, particularly in African American and low-income communities.

National toxicovigilance for pesticide exposures resulting in health care contact - An example from the UK's National Poisons Information Service.

BACKGROUND: Although there are extensive systems in place for pharmacovigilance, similar systems for detecting adverse health effects relating to pesticide exposure are rare. In 2004, the National Poisons Information Service (NPIS) pesticide surveillance study was implemented to identify cases requiring health care contact in the UK. This report describes the epidemiology of pesticide exposures reported to poison centres in the UK over a 9-year period. METHODS: Data on exposures were gathered through monitoring access to the NPIS's online clinical toxicology database TOXBASE(®) and through monitoring calls to the four NPIS units (Edinburgh, Cardiff, Newcastle and Birmingham). Severity was judged by both caller and NPIS staff. RESULTS: During the 9 years, 34,092 enquiries concerning pesticides were recorded; 7,804 cases of pesticide exposure were derived from these enquiries. Exposures were predominantly unintentional and acute (6,789; 87.0%); 217 (2.8%) and 755 (9.7%) were chronic unintentional and acute deliberate self-harm exposures, respectively. The majority of cases occurred in children, especially the 0-4 year age group The minimum incidence of pesticide exposure requiring health care contact was 2.0 cases/100,000 population per year. Reported numbers were 6- to 25-fold greater than those picked up through other UK pesticide toxicovigilance schemes. There were 81 cases of severe toxicity and 38 cases of fatal exposure. Deliberate self-harm accounted for 62.3% of severe cases and 79% of deaths. Aluminium phosphide, paraquat, diquat and glyphosate were responsible for most severe and fatal cases. CONCLUSIONS: The data gathered from this pesticide surveillance study indicate that poison centre resources can usefully monitor pesticide exposures resulting in health care contact in the UK. The NPIS may usefully be one component of the UK's response to European legislation requiring surveillance of complications resulting from pesticide use.

Increasing pathology utilisation lies behind increasing pathology costs.

Recent increases in pathology costs per scheme member are a concern to medical schemes and pathologists alike. To better understand the observed increasing costs, the National Pathology Group commissioned Prognosys to analyse the trends affecting these increases. We found that these increases are driven by inflation, increases in utilisation, and redistribution of the burden of cost. The identification of utilisation as a cost driver for pathology services is noteworthy as almost all pathology services are by referral from another doctor.

Psychosocial determinants of socioeconomic inequalities in cancer screening participation: a conceptual framework.

Cancer screening participation shows a strong, graded association with socioeconomic status (SES) not only in countries such as the United States, where insurance status can be a barrier for lower income groups, but also in the United Kingdom, where the National Health Service provides all health care to residents, including screening, for free. Traditionally, the literature on socioeconomic inequalities has focused on upstream factors, but more proximal (downstream) influences on screening participation also need to be examined, particularly those that address the graded nature of the association rather than focusing specifically on underserved groups. This review offers a framework that links some of the components and corollaries of SES (life stress, educational opportunities, illness experience) to known psychosocial determinants of screening uptake (beliefs about the value of early detection, fatalistic beliefs about cancer, self-efficacy). The aim is to explain why individuals from lower SES backgrounds perceive cancer screening tests as more threatening, more difficult to accomplish, and less beneficial. A better understanding of the mechanisms through which lower SES causes negative attitudes toward screening could facilitate the development of intervention strategies to reduce screening inequalities.

Introgression of B-genome chromosomes in a doubled haploid population of Brassica napus x B. carinata.

The Brassica B-genome species possess many valuable agronomic and disease resistance traits. To transfer traits from the B genome of B. carinata into B. napus, an interspecific cross between B. napus and B. carinata was performed and a doubled haploid (DH) population was generated from the BC2S3 generation. Successful production of interspecific DH lines as identified using B-genome microsatellite markers is reported. Five percent of DH lines carry either intact B-genome chromosomes or chromosomes that have deletions. All of the DH lines have linkage group J13/B7 in common. This was further confirmed using B. nigra genomic DNA in a fluorescent in situ hybridization assay where the B-genome chromosomes were visualized and distinguished from the A- and C-genome chromosomes. The 60 DH lines were also evaluated for morphological traits in the field for two seasons and were tested for resistance to blackleg, caused by Leptosphaeria maculans, under greenhouse conditions. Variation in the DH population followed a normal distribution for several agronomic traits and response to blackleg. The lines with B-genome chromosomes were significantly different (p < 0.01) from the lines without B-genome chromosomes for both morphological and seed quality traits such as days to flowering, days to maturity, and erucic acid content.

