Nutrient Strength and Dissolution Test Results of Nationally Representative Prescription Prenatal Multivitamin/Mineral (RxP MVM) Supplements

Objectives

US pregnant women are at risk of dietary deficiencies of iron, folate, calcium and vitamin D and take Rx or non-Rx MVM supplements to optimize their nutritional status. The efficacy of a MVM is determined not only by its ingredient content but also by the ability of tablets and capsules to properly disintegrate and release nutrients. The goals of this Dietary Supplement Ingredient Database study were to measure micronutrients in RxP MVMs and to assess dosage form adherence to the United States Pharmacopeial (USP) dissolution standards.

Methods

Multiple lots of 24 RxP MVMs, representing 61% of the market were tested by commercial laboratories. We compared the content with Recommended Dietary Allowances (RDAs) and Upper Tolerable Intake Levels (ULs). The MVMs were tested for folic acid, iron, riboflavin, and retinol dissolution. To pass, at least 75% of the labeled amount must be released in 1 hour.

Results

The means of daily intakes provided by most RxP MVMs were below 20% RDAs for calcium and magnesium, at about half of the RDA for iodine, at or slightly above RDAs for iron and copper, and almost twice the RDA for zinc. The mean amounts of daily intakes of vitamins A, C, D, E, niacin, and thiamin provided by most MVMs were 70–160%RDAs, although some products contained thiamin, vitamins C or D at 170–240% of RDAs. All MVMs provided amounts of folic acid exceeding the RDA (mean %RDA ± SD; 334 ± 49). Average measured contents of vitamins and minerals exceeded labeled amounts, including those labeled with amounts above ULs. However, none of the 15 tablet and 4 soft gel products passed dissolution testing for all ingredients required by USP. None of 7 products passed the test for retinol. Only 55% of 11 MVMs in tablets with fast releasing iron sources passed dissolution tests for iron, folic acid and riboflavin. For at least one of those three ingredients, 80–93% of 12–15 tablets passed dissolution, and only 1 of 4 soft gels passed the test with pepsin added to the testing media.

Conclusions

Although RxP MVMs contained several micronutrients significantly exceeding RDAs that might help to close nutrient gaps, the sample of nationally representative RxP MVMs failed to meet all USP standards for ingredient dissolution. This is a concern for pregnant women because nutrients in failed products might not be available for absorption and utilization.

Funding Sources

NIH ODS and the USDA.

Sampling Plan for a Study of Cranberry Dietary Supplements (DS) for the Dietary Supplement Ingredient Database (DSID)

Objectives

The intake of cranberry juice or supplements has been found in several, but not all, clinical studies to reduce the recurrence of urinary tract infections (UTIs). Several studies indicate that cranberry proanthocyanidins (PACs) may have a role in UTI prevention due to their ability to inhibit bacterial adhesion. For cranberry DS products on the US market, the relationship between PAC content and the cranberry source (e.g., powder, juice, extract) used in formulations is largely unknown. Therefore, a sampling plan was developed to identify and purchase DS for PAC testing as part of the Dietary Supplement Ingredient Database project. This will include popular cranberry DS, those used in clinical trials, and products with a variety of label claims and source ingredients.

Methods

DS usage data from the National Health and Nutrition Examination Survey and retail sales data were used to identify the most popular cranberry DS in the natural health (NH), mass market (MM), and direct distribution sales channels. Other sources of information were the Dietary Supplement Label Database and web-based DS sellers. Three DS label categories were identified: those with a trademarked cranberry ingredient, those without a trademarked cranberry ingredient, and those with a numeric PAC claim. Some products may fall into two categories. Most products chosen for the study had cranberry as the primary ingredient by weight. Popular products with D-mannose and vitamin C were also included.

Results

In the first phase of this study, we purchased 41 DSs (18 MM, 11 NH, and 12 direct). Our sample included caplets, capsules, soft gels, tablets, and liquid DSs. Cranberry source materials for the DSs included extracts, concentrates, powder, juice, and whole fruit. Fifteen (15) supplements had trademarked cranberry ingredients and 9 had a specific voluntary claim for PAC content.

Conclusions

In 2020, cranberries were the 6th ranked herbal ingredient sold in the US, according to the Nutrition Business Journal. The range of PAC content in the diverse cranberry DSs on the market is currently not known, since there is no requirement for this information on labels. This study will answer questions about the PAC content in a variety of DSs and whether multiple laboratories testing using the dimethylaminocinnamaldehyde (DMAC) method will yield similar results.

