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Autism manifests in various progressive, fluctuating, or static differences that may be disabling. This requires healthcare staff to provide individualized, culturally competent care for autistic people (AP). However, staff are underprepared since disability curricula are not universally implemented, which may exacerbate health disparities for AP. The Alliance for Disability in Health Care Education (ADHCE) delineated staff competencies to address disparities. The purpose of this review was to describe what is known about disability education initiatives and health-related outcomes for AP. The review included published literature on disability education for any health personnel providing services to AP in any setting where healthcare services are delivered. In June 2023, six databases were queried. Of 3,396 screened reports, 42 were extracted. Most articles originated in the United States and reported various instructional strategies on child-focused educational content for small interprofessional groups in various settings. The biomedical and biopsychosocial disability models were prominent. The training covered few, if any, ADHCE competencies and rarely involved collaboration with AP. Positive outcomes included improved functional health, behavior, and communication. Patient-reported outcomes and physical and psychosocial health were underreported. Future initiatives should involve scaled-up global efforts, address core competencies for care across the lifespan, and establish community partnerships to ensure meaningful outcomes.

Background: The Millennium Villages Project (MVP) was a 10 year, multisector, rural development project, initiated in 2005, operating across ten sites in ten sub-Saharan African countries to achieve the Millennium Development Goals (MDGs). In this study, we aimed to estimate the project's impact, target attainment, and on-site spending., Methods: In this endline evaluation of the MVP, we retrospectively selected comparison villages that best matched the project villages on possible confounding variables. Cross-sectional survey data on 40 outcomes of interest were collected from both the project and the comparison villages in 2015. Using these data, as well as on-site spending data collected during the project, we estimated project impacts as differences in outcomes between the project and comparison villages; target attainment as differences between project outcomes and prespecified targets; and on-site spending as expenditures reported by communities, donors, governments, and the project. Spending data were not collected in the comparison villages., Findings: Averaged across the ten project sites, we found that impact estimates for 30 of 40 outcomes were significant (95% uncertainty intervals [UIs] for these outcomes excluded zero) and favoured the project villages. In particular, substantial effects were seen in agriculture and health, in which some outcomes were roughly one SD better in the project villages than in the comparison villages. The project was estimated to have no significant impact on the consumption-based measures of poverty, but a significant favourable impact on an index of asset ownership. Impacts on nutrition and education outcomes were often inconclusive (95% UIs included zero). Averaging across outcomes within categories, the project had significant favourable impacts on agriculture, nutrition, education, child health, maternal health, HIV and malaria, and water and sanitation. A third of the targets were met in the project sites. Total on-site spending decreased from US$132 per person in the first half of the project (of which $66 was from the MVP) to $109 per person in the second half of the project (of which $25 was from the MVP)., Interpretation: The MVP had favourable impacts on outcomes in all MDG areas, consistent with an integrated rural development approach. The greatest effects were in agriculture and health, suggesting support for the project's emphasis on agriculture and health systems strengthening. The project conclusively met one third of its targets., Funding: The Open Society Foundations, the Islamic Development Bank, and the governments of Japan, South Korea, Mali, Senegal, and Uganda., (Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Autism Spectrum Disorder (ASD) is a heterogeneous neurodevelopmental disorder characterized by deficits in social interaction and communication as well as restricted patterns of behaviors and interests. Irritability marked by tantrums, self-injury and aggression occurs frequently in youth with ASD, causing significant parent and caregiver distress. Atypical antipsychotics have been the most studied drug class targeting irritability in ASD. Risperidone and aripiprazole are Food and Drug Administration (FDA)-approved atypical antipsychotics for treatment of irritability in youth with ASD. However, other atypical antipsychotics, such as lurasidone, are often considered for off-label use in the treatment of irritability, whether because of tolerability issues with risperidone and aripiprazole or because of the drug-refractory nature of this symptom cluster. Areas covered: Following a comprehensive review of the literature this article summarizes information on the efficacy and tolerability of lurasidone as a potential off label treatment of irritability in children and adolescents with ASD. Available data included a 6 week randomized, blind, fixed dose, placebo-controlled study and a case study. Expert opinion: To date the safety and tolerability of lurasidone in treating irritability in youth with ASD has yet to be established with, lurasidone being the only antipsychotic with published negative placebo-controlled results.

