Sagittal Full-Spine vs. Sectional Cervical Lateral Radiographs: Are the Measurements of Cervical Alignment Interchangeable?

(1) Background: This study assessed the relationship between cervical spine parameters taken on standing full-spine lateral radiographic images compared to sectional lateral cervical radiographs. (2) Methods: Full-spine (FS) and sectional lateral cervical (LC) radiographs from four spine treatment facilities across the USA retrospectively provided data collected on 220 persons to assess the comparison of three sagittal cervical radiographic measurements between the two views. The measures included cervical lordosis using the absolute rotation angle from C2-C7, sagittal cervical translation of C2-C7, and atlas plane angle to horizontal. Linear correlation and R2 models were used for statistical comparison of the measures for the two views. (3) Results: The mean values of the three measurements were statistically different from each other: C2-C7 translation (FS = 19.84 ± 11.98 vs. LC = 21.18 ± 11.8), C2-C7 lordosis (FS = -15.3 ± 14.63 vs. LC = -18.32 ± 13.16), and atlas plane (FS = -19.99 ± 8.88 vs. LC = -22.56 ± 8.93), where all values were p < 0.001. Weak-to-moderate-to-strong correlations existed between the full-spine and sectional lateral cervical radiographic variables. The R2 values varied based on the measurement were R2 = 0.768 (p < 0.001) for sagittal cervical translation of C2-C7 (strong), R2 = 0.613 (p < 0.001) for the absolute rotation angle C2-C7 (moderate), and R2 = 0.406 (p < 0.001) for the atlas plane line (weak). Though a linear correlation was identified, there were consistent intra-person differences between the measurements on the full spine versus sectional lateral cervical radiographic views, where the full-spine view consistently underestimated the magnitude of the variables. (4) Conclusion: Key sagittal cervical radiographic measurements on the full spine versus sectional lateral cervical radiographic views show striking intra-person differences. The findings of this study confirm that full spine versus sectional lateral cervical radiographic views provide different biomechanical magnitudes of cervical sagittal alignment, and caution should be exercised by health care providers as these are not interchangeable. We recommend the LC view for measurement of cervical sagittal alignment variables.

Two Methods of Forward Head Posture Assessment: Radiography vs. Posture and Their Clinical Comparison.

Background: Forward head posture (FHP) and altered cervical lordotic curvatures are common spine displacements often associated with neck pain and disability. Two primary categories for determining FHP exist: radiographic and postural measurements. Methods: This study investigated the correlation between the craniovertebral angle (CVA), the radiographically measured C2-C7 sagittal vertical axis (SVA), and cervical lordosis (absolute rotation angle: ARA C2-C7) in a sample of participants with chronic myofascial pain (CMP). In 120 participants, we performed both a postural measurement of the CVA and a lateral cervical radiograph, where the C2-C7 SVA and ARA C2-C7 were measured. A linear-regression R2 value to assess the correlation between the CVA, C2-C7 SVA, and ARA C2-C7 was sought. Results: A statistically significant weak linear fit was identified (Spearman's r = 0.549; R2 = 0.30, p < 0.001) between the CVA and C2-C7 SVA, having considerable variation between the two measures. A statistically significant linear fit (very weak) was identified for the lordosis ARA C2-C7 and the CVA: Spearman's r = 0.524; R2 = 0.275; p < 0.001. A value of 50° for the CVA corresponded to a value of 20 mm for the C2-C7 SVA on an X-ray. Conclusion: While the CVA and radiographic C2-C7 SVA are weakly correlated in an individual, they seem to represent different aspects of sagittal cervical balance. The CVA cannot replace radiographically measured cervical lordosis. We recommend that more emphasis be given to radiographic measures of sagittal cervical alignment than the CVA when considering patient interventions.

Can the Mismatch of Measured Pelvic Morphology vs. Lumbar Lordosis Predict Chronic Low Back Pain Patients?