Funding Sources

NIH ODS and the USDA.

Overcoming barriers to promotion for women and underrepresented in medicine faculty in academic emergency medicine

Equity in the promotion of women and underrepresented minorities (URiM) is essential for the advancement of academic emergency medicine and the specialty as a whole. Forward-thinking healthcare organizations can best position themselves to optimally care for an increasingly diverse patient population and mentor trainees by championing increased diversity in senior faculty ranks, leadership, and governance roles. This article explores several potential solutions to addressing inequities that hinder the advancement of women and URiM faculty. It is intended to complement the recently approved American College of Emergency Physicians (ACEP) policy statement aimed at overcoming barriers to promotion of women and URiM faculty in academic emergency medicine. This policy statement was jointly released and supported by the Society for Academic Emergency Medicine (SAEM), American Academy of Emergency Medicine (AAEM), and the Association of Academic Chairs of Emergency Medicine (AACEM).

A Distance-Learning Approach to Point-of-Care Ultrasound Training (ADAPT): A Multi-Institutional Educational Response During the COVID-19 Pandemic

PROBLEM

The COVID-19 pandemic significantly disrupted point-of-care ultrasound (POCUS) education. Medical schools and residency programs placed restrictions on bedside teaching and clinical scanning as part of risk mitigation. In response, POCUS faculty from 15 institutions nationwide collaborated on an alternative model of ultrasound education, A Distance-learning Approach to POCUS Training (ADAPT).

APPROACH

ADAPT was repeated monthly from April 1 through June 30, 2020. It accommodated 70 learners, who included 1- to 4-week rotators and asynchronous learners. The curriculum included assigned prework and learning objectives covering 20 core POCUS topics. A rotating group of 30 faculty and fellows delivered daily virtual teaching sessions that included gamification to increase learner engagement and hands-on instruction through teleguidance. After participation, faculty and learners completed anonymous surveys.

OUTCOMES

Educators reported a significant decrease in preparatory time (6.2 vs 3.1 hours per week, P < .001) dedicated to ultrasound education after implementing ADAPT. The majority of 29 learners who completed surveys felt "somewhat confident" or "very confident" in their ability to acquire (n = 25, 86.2%) and interpret (n = 27, 93.1%) ultrasound images after the intervention; the majority of 22 educators completing surveys rated the program "somewhat effective" or "very effective" at contributing to learner's ability to acquire (n = 13, 59.1%) and interpret (n = 20, 90.9%) images. Most learners (n = 28, 96.6%) and all educators (n = 22, 100%) were "satisfied" or "very satisfied" with ADAPT as a whole, and the large majority of educators were "very likely" (n = 18, 81.8%) to recommend continued use of this program.

NEXT STEPS

A virtual curriculum that pools the efforts of multiple institutions nationwide was implemented rapidly and effectively while satisfying educational expectations of both learners and faculty. This collaborative framework can be replicated and may be generalizable to other educational objectives.

846 Dysphagia Rates in Single- And Multiple-Level Anterior Cervical Discectomy and Fusion Surgery: A Meta-Analysis

Aim

To conduct a meta-analysis to assess dysphagia complicating single-level and multiple-level (≥2) anterior cervical discectomy and fusion (ACDF) surgery.

Method

Electronic searches were performed using four electronic databases from their inception to December 2017. Relevant studies reporting the rate of dysphagia as an endpoint for patients undergoing ACDF for degenerative disease, myelopathy, cervical canal stenosis or ossification of the posterior longitudinal ligament were identified according to prior inclusion and exclusion criteria. Statistical analysis was performed using a fixed effect model. P-scores were used to rank the levels of ACDF based on the rate of dysphagia. I2 was used to explore heterogeneity.

Results

Ten studies were identified and included in the systematic review and meta-analysis, with a total of 4,018 patients identified; 2,362 patients underwent single-level ACDF, while 1,656 underwent multiple level (≥2 ACDF). The mean age ranged from 49.45 to 57.77 years. Mean follow-up time ranged from 2 days to 27.3 months. Overall, meta-analysis demonstrated a statistically significant higher dysphagia rate for multiple-level ACDF (6.6%) than for single-level ACDF (4%) (P heterogeneity =0.151, OR = 1.42, 95% CI: 1.05–1.91, I2=32%).

