Factors that may influence the likelihood that a provider will have this discussion include their understanding of the risks of medical imaging, the amount of time that is available with the patient prior to ordering a test, concerns related to prior false-negative imaging examination findings, and unfavorable outcomes related to a past approach to an incidentaloma. We found that most frontline providers in our study had very little training in the potential radiation risks from medical imaging and that these providers felt uncomfortable discussing the risks with patients. Alternatively, providers who feel comfortable may choose not to discuss the risks with patients for other reasons, such as relatively small perceived risk compared with the perceived benefits or time limitations. As further dialogue ensues about how to communicate with patients about the risks of medical testing, consideration should be given to the infrequency of these discussions in current practice. Future studies should investigate other potential reasons that providers are not engaging in these discussions and evaluate interventions to increase the frequency and efficacy of these discussions.
Chad Stickrath, MD Jeffrey Druck, MD Nathan Hensley, MD Thomas M. Maddox, MD Daniel Richlie, MD
Published Online: June 4, 2012. doi:10.1001 /archinternmed.2012.1791 Author Affiliations: Divisions of General Internal Medicine (Drs Stickrath and Richlie) and Cardiology (Dr Maddox), Department of Medicine, Department of Emergency Medicine (Dr Druck), and Department of Radiology (Dr Hensley), University of Colorado Denver School of Medicine, Denver; and Denver VA Medical Center, Denver (Drs Stickrath, Hensley, Maddox, and Richlie). Correspondence: Dr Stickrath, Denver VA Medical Center, 1055 Clermont St (111), Denver, CO 80220 (Chad .stickrath@va.gov). Author Contributions: Drs Stickrath and Richlie had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Stickrath, Druck, and Richlie. Acquisition of data: Stickrath, Druck, and Hensley. Analysis and interpretation of data: Stickrath, Maddox, and Richlie. Drafting of the manuscript: Stickrath, Druck, and Hensley. Critical revision of the manuscript for important intellectual content: Stickrath, Druck, Hensley, Maddox, and Richlie. Statistical analysis: Druck. Administrative, technical, and material support: Stickrath, Druck, and Richlie. Study supervision: Stickrath, Hensley, Maddox, and Richlie. Financial Disclosure: None reported. Additional Contributions: Allan Prochazka, MD, contributed to the design of the study and assisted with the statistical analysis; Howard Li, MD, contributed to the recruitment of participants and assisted with interpretation of the results; and Tanner Caverly, MD, contributed to the interpretation of the results and assisted with editing and preparing the manuscript.

