Dietary Supplement Use in Middle-aged and Older Adults.

OBJECTIVES: Despite limited evidence of clinical benefits, dietary supplement use is increasingly common among older adults. The aim of this study was to characterise the prevalence of dietary supplement use in a national sample of community-dwelling middle-aged and older adults and investigate factors associated with its use. DESIGN/SETTING/PARTICIPANTS: This was a cross-sectional study using data from the Health and Retirement Study (HRS), a biennial, nationally representative survey of individuals aged 50 years and older in the United States. This study combined data from the 2013/14 Health Care and Nutrition Survey (HCNS) and 2012 Core Survey. MEASUREMENTS: The primary outcome was the use of any dietary supplement at least once a week. Secondary outcomes were the use of multivitamins and specific vitamin and supplement types. Multivariable regression models were used to identify factors associated with any dietary supplement use. RESULTS: A total of 6045 participants (weighted n = 71,268,015) were included in the final analytical sample (mean age 67.7 years, 59.3% female). Of these, 84.6% (n=60,292,704) were regular dietary supplement users, with participants taking a mean of 3.2±0.1 different dietary supplements and 41.9% taking four or more. Multivitamins were the most common, used by 57.5% (n=41,147,146) of participants. Other commonly used dietary supplements were vitamin D, fish oil, calcium, vitamin C, and vitamin B12. Older age (75+ years), female sex, higher education, daily alcohol use, vigorous physical activity, regular medication use, and arthritis were associated with higher odds of dietary supplement use. CONCLUSIONS: In this sample of middle-aged and older Americans, more than 4 out of 5 used a dietary supplement. Certain demographic, behavioural, and clinical factors were associated with their use. Given the lack of evidence for improving health outcomes, our findings suggest potential overuse of dietary supplements in people over the age of 50.

Peer-led pediatric resuscitation training: effects on self-efficacy and skill performance.

BACKGROUND: Peer-led basic life support training in medical school may be an effective and valued way of teaching medical students, yet no research has been conducted to evaluate the effect on the self-efficacy of medical students. High self-efficacy stimulates healthcare professionals to initiate and continue basic life support despite challenges. METHODS: A randomized controlled trial, in which medical students received pediatric basic life support (PBLS) training, provided by either near-peer instructors or expert instructors. The students were randomly assigned to the near-peer instructor group (n = 105) or expert instructor group (n = 108). All students received two hours of PBLS training in groups of approximately 15 students. Directly after this training, self-efficacy was assessed with a newly developed questionnaire, based on a validated scoring tool. A week after each training session, students performed a practical PBLS exam and completed another questionnaire to evaluate skill performance and self-efficacy, respectively. RESULTS: Students trained by near-peers scored significantly higher on self-efficacy regarding all aspects of PBLS. Theoretical education and instructor feedback were equally valued in both groups. The scores for the practical PBLS exam and the percentage of students passing the exam were similar in both groups. CONCLUSIONS: Our findings point towards the fact that near-peer-trained medical students can develop a higher level of PBLS-related self-efficacy than expert-trained students, with comparable PBLS skills in both training groups. The exact relationship between peer teaching and self-efficacy and between self-efficacy and the quality of real-life pediatric resuscitation should be further explored. TRIAL REGISTRATION: ISRCTN, ISRCTN69038759 . Registered December 12th, 2019 - Retrospectively registered.

Association of renin-angiotensin-aldosterone system genetic polymorphisms with maternal hypotension during spinal anaesthesia for caesarean delivery: a retrospective cohort study.

