Remote real-time supervision via tele-ultrasound in focused cardiac ultrasound: A single-blinded cluster randomized controlled trial.

BACKGROUND: Supervision via tele-ultrasound presents a remedy for lacking on-site supervision in focused cardiac ultrasound, but knowledge of its impact is largely absent. We aimed to investigate tele-supervised physicians' cine-loop quality compared to that of non-supervised physicians and compared to that of experts. METHODS: We conducted a single-blinded cluster randomized controlled trial in an emergency department in western Denmark. Physicians with basic ultrasound competence scanned admitted patients twice. The first scan was non-supervised, and the second was non-supervised (control) or tele-supervised (intervention). Finally, experts in focused cardiac ultrasound scanned the same patient. Two blinded observers graded cine-loops recorded from all scans on a 1-5 scale. The outcome was the mean summarized scan gradings compared with a linear mixed-effects model. RESULTS: In each group, 10 physicians scanned 44 patients. From the mean summarized gradings, on a scale from 4 to 20, the second non-supervised scan grading was 10.9 (95% CI 10.2-11.7), whereas the tele-supervised grading was 12.6 (95% CI: 11.8-13.3). From the first to the second scan, tele-supervised physicians moved 9% (1.09; 95% CI: 1.00-1.19; P = 0.041) closer to the experts' quality than the non-supervised physicians. CONCLUSION: Tele-supervised physicians performed scans of better quality than non-supervised physicians. The present study supports the use of tele-supervision for physicians with basic focused ultrasound competence in a setting where on-site supervision is unavailable.

Assessing clinical probability of pulmonary embolism: prospective validation of the simplified Geneva score.

Essentials The simplified Geneva score allows easier pretest probability assessment of pulmonary embolism (PE). We prospectively validated this score in the ADJUST-PE management outcome study. The study shows that it is safe to manage patients with suspected PE according to this score. The simplified Geneva score is now ready for use in routine clinical practice. SUMMARY: Background Pretest probability assessment by a clinical prediction rule (CPR) is an important step in the management of patients with suspected pulmonary embolism (PE). A limitation to the use of CPRs is that their constitutive variables and corresponding number of points are difficult to memorize. A simplified version of the Geneva score (i.e. attributing one point to each variable) has been proposed but never been prospectively validated. Aims Prospective validation of the simplified Geneva score (SGS) and comparison with the previous version of the Geneva score (GS). Methods In the ADJUST-PE study, which had the primary aim of validating the age-adjusted D-dimer cut-off, the SGS was prospectively used to determine the pretest probability in a subsample of 1621 study patients. Results Overall, PE was confirmed in 294 (18.1%) patients. Using the SGS, 608 (37.5%), 980 (60.5%) and 33 (2%) were classified as having a low, intermediate and high clinical probability. Corresponding prevalences of PE were 9.7%, 22.4% and 45.5%; 490 (30.1%) patients with low or intermediate probability had a D-dimer level below 500 µg L-1 and 653 (41.1%) had a negative D-dimer test according to the age-adjusted cut-off. Using the GS, the figures were 491(30.9%) and 650 (40.9%). None of the patients considered as not having PE based on a low or intermediate SGS and negative D-dimer had a recurrent thromboembolic event during the 3-month follow-up. Conclusions The use of SGS has similar efficiency and safety to the GS in excluding PE in association with the D-dimer test.

Staphylococcal toxic shock syndrome.

A 28 year old male presented with fever, tachycardia, generalized lymphadenopathy and diffuse rash over the body. He failed to respond to intravenous antibiotics and developed cardiogenic shock, multiple organ failure and died within six hours after hospitalization. Staphylococcus aureus colonies were revealed on blood culture.

Rosai Dorfman syndrome with sinonasal mucosa and intraocular involvement.

A 15 year-old-male presented with concurrent sinonasal polyposis and anterior uveitis with cervical lymph node enlargement. Cervical lymph node biopsy confirmed Rosai-Dorfman disease. Though patient's eye symptoms did not respond well to topical corticosteroid treatment but he showed a remarkable regression in the size of nasal polyps and cervical lymph nodes after systemic corticosteroids. Intraocular involvement in such a case is rare.

