The Conflict between Regulatory Agencies over the 20,000-Fold Lowering of the Tolerable Daily Intake (TDI) for Bisphenol A (BPA) by the European Food Safety Authority (EFSA)

BACKGROUND

The European Food Safety Authority (EFSA) recommended lowering their estimated tolerable daily intake (TDI) for bisphenol A (BPA) 20,000-fold to 0.2  ng / kg  body weight  ( BW ) / day . BPA is an extensively studied high production volume endocrine disrupting chemical (EDC) associated with a vast array of diseases. Prior risk assessments of BPA by EFSA as well as the US Food and Drug Administration (FDA) have relied on industry-funded studies conducted under good laboratory practice protocols (GLP) requiring guideline end points and detailed record keeping, while also claiming to examine (but rejecting) thousands of published findings by academic scientists. Guideline protocols initially formalized in the mid-twentieth century are still used by many regulatory agencies. EFSA used a 21st century approach in its reassessment of BPA and conducted a transparent, but time-limited, systematic review that included both guideline and academic research. The German Federal Institute for Risk Assessment (BfR) opposed EFSA's revision of the TDI for BPA.

OBJECTIVES

We identify the flaws in the assumptions that the German BfR, as well as the FDA, have used to justify maintaining the TDI for BPA at levels above what a vast amount of academic research shows to cause harm. We argue that regulatory agencies need to incorporate 21st century science into chemical hazard identifications using the CLARITY-BPA (Consortium Linking Academic and Regulatory Insights on BPA Toxicity) nonguideline academic studies in a collaborative government-academic program model.

DISCUSSION

We strongly endorse EFSA's revised TDI for BPA and support the European Commission's (EC) apparent acceptance of this updated BPA risk assessment. We discuss challenges to current chemical risk assessment assumptions about EDCs that need to be addressed by regulatory agencies to, in our opinion, become truly protective of public health. Addressing these challenges will hopefully result in BPA, and eventually other structurally similar bisphenols (called regrettable substitutions) for which there are known adverse effects, being eliminated from all food-related and many other uses in the EU and elsewhere. https://doi.org/10.1289/EHP13812.

Diabetes and Toxicant Exposure

The worldwide prevalence of obesity has near tripled between 1975 and 2016. Diabetes was the direct cause of an estimated 1.6 million deaths in 2015. Diabetogens, otherwise known as toxicants that cause insulin resistance in animal models and humans as a result of pancreatic β-cell damage include the persistent organochlorine pesticides trans-nonachlor, oxychlordane, and DDE -the main metabolite of DDT, as well as another class of persistent organic pollutants, polychlorinated biphenyls (PCBs). Other toxicants that are now considered diabetogens: BPA, arsenic, phthalates, perfluorinates (PFOS), diethyl hexyl phthalate (DEHP), and dioxin (TCDD) are commonly found in the blood and urine in the CDC NHANES populations and presumed to also be commonly found in the U.S. population as a whole. A review of the literature on the risk for diabetes in epidemiologic studies considering these toxicants, challenges for clinicians using lab testing for these diabetogens, and the necessary interventions for lowering body burden of persistent toxicants are discussed.

Gastroesophageal reflux disease (GERD): a review of conventional and alternative treatments

Gastroesophageal reflux disorder (GERD), a common disorder in the Western world, can lead to complications that include esophageal stricture and esophageal adenocarcinoma. Multiple challenges are associated with GERD treatment. First, lack of symptoms does not correlate with the absence of or the healing of esophageal lesions. Second, proton pump inhibitors, the current standard of care for GERD, are ineffective for the majority of GERD patients who have non-erosive disease. This article discusses these challenges, investigates the mechanisms of damage in GERD, and explores the existing data on unconventional forms of treatment, including melatonin, acupuncture, botanicals, and dietary interventions.

