Development of a novel observed structured clinical exam to assess clinical ultrasound proficiency in undergraduate medical education.

OBJECTIVES: A pilot study was performed to develop and test an observed structured clinical exam (OSCE) for clinical ultrasound in second-year medical students. The goal was to assess a longitudinal clinical ultrasound curriculum for medical students and to help determine readiness to perform ultrasound during clinical clerkships. METHODS: The OSCE contained 40 tasks over 30 min in a one-to-one examiner to examinee environment using standardized patients covering cardiac, pulmonary, and inferior vena cava (IVC) ultrasound exams along with 6 critical diagnoses. Examinees were assessed using a binary checklist approach. A two-way ANOVA analysis was performed to determine if there were differences between the day and session the OSCE was administered. Results are presented as mean ± standard deviation. RESULTS: One hundred fifty-two students were tested with an overall mean score of 64.9 ± 17.6%. Scores between the cardiac, IVC, and lung sections varied-67.8% ± 18.8%, 62.4% ± 26.2%, and 57.1% ± 20.6%, respectively. One hundred twenty-six (82.9%) answered at least one critical diagnosis incorrectly. Students in the late session performed better than the early session (1: 60% vs 2: 69%, p = .001). CONCLUSIONS: Students performed better in later sessions. Additionally, the number of questions left blank at the end of the exam suggests that the length of the OSCE should be evaluated. Incorporating critical diagnoses was challenging for examinees. The proposed OSCE is a valuable assessment tool that could be adapted to assess student's readiness to use clinical ultrasound prior to clerkships.

Diagnosis of Renal Artery Aneurysm by Point-of-Care Ultrasound in the Emergency Department: A Case Report and Brief Review of the Literature.

BACKGROUND: Renal artery aneurysm (RAA) is defined as a focal dilatation of ≥50% of the adjacent, disease-free artery. Although typically asymptomatic, RAA can lead to hypertension, hematuria, and rupture. The risk of rupture is higher in pregnant patients and may result in the death of the mother and the fetus. We describe a case of RAA discovered on point-of-care ultrasound (POCUS) in the emergency department. CASE REPORT: A 46-year-old woman with no medical history presented to the emergency department with lower abdominal pain, vomiting, diarrhea, and increased urination. POCUS was performed to evaluate the cause of the patient's symptoms. This study revealed a 2.40 cm × 3.65 cm aneurysm in the right kidney. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Rupture of RAA occurs in 3% to 5% of cases. Mortality to both the mother and the fetus is particularly high in gravid patients. RAA may be mistaken for other renal entities such as prominent renal veins or hydronephrosis. Properly identifying this pathology via POCUS can lead to early intervention. © 2022 Elsevier Inc.

Utility of Point-of-Care Ultrasound for the Rapid Evaluation of Acute Sialadenitis: A Case Report.

Acute suppurative sialadenitis is a bacterial infection of the salivary glands which leads to a painful, tender, and swollen salivary gland. Point-of-care ultrasound (POCUS) is a limited ultrasound performed by the provider to answer a specific clinical question. We present a case describing the efficient utilization of POCUS for the rapid diagnosis of acute suppurative sialadenitis in the Emergency Department.

Point-of-Care Ultrasound for Bedside Diagnosis of Lower Extremity DVT.

The point-of-care ultrasound DVT (POCUS DVT) examination can facilitate rapid bedside diagnosis and treatment of lower extremity DVT. Awaiting radiology-performed Doppler ultrasonography and interpretation by radiologists can lead to delays in lifesaving anticoagulation, and the POCUS DVT examination can provide timely diagnostic information in the patient with lower extremity symptoms. This article outlines accepted techniques for the POCUS DVT examination, discusses the historical context from which the current recommendations have evolved, and provides illustrations alongside ultrasound images of relevant venous anatomy to orient the clinician. Finally, common pitfalls and methods to avoid them are described.

Quantitative characterization of left ventricular function during pulseless electrical activity using echocardiography during out-of-hospital cardiac arrest.