Interaction of MSG taste with nutrition: perspectives in consummatory behavior and digestion.

Studies in the taste system of mammals indicate that monosodium glutamate (MSG) produces a unique taste sensation termed umami. As a derivative of glutamic acid, MSG is a naturally occurring nutrient in many foods; its commercial use to improve food palatability for humans is well documented. Behavioral studies with experimental animals have revealed that preference for MSG in solutions and selection of MSG-flavored diets can be explained by sensory means with no appreciable effects on preference by postingestive consequences. However, preference for umami-flavored fluids is reduced by feeding rats low-protein diets or low quality protein. MSG-flavored diets, initially unpreferred, were subsequently highly selected. However, the adulteration of diets by MSG either did not or only slightly increased food intake. In light of the significant contribution of MSG to diet taste, apparently as a signal coupled to dietary proteins, physiological studies have been initiated to reveal its role as a stimulator of the cephalic phase of pancreatic exocrine secretion. Modified sham-feeding experiments with dogs have shown that oral stimulation by MSG produced significant stimulation of both pancreatic flow and protein output in conscious dogs.

Nonreceptor-mediated responses of adenylate cyclase in membranes from liver, muscle, and white and brown adipose tissue of obese (fa/fa) and lean (Fa/) Zucker rats.

Adenylate cyclase activity was determined in membranes of liver, muscle, white adipose tissue, and brown adipose tissue (BAT) of lean (Fa/) and obese (fa/fa) Zucker rats. Responses were monitored following beta-adrenergic receptor stimulation and addition of GTP, GTP gamma S, or forskolin. beta-Adrenergic responses in liver, white adipose tissue, and BAT were lower in obese than in lean animals. No such difference was observed in muscle membranes. Production of cAMP after addition of guanine nucleotides was lower in liver and white adipose tissue membranes from obese rats compared with their lean littermates. Synthesis of cAMP in muscle membranes of obese animals after addition of GTP was either not different, or slightly higher, than that observed in muscle membranes from lean animals. Furthermore, production of cAMP after forskolin addition to muscle membranes of obese rats was significantly higher than that observed from lean rats under the same conditions. Interestingly, BAT membranes of obese rats were significantly more sensitive to guanine nucleotide activation than those of lean animals. The results confirm recent findings indicating inferior function of G proteins in liver plasma membranes of obese Zucker rats, and extend this observation to adipose tissue. The present results further suggest that the "nonreceptor" components (e.g., G proteins) responsible for the activation of adenylate cyclase in BAT membranes of obese rats are more responsive to stimulation than those of lean animals. Such sensitivity may be related to and perhaps compensate for the reduced thermogenic activity in the obese Zucker rat during the development of obesity.

Dietary evaluation of patients with smell and/or taste disorders.

The impact of smell and taste disorders on dietary habits and nutritional status has received limited research attention. This paper reports findings obtained from questionnaires and diet records completed by 40 healthy subjects and 118 patients with chemosensory dysfunction. Chemosensory disorders were frequently associated with decreases in food acceptability. Although dietary responses to these dysfunctions varied greatly, patients with distorted or phantom smell and/or taste sensations tended to report weight loss whereas those with simple sensory loss were more likely to report weight gain. Indices derived from diet records did not indicate that either group of patients was at substantial nutritional risk, but food frequency responses and estimates of body mass index were consistent with patient reports of changes in dietary patterns and weight. In addition, marked weight change and aberrant dietary practices were noted in individual patients. Thus, there were indications that chemosensory dysfunction may be associated with nutritionally important dietary alterations.

Cephalic reflexes: their role in digestion and possible roles in absorption and metabolism.