Background: Standardized dental diagnostic terminologies (SDDxTs) were introduced decades ago. Their use has been on the rise, accompanying the adoption of electronic health records (EHRs). One of the most broadly used terminologies is the Dental Diagnostic System (DDS). Our aim was to assess the adoption of SDDxTs by US dental schools by using the Rogers diffusion of innovations framework, focusing on the DDS., Methods: The authors electronically surveyed clinic deans in all US dental schools (n = 61) to determine use of an EHR and SDDxT, perceived barriers to adoption of an SDDxT, and the effect of implementing an SDDxT on clinical productivity., Results: The response rate was 57%. Of the 35 responses, 91% reported using an EHR to document patient care, with 84% using axiUm; 41% used the DDS. Fifty-four percent of those who did not use an SDDxT had considered adopting the DDS, but 38% had not, citing barriers such as complexity and compatibility., Conclusions: Adoption of an SDDxT, particularly the DDS, is on the rise. Nevertheless, a large number of institutions are in the Rogers late majority and laggards categories with respect to adoption. Several factors may discourage adoption, including the inability to try out the terminology on a small scale, poor usability within the EHR, the fact that it would be a cultural shift in practice, and a perception of unclear benefits. However, the consolidation of the DDS and American Dental Association terminology efforts stands to encourage adoption., Practical Implications: The successful adoption of dental innovation depends not only on the intrinsic merit of the innovation, as some useful innovations do not achieve widespread traction. As such, it is important for health care providers to understand how to disseminate their ideas in order to ensure traction and widespread adoption., (Copyright © 2017 American Dental Association. Published by Elsevier Inc. All rights reserved.)

Importance: Frontal fibrosing alopecia has previously been reported as rare among patients of African descent. The authors present 18 cases of frontal fibrosing alopecia affecting African American patients and review all published cases of frontal fibrosing alopecia involving patients of African descent. Observations: Since 2010, there have been 66 published cases of frontal fibrosing alopecia among patients of African descent; 59 women, five men, and two cases of unknown gender. Frontal fibrosing alopecia is not uncommon among patients of African descent. In this study, the authors find that female African American patients may have fewer symptoms and unique clinical presentations. Conclusion and relevance: Frontal fibrosing alopecia is an entity that can be seen in patients with many different ethnic backgrounds, often with varying presentations. The diagnosis of frontal fibrosing alopecia must be considered in any patient of African descent who presents with frontotemporal alopecia. In the authors' patient population, there was a younger age of presentation. The presence of perifollicular hyperpigmentation along the hairline and concomitant facial hyperpigmentation may aid in making the diagnosis and distinguishing this entity from traction alopecia.

Background: Quality improvement requires using quality measures that can be implemented in a valid manner. Using guidelines set forth by the Meaningful Use portion of the Health Information Technology for Economic and Clinical Health Act, the authors assessed the feasibility and performance of an automated electronic Meaningful Use dental clinical quality measure to determine the percentage of children who received fluoride varnish., Methods: The authors defined how to implement the automated measure queries in a dental electronic health record. Within records identified through automated query, the authors manually reviewed a subsample to assess the performance of the query., Results: The automated query results revealed that 71.0% of patients had fluoride varnish compared with the manual chart review results that indicated 77.6% of patients had fluoride varnish. The automated quality measure performance results indicated 90.5% sensitivity, 90.8% specificity, 96.9% positive predictive value, and 75.2% negative predictive value., Conclusions: The authors' findings support the feasibility of using automated dental quality measure queries in the context of sufficient structured data. Information noted only in free text rather than in structured data would require using natural language processing approaches to effectively query electronic health records., Practical Implications: To participate in self-directed quality improvement, dental clinicians must embrace the accountability era. Commitment to quality will require enhanced documentation to support near-term automated calculation of quality measures., (Copyright © 2016 American Dental Association. Published by Elsevier Inc. All rights reserved.)

