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The emergency department utility of Simplify D-dimer to exclude pulmonary embolism in patients with pleuritic chest pain.

STUDY OBJECTIVE: Pleuritic chest pain is a common presenting complaint in the emergency department (ED) and a symptom of pulmonary embolism. Patients with pleuritic chest pain would benefit from a simple and rapid way of screening for pulmonary embolism. The aim of this study is to assess the utility of Simplify D-dimer as a rule-out tool for pulmonary embolism in ED patients with pleuritic chest pain. METHODS: This was a prospective diagnostic study in a large city-center ED. Four hundred twenty-five patients with pleuritic chest pain were prospectively recruited between February 2002 and June 2003. Simplify D-dimer testing was performed on each patient in the ED. All patients followed an independent reference standard diagnostic algorithm for pulmonary embolism. Each patient was followed up clinically for 3 months. RESULTS: The calculated sensitivity of Simplify D-dimer for pulmonary embolism was 81.8% (95% confidence interval [CI] 61.4% to 92.7%), and specificity was 74.2% (95% CI 69.6% to 78.4%). The negative predictive value was 98.6% (95% CI 96.6% to 99.6%), positive predictive value 15.0% (95% CI 9.1% to 22.7%), negative likelihood ratio 0.25 (95% CI 0.10 to 0.52) and positive likelihood ratio 3.17 (95% CI 2.30 to 3.97). The study cohort pretest probability was 5.3%. A negative Simplify result reduced the posttest probability to 1.3% (95% CI 0.5% to 3.4%). CONCLUSION: The Simplify D-dimer is not sufficiently sensitive to exclude the diagnosis of pulmonary embolism in all patients presenting to the ED with pleuritic chest pain.

Adult↗

Screening for primary aldosteronism in essential hypertension: diagnostic accuracy of the ratio of plasma aldosterone concentration to plasma renin activity.

BACKGROUND: The ratio of plasma aldosterone concentration to plasma renin activity (PRA) is considered the screening test of choice for primary aldosteronism. Uncertainty exists, however, regarding its diagnostic accuracy and the effects of antihypertensive drugs and dietary sodium balance on test characteristics. METHODS: We measured PRA and aldosterone in 118 white adults [71 men and 47 women; mean (SD) age, 51 (7) years] with previously diagnosed essential hypertension. Measurements were made while individuals were on antihypertensive drug therapy, after a 2-week drug-free period, after 4 days of dietary sodium loading, and after acute furosemide diuresis. We measured 24-h urine aldosterone excretion and PRA on the 4th day of dietary sodium loading to establish the diagnosis of primary aldosteronism. ROC curves were constructed for ratios measured under each clinical condition, and likelihood ratios were determined for individuals on or off antihypertensive drug therapy. RESULTS: Fifteen patients [13%; 95% confidence interval (CI), 7-20%] met the reference standard for primary aldosteronism. The mean (SD) areas under the ROC curves did not differ significantly across conditions of measurement [range, 0.80 (0.10) to 0.85 (0.04); P = 0.72]. When measured on and off antihypertensive drug therapy, the 95% CIs for the optimum cutpoint for the ratio overlapped. Point estimates of sensitivity on and off therapy were 73% (95% CI, 50-96%) and 87% (70-100%), respectively, and specificities were 74% (65-83%) and 75% (66-84%). Under either condition, increased ratios were associated with 2.4- to 13-fold increases of posttest odds above pretest odds. CONCLUSIONS: The aldosterone:PRA ratio provides only fair diagnostic accuracy in screening for primary aldosteronism, but concomitant antihypertensive drug therapy or acute variation in dietary sodium balance does not adversely affect test accuracy. Reporting of likelihood ratios associated with ranges of values of the aldosterone:PRA ratio, rather than use of a single "optimum" cutpoint, may enhance the usefulness of the test.

Adult↗

Dietary Reference Intakes for the macronutrients and energy: considerations for physical activity.