BACKGROUND: Several prospective studies have demonstrated that the echocardiographic detection of any myocardial activity during PEA is strongly associated with higher rates of return of spontaneous circulation (ROSC). We hypothesized that PEA represents a spectrum of disease in which not only the presence of myocardial activity, but more specifically that the degree of left ventricular (LV) function would be a predictor of outcomes. The purpose of this study was to retrospectively assess the association between LV function and outcomes in patients with OHCA. MATERIALS AND METHODS: Using prospectively obtained data from an observational cohort of patients receiving focused echocardiography during cardiopulmonary resuscitation (CPR) in the Emergency Department (ED) setting, we analyzed 312 consecutive subjects with available echocardiography images with initial rhythm of PEA. We used left ventricular systolic fractional shortening (LVFS), a unidimensional echocardiographic parameter to perform the quantification of LV function during PEA. Regression analyses were performed independently to evaluate for relationships between LVFS and a primary outcome of ROSC and secondary outcome of survival to hospital admission. We analyzed LVFS both as a continuous variable and as a categorial variable using the quartiles and the median to perform multiple different comparisons and to illustrate the relationship of LVFS and outcomes of interest. We performed survival analysis using Cox proportional hazards model to evaluate the hazard corresponding to length of resuscitation. RESULTS: We found a positive association between LVFS and the primary outcome of ROSC (OR 1.04, 95%CI 1.01-1.08), but not with the secondary outcome of survival to hospital admission (OR 1.02, 95%CI 0.96-1.08). Given that the relationship was not linear and that we observed a threshold effect in the relationship between LVFS and outcomes, we performed an analysis using quartiles of LVFS. The predicted probability of ROSC was 75% for LVFS between 23.4-96% (fourth quartile) compared to 47% for LVFS between 0-4.7% (first quartile). The hazard of not achieving ROSC was significantly greater for subjects with LVFS below the median (13.1%) compared to the subgroup with LVFS greater than 13.1% (p < 0.05), with the separation of the survival curves occurring at approximately 40 min of resuscitation duration. CONCLUSIONS: Left ventricular function measured by LVFS is positively correlated with higher probability of ROSC and may be associated with higher chances of survival in patients with PEA arrest.

In vivo toxicology of excipients commonly employed in drug discovery in rats.

INTRODUCTION: Toxicology and pharmacology studies conducted in the early stages of drug discovery often require formulation strategies involving the use of excipients with limited knowledge regarding their preclinical safety liabilities. The use of excipients is vital to efforts to solubilize and deliver small molecules in drug discovery. Whilst excipients can have a significant impact on pharmacology and toxicology studies by enabling solubility to maximize systemic exposure, they also have the potential to obscure clinical pathology endpoints. In this article, we report on the in vivo safety in rats for 18 excipients commonly employed in formulations for preclinical pharmacology and toxicology studies. METHODS: The test articles were administered once daily for five days, by oral gavage to male Sprague Dawley rats, and the animals monitored for visible clinical signs. At the end of the study, routine necropsy and clinical pathology endpoints were investigated. RESULTS: None of the excipients tested were acutely toxic. However, there were effects on parameters commonly evaluated as indicators of health and/or toxicological response in regulated preclinical safety studies. DISCUSSION: While the excipients tested were generally well tolerated, several were found to affect common clinical pathology endpoints in a manner that might confound or conceivably mask the interpretation of compound mediated adverse/pharmacological effects.

Acute lymphoid and gastrointestinal toxicity induced by selective p38alpha map kinase and map kinase-activated protein kinase-2 (MK2) inhibitors in the dog.