The Relationship Between Vocational Interests, Self-Efficacy, and Achievement in the Prediction of Educational Pathways

The influence of vocational interest, self-efficacy beliefs, and academic achievement on choice of educational pathway is described for a cohort of Australian students. Participants were 189 students aged 14—15 years, who were considering either academic or applied learning pathways and subject choices for the final 3 years of secondary school. Using Holland’s interest model within a social cognitive career theory (SCCT) framework, logistic regression analyses indicated that all three constructs were significant predictors of pathway and subject selection and enrolment. The best predictive model for students with strong Realistic interests was an interaction of self-efficacy and interest. For Investigative students, both self-efficacy and achievement were best predictors and for Artistic, Social, and Conventional, achievement was the best predictor of future course enrolment. The results of this research offer partial support for the theory of Lent, Brown, and Hackett in that a variable pattern of associations between vocational interest, self-efficacy, and achievement emerged across the Holland interest themes.

Thyroid disruption: mechanism and clinical implications in human health

Exposure to specific environmental toxins, including polychlorinated biphenyls, dioxins, phthalates, polybrominated diphenyl ethers (PBDEs), and other halogenated organochlorines, has been shown to interfere with the production, transportation, and metabolism of thyroid hormones by a variety of mechanisms. A broad range of chemicals, with structural similarity to thyroid hormone, have been shown to bind to thyroid receptors with both agonist and antagonist effects on thyroid hormone signaling. The incidence of thyroid disease in the United States, particularly for thyroid cancer and thyroid autoimmune disease, is increasing substantially. The evidence for the significant effects of background levels of thyroid-disrupting chemicals, the known pathways for thyroid disruptors, and the evidence and implications for neurodevelopmental damage due to thyroid-disrupting chemicals is reviewed.

Mercury exposure, nutritional deficiencies and metabolic disruptions may affect learning in children

Among dietary factors, learning and behavior are influenced not only by nutrients, but also by exposure to toxic food contaminants such as mercury that can disrupt metabolic processes and alter neuronal plasticity. Neurons lacking in plasticity are a factor in neurodevelopmental disorders such as autism and mental retardation. Essential nutrients help maintain normal neuronal plasticity. Nutritional deficiencies, including deficiencies in the long chain polyunsaturated fatty acids eicosapentaenoic acid and docosahexaenoic acid, the amino acid methionine, and the trace minerals zinc and selenium, have been shown to influence neuronal function and produce defects in neuronal plasticity, as well as impact behavior in children with attention deficit hyperactivity disorder. Nutritional deficiencies and mercury exposure have been shown to alter neuronal function and increase oxidative stress among children with autism. These dietary factors may be directly related to the development of behavior disorders and learning disabilities. Mercury, either individually or in concert with other factors, may be harmful if ingested in above average amounts or by sensitive individuals. High fructose corn syrup has been shown to contain trace amounts of mercury as a result of some manufacturing processes, and its consumption can also lead to zinc loss. Consumption of certain artificial food color additives has also been shown to lead to zinc deficiency. Dietary zinc is essential for maintaining the metabolic processes required for mercury elimination. Since high fructose corn syrup and artificial food color additives are common ingredients in many foodstuffs, their consumption should be considered in those individuals with nutritional deficits such as zinc deficiency or who are allergic or sensitive to the effects of mercury or unable to effectively metabolize and eliminate it from the body.

Mercury from chlor-alkali plants: measured concentrations in food product sugar

Mercury cell chlor-alkali products are used to produce thousands of other products including food ingredients such as citric acid, sodium benzoate, and high fructose corn syrup. High fructose corn syrup is used in food products to enhance shelf life. A pilot study was conducted to determine if high fructose corn syrup contains mercury, a toxic metal historically used as an anti-microbial. High fructose corn syrup samples were collected from three different manufacturers and analyzed for total mercury. The samples were found to contain levels of mercury ranging from below a detection limit of 0.005 to 0.570 micrograms mercury per gram of high fructose corn syrup. Average daily consumption of high fructose corn syrup is about 50 grams per person in the United States. With respect to total mercury exposure, it may be necessary to account for this source of mercury in the diet of children and sensitive populations.

Iodine: deficiency and therapeutic considerations

Iodine deficiency is generally recognized as the most commonly preventable cause of mental retardation and the most common cause of endocrinopathy (goiter and primary hypothyroidism). Iodine deficiency becomes particularly critical in pregnancy due to the consequences for neurological damage during fetal development as well as during lactation. The safety of therapeutic doses of iodine above the established safe upper limit of 1 mg is evident in the lack of toxicity in the Japanese population that consumes 25 times the median intake of iodine consumption in the United States. Japan's population suffers no demonstrable increased incidence of autoimmune thyroiditis or hypothyroidism. Studies using 3.0- to 6.0-mg doses to effectively treat fibrocystic breast disease may reveal an important role for iodine in maintaining normal breast tissue architecture and function. Iodine may also have important antioxidant functions in breast tissue and other tissues that concentrate iodine via the sodium iodide symporter.

