Single hair analysis by X-ray fluorescence spectrometry detects small changes in dietary zinc intake: A nested randomized controlled trial.

The aim of this study was to determine whether X-ray fluorescence spectrometry (XRF) could be used to detect changes in hair zinc concentration in response to a modest daily increase in zinc from the consumption of zinc biofortified wheat flour. This study was conducted as part of an effectiveness trial (BiZiFED2) exploring the potential for zinc biofortified wheat to alleviate zinc deficiency in adolescent girls aged 10-16 years in Pakistan (trial registration ID ISRCTN17107812). A randomized controlled design was used. Participants received either control flour or zinc biofortified flour for 6 months. Consumption of biofortified flour resulted in an average daily increase in dietary zinc intake of 1.5 mg per day above that of the control flour. At baseline and at the end of the intervention, individual hair samples (control: n = 59, intervention: n = 64) were analyzed for zinc and sulfur content by XRF. Data were analyzed using linear mixed effects models to contrast between trial groups the changes from baseline to end point and also to compare baseline and end point values within each trial group. Increases from baseline to endpoint in both sulfur and zinc were significantly greater in the intervention group compared to control (sulfur counts. CONTROL: baseline = 119.87 ± 20.33 and endpoint = 121.58 ± 23.58/intervention: baseline = 122.67 ± 24.19 and endpoint = 131.60 ± 21.34); (Zinc counts. CONTROL: baseline = 50.88 ± 14.33 and endpoint = 54.82 ± 14.61/intervention: baseline = 49.61 ± 10.77 and endpoint = 58.79 ± 12.20). For these parameters, there were also significant increases from baseline to endpoint in the intervention group but not in control. Furthermore, for Zn:S count ratio there were no differences in terms of the magnitude of the change from baseline to endpoint in the control group, although significant increases from baseline to endpoint were evident in the intervention group (Zn:S count ratio. CONTROL: baseline = 0.42 ± 0.10 and endpoint = 0.45 ± 0.08/intervention: baseline = 0.41 ± 0.08 and endpoint = 0.45 ± 0.08). A modest increase in dietary zinc over 6 months resulted in a detectable increase in both sulfur and zinc counts in individual hairs measured using XRF. This offers a sensitive, non-invasive method to monitor changes within subjects in response to dietary zinc interventions.

Assessment of X-ray fluorescence capabilities for nail and hair matrices through zinc measurement in keratin reference materials.

BACKGROUND: Novel and emerging biomarkers of zinc status are being developed to help study and address zinc deficiency around the world. Two potential biomarkers, nail and hair, involve the measurement of zinc from easily accessible keratin-based components of the body. Portable X-ray fluorescence (XRF) is a relatively new approach to the assessment of zinc in nail or hair, and has a number of compelling advantages compared with other techniques. The aim of the current study was to test the ability of XRF to measure zinc in keratinized reference materials (RMs) designed to simulate nail and hair. METHODS: Four Keratin Matrix RMs were prepared and characterized for numerous trace elements by the New York State Department of Health's Wadsworth Center. The Keratin Matrix RMs consisted of powdered samples of caprine (goat) horns pooled from several animals. Concentrations of zinc, as assessed by inductively coupled plasma mass spectrometry (ICP-MS), were similar to what would be expected from human nail or hair tissues. Repeat measurements of the RMs were made using a portable XRF system. The XRF zinc results were compared with the ICP-MS zinc concentrations. Three different approaches to quantifying the zinc content by XRF were performed: (1) zinc signal to total signal ratio, (2) zinc signal to sulfur signal ratio, and (3) system output zinc concentration. RESULTS: The portable XRF results from a given RM were found to be consistent across repeat trials under all three approaches to XRF quantitation. Precision, calculated as the relative standard deviation of repeat measurements ranged from an average result of 0.8 % (using the system output zinc concentration method) to 6.1 % (using the zinc signal to sulfur signal ratio method). Measurement of the RMs provided XRF zinc results which scaled well with ICP-MS zinc concentration, particularly when using the XRF zinc to total and system zinc concentration methods. A Bland-Altman plot showed that the XRF system zinc concentration output exceeded the ICP-MS zinc concentration by, on average, 10.2 % ± 1.2 %. CONCLUSION: Overall, both accuracy and precision of measurement were found to be promising for portable XRF, provided appropriate conversions to concentration are introduced. The results of this study indicate that portable XRF is an effective and dependable method of assessing zinc concentration in keratinized tissue RMs. This will have implications for the future use of portable XRF to monitor zinc status in humans through measurements of nail and hair.