Conclusions

Dysphagia is a relatively common complication in the early postoperative period following ACDF and may cause patients significant discomfort and distress. This meta-analysis demonstrates a higher rate of dysphagia with multiple-level ACDF than with single-level ACDF at a period of 12–24 months.

Comparison of Label Claims, Measured Curcuminoid Content and Dosage Form Performance Quality With Industry Standards for Turmeric Dietary Supplements

Objectives

Turmeric (Curcuma longa) is a popular ingredient in dietary supplements (DS), promoted for a variety of health effects. FDA label regulations require information on the total weight of each botanical or extract present in a botanical DS, unless it is part of a proprietary blend. Information on the concentration of phytochemicals in extracts is voluntary. DS with turmeric rhizome powders and/or extracts were tested for curcuminoid content and the results compared to label claims and industry standards as part of the Dietary Supplement Ingredient Database (DSID) research program. The performance quality of the dosage forms was also evaluated.

Methods

Commonly consumed DS (n = 54 × 2 lots) with turmeric as the only or primary ingredient were analyzed for curcumin, demethoxycurcumin, and bisdemethoxycurcumin. Certified reference materials, in-house controls and blind sample duplicates were measured to ensure the quality of results from three laboratories. Percentages of total curcuminoids (TC) and ratios of the three curcuminoids were compared to published standards. Voluntary content claims were categorized as “complete” (all listed turmeric ingredients had a TC claim) or “partial” (only one of two had a TC claim). Tablets/caplets (n = 9) and capsules (n = 39) were also tested for disintegration and soft gels (n = 4) for rupture.

Results

Measured TC amounts varied widely among products. At the most common labeled level of 500 mg of turmeric per day, measured TC results ranged from 16 to 554 mg (n = 12). DS with voluntary claims for TC (n = 41) had analytical content averaging 6.2% above label, and 63% within ± 10% of claims. DS with complete TC claims had significantly higher levels in mg per day than those with partial or no claims (735 ± 87, 137 ± 37, 196 ± 57; mean ± SE, respectively). The curcuminoid ratios and/or the percentages of TC differed significantly from United States Pharmacopeial (USP) standards for at least 10 DS. Most (87.5%) DS passed disintegration tests and all soft gels passed the rupture test.

Conclusions

Current labeling requirements for turmeric DS may be insufficient to inform researchers and consumers about the actual content of TC in DS because the extract concentrations vary widely. Voluntary claims for TC amounts were reasonably accurate. Most turmeric DS met USP disintegration and composition standards.

Funding Sources

NIH-ODS and USDA-ARS.

Focal Segmental Membranoproliferative Glomerulonephritis: A Histological Variant of Denys-Drash Syndrome

Introduction: Denys-Drash Syndrome (DDS) consists of a triad of pseudohermaphroditism, Wilms'tumor and nephropathy. This condition may manifest as a complete triad or in an incomplete form; with either one or a combination of the above features. The characteristic glomerular abnormality in DDS is diffuse mesangial sclerosis (DMS).Case report: We report two cases of DDS with focal membranoproliferative glomerulonephritis (MPGN). Both of our cases were males with ambiguous genitalia. They had a similar heterozygous germline mutation in exon 9 of WT1, c.1180C>T, p.R394W; a known mutation hotspot for DDS. Case 1 had nephropathy at the age of 4 years and Case 2 at 2.5 years with different rates of progression to end-stage renal failure. Conclusion: Our findings, in combination with other reports, illustrate the clinicopathological heterogeneity of DDS. There are no universal recommendations for optimal management of patients with DDS due to the inability to accurately predict affected individuals' progress.

Children's Multivitamin/Mineral Supplements: Label Claims and Measured Content Compared to Recommended Dietary Allowances and Tolerable Upper Intake Levels

Objectives

US children ages 4 and older use multivitamin/mineral supplements (MVMs) formulated to meet the Daily Values for adults. To better evaluate the potential for nutrient adequacy and excess, it is helpful to determine actual ingredient content instead of amounts declared on labels. We tested children's MVMs and compared the products’ labeled and measured contents with Recommended Dietary Allowances (RDA) and Upper Tolerable Intake Levels (UL) established for children ages 4 to 8 years.

