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NHANES needs urgent attention to ensure its future, which is facing emerging challenges associated with data collection, stagnant funding that has undercut innovation, and the increased call for granular data for subpopulations and groups at risk. The concerns do not rest merely on securing more funding but focus on the need for a constructive review of the survey to explore new approaches and identify appropriate change. This white paper, developed under the auspices of the ASN's Committee on Advocacy and Science Policy (CASP), is a call to the nutrition community to advocate for and support activities to prepare NHANES for future success in a changing nutrition world. Furthermore, because NHANES is much more than a nutrition survey and serves the needs of many in health fields and even commercial arenas, effective advocacy must be grounded in alliances among the survey's diverse stakeholders so that the full range of expertise and interests can engage. This article highlights the complicated nature of the survey along with key overarching challenges to underscore the importance of a measured, thoughtful, comprehensive, and collaborative approach to considering the future of NHANES. Starting-point questions are identified for the purposes of focusing dialog, discussion forums, and research. In particular, the CASP calls for a National Academies of Sciences, Engineering, and Medicine study on NHANES to articulate an actionable framework for NHANES going forward. With a well-informed and integrated set of goals and recommendations that could be provided by such a study, a secure future for NHANES is more readily achievable., (Copyright © 2023 American Society for Nutrition. Published by Elsevier Inc. All rights reserved.)

Background: Barth Syndrome (BTHS) is a rare, X-linked disease characterized by cardioskeletal myopathy and neutropenia. Comparative outcomes after heart transplantation have not been reported., Methods: We identified BTHS recipients across 3 registries (Pediatric Heart Transplant Study Registry [PHTS], Barth Syndrome Research Registry and Repository, and Scientific Registry of Transplant Recipient-Pediatric Health Information System) and matched them 1:4 to non-BTHS, male heart transplant (HT) recipients listed with dilated cardiomyopathy in PHTS. Demographics and survival data were analyzed for all recipients, whereas post-HT infection, malignancy, allograft vasculopathy, and acute rejection were only available for analysis for individuals with PHTS data., Results: Forty-seven BTHS individuals with 51 listings and 43 HTs (including 2 re-transplants) were identified. Age at primary HT was 1.7 years (IQR: 0.6-4.5). Mechanical circulatory support at HT was common (ventricular assist device 29%, extracorporeal membrane oxygenation 5%). Over a median follow-up of 4.5 years (IQR 2.7-9.1), survival for BTHS HT recipients was no different than non-BTHS HT recipients (HR 0.91, 95% CI 0.40-2.12, p = 0.85). Among those with PHTS data (n = 28), BTHS HT recipients showed no difference in freedom from infection (HR 0.64, 0.34-1.22; p = 0.18), malignancy (HR 0.22, 0.02-2.01, p = 0.18), and allograft vasculopathy (HR 0.58, 0.16-2.1, p = 0.41). Freedom from acute rejection (HR 0.39, 0.17-0.86, p = 0.02) was greater for BTHS HT recipients despite similar use of induction (61 vs 73%, p = 0.20), steroids at 30-days (75 vs 62%, p = 0.27), and dual/triple drug immunosuppression at 1-year (80 vs 84%, p = 0.55)., Conclusions: In this largest cohort yet reported, individuals with BTHS have equivalent survival with less acute rejection and no difference in infection or malignancy after HT. When indicated, HT for individuals with BTHS is appropriate., (Copyright © 2021 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Introduced wildlife may be important alternative hosts for generalist ticks that cause health issues for humans and companion animals in urban areas, but to date are rarely considered as part of the tick-host community compared to native wildlife. In Australia, European rabbits, Oryctolagus cuniculus, are a widespread and abundant invasive species common to a range of human-modified ecosystems. To understand the potential role of rabbits in the life cycle of Australian ticks, we investigated the seasonal abundance of all tick life stages (larva, nymph, and adult) on rabbits collected from pest control programs in two urban forest remnants in Sydney, Australia. We also recorded whether larvae, nymphs, and adults were attached to the head, body, or limbs of rabbits to reveal patterns of tick attachment. Of the 2426 Ixodes ticks collected from 42 rabbits, larvae were by far the most abundant life stage (2360), peaking in abundance in autumn, while small numbers of nymphs (62) and adults (4) were present in winter and summer respectively. Larvae were found all over the body, whereas adults and nymphs were predominantly attached to the head, suggesting that the mature life stages use the host landscape differently, or that adults or nymphs may be groomed off the body. The most abundant tick species, as determined by morphology and DNA sequencing, was Ixodes holocyclus, a generalist tick responsible for significant human and companion animal health concerns in Australia. Our findings highlight the importance of understanding the role of introduced wildlife in tick dynamics particularly in novel ecosystems where non-native hosts may be more abundant than native hosts., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier GmbH. All rights reserved.)