Multi-institutional phase I trials involve more patients and longer accrual time compared to single institution trials

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Background: There has been a suggested increase in the number of multi-institutional phase I trials over the past decade. Methods: We reviewed all published phase I studies between 1/98 and 12/05 from the Journal of Clinical Oncology and Clinical Cancer Research. 452 phase I studies were identified. The following data were obtained from each study: sponsor (NIH/foreign equivalent vs. pharma), year published, number of participating institutions, mechanism of drug action (8 categories; most common are cytotoxic and targeted therapies), country, number of patients accrued, accrual time and study endpoint (maximum tolerated dose-MTD vs. optimal biological dose- OBD). Results: 55% of phase I trials were single institutional and 21% accrued patients from = 3 institutions. There was no increase over time in the number of multi-institutional studies and no significant association was seen between sponsor and number of institutions. No association was seen between mechanism of drug action and number of participating institutions. There was a highly significant association between number of institutions and number of patients enrolled with multi-institutional studies having higher number of patients per trial (p=0.0003). Pharmaceutical sponsored studies are associated with a greater number of patients per trial (mean 32.8±0.9) as compared to government sponsored (28.4±1) (p<0.05). Only 34% of trials report accrual time. Accrual time is increased in multi-institutional studies (= 3 centers) as compared to single institutional studies (mean 25 vs 22.5 mos) but does not reach statistical significance (p=0.613). No correlation was seen between endpoint of the phase I trial (MTD vs OBD) and number of institutions. OBD studies were strongly associated with agents defined as “targeted”. Studies of cytotoxic agents defined the MTD in 99% of trials versus only 64% of agents categorized as targeted therapies (p<0.0001). Conclusions: Although there has been no increase in the number of published multi-institutional phase I studies, these multi- institutional trials accrue more patients only to reach the same study endpoint but at a cost of greater accrual time. The clinical value of multi- institutional phase I studies is not apparent. Supported by K23 CA109348–01

No significant financial relationships to disclose.

Small cell lung cancer in African Americans

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Background: Several factors associated with prognosis in patients with small cell lung cancer (SCLC) have been established. The association between these known prognostic factors and race, in particular in African Americans has not been reported. This study was conducted to detect differences in presentation and prognostic factors among African Americans when compared to Caucasians. Methods: A retrospective chart review was performed identifying patients diagnosed with SCLC between July 1998 and December 2005. Data collected included demographic information (age, gender and race) as well as clinical information: stage at time of diagnosis, date of diagnosis, date of death, sites of metastases, response to chemotherapy as well as presenting symptoms and lab values including serum sodium, hemoglobin, WBC, platelets, LDH and any evidence of a neurological presentation. Results: Data was available for 198 patients. There was no significant association between race and stage (p=0.594), gender and stage (p=0.731), age and stage (p=0.505) or presence of a neurological symptom at time of diagnosis and stage (p=0.63). There was a trend that African Americans were more likely to present with a neurological symptom when compared to Caucasians (25% vs. 17% respectively) but this was not statistically significant (p=0.285). There was a significant association between race and gender (p=0.019). Of African Americans with SCLC, 71.4% were female while among Caucasians there was a more even distribution between sexes (51% female, 49% male). No significant difference was detected in overall survival when gender or race were examined (p=0.595 and p=0.953 respectively) and the difference when evaluating those with a neurological presentation was marginal (p=0.086). Other prognostic factors were similar amongst Caucasians and African Americans. Conclusions: When compared with Caucasian females, African American females are more likely to be diagnosed with SCLC than their male counterparts. Although not statistically significant, there is also a trend that African Americans with SCLC are more likely to present with neurological symptoms.

No significant financial relationships to disclose.