Methods

Children's MVMs were defined as dietary supplements (DSs) containing three or more vitamins with or without minerals and other bioactive components labeled for individuals ages 4 and older. Nationally representative children's MVMs were identified based on relative market share estimates (RMSE) derived from frequency of use and respondents’ weights in infant/pediatric MVM subsets of 2003–2006 National Health and Nutrition Examination Surveys, and store surveys. The 21 top and 43 lower market share DSs selected for this study represented ∼72% of the total RMSE. The DSs were purchased in 2008 from multiple market channels in regions of AL, CA, MI, MO, NY, and OK identified using a multistage probability-proportional-to-size approach. Vitamin and mineral content was measured by commercial labs in 3 to 6 lots of 47 chewable tablets, 11 gummies, 4 liquids, 1 gumball, and 1 powder DS.

Results

For 13 of 16 nutrients (copper, iodine, iron, zinc, folic acid, niacin, riboflavin, thiamin, vitamins A, B-12, B-6, D and E), most MVMs were labeled at or above the RDA but below UL levels. For calcium, magnesium and phosphorus, all the studied DSs were labeled below the RDAs. The DSs that contained zinc, niacin and retinol labeled above their ULs had overall mean RMSEs comparable to the DSs labeled within the RDA-UL ranges. Overages resulted in levels exceeding the UL for folic acid in 24 out of 29 DSs labeled at the UL and for retinol in 10 out 40 DSs labeled below the UL, including one of the three most highly consumed MVMs.

Conclusions

The prevalence of children's MVMs on the US market with labeled levels at or above the RDA, or at UL, combined with analytically verified overages, suggests risks of excess in intakes for zinc, niacin, retinol and folic acid, especially when MVM use is combined with diets containing many highly fortified foods.

Funding Sources

NIH ODS and USDA ARS.

Content of Caffeine and Catechins Measured in Multi-ingredient Dietary Supplements Containing Green Tea: Association with Label Claims and Proprietary Blends

Objectives

Multi-ingredient dietary supplements (DSs) containing green tea (GT) were analyzed for their phytochemical content (seven catechins and caffeine) as part of a Dietary Supplement Ingredient Database project. The label information required by FDA is the weight of the GT extract or leaf powder, unless it is part of a proprietary blend (only the blend weight needed). Any information about the concentration of GT phytochemicals is voluntary. We assessed the accuracy of the mandatory and voluntary portions of labels and the effect of proprietary blends on the phytochemical content.

Methods

Two lots of 37 GT DSs, estimated to contain ≥40 mg/serving of GT, were purchased in a variety of market channels. Samples were sent for analysis to two experienced laboratories. Means and standard errors for the analytically measured content of epigallocatechin gallate (EGCG; the most prevalent catechin), the summed content of the catechins (total catechins, TC), and caffeine were derived for each DS and compared to label information.

Results

The measured content of EGCG, TC, and caffeine showed wide ranges (0 (not detected) - 442, 0–711, and 0–982 mg/day, respectively). DSs with concentration claims for EGCG and caffeine (32% and 43%, respectively) had higher content per serving compared to DSs without such information (P &lt; 0.05). Most DSs with voluntary claims for EGCG, TC or caffeine content (74%) had actual content within ± 20% of the labels. The catechin content was not significantly different in DSs with GT amounts listed on the label (n = 20) compared with DSs listing GT as part of a proprietary blend (n = 17). However, DSs with GT in a blend had significantly more caffeine than those with a label claim for GT amount (means (SE) per day 197 (63) vs. 49 (18), respectively; P = 0.037).

Conclusions

The actual content of GT constituents such as EGCG, TC and caffeine in multi-ingredient GT DSs varied depending on the labeling formats. DSs with a voluntary label claim for EGCG had significantly higher EGCG content than those with only the required claims. DSs with GT listed as a part of a blend had significantly higher levels of caffeine than products with labeled GT amounts. More complete label information would be beneficial both for consumers and for researchers who track phytochemical intakes and their associations with health outcomes.

Funding Sources

NIH/ODS and USDA/ARS.

Disintegration and Dissolution Testing of Green Tea Dietary Supplements: Application and Evaluation of United States Pharmacopeial Standards