Background: Attitudes and views are critical to the adoption of innovation. Although there have been broadening calls for a standardized dental diagnostic terminology, little is known about the views of private practice dental team members regarding the adoption of such a terminology., Methods: The authors developed a survey by using validated questions identified through literature review. Domain experts' input allowed for further modifications. The authors administered the final survey electronically to 814 team members at a multioffice practice based in the US Pacific Northwest., Results: Response proportion was 92%. The survey had excellent reliability (Cronbach α coefficient = 0.87). Results suggested that participants showed, in general, positive attitudes and beliefs about using a standardized diagnostic terminology in their practices. Additional written comments by participants highlighted the potential for improved communication with use of the terminology., Conclusions: Dental care providers and staff in 1 multioffice practice showed positive attitudes about the use of a diagnostic terminology; specifically, they believed it would improve communication between the dentist and patient, as well as among providers, while expressing some concerns about whether using standardized dental diagnostic terms helps clinicians to deliver better dental care., Practical Implications: As the dental profession is advancing toward the use of standardized diagnostic terminology, successful implementation will require that dental team leaders prepare their teams by gauging their attitude about the use of such a terminology., (Copyright © 2015 American Dental Association. Published by Elsevier Inc. All rights reserved.)

Objectives: Feasibility of using split-dose bowel preparation in an inpatient setting has not been extensively studied. We conducted a single-centre multiphase study to (1) understand the perceived barriers to split-dose administration among nursing and providers, (2) develop and implement a split-dose electronic order set and (3) evaluate the use and impact of split-dose administration on 100 consecutive colonoscopies., Methods: Nurse/provider interviews were conducted to understand perceived concerns and potential barriers to split-dose preparation. Next, an order set containing specific nursing instructions was developed, disseminated and implemented into the electronic health record as the default order set for inpatient colonoscopies. Finally, 100 consecutive inpatients undergoing colonoscopy were interviewed to determine prep consumption, tolerability and rate of procedural delays due to inadequate preparation., Results: Survey results indicated perceived concerns about inpatients' ability to tolerate and complete the preparation, insufficient nursing support and complexity of preparation administration. Based on this, prep orders were adjusted to accommodate nursing concerns prior to implementation. 54% of inpatients actually completed the bowel preparation in split doses (SPLIT group); the remainder had the conventional full dose preparation (NON-SPLIT). Less procedural delay and a lower rate of additional laxatives use (13% vs 30.4%) were seen in the SPLIT versus NON-SPLIT group. Split-dose preparation was well tolerated among inpatients., Conclusions: Split-dose bowel preparation can be implemented for inpatients undergoing colonoscopy. This multiphase study demonstrates the steps used to implement split-dose preparation at our institution and may provide others with strategies that they could use at their institutions.

Objectives: We investigated general dentists' reasons for recommending removal or retention of third molars and whether patients adhered to dentists' recommendations., Methods: In a 2-year prospective cohort study (2009-2011) in the Pacific Northwest, we followed 801 patients aged 16 to 22 years from 50 general dental practices. Generalized estimating equations logistic regressions related patient and dentist characteristics to dentists' recommendations to remove third molars and to patient adherence., Results: General dentists recommended removal of 1683 third molars from 469 (59%) participants, mainly to prevent future problems (79%) or because a third molar had an unfavorable orientation or was unlikely to erupt (57%). Dentists recommended retention and monitoring of 1244 third molars from 366 (46%) participants, because it was too early to decide (73%), eruption path was favorable (39%), or space for eruption was sufficient (26%). When dentists recommended removal, 55% of participants adhered to this recommendation during follow-up, and the main reason was availability of insurance (88%)., Conclusions: General dentists frequently recommended removal of third molars for reasons not related to symptoms or pathology, but rather to prevent future problems.

Surveys are widely used to gather health information from a sample of individuals. This brief report reviews 14 free and low-cost software packages (< dollar 1,000) that can be used when conducting health surveys with a limited budget. Information available on the Internet or directly from the provider in response to inquiry was reviewed for key features used by health survey researchers. Many free or low-cost software options appropriate for questionnaire development are readily available. Questionnaire mode and complexity, data management and analytical needs, and computing environment are all important considerations in selecting survey software.