BACKGROUND: Unless prevented, hypotension occurs in up to 80% of normotensive women undergoing spinal anaesthesia for caesarean delivery. Renin-angiotensin-aldosterone system genetic polymorphisms have been associated with hypertensive disease, but few studies investigated effects on blood pressure regulation under spinal anaesthesia. We postulated that these polymorphisms increased vasodilation and maternal hypotension during spinal anaesthesia. METHODS: A retrospective secondary analysis of data from four prospective trials with similar inclusion/exclusion criteria evaluating phenylephrine/ephedrine delivery systems during spinal anaesthesia for elective caesarean delivery. Angiotensin type-1 receptor (AT1R) (A1166C), angiotensin-converting enzyme (ACE) (I/D), and aldosterone synthase CYP11B2 (C344T) polymorphisms were identified from stored specimens. The associations between the polymorphisms and hypotension (systolic blood pressure <80% of baseline), and vasopressor use, were determined by univariable and multivariable regression. RESULTS: Of 556 patients, 378 (68.0%) had hypotension. The AC/CC genotypes of AT1R (A1166C) were associated with hypotension by univariable analysis (OR 2.70, 95% CI 1.38 to 5.28, P=0.004]) and multivariable analysis (OR 3.65, [95% CI 1.68 to 7.94, P=0.004]) after adjustment for age, race, intravenous fluid volume, and block height. No difference in vasopressor use or adverse maternal or fetal outcomes were noted. Baseline characteristics were similar, with the exception of higher baseline blood pressure, block height, and intravenous fluid volume in the hypotensive group. There was no significant association between ACE and CYP11B2 polymorphisms and hypotension. CONCLUSION: AC/CC genotypes of AT1R (A1166C) polymorphism were associated with maternal hypotension under spinal anaesthesia for caesarean delivery. An association with cardiovascular indices and high-risk parturients should be examined.

[How can life-threatening external blood loss be stopped? Treatment options in the prehospital phase]. / Hoe stop je levensbedreigend uitwendig bloedverlies?

- 3,500 people die of injuries in the Netherlands every year; 40% of the deaths are attributable to bleeding.- Treatment of patients with life-threatening blood loss is part of the trauma care continuum: all the way from incident to hospital treatment.- This article presents an overview of all treatment options for stopping life-threatening external blood loss, divided in medical assistance phases. It also makes a distinction between different types of care providers, based on the presence or absence of their medical skills.

Paediatric pelvic fractures: how do they differ from adults?

BACKGROUND: The aim of this article was to review the incidence, presentation, treatment and complications of paediatric pelvic fractures of children who were admitted to our level 1 trauma centre and to compare them with our data from adult pelvic fracture patients. METHODS: We conducted a retrospective chart review of all children with pelvic fractures who were managed at our institution between January 1993 and December 2013 and compared the data with our database on pelvic fractures in adults during the period 2007 to 2012. RESULTS: We identified 51 children and 268 adults with pelvic fractures. The median age of the paediatric patients was 11 years. Children were significantly more involved in traffic accidents than adults (p < 0.001). Adults had a significantly higher Injury Severity Score (ISS) (31 vs 24.5; p < 0.03) and were significantly more often haemodynamically unstable (p < 0.01). Adults had a type C fracture more often, while children had a type B fracture (p < 0.001). Associated injuries were seen in both groups; however, thoracic injuries were significantly higher in adults (p < 0.01) and injuries to the extremities were higher in children (p < 0.01). Adults were significantly more often treated with open reduction and internal fixation (p < 0.001). Mortality in both groups, however, did not differ (6% vs 8%). CONCLUSION: Paediatric pelvic fractures are rare. They differ from adult pelvic fractures in presentation, associated injuries and management. Mortality, however, is substantial and does not differ from the adult population. Mortality is often due to concomitant injuries and not to exsanguination from the pelvic fracture.

Prehospital control of life-threatening truncal and junctional haemorrhage is the ultimate challenge in optimizing trauma care; a review of treatment options and their applicability in the civilian trauma setting.

