Autosomal sex reversal and campomelic dysplasia are caused by mutations in and around the SRY-related gene SOX9

A human autosomal XY sex reversal locus, SRA1, associated with the skeletal malformation syndrome campomelic dysplasia (CMPD1), has been placed at distal 17q. The SOX9 gene, a positional candidate from the chromosomal location and expression pattern reported for mouse Sox9, was isolated and characterized. SOX9 encodes a putative transcription factor structurally related to the testis-determining factor SRY and is expressed in many adult tissues, and in fetal testis and skeletal tissue. Inactivating mutations on one SOX9 allele identified in nontranslocation CMPD1-SRA1 cases point to haploinsufficiency for SOX9 as the cause for both campomelic dysplasia and autosomal XY sex reversal. The 17q breakpoints in three CMPD1 translocation cases map 50 kb or more from SOX9.

Translocation breakpoints in three patients with campomelic dysplasia and autosomal sex reversal map more than 130 kb from SOX9

Campomelic dysplasia (CMPD1) and autosomal XY sex reversal (SRA1) are caused by mutations in the SRY-related gene SOX9 on 17q. Unexpectedly, the 17q breakpoints in four CMPD1 translocation cases previously analyzed by us and others map 50 kb or more from SOX9. Here, we present clinical, cytogenetic, and molecular data from a new CMPD1/SRA1 patient with t(6;17)(q14;q24). Fluorescence in situ hybridization has shown that the 17q breakpoint in this case maps to the same region as the breakpoints in the other translocation cases, at least 130 kb from SOX9. Likewise, the breakpoints in two of the previously described cases also map more than 130 kb and, as shown by pulsed field gel electrophoresis analysis, at most 400 kb or 690 kb from SOX9. By using a SOX9 coding sequence polymorphism, expression of both SOX9 alleles has been demonstrated by the reverse transcriptase polymerase chain reaction in lymphoblastoid cells from one of the translocation cases.

Mouse Dac, a novel nuclear factor with homology to Drosophila dachshund shows a dynamic expression in the neural crest, the eye, the neocortex, and the limb bud

Dac is a novel nuclear factor in mouse and humans that shares homology with Drosophila dachshund (dac). Alignment with available sequences defines a conserved box of 117 amino acids that shares weak homology with the proto-oncogene Ski and Sno. Dac expression is found in various neuroectodermal and mesenchymal tissues. At early developmental stages Dac is expressed in lateral mesoderm and in neural crest cells. In the neural plate/tube Dac expression is initially seen in the prosencephalon and gets gradually restricted to the presumptive neocortex and the distal portion of the outgrowing optic vesicle. Furthermore, Dac transcripts are detected in the mesenchyme underlying the Apical Ectodermal Ridge (AER) of the extending limb bud, the dorsal root ganglia and chain ganglia, and the mesenchyme of the growing genitalia. Dac expression in the Gli 3 mutant extra toes (Xt/Xt) shows little difference compared to the expression in wild-type limb buds. In contrast, a significant expansion of Dac expression are observed in the anterior mesenchyme of the limb buds of hemimelic extra toes (Hx/+) mice. FISH analysis reveals that human DAC maps to chromosome 13q22.3-23 and further fine-mapping defined a position of the DAC gene at 54cM or 13q21.1, a locus that associates with mental retardation and skeletal abnormalities.

Influence of gender on rates of hospitalization, hospital course, and hypercapnea in high-risk patients admitted for asthma : a 10-year retrospective study at Yale-New Haven Hospital

STUDY OBJECTIVES

To compare the relative numbers and hospital course of men vs women admitted at least twice with asthma or status asthmaticus to Yale-New Haven Hospital (YNHH) during the period from 1985 to 1994.

DESIGN

A retrospective chart review.

SETTING

YNHH.

PATIENTS

High-risk men and women (age range, 18 to 50 years) admitted at least twice during the study period with the discharge diagnosis of asthma or status asthmaticus.