Approved performance quality tests are lacking in the United States Pharmacopeia (USP) for dietary supplements (DSs) containing green tea extracts. We evaluated the applicability of USP <2040 > general chapter protocols for disintegration and dissolution testing of botanicals to GT DSs. Of 28 single-ingredient GT DSs tested in 2 to 4 lots, 9 (32.1%) always passed the disintegration test, 8 (28.6%) always failed, and 11 (39.3%) showed inconsistent results. Of 34 multi-ingredient DSs tested in 2 lots, 21 (61.8%) passed and 8 (23.5%) failed in both lots, and 5 (14.7%) exhibited inconsistent performance. When stronger destructive forces were applied (disk added), all of the capsules that had failed initially, but not the tablets, passed. In dissolution testing, for the release of epigallocatechin-3-gallate (EGCG), only 6 of 20 single-ingredient DSs passed. Unexpectedly, with the addition of pepsin (prescribed by USP), only one additional DS passed. These results raise concerns that EGCG was not released properly from GT DS dosage forms. However, the general USP protocols may be inadequate for this botanical. More biorelevant destructive forces may be needed to break down capsules and tablets strengthened by the EGCG's interaction with shell material and to overcome the inhibition of digestive enzymes by EGCG.

How Accurate Is the Labeled Content of Prescription Prenatal Multivitamin/mineral (MVM)? -an Analytical Pilot Study for the Dietary Supplement Ingredient Database (DSID) (OR14-08-19)

Objectives

US national surveys report that pregnant women are at risk of dietary deficiency for several key nutrients, including calcium, iron, folate, and vitamin D. Most pregnant women take prenatal multivitamins (MVM). However intake studies have used only product label information, which may lead to incorrect estimates of their impact on nutrition status. It is unknown if the label information for prescription prenatal (RxP) MVM correctly reflects the composition of these products. The objective of this study was to investigate the relationship between labeled and analytically measured content of ingredients in RxP MVM.

Methods

From a list of 338 Rx prenatal MVM sold by retail and mail order pharmacies from 06–2015 to 06–2016, a selection of representative products was generated using random sampling weighted by market share. Multiple lots of 24 products, representing 61% of the market were tested by commercial laboratories for their vitamin, mineral and docosahexaenoic acid (DHA) content. Laboratories were selected based on the results from quality control materials, including National Institute of Standards and Technology Standard Reference Materials.

Results

The RxP MVM evaluated in this study varied in their labeled ingredient content. All RxP MVM labels listed folic acid, vitamins B-6, D, E and iron; 83–92% contained niacin, riboflavin, thiamin, and vitamins C, B-12, and zinc; and 71% contained calcium. Only 46–54% contained vitamin A, iodine and DHA. Analytical results showed mean overages of ≥20% for 6 vitamins (folic acid, niacin, riboflavin and vitamins A, B-12, D); 10–15% for vitamins B-6, C, E; and slightly below (−4%) label results for thiamin. For minerals and DHA, analytical content was close to labeled content, averaging 1–11% above label.

Conclusions

Many of the less expensive, highly consumed products were formulated without iodine or DHA despite recommendations for iodine supplementation from leading health authorities in the US and worldwide and data indicating that DHA may improve pregnancy outcomes. Analytical testing revealed that most RxP MVM had vitamin and mineral levels above label, with vitamin D the highest, averaging 29% above label. Thus, the intake of some nutrients from Rx prenatal MVM could be underestimated.

Funding Sources

NIH Office of Dietary Supplements and USDA Agricultural Research Service.

Dietary Supplement Ingredient Database (DSID) and the Application of Analytically Based Estimates of Ingredient Amount to Intake Calculations

OBJECTIVE

We describe the purpose of the Dietary Supplement Ingredient Database (DSID), the statistical methodology underlying online calculators of analytically verified supplement content estimates, and the application and significance of DSID label adjustments in nutritional epidemiology.

BACKGROUND AND HISTORY

During dietary supplement (DS) manufacturing, many ingredients are added at higher than declared label amounts, but overages are not standardized among manufacturers. As a result, researchers may underestimate nutrient intakes from DSs. The DSID provides statistical tools on the basis of the results of chemical analysis to convert label claims into analytically predicted ingredient amounts. These adjustments to labels are linked to DS products reported in NHANES.

RATIONALE

Tables summarizing the numbers of NHANES DS products with ingredient overages and below label content show the importance of DSID adjustments to labels for accurate intake calculations.

RECENT DEVELOPMENTS

We show the differences between analytically based estimates and labeled content for vitamin D, calcium, iodine, caffeine, and omega-3 (n-3) fatty acids and their potential impact on the accuracy of intake assessments in large surveys. Analytical overages >20% of label levels are predicted for several nutrients in 50-99% of multivitamin-mineral products (MVMs) reported in NHANES: for iodine and selenium in adult MVMs, for iodine and vitamins D and E in children's MVMs, and for iodine, chromium, and potassium in nonprescription prenatal MVMs. Predicted overages of 10-20% for calcium can be applied to most MVMs and overages >10% for folic acid in the vast majority of adult and children's MVMs.