INTRODUCTION: Exsanguination following trauma is potentially preventable. Extremity tourniquets have been successfully implemented in military and civilian prehospital care. Prehospital control of bleeding from the torso and junctional area's remains challenging but offers a great potential to improve survival rates. This review aims to provide an overview of potential treatment options in both clinical as preclinical state of research on truncal and junctional bleeding. Since many options have been developed for application in the military primarily, translation to the civilian situation is discussed. METHODS: Medline (via Pubmed) and Embase were searched to identify known and potential prehospital treatment options. Search terms were|: haemorrhage/hemorrhage, exsanguination, junctional, truncal, intra-abdominal, intrathoracic, intervention, haemostasis/hemostasis, prehospital, en route, junctional tourniquet, REBOA, resuscitative thoracotomy, emergency thoracotomy, pelvic binder, pelvic sheet, circumferential. Treatment options were listed per anatomical site: axilla, groin, thorax, abdomen and pelvis Also, the available evidence was graded in (pre) clinical stadia of research. RESULTS: Identified treatment options were wound clamps, injectable haemostatic sponges, pelvic circumferential stabilizers, resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta (REBOA), intra-abdominal gas insufflation, intra-abdominal self-expanding foam, junctional and truncal tourniquets. A total of 70 papers on these aforementioned options was retrieved. No clinical reports on injectable haemostatic sponges, intra-abdominal insufflation or self-expanding foam injections and one type of junctional tourniquets were available. CONCLUSION: Options to stop truncal and junctional traumatic haemorrhage in the prehospital arena are evolving and may offer a potentially great survival advantage. Because of differences in injury pattern, time to definitive care, different prehospital scenario's and level of proficiency of care providers; successful translation of various military applications to the civilian situation has to be awaited. Overall, the level of evidence on the retrieved adjuncts is extremely low.

Common variants of catechol-O-methyltransferase influence patient-controlled analgesia usage and postoperative pain in patients undergoing total hysterectomy.

Catechol-O-methyltransferase (COMT) gene polymorphisms and haplotypes have been associated with both experimental and clinical pain phenotypes. In this prospective study, we investigated the association of three common polymorphisms with experimentally induced pressure pain, postoperative pain and amount of self-administered morphine in 973 patients who underwent scheduled total hysterectomy. DNA extracted from peripheral blood was genotyped for three COMT polymorphisms by Taqman assay or a PCR-based method. In the overall sample, rs4633 and rs4680 were significantly associated with morphine use, whereas rs4818 was associated with time-averaged pain scores. Statistically significant associations were found between COMT rs4633 and rs4680 genotypes and the amount of morphine self-administered through a patient-controlled analgesia pump. For rs4818, the only statistically significant association was with time-averaged pain scores. Haplotype analysis showed statistically significant association of the low pain sensitivity haplotype with time-averaged pain scores; and average pain sensitivity haplotype with total morphine and weight-adjusted morphine.

Cockayne Syndrome due to a maternally-inherited whole gene deletion of ERCC8 and a paternally-inherited ERCC8 exon 4 deletion.

Cockayne Syndrome (CS) is an autosomal recessive disorder that causes neurological regression, growth failure and dysmorphic features. We describe a Chinese female child with CS caused by deletions of exon 4 of ERCC8 on one chromosome and exons 1-12 on the other chromosome. By using chromosomal microarray, multiplex ligation-dependant probe analysis and long range PCR, we showed that she inherited a 277 kb deletion affecting the whole ERCC8 gene from the mother and a complex rearrangement resulting in deletion of exon 4 together with a 1,656 bp inversion of intron 4 from the father. A similar complex rearrangement has been reported in four unrelated Japanese CS patients. Analysis of the deletion involving exon 4 identified LINE and other repeat elements that may predispose the region to deletions, insertions and inversions. The patient also had insulin-dependent diabetes mellitus, a rare co-existing feature in patients with CS. More research will be needed to further understand the endocrine manifestations in CS patients.

Screening of antiviral activities in medicinal plants extracts against dengue virus using dengue NS2B-NS3 protease assay.