Lead toxicity part II: the role of free radical damage and the use of antioxidants in the pathology and treatment of lead toxicity

Lead is an environmentally persistent toxin that causes neurological, hematological, gastrointestinal, reproductive, circulatory, and immunological pathologies. The propensity for lead to catalyze oxidative reactions and generate reactive oxygen species has been demonstrated in multiple studies. These reactive oxygen species (ROS) inhibit the production of sulfhydryl antioxidants, inhibit enzyme reactions impairing heme production, cause inflammation in vascular endothelial cells, damage nucleic acids and inhibit DNA repair, and initiate lipid peroxidation in cellular membranes. These wide-ranging effects of ROS generation have been postulated to be major contributors to lead-exposure related disease. Antioxidants - vitamins B6, C and E, zinc, taurine, N-acetylcysteine, and alpha-lipoic acid, either alone or in conjunction with standard pharmaceutical chelating agents - have been studied in lead-exposed animals. The evidence for their use in lead exposure, alone and in conjunction with chelating agents, is reviewed in this article.

Lead toxicity, a review of the literature. Part 1: Exposure, evaluation, and treatment

The phasing out of leaded gasoline for transportation vehicles between 1973 and 1995 and the removal of lead from paint by federal mandate by 1978 have resulted in substantial lowering of mean blood lead levels in all segments of the U.S. population. However, because lead is a persistent metal, it is still present in the environment - in water, brass plumbing fixtures, soil, dust, and imported products manufactured with lead. Diagnosis of lead toxicity has traditionally been based on significantly elevated blood lead levels. However, data now implicates low-level exposures and blood lead levels previously considered normal as causative factors in cognitive dysfunction, neurobehavioral disorders, neurological damage, hypertension, and renal impairment. Chelation is the conventional recommendation in the case of blood levels associated with acute toxicity and encephalopathic damage. Issues surrounding the assessment of body lead burden and the consequences of low-level environmental exposure are critical in the treatment of chronic disease related to lead toxicity.

Selenium biochemistry and cancer: a review of the literature

In recent years, the role of selenium in the prevention of a number of degenerative conditions including cancer, inflammatory diseases, thyroid function, cardiovascular disease, neurological diseases, aging, infertility, and infections, has been established by laboratory experiments, clinical trials, and epidemiological data. Most of the effects in these conditions are related to the function of selenium in antioxidant enzyme systems. Replenishing selenium in deficiency conditions appears to have immune-stimulating effects, particularly in patients undergoing chemotherapy. However, increasing the levels of selenoprotein antioxidant enzymes (glutathione peroxidase, thioredoxin reductase, etc.) appears to be only one of many ways in which selenium-based metabolites contribute to normal cellular growth and function. Animal data, epidemiological data, and intervention trials have shown a clear role for selenium compounds in both prevention of specific cancers and antitumorigenic effects in post-initiation phases of cancer.

Toxic metals and antioxidants: Part II. The role of antioxidants in arsenic and cadmium toxicity

Exposure to toxic metals has become an increasingly recognized source of illness worldwide. Both cadmium and arsenic are ubiquitous in the environment, and exposure through food and water as well as occupational sources can contribute to a well-defined spectrum of disease. The symptom picture of arsenic toxicity is characterized by dermal lesions, anemia, and an increased risk for cardiovascular disease, diabetes, and liver damage. Cadmium has a significant effect on renal function, and as a result alters bone metabolism, leading to osteoporosis and osteomalacia. Cadmium-induced genotoxicity also increases risk for several cancers. The mechanisms of arsenic- and cadmium-induced damage include the production of free radicals that alter mitochondrial activity and genetic information. The metabolism and excretion of these heavy metals depend on the presence of antioxidants and thiols that aid arsenic methylation and both arsenic and cadmium metallothionein-binding. S-adenosylmethionine, lipoic acid, glutathione, selenium, zinc, N-acetylcysteine (NAC), methionine, cysteine, alpha-tocopherol, and ascorbic acid have specific roles in the mitigation of heavy metal toxicity. Several antioxidants including NAC, zinc, methionine, and cysteine, when used in conjunction with standard chelating agents, can improve the mobilization and excretion of arsenic and cadmium.