Diagnostic and treatment concordance in primary care participants and dermatologists utilizing Extension for Community Health Outcomes (ECHO).

INTRODUCTION: Suboptimal access to dermatologic care is dependent on patient location and insurance type. Although there have been attempts to address access issues, barriers to providing excellent dermatologic care to all patients at the right time still exist. The objective of this study was to investigate the clinical impact of Dermatology Extension for Community Healthcare Outcomes (ECHO) project participation on primary care providers' diagnostic and treatment tendencies and accuracy. METHODS: This was a retrospective cohort study constructed using Dermatology Extension for Community Healthcare Outcomes case and recommendation data from November 2015 to June 2021. The University of Missouri-based Dermatology Extension for Community Healthcare Outcomes specialty hub team offers regularly scheduled live interactive tele-mentoring sessions for primary care providers who practice in rural and underserved areas. 524 patient cases presented by 25 primary care providers were included in the analysis. Of those, 449 cases were included in diagnostic concordance, and 451 in treatment concordance analysis. RESULTS: Less than 40% of all diagnoses were fully concordant with an expert panel. Over 33% of patients were misdiagnosed, and over 26% received partially correct diagnosis. Only 16% of all treatment recommendations were fully concordant with an expert panel. DISCUSSION: Diagnostic and treatment accuracy of participants is low, and Dermatology Extension for Community Healthcare Outcomes platform ensured patients received correct diagnosis and treatment quickly. Although tele-dermatology models are effective, they continue to be underutilized. Dermatologists in practice and training should be encouraged to adopt innovative clinical educational models, like Dermatology ECHO, to expand access to dermatologic expertise for the most marginalized populations.

Investigating methods of normalization for X-ray fluorescence measurements of zinc in nail clippings using the TOPAS Monte Carlo code.

Development of portable X-ray fluorescence devices has made it easier to quickly assess trace elements such as zinc in human tissue. A TOPAS Monte Carlo code was used to investigate the use of a portable X-ray fluorescence system for detecting zinc in nail clippings. The obtained energy spectra from different nail thicknesses were analyzed and three different normalization techniques (coherent, Compton, and entire spectrum) were introduced. The simulation results suggested that coherent normalization can be a particularly robust normalization procedure.

Okra (Abelmoschus esculentus) in a refugee context in East Africa: Kitchen gardening helps with mineral provision.

Kitchen gardening is considered a way to reconnect with agriculture and complement the cereal-based relief food offered to refugees in East Africa. This work aimed at profiling mineral content of okra in four refugee camps and settlements located in Ethiopia and Uganda and its contribution to adequate intake (AIs) or recommended dietary allowances (RDAs) for young children and pregnant and lactating women (PLW). The study also evaluated the applicability of portable X-ray fluorescence (PXRF) as compared with inductively coupled plasma mass spectrometry (ICP-MS) for mineral profiling of okra powder samples. The contents of minerals (mg kg-1) from the ICP-MS readings were in the following ranges: K (14,385-33,294), Ca (2610-14,090), P (3178-13,248), Mg (3896-7986), Cu (3.81-19.3), Fe (75.7-1243), Zn (33-141) and Mn (23.1-261). Regardless of geographic origin, at low-end consumption probability (17 g day-1 for young children and 68 g day-1 for PLW), okra could contribute ˂ 15% (2.7-12.9%) AI for macro-minerals (K and Ca). In addition, the contributions to RDA values for Fe and Zn, elements of known public health interest, ranged from 4.5 to 34.7% for young children. Interestingly, regression lines revealed strong agreement between ICP-MS and PXRF readings for Mn and Zn, with R2 values > 0.91. This information is useful in support of nutrition-sensitive kitchen gardening programs through scaling culturally important crops in refugee settings. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s42452-021-04898-6.

Assessing arsenic in human toenail clippings using portable X-ray fluorescence.