Dengue virus infects millions of people worldwide and there is no vaccine or anti-dengue therapeutic available. Screening large numbers of medicinal plants for anti-dengue activities is an alternative strategy in order to find the potent therapeutic compounds. Therefore, this study was designed to identify anti-dengue activities in nineteen medicinal plant extracts that are used in traditional medicine. Local medicinal plants Vernonia cinerea, Hemigraphis reptans, Hedyotis auricularia, Laurentia longiflora, Tridax procumbers and Senna angustifolia were used in this study. The highest inhibitory activates against dengue NS2B-NS3pro was observed in ethanolic extract of S. angustifolia leaves, methanolic extract of V. cinerea leaves and ethanol extract of T. procumbens stems. These findings were further verified by in vitro viral inhibition assay. Methanolic extract of V. cinerea leaves, ethanol extract of T. procumbens stems and at less extent ethanolic extract of S. angustifolia leaves were able to maintain the normal morphology of DENV2-infected Vero cells without causing much cytopathic effects (CPE). The percentage of viral inhibition of V. cinerea and T. procumbens extracts were significantly higher than S. angustifolia extract as measured by plaque formation assay and RT-qPCR. In conclusion, The outcome of this study showed that the methanolic extract of V. cinerea leaves and ethanol extract of T. procumbens stems possessed high inhibitory activates against dengue virus that worth more investigation.

Challenges in the training of military surgeons: experiences from Dutch combat operations in southern Afghanistan.

BACKGROUND: To improve care for battle casualties, we analyzed the surgical workload during the Dutch deployment to Uruzgan, Afghanistan. This surgical workload was compared with the resident surgical training and the pre-deployment medical specialist program. METHODS: Patient data from the trauma registry (2006-2010) at the Dutch Role 2 Medical Treatment Facility (MTF) were analyzed. The case logs of chief residents (n = 15) from the general surgery training program in the Netherlands were used for comparison. RESULTS: The trauma registry query yielded 2,736 casualties, among whom 60 % (1,635/2,736) were classified as disease non-battle casualties and 40 % (1,101/2,736) as battle casualties. During the study period, 1,427 casualties (336 pediatric cases) required 2,319 surgical procedures. Each graduating chief resident handled an average of 1,444 cases, including 165 laparotomies, 19 major vessel repairs, 28 amputations, and 153 fracture stabilizations, during their residency. Residents had limited exposure to injuries requiring a thoracotomy, craniotomy, nephrectomy, IVC repair, or external genital trauma. CONCLUSIONS: The injuries treated at the Dutch Role 2 MTF were often severe, and exposure to pediatric cases was much higher than reported for other combat hospitals in Iraq and in Afghanistan. The current civilian resident training does not equip the trainees with the minimally required competences of a fully trained military surgeon. The recognition in the Netherlands of military surgery as a subspecialty within general (trauma) surgery, with a formal training curriculum, should be considered. The introduction of a North Atlantic Treaty Organization Military (and Disaster) Surgery standard may facilitate the achievement of this aim.

Partial trisomy 3p and partial monosomy 11q associated with atrial septal defect, cleft palate, and developmental delay: a case report.

Unbalanced translocation involving both chromosome 3p duplication and 11q deletion in the same patient is extremely rare; only 1 live-born case was reported previously. This karyotype was also detected during prenatal diagnosis of 2 different pregnancies in a Taiwanese family which were both terminated. In all 3 cases, only standard karyotyping was done to detect the abnormal karyotypes. Here, we report a 4-year-old boy with cleft palate, atrial septal defect, and hypotonia with gross and fine motor delay. Oligonucleotide-based array comparative genomic hybridization showed copy number gain from 3pter to 3p24.2 (approximately 24.5 Mb) and copy number loss from 11q25 to 11qter (approximately 5.8 Mb). This de novo unbalanced translocation event involving a terminal 3p duplication and a terminal 11q deletion provides candidate genes for further investigation of dosage effect leading to the patient's multiple phenotypic abnormalities. Genotype-phenotype correlation is difficult to make in this case due to the large number of genes involved. However, the description of such cases together with precise gene-level mapping of chromosomal breakpoints will add to further refinement of candidate genes to be investigated for terminal imbalances in 3p and 11q when more similar cases are reported.