Mercury toxicity and antioxidants: Part 1: role of glutathione and alpha-lipoic acid in the treatment of mercury toxicity

Mercury exposure is the second-most common cause of toxic metal poisoning. Public health concern over mercury exposure, due to contamination of fish with methylmercury and the elemental mercury content of dental amalgams, has long been a topic of political and medical debate. Although the toxicology of mercury is complex, there is evidence for antioxidant protection in the prevention of neurological and renal damage caused by mercury toxicity. Alpha-lipoic acid, a coenzyme of pyruvate and alpha-ketoglutarate dehydrogenase, has been used in Germany as an antioxidant and approved treatment for diabetic polyneuropathy for 40 years. Research has attempted to identify the role of antioxidants, glutathione and alpha-lipoic acid specifically, in both mitigation of heavy metal toxicity and direct chelation of heavy metals. This review of the literature will assess the role of glutathione and alpha-lipoic acid in the treatment of mercury toxicity.

Nonalcoholic fatty liver disease: relationship to insulin sensitivity and oxidative stress. Treatment approaches using vitamin E, magnesium, and betaine

Nonalcoholic steatotic hepatitis (NASH), the most prevalent form of progressive liver disease in the United States, is considered to be a manifestation of insulin resistance syndrome. There is increasing evidence that steatosis in NASH is a result of the pathology in fat metabolism occurring in obesity and insulin resistance. For steatosis to progress to necroinflammation and fibrosis, however, the theory of mitochondrial oxidative-stress induced cellular damage is receiving wide acceptance. Treatment approaches that address these etiologies are reviewed: betaine, magnesium, and vitamin E.

Eating disorders: a review of the literature with emphasis on medical complications and clinical nutrition

Eating disorders, including anorexia nervosa, bulimia nervosa, binge-eating disorder, and atypical eating disorder (eating disorder not otherwise specified or NOS), are estimated to occur in 5-10 million young and adult women and one million males in the United States. The etiology of eating disorders is complex and appears to include predisposing genetic factors and serotonin dysregulation, as well as psychological factors that include a history of trauma and childhood sexual abuse. Both anorexia nervosa and bulimia nervosa are medical conditions complicated by multiple neuroendocrine dysfunctions, nutritional deficiencies, and psychiatric diagnoses. Medical complications, specific nutritional deficiencies, and research involving the therapeutic use of inositol and zinc are reviewed.

Cumulative illness and neuropsychological decline in hospitalized geriatric patients

A substantial portion of elderly patients admitted for inpatient rehabilitation treatment evidence cognitive dysfunction. Frequently, such patients also present with considerable medical comorbidity, that is, multiple concurrent illnesses. Identifying the potential role of cumulative illness in the etiology of cognitive decline in this group of frail elderly is limited by a lack of empirical information as little is known about this relationship. The goal of the present research was thus to investigate the relationship between cumulative illness and cognitive dysfunction while controlling for age and neurological and psychiatric symptomatology as these are previously known to affect cognitive function. Results indicate that cumulative illness predicts neuropsychological decline beyond the effects attributable to advanced age, mood, neurological pathology and psychiatric impairments. Even mild illness, if cumulative across several physical systems, can be predictive of cognitive deficits in this frail population. Of 11 organ systems studied, impairment of the vascular system was associated with the most diffuse profile of declined neuropsychological performance. Performances on measures of reasoning and judgment showed the strongest associations with cumulative illness. Implications of findings for neuropsychological diagnosis and prognosis are reviewed.

Medical comorbidity and rehabilitation efficiency in geriatric inpatients

OBJECTIVES

To measure and describe medical comorbidity in geriatric rehabilitation patients and investigate its relationship to rehabilitation efficiency.

DESIGN

Prospective, multivariate, within-subject design.

SETTING

The Geriatric Rehabilitation inpatient unit of the SCO Health Service in Ottawa, Canada.

PARTICIPANTS

One hundred ten patients, with a mean age of 82 years.

MEASUREMENTS

The rehabilitation efficiency ratio, based on gains in functional status achieved with rehabilitation treatment, and the length of stay were computed for all patients. Values were regressed on the scores of the Cumulative Illness Rating Scale (CIRS), the Mini-Mental State Examination, and the Geriatric Depression Scale to establish predictive power.

RESULTS

The findings suggest that geriatric rehabilitation patients experience considerable medical comorbidity. Sixty percent of patients had impairments across six of the 13 dimensions of the CIRS, whereas 36% of patients had impairments across 11 of the 13 dimensions. In addition, medical comorbidity was negatively related to rehabilitation efficiency. This relationship was significant even after controlling for age, cognitive status, depressive symptoms, and functional independence status at admission.