RESULTS

Of 561 adult asthma patients admitted during the study period, 188 were admitted at least twice and accounted for 68% of the total asthma admissions. One hundred three of the 188 patients were randomly selected, and all of their asthma admissions were retrospectively reviewed. The 103 patients accounted for 382 admissions. Seventy-two percent of these patients and 68.6% of the admissions were women. The proportions of each gender requiring admission to the medical ICU (15.65% women vs 11.67% men) or intubation (8.00% women vs 5.80% men) were not significantly different. Women did exhibit a definite trend toward longer admissions (4.92 days vs 4.04 days; p < 0.554). A significantly higher proportion of female patient admissions underwent initial arterial blood gas analysis than men (56.9% vs 44.2%; p < 0.05). Factorial analysis demonstrated a highly significant main effect of gender on PCO(2) levels (p < 0.0001). Men, overall, had higher PCO(2) levels than women (48.73 mm Hg vs 41.04 mm Hg; p < 0.036). Male patients admitted to the medical ICU or requiring intubation had significantly higher PCO(2) levels than their respective female counterparts (p < 0.05).

CONCLUSIONS

At YNHH, 68% of all admissions for asthma in this age group are attributable to high-risk patients. High-risk female patients are admitted twice as often as high-risk male patients and tend to have longer admissions. Once admitted, however, the proportion of men and women requiring the medical MICU or intubation were similar. High-risk male patients on presentation are consistently more hypercapneic than high-risk female patients. Therefore, the mechanisms contributing to the gender differences in asthma admissions may include differences in the ventilatory response to hypercapnea or in the tolerance to airway obstruction.

A translocation breakpoint cluster disrupts the newly defined 3' end of the SNURF-SNRPN transcription unit on chromosome 15

Balanced translocations affecting the paternal copy of 15q11--q13 are a rare cause of Prader-Willi syndrome (PWS) or PWS-like features. Here we report on the cytogenetic and molecular characterization of a de novo balanced reciprocal translocation t(X;15)(q28;q12) in a female patient with atypical PWS. The translocation breakpoints in this patient and two previously reported patients map 70-80 kb distal to the SNURF-SNRPN gene and define a breakpoint cluster region. The breakpoints disrupt one of several hitherto unknown 3' exons of this gene. Using RT--PCR we demonstrate that sequences distal to the breakpoint, including the recently identified C/D box small nucleolar RNA (snoRNA) gene cluster HBII-85 as well as IPW and PAR1, are not expressed in the patient. Our data suggest that lack of expression of these sequences contributes to the PWS phenotype.

Silicone rubber temporomandibular joint (TMJ) meniscal replacements: postimplant histopathologic and material evaluation

Medical grade silicone rubber has long been considered a suitable meniscal replacement, but there has been increasing concern about migration of this material into adjacent tissues. The objectives of this study were to determine the definitive composition of tissue-incorporated material which is presumed by light microscopy to be silicone and to identify long term histopathologic sequelae of meniscal replacements. Adult female patients underwent meniscectomy and replacement with silicone rubber (Silastic) implants. After 12 to 18 months, recurrence of symptoms in 8% of these cases led to implant removal with excision of peri-implant fibrous pseudocapsules. Excised tissues, including one preauricular lymph node and implants were submitted for light microscopy, SEM, and energy dispersive x-ray microanalysis (EDX) for the identification of elemental composition, critical surface tension measurement, and internal reflection infrared spectroscopy. EDX revealed prominent peaks for silicon in both pseudocapsular and nodal tissues. Morphologic findings surrounding the long-term implants included foreign body reaction, synovitis, dystrophic calcification, fibrocartilaginous metaplasia, hyalinization, and scarring. Particulate silicone debris induced a pathologic response in the tissues and migrated to nodes. These findings suggest that periodic evaluation be performed over the life of such implants to rule out breakdown under function. These findings should intensify the search for improvements or replacements for silicone rubber as an interpositional material in the temporomandibular joint.