Inequalities in colorectal cancer screening participation in the first round of the national screening programme in England.

BACKGROUND: Introduction of organised, population-based, colorectal cancer screening in the United Kingdom using the faecal occult blood test (FOBT) has the potential to reduce overall colorectal cancer mortality. However, socio-economic variation in screening participation could exacerbate existing inequalities in mortality. METHODS: This study examined FOBT uptake rates in London, England in relation to area-level socio-economic deprivation over the first 30 months of the programme during which 401 197 individuals were sent an FOBT kit. Uptake was defined as return of a completed test kit within 3 months. Area-level deprivation in each postcode sector was indexed with the Townsend Material Deprivation Index. Analyses controlled for area-level household mobility, ethnic diversity and poor health, each of which was associated with lower return rates. RESULTS: The results showed a strong socio-economic gradient in FOBT uptake, which declined from 49% in the least deprived quintile of postcodes to 38% in the middle quintile and 32% in the most deprived quintile. Variation in socio-economic deprivation between sectors accounted for 62% of the variance in return rates, with little attenuation as a result of controlling for ethnic diversity, household mobility or health status. CONCLUSION: These results highlight the need to understand the causes of socio-economic gradients in screening participation and address barriers that could otherwise increase disparities in colorectal cancer survival.

The use of atropine in a nerve agent response with specific reference to children: are current guidelines too cautious?

This review examines the potential use of nerve agents by a terrorist organisation against a civilian population, which has become an increasingly apparent threat in the UK. Present guidelines for the use of atropine, particularly in children, following such an event are unclear. No precise agreement exists on the most appropriate dose of atropine, or the frequency with which it should be administered. This uncertainty leaves children vulnerable as potentially life-saving treatment may be crucially delayed. Guidelines must be standardised to allow rapid antidotal delivery and maximise the potential for survivors. This review examines the issues currently surrounding the use of atropine in children following a nerve agent attack and propose strategies for treating exposed children.

Interpretation of clinical guidelines for poisoned patients: positive and negative effects of standard phrases used in TOXBASE.

INTRODUCTION: Electronic information sources are increasingly relied upon for clinical management advice. TOXBASE is a standardised online resource that offers clinical advice on the management of poisoned patients and is the first point of contact between clinicians and the National Poisons Information Service in the United Kingdom. Advice is delivered using a series of standard phrases. The present study examined how healthcare professionals interpret the phrases and studied their impact on clinical decision-making. METHODS: A structured prospective written questionnaire was offered to healthcare staff in the Lothian region, and an electronic questionnaire issued to TOXBASE users across the United Kingdom. Participants were asked to respond to a variety of scenarios representing acutely poisoned patients. Clinical management advice was offered via TOXBASE using a variety of standard phrases, and participants were asked to express the likelihood that they would then administer gut decontamination treatment. RESULTS: There were 70 respondents to written questionnaires, and 119 respondents to the electronic version. Phrases that included didactic instructions, for example 'give', 'contraindicated', 'do' and 'perform' were associated with strongly positive or strongly negative responses. In contrast, advice that consisted of open phrases such as 'consider', 'benefit uncertain', and 'few data' were associated with inconsistent responses. CONCLUSION: Didactic words and phrases are associated with more consistent interpretation and response than open-ended words and phrases. The choice of words and phrases used in electronic systems can have an independent impact on clinical decision-making and require further consideration.

UK childhood exposures to pesticides 2004-2007: a TOXBASE toxicovigilance study.