FUTURE DIRECTIONS

DSID studies are currently evaluating ingredient levels in prescription prenatal MVMs and levels of constituents in botanical DSs.

CONCLUSIONS

We estimate that the majority of MVM products reported in NHANES have significant overages for several ingredients. It is important to account for nonlabeled additional nutrient exposure from DSs to better evaluate nutritional status in the United States.

Emergency and critical care applications for contrast-enhanced ultrasound

INTRODUCTION

Contrast-enhanced ultrasound (CEUS) using intravascular microbubbles has potential to revolutionize point-of-care ultrasonography by expanding the use of ultrasonography into clinical scenarios previously reserved for computed tomography (CT), magnetic resonance imaging, or angiography.

METHODS

We performed a literature search and report clinical experience to provide an introduction to CEUS and describe its current applications for point-of-care indications.

RESULTS

The uses of CEUS include several applications highly relevant for emergency medicine, such as solid-organ injuries, actively bleeding hematomas, or abdominal aortic aneurysms. Compared with CT as the preeminent advanced imaging modality in the emergency department, CEUS is low cost, radiation sparing, repeatable, and readily available. It does not require sedation, preprocedural laboratory assessment, or transportation to the radiology suite.

CONCLUSIONS

CEUS is a promising imaging technique for point-of-care applications in pediatric and adult patients and can be applied for patients with allergy to CT contrast medium or with impaired renal function. More high-quality CEUS research focusing on accuracy, patient safety, health care costs, and throughput times is needed to validate its use in emergency and critical care settings.

Transition of Care from the Emergency Department to the Outpatient Setting: A Mixed-Methods Analysis

Introduction

The goal of this study was to characterize current practices in the transition of care between the emergency department and primary care setting, with an emphasis on the use of the electronic medical record (EMR).

Methods

Using literature review and modified Delphi technique, we created and tested a pilot survey to evaluate for face and content validity. The final survey was then administered face-to-face at eight different clinical sites across the country. A total of 52 emergency physicians (EP) and 49 primary care physicians (PCP) were surveyed and analyzed. We performed quantitative analysis using chi-square test. Two independent coders performed a qualitative analysis, classifying answers by pre-defined themes (inter-rater reliability > 80%). Participants' answers could cross several pre-defined themes within a given question.

Results

EPs were more likely to prefer telephone communication compared with PCPs (30/52 [57.7%] vs. 3/49 [6.1%] P < 0.0001), whereas PCPs were more likely to prefer using the EMR for discharge communication compared with EPs (33/49 [67.4%] vs. 13/52 [25%] p < 0.0001). EPs were more likely to report not needing to communicate with a PCP when a patient had a benign condition (23/52 [44.2%] vs. 2/49 [4.1%] p < 0.0001), but were more likely to communicate if the patient required urgent follow-up prior to discharge from the ED (33/52 [63.5%] vs. 20/49 [40.8%] p = 0.029). When discussing barriers to effective communication, 51/98 (52%) stated communication logistics, followed by 49/98 (50%) who reported setting/environmental constraints and 32/98 (32%) who stated EMR access was a significant barrier.

Conclusion

Significant differences exist between EPs and PCPs in the transition of care process. EPs preferred telephone contact synchronous to the encounter whereas PCPs preferred using the EMR asynchronous to the encounter. Providers believe EP-to-PCP contact is important for improving patient care, but report varied expectations and multiple barriers to effective communication. This study highlights the need to optimize technology for an effective transition of care from the ED to the outpatient setting.

Interobserver and Intraobserver Agreement on Qualitative Assessments of Right Ventricular Dysfunction With Echocardiography in Patients With Pulmonary Embolism

OBJECTIVES

To evaluate observer agreement using qualitative goal-directed echocardiographic criteria for right ventricular (RV) dysfunction prognostication in submassive pulmonary embolism (PE).

METHODS

Two emergency physicians and 2 cardiologists independently reviewed 31 packets of goal-directed echocardiographic video clips consisting of at least 3 windows obtained by emergency physicians from normotensive patients with PE. Nine packets were repeated to assess for intraobserver agreement. Right ventricular dysfunction criteria on goal-directed echocardiography were as follows: RV enlargement was present, with a right-to-left ventricular basal diameter ratio of 1.0 or higher and blunting of the apex of the RV in 2 or more different windows; RV systolic dysfunction was present if the tricuspid annulus moved toward the apex 10 mm or less and there was RV free wall hypokinesis; and septal deviation was present with any flattening or deviation of the ventricular septum toward the left ventricle.