Online-Only Material: The eAppendix is available at http: //www.archinternmed.com.
1. Berrington de Gonza´lez A, Mahesh M, Kim KP, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med. 2009;169(22):2071-2077.
2. Redberg RF. Cancer risks and radiation exposure from computed tomographic scans: how can we be sure that the benefits outweigh the risks? Arch Intern Med. 2009;169(22):2049-2050.
3. Berland LL, Silverman SG, Gore RM, et al. Managing incidental findings on abdominal CT: white paper of the ACR incidental findings committee. J Am Coll Radiol. 2010;7(10):754-773.
4. Hall WB, Truitt SG, Scheunemann LP, et al. The prevalence of clinically relevant incidental findings on chest computed tomographic angiograms ordered to diagnose pulmonary embolism. Arch Intern Med. 2009;169(21): 1961-1965.
5. Dauer LT, Thornton RH, Hay JL, Balter R, Williamson MJ, St Germain J. Fears, feelings, and facts: interactively communicating benefits and risks of medical radiation with patients. AJR Am J Roentgenol. 2011;196(4):756761.
6. Balter S. Radiation need not be feared, but it must be respected. AJR Am J Roentgenol. 2011;196(4):754-755.
DMAA as a Dietary Supplement Ingredient
T he pharmaceutical amphetamine derivative 1,3dimethylamylamine (DMAA) was introduced in 1948 as a nasal inhaler for rhinitis by Eli Lilly & Co. By the 1970s, it had been withdrawn as an approved pharmaceutical. Surprisingly, DMAA is currently used as an ingredient in roughly 200 sports supplements, many sold in major franchises throughout the United States, with sales topping $100 million in 2010 alone (Table).1-4
See also page 1035
For DMAA to be legally sold as a dietary supplement, it must be a naturally occurring substance with a documented history of use prior to 1994. Remarkably, the evidence to support the sale of DMAA-containing supplements hinges on a single study.5 In this 1 study, published in the now defunct Journal of the Guizhou Institute of Technology, geranium oil (extracted from the fresh leaves and stems of Pelargonium graveolens) was found to contain less than 0.7% DMAA based on a gas chromatography and mass spectrometry analysis. The researchers do not describe their methodology but presumably based their conclusions on matching an unknown peak spectrum of geranium oil with the library mass spectrum of DMAA. The appropriate confirmatory test, using a standardized preparation of DMAA to confirm its presence, was not described.
Since the publication of this study, more than a halfdozen peer-reviewed reports have been unable to confirm this finding.6 Health Canada, for one, has concluded that “there is no credible scientific evidence that DMAA is captured as an isolate of a plant.”6 This lack of evidence has not deterred multiple supplement companies from marketing DMAA as if it were isolated from geranium. For example, the popular Jack3d product (USPlabs) sold at GNC (General Nutrition Centers) is labeled as containing “1,3-dimethylamylamine (Geranium [Stem])” (label available from the author on request).

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Table. List of DMAA-Containing Supplements Withdrawn From All Military Exchanges as of December 7, 20111

Supplement Proprietary Name
Jack3d (tropical fruit and lemon lime)
OxyELITE Pro Lipo 6 Black Lipo 6 Black Ultra Hemo Rage Black PWR Ultra Concentrated Pre
Workout Revolution Neurocore Powder HydroxyStim Lean EFX Napalm Nitric Blast Biorhythm SSIN Juice Code Red
MethylHex4,2 Arson Fat Burner Capsule Spirodex

Manufacturer
USPlabs
USPlabs Nutrex Research Inc Nutrex Research Inc Nutrex Research Inc iSatori Technologies LLC
MuscleTech MuscleTech Fahrenheit Nutrition Muscle Warfare Sports Nutrition International Exclusive Supplements MuscleMeds Performance
Technologies SEI Pharmaceuticals Muscle Asylum Project Gaspari Nutrition

Given its wide availability, physicians should understand DMAA’s potential health effects. Supplements containing DMAA have been implicated as potentially contributing agents in multiple serious adverse events, including panic attacks, seizures, stress-induced cardiomyopathy,7 and 2 deaths.2 In Europe and New Zealand, DMAA use as a party drug has been implicated in at least 1 hemorrhagic stroke.8 Causality has yet to be proven, but these adverse effects are consistent with DMAA’s known pharmacologic actions. In The Dispensatory of the United States of America 1950 Edition,9 DMAA’s systemic toxic effects in animals was described as “greater than that of ephedrine and less than that of amphetamine,”9(p2049) and the authors counseled that if DMAA’s use as a nasal inhaler “produces side effects such as headache, nervousness, mental stimulation, or tremors, the drug should be discontinued.”9(p2049) Small trials have also demonstrated that DMAA-containing supplements increase blood pressure and heart rate.10
Last summer, Health Canada banned DMAA from all supplements,6 and last December, the US military removed DMAA-containing supplements from all military exchanges worldwide (Table).1 In late April 2012, 6 years after DMAA had been introduced as a dietary supplement, the US Food and Drug Administration (FDA) sent warning letters to 10 manufacturers requiring them to provide evidence to support their conclusion that DMAA is a safe supplement ingredient.11 Given that DMAA is a potentially dangerous ingredient and that manufacturers’ claims that it is naturally derived are unsubstantiated, manufacturers and distributors should immediately recall all DMAA-containing supplements.
The extensive mainstream sales of DMAA combined with the FDA’s delayed response expose the potentially serious public health risks entailed when consuming new supplement ingredients.
Pieter A. Cohen, MD