OBJECTIVE: There are no systematic methods for toxicovigilance of non-medicinal products in the UK. This is particularly relevant for pesticides, where there is significant public concern about potential adverse effects. This study describes a prospective toxicovigilance scheme based on follow-up of enquiries to the National Poisons Information Service (NPIS) through its online poisons information system TOXBASE. These enquiries reflect acute exposures and the patterns of acute illness that result. RESULTS: A total of 10 061 pesticide-related enquiries were identified. After follow-up, data were gathered on 2364 suspected exposures, of which 1162 involved children. After exclusions, 1147 exposures are reported here. No deaths were reported and only 37 children were admitted to hospital. The majority were considered to have either minimal or no features (925, 80.6%). Symptoms for 38 children were unknown. Symptoms reported in the other 184 children included nausea or vomiting (58), eye irritation, pain or conjunctivitis (29), skin irritation (28), abdominal pain (24), mouth or throat irritation (18) and diarrhoea (15). Where age was recorded, 60.5% (680) of children involved in suspected pesticide exposures were aged 2 years or less. The most common scenario for acute accidental exposure to pesticide in children was exposure after application (329, 28.7%) or due to poor storage (228, 19.9%). CONCLUSIONS: Areas of potential concern identified included storage, access of young children to "laid" baits and pesticides, and exposures as a result of medication errors, with liquid head lice preparations being confused with other medicines. Use of NPIS systems provides a potentially useful method of toxicovigilance.

Acute caffeine ingestion: clinical features in patients attending the emergency department and Scottish poison centre enquiries between 2000 and 2008.

BACKGROUND AND AIMS: Little information is available regarding the healthcare burden associated with deliberate caffeine ingestion. The present study sought to establish the impact of caffeine ingestion on hospital attendances and Poisons Centre enquiries in Scotland. METHODS: Retrospective analyses of clinical data from patients attending the Royal Infirmary of Edinburgh after acute caffeine ingestion, and TOXBASE enquiries from Scotland regarding caffeine poisoning between 2000-2008 inclusive. Cochran-Armitage trend tests were used to evaluate changes in annual admissions and TOXBASE enquiries. RESULTS: There were 43 hospital attendances due to deliberate caffeine ingestion, representing 0.2% of all poisoning cases. The median (interquartile range) stated dose was 1040 mg (600-1500 mg). Minor gastrointestinal symptoms were common, and no patient developed features of severe toxicity. There were 1418 enquiries to TOXBASE concerning caffeine poisoning, representing 0.2% of all poisoning enquiries from Scotland. The proportions of hospital admissions and TOXBASE enquiries due to caffeine ingestion have remained constant. CONCLUSION: Caffeine ingestion is uncommon, and results in only a small number of hospital attendances and Poisons Centre enquiries. In contrast to patterns reported elsewhere, the prevalence of caffeine abuse has not increased in Scotland over recent years.

Survey of cases of paracetamol overdose in the UK referred to National Poisons Information Service (NPIS) consultants.

BACKGROUND: Paracetamol is the most common means of drug overdose in the UK. Guidance on management is available to junior doctors through TOXBASE, the online resource managed by the UK National Poisons Information Service (NPIS) and in poster form. TOXBASE is supported by NPIS units and further by a UK national rota of clinical toxicologists. A study was undertaken to examine reasons why calls about paracetamol are referred to consultants to better understand issues in managing this common poisoning. METHODS: Calls relating to paracetamol overdose referred by a poisons information specialist to the duty NPIS consultant between 1 May 2005 and 30 April 2006 were identified from the database and the number of TOXBASE accesses during the same time period was determined. Enquiries that resulted in consultant referral were classified into six categories. RESULTS: Calls referred to NPIS consultants pertain mainly to patients who present late, staggered overdoses, adverse reactions to N-acetylcysteine, and interpretation of blood results. This information has been used to inform the development of TOXBASE so that comprehensive advice is readily available to end users. CONCLUSIONS: The operation of a national consultant rota enables information on difficult or unusual cases of poisoning to be pooled so that treatment guidelines can be developed to optimise treatment throughout the UK.

Pattern of lithium exposure predicts poisoning severity: evaluation of referrals to a regional poisons unit.