CONCLUSION

Medical comorbidity was a significant predictor of rehabilitation efficiency in geriatric patients. Comorbidity scores >5 were prognostic of poorer rehabilitation outcomes and can serve as an empirical guide in estimating a patient's suitability for rehabilitation. Medical comorbidity predicted both the overall functional change achieved with retabilitation (Functional Independence Measure gains) and the rate at with which those gains were reached (rehabilitation efficiency ratio).

Selecting patients for falls-prevention protocols: an evidence-based approach on a geriatric rehabilitation unit

Geriatric rehabilitation treatment focuses on maximizing functional independence in older adults to facilitate a return to independent living following hospitalization. Rehabilitation professionals must therefore balance the need to foster increasing activity levels among patients while, at the same time, preventing falls and potential injuries. This study investigated measures of patient cognition and aspects of health as predictors of the risk for falls among geriatric rehabilitation patients. Fall rates and patient data were collected over an 18-month period. Data from 98 patients were included in the data set. The number of falls was regressed on the patient data to investigate their predictive power. Analyses were also conducted comparing fallers and nonfallers across the independent variables. Results revealed that the primary diagnosis was the only factor evidencing sufficient power for empirical identification of patients at the greatest risk for falls. The clinical implications of findings, in terms of an evidence-based approach to managing falls risk in this population, are discussed in this article.

Cardiovascular disease: C-reactive protein and the inflammatory disease paradigm: HMG-CoA reductase inhibitors, alpha-tocopherol, red yeast rice, and olive oil polyphenols. A review of the literature

The current understanding of the origin of atherosclerosis is that of an inflammatory process that involves the acute phase response -an innate biological response to a disturbance in homeostasis -infection, inflammation, tissue injury, neoplasm, or immune disturbance. The activation of the acute phase response, signaled by interleukin-6, produces proteins (fibrinogen, C-reactive protein (CRP), serum amyloid A) that lead to inflammatory reactions. The tissues themselves contain elevated levels of acute phase proteins and cytokines resulting in a localized inflammatory effect. Localized inflammatory responses in the intimal layer of the arterial wall have been shown to be responsible for many of the aspects of intimal thickening and plaque disruption, leading to acute cardiovascular events. The predictive value of plasma C-reactive protein as a risk factor for cardiovascular events has led some researchers to support the use of CRP as a main cardiovascular risk assessment tool, along with total cholesterol:HDL ratios and homocysteine levels. The ability of HMG-CoA reductase inhibitors to lower C-reactive protein levels has recently brought into question the mechanisms of action of the statin drugs. Because these medications lower incidences of acute cardiovascular events as well as decreasing morbidity and mortality well before the effects of lowered LDL cholesterol can be expected to occur, questions have been asked about whether they may work independently of LDL-lowering mechanisms. Red yeast rice contains a naturally-occurring statin (lovastatin) as well as other cholesterol-lowering compounds, some with antioxidant effects. Alpha-tocopherol also significantly lowers CRP levels in diabetics and nondiabetics, and minimizes other aspects of the acute phase response and inflammatory damage involved in atherosclerosis. This may account for alpha-tocopherol's positive effect on cardiovascular morbidity and mortality. Finally, polyphenolic compounds present in virgin olive oil also have anti-inflammatory and antioxidative effects in cardiovascular disease. The phenolic compounds in virgin olive oil may explain some of the protective effects found in epidemiological studies.

Beta-carotene: the controversy continues

The three beta-carotene intervention trials: the Beta Carotene and Retinol Efficacy Trial (CARET), Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study (ATBC), and Physician's Health Study (PHS) have all pointed to a lack of effect of synthetic beta-carotene in decreasing cardiovascular disease or cancer risk in well-nourished populations. The potential contribution of beta-carotene supplementation to increased risk of lung cancer in smokers has been raised as a significant concern. The safety of synthetic beta-carotene supplements and the role of isomeric forms of beta-carotene (synthetic all-trans versus "natural" cis-trans isomeric mixtures), in addition to the importance of the protective role of other carotenoids like lycopene and lutein, have become topics of debate in the scientific and medical communities. This review addresses the biochemistry and physiology of the cis versus trans isomers of beta-carotene as well as relevant studies comparing the absorption and storage of the synthetic versus natural forms of beta-carotene. In addition, the risk of potential pro-oxidant effects of synthetic beta-carotene supplementation in intervention trials is evaluated.