The influence of ATP-binding cassette sub-family B member -1 (ABCB1) genetic polymorphisms on acute and chronic pain after intrathecal morphine for caesarean section: a prospective cohort study.

BACKGROUND: Polymorphisms of the ATP-binding cassette sub-family B member -1 (ABCB1) gene that codes for P-glycoprotein could influence the efflux of morphine from the central nervous system affecting its analgesic action. We investigated the effect of ABCB1 gene polymorphisms on analgesia and the development of persistent pain in post caesarean patients. METHODS: Women of Chinese descent who received spinal anaesthesia with intrathecal morphine for elective caesarean section were recruited. They were given intravenous morphine via a patient-controlled analgesia pump for postoperative analgesia. Blood samples were collected and analysed for the presence of C1236T, G2677T/A and C3435T single nucleotide polymorphisms of the ABCB1 gene. We primarily investigated the association between ABCB1 polymorphisms and the effect of morphine. In a postpartum phone survey of the subjects six months after surgery, the occurrence of persistent abdominal wound scar pain was established. RESULTS: We found no significant statistical difference in total morphine consumption, pain scores and side effects among the various genotypes. For C3435T polymorphism, there was a trend towards the association of the T allele and persistent pain for three months after surgery but this did not reach statistical significance (P=0.07). The TT genotype had the longest mean survival time of wound pain in comparison with CT and CC genotypes (P=0.004 and P=0.014, respectively). CONCLUSION: Polymorphisms of ABCB1 were not associated with differences in morphine use in the first 24h after surgery. Women with the T allele of C3435T polymorphism showed a trend towards a higher risk of developing persistent postoperative pain.

Potential use of cholecalciferol polyethylene glycol succinate as a novel pharmaceutical additive.

D-alpha-tocopheryl polyethylene glycol succinate (TPGS) has been utilized in numerous drug delivery formulations in recent years. Because of its amphiphilic structure, it can be used as emulsifier and vehicle for lipid-based drug delivery formulations. It is also an effective P-glycoprotein (P-gp) inhibitor. However, TPGS represents only one of the surfactants in the class of "Vitamin-PEG" conjugated surfactants. To design a new adjuvant or additive, a conjugate made of vitamin D (cholecalciferol) and PEG-cholecalciferol polyethylene glycol succinate (CPGS) was synthesized via a two-step reaction. We hypothesized that CPGS may exhibit similar characteristics to TPGS, and thus the physicochemical properties as well as the anticancer properties of CPGS were studied. The results demonstrated that CPGS reduced the particle size and increased the encapsulation efficiency of the PLGA nanoparticles, indicating that CPGS may also have the emulsifier function similar to TPGS. The drug release profiles showed that the nanoparticles with CPGS additive had a lower initial burst and more sustained release pattern. In vitro testing with Caco-2 cells showed that CPGS could increase the cytotoxicity of DOX-loaded PLGA nanoparticles. Based on the rhodamine accumulation study, the increased cytotoxicity is possibly due to the P-gp inhibition by CPGS. From current results, the use of CPGS as an adjuvant is promising and may enhance the efficacy of the overall drug delivery system.

Diagnosis and treatment of acute appendicitis in children: a survey among Dutch surgeons and comparison with evidence-based practice.