Stimulation of the oral cavity immediately elicits salivation, gastric acid secretion and pancreatic exocrine and endocrine secretions that serve to prepare the alimentary canal for digestion, transport and utilization of ingested nutrients. Oropharyngeal-stimulated responses are reliably initiated by the taste and smell of food. These gastrointestinal reflexes, often referred to as anticipatory or cephalic phase responses, are mediated by the autonomic nervous system and are believed to be independent of the postabsorptive effects of ingested nutrients. A common pathway used by cephalic phase responses to trigger gastrointestinal secretions is the vagus. Several studies have also demonstrated that cephalic stimulation activates both the sympathetic and parasympathetic nervous systems and thus, many cephalic-metabolic reflexes may arise indirectly from more general physiological changes that accompany oropharyngeal stimulation. The present studies suggest that oral stimulation results in alterations in intestinal function. Specifically, oropharyngeal stimulation of conscious, unrestrained rats with sucrose increases the uptake of radioactive glucose from the small intestine into the hepatic portal blood.

The preference-aversion behavior of rats for nutritionally-controlled diets containing oil or fat.

The preference-aversion behavior of Sprague-Dawley rats for semi-purified diets containing various levels of either corn oil, animal fat (lard) or hydrogenated vegetable oil (Crisco) was determined in brief and long-term, two-choice preference tests. After the first day of exposure, rats selected more calories from the control-unadulterated diet than from experimental diets containing either oil or fat. Only in the first hour of exposure (with diets containing either 5% Crisco, 15 or 25% lard) or in the first day (with diets containing 5% Crisco, 5 or 15% lard) was a preference for experimental diets observed. There were significant effects of oil and fat concentration and of exposure time upon preference for experimental diets, such that preference for the experimental diets was reduced as levels of oil or fat and as the time of experiment increased. Changes in diet selection had no major effect on total caloric intake measured as the sum of both experimental and control dietary choices, although total intake on a daily basis tended to decrease during the middle portion (2-4 days) of the study, then recover by the end of the study. The results suggest that postingestional factors related to the dietary oil and fat (rather than the sensory properties of the diets) directed the long-term preference behavior of rats for semi-purified diets adulterated with various levels of either corn oil, animal fat (lard) or hydrogenated vegetable oil (Crisco).

Preference of rats for food flavors and texture in nutritionally controlled semi-purified diets.

Preference for nutritionally controlled, semi-purified diets modified by the addition of potent food flavors was determined for Sprague Dawley rats using two-choice diet preference tests. Intake of each food cup was monitored after 1 hr and for each 24 hr period thereafter up to 5 days. Preference was also determined for the flavored diets prepared in three forms differing in texture: powdered, and pellets of two sizes. Rats easily detected minor amounts of the food flavors, and the tests provided a catalog of 12 preferred flavors. Exposure time to the diets altered preference for a minority of flavors; diets initially avoided in the first hour test were likely to become less aversive upon continued exposure. Whether or not a specific flavored diet was preferred, total food intake was not affected during the 5 day period monitored. Rats displayed strong preference for diets of a pelleted texture compared to the same diets in a powdered form.

Gustatory sequelae of alimentary disorders.

Disorders in different regions of the alimentary tract have been associated with alterations in gustatory function. Current understanding of mechanisms underlying the taste disturbances and their impact on the physical and emotional well-being of patients is incomplete. Indeed, in most instances, present knowledge remains at a descriptive level. Accumulating evidence that profound interactions occur between the sense of taste and alimentary function poses a challenge to apply this knowledge in the clinic setting.

Energy intake, weight gain and fat deposition in rats fed flavored, nutritionally controlled diets in a multichoice ("cafeteria") design.

The effect of flavor variety on diet selection, energy intake, weight gain and fat deposition was studied in male rats fed flavored, nutritionally controlled, purified diets in a multichoice "cafeteria" (CAF) arrangement. Serum insulin, L-3,3',5-triiodothyronine (T3) and thyroxine (T4) levels were also determined. Rats fed nutritionally balanced diets containing a variety of preferred flavors and textural forms ad libitum in a CAF design did not consume more energy nor did they gain more weight than rats fed a single choice of nutritionally balanced diet with no modifications in flavor or texture. Feeding high fat, high sucrose diets containing a variety of flavors in a CAF arrangement resulted in higher energy intake, body weight gain, lipid content in fat pads and serum T3 levels than did feeding the nutritionally balanced diet. However, the high fat diet with no added flavors also resulted in an energy intake, body weight gain and lipid content of fat pads at a level equal or close to that produced by the CAF feeding of the flavored, high fat, high sucrose diet. It is therefore concluded that the effect of a variety of food flavors on hyperphagia and fat deposition is of minor importance in purified diets compared to the stimulating effect of the fat in the diet.