Nutrients and HIV: part three - N-acetylcysteine, alpha-lipoic acid, L-glutamine, and L-carnitine

The role of antioxidants in preventing apoptosis and viral activation in HIV is well documented. N-acetylcysteine, glutathione, and alpha-lipoic acid have been shown to interrupt the process of viral activation and CD4 cell death. L-glutamine has been shown to improve glutathione levels and significantly increase lean body mass in HIV infection. The literature on the use of L-carnitine and acetyl-L-carnitine in treating mitochondrial toxicity, both in muscle and nerve pathologies is relevant in nutritional treatment of HIV, given the mitochondrial toxicity of nucleoside analog reverse transcriptase inhibitor therapy. The current use of highly active antiviral therapies, their toxicity, and significant failure rates have created the need for a more conservative reassessment of HIV treatment. The adjunctive use of nutrient therapy in the treatment of HIV is reviewed here.

Nutrients and HIV: part two--vitamins A and E, zinc, B-vitamins, and magnesium

There is compelling evidence that micronutrient deficiencies can profoundly affect immunity; micronutrient deficiencies are widely seen in HIV, even in asymptomatic patients. Direct relationships have been found between deficiencies of specific nutrients, such as vitamins A and B12, and a decline in CD4 counts. Deficiencies appear to influence vertical transmission (vitamin A) and may affect progression to AIDS (vitamin A, B12, zinc). Correction of deficiencies has been shown to affect symptoms and disease manifestation (AIDS dementia complex and B12; diarrhea, weight loss, and zinc), and certain micronutrients have demonstrated a direct anti-viral effect in vitro (vitamin E and zinc). The previous article in this series focused on selenium and beta carotene deficiencies in HIV/AIDS. This literature review elucidates how deficiencies of the micronutrients zinc, magnesium, vitamins A, E, and specific B vitamins relate to HIV symptomology and progression, and clearly illustrates the need for nutritional supplementation in HIV disease.

Nutrients and HIV: part one -- beta carotene and selenium

Micronutrient deficiencies are common in HIV/AIDS, resulting from both malabsorption and virally-caused depletion. Beta carotene and selenium deficiencies, two of the most common nutrient deficiencies, are important due to their dual function as nutrients necessary for immune modulation and as antioxidants. Beta carotene deficiencies are common in all stages of HIV/AIDS and may signal malabsorption. Supplementation has been shown to affect specific T lymphocyte populations and decrease markers of lipoperoxides. Selenium levels are highly significant in predicting AIDS-related mortality; and the HIV virus manufactures selenoproteins that are involved in the regulation of viral replication, possibly depleting host levels of selenium. Supplementation trials with individual antioxidants have shown improvement in immunological parameters and decreased evidence of lipid peroxidation.

Hepatitis C: epidemiology and review of complementary/alternative medicine treatments

Hepatitis C is emerging as a serious worldwide problem. In the United States the current mortality figures may triple in the next ten years, rivaling HIV. The disease has a latency of 10-30 years and symptoms or signs may not appear until cirrhosis is evident. Adequate diagnosis, including liver biopsy, is essential in assessing the current stage of the viral infection and the need for treatment. Hepatitis C may manifest as hepatic fibrosis, cirrhosis, hepatocellular carcinoma, lichen planus, glomerulonephritis, mixed cryoglobulinemia, or porphyria. The hepatic damage is due both to the cytopathic effect of the virus and the inflammatory changes secondary to immune activation. The use of the botanical components glycyrrhizin, catechin, silymarin and phytosterols, and the antioxidants N-acetylcysteine and vitamin E are reviewed for their efficacy in treating chronic hepatitis and affecting liver damage.