RESULTS

Among the 4 participants, there was 83.9% agreement on the presence or absence of RV enlargement (κ = 0.84), 74.2% agreement on the presence or absence of RV systolic dysfunction (κ = 0.69), and 71.0% agreement on the presence or absence of septal deviation (κ = 0.59). Intraobserver agreement was 100% for each RV dysfunction variable for each observer (κ = 1.0).

CONCLUSIONS

Agreement was substantial for both severe RV enlargement and RV systolic dysfunction and moderate for septal deviation. Right ventricular dysfunction assessment with qualitative goal-directed echocardiographic criteria is reproducible for PE risk stratification.

New drugs of abuse

Drug abuse is a common problem and growing concern in the United States, and over the past decade, novel or atypical drugs have emerged and have become increasingly popular. Recognition and treatment of new drugs of abuse pose many challenges for health care providers due to lack of quantitative reporting and routine surveillance, and the difficulty of detection in routine blood and urine analyses. Furthermore, street manufacturers are able to rapidly adapt and develop new synthetic isolates of older drugs as soon as law enforcement agencies render them illegal. In this article, we describe the clinical and adverse effects and purported pharmacology of several new classes of drugs of abuse including synthetic cannabinoids, synthetic cathinones, salvia, desomorphine, and kratom. Because many of these substances can have severe or life-threatening adverse effects, knowledge of general toxicology is key in recognizing acute intoxication and overdose; however, typical toxidromes (e.g., cholinergic, sympathomimetic, opioid, etc.) are not precipitated by many of these agents. Medical management of patients who abuse or overdose on these drugs largely consists of supportive care, although naloxone may be used as an antidote for desomorphine overdose. Symptoms of aggression and psychosis may be treated with sedation (benzodiazepines, propofol) and antipsychotics (haloperidol or atypical agents such as quetiapine or ziprasidone). Other facets of management to consider include treatment for withdrawal or addiction, nutrition support, and potential for transmission of infectious diseases.

Frequent occurrence of gastric cancer in Asian kindreds with Li-Fraumeni syndrome

Type of cancer and age of onset in individuals with inherited aberrations in the tumour suppressor gene TP53 are variable, possibly influenced by genetic modifiers and different environmental exposure. Since 2009, the modified Chompret criteria (MCC) have been used to identify individuals for TP53 mutation screening. Using the TP53 mutation database maintained by the International Agency for Research on Cancer (IARC), we investigated if the MCC, mainly developed for a Caucasian population, was also applicable in Asia. We identified several differences in Asian families compared with similar Caucasian cohorts, suggesting that identification and management of Li-Fraumeni syndrome in Asia do not completely mirror that of North America and Western Europe. Early gastric cancer (<40 years) may be considered a new addition to the MCC especially for Asian families.

Immunomodulatory effects of H.P. Acthar Gel on B cell development in the NZB/W F1 mouse model of systemic lupus erythematosus

H.P. Acthar Gel® (Acthar) is a highly purified repository gel preparation of adrenocorticotropic hormone (ACTH1-39), a melanocortin peptide that can bind and activate specific receptors expressed on a range of systemic lupus erythematosus (SLE)-relevant target cells and tissues. This study was performed to evaluate the effects of Acthar in a mouse model of SLE, using an F1 hybrid of the New Zealand Black and New Zealand White strains (NZB/W F1). Twenty-eight week old NZB/W F1 mice with established autoimmune disease were treated with Acthar, Placebo Gel (Placebo), or prednisolone and monitored for 19 weeks. Outcomes assessed included disease severity (severe proteinuria, ≥ 20% body weight loss, or prostration), measurement of serial serum autoantibody titers, terminal spleen immunophenotyping, and evaluation of renal histopathology. Acthar treatment was linked with evidence of altered B cell differentiation and development, manifested by a significant reduction in splenic B cell follicular and germinal center cells, and decreased levels of circulating total and anti-double-stranded DNA (IgM, IgG, and IgG2a) autoantibodies as compared with Placebo. Additionally, Acthar treatment resulted in a significant decrease of proteinuria, reduced renal lymphocyte infiltration, and attenuation of glomerular immune complex deposition. These data suggest that Acthar diminished pathogenic autoimmune responses in the spleen, peripheral blood, and kidney of NZB/W F1 mice. This is the first preclinical evidence demonstrating Acthar's potential immunomodulatory activity and efficacy in a murine model of systemic lupus erythematosus.