Arsenic is a toxic metalloid which has been associated with a wide range of health effects in humans including skin abnormalities and an elevated risk of skin, bladder, kidney, and lung cancer, diabetes, and cardiovascular disease. The measurement of arsenic concentration in nail clippings is often used in population studies as an indicator of arsenic exposure. Portable X-ray fluorescence (XRF) is an emerging technique for measuring arsenic in nail clippings. In the current study, single toenail clippings from 60 Atlantic Canadian participants were assessed for arsenic using a new portable XRF approach. A mono-energetic portable XRF system using doubly curved crystal optics was used to measure each clipping for a total of 900 s. Energy spectra from each clipping were analyzed for arsenic characteristic X-rays to provide a normalized arsenic signal. The same clippings were then analyzed for arsenic concentration using a "gold standard" method of inductively coupled plasma mass spectrometry (ICP-MS). Nail clipping arsenic concentrations measured by ICP-MS ranged from 0.030 µg/g to 2.57 µg/g, with a median result of 0.14 µg/g. Portable XRF results for arsenic were compared against ICP-MS arsenic concentrations, with a linear equation of best fit determined between the two variables. A correlation coefficient of r = 0.77 was found from the 59 nail clippings returning an ICP-MS arsenic concentration above the limit of quantitation. When the comparison was limited to the 20 clippings having an XRF normalized signal at least twice as large as the associated uncertainty of measurement, the correlation coefficient was r = 0.89. With the selection of an arsenic concentration of 0.1 µg/g as a cut-off value between "exposed" and "non-exposed" individuals, the XRF method provided a test sensitivity of 76% and a specificity of 81%. The corresponding positive predictive value was 88% and the negative predictive value was 65%. The portable XRF technique used in this study shows promise as a means of assessing arsenic concentration in toenail clippings.

Probing Trace Elements in Human Tissues with Synchrotron Radiation.

For the past several decades, synchrotron radiation has been extensively used to measure the spatial distribution and chemical affinity of elements found in trace concentrations (

Portable X-ray fluorescence of zinc applied to human toenail clippings.

Zinc is an essential trace element in humans. Zinc deficiency can result in a range of serious medical conditions which include effects on growth and development, the immune system, the central nervous system, and the gastrointestinal system. Diagnosis of zinc deficiency is often precluded by the lack of a noninvasive and reliable biomarker. Zinc concentration in nail is considered an emerging biomarker of zinc status in humans. Whether zinc in nail accurately reflects zinc status is beyond the scope of the current study, but is an important research question. The development of a portable method to quickly assess zinc concentration from a single nail clipping could be a useful advance. In this study, single toenail clippings from 60 individuals living in Atlantic Canada were measured for zinc using a portable X-ray fluorescence (XRF) technique. These samples were obtained from the Atlantic PATH cohort, part of the largest chronic disease study ever performed in Canada. Each toenail clipping was measured using three 300 s trials with a mono-energetic portable XRF system. Results were then assessed using two different approaches to the XRF analysis: (1) factory-calibrated zinc concentrations were output from each trial, and (2) energy spectra were analyzed for the characteristic X-rays resulting from zinc. Following the measurement of zinc using the non-destructive portable XRF method, the same clippings were measured for zinc concentration using the "gold standard" technique of inductively coupled plasma-mass spectrometry (ICP-MS). A linear equation of best fit was determined for the relationship between average XRF output zinc concentration and ICP-MS zinc concentration, with a correlation coefficient r = 0.60. Similarly, a linear equation of best fit was found for the relationship between a normalized XRF energy spectrum zinc signal and ICP-MS zinc concentration, with a correlation coefficient r = 0.68. Individual ICP-MS zinc concentrations ranged from 32 µg/g to 140 µg/g, with a population average of 85 µg/g. The results of this study indicate that portable XRF is a sensitive method for the measurement of zinc in a single nail clipping, and provides a reasonable estimation of zinc concentration. Further method development is required before portable XRF be considered a routine alternative to ICP-MS for the assessment of zinc in nail clippings.

Contents of Metal(loid)s in a Traditional Ethiopian Flat Bread (Injera), Dietary Intake, and Health Risk Assessment in Addis Ababa, Ethiopia.

The traditional Ethiopian flat bread, injera, is a regular component of daily diets in Ethiopia and Eritrea. This bread is also popular among urban refugees particularly Eritreans in Addis Ababa. The levels of metal(loid)s in 40 composite (120 sub-samples) injera samples, representing 4 types of market establishments in Addis Ababa, were determined using inductively coupled plasma-mass spectrometry (ICP-MS) and portable X-ray fluorescence (PXRF). For ICP-MS analysis, the accuracy of the method was evaluated by the analysis of a certified reference material and recovery experiments. It was found that the correlations between the mean levels of Al and Fe and between Al and Mn in injera were highly significant (p < 0.001). It was also found that 1.5 fresh injeras would cover 48-75% of recommended dietary allowance (RDA) for Mg, 17-21% of RDA for K, 19-23% of RDA for Ca, and 60-72% of RDA for P for an adult group aged between 19 and 50. Daily intakes of Al, Fe, and Mn were found to be above the provisional tolerable daily intake (PTDI)/maximum tolerable daily intake (MTDI) values. The mean target hazard quotient (THQ) values for Fe and Mn were greater than 1. The total THQ values varied from 6.52 to 8.53 among market establishments. Estimating carcinogenic risk due to exposure to As, Cr, and Pb indicated that perennial injera consumers might remain at cancer risk. This would further escalate if other staple food items and spices are considered. Hence, there is a need for home-based strategies to reduce extrinsic soil-Al-Fe-Mn in injera/tef batter.