Comparative absorption of calcium sources and calcium citrate malate for the prevention of osteoporosis

Anthropologically speaking, humans were high consumers of calcium until the onset of the Agricultural Age, 10,000 years ago. Current calcium intake is one-quarter to one-third that of our evolutionary diet and, if we are genetically identical to the Late Paleolithic Homo sapiens, we may be consuming a calcium-deficient diet our bodies cannot adjust to by physiologic mechanisms. Meta-analyses of calcium and bone mass studies demonstrate supplementation of 500 to 1500 mg calcium daily improves bone mass in adolescents, young adults, older men, and postmenopausal women. Calcium citrate malate has high bioavailability and thus has been the subject of calcium studies in these populations. Positive effects have been seen in prepubertal girls, adolescents, and postmenopausal women. The addition of trace minerals and vitamin D in separate trials has improved the effect of calcium citrate malate on bone density and shown a reduction of fracture risk.

A standardized assessment and intervention protocol for managing risk for falls on a geriatric rehabilitation unit

This article describes the intervention protocols implemented at the Sisters of Charity Hospital of Ottawa, Canada on a 36-bed geriatric rehabilitation unit for managing the risk for falls in patients assessed to be at high, moderate, or low risk. The implementation of tailored protocols is of particular importance on rehabilitation units because staff must balance the treatment goal to increase patient mobility, activity level, and independence with the need to prevent falls. Thus, this article also describes the related standardized criteria and decisional guidelines used in determining patients' level of independence on the unit for each fall-risk category. This article concludes with an outline of practices designed to facilitate safe transfers and completion of activities of daily living among geriatric patients with functional impairments by teaching and promoting the use of behavioral compensatory strategies for disability-related deficits.

Aspects of cognitive status as predictors of mobility following geriatric rehabilitation

This study aimed to determine the specific aspects of cognitive functioning which are related to geriatric rehabilitation treatment-outcome, and was based on a within-subject repeated measures design. In the setting of the inpatient Geriatric Rehabilitation Program (GRP) of the SCO Hospital in Ottawa, Canada 40 patients underwent six weeks of physiotherapy treatment for mobility training, on a twice daily schedule. Measurements were performed by the Clinical Outcome Variables Scale (COVS) and a mental status battery composed of five neuropsychological tests. Patients with a poorer mobility status at admission were significantly more depressed, more apraxic, less educated and had greater memory problems than their counterparts. The extent of treatment gains achieved by discharge was significantly related to a single aspect of cognition, namely procedural memory. Longer-term maintenance of treatment gains, however, was predicted by cognitive functioning more globally, including measures of praxis, declarative memory and reasoning. Together, the measures of cognition explained 52% of the variance in functional mobility outcome. In conclusion, patients with mild-to-moderate difficulties of cortically-based higher-order cognitive functions may still achieve significant gains in mobility function following geriatric rehabilitation. However, these patients may not be able to maintain their gains over time to the same extent as their cognitively healthier counterparts. Thus, from an empirical viewpoint, the decision to include or exclude cognitively impaired patients in GRPs varies with the definition of "treatment success" selected (i.e., short-term vs long-term gains). Alternatively, cognitively impaired patients may require more frequent follow-up rehabilitation services in order to maintain their gains.

Synergism in work site adoption of employee assistance programs and health promotion activities

As workplaces increasingly adopt proactive programs directed toward employee health issues, the interrelation between different programs becomes an important issue. Of interest here is the "synergy" in patterns of program adoption between employee assistance programs (EAPs) and health promotion activities (HPAs). We utilize the 1985 National Survey of Worksite Health Promotion Activities (N = 1358) for analyses of the dual presence of EAPs and HPAs, and in multivariate analyses we consider factors affecting such dual presence. The data suggest that synergy occurs, with EAP adoption appearing to influence HPA adoption to a greater extent than the reverse. In multivariate analyses, synergy is confirmed by the finding that, among a variety of relevant organizational characteristics, EAP presence and HPA presence are the best predictors of each other's presence. The analyses also indicate that there is minimal commonality in program ingredients across organizations reporting the presence of HPAs. Implications of the data for the future development of these two programming strategies are discussed.

Impaired interns and residents

In 1981 a study was undertaken to determine intern and resident psychological well-being and identify those house staff who were psychologically impaired. Fourteen percent of house staff were found to be impaired. Single females and house staff who were chronically fatigued or socially isolated were at highest risk for impairment. Impairment arose out of the interaction between sleep and social deprivation and individual vulnerability. Minor tranquilizers, but not alcohol, were used as a coping response to impairment.