Background: Concerns about teratogenicity and maternal and offspring complications restrict the use of lithium during pregnancy for the treatment of mood disorders. We aimed to investigate the association between in-utero lithium exposure and risk of pregnancy complications, delivery outcomes, neonatal morbidity, and congenital malformations., Methods: In this meta-analysis, primary data from pregnant women and their children from six international cohorts based in the community (Denmark, Sweden, and Ontario, Canada) and in clinics (the Netherlands, UK, and USA) were analysed. Pregnancies were eligible for analysis if the pregnancy resulted in a liveborn singleton between 1997 and 2015, if health-related information was available for both mother and infant, and if the mother had a mood disorder (bipolar disorder or major depressive disorder) or if she had been given lithium during pregnancy (at least two dispensations of lithium during pregnancy that were dispensed any time from 1 month before conception until the delivery, or a single lithium dispensation during pregnancy when there was at least one other lithium dispensation within 6 months before or after this date). Pregnancies during which the mother had been prescribed known teratogenic drugs were excluded. Pregnancies were grouped into a lithium-exposed group and a mood disorder reference group. The main outcome measures were pregnancy complications, delivery outcomes, neonatal readmission to hospital within 28 days of birth, and congenital malformations (major malformations and major cardiac malformations). Analyses were done at each site by use of a shared protocol. Adjusted odds ratios (aORs) and 95% CIs were calculated by use of logistic regression models, and site-specific prevalence rates and ORs were pooled by use of random-effects meta-analytical models., Findings: 22   124 eligible pregnancies were identified across the six cohorts, of which 727 pregnancies were eligible for inclusion in the lithium-exposed group (557 [77%] from register-based cohorts and 170 [23%] from clinical cohorts). Lithium exposure was not associated with any of the predefined pregnancy complications or delivery outcomes. An increased risk for neonatal readmission within 28 days of birth was seen in the lithium-exposed group compared with the reference group (pooled prevalence 27·5% [95% CI 15·8-39·1] vs 14·3% [10·4-18·2]; pooled aOR 1·62, 95% CI 1·12-2·33). Lithium exposure during the first trimester was associated with an increased risk of major malformations (pooled prevalence 7·4% [95% CI 4·0-10·7] vs 4·3% [3·7-4·8]; pooled aOR 1·71, 95% CI 1·07-2·72) but for major cardiac malformations the difference was not significant (2·1% [0·5-3·7] vs 1·6% [1·0-2·1]; pooled aOR 1·54, 95% CI 0·64-3·70)., Interpretation: Considering both the effect sizes and the precision of the estimates in this meta-analysis, treatment decisions for pregnant women with mood disorders must weigh the potential for increased risks of lithium during pregnancy-in particular those associated with use of lithium during the first trimester-against its effectiveness at reducing relapse., Funding: None., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

This report addresses the evidence and the uncertainties, knowledge gaps, and research needs identified by participants at the NIH workshop related to iron screening and routine iron supplementation of largely iron-replete pregnant women and young children (6-24 mo) in developed countries. The workshop presentations and panel discussions focused on current understanding and knowledge gaps related to iron homeostasis, measurement of and evidence for iron status, and emerging concerns about supplementing iron-replete members of these vulnerable populations. Four integrating themes emerged across workshop presentations and discussion and centered on 1 ) physiologic or developmental adaptations of iron homeostasis to pregnancy and early infancy, respectively, and their implications, 2 ) improvement of the assessment of iron status across the full continuum from iron deficiency anemia to iron deficiency to iron replete to iron excess, 3 ) the linkage of iron status with health outcomes beyond hematologic outcomes, and 4 ) the balance of benefit and harm of iron supplementation of iron-replete pregnant women and young children. Research that addresses these themes in the context of the full continuum of iron status is needed to inform approaches to the balancing of benefits and harms of screening and routine supplementation., (© 2017 American Society for Nutrition.)