Volatile compounds released by enzymatic hydrolysis of glycoconjugates of leaves and grape berries from Vitis vinifera Muscat of Alexandria and Shiraz cultivars

Glycoconjugates from Muscat of Alexandria and Shiraz leaves and grape berries were isolated by adsorption on Amberlite XAD-2 resin, and enzymatically released aglycons were analyzed by GC-FID and GC-MS. About 120 aglycons were fully or tentatively identified. Compositional differences were observed between leaves and berries of the two varieties in five aglycon chemical groups: C6 alcohols, aliphatic alcohols, monoterpenes, shikimates, and C(13)-norisoprenoids, which were much more abundant in the leaves than in the berries. The differences observed for C(13)-norisoprenoids were in agreement with their hypothetical independent biosynthesis in leaves and berries. Thus, 3-hydroxy-beta-damascone, an important norisoprenoid aglycon of grape berries, was not detected in leaves, whereas its oxidized derivative, 3-oxo-alpha-damascone, was absent in berries. Compositional differences were also observed between Muscat and Shiraz leaves. 3-Oxo-alpha-ionol was not detected in Shiraz leaves, and its retro derivatives were less abundant than in Muscat of Alexandria leaves. Conversely, in Shiraz leaves the levels of 7,8-dihydroionone derivatives, such as megastigman-3,9-diol and 3-oxo-7,8-dihydro-alpha-ionol, were higher than in Muscat of Alexandria leaves.

Clinical and molecular-cytogenetic studies in seven patients with ring chromosome 18

We report the results of detailed clinical and molecular-cytogenetic studies in seven patients with ring chromosome 18. Classical cytogenetics and fluorescence in situ hybridization (FISH) analysis with the chromosome 18 painting probe identified five non-mosaic and two complex mosaic 46,XX,dup(18)(p11.2)/47,XX,dup(18)(p11.2),+r(18) and 46,XX,dup(18)(p11.32)/47,XX,dup(18)(p11.32),+r(18) cases. FISH analysis was performed for precise characterization of the chromosome 18 breakpoints using chromosome 18-specific short-arm paint, centromeric, subtelomeric, and a panel of fifteen Alu- and DOP-PCR YAC probes. The breakpoints were assessed with an average resolution of approximately 2.2 Mb. In all r(18) chromosomes, the 18q terminal deletions ranging from 18q21.2 to 18q22.3 ( approximately 35 and 9 Mb, respectively) were found, whereas only in four cases could the loss of 18p material be demonstrated. In two cases the dup(18) chromosomes were identified as inv dup(18)(qter-->p11.32::q21.3-->qter) and inv dup(18)(qter-->p11.32::p11.32-->p11.1: :q21.3-->qter)pat, with no evidence of an 18p deletion. A novel inter-intrachromatid mechanism of formation of duplications and ring chromosomes is proposed. Although the effect of "ring instability syndrome" cannot be excluded, the phenotypes of our patients with characteristic features of 18q- and 18p- syndromes are compared and correlated with the analyzed genotypes. It has been observed that a short neck with absence of cardiac anomalies may be related to the deletion of the 18p material from the r(18) chromosome.

Functional hemizygosity of PAFAH1B3 due to a PAFAH1B3-CLK2 fusion gene in a female with mental retardation, ataxia and atrophy of the brain

We report on the molecular characterization of a translocation t(1;19)(q21.3;q13.2) in a female with mental retardation, ataxia and atrophy of the brain. Sequence analysis of the breakpoints revealed an ALU:-repeat-mediated mechanism of recombination that led to truncation of two genes: the kinase CLK2 and PAFAH1B3, the gene product of which interacts with LIS1 as part of a heterotrimeric G protein complex PAF-AH1B. In addition, two reciprocal fusion genes are present. One expressed fusion gene encodes the first 136 amino acids of PAFAH1B3 followed by the complete CLK2 protein. Truncated PAFAH1B3 protein lost its potential to interact with LIS1 whereas CLK2 activity was conserved within the fusion protein. These data emphasize the importance of PAF-AH1B in brain development and functioning and demonstrate the first fusion gene apparently not associated with cancer.

High resolution comparative genomic hybridisation analysis reveals imbalances in dyschromosomal patients with normal or apparently balanced conventional karyotypes

A sensitive technique is needed for screening whole genome imbalances in dyschromosomal patients when G-banding shows normal karyotypes or apparently balanced translocations. In this study we performed highly sensitive comparative genomic hybridisation analysis on a number of such cases and revealed chromosomal imbalances in all.