Variations of the flexor digitorum superficialis as determined by an expanded clinical examination

PURPOSE

Current examination techniques do not detect the wide clinical variability of the flexor digitorum superficialis (FDS). Modification of current examination techniques may be necessary to detect anomalies and lead to more accurate diagnosis. We examined 500 subjects using an expansion of current techniques to elicit the range of variations in FDS function discernable on clinical examination.

METHODS

FDS function was evaluated by asking subjects to flex the finger of interest while all other fingers were held fully extended at the metacarpophalangeal and interphalangeal joints. Isolated flexion at the proximal interphalangeal (PIP) joint indicated independent FDS function. Obligatory flexion at the distal interphalangeal (DIP) joint indicated flexor digitorum profundus (FDP) activity. Because FDS activity could not be evaluated if concurrent FDP activity was present, these fingers were designated as having FDP substitution. Difficulty isolating PIP joint flexion suggested connections to adjacent FDS or FDP, prompting the examiner to serially release adjacent fingers while observing for improvement in PIP or DIP range of motion.

RESULTS

Independent FDS function was most consistently present in the ring and middle fingers, less so in the index finger, and least in the small finger. Variations included FDP substitution or connections to flexor tendons in 1 or 2 adjacent fingers with or without evidence of FDP substitution. Absent FDS function cannot be presumed in any subject based solely on clinical examination of a single digit.

CONCLUSIONS

Current examination techniques are inadequate to discern among the multiple variations of FDS function. An expanded examination technique is recommended for accurate diagnosis of FDS function following flexor tendon injury.

Mice with conditional inactivation of fibroblast growth factor receptor-2 signaling in oligodendrocytes have normal myelin but display dramatic hyperactivity when combined with Cnp1 inactivation

Fibroblast growth factor receptors (Fgfr) comprise a widely expressed family of developmental regulators implicated in oligodendrocyte (OL) maturation of the CNS. Fgfr2 is expressed by OLs in myelinated fiber tracks. In vitro, Fgfr2 is highly upregulated during OL terminal differentiation, and its activation leads to enhanced growth of OL processes and the formation of myelin-like membranes. To investigate the in vivo function of Fgfr2 signaling by myelinating glial cells, we inactivated the floxed Fgfr2 gene in mice that coexpress Cre recombinase (cre) as a knock-in gene into the OL-specific 2',3'-cyclic nucleotide phosphodiesterase (Cnp1) locus. Surprisingly, no obvious defects were detected in brain development of these conditional mutants, including the number of OLs, the onset and extent of myelination, the ultrastructure of myelin, and the expression level of myelin proteins. However, unexpectedly, a subset of these conditional Fgfr2 knock-out mice that are homozygous for cre and therefore are also Cnp1 null, displayed a dramatic hyperactive behavior starting at approximately 2 weeks of age. This hyperactivity was abolished by treatment with dopamine receptor antagonists or catecholamine biosynthesis inhibitors, suggesting that the symptoms involve a dysregulation of the dopaminergic system. Although the molecular mechanisms are presently unknown, this novel mouse model of hyperactivity demonstrates the potential involvement of OLs in neuropsychiatric disorders, as well as the nonpredictable role of genetic interactions in the behavioral phenotype of mice.

Pain during elective caesarean section under epidural anaesthesia: the effect of a 10° head-up tilt position

One hundred patients scheduled for elective caesarean section under epidural anaesthesia were randomized to have epidural loading doses in either the horizontal or a 10 degrees head-up position. They were assigned to their position only after an initial dose of 4 ml of 0.5% bupivacaine had been given. Ten minutes after this dose they were given 10 ml of 0.5% bupivacaine and 50 microg of fentanyl in their allocated position. Pain during surgery was assessed by the patients using a visual analogue scale and by a blinded anaesthetist. Giving the main dose in the head-up tilt position reduced the incidence of intea-operative pain significantly. The median pain score for the head-up position was zero while the score was two for the horizontal position. The inter-quartile range was 0 to 2 for the head-up tilt position and 0 to 4 for the horizontal position (P<0.05). Position had no significant effect on the blood pressure or Bromage score. A 10 degrees head-up tilt position is useful during the establishment of epidural anaesthesia to reduce the pain experienced by the patient during caesarean section.