The NIH Office of Dietary Supplements convened a public workshop on iron screening and supplementation in iron-replete pregnant women and young children in 2016 in Bethesda, Maryland. The starting point for the workshop was the recent reports from the US Preventive Services Task Force concluding that there was insufficient evidence to evaluate the benefits and harms associated with iron screening and routine supplementation among asymptomatic pregnant women and young children (6-24 mo old) in the United States. The goal of the workshop was to explore and refine understanding about the existing knowledge gaps and research needs associated with these preventive services for these groups. Given the focus on the United States, planning for the workshop took into account the higher iron status in the United States compared with developing countries and, in turn, included a focus on iron-replete individuals consistent with the U-shaped risk curve for nutrient-health relations. Topic areas included adaptations in iron homeostasis associated with pregnancy and young childhood, the impact of inflammation, measurement of iron status, current estimates of iron status for pregnant women and young children in the United States and in Europe, and emerging evidence suggesting adverse effects associated with iron supplementation of iron-replete individuals. A crosscutting dialogue conducted at the close of the workshop formed the basis for a workshop summary that specified evidence gaps and research needs in a range of areas centered on the relation of these adaptations of iron homeostasis with the response to and risk from iron supplementation as well as the need for indicators informative of the full continuum of iron status and based on health outcomes, not just erythropoiesis., (© 2017 American Society for Nutrition.)

Understanding the iron status in pregnant women in Europe provides a foundation for considering the role of iron screening and supplementation. However, available reports and studies have used different approaches that challenge the devising of overall summaries. Moreover, data on pregnant women are limited, and thus, data on women of reproductive age provide useful background information including baseline iron stores in pregnant women. This review considered data that are available from >15 European countries including national surveys and relevant clinical studies. In European women of reproductive age, median or geometric mean serum ferritin (SF) concentrations were estimated at 26-38 μg/L. Approximately 40-55% of this population had small or depleted iron stores (i.e., SF concentration ≤30 μg/L), and 45-60% of this population had apparently replete iron stores. The prevalence of iron deficiency (ID) and iron deficiency anemia (IDA) was 10-32% and 2-5%, respectively, depending on the cutoffs used. Approximately 20-35% of European women of reproductive age had sufficient iron stores (SF concentration >70 μg/L) to complete a pregnancy without supplementary iron. During pregnancy, European women in controlled supplementation trials who were not receiving iron supplements displayed increasing prevalences of ID and IDA during pregnancy, which peaked in the middle to late third trimester. Available evidence has suggested that, in gestational weeks 32-39, the median or geometric mean SF concentrations were 6-21 μg/L, and prevalences of ID and IDA were 28-85% and 21-35%, respectively. Women who were taking iron supplements had higher iron status and lower prevalences of ID and IDA, which were dependent on the dose of iron and compliance. The data suggest that, in Europe, the iron status of reproductive-aged women varies by region and worsens in pregnancy without iron supplementation., (© 2017 American Society for Nutrition.)

Background: Public health concerns with regard to both low and high folate status exist in the United States. Recent publications have questioned the utility of self-reported dietary intake data in research and monitoring. Objectives: The purpose of this analysis was to examine the relation between self-reported folate intakes and folate status biomarkers and to evaluate their usefulness for several types of applications. Design: We examined usual dietary intakes of folate by using the National Cancer Institute method to adjust two 24-h dietary recalls (including dietary supplements) for within-person variation and then compared these intakes with serum and red blood cell (RBC) folate among 4878 men and nonpregnant, nonlactating women aged ≥19 y in NHANES 2011-2012, a nationally representative, cross-sectional survey, with respect to consistency across prevalence estimates and rank order comparisons. Results: There was a very low prevalence (<1%) of folate deficiency when serum (<7 nmol/L) and RBC (<305 nmol/L) folate were considered, whereas a higher proportion of the population reported inadequate total dietary folate intakes (6%). Similar patterns of change occurred between intakes and biomarkers of folate status when distributions were examined (i.e., dose response), particularly when diet was expressed in μg. Intakes greater than the Tolerable Upper Intake Level greatly increased the odds of having high serum folate (OR: 17.6; 95% CI: 5.5, 56.0). Conclusions: When assessing folate status in the United States, where fortification and supplement use are common, similar patterns in the distributions of diet and biomarkers suggest that these 2 types of status indicators reflect the same underlying folate status; however, the higher prevalence estimates for inadequate intakes compared with biomarkers suggest, among other factors, a systematic underestimation bias in intake data. Caution is needed in the use of dietary folate data to estimate the prevalence of inadequacy among population groups. The use of dietary data for rank order comparisons or to estimate the potential for dietary excess is likely more reliable., (© 2017 American Society for Nutrition.)