The Dietary Reference Intakes (DRIs) are the North American reference standards for nutrients in the diets of healthy individuals. The macronutrient DRI report includes the standards for energy, fat and fatty acids, carbohydrate and fiber, and protein and amino acids. Equations used to identify the Estimated Energy Requirement (EER) were also developed based on individual characteristics including levels of physical activity. The DRIs for the macronutrients are presented as Recommended Dietary Allowances (RDAs) or Adequate Intakes (AIs), as well as Acceptable Macronutrient Distribution Ranges (AMDRs), and were arrived at by considering both nutrient inadequacies and excesses. In addition, recommendations are made that would reduce the risk of chronic diseases, such as setting intake limits for added sugar; reducing cholesterol, saturated, and trans fatty acids consumption; and increasing levels of physical activity. As healthy individuals include those engaged in various levels of physical activity, the DRIs should apply to the athlete and address their macronutrient and energy needs. This paper summarizes the macronutrient DRI report as applied to the adult, with discussion of the dietary needs of those engaged in various levels of physical activity, including the athlete.

Amino Acids↗

An ELISA assay for the detection of factor VIII antibodies - comparison with the conventional Bethesda assay in a large cohort of haemophilia samples.

An enzyme-linked immunosorbent assay (ELISA) has been developed to measure factor VIII antibodies in haemophilia patients. The assay utilizes binding of the antibodies in the plasma to solid phase antigen, i.e. recombinant factor VIII which was subsequently detected by a human polyclonal IgG labelled with the alkaline phosphatase-p-nitrophenyl phosphate substrate system. Comparisons were made with the Bethesda assay for the quantitation of factor VIIII inhibitors. Dose response curves for the reference standards were consistently linear and reproducible. The assay was specific for factor VIII antibodies, showing a negative reaction for antibodies to other coagulation factors, antinuclear factors and antiphospholipid antibodies. Using this method, 312 samples from haemophilia A patients and 31 samples from healthy controls were screened for the presence of inhibitors and compared with the conventional Bethesda assay. Twenty-four cases were found to be positive for inhibitors in both the ELISA and Bethesda assay. Five additional cases were also found to be positive in the ELISA assay, which, however, were negative in Bethesda assay. One patient who was initially positive for factor VIII inhibitors both by the Bethesda assay and ELISA eventually became negative for the Bethesda assay (<0.5 BU/ml) but was still positive for the ELISA assay. The ELISA thus described had a specificity of 97.8% and a sensitivity of 100% when tested against a large cohort of haemophilia A samples.

Case-Control Studies↗

Assessment of an indirect ELISA in milk for the diagnosis of ovine Brucellosis.

The possibility of using an ELISA for the diagnosis of ovine brucellosis in milk (M-ELISA) was investigated. The aim of the study was to establish whether the specificity and sensitivity of the M-ELISA would be high enough to detect low levels of Brucella antibodies in ewe milk. The diagnostic performances of the test under study were established by means of reference standards and compared with conventional screening and confirmatory tests under field conditions. The diagnostic specificity of the M-ELISA established on a number of samples from Brucella-free flocks was 100% while relative to RBT and CFT positive reactors the M-ELISA demonstrated sensitivity of 65 and 83% respectively. Its sensitivity relative to culture positive animals was of 92%. The course of Brucella antibodies in milk of positive sheep was evaluated in colostrum and in mature milk for a period of 30 days after delivery and it appeared that concentrations of immunoglobulins in milk tend to sharply decrease soon after parturition while in blood serum these remained constantly high. It was concluded that the M-ELISA for Brucella antibodies in ewe milk can be regarded as a complementary diagnostic tool for individual testing but it would be poorly viable if used as a screening test applied to pooled flock milks.

Animals↗

Leucine metabolism and body cell mass in cystic fibrosis.

To further investigate the nature of malnutrition in cystic fibrosis (CF), specifically to evaluate the influence of body composition on leucine metabolism and determine whether measures used as reference standards alter comparative differences in protein metabolism, we measured [13C]leucine kinetics in nine well-nourished and eight malnourished, height-, FEV1-, and sex-matched CF subjects. Body cell mass was measured by total-body potassium (K40) analysis. Leucine turnover did not significantly differ between groups in absolute values or when corrected for body weight, body height, or surface area. However, malnourished CF patients had accelerated leucine turnover based on body cell mass measurements. Mean leucine synthesis per unit body cell mass in the malnourished group was 147% higher than that of the well-nourished group (p < 0.001). These data indicate that altered body composition is an important factor influencing protein metabolism in CF and should be considered in future metabolic studies. The importance of potentially serious but possibly correctable deficits in body cell mass in CF is emphasized.

