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We write in response to Doug Hirst's note on requests for analyses reportedly following advice from the NPIS and subsequent comments. The NPIS currently deals with some 250,000 calls per annum. There are 7 centres (London (Guy's), Birmingham, Newcastle, Leeds, Cardiff, Edinburgh, and Belfast). Leeds is due to merge with Newcastle in the near future. The service is, in the main, paid for out of central funds. At peak times (between about 20.00 and 02.00) an information officer at the London centre will deal with 20 enquiries per hour. Details of each call, including any suggested treatment, are recorded. Audit is carried out. A "clinical standards group" reviews the quality/relevance of the advice given. Responsibility for the care of the patient remains that of the clinician looking after the patient. The clinician must justify any requests for analyses on the basis that they will influence the care of the patient. The NPIS must perforce offer best available advice based on current thinking otherwise they themselves might be considered negligent. This being said the NPIS is always cautious about recommending emergency analyses in general, and emergency toxicological analyses in particular, and this has been emphasised in many publications associated with this Unit over the years (see, for example, Simple tests to detect poisoning. J Clin Pathol 1988;41:996-1004 and Basic analytical toxicology. WHO, Geneva, 1995). As regards Doug Hirst's question about urgent T3 and T4 assays, it would appear that the London centre was indeed contacted about the patient in question. However, from our records it seems that T3 and T4 assays were NOT recommended, only mentioned as possible indicators of exposure which could be measured if required in the management of a very sick patient This illustrates one problem: how to ensure that NPIS advice is recorded correctly by the user and that appropriate action is taken. The NPIS emphasis is to try to stop second/third hand accounts and when possible give information directly to the clinician looking after the patient, i.e. to establish clear lines of communication. Obviously Path Labs need to do the same. How can the lab check that the interpretation made by the doctor is in line with the information given out by the NPIS? Well, in addition to publications/textbooks, many hospitals in Scotland and Northern Ireland and about 50 % in England have access to the NPIS TOXBASE system which allows on-line viewing of the NPIS Poisons Information database. TOXBASE is an on-line database and is currently in viewdata format. Any NHS professional can register free of charge. If a PC with Windows 95 and a modem is available the only cost is that of a local phone call. During 1999 TOXBASE will change to be available via the internet, NHSnet and possibly, for some users, CD-Rom. For further information or to register please contact: e-mail: [log in to unmask] phone: 0131 536 2298/2303 post: Scottish Poisons Information Bureau, The Royal Infirmary, Edinburgh EH3 9YW The second problem is that of the non-availability of urgent assays which may be required to give the clinician the best service. The classic examples here are methanol and ethylene glycol. Clearly the clinician must be made aware of the potential value of these assays, but the advice must be realistic in view of what is actually available. The NPIS does try to be realistic, but how this is translated into demands on local services is unknown. By analogy with orphan drugs, we think of these assays as orphan toxicological analyses - so little used as never to be viable on a cost/test basis, but potentially extremely valuable in certain circumstances. Our own laboratory receives no central funding and we use funds from more profitable/larger volume services to subsidise "orphan" assays, but this does not extend to a full out-of- hours service for these analytes. TOXBASE includes lists of analyses available from Belfast, Birmingham, Edinburgh, Glasgow, and London with advice on who to contact to arrange assays. If an emergency analysis is not available then follow Robert Forrest's advice - get the appropriate samples collected and offer to arrange the analysis at the earliest opportunity if patient care might be influenced, otherwise store the samples in case an analysis might be useful in retrospect. Finally, colleagues might like to know that there is currently a restructuring of the NPIS across the UK with a new management board which includes A+E consultants, a paediatrician, and a GP in addition to the NPIS directors. It might be sensible to have a clinical chemist or other lab-aware person on the board as well. We would be grateful for your comments. It would also be helpful if colleagues would send us ([log in to unmask]) details of problems they encounter in providing laboratory services for poisoned patients, including, if possible, the date and time of any enquiry to the NPIS, a statement of the advice given and from which NPIS centre the advice originated. Glyn Volans, Director Nick Edwards, Manager NPIS (London) Bob Flanagan, Consultant Biochemist Medical Toxicology Unit Avonley Road London SE14 5ER Tel: +44 171 771 5365 Fax: +44 171 771 5363 e-mail: [log in to unmask] %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%