Background: Measures of lumbar lordosis (LL) and elliptical modeling variables have been shown to discriminate between normal and chronic low back pain (CLBP) patients. Pelvic morphology influences an individual's sagittal lumbar alignment. Our purpose is to investigate the sensitivity and specificity of lumbar sagittal radiographic alignment and modeling variables to identify if these can discriminate between normal controls and CLBP patients. Methods: We conducted a computer analysis of digitized vertebral body corners on lateral lumbar radiographs of normal controls and CLBP patients. Fifty normal controls were attained from a required pre-employment physical examination (29 men; 21 women; mean age of 27.7 ± 8.5 years), with no history of low back pain, a normal spinal examination, no pathologies, anomalies, or instability. Additionally, 50 CLBP patients (29 men; 29.5 ± 8 years of age) were randomly chosen and matched to the characteristics of the controls. The inclusion criteria required no abnormalities on lumbar spine radiographs. The parameters included the following: ARA L1-L5 lordosis, ARA T12-S1 lordosis, Cobb T12-S1, b/a elliptical modelling ratio, sacral base angle (SBA), and S1 posterior tangent to vertical (PTS1). Two measures of pelvic morphology were determined for each person-the angle of pelvic incidence (API) and posterior tangent pelvic incidence angle (PTPIA)-and the relationships between API - ARA T12-S1, API - Cobb T12-S1, and API - ARA L1-5 was determined. Descriptive statistics and correlations among the primary variables were determined. The receiver operating characteristic curves (ROC curves) for primary variables were analyzed. Results: The mean values of LL were statistically different between the normal and CLBP groups (p < 0.001), indicating a hypo-lordotic lumbar spine for the CLBP group. The mean b/a ratio was lower in the chronic pain group (p = 0.0066). The pelvic morphology variables were similar between the groups (p > 0.05). API had a stronger correlation to the SBA and Cobb T12-S1 than PTPIA did, while PTPIA had a stronger correlation to the S1 tangent and ARA T12-S1 than API did. While CLBP patients had a stronger correlation of ARA T12-S1 and Cobb T12-S1 relative to the pelvic morphology, they also had a reduced correlation of ARA L1-L5 lordosis relative to their SBA and pelvic morphology measures. API - T12-S1, API - L1-L5, and API - Cobb T12-S1 were statistically different between the groups, p < 0.001. Using ROC curve analyses, it was identified that ARA L1-L5 lordosis of 36° and ARA T12-S1 of 68° have a good sensitivity and specificity to discriminate between normal and CLBP patients. ROC curve analyses identified that lordosis ARAT12-S1 < 68° (AUC = 0.83), lordosis ARAL1-L5 < 36° (AUC = 0.78), API - ARA T12-S1 < -18° (AUC = 0.75), API - ARAL1-L5 > 35° (AUC = 0.71), and API - Cobb T12-S1 < -5° (AUC = 0.69) had moderate to good discrimination between groups (AUC = 0.83, 0.78, 0.75, and 0.72). Conclusions: Pelvic morphology is similar between normal and CLBP patients. CLBP patients have an abnormal 'fit' of their API - ARAT12-S1 and L1-L5 lumbar lordosis relative to their pelvic morphology and sacral tilt shown as a hypolordosis.

United States Pharmacopeia (USP) Safety Review of Gamma-Aminobutyric Acid (GABA).

Gamma-amino butyric acid (GABA) is marketed in the U.S. as a dietary supplement. USP conducted a comprehensive safety evaluation of GABA by assessing clinical studies, adverse event information, and toxicology data. Clinical studies investigated the effect of pure GABA as a dietary supplement or as a natural constituent of fermented milk or soy matrices. Data showed no serious adverse events associated with GABA at intakes up to 18 g/d for 4 days and in longer studies at intakes of 120 mg/d for 12 weeks. Some studies showed that GABA was associated with a transient and moderate drop in blood pressure (<10% change). No studies were available on effects of GABA during pregnancy and lactation, and no case reports or spontaneous adverse events associated with GABA were found. Chronic administration of GABA to rats and dogs at doses up to 1 g/kg/day showed no signs of toxicity. Because some studies showed that GABA was associated with decreases in blood pressure, it is conceivable that concurrent use of GABA with anti-hypertensive medications could increase risk of hypotension. Caution is advised for pregnant and lactating women since GABA can affect neurotransmitters and the endocrine system, i.e., increases in growth hormone and prolactin levels.

Radiophobia Overreaction: College of Chiropractors of British Columbia Revoke Full X-Ray Rights Based on Flawed Study and Radiation Fear-Mongering.