Adolescent↗

Accuracy of pQCT for evaluating the aged human radius: an ashing, histomorphometry and failure load investigation.

INTRODUCTION: Quantifying the determinants of bone strength is essential to understanding if or how the structure will fail under load. Determining failure requires knowledge of material and geometric properties. However, characterizing the relative contributions of geometric parameters of bone to overall bone strength has been difficult to date because of limitations in imaging technology. Peripheral quantitative computed tomography (pQCT) uses digital images to derive estimates of bone strength in the peripheral skeleton and is a relatively safe technique to differentiate cortical from trabecular bone and assess bone geometry and density. However, in a compromised osteoporotic bone, thin cortices and low scan resolution can limit accurate analysis. METHODS: Therefore, in this two-part investigation we scanned ten pairs (n=20) of fresh-frozen radial specimens [female, mean (SD) age 79(6) years] using pQCT (XCT 2000) at the 4 and 30% sites of the distal radius. We investigated the accuracy of four different acquisition resolutions (200, 300, 400, 500 microm) and several analysis modes and thresholds. We evaluated (1) the accuracy of the Norland/Stratec XCT 2000 pQCT in assessing low-density bones by comparing pQCT outcomes to ashing and histomorphometry and (2) the association of geometric parameters by pQCT and areal bone mineral density (aBMD) by dual-energy X-ray absorptiometry (DXA) to failure load at the distal radius. RESULTS: Using histomorphometry and ashing as reference standards, we found that pQCT scans varied systematically and underestimated or overestimated total area and mineral content at the radial midshaft depending on the analysis algorithm and selected threshold. Overall, most pQCT analysis modes were accurate. In the mechanical testing studies, bone mineral content and cortical bone content at the midshaft were strongly associated with failure load. The pQCT parameters that best accounted for failure load were total content at the 4% site and cortical thickness at the 30% site and they accounted for up to 81% of the variance. The best DXA predictor of failure load was total density at the distal third site and it explained 75% of the variance. CONCLUSIONS: In summary, analysis mode, resolution and thresholding affected pQCT outputs at the radial midshaft. This study extends our understanding of pQCT analysis and provides important data regarding determinants of bone strength at the distal radius.

Aged↗

Diagnostic accuracy with US: remote radiologists' versus on-site radiologists' interpretations.

PURPOSE: To compare the diagnostic accuracy of radiologists interpreting static ultrasonographic (US) images electronically transmitted to an academic medical center (remote radiologists) with that of radiologists performing "hands-on" US at a community-based outpatient site (on-site radiologists). MATERIALS AND METHODS: During 8 months, 80 patients underwent pelvic US at a community-based outpatient site. Images were electronically transmitted to a remote medical center as they were acquired at the community site and were printed on a laser printer identical to the one used at the outpatient site. The reference standard for correct diagnosis was based on histopathologic findings (n = 13), additional imaging results (n = 34), or review by a second independent observer (n = 33). Both an on-site and a remote radiologist interpreted the images, and their interpretations were rated as agree, both correct; agree, both incorrect; or disagree. Cases of disagreement were rated as major or minor. RESULTS: On-site and remote radiologists agreed in 69 of 80 patients (86%), and both radiologists were correct in all of these cases. There were 10 minor discrepancies and one major discrepancy. The diagnostic accuracies of the one-site and remote radiologists were 92% and 94%, respectively. CONCLUSION: High levels of diagnostic accuracy can be achieved by radiologists interpreting static US images. Strict protocols and excellent communication between the radiologist and sonographer are necessary to avoid diagnostic errors.

Academic Medical Centers↗

Impact of microscopy error on estimates of protective efficacy in malaria-prevention trials.

Microscopy is an imperfect reference standard used for malaria diagnosis in clinical trials. The purpose of this study was to provide an assessment of the accuracy of basic microscopy, to compare polymerase chain reaction (PCR)-based diagnosis with microscopy results, and to assess the effect of microscopy error on apparent protective efficacy. The sensitivity and specificity of basic, compared with expert, microscopy was determined to be 91% and 71%, respectively. In a clinical trial, agreement between PCR and microscopy results improved with expert confirmation of initial results. In a simulated 12-week trial with weekly routine malaria smears, a very high specificity (>99%) for each malaria smear was found to be necessary for an estimate of protective efficacy to be within 10%-25% of the true value, but sensitivity had little effect on this estimate. Microscopy error occurs and can affect clinical trial results.