Exposure to moderately selective p38alpha mitogen-activated protein kinase (MAPK) inhibitors in the Beagle dog results in an acute toxicity consisting of mild clinical signs (decreased activity, diarrhea, and fever), lymphoid necrosis and depletion in the gut-associated lymphoid tissue (GALT), mesenteric lymph nodes and spleen, and linear colonic and cecal mucosal hemorrhages. Lymphocyte apoptosis and necrosis in the GALT is the earliest and most prominent histopathologic change observed, followed temporally by neutrophilic infiltration and acute inflammation of the lymph nodes and spleen and multifocal mucosal epithelial necrosis and linear hemorrhages in the colon and cecum. These effects are not observed in the mouse, rat, or cynomolgus monkey. To further characterize the acute toxicity in the dog, a series of in vivo, in vitro, and immunohistochemical studies were conducted to determine the relationship between the lymphoid and gastrointestinal (GI) toxicity and p38 MAPK inhibition. Results of these studies demonstrate a direct correlation between p38alpha MAPK inhibition and the acute lymphoid and gastrointestinal toxicity in the dog. Similar effects were observed following exposure to inhibitors of MAPK-activated protein kinase-2 (MK2), further implicating the role of p38alpha MAPK signaling pathway inhibition in these effects. Based on these findings, the authors conclude that p38alpha MAPK inhibition results in acute lymphoid and GI toxicity in the dog and is unique among the species evaluated in these studies.

Early toxicology signal generation in the mouse.

The rat has been the preferred rodent toxicology species since before regulatory requirements have been in place, and there exists in the pharmaceutical industry and the regulatory agencies a significant amount of historical data for the rat. The resulting experience base with the rat makes the possibility of replacing it with the mouse for regulated toxicology studies untenable for all but the most extreme circumstances. However, toxicologists are very familiar with the mouse as a model for chronic carcinogenicity studies, and there exist multiple preclinical mouse models of disease. The authors evaluated the use of the mouse for early in vivo toxicology signal generation and prioritization of small molecule lead compounds prior to nomination of a development candidate. In five-day oral gavage studies with three test agents in the mouse, the authors were able to identify the same dose-limiting toxicities as those identified in the rat, including examples of compound-mediated hemolysis as well as microscopic lesions in the alimentary canal, kidney, and pancreas. Performing early signal generation studies in the mouse allows for earlier assessment of the safety liabilities of small molecules, requires significantly less compound, and allows evaluation of more compounds earlier in the project's life cycle.

Development of a high-throughput human HepG(2) dual luciferase assay for detection of metabolically activated hepatotoxicants and genotoxicants.

Hepatic toxicity remains a major concern for drug failure; therefore, a thorough examination of chemically induced liver toxicity is essential for a robust safety evaluation. Current hypotheses suggest that the metabolic activation of a drug to a reactive intermediate is an important process. In this article, we describe a new high-throughput GADD45beta reporter assay developed for assessing potential liver toxicity. Most importantly, this assay utilizes a human cell line and incorporates metabolic activation and thus provides significant advantage over other comparable assays used to determine hepatotoxicity. Our assay has low compound requirement and relies upon 2 reporter genes cotransfected into the HepG(2) cells. The gene encoding Renilla luciferase is fused to the CMV promoter and provides a control for cell numbers. The firefly luciferase gene is fused to the GADD45beta promoter and used to report an increase in DNA damage. A dual luciferase assay is performed by measuring the firefly and Renilla luciferase activities in the same sample. Results are expressed as the ratio of the 2 luciferase activities; increases over the control are interpreted as evidence of stress responses. This mammalian dual luciferase reporter has been characterized with, and without, metabolic activation using positive and negative control agents. Our data demonstrate that this assay provides for an assessment of potential toxic metabolites, is adaptable to a high-throughput platform, and yields data that accurately and reproducibly detect hepatotoxicants.

Development of a highthroughput yeast-based assay for detection of metabolically activated genotoxins.