Fears over radiation have created irrational pressures to dissuade radiography use within chiropractic. Recently, the regulatory body for chiropractors practicing in British Columbia, Canada, the College of Chiropractors of British Columbia (CCBC), contracted Pierre Côté to review the clinical use of X-rays within the chiropractic profession. A "rapid review" was performed and published quickly and included only 9 papers, the most recent dating from 2005; they concluded, "Given the inherent risks of radiation, we recommend that chiropractors do not use radiographs for the routine and repeat evaluation of the structure and function of the spine." The CCBC then launched an immediate review of the use of X-rays by chiropractors in their jurisdiction. Member and public opinion were gathered but not presented to their members. On February 4, 2021, the College announced amendments to their Professional Conduct Handbook that revoked X-ray rights for routine/repeat assessment and management of patients with spine disorders. Here, we highlight current and historical evidence that substantiates that X-rays are not a public health threat. We also point out critical and insurmountable flaws in the single paper used to support irrational and unscientific policy that discriminates against chiropractors who practice certain forms of evidence-based X-ray-guided methods.

United States Pharmacopeia (USP) comprehensive review of the hepatotoxicity of green tea extracts.

As part of the United States Pharmacopeia's ongoing review of dietary supplement safety data, a new comprehensive systematic review on green tea extracts (GTE) has been completed. GTEs may contain hepatotoxic solvent residues, pesticide residues, pyrrolizidine alkaloids and elemental impurities, but no evidence of their involvement in GTE-induced liver injury was found during this review. GTE catechin profiles vary significantly with manufacturing processes. Animal and human data indicate that repeated oral administration of bolus doses of GTE during fasting significantly increases bioavailability of catechins, specifically EGCG, possibly involving saturation of first-pass elimination mechanisms. Toxicological studies show a hepatocellular pattern of liver injury. Published adverse event case reports associate hepatotoxicity with EGCG intake amounts from 140 mg to ∼1000 mg/day and substantial inter-individual variability in susceptibility, possibly due to genetic factors. Based on these findings, USP included a cautionary labeling requirement in its Powdered Decaffeinated Green Tea Extract monograph that reads as follows: "Do not take on an empty stomach. Take with food. Do not use if you have a liver problem and discontinue use and consult a healthcare practitioner if you develop symptoms of liver trouble, such as abdominal pain, dark urine, or jaundice (yellowing of the skin or eyes)."

Disintegration and Dissolution Testing of Green Tea Dietary Supplements: Application and Evaluation of United States Pharmacopeial Standards.

Approved performance quality tests are lacking in the United States Pharmacopeia (USP) for dietary supplements (DSs) containing green tea extracts. We evaluated the applicability of USP <2040 > general chapter protocols for disintegration and dissolution testing of botanicals to GT DSs. Of 28 single-ingredient GT DSs tested in 2 to 4 lots, 9 (32.1%) always passed the disintegration test, 8 (28.6%) always failed, and 11 (39.3%) showed inconsistent results. Of 34 multi-ingredient DSs tested in 2 lots, 21 (61.8%) passed and 8 (23.5%) failed in both lots, and 5 (14.7%) exhibited inconsistent performance. When stronger destructive forces were applied (disk added), all of the capsules that had failed initially, but not the tablets, passed. In dissolution testing, for the release of epigallocatechin-3-gallate (EGCG), only 6 of 20 single-ingredient DSs passed. Unexpectedly, with the addition of pepsin (prescribed by USP), only one additional DS passed. These results raise concerns that EGCG was not released properly from GT DS dosage forms. However, the general USP protocols may be inadequate for this botanical. More biorelevant destructive forces may be needed to break down capsules and tablets strengthened by the EGCG's interaction with shell material and to overcome the inhibition of digestive enzymes by EGCG.

Potentially toxic pyrrolizidine alkaloids in Eupatorium perfoliatum and three related species. Implications for herbal use as boneset.