BACKGROUND: Lithium toxicity may result in severe clinical features. There is on-going uncertainty about the significance of serum lithium concentrations in patients with lithium toxicity. AIM: To examine potential relationships between stated quantity of lithium ingested, serum lithium concentrations, and poisoning severity among patients referred to a regional poisons centre. METHODS: Prospective evaluation of enquiries to the Scottish Poisons Information Bureau about lithium toxicity between 2000-2005 inclusive. RESULTS: There were 172 enquiries, relating to acute ingestion (n = 101), acute-on-therapeutic ingestion (n = 38), or chronic poisoning (n = 33). Poisoning severity was moderate or severe in 9.9%, 26.3% (p < 0.05 vs. acute) and 54.5% (p < 0.005 vs. acute) of each group, respectively. Median (IQR) serum lithium concentrations in each group were: 2.4 (1.7-3.3) mmol/l, 2.1 (1.4-3.8) mmol/l, and 2.3 (1.9-3.3) mmol/l, respectively. The median stated quantities ingested in acute and acute-on-therapeutic lithium exposure were 5000 mg (2000-11 050 mg) and 4000 mg (2400-8820 mg), respectively. DISCUSSION: Patients with acute-on-therapeutic and chronic poisoning are at greatest risk of severe toxicity. These differences cannot be explained by either the quantity of lithium ingested or serum lithium concentration alone.

Identification of quantitative trait loci (QTL) for oil and protein contents and their relationships with other seed quality traits in Brassica juncea.

A detailed RFLP-genomic map was used to study the genetics of oil, seed and meal protein and sum of oil and seed/meal protein contents in a recombinant doubled-haploid population developed by crossing black- and yellow-seeded Brassica juncea lines. Two yellow seed color genes (SC-B4, SC-A6) and one QTL for erucic acid content (E(1b)) showed pleiotropic effect for oil, protein and sum of oil and seed/meal protein contents. Six (O-A1, O-A6, O-A9, O-B3, O-B4, O-B5) and five (SP-A1, SP-A9, SP-B4, SP-B6, SP-C) QTLs were significant for oil and seed protein contents, respectively. Tight linkage of three of these QTLs (SP-A1, SP-A9, SP-B4, O-A1, O-A9, O-B4), with opposite effects, poses challenge to the plant breeders for simultaneous improvement of negatively correlated (r = -0.7**) oil and seed protein contents. However, one QTL for oil content (O-B3) and two for seed protein content (SP-B6, SP-C) were found to be unlinked, which offer the possibility for simultaneous improvement of these two traits. QTLs significant for meal protein (MP-A1, MP-A6, MP-A9, MP-B5, MP-B6) were significant at least for oil, seed protein or sum of oil and seed/meal protein contents (T-A6, T-A7, T-B4, T-B5). Sum of oil and seed protein contents and sum of oil and meal protein contents had a perfect correlation, as well as same epistatic interactions and QTLs with similar additive effect. This indicates that protein in seed or meal has practically the same meaning for breeding purposes. Epistatic interactions were significant for the quality traits, and their linkage reflected association among the traits.

Five years of poisons information on the internet: the UK experience of TOXBASE.

INTRODUCTION: In 1999, the UK adopted a policy of using TOXBASE, an internet service available free to registered National Health Service (NHS) departments and professionals, as the first point of information on poisoning. This was the first use worldwide of the internet for provision of clinical advice at a national level. We report the impact on database usage and NPIS telephone call loads. METHODS: Trends in the pattern of TOXBASE usage from 2000-2004 are reported by user category. Information on the monographs accessed most frequently was also extracted from the webserver and sorted by user category. The numbers of telephone calls to the National Poisons Information Service (NPIS) were extracted from NPIS annual reports. RESULTS: Numbers of database logons increased 3.5 fold from 102,352 in 2000 to 368,079 in 2004, with a total of 789,295 accesses to product monographs in 2004. Registered users increased almost tenfold, with approximately half accessing the database at least once a year. Telephone calls to the NPIS dropped by over half. Total contacts with NPIS (web and telephone) increased 50%. Major users in 2004 were hospital emergency departments (60.5% of logons) and NHS public access helplines (NHS Direct and NHS24) (29.4%). Different user groups access different parts of the database. Emergency departments access printable fact sheets for about 10% of monographs they access. CONCLUSION: Provision of poisons information by the internet has been successful in reducing NPIS call loads. Provision of basic poisons information by this method appears to be acceptable to different professional groups, and to be effective in reducing telephone call loads and increasing service cost effectiveness.