The potential genotoxicity of drug candidates is a serious concern during drug development. Therefore, it is important to assess the potential genotoxicity and mutagenicity of a compound early in the discovery phase of drug development. AMES Salmonella assay is the most widely used assay for the assessment of mutagenicity and genotoxicity. However, the AMES assay is not readily adaptable to highthroughput screening and several strains of Salmonella must be employed to ensure that different types of DNA damage can be studied. Therefore, an additional robust highthroughput genotoxicity screen would be of significant value in the early detection and elimination of genotoxicity. The complexity of DNA damage requires numerous cellular pathways, thus using single model organism to predict genotoxicity in early stage is challenging. Another critical component of such screens is that they incorporate the capability of metabolic activation to ensure that no genotoxic metabolites are generated. We have developed a novel highthroughput reporter assay for DNA repair that detects genotoxicity, and which incorporates metabolic activation. The assay has a low compound requirement as compared to Ames, and relies upon two different reporter genes cotransfected into a yeast strain. The gene encoding Renilla luciferase is fused to the constitutive 3-phosphoglycerate kinase (PGK1) promoter and integrated into the yeast genome to provide a control for cell numbers. The firefly luciferase gene is fused to the RAD51 (bacterial RecA homolog) promoter and used to report an increase in DNA repair activity. A dual luciferase assay is performed by measuring the firefly and Renilla luciferase activities in the same sample. The result is expressed as the ratio of the two luciferase activities; changes from the base level (control) are interpreted as induction of the RAD51 promoter and evidence of DNA repair activity in eukaryote cells due to DNA damage. The yeast dual luciferase reporter has been characterized with and without S-9 activation using positive and negative control agents. This assay is efficient, requires little time and low amounts of compound. The assay is compatible with metabolic activation, adaptable to a highthroughput platform, and yields data that accurately and reproducibly detects DNA damage. Whereas the normal yeast cell wall, plasma membrane composition and the presence of active transporters can prevent the entry or persistence of some compounds internally in yeast cells, our assay did show concordance with regulatory mutagenicity assays, many of which require metabolic activation and are poorly detected by bacterial mutagenicity assays. Although there were false negative results, in our hands this assay performs as well as or better than other commercially available genetox assays. Furthermore, the RAD51 gene is strongly inducible by homologous intrachromosomal recombination; thus this assay may provide a means to detect clastogens. The RAD51 promoter fused dual luciferase assay represents a valuable addition to the armamentarium for the early detection of genotoxic compounds.

Designing safe drugs: what to consider?

Toxicity continues to be a primary source of attrition at all stages of drug development. Attention to a few key considerations has the potential to move safety-related attrition earlier, before the expenditure of significant resources on a compound with a low chance of successfully reaching the market. The use of predictive in vitro toxicity assays, early in vivo signal generation studies, and application of new technologies will significantly reduce time spent and money lost owing to failures during development. In addition, more deliberate and informed application of assays for reducing the risk of human-specific toxicity holds promise for improving drug development success rates and reducing late-stage failures and post-approval withdrawals.

The application of discovery toxicology and pathology towards the design of safer pharmaceutical lead candidates.

Toxicity is a leading cause of attrition at all stages of the drug development process. The majority of safety-related attrition occurs preclinically, suggesting that approaches to identify 'predictable' preclinical safety liabilities earlier in the drug development process could lead to the design and/or selection of better drug candidates that have increased probabilities of becoming marketed drugs. In this Review, we discuss how the early application of preclinical safety assessment--both new molecular technologies as well as more established approaches such as standard repeat-dose rodent toxicology studies--can identify predictable safety issues earlier in the testing paradigm. The earlier identification of dose-limiting toxicities will provide chemists and toxicologists the opportunity to characterize the dose-limiting toxicities, determine structure-toxicity relationships and minimize or circumvent adverse safety liabilities.

Genomic-based biomarkers of drug-induced nephrotoxicity.

Typical drug development timelines are 10 - 15 years, with high attrition rates that make it difficult for companies to sustain productive pipelines. Investigational and discovery toxicology are novel and revolutionary extensions of the field of general toxicology, which has been created to fulfil the growing need for generating higher throughput, and integrative and predictive toxicological information, in an effort to reduce attrition. Included in this new paradigm is transcript profiling, and recent innovations have led some to speculate that genomics would help revolutionise drug development, as more better predictive biomarkers of organ damage would be identified. The kidney has been a focus of toxicogenomics investigations, and candidate genomic-based biomarkers of renal damage have been identified for rodent as well as nonhuman primate models of nephrotoxicity. This review highlights published results that have led to the preliminary identification of candidate genomic-based markers of nephrotoxicity and provides insight into the future of toxicogenomics.