BACKGROUND: Considerable variability exists in the surgical approach to acute appendicitis in children, affecting both quality and costs of care. A national survey provides insight into daily surgical practice and enables comparison of practice with the available evidence. METHODS: A national survey was conducted in all 121 Dutch hospitals asking detailed information concerning diagnosis and treatment of children suspected of acute appendicitis. An evidence-based practice (EBP) score was developed on the basis of a critical appraisal of the literature, allowing for classification of reported practices with regard to the level of evidence and identification of hospitals working in accordance with the best available evidence. RESULTS: The overall response rate was 93%. For the diagnosis of acute appendicitis, respondents relied predominantly on patient history (29%) and clinical examination (31%), followed by laboratory results (22%). Only 20% of the departments routinely measured total white blood cell count (WBC), C-reactive protein (CRP) and leukocyte differential count (proportion of polymorphonuclear cells), being part of the triad that provides diagnostic evidence. Although strong evidence exists in favour of routine prophylaxis for suspected appendicitis, only two thirds of surgical departments reported this as part of their routine practice. For a number of issues, reasonably consistent evidence is available (e.g. primarily versus delayed closure, drainage versus lavage, routine peritoneal culturing). Thirty-eight percent of the departments routinely cultured abdominal fluid despite various reports that it provides no therapeutic advantage. Not more than 22% of the departments closed the skin in perforated appendicitis in spite of clear supportive evidence. Considerable variation exists in cleaning the abdomen in perforated appendicitis, despite evidence favouring lavage. Comparing departments in terms of compliance with available evidence revealed that most paediatric surgery departments worked according to evidence-based medicine. CONCLUSIONS: Available evidence on diagnosis and treatment of acute appendicitis in children is only partly applied in a small proportion of hospitals in the Netherlands. It is recommended that national guidelines be published, which could decrease health care costs and increase more uniform policy, improve quality of care for this group of patients and improve training of residents in general surgery in the Netherlands.

[The level of first aid and basic life support for the next generation of physicians]. / Het niveau van eerstehulpverlening en basale reanimatie door aankomende artsen.

According to Dutch medical-education guidelines junior doctors are expected to be able to carry out first aid and basic life support. We determined the level of first aid and basic life support of junior doctors at the Radboud University Nijmegen Medical Centre, The Netherlands. Of the 300 junior doctors 54 (18%) were submitted to a theoretical test, consisting of 52 multiple-choice questions on first aid and basic life support. This was followed by a practical test consisting of two first aid and basic life support scenarios including cardiopulmonary resuscitation (CPR). The scenarios were evaluated by certified examiners who used Berden's internationally accepted criteria. 19% of the junior doctors passed the theoretical test. The first-aid scenario was performed correctly in 11% of the cases. According to the examiners the CPR situation was performed correctly by 30% of the junior doctors but when assessed by Berden's international criteria only 6% of the junior doctors had performed CPR correctly. The level of first aid and basic life support amongst junior doctors was low and so the majority of them did not meet the required level as stated in the guidelines for practice of medical education in The Netherlands on this subject.

Capillary blood gas analysis in complex regional pain syndrome: a pilot study.

BACKGROUND: The pathophysiology of complex regional pain syndrome type 1 (CRPS 1) is still a matter of debate. An inflammatory reaction may cause the syndrome. Increasing evidence points to a role for impairment of oxygen metabolism in the affected limb. METHODS: In this pilot study (16 patients) we performed capillary blood gas analysis in extremities with acute CRPS 1, in order to assess oxygen saturation and lactate concentrations. Comparison was made with the unaffected limb for capillary blood pH, pO(2), SaO(2), and lactate and glucose concentrations. RESULTS: No statistically significant differences could be found. CONCLUSIONS: Capillary blood gas analysis is not useful to detect changes in oxygen saturation and lactate concentrations in CRPS 1.

[Acute appendicitis in children: serious complications when treatment is delayed]. / Appendicitis acuta bij kinderen: ernstige complicaties bij vertraging in de behandeling.

Three children, two boys aged 9 and 6 and a 12-year-old girl, had diffuse abdominal complaints, diarrhoea and a (sub)febrile temperature for several days. On admission, they were found to have a perforated inflamed appendix and peritonitis. Following asystole, intra-abdominal abscesses and an enterocutaneous fistula, the oldest boy showed good recovery after a hospital stay of two months; the girl recovered after one month in hospital following a psoas muscle abscess and two episodes of constrictive pericarditis with threatened tamponade. The younger boy was dead on arrival at the hospital. Appendicitis is not always easy to diagnose. An atypical presentation, very often with diarrhoea, can result in diagnostic delay. Early surgical consultation is mandatory in a child with progressive abdominal pain.