Animals↗

Determination of the epimeric composition of ibuprofenyl-CoA.

Ibuprofen [racemic2-(4-isobutylphenyl)propionic acid] is a 2-arylpropionic acid nonsteroidal anti-inflammatory drug which undergoes unidirectional, R to S chiral inversion in vivo. It has been proposed that this chiral inversion phenomenon occurs via a coenzyme A (CoA) thioester intermediate. To characterize the formation and metabolism of this metabolic intermediate, ibuprofenyl-CoA, reference standards were needed and thus the CoA derivatives of (R)-, (S)-, and racemic ibuprofen were chemically synthesized. An HPLC assay employing a C18 reverse-phase column was developed to quantitate "total" ibuprofenyl CoA. Samples collected from this assay were then analyzed for ibuprofenyl-CoA epimeric composition by chiral chromatography employing a Chiral-AGP alpha 1-acid glycoprotein column. The applicability of these methods was demonstrated by assessing (R)- and (S)-ibuprofenyl-CoA hydrolysis and epimerization following incubation with rat liver homogenates. Rat liver homogenate catalyzed the complete and rapid epimerization of ibuprofenyl-CoA and the rate constants for (R)- and (S)-ibuprofenyl-CoA hydrolysis were equal. ATP and CoA were found to inhibit rat liver-catalyzed ibuprofenyl-CoA hydrolysis by 70-80% with no effect on epimerization. Additionally, it was demonstrated that traditional indirect ibuprofenyl-CoA assays which employ basic hydrolysis result in erroneous epimeric ratio determinations due to chemical epimerization.

Acyl Coenzyme A↗

Study of industrial microencapsulated ferrous sulfate by means of the prophylactic-preventive method to determine its bioavailability.

Radio-iron tests are frequently used to measure the bioavailability of different iron sources for food fortification. As the labeling procedures must be done under laboratory conditions, complementary studies should be carried out to evaluate the bioavailability of iron sources produced on an industrial scale. The iron bioavailability of SFE-171 (ferrous sulfate microencapsulated with phospholipids) was studied in previous reports using the compounds labeled with 59Fe and 55Fe; the results showed an iron bioavailability similar to that of ferrous sulfate. In the present work, the iron bioavailability of industrial SFE-171 was studied by the prophylactic-preventive method in rats using ferrous sulfate as the reference standard. Elemental iron powder was also studied by the same method for comparative purposes. The liver iron concentration of each animal was determined at the end of the experiment in order to evaluate the influence of each iron source on the liver iron stores. Relative biological values of 98 and 34% were found for SFE-171 and elemental iron powder, respectively, while the corresponding relative liver iron concentrations were 104 and 45%. The results provided by the prophylactic-preventive method show that the iron bioavailability of industrial SFE-171 is similar to that of ferrous sulfate; these results are also in agreement to those obtained with the radioactive compounds. We can conclude that the SFE-171 obtained by industrial procedures for massive use in iron food fortification has the same bioavailability as that of the SFE-171 produced and labeled under laboratory conditions.

Animals↗

Enantioselective cytotoxic activity of bromine-substituted analogues of ifosfamide. A microsomal implication.

Nine investigated chlorobromine-, bromine-, and dibromine-ifosfamide analogues including 3 racemates and 6 enantiomers, caused about 10-fold increase in in vitro cytotoxic activity, similar to reference standards ifosfamide and cyclophosphamide in HeLa (KB) human tumor cell culture systems with the addition of rat liver microsomal preparations (ED50 = 0.11 - 0.27 x 10(-3) mole/l) as compared to microsomally non induced samples. The chlorobromine-analogues (ED50 = 0.11 - 0.20 x 10(-3) mole/l) demonstrated the highest cytotoxicity in comparison with bromine-, or dibromine-analogues (SAR). Their levorotatory (-)-(S)- enantiomers (ED50 = 0.11 : 0.21 : 0.24 x 10(-3) mole/l) appear to be more active than their dextrorotatory (+)-(R)-antipodes (ED50 = 0.20 : 0.26 : 0.27 x 10(-3) mole/l, respectively) (ESAR). The stereodifferentiated enhancement of their in vitro cytotoxicity, correlated with the decreasing of in vivo L1210 antileukemic effect following phenobarbital metabolic induction in terms of a whole--strong antitumor activity, indicate that their cytostatic activity depends enantioselectively on the mixed function oxidases-system activity, and presumably on the efficacy of the rate of drug metabolic transformation to their cytostatically active metabolites/intermediates.