Background: Recommendations that may help reduce adverse events outside the perioperative period are uncommon. We identified the primary factors that contributed to patient injury in neurosurgical practice both within the perioperative period and outside the perioperative period., Methods: Medical malpractice claims (n = 355) from The Doctors Company that were closed over 7 years were reviewed by neurosurgical medical experts. Objective neurosurgical expert analysis of the cases identified patient injuries and the primary factor that contributed to the patient injury., Results: Continued pain, nerve damage, and need for additional surgery were the most common injuries. In 145 cases (40.8%), the primary factor that contributed to patient injury occurred outside the perioperative period: assessment (evaluation and diagnosis), selection and management of therapy, and communication between the physician and patient/family. In 138 (38.9%) cases, the primary factor that contributed to patient injury occurred within the perioperative period. Surgical complication (a known risk of the procedure) was the primary factor in 99 cases (27.9%), and technical performance of surgery was the primary factor in only 39 cases (11.0%)., Conclusions: In addition to excellent surgical technique, checklists, teamwork, outcomes measurement, and regionalization of subspecialty care, improving patient safety in neurosurgical practice requires careful attention to care provided outside the perioperative period. Differential diagnosis, consideration of all relevant clinical data, active pursuit of good physician-patient relationships, and adequate monitoring of patients receiving nonsurgical treatment may also help improve patient safety in neurosurgical practice., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The 2007-2010 NHANES provides the first US nationally representative serum 25-hydroxyvitamin D [25(OH)D] concentrations measured by standardized liquid chromatography-tandem mass spectrometry., Objective: We describe patterns for total 25(OH)D and individual metabolites in persons aged ≥1 y stratified by race-ethnicity and grouped by demographic, intake, physiologic, and lifestyle variables., Methods: We measured 25-hydroxycholecalciferol [25(OH)D3], 25-hydroxyergocalciferol [25(OH)D2], and C3-epimer of 25(OH)D3 [C3-epi-25(OH)D3] in serum samples (n = 15,652) from the 2007-2010 cross-sectional NHANES [total 25(OH)D = 25(OH)D3 + 25(OH)D2]., Results: Concentrations (median, detection rate) of 25(OH)D3 (63.6 nmol/L, 100%) and C3-epi-25(OH)D3 (3.40 nmol/L, 86%) were generally detectable; 25(OH)D2 was detectable in 19% of the population. Total 25(OH)D, 25(OH)D3, and C3-epi-25(OH)D3 displayed similar demographic patterns and were strongly correlated (Spearman's r > 0.70). Concentrations of 25(OH)D2 (90th percentile) were much higher in persons aged ≥60 y (17.3 nmol/L) than in younger age groups (≤4.88 nmol/L). We noted significant race-ethnicity differences in mean total 25(OH)D [non-Hispanic blacks (NHBs), Hispanics, and non-Hispanic whites (NHWs): 46.6, 57.2, and 75.2 nmol/L, respectively] and in the prevalence of total 25(OH)D <30 nmol/L overall (24% of NHBs, 6.4% of Hispanics, and 2.3% of NHWs) as well as stratified by season (winter months: 30% of NHBs, 7.5% of Hispanics, and 3.8% of NHWs; summer months: 17% of NHBs, 4.4% of Hispanics, and 1.6% of NHWs). Persons with higher vitamin D intakes (diet, supplements, or both) and those examined during May-October had significantly higher total 25(OH)D. Significant race-ethnicity interactions in a multiple linear regression model confirmed the necessity of providing race-ethnicity-specific estimates of total 25(OH)D., Conclusions: Race-ethnicity differences in the prevalence of low total 25(OH)D remained strong even after adjustment for season to account for the NHANES design imbalance between season, latitude, and race-ethnicity. The strong correlation between C3-epi-25(OH)D3 and 25(OH)D3 may be because the epimer is a metabolite of 25(OH)D3. The presence of 25(OH)D2 mainly in older persons is likely a result of high-dose prescription vitamin D2., (© 2016 American Society for Nutrition.)

Background: The purpose of food fortification is to affect those at the lower end of the distribution curve for nutrient status while avoiding unintended consequences for those at the high end of the distribution. Vitamin D presents challenges in this regard., Objectives: We used scenarios to model changes in concentrations of serum 25-hydroxyvitamin D [25(OH)D] based on increases made because of assumptions about fortification. We then examined the outcomes for balance between improving serum 25(OH)D status for those at risk of inadequacy while avoiding high concentrations for those not at risk., Methods: Data from NHANES 2001-2006 served as baseline serum 25(OH)D concentrations and were used to model shifts in serum 25(OH)D distribution after application of 3 fortification scenarios, including conceptual scenarios and an experiential predictive scenario we developed with the use of statistical modeling of changes in NHANES serum folate concentrations between prefortification and postfortification time periods., Results: All scenarios suggested the possibility of increasing serum 25(OH)D above 125 nmol/L among the proportion of the population at the high end of baseline serum 25(OH)D distribution. The scenario based on serum folate change struck a middle ground between the 2 conceptual scenarios. It predicted a prevalence of 11% <40 nmol/L serum 25(OH)D compared with 17% currently (study baseline), and 8% prevalence of serum 25(OH)D >125 nmol/L compared with <1% currently (study baseline). It also confirmed that fortification affects those at the low end of the status distribution curve differently from those at the high end., Conclusions: Nutrient inadequacy of the type demonstrated by vitamin D--in which the risk is not universal--requires a thorough exploration of the unintended consequences of the overall shift in the distribution of serum 25(OH)D if efforts are made to use fortification to increase the status of persons at risk of deficiency. Fortification is at best a blunt instrument that must be implemented with caution. Moreover, fortification must be preceded by more research to elucidate the dose-response relation between intake and changes in serum 25(OH)D., (© 2015 American Society for Nutrition.)

Fortification is the process of adding nutrients or non-nutrient bioactive components to edible products (e.g., food, food constituents, or supplements). Fortification can be used to correct or prevent widespread nutrient intake shortfalls and associated deficiencies, to balance the total nutrient profile of a diet, to restore nutrients lost in processing, or to appeal to consumers looking to supplement their diet. Food fortification could be considered as a public health strategy to enhance nutrient intakes of a population. Over the past century, fortification has been effective at reducing the risk of nutrient deficiency diseases such as beriberi, goiter, pellagra, and rickets. However, the world today is very different from when fortification emerged in the 1920s. Although early fortification programs were designed to eliminate deficiency diseases, current fortification programs are based on low dietary intakes rather than a diagnosable condition. Moving forward, we must be diligent in our approach to achieving effective and responsible fortification practices and policies, including responsible marketing of fortified products. Fortification must be applied prudently, its effects monitored diligently, and the public informed effectively about its benefits through consumer education efforts. Clear lines of authority for establishing fortification guidelines should be developed and should take into account changing population demographics, changes in the food supply, and advances in technology. This article is a summary of a symposium presented at the ASN Scientific Sessions and Annual Meeting at Experimental Biology 2014 on current issues involving fortification focusing primarily on the United States and Canada and recommendations for the development of responsible fortification practices to ensure their safety and effectiveness., (© 2015 American Society for Nutrition.)

The discrepancy between the commonly used vitamin D status measures-intake and serum 25-hydroxyvitamin D [25(OH)D] concentrations--has been perplexing. Sun exposure increases serum 25(OH)D concentrations and is often used as an explanation for the higher population-based serum concentrations in the face of apparently low vitamin D intake. However, sun exposure may not be the total explanation. 25(OH)D, a metabolite of vitamin D, is known to be present in animal-based foods. It has been measured and reported only sporadically and is not currently factored into U.S. estimates of vitamin D intake. Previously unavailable preliminary USDA data specifying the 25(OH)D content of a subset of foods allowed exploration of the potential change in the reported overall vitamin D content of foods when the presence of 25(OH)D was included. The issue of 25(OH)D potency was addressed, and available commodity intake estimates were used to outline trends in projected vitamin D intake when 25(OH)D in foods was taken into account. Given the data available, there were notable increases in the total vitamin D content of a number of animal-based foods when potency-adjusted 25(OH)D was included, and in turn there was a potentially meaningful increase (1.7-2.9 μg or 15-30% of average requirement) in vitamin D intake estimates. The apparent increase could reduce discrepancies between intake estimates and serum 25(OH)D concentrations. The relevance to dietary interventions is discussed, and the need for continued exploration regarding 25(OH)D measurement is highlighted.

Background: There are questions about the appropriate method for the accurate estimation of the population prevalence of nutrient inadequacy on the basis of a biomarker of nutrient status (BNS)., Objective: We determined the applicability of a statistical probability method to a BNS, specifically serum 25-hydroxyvitamin D [25(OH)D]. The ability to meet required statistical assumptions was the central focus., Design: Data on serum 25(OH)D concentrations in adults aged 19-70 y from the 2005-2006 NHANES were used (n = 3871). An Institute of Medicine report provided reference values. We analyzed key assumptions of symmetry, differences in variance, and the independence of distributions. We also corrected observed distributions for within-person variability (WPV). Estimates of vitamin D inadequacy were determined., Results: We showed that the BNS [serum 25(OH)D] met the criteria to use the method for the estimation of the prevalence of inadequacy. The difference between observations corrected compared with uncorrected for WPV was small for serum 25(OH)D but, nonetheless, showed enhanced accuracy because of correction. The method estimated a 19% prevalence of inadequacy in this sample, whereas misclassification inherent in the use of the more traditional 97.5th percentile high-end cutoff inflated the prevalence of inadequacy (36%)., Conclusions: When the prevalence of nutrient inadequacy for a population is estimated by using serum 25(OH)D as an example of a BNS, a statistical probability method is appropriate and more accurate in comparison with a high-end cutoff. Contrary to a common misunderstanding, the method does not overlook segments of the population. The accuracy of population estimates of inadequacy is enhanced by the correction of observed measures for WPV.

In the US, recognition of the appropriateness of including an upper level of intake estimate among reference values for nutrient substances was made in 1994 when the Food and Nutrition Board of the Institute of Medicine (IOM) specified the inclusion of an "upper safe" level among its proposed reference points for intake of nutrients and food components. By 1998, a group convened by the IOM had established a risk assessment model for establishing upper intake levels for nutrients, eventually termed the tolerable upper intake levels (UL). A risk assessment framework (i.e., a scientific undertaking intended to characterize the nature and likelihood of harm resulting from human exposure to agents in the environment), as developed in other fields of study, was a logical fit for application to nutrients. But importantly, whereas risk assessment requires that information be organized in specific ways, it does not require specific scientific evaluation methods. Rather, it makes transparent and documents the decision-making that occurs given the available data and the related uncertainties. During the 1990s and beyond, the various IOM committees charged with developing UL for a range of nutrients utilized the risk assessment framework, making modifications and adjustments as dictated by the data. This experience informed the general organizational process for establishing UL but also underscored the dearth of data. For many reasons, undertaking scientific research and obtaining data about the effects of excessive intake have been challenging. It is time to consider creative and focused strategies for modeling, simulating, and otherwise studying the effects of excessive intake of nutrient substances.

Background: Myocarditis is a recognized but rare complication of smallpox immunization. It typically presents within 30 days of immunization and on initial presentation shares many characteristics with acute coronary syndrome. Electrocardiogram findings, elevated cardiac enzymes, and undifferentiated chest pain require immediate implementation of therapy directed towards an acute coronary syndrome. In an austere environment, access to advanced care may be limited., Objectives: Smallpox vaccine-mediated myocarditis may present, typically within 30 days of immunization, in such a fashion that it is impossible to distinguish from acute myocardial infarction. The purpose of this article is to alert the clinician to this problem and to provide information to assist in making a suitable diagnosis and disposition in the absence of an absolute diagnosis., Case Report: We present a case of smallpox vaccine-associated myocarditis in an American serviceman deployed in Iraq, and review the literature to determine management of these cases in an emergency setting., Conclusions: This case serves to increase awareness of the association of vaccine-mediated myocarditis in the month after immunization, and the fact that it may present similar to infarction. If the clinical probability of myocarditis is greater than infarction, this will lead the clinician to different treatment modalities., (Published by Elsevier Inc.)

Objective: This study investigated the risks for cerebral palsy in survivors of multiple pregnancies with cofetal loss (< 20 weeks' gestation) or cofetal death (>or= 20 weeks' gestation)., Study Design: The total Western Australian population-based case-control study included 741 cases of cerebral palsy., Results: Antenatal cofetal loss or death occurred in 3% of all cases of cerebral palsy, which is a small but significant contribution. The odds ratio for cerebral palsy in survivors of cofetal loss that included iatrogenic pregnancy reduction was 2.65 (95% confidence interval [CI], 0.78-8.98), which gave a population-attributable proportion of 7.28% (95% CI, 0-27.5), compared with 4.25 (95% CI, 1.12-16.10) and 10.6% (95% CI, 1.0-35.6) for survivors of cofetal death., Conclusion: This study quantifies the contribution of cofetal death to cerebral palsy and suggests that cofetal loss makes a similar, although somewhat smaller, contribution to the risk for cerebral palsy in survivors of multiple pregnancies.

Regulatory officials world-wide are paying attention to the process for establishing the upper level of intake for nutrient substances. The rapidly expanding use of dietary supplements, fortified foods, and functional foods, coupled with increased trade in these products, has focused attention on ensuring their safety and on harmonizing standards internationally. The more traditional approaches, in which the regulators either provided no standards for upper levels of intake or developed standards based on some arbitrary multiple of the intake level known to provide an adequate amount of the nutrient, are recognized as outdated or inappropriate for the emerging issues. Preferred approaches are those that rely on the systematic scientific assessment of risk to determine the levels of intake below which no harm may occur. The scientific study of risk is playing an increased role in establishing the regulatory upper levels of "safe" nutrient intake. Risk assessment, as a component of risk analysis, offers a scientific basis for regulatory decision-making regarding the regulators' task associated with specifying safe upper levels of intake for nutrient substances. This article describes the key components of risk assessment as they are applied within the nutrition field. Although regulatory frameworks vary from country to country and all countries retain their right to determine their own level of protection, regulatory systems operate most effectively and are more likely to converge toward harmonization if they are informed by independent, organized, and scientific reviews that are conducted systematically in a transparent manner.

Atropine autoinjectors are used by the U.S. military as pre-hospital first-line therapy for nerve agent exposure. This case report examines the misuse of these devices in a suicide attempt. An anticholinergic toxidrome resulted from this misuse. The patient was successfully treated.

Objective: This paper will report the results of a pilot test of a 6-month, 21-session intervention to increase breast cancer survivors' physical activity by teaching them to incorporate short periods of moderate activity into their daily routines (lifestyle intervention). The effect of the intervention on physical performance, quality of life, and physical activity are reported., Methods: Sixty breast cancer survivors were randomized to either a lifestyle intervention or a standard care control group. Physical performance, quality of life (Medical outcomes study short form-36 [SF-36]), and physical activity (7-day recall and motivation readiness), were assessed at baseline and 6 months., Results: The lifestyle group had significantly better performance in the 6-min walk task than the controls (p=0.005) at 6 months. The intervention had positive effects on the bodily pain (p=0.020) and general health (p=0.006) subscales from the SF-36. The lifestyle group had a greater motivational readiness for physical activity at 6-month than standard care, but no significant differences were seen between the two in terms of number of minutes of moderate or more intense physical activity or number of days on which they did > or =30 min of moderate or more intense activity., Conclusions: Despite the small sample size, the lifestyle intervention showed promise for improving physical functioning and quality of life and increasing physical activity, and should be tested in a larger randomized trial., Practice Implications: If the lifestyle approach is shown to be effective in a larger trial, it represents a highly feasible intervention that it can be delivered to cancer survivors by health care institutions or community organizations without dedicated exercise facilities and equipment.

It has been shown that men who have sex with men actively seek lubricants that contain nonoxynol-9 (N-9) because they believe that N-9 may help to prevent infection by HIV. However, indirect evidence suggests that N-9 may actually enhance infection. Microscopic examination of rectal lavage and biopsy specimens collected at different time points following rectal application of a lubricant containing 2% N-9 showed rapid exfoliation of the rectal epithelium. Because the rectal epithelium protects target cells in the submucosa from HIV, we conclude that lubricants containing N-9 should be avoided during rectal sex.

Prostate cancer patients receiving androgen ablation therapy experience significant physical and psychological sequelae associated with their disease and treatment. Because physical activity improves physical and psychological well-being, a lifestyle physical activity intervention may help slow or reverse the associated decline in quality of life (QOL). No studies have evaluated an intervention to improve multiple QOL domains in patients receiving androgen ablation therapy. Active for Life After Cancer is a three-group randomized controlled trial designed to evaluate the effectiveness of a lifestyle physical activity intervention (Lifestyle Program) in improving QOL. The Lifestyle Program, a 6-month behavioral skills training group, is compared to an Educational Support Program and Standard Care. The purpose of this paper is to describe the design of the randomized trial and present baseline data that will characterize the QOL of the sample. Challenges to recruitment for the trial also will be presented and discussed.

Nonoxynol-9 (N-9) containing spermicides and other N-9 containing products are commonly used as lubricants during rectal intercourse. We have previously demonstrated that rectal application of N-9 products in mice can cause exfoliation of epithelial cells, increasing the probability of infection by HSV-2. To determine if N-9-containing products would have a similar effect on the rectal epithelium in humans, the application of K-Y Plus and ForPlay, both over-the-counter (OTC) N-9 products, were compared to the application of two formulations, carrageenan and methyl cellulose, that do not contain N-9. The effects of each formulation were evaluated in 4 human participants. Light and electron microscope examination of rectal lavage specimens collected 15 min post application of N-9 products revealed the presence of sheets of epithelium. Each sheet contained hundreds of epithelial cells that included columnar and goblet cells, varieties of cells typical of rectal epithelial morphology. Sheets of epithelium were not observed in rectal lavage specimens collected 8 to 12 hr post N-9 product use or in either of the timed lavages involving non-N-9 containing formulations. In addition, no sheets of epithelial cells were observed in the baseline lavage specimens. We conclude that the rectal use of N-9-containing products causes a rapid exfoliation of extensive areas of the rectal epithelium. Exfoliation of the epithelium is no longer observed at 8 hr. It is reasonable to assume that the loss of the protective epithelium would render a person more at risk for infection by HIV and other sexually transmitted pathogens. We, therefore, caution against the use of N-9-containing products during rectal intercourse.

Conventional topical slush cooling limits lung transport to 4 to 6 hours. For this canine study of an alternate air cooling system, 37 canine lungs were removed: 24 were placed in plastic bags, and inserted in a Transplanthermm container at core air temperatures (n = 6 lungs each) of (A) 4 degrees C, (B) 8 degrees C, (C) 12 degrees C, and (D) 20 degrees C; 6 were stored conventionally in ice slush (E); and 7 were transplanted immediately (F). After 8 hours, the stored lungs were transplanted and the contralateral pulmonary artery was ligated. Survival, arterial oxygen tension, and extravascular lung water were monitored at 15 minutes and every hour for 4 hours. Four-hour survival was 100% in groups A, B, and F; 83% in group C, 50% in group D, and 17% in group E. The mean arterial oxygen tension at 1 hour was lower in group E (6.4 +/- 2.4 kPa) than in group A (39.8 +/- 13.2 kPa) (p = 0.0002) or in group F (42.0 +/- 16.2 kPa) (p = 0.0035). Extravascular lung water in group E was higher at 15 minutes (15.44 +/- 5.63 mL/kg) than in group A (3.76 +/- 0.63 mL/kg) (p = 0.0001) and group F (4.69 +/- 1.65 mL/kg) (p = 0.003). Cold air storage appears to provide better lung preservation than hypothermic immersion in ice slush.

Of 2598 acute admissions to the intensive therapy unit and medical, surgical, orthopaedic, and casualty wards of a general hospital in London, 313 (12%) were definitely alcohol related. Over half (163) the patients concerned were aged between 14 and 40 and 70% (219) were male. The proportion of alcohol-related admissions varied from 7.2% for a general surgical ward up to 26.3% for the casualty overnight observation ward. Substantially higher than average rates of alcohol-related admission were seen in Irish, Scottish, and Polish patients. Of the 23 deaths in the beds under scrutiny in patients aged 17-60 years, 9 were directly attributable to acute or chronic alcohol abuse.

Color flow imaging provides visualization of intracardiac blood flow. The usefulness of this technique was evaluated in 93 patients with atrial septal defect. Color flow imaging improves the sensitivity of two-dimensional Doppler echocardiography in the diagnosis of atrial septal defect. In addition, it enhances communication between the cardiologist and the cardiovascular surgeon.

Two questionnaire measures of the alcohol dependence syndrome, one of alcoholism, and one of alcohol-related problems were compared in a sample of 101 subjects attending a specialist alcohol treatment unit. There was substantial agreement between the two measures of alcohol dependence, and lesser agreement between any other pairing. The measures of alcohol dependence also showed the strongest correlation with reported weekly alcohol consumption. The findings are compared with previous research, and the suitability of the various questionnaires as case-defining instruments in empirical investigations is discussed.