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Lower respiratory tract infections are frequently treated with antibiotics, despite a viral cause in many cases. It remains unknown whether low procalcitonin concentrations can identify patients with lower respiratory tract infection who are unlikely to benefit from antibiotics. We aimed to compare the efficacy and safety of azithromycin versus placebo to treat lower respiratory tract infections in patients with low procalcitonin.We conducted a randomised, placebo-controlled, double-blind, non-inferiority trial at five health centres in the USA. Adults aged 18 years or older with clinically suspected non-pneumonia lower respiratory tract infection and symptom duration from 24 h to 28 days were eligible for enrolment. Participants with a procalcitonin concentration of 0·25 ng/mL or less were randomly assigned (1:1), in blocks of four with stratification by site, to receive over-encapsulated oral azithromycin 250 mg or matching placebo (two capsules on day 1 followed by one capsule daily for 4 days). Participants, non-study clinical providers, investigators, and study coordinators were masked to treatment allocation. The primary outcome was efficacy of azithromycin versus placebo in terms of clinical improvement at day 5 in the intention-to-treat population. The non-inferiority margin was -12·5%. Solicited adverse events (abdominal pain, vomiting, diarrhoea, allergic reaction, or yeast infections) were recorded as a secondary outcome. This trial is registered with ClinicalTrials.gov, NCT03341273.Between Dec 8, 2017, and March 9, 2020, 691 patients were assessed for eligibility and 499 were enrolled and randomly assigned to receive azithromycin (n=249) or placebo (n=250). Clinical improvement at day 5 was observed in 148 (63%, 95% CI 54 to 71) of 238 participants with full data in the placebo group and 155 (69%, 61 to 77) of 227 participants with full data in the azithromycin group in the intention-to-treat analysis (between-group difference -6%, 95% CI -15 to 2). The 95% CI for the difference did not meet the non-inferiority margin. Solicited adverse events and the severity of solicited adverse events were not significantly different between groups at day 5, except for increased abdominal pain associated with azithromycin (47 [23%, 95% CI 18 to 29] of 204 participants) compared with placebo (35 [16%, 12 to 21] of 221; between-group difference -7% [95% CI -15 to 0]; p=0·066).Placebo was not non-inferior to azithromycin in terms of clinical improvement at day 5 in adults with lower respiratory tract infection and a low procalcitonin concentration. After accounting for both the rates of clinical improvement and solicited adverse events at day 5, it is unclear whether antibiotics are indicated for patients with lower respiratory tract infection and a low procalcitonin concentration.National Institute of Allergy and Infectious Diseases, bioMérieux.

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.

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.

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.

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.

Finding the right US director position requires the applicant to reflect on career goals, ultrasound-related goals, and personal goals. Unique elements such as timing, salary, location, work responsibilities, departmental resources, and individual priorities impact the job search. Negotiation and contracts are discussed in general and in regard to ultrasound responsibilities.

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.

Simulation-based mastery learning (SBML) improves procedural skills among medical trainees. We employed an SBML method that includes an asynchronous knowledge acquisition portion and a hands-on skill acquisition portion with simulation to assess senior medical student performance and retention of the following 6 core clinical skills: (a) ultrasound-guided peripheral intravenous placement, (b) basic skin laceration repair, (c) chest compressions, (d) bag-valve mask ventilation, (e) defibrillator management, and (f) code leadership.Seven emergency medicine (EM) faculty members developed curricula, created checklists, and set minimum passing standards (MPSs) to test mastery of the 6 skills. One hundred thirty-five students on an EM clerkship were pretested on all 6 skills, viewed online videos asynchronously followed by a multiple choice computer-based skill-related quiz, received one-on-one hands-on skill training using deliberate practice with feedback, and were posttested until MPS was met. We compared pretest and posttest performance. We also retested, unannounced, a convenience sample (36%) of students from 1 to 9 months postintervention to assess skill retention.All students passed each quiz. The percentage of students who reached each MPS increased significantly (P0.001) from pretest to posttest for all 6 clinical skills. Ninety-eight percent of the students scored at or above the MPS when retested 1 to 9 months later. There was no significant decrease in mean score for any of the 6 skills between posttest and retention testing.Simulation-based mastery learning using a substantial asynchronous component is an effective way for senior medical students to learn and retain EM clinical skills. This method can be adapted to other skill training necessary for residency readiness.

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.

Placement of peripheral intravenous (IV) catheters is a fundamental skill that all health care professionals should possess. Unfortunately, it can be difficult to obtain IV access in some patients, including obese patients, children, and patients who have undergone placement of many IVs or who have a history of difficult IV access. Ultrasound guidance enables visualization of veins that are not apparent on physical examination, resulting in fewer needlesticks, more rapid cannulation, and less discomfort in patients with difficult IV access. 1-3 Ultrasound-guided IV placement is indicated when it is difficult or impossible to use traditional techniques. There is no contraindication to ultrasound-guided IV placement, but it is unnecessary when traditional techniques are sufficient. Health care providers who are proficient in standard placement techniques will find it relatively easy to learn ultrasound-guided techniques. There are two common approaches to the position of the transducer during ultrasound-guided placement of IV catheters: transverse and longitudinal. The transverse approach is easier to learn, but the longitudinal approach is preferred by many experienced providers because it allows better visualization of the needle. 4,5 It is best to learn both techniques. Potential cannulation sites are the hand, the antecubital veins of the forearm, and the basilic, cephalic, and brachial veins of the upper arm. Preparation To get started, wash your hands, adhere to universal precautions, clean the ultrasound transducer with a germicidal solution, place a tourniquet, and apply sterile gel or surgical lubricant to the transducer. Adjust the gain and depth settings of the ultrasound system so that vessels appear black and are in the center of the ultrasound image. Find an appropriate vein by scanning the arm in the transverse orientation, which provides a cross-sectional view of the anatomy and allows simultaneous visualization of veins, arteries, and other structures (Fig. 1). Vessels appear as circular structures, and veins are easily distinguished from arteries because veins collapse with compression. When choosing a vein, remember that a vein with a relatively large diameter is more likely to result in successful catheterization. The depth of a vein is not as important as its diameter, but longer IV catheters are needed for veins that lie more than 1 cm from the surface of the skin. Standard IV catheters are 3.2 cm long (Fig. 2). Common sizes range from 24-gauge for newborns to 14-gauge for adult patients with trauma. Angiocatheters that are 6.4 cm long are adequate for cannulating vessels that are a maximum of about 2 cm from the surface of the skin. Specialized catheters may be best for cannulation of deeper veins. 24-gauge