An important national health care effort is elimination of racial and ethnic disparities in six specific conditions: infant mortality, cancer screening and management, cardiovascular disease, diabetes, human immunodeficiency virus infection, and child and adult immunizations. To address this concern, several health entities in Nashville, Tennessee responded to a grant initiative from the Centers for Disease Control and Prevention to develop a Racial and Ethnic Approaches to Community Health (REACH) demonstration project. The resulting award is the Nashville REACH 2010 Project, charged to develop sustainable methods to reduce and, in time, eliminate racial and ethnic disparities in cardiovascular disease and diabetes in the North Nashville community, where mortality rates of these diseases are substantially higher than in other parts of the county. As one of its many interests, the project included potential health care providers to receive and disseminate messages about disease prevention and health education. The present paper describes the community-campus partnership between the Nashville REACH 2010 project and the post-baccalaureate program of Meharry Medical College, a partnership that enfolded Meharry's pre-professional health care students into the community-based participatory service research project to increase the awareness and sensitivity of future minority health care providers to issues in minority and poor, underserved populations and to increase potential providers' familiarity with the processes involved in community-based participatory research.

Depression and psychological distress often go unrecognized and untreated in primary care settings. The association between depression, socioeconomic status, and chronic disease underscore the importance of incorporating mental health education and screening into community-based health initiatives. This is particularly critical for African Americans who bear a disproportionate burden of poverty and chronic disease. This descriptive study assessed associations between symptoms of depression, socioeconomic status, healthcare utilization, physical and mental health functioning, and reactions to race among a sample of low-income African Americans. Consistent with the findings of previous research, respondents with symptoms of depression reported lower levels of physical and mental health functioning, and perceived that they had been treated worse by others at work, and had worse healthcare experiences than those of other races. Community-based programs for reducing disparities in physical illness may need to address the burden of undiagnosed and untreated depression in order to become optimally effective.

Incidence of type II diabetes is increasing in the United States and is most prevalent among low-income African Americans. Community health initiatives supported by partnerships of community leaders and health professionals can contribute to the elimination of inequalities in health status. The focus of Racial and Ethnic Approaches to Community Health (REACH) 2010, an initiative sponsored by the Centers for Disease Control and Prevention, is to facilitate the initiation of community-wide changes as well as increase individual empowerment to reduce disparities in diabetes, cardiovascular disease, and cancer. A pilot program developed by REACH health educators and community health partners to improve disease self-management among low-income African American diabetic patients was implemented at a community health center in Nashville, Tenn. The program's major components included health education, individual counseling, screenings, and outreach. The program shows promise of improving patient care and outcomes.

To better understand how neighborhood environments contribute to health outcomes by encouraging or discouraging healthy lifestyles, we studied the clustering of health outcomes, health behaviors, and environmental characteristics in Nashville, Tenn. Data from 2 large telephone surveys (N = 7606) were geocoded and linked to the long-form census data at the census-tract level. Cluster analysis was used to create 12 scales that measured neighborhood characteristics using census variables. A geographic information system was used to map patterns of health, health behavior, and neighborhood characteristics at the census-tract level. Pearson correlations across the 129 census tracts were in the 0.20 to 0.60 range and provided evidence for spatial clustering of health outcomes, health behaviors, and neighborhood characteristics.

Racial and Ethnic Approaches to Community Health (REACH 2010) is a federally sponsored initiative with the goal of reducing and eliminating disparities in health by 2010. The approach is community-driven, wherein community coalitions design, implement, and evaluate the strategies to eliminate health disparities. This article describes the history, development, and activities of Nashville, Tenn, REACH 2010's initiative that targets the reduction of cardiovascular disease and diabetes in African Americans. The team-based strategies, generated with considerable community input, focused on effecting changes in access to healthcare, health and wellness, screening, and tobacco use with the goal of making sustainable behavioral and environmental changes. Evaluation includes a Web-based system for collecting process data and random telephone surveys to monitor the program's impact on health disparities.

This study examined the relation between sense of community (SOC), sociodemographic characteristics, and health status to inform community-based interventions designed to prevent and reduce chronic disease in African Americans. A telephone survey was conducted with 1463 randomly selected residents in Nashville, Tenn. Respondents were majority female (69%), African American (59%), and single (59%), with a mean age of 55 (+/-17.61 years). African Americans have lower overall SOC scores, or lower scores on the domains related to perceived influence over community and sharing of common community values compared to Whites. High rates of chronic disease and low SES, combined with a low SOC, can hinder efforts to reduce and eliminate disparities. The goal of community-based participatory initiatives is to create programs that are sustainable by the target community after the funding is gone. Thus, to maximize the success, uptake, and sustainability of disease-specific interventions, it is imperative to incorporate assessment of SOC, identify factors that depress SOC, and engage in community collaboration to develop a plan to improve SOC.