Institutional forces in the acceptance of managed care practices by physicians.

We evaluated physicians' acceptance of managed care using data from Connecticut physicians. We grouped physicians' attitudinal responses on three dimensions and applied an institutional distance framework to evaluate factors that influence physicians' acceptance of managed care practices. Our results demonstrate the potency of institutional forces in affecting physician attitudes: health care organizations must more effectively integrate their values and beliefs with the physician community. The institutional distance theory evaluated in this article provides new information for policymakers and managers as gaining physician acceptance of certain practices is necessary to ongoing efforts to reform the health care system.

Differential display in rat livers treated for 13 weeks with phenobarbital implicates a role for metabolic and oxidative stress in nongenotoxic carcinogenicity.

Hepatic enzyme inducers such as phenobarbital are often nongenotoxic rodent hepatocarcinogens. Currently, nongenotoxic hepatocarcinogens can only be definitively identified through costly and extensive long-term, repeat-dose studies (e.g., 2-year rodent carcinogenicity assays). Although liver tumors caused by these compounds are often not found to be relevant to human health, the mechanism(s) by which they cause carcinogenesis are not well understood. Toxicogenomic technologies represent a new approach to understanding the molecular bases of toxicological liabilities such asnongenotoxic carcinogenicity early in the drug discovery/development process. Microarrays have been used to identify mechanistic molecular markers of nongenotoxic rodent hepatocarcinogenesis in short-term, repeat-dose preclinical safety studies. However, the initial "noise" of early adaptive changes may confound mechanistic interpretation of transcription profiling data from short-term studies, and the molecular processes triggered by treatment with a xenobiotic agent are likely to change over the course of long-term treatment. Here, we describe the use of a differential display technology to understand the molecular mechanisms related to 13 weeks of dosing with the prototype rodent nongenotoxic hepatocarcinogen, phenobarbital. These findings implicate a continuing role for oxidative stress in nongenotoxic carcinogenicity.An Excel data file containing raw data is available in full at http://taylorandfrancis.metapress.com/openurl.asp?genre=journal&issn=0192-6233. Click on the issue link for 33(1), then select this article. A download option appears at the bottom of this abstract. The file contains raw data for all gene changes detected by AFLP, including novel genes and genes of unknown function; sequences of detected genes; and animal body and liver weight ratios. In order to access the full article online, you must either have an individual subscription or a member subscription accessed through www.toxpath.org.

Acute molecular markers of rodent hepatic carcinogenesis identified by transcription profiling.

Currently, the only way to identify nongenotoxic hepatocarcinogens is through long-term repeat dose studies such as the 2 year rodent carcinogenicity assay. Such assays are both time consuming and expensive and require large amounts of active pharmaceutical or chemical ingredients. Thus, the results of the 2 year assay are not known until very late in the discovery and development process for new pharmaceutical entities. Although in many cases nongenotoxic carcinogenicity in rodents is considered to be irrelevant for humans, a positive finding in a 2 year carcinogenicity assay may increase the number of studies to demonstrate the lack of relevance to humans, delay final submission and subsequent registration of a product, and may result in a "black box" carcinogenicity warning on the label. To develop early identifiers of carcinogenicity, we applied transcription profiling using several prototype rodent genotoxic and nongenotoxic carcinogens, as well as two noncarcinogenic hepatotoxicants, in a 5 day repeat dose in vivo toxicology study. Fluorescent-labeled probes generated from liver mRNA prepared from male Sprague-Dawley rats treated with one of three dose levels of bemitradine, clofibrate, doxylamine, methapyrilene, phenobarbital, tamoxifen, 2-acetylaminofluorene, 4-acetylaminofluorene, or isoniazid were hybridized against rat cDNA microarrays. Correlation of the resulting data with an estimated carcinogenic potential of each compound and dose level identified several candidate molecular markers of rodent nongenotoxic carcinogenicity, including transforming growth factor-beta stimulated clone 22 and NAD(P)H cytochrome P450 oxidoreductase.