Effects of sodium saccharin on the activity of trypsin, chymotrypsin, and amylase and upon bacteria in small intestinal contents of rats.

Rats fed a diet containing 2.5% sodium saccharin (NaSacc) displayed a rapid (24-36 hr) increase in tryptic and chymotryptic activity in the lower half of the small intestine and the cecum compared with control animals. Cecal pH of rats fed NaSacc was lower than controls. The effect of NaSacc on enzymatic activity of intestinal contents and on indigenous bacterial microflora was studied further in vitro. Intestinal contents incubated anaerobically with or without NaSacc revealed that the presence of NaSacc led to higher tryptic and chymotryptic activity and higher final pH. Changes in pH do not appear, however, to be important for the increased proteolytic activity induced by NaSacc since autodigestion of trypsin and chymotrypsin in filter-sterilized samples was only slightly affected by pH during in vitro incubation. Amylolytic activity, on the other hand, was stabilized by higher pH values. Saccharin stabilized chymotryptic and led to almost complete loss of amylolytic activity during incubation of filter-sterilized samples maintained at adjusted pH values. The amount of reducing sugars remaining in the NaSacc-containing contents from either cecum (in vivo) or from in vitro incubation of unsterilized small intestinal samples was greater than controls not containing NaSacc. The growth of six bacterial strains isolated from small intestinal contents and incubated in laboratory media was inhibited by NaSacc. Extracellular proteolytic activity from bacterial sources was undetectable after incubation of intestinal bacteria in laboratory media. The present results suggest that the effect of NaSacc upon digestive enzyme composition in the small intestine of rats is not mediated through a direct physiological effect of NaSacc on pancreatic exocrine secretion. It is hypothesized that an inhibition of enzymatic activity by NaSacc in the small intestine and the bacteriostatic effect of NaSacc on bacteria may be responsible for the increased proteolytic activity observed in vivo in the cecum following the feeding of a NaSacc-containing diet to rats.

Effect of unpalatable diets, food restriction and saccharin-adulterated diet on tryptic, chymotryptic, and amylolytic activity in pancreas, intestine and feces of rats.

Growing rats were fed either 10 to 17% protein (casein) diets whose taste was changed daily by addition of aversive stimuli. Under these circumstances food intake and body weight gain were reduced compared with controls fed unadulterated diets. More amylolytic activity per gram pancreas was found in rats fed a 10% protein, aversive diet and in their pair-fed controls fed restricted amounts of an unadulterated diet compared with ad libitum controls. More amylolytic activity per gram chyme of small intestine was also found in rats fed less than ad libitum amounts of a 10% protein diet. The chymotrypsin activity in the pancreas of rats fed a 17% protein, aversive diet was greater than in that of control animals or that of the pair-fed animals. The 2- to 10-fold higher proteolytic activity found in the small intestine and especially in the large intestine and feces of rats fed the aversive diet was specifically related to the adulteration of the diet with sodium saccharin. Feeding a diet containing sodium saccharin led to lower cecal pH. Under conditions of the present experiments, changes in digestive enzyme activity are not directly related to the aversive taste of the diet.

Distribution of taste buds on fungiform and circumvallate papillae of bovine tongue.

The distribution of taste buds on the fungiform and circumvallate papillae of the cow tongue has been determined. The two tongues studied were from Holstein-Friesian cows four to six years of age; they contained 14,765 and 21,691 taste buds, respectively. The tip of the tongue is well supplied with fungiform papillae, and the posterior portion contains the circumvallate papillae. The midportion of the tongue contains relatively few taste papillae. The fungiform papillae contained 1,580 and 1,838 taste buds on the two tongues, respectively, and the circumvallate papillae were estimated to contain 13,185 and 19,853 taste buds. The highest concentration of taste buds therefore occurs in the circumvallate papillae; these relatively few papillae contain approximately 90% of the taste buds. On a circumvallate papilla, taste buds are found only on the papillary sidewall, with none either on the apical surface of the papilla or on the outer wall of the moat.