INTRODUCTION: Pro-toxic dehydropyrrolizidine alkaloids are associated with liver disease in humans. The potential for long-term, low-level or intermittent exposures to cause or contribute to chronically-developing diseases is of international concern. Eupatorium perfoliatum is a medicinal herb referred to as boneset. While the presence of dehydropyrrolizidine alkaloids in some Eupatorium species is well-established, reports on Eupatorium perfoliatum are scant and contradictory. OBJECTIVE: To investigate the presence of dehydropyrrolizidine alkaloids in a survey of boneset samples and related alcoholic tinctures, and hot water infusions and decoctions. METHODS: Methanol, hot water or aqueous ethanol extracts of Eupatorium perfoliatum and three closely-related species were subjected to HPLC-ESI(+)MS and MS/MS analysis using three complementary column methods. Dehydropyrrolizidine alkaloids were identified from their MS data and comparison with standards. RESULTS: Forty-nine samples of Eupatorium perfoliatum were shown to contain dehydropyrrolizidine alkaloids (0.0002-0.07% w/w), the majority dominated by lycopsamine and intermedine, their N-oxides and acetylated derivatives. Alcoholic tinctures and hot water infusions and decoctions had high concentrations of the alkaloids. Different chemotypes, hybridisation or contamination of some Eupatorium perfoliatum samples with related species were suggested by the co-presence of retronecine- and heliotridine-based alkaloids. CONCLUSIONS: Sampling issues, low and high alkaloid chemotypes of Eupatorium perfoliatum or interspecies hybridization could cause the wide variation in dehydropyrrolizidine alkaloid concentrations or the different profiles observed. Concerns associated with dehydropyrrolizidine alkaloids provide a compelling reason for preclusive caution until further research can better define the toxicity and carcinogenicity of the dehydropyrrolizidine alkaloid content of Eupatorium perfoliatum. [Correction added on 12 July 2018, after first online publication: The 'Conclusions' section in the abstract has been added.].

Naturally complex: Perspectives and challenges associated with Botanical Dietary Supplement Safety assessment.

Due to the extensive use of botanical dietary supplements by consumers in the United States, there is a need for appropriate research and data to support safety assessments. Complexity and variability, both natural and introduced, of botanical dietary supplements make research on these products difficult. Botanical dietary supplements are regulated by the Food and Drug Administration (FDA) under the Federal Food, Drug, and Cosmetic Act (FD&C Act), as amended by the 1994 Dietary Supplement Health and Education Act (DSHEA). They are regulated as a category of food, which differs from the regulation of pharmaceutical products. Both manufacturers and the FDA are faced with the challenge of determining the best approaches for evaluating and monitoring the safety of botanical products. High quality botanicals research requires accurate identification and characterization of the material being studied. Inconsistent results in efficacy studies of botanical dietary supplements have led to efforts to improve the rigor and reproducibility of research in the field. Addressing the challenges associated with botanical dietary supplement safety is a global effort requiring coordination between numerous stakeholders, including researchers, suppliers, manufacturers, and regulators, all of whom play a role in ensuring that high quality products are available on the market.

Anterior head translation following cervical fusion-a probable cause of post-surgical pain and impairment: a CBP® case report.

[Purpose] To present the case of the dramatic reduction in pain, disability, and neurologic symptoms following the reduction of forward head translation and increased cervical curvature in a patient suffering from post-surgical radiculopathy. [Subject and Methods] A 52-year-old male mechanic presented with chronic neck pain, unilateral paresthesia along the C5 and C6 dermatome distributions and diminished unilateral grip strength for 12 years following a C5-C6 cervical discectomy and fusion. Outcome measures included the neck disability index, the numerical pain rating scale, and the Zebris cervical range of motion system. Radiographs and computerized posture analysis revealed excessive forward head posture. Initial traditional 'symptom-relief' chiropractic rehabilitation was provided, followed by CBP® structural rehabilitation of head and neck posture with a 2.5 year follow-up. [Results] The initial traditional chiropractic rehabilitation did not improve posture or disability scores. CBP methods resulted in radiograph-verified postural alignment improvements corresponding with clinically significant improvements in the patient's neurologic condition, pain and disability scores. These results were maintained at a 2.5 year follow-up with minimal treatment. [Conclusion] Patients with post-surgical axial symptoms and/or radicular complaints should be screened for altered cervical alignment and anterior head translation. Future studies should attempt to duplicate these positive results in a trial with long-term follow-up.

FT-NIR characterization with chemometric analyses to differentiate goldenseal from common adulterants.