Mapping genes for resistance to Leptosphaeria maculans in Brassica juncea.

Blackleg disease of crucifers, caused by the fungus Leptosphaeria maculans, is a major concern to oilseed rape producers worldwide. Brassica species containing the B genome have high levels of resistance to blackleg. Brassica juncea F2 and first-backcross (B1) populations segregating for resistance to a PG2 isolate of L. maculans were created. Segregation for resistance to L. maculans in these populations suggested that resistance was controlled by two independent genes, one dominant and one recessive in nature. A map of the B. juncea genome was constructed using segregation in the F2 population of a combination of restriction fragment length polymorphism (RFLP) and microsatel lite markers. The B. juncea map consisted of 325 loci and was aligned with previous maps of the Brassica A and B genomes. The gene controlling dominant resistance to L. maculans was positioned on linkage group J13 based on segregation for resistance in the F2 population. This position was confirmed in the B1 population in which the resistance gene was definitively mapped in the interval flanked by pN199RV and sB31143F. The provisional location of the recessive gene controlling resistance to L. maculans on linkage group J18 was identified using a subset of informative F2 individuals.

Co-proxamol overdose is associated with a 10-fold excess mortality compared with other paracetamol combination analgesics.

AIMS: To assess the relative toxicity of co-proxamol in overdose in comparison to the 2 other paracetamol-opioid combination products, co-codamol and co-dydramol. METHODS: Data collected over a 2-year period (July 2000-June 2002) was used to estimate the frequency of overdose and death for the three most popular paracetamol-opioid compound analgesics. Prescription data for Scotland and Edinburgh, the number of overdoses (derived from overdose admissions in Edinburgh) or Poisons Information Service contacts in Scotland, and national death records were used to calculate a series of indicators relating morbidity (admissions), surrogates of morbidity (poisons enquiries by telephone or internet) and mortality to prescriptions. RESULTS: When related to prescription volume overdoses involving co-proxamol in Scotland were 10 times more likely to be fatal (24.6 (19.7, 30.4)) when compared with co-codamol (2.0 (0.88, 4.0)) or co-dydramol (2.4 (0.5, 7.2)). In contrast there was no difference in the presentation rate or enquiry rates for these analgesics when corrected for prescriptions. CONCLUSIONS: The excess hazard from co-proxamol is due to inherent toxicity rather than increased use in overdose. We estimate from this study that withdrawal of co-proxamol would prevent 39 excess deaths per annum in Scotland alone.

Molecular markers for seed colour in Brassica juncea.

A detailed RFLP map was used to map QTLs associated with seed colour in Brassica juncea using a doubled-haploid population derived from a cross between a black/brown-seeded cultivar and a yellow-seeded breeding line. Segregation analysis suggested that seed colour was under control of 2 unlinked loci with duplicate gene action. However, QTL analysis revealed 3 QTLs, SC-B4, SC-A10 and SC-A6, affecting seed colour. The QTLs were consistent across environments, and individually explained 43%, 31%, and 16%, respectively, and collectively 62% of the phenotypic variation in the population. Digenic interaction analysis showed that closest flanking locus of QTL SC-B4, wg7b6cNM, had strong epistasis with the locus wg5a1a, which is tightly linked to QTL SC-A6. The interaction of these 2 loci explained 27% of the phenotypic variation in the population, while the whole model explained 84%. In a multiple regression model, the effects of QTL SC-A10, as well as its interaction with other loci, were non-significant, whereas the effects of loci wg7b6cNM and wg5a1a and their interaction were significant. Ninety-eight percent of the DH lines carried the expected alleles of loci wg7b6cNM and wg5a1a for seed colour, confirming that only these 2 loci were linked to seed colour in B. juncea. Four additional digenic interactions significantly affected seed colour, and all 5 digenic interactions were consistent across environments.