Telehealth Ethics: The Role of Care Partners.

During telehealth encounters, care partners may assist with physical maneuvers or examinations. These care partners may be friends or family members of the patient. There are unique ethical considerations in the use of care partners during telehealth examinations, yet there is limited guidance for such interactions. Evidence-based guidelines should be created to ensure the safety and quality of telehealth encounters when care partners are used.

The effects of short-term musical training on the neural processing of speech-in-noise in older adults.

Experienced musicians outperform non-musicians in understanding speech-in-noise (SPIN). The benefits of lifelong musicianship endure into older age, where musicians experience smaller declines in their ability to understand speech in noisy environments. However, it is presently unknown whether commencing musical training in old age can also counteract age-related decline in speech perception, and whether such training induces changes in neural processing of speech. Here, we recruited older adult non-musicians and assigned them to receive a short course of piano or videogame training, or no training. Participants completed two sessions of functional Magnetic Resonance Imaging where they performed a SPIN task prior to and following training. While we found no direct benefit of musical training upon SPIN perception, an exploratory Region of Interest analysis revealed increased cortical responses to speech in left Middle Frontal and Supramarginal Gyri which correlated with changes in SPIN task performance in the group which received music training. These results suggest that short-term musical training in older adults may enhance neural encoding of speech, with the potential to reduce age-related decline in speech perception.

The impact of aging on neurophysiological entrainment to a metronome.

In music, entrainment to the beat allows listeners to make predictions about upcoming events. Previous work has shown that neural oscillations will entrain to the beat of the music or rhythmic stimuli. Despite the fact that aging is known to impact both auditory and cognitive processing, little is known about how aging affects neural entrainment to rhythmic stimuli. In this study, younger and older participants listened to isochronous sequences at a slower and faster rate while EEG data was recorded. Steady-state evoked potentials had amplitude peaks at the stimulus rate and its harmonics. Steady-state evoked potentials at the stimulus rate and the first harmonic was attenuated in older adults compared to younger adults. Additionally, no amplitude difference was found for the second and third harmonics in older adults, while there was a decrease in amplitude in younger adults. This age-related decline in the entrainment specificity of the brain responses to the stimulus rate, suggests that aging may decrease the ability to entrain to stimuli in the environment, and further suggests that older adults may be less able to inhibit neural entrainment that is not directly related to the incoming stimulus.

Assessment of alternative methods for analyzing X-ray fluorescence spectra.

When analyzing characteristic peaks in X-ray fluorescence (XRF) spectra, the peak area is the value most often used to quantify peak size. However, some studies have reported the amplitude of the peak instead of the area. When the width of the peak is allowed to vary from trial to trial in order to provide the best possible fit to the data, these two alternative methods can yield slightly different results. In the current study, these two approaches to peak analysis are compared for data obtained from bone reference materials having certified lead concentrations of 1.09 ±â€¯0.03 µg/g, 16.1 ±â€¯0.3 µg/g, 13.2 ±â€¯0.3 µg/g, and 31.5 ±â€¯0.7 µg/g. Measurements were made with an Olympus Innov-X Delta Premium portable XRF system. Using both the area and amplitude methods, lines of best fit were constructed for the lead Lα and lead Lß signals as a function of lead concentration. Additionally, coefficients of variation were calculated for each reference material and condition of analysis. To assess possible variations over time, the procedure was performed at two points separated by about one year. The amplitude and area methods were found to produce results which were consistent and proportional. Using either method, lead XRF signal plotted as a function of known lead concentration produced adjusted r2 values of ∼0.99. The amplitude method provided slightly higher adjusted r2 values overall. Coefficients of variation were generally very similar between the two methods, although more pronounced differences emerged from measurements of the lowest concentration reference material.

Assessing zinc from a nail clipping using mono-energetic portable X-ray fluorescence.