Animals↗

The ECHO technique--the more effective way of data evaluation in liquid chromatography-tandem mass spectrometry analysis.

The aim of this study was to evaluate the applicability of ECHO technique in pesticide residue analysis using LC/MS/MS instruments with atmospheric pressure chemical (APCI) and electrospray (ESI) ionization. The technique is based on simultaneous injections of reference standards and samples in one run. First and second injections are made ahead and behind a precolumn, respectively, thus resulting in a short difference of retention times between standard and sample peak. The obtained couple of peaks were applied to the easy detection of pesticides and simultaneous estimation of the residue content in real samples in a single run. If residues were not observed, the second sample peak did not occur and the ECHO peaks were used to demonstrate instrument performance in each run and for each analyte. Another advantage of ECHO technique is its potential to compensate matrix effects. The occurrence and compensation of matrix effects using APCI was tested with four matrix types (water containing, acidic, dry and sugar containing) and 22 pesticides. The same matrix types but 58 pesticides were used tests with electrospray ionization. Most often matrix effects had been observed with lemon. The percentage of pesticides showing significant matrix effects did not differ between APCI and ESI. But these effects caused signal enhancement in APCI measurements and signal suppression, when ESI was used. The ECHO technique was able to compensate many matrix effects in measurements with both types of ion sources.

Calibration↗

Usefulness of turbo spin-echo MR imaging in the evaluation of meniscal tears: comparison with a conventional spin-echo sequence.

OBJECTIVE: Fast (turbo) spin-echo imaging techniques have replaced conventional spin-echo protocols in a large proportion of MR applications, with the principle advantage of decreased imaging time. The choice of echo train length is a key determinant of time savings realized, but the echo train length can also adversely affect image quality if too many echoes are incorporated into an image. Several recent studies have shown conflicting results regarding the usefulness of turbo spin-echo imaging in the evaluation of meniscal tears. We compare a turbo spin-echo sequence that has an echo train length of five with a conventional spin-echo sequence for evaluating meniscal tears. SUBJECTS AND METHODS: Forty knees in 39 consecutive patients referred for MR study of the knee were imaged using both conventional spin-echo and turbo spin-echo sequences. The turbo spin-echo sequence provided both proton density-weighted and T2-weighted images (dual echo technique) with an effective echo-train length of five. Nineteen knees (38 menisci) were studied arthroscopically. The arthroscopic findings were considered the reference standard. Spin-echo and turbo spin-echo images were reviewed retrospectively, and results were compared statistically. RESULTS: Of the 80 menisci evaluated with MR imaging, spin-echo and turbo spin-echo images provided concordant results in 95% of cases, with no statistically significant difference found between the two techniques (p < .05). Seventeen tears were found at arthroscopy in 38 menisci studied. Spin-echo and turbo spin-echo imaging had identical specificities (90%) and similar sensitivities (88% and 82%, respectively). CONCLUSION: This study shows that proton density-weighted sequences with an echo train length of five preserve sufficient high-spatial-frequency information to provide performance similar to that of conventional spin-echo sequences. Our data support the conclusion that fast spin-echo imaging with short echo train length is a reasonable substitute for conventional spin-echo imaging in the evaluation of the knee.

Adult↗

Normalized quantification of human cytomegalovirus DNA by competitive real-time PCR on the LightCycler instrument.