Goldenseal (Hydrastis canadensis L.) has been a popular herb since the 1970s, with a US market share of over $32 million in 2014. Wild goldenseal has been listed in the Convention on International Trade in Endangered Species for decades. Limits in supply and greed for profit have led to adulteration with similar but more accessible and inexpensive plant materials. Fourier transform near-infrared spectroscopy (FT-NIR) coupled with three different chemometric models, partial least squares (PLS) regression, soft independent modeling of class analogy (SIMCA), and moving window principal component analysis (MW-PCA) provide fast, simple, nondestructive approaches to differentiating pure goldenseal from 4 common pure adulterants (yellow dock, yellow root, coptis, Oregon grape). All three models successfully differentiated authentic goldenseal from adulterants. The models were t-tested for detection of goldenseal intentionally mixed with individual adulterants at 2% to 95% theoretical levels made computationally. The PLS model was unable to detect adulterants mixed with goldenseal at any level. The SIMCA model was the best for detection of yellow root and Oregon grape adulteration in goldenseal, as low as 10%. The MW-PCA model proved best for detection of yellow dock at ≥ 15% and coptis adulteration ≥5% in goldenseal. This study demonstrates that NIR spectroscopy coupled with chemometric analyses is a good tool for industry and investigators to implement for rapid detection of goldenseal adulteration in the marketplace, but also indicates that the specific approach to chemometric analysis must be evaluated and selected on a case-by-case basis in order to achieve useful sensitivity and specificity.

Relief of exertional dyspnea and spinal pains by increasing the thoracic kyphosis in straight back syndrome (thoracic hypo-kyphosis) using CBP® methods: a case report with long-term follow-up.

[Purpose] To present the clinically significant improvement of straight back syndrome (SBS) in a patient with spinal pain and exertional dyspnea. [Subject and Methods] A 19 year old presented with excessive thoracic hypokyphosis and other postural deviations. A multimodal CBP® mirror image® protocol of corrective exercises, traction procedures and spine/posture adjusting were given over an initial 12-week course of intensive treatment followed by a 2.75 year follow-up with minimal supportive treatment. [Results] The patient had significant postural improvements in all postural measures and specifically a 14° increase in the thoracic kyphosis that was maintained at long-term follow-up. The postural improvements were consistent with relief of exertional dyspnea and pain, as well as increases in both antero-posterior thoracic diameter and the ratio of antero-posterior to transthoracic diameter, measurements critical to the wellbeing of patients with SBS. [Conclusion] Long-term follow-up confirmed stable improvement in physiologic thoracic kyphosis in this patient. Nonsurgical correction in thoracic hypokyphosis/SBS can be achieved by mirror image traction procedures configured to flex the thoracic spine into hyperkyphosis as well as corrective exercise and manipulation as a part of CBP technique protocols.

Challenges in Developing Analytically Validated Laboratory-Derived Dietary Supplement Databases.

The Dietary Supplement Label Database (DSLD) is sponsored by the Office of Dietary Supplements (ODS) and the National Library of Medicine (NLM). It provides a searchable, free database of the contents of ∼65,000 supplement labels. A companion database of analytically verified product labels [the Dietary Supplement Ingredient Database (DSID)] was created by ODS, NLM, and the USDA. There are considerable challenges to populating both databases, but the DSID faces unique analytic chemistry challenges. This article describes the challenges to creating analytically verified marketplace surveys of dietary supplement (DS) product content claims for inclusion in public databases. Nutritionists and public health scientists require information on actual exposures to DS constituents because labeled content may not match labeled product content. Analytic verification of composition of DSs provides a link to actual exposure. A public database of analytically derived DS content was developed to provide more accurate estimates of dietary intake in population-based epidemiologic studies. The DSID has conducted surveys of several types of vitamin- and mineral-containing DSs. Results showing label content claims as analytically derived values are available in the current DSID. A recent pilot project explored the feasibility of adding botanical DS products to the DSID. Candidates for future botanical DSID studies will be based on sales volume, potential public health impacts, and the availability of validated analytic methods and reference materials. Databases like DSID and the DSLD are essential for researchers and clinicians to evaluate dietary ingredient intakes in population-based epidemiologic studies. Together, these databases provide a picture of the DS marketplace. The DSID provides an analytic survey of marketed DSs. However, selection of future botanical supplements for DSID evaluation involves analytic challenges. Even when appropriate resources are available, method selection and data evaluation are resource- and time-consuming.

Dietary Supplement Ingredient Database (DSID) and the Application of Analytically Based Estimates of Ingredient Amount to Intake Calculations.