A mono-energetic X-ray beam from a portable X-ray fluorescence device was used to excite characteristic X-rays from zinc in a series of nail clipping phantoms. Twenty nail clipping phantoms having equal zinc concentrations of ~40 µg/g, but with different physical characteristics, were measured individually for 300 s using a small diameter (~1 mm) X-ray beam. Energy spectra obtained from the measurements were analyzed using PyMca software. Zinc signal size varied widely between the different clippings, with a relative standard deviation of 41% observed in the combined signal from zinc Kα and Kß characteristic X-rays. Three different normalization approaches were introduced to account for variation in the amounts of sample interrogated by the X-ray beam. All three approaches produced similar results, and successfully reduced the relative standard deviation to between 12% and 13%. A clear trend was still observed, however, between the normalized zinc signal and the thickness of clipping measured. To account for this effect, normalized signals were adjusted to calculate "thickness-corrected" values. The relative standard deviation of these thickness-corrected values was 6.2%. Reproducibility of measurement from individual clippings was excellent, with relative standard deviations on the order of 1%, with or without normalization. Overall, this new method of measuring zinc in nail shows promise for the assessment of zinc status in humans using a portable device. The method is sensitive, rapid, and requires only a single nail clipping.

Feasibility of measuring zinc in human nails using portable x-ray fluorescence.

A variety of adverse health effects have been identified as resulting from zinc deficiency. Zinc supplementation may therefore be indicated for certain individuals or populations. A rapid and straightforward means of assessing zinc status in humans would be of considerable medical benefit. In this study, the feasibility of measuring zinc levels in human fingernails or toenails using a portable x-ray fluorescence technique was assessed. Whole nail models (or phantoms) were constructed from resin, and dosed with various concentrations of zinc. These different concentration "nails" were cut into small slices of 4.4 ±â€¯0.2 mm width. The combination of these various slices into different arrangements allowed the modeling of different time-dependent zinc exposure scenarios. A portable x-ray fluorescence device was tested using an "open beam" configuration having a beam diameter of ∼9 mm, and using a "weld mask" configuration with the beam width reduced to 2.9 mm. Minimum detection limits were determined to be 0.15 ±â€¯0.01 ppm for the open beam, and 1.13 ±â€¯0.08 ppm when using the weld mask. By scanning across the length of the model nails, it was demonstrated that differences in zinc levels deposited over time could be detected, and that the weld mask configuration was better suited to resolving spatial changes. The x-ray fluorescence approach was found to be highly sensitive for detecting zinc in nail, and capable of differentiating patterns of zinc uptake over time.

Dermatology ECHO - an innovative solution to address limited access to dermatology expertise.

INTRODUCTION: The present maldistribution of dermatologists in the USA may make it difficult for patients to access timely and quality care. Access to specialty care may be even more challenging for rural and underserved patients due to geographical limitations and other socioeconomic hardships. With over one-third of primary care patients seeking care for at least one skin problem, it is important to follow the American Academy of Dermatology Special Positioning Workgroup\'s core areas of impact regarding treatment of conditions that affect millions of patients by using a team-based approach and telemedicine technologies. The objective of this study was to demonstrate the Dermatology Extension for Community Healthcare Outcomes (ECHO) project approach in multidisciplinary telementoring and education of primary care providers (PCPs) in treatment and management of complex, costly, and common skin diseases via live interactive video technologies. METHODS: Dermatology ECHO is a distance education telementoring platform that uses a multidisciplinary case-based approach in a non-judgemental environment. A team of specialists, including general dermatologists, pediatric dermatologists, a dermatopathologist, a clinical psychologist, and a nurse practitioner, meets via video with a number of PCPs from isolated, rural, or underserved areas to discuss de-identified patient cases and present dermatology-specific continuing medical education (CME)-approved didactic presentations. The University of Missouri, Department of Dermatology, leads the first Dermatology ECHO in the USA. They partner with various primary care clinics across Missouri to provide mentoring in the treatment of skin conditions. Missouri Telehealth Network provides operational support through the Show-Me ECHO project. The network also assists with provider recruitment activities. RESULTS: The authors describe a patient case to illustrate the effect of ECHO on provider distance learning and patient outcomes. A 69-year-old woman from rural Missouri was spurred by a rooster. She presented to her primary care clinic six times over a 2-month period. She was prescribed several different medications and underwent tests and one procedure, including vaccination. After the patient\'s case was presented during the Dermatology ECHO session, she was correctly diagnosed with a Mycobacterium skin infection, and new recommendations were made. The patient improved significantly within 2 weeks. CONCLUSIONS: As specialty medical evidence-based recommendations continue to increase, providers practicing in isolated rural and underserved areas may find it challenging to keep up with the new knowledge. Dermatology ECHO creates a community of practice that allows participating providers to discuss complex cases, receive specific guidance and mentoring, and participate in CME presentations. The case presented here supports the authors\' observations that Dermatology ECHO is an appropriate platform for learning evidence-based medical knowledge via videoconferencing technology.