Published Online: May 7, 2012. doi:10.1001 /archinternmed.2012.1677. Corrected May 14, 2012. Author Affiliations: Department of Medicine, Harvard Medical School, Cambridge Health Alliance, Somerville, Massachusetts. Correspondence: Dr Cohen, Harvard Medical School, Cambridge Health Alliance, 236 Highland Ave, Somerville, MA 02143 (pcohen@challiance.org). Financial Disclosure: None reported.
1. Allied Communications Publication. ALFOODACT 036-2011 UPDATE/ CORRECTION for ALFOODACT 034-2011 Dimethylamylamine (DMAA) is placed on medical hold due to possible serious adverse health effects. http: //www .troopsupport .dla .mil /subs /fso /alfood /2011 /alf03611 .pdf. Accessed March 22, 2012.
2. Lattman P, Singer N. Army studies workout supplement after deaths. New York Times. February 3, 2012;B1.
3. Therapeutic Research Faculty. Natural medicines comprehensive database [registration required]. http: //naturaldatabase .therapeuticresearch .com /home .aspx ?cs= & amp; s= ND. Accessed March 28, 2012.
4. Nutrition Business Journal. Moving the needle: “geranium extracts” exit the marketplace. http: //newhope360 .com /research /moving-needle-geraniumextracts-exit-marketplace ?page= 1. Accessed March 28, 2012.
5. Ping Z, Jun Q, Qing L. A study on the chemical constituents of geranium oil [in Chinese]. J Guizhou Inst Tech. 1996;25(1):82-85.
6. Health Canada, Health Products and Food Branch. Classification of 1,3dimethylamylamine (DMAA). http://www.scribd.com/doc/82744576 /DMAA-Health-Canada-2011. Accessed March 22, 2012.
7. Salinger L, Daniels B, Sangalli B, Bayer M. Recreational use of bodybuilding supplement resulting in severe cardiotoxicity. Clin Toxicol. 2011;49(6): 573-574.
8. Gee P, Jackson S, Easton J. Another bitter pill: a case of toxicity from DMAA party pills. N Z Med J. 2010;123(1327):124-127.
9. Osol A, Farrar G, eds. The Dispensatory of the United States of America 1950 Edition. Philadelphia, PA: JB Lippincott Co; 1950.
10. McCarthy CG, Farney TM, Canale RE, Alleman RJ, Bloomer RJ. A finished dietary supplement stimulates lipolysis and metabolic rate in young men and women. Nutr Meta Insights. 2012;5(1):23-31.
11. US Food and Drug Administration. FDA challenges marketing of DMAA products for lack of safety evidence. http: //www .fda .gov /NewsEvents /Newsroom /PressAnnouncements /ucm302133 .htm. Accessed May 5, 2012.
Factors Associated With Serious
Traffic Crashes: A Prospective Study
in Southwest France
D rugs affecting driving ability (DADAs) directly1-4 or by indicating at-risk diseases5 are classified in a 4-level standardized classification associated with a graded pictogram.6 A study in the French police database of crashes and in the national health care database showed an increased risk of being responsible in drivers exposed to level 2 or level 3 drugs7 but did not include information on sleepiness, the use of illicit drugs, or other occupational factors.
Our objective was to describe the factors associated with being responsible for a serious road crash and patientreported use of labeled medicines.
Methods. All adult drivers hospitalized at least 24 hours (ie, a serious crash) in Limoges, Bordeaux, or Toulouse, France, in 2007 through 2009 were queried using structured questionnaires8,9 about the circumstances of the crash, use of medicines and drugs, and other risk factors (eg, alcohol, sleepiness at the wheel, sleep apnea, or concomitant diseases). Blood alcohol content was abstracted from patient files. Police reports provided responsibility for the crash. Exposure to risk factors, including medication, was compared between responsible

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