The development of a novel normalized quantitative competitive real-time PCR on the LightCycler instrument (NQC-LC-PCR) and its application to the quantification of cytomegalovirus (CMV) DNA in clinical samples are described. A heterologous competitor DNA was spiked into test samples and served as an internal amplification control. The internal control (IC) DNA in the test samples was coamplified with the CMV DNA and was tested against a calibrator sample that contained equal amounts of IC DNA and CMV reference standard DNA. An algorithm was developed to normalize possible varying amplification efficiencies between the standard and the samples. After normalization, CMV DNA copy numbers were determined in absolute terms. In a routine clinical setting, normalized quantification by NQC-LC-PCR using a single IC concentration led to results ranging from 500 to 50,000 CMV DNA copies/ml. The results obtained with conventional real-time quantification on the LightCycler instrument were almost identical to those obtained with the NQC-LC-PCR-based quantification. This was the case only for samples in which the PCR was not inhibited. With partially inhibited samples, NQC-LC-PCR was still able to correctly quantify CMV DNA copy numbers even when the PCR was inhibited by about 70%. By analyzing 80 undefined clinical samples, we found that NQC-LC-PCR was suitable for the routine assessment of CMV DNA in clinical plasma samples. Since the ICs were already added to the samples during the DNA purification, almost the entire assay was controlled for sample adequacy. Thus, false negative results were precluded. The NQC-LC-PCR approach developed should be adaptable for additional microbiological applications.

Cytomegalovirus↗

Promoting rational prescribing: an international perspective.

Irrational prescribing is a global problem. Rational prescribing cannot be defined without a method of measurement and a reference standard. The former is now available but the latter needs further development. Proven effective interventions to promote rational prescribing in developed countries are treatment protocols based on wide consultation and consensus, properly introduced and with a possibility of feedback; face-to-face education focussed on a particular prescribing problem in selected individuals; structured order forms; and focussed educational campaigns. Essential drugs lists are probably effective when based on consensus and used within a comprehensive educational programme. Printed materials alone are not effective. In most cases the usefulness of such strategies in developing countries has not been proven and should be studied. Medical education in clinical pharmacology and pharmacotherapy should be based on the practical needs of future prescribes, should include the principles of rational therapeutics and problem solving, and should immunize the students against the influences they are likely to encounter in their professional life, such as patient pressure, drug promotion and irrational prescribing by peers. Within the scope of a national formulary, specialist departments in teaching hospitals should define prescribing policies as the basis for prescribing, teaching, examinations and medical audit.

Drug Prescriptions↗

Introduction to dietary reference intakes.

Dietary Reference Intakes (DRIs) are nutrient reference standards used for planning and assessing the diets of apparently healthy Canadians and Americans. The development of DRIs reflects a joint initiative by the United States and Canada to update, expand on, and replace the former Recommended Nutrient Intakes for Canadians and Recommended Dietary Allowances for Americans. DRIs include the Estimated Average Requirement (EAR), Recommended Dietary Allowance (RDA), Adequate Intake (AI), and Tolerable Upper Intake Level (UL). The EAR is the average daily intake level that meets the requirement of 50% of healthy individuals in a life stage and gender group, whereas the RDA is set at a level that will meet the requirements of almost all (97%-98%) individuals in that life stage and gender group. An AI is a recommended intake level that is thought to meet the needs of almost all healthy individuals, and is set when there are insufficient data to establish an EAR (and therefore an RDA). The UL represents a threshold above which adverse effects of excessive intake may increase. In addition to these DRIs, macro nutrients have an Acceptable Macro nutrient Distribution Range (AMDR) and, for energy, an Estimated Energy Requirement (EER) is described.

Humans↗

Calibration-free quantitative analysis of mRNA.

Here we introduce a method for accurate and sensitive quantitative analysis of mRNA, which does not require calibration with mRNA. The method uses a fluorescently labeled hybridization probe as a reference standard. It involves the following: (i) annealing mRNA to the excess of the fluorescently labeled ssDNA hybridization probe, (ii) separation of the mRNA-probe hybrid from the excess of the probe by gel-free capillary electrophoresis mediated by ssDNA-binding protein, (iii) fluorescence detection of the hybrid and the excess probe, and (iv) quantification of mRNA using a simple algebraic formula. The method also overcomes a number of other limitations of conventional methods: the entire procedure currently takes only 2 h and accurately quantifies 10(5) copies of mRNA. With further improvements to the method, the procedure can be potentially shortened to 10 min, and the limit of quantification can be decreased to as few as 100 copies of mRNA. In this work, we prove the principle of the method by quantifying mRNA of green fluorescent protein in the matrix of total cellular RNA. The developed method is quantitative, simple, fast, and highly sensitive. It requires commercially available instrumentation only. The method will be an indispensable tool for molecular and cell biology studies.

Electrophoresis, Capillary↗