Viral assemblage composition in Yellowstone acidic hot springs assessed by network analysis

Understanding of viral assemblage structure in natural environments remains a daunting task. Total viral assemblage sequencing (for example, viral metagenomics) provides a tractable approach. However, even with the availability of next-generation sequencing technology it is usually only possible to obtain a fragmented view of viral assemblages in natural ecosystems. In this study, we applied a network-based approach in combination with viral metagenomics to investigate viral assemblage structure in the high temperature, acidic hot springs of Yellowstone National Park, USA. Our results show that this approach can identify distinct viral groups and provide insights into the viral assemblage structure. We identified 110 viral groups in the hot springs environment, with each viral group likely representing a viral family at the sub-family taxonomic level. Most of these viral groups are previously unknown DNA viruses likely infecting archaeal hosts. Overall, this study demonstrates the utility of combining viral assemblage sequencing approaches with network analysis to gain insights into viral assemblage structure in natural ecosystems.

Molecular cytogenetic characterisation of partial trisomy 9q in a case with pyloric stenosis and a review

Partial trisomy 9q represents a rare and heterogeneous group of chromosomal aberrations characterised by various clinical features including pyloric stenosis. Here, we describe the case of a 1 year old female patient with different dysmorphic features including pyloric stenosis and prenatally detected partial trisomy 9q. This partial trisomy 9q has been analysed in detail to determine the size of the duplication and to characterise the chromosomal breakpoints. According to the data gained by different molecular cytogenetic techniques, such as fluorescence in situ hybridisation (FISH) with whole and partial chromosome painting probes, yeast artificial chromosome (YAC) probes, and comparative genomic hybridisation (CGH), the derivative chromosome 9 can be described as dup(9)(pter-->q22. 1::q31.1-->q22.1::q31.1--> q22.1::q31.1-->qter). Four breakpoint spanning YACs have been identified (y806f02, y906g6, y945f5, and y747b3) for the proximal breakpoint. According to this new case and previously published data, the recently postulated putative critical region for pyloric stenosis can be narrowed down to the subbands 9q22.1-q31.1 and is the result of either partial trisomy of gene(s) located in this region or a gene disrupted in 9q31.

Elliptic flow in Au+Au collisions at square root(S)NN = 130 GeV

Elliptic flow from nuclear collisions is a hadronic observable sensitive to the early stages of system evolution. We report first results on elliptic flow of charged particles at midrapidity in Au+Au collisions at square root(S)NN = 130 GeV using the STAR Time Projection Chamber at the Relativistic Heavy Ion Collider. The elliptic flow signal, v2, averaged over transverse momentum, reaches values of about 6% for relatively peripheral collisions and decreases for the more central collisions. This can be interpreted as the observation of a higher degree of thermalization than at lower collision energies. Pseudorapidity and transverse momentum dependence of elliptic flow are also presented.

Complex FISH probes for the subtelomeric regions of all human chromosomes: comparative hybridization of CEPH YACs to chromosomes of the Old World monkey Presbytis cristata and great apes

We have generated a human subtelomere probe panel, utilizing well characterized CEPH YACs, for the investigation of human chromosome pathology and evolution through fluorescent in situ hybridization (FISH). Region-specific FISH probes will be extremely valuable for detecting cytogenetically cryptic telomere abnormalities. Here, we present the first comparative mapping study (with 29 subtelomere probes and 6 chromosome paints) to the Old World monkey Presbytis cristata, followed by hybridizations to the great apes, gorilla and orangutan, when rearrangements were detected. We observed that the position of telomere-associated genomic sequences has been only moderately conserved during primate evolution. YAC 364f9, specific for the subtelomeric long arm of human chromosome 3, contains an evolutionary inversion breakpoint that was involved in independent chromosome rearrangements in P. cristata and gorilla.

Sequence determination and molecular characterization of gigantin, a cytotoxic protein produced by the mould Aspergillus giganteus IFO 5818

Gigantin is a 17-kDa ribonuclease secreted by Aspergillus giganteus IFO 5818. The sequence of the genomic DNA coding for this protein is reported. The deduced amino acid sequence reveals nine amino acid variations with respect to alpha-sarcin, a well-characterized ribosome-inactivating protein from A. giganteus MDH 18894. The peptides obtained after tryptic digestion of reduced and carboxyamidomethylated gigantin have been chromatographically separated. The analysis of these peptides in comparison to those originating from alpha-sarcin corroborates the above sequence differences. These do not sensibly modify the conformation of the protein, based on the coincidence of the circular dichroism and fluorescence emission spectra of the two proteins. The obtained results are discussed in terms of the involvement of the distinctive residues in the immunological and catalytic properties that distinguish gigantin from alpha-sarcin.