OBJECTIVE: We describe the purpose of the Dietary Supplement Ingredient Database (DSID), the statistical methodology underlying online calculators of analytically verified supplement content estimates, and the application and significance of DSID label adjustments in nutritional epidemiology. BACKGROUND AND HISTORY: During dietary supplement (DS) manufacturing, many ingredients are added at higher than declared label amounts, but overages are not standardized among manufacturers. As a result, researchers may underestimate nutrient intakes from DSs. The DSID provides statistical tools on the basis of the results of chemical analysis to convert label claims into analytically predicted ingredient amounts. These adjustments to labels are linked to DS products reported in NHANES. RATIONALE: Tables summarizing the numbers of NHANES DS products with ingredient overages and below label content show the importance of DSID adjustments to labels for accurate intake calculations. RECENT DEVELOPMENTS: We show the differences between analytically based estimates and labeled content for vitamin D, calcium, iodine, caffeine, and omega-3 (n-3) fatty acids and their potential impact on the accuracy of intake assessments in large surveys. Analytical overages >20% of label levels are predicted for several nutrients in 50-99% of multivitamin-mineral products (MVMs) reported in NHANES: for iodine and selenium in adult MVMs, for iodine and vitamins D and E in children's MVMs, and for iodine, chromium, and potassium in nonprescription prenatal MVMs. Predicted overages of 10-20% for calcium can be applied to most MVMs and overages >10% for folic acid in the vast majority of adult and children's MVMs. FUTURE DIRECTIONS: DSID studies are currently evaluating ingredient levels in prescription prenatal MVMs and levels of constituents in botanical DSs. CONCLUSIONS: We estimate that the majority of MVM products reported in NHANES have significant overages for several ingredients. It is important to account for nonlabeled additional nutrient exposure from DSs to better evaluate nutritional status in the United States.

Characteristics and Challenges of Dietary Supplement Databases Derived from Label Information.

Launched in 2008, the Dietary Supplement Label Database (DSLD) permits the search of any term that appears anywhere on product labels. Since then, the database's search and download features have been periodically improved to enhance use for researchers and consumers. In this review, we describe how to customize searches and identify products and ingredients of interest to users in the DSLD, and provide the limitations of working with information derived from dietary supplement product labels. This article describes how data derived from information printed on product labels are entered and organized in the DSLD. Among the challenges are determining the chemical forms, types of extract, and amounts of dietary ingredients, especially when these are components of proprietary blends. The FDA announced new dietary supplement labeling regulations in May 2016. The 2017 DSLD has been updated to reflect them. These new regulations and examples cited in this article refer to this redesigned version of the DSLD. Search selection characteristics such as for product type and intended user group are as described in FDA guidance and regulations for dietary supplements. For this reason, some age groups (such as teens and seniors) and marketing recommendations for use (e.g., weight loss, performance, and other disease- or condition-specific claims) are not included in the search selections. The DSLD user interface features will be revised periodically to reflect regulatory and technologic developments to enhance user experience. A comprehensive database derived from analytically verified data on composition would be preferable to label data, but is not feasible for technical, logistic, and financial reasons. Therefore, a database derived from information printed on product labels is the only practical option at present for researchers, clinicians, and consumers interested in the composition of these products.

The Dietary Supplement Label Database: Recent Developments and Applications.

Objective: To describe the history, key features, recent enhancements, and common applications of the Dietary Supplement Label Database (DSLD). Background and History: Although many Americans use dietary supplements, databases of dietary supplements sold in the United States have not been widely available. The DSLD, an easily accessible public-use database was created in 2008 to provide information on dietary supplement composition for use by researchers and consumers. Rationale: Accessing current information easily and quickly is crucial for documenting exposures to dietary supplements because they contain nutrients and other bioactive ingredients that may have beneficial or adverse effects on human health. This manuscript details recent developments with the DSLD to achieve this goal and provides examples of how the DSLD has been used. Recent Developments: With periodic updates to track changes in product composition and capture new products entering the market, the DSLD currently contains more than 71,000 dietary supplement labels. Following usability testing with consumer and researcher user groups completed in 2016, improvements to the DSLD interface were made. As of 2017, both a desktop and mobile device version are now available. Since its inception in 2008, the use of the DSLD has included research, exposure monitoring, and other purposes by users in the public and private sectors. Future Directions: Further refinement of the user interface and search features to facilitate ease of use for stakeholders is planned. Conclusions: The DSLD can be used to track changes in product composition and capture new products entering the market. With over 71,000 DS labels it is a unique resource that policymakers, researchers, clinicians, and consumers may find valuable for multiple applications.