Community-based screening is 1 of 4 strategies selected by the Nashville REACH 2010 project for reducing disparities in heart disease and diabetes among African Americans in North Nashville, Tenn. We evaluated our screening efforts by asking 4 questions: (1) Are the screening participants representative of the target population? (2) How often were screening participants with possible undiagnosed hypertension, high cholesterol, and diabetes identified? (3) How often were screening participants with an elevated risk for developing hypertension, high cholesterol, and diabetes identified? and (4) How often did we identify screening participants with known hypertension, high cholesterol, and diabetes whose disease management was suboptimal? Results from 1757 persons screened were compared to telephone surveys from 16,199 Nashville residents. Those screened were younger and healthier than the target population. Rates of potentially undiagnosed cases among African Americans were 0.8% for diabetes, 17.4% for hypertension, and 32.7% for high cholesterol. High-risk individuals were identified 13.1% of the time for diabetes, 45.3% of the time for hypertension, and 21.3% of the time for total cholesterol. Rates of poorly controlled known disease were 23.5% for diabetes, 39.0% for hypertension, and 58.2% for total cholesterol. Although we reached a younger and healthier group than the community population, community-based screenings identified many people with potential health risks. We present a model of how to organize and implement successful community-based screening.

The Mouse Genome Database (MGD) forms the core of the Mouse Genome Informatics (MGI) system (http://www.informatics.jax.org), a model organism database resource for the laboratory mouse. MGD provides essential integration of experimental knowledge for the mouse system with information annotated from both literature and online sources. MGD curates and presents consensus and experimental data representations of genotype (sequence) through phenotype information, including highly detailed reports about genes and gene products. Primary foci of integration are through representations of relationships among genes, sequences and phenotypes. MGD collaborates with other bioinformatics groups to curate a definitive set of information about the laboratory mouse and to build and implement the data and semantic standards that are essential for comparative genome analysis. Recent improvements in MGD discussed here include the enhancement of phenotype resources, the re-development of the International Mouse Strain Resource, IMSR, the update of mammalian orthology datasets and the electronic publication of classic books in mouse genetics.

In order to gain a better understanding of diabetes-related health disparities, Nashville REACH 2010 conducted a community baseline survey on health status. A total of 3204 randomly selected African-American (AA) and Caucasian (C) residents of North Nashville, and a comparison sample of residents living in Nashville/Davidson County were interviewed using a computer-assisted telephone interviewing system. Diabetes prevalence was determined, and similarities/differences relative to access to health care, co-morbid conditions, diabetes care, and lifestyle behaviors, were examined. Age-adjusted prevalence of diabetes was 1.7 times higher among AAs. Increasing age (P<.0001) and being AA (P<.01) were predictive of diabetes status in a regression model. African Americans were more likely to be uninsured (P<.01), while Cs had to travel farther to get medical care (P<.0002). Compared to Caucasians, African Americans were 1.6 times more likely to have co-morbid hypertension (P<.004). Reported insulin use was higher (P<.0001) in AAs, and more Cs (25.5% vs 9.1%, respectively) reported taking no medications. African Americans were more likely to report (P<.0001) daily glucose self-monitoring, while more Cs (P<.04) reported having had an eye exam in the last 1 to 2 years. Caucasians reported more (P<.05) active lifestyle behaviors, while AA reported more (P<.001) fat-increasing behaviors. In conclusion, interventions addressing diabetes disparities in the target population should focus on insuring equitable awareness of, and access to, insurance options; managing co-morbidities; improving provider adherence to standards of care; and establishing multi-level supports for lifestyle modifications.

To gain an understanding of health-related practices and perceptions, Nashville REACH 2010 conducted focus studies among 5 community groups. Attitudes about health, personal risk behaviors, quality of health care, and models of personal behavior change were assessed. All focus-group sessions were transcribed and analyzed using a consensus panel methodology. A combined analysis of the focus groups revealed 3 categories of barriers to healthier living: 1) personal, 2) environmental, and 3) systemic. Personal barriers included lack of adequate finances, physical limitations, lack of knowledge, and stress. Environmental barriers were related to the unavailability of healthy food choices and adequate places to exercise in the community. The accessibility and quality of health care were the most pervasive systemic barriers identified. Though these findings are not novel to urban African-American communities, they will serve as the framework by which Nashville REACH 2010 will implement strategies to reduce and, ultimately, eliminate cardiovascular disease and diabetes disparities.

This report chronicles recurring outbreaks of Haemoproteus lophortyx infection in captive bobwhite quail. Clinically, the signs of infection included reluctance to move, ruffled appearance, prostration, and death. These signs were associated with parasitemia, anemia, and the presence of large megaloschizonts in skeletal muscles, particularly those of the thighs and back. The average cumulative mortality for flocks experiencing outbreaks was over 20%. In a typical outbreak, mortality rose when the birds were 5-6 wk of age, peaked in 8-to-10-wk-old quail, and declined rapidly when the quail were 9-11 wk old. Outbreaks occurred exclusively between the months of May and October, and warm weather was determined to be a risk factor for H. lophortyx mortality. This protozoan most likely overwinters in native California quail in the area and is transmitted to quail on the ranch by an insect vector that emerges in warm weather. Infection of the large population of naïve bobwhite quail on the ranch leads to amplification of H. lophortyx, resulting in epidemics in successive flocks.

Despite the increasing acceptance of high frequency jet ventilation (HFJV), very little work has been done to determine if lung damage results from its use. We performed an experimental study to compare the effects of conventional ventilation with those of HFJV on the lung parenchyma of anesthetized dogs. Thirteen animals were studied for periods ranging from 2-24 h. Using a double-lumen Carlen's endotracheal tube, each animals's lungs were ventilated simultaneously but independently, one with conventional ventilation, the other with HFJV. No gross or microscopic evidence of atelectasis or barotrauma was noted in either group. Less hyperaeration was seen in the majority of jet ventilated lungs compared to the conventionally ventilated. In no case did the jet ventilated side show more damage than the control. We concluded that it is possible to use HFJV for 24 h without apparent parenchymal lung damage. Reduced hyperaeration is identified as a possible advantage of HFJV over conventional methods.

The clinical application of high frequency jet ventilation (HFJV), especially in pediatrics, has been hindered by the lack of adequate heating and humidification of the delivered gas. A technique of injecting particulate water into the gas from the jet ventilator has been described in the literature. However, it has been used primarily on adults and may cause fluid overload or hypothermia when used on infants. We describe a device for use during HFJV that provides gas (free of particulate water) to the patient at or near body temperature, with a relative humidity of 91%. This system has been used on 34 persons (14 premature infants, 17 small children, and 3 adults) without complications associated with improper conditioning of inspired gas.

Current techniques of connecting a patient's endotracheal tube to the delivery circuit of a high frequency jet ventilator have several disadvantages. We describe a rigid, interchangeable adapter with a built-in jet injector that connects to any type or size of endotracheal tube. The device is reusable and avoids some of the disadvantages, such as catheter kinking, difficulty in accommodating injectors of different diameters, and tracheal tube obstruction, inherent in other commonly used techniques. It has been used successfully on 44 patients ranging in size from premature infants to adults.

In this study malondialdehyde (MDA) was measured as the thiobarbituric acid (TBA) adduct by high performance liquid chromatography with linolenic acid (LA), as well as with LA to which the following metal ions were added: Ag+1, Al+3, As+5, Ba+2, Cd+2, Co+2, Cu+1, Cu+2, Fe+2, Fe+3, Hg+2, Mn+2, Ni+2, Pb+2, and Zn+2. Our results showed that Fe+3 is a particularly potent catalyst of this oxidation reaction. Several other metals also significantly increased the production of MDA over LA alone, as shown by the Mann-Whitney test, including Al+3 and Fe+2 (p less than 0.001), Cu+2, Ba+2, Mn+2 (p less than 0.01), and As+5 (p less than 0.05). Pb+2 almost completely inhibited the production of MDA from LA (p less than 0.001). Addition of the free radical scavenger, butylated hydroxytoluene (BHT), significantly inhibited MDA formation in these latter reactions, indicating they are free-radical mediated. Pre-incubation of the reaction mixtures at 37 degrees C and physiologic pH with both Fe+2 and Fe+3 greatly increased MDA formation, suggesting that in acute metal toxicity the initiating free-radical process might be primarily due to direct metal catalysis of preformed lipid peroxides.