Urinary incontinence in gynecological oncology patients

The objective of this study was to investigate the prevalence and significance of urinary incontinence (UI) symptoms in gynecological oncology (GO) patients and to test the gynecologists' proficiency in eliciting these symptoms. A prospective survey using questionnaires was designed. Two faculty practice offices in the United States were chosen for the study. Forty GO patients and 40 general gynecology patients were selected from the most recent outpatient appointments of the two hospitals. We used the Urogenital Distress Inventory and the Incontinence Impact Questionnaire to elicit UI symptoms in GO patients and compared the results with their medical records. A control group, selected from a general gynecological practice, was included for comparison. The main outcome measures were to investigate the prevalence and detection rates of UI in GO patients. GO patients were significantly more likely to report UI symptoms on the questionnaire than their gynecologist was able to elicit during a consultation (P < 0.001). The survey found that 60% (24/40) of the GO patients reported at least one symptom of UI, with 23% complaining of "severe" symptoms. Of those patients who reported the symptoms on questionnaire, only 5% (2/40) were detected at the initial physician assessment (P < 0.01). Eighteen percent of the GO patients reported that the UI symptoms adversely affected their quality of life. The prevalence of symptoms was not associated with the primary cancer site. There was no difference in detection rates between the two practice settings. In a multivariate analysis, there was no factor that emerged as the best discriminator for a positive response to the questionnaire. A significant proportion of GO patients report severe UI symptoms that are not detected by gynecologic oncologists or gynecologists during routine consultations.

LAR-PTPase cDNA transfection suppression of tumor growth of neu oncogene-transformed human breast carcinoma cells

The incidence of amplification of neu oncogene-encoded protein tyrosine kinase in human breast cancer strongly supports the concept that protein tyrosine phosphorylation and dephosphorylation are key regulatory mechanisms in the proliferation, differentiation, and neoplastic transformation of breast epithelial cells. We examined the potential regulatory role of protein tyrosine phosphatases (PTPases) in the maintenance of cellular tyrosine phosphorylation by the introduction of leukocyte common-antigen-related PTPase (LAR-PTPase) cDNA into a tumorigenic human breast carcinoma cell line that overexpressed p185neu protein tyrosine kinase. The transfected human breast carcinoma cells expressed elevated levels of LAR-PTPase as assessed by reverse transcription-polymerase chain reaction and by analysis of LAR-PTPase protein. The LAR-PTPase-transfected human breast carcinoma cells had a significantly (P < 0.01) slower proliferation rate in vitro than control-transfected cells. When LAR-PTPase-transfected cells were inoculated into athymic nude mice, a consistent and significant (P < 0.05) suppression of tumor growth was observed. These results provide evidence that a specific PTPase, LAR-PTPase, can play a suppressive regulatory role in the tumor growth of human breast carcinoma cells that overexpress p185neu protein tyrosine kinase.

Molecular cytogenetic detection of 9q34 breakpoints associated with nail patella syndrome

The nail patella syndrome (NPS1) is an autosomal dominant disorder characterised by dysplasia of the finger nails and skeletal abnormalities. NPS1 has been mapped to 9q34, to a 1 cM interval between D9S315 and the adenylate kinase gene (AK1). We have mapped the breakpoints within the candidate NPS1 region in two unrelated patients with balanced translocations. One patient [46,XY,t(1;9)(q32.1;q34)] was detected during a systematic survey of old cytogenetic files in Denmark and southern Sweden. The other patient [46,XY,t(9;17)(q34.1;q25)] was reported previously. D9S315 and AK1 were used to isolate YACs, from which endclones were used to isolate PACs. Two overlapping PAC clones span the 9q34 breakpoints in both patients, suggesting that NPS1 is caused by haploinsufficiency due to truncation or otherwise inactivation of a gene at or in the vicinity of the breakpoints.

Micronutrient status in Jordan: 2002 and 2010

BACKGROUND/OBJECTIVES

Two national surveys were conducted in Jordan in 2002 and 2010 to investigate the micronutrient status in women and children. To determine the prevalence of anemia, iron and folate deficiency among women and children in 2010 and compare with the prevalence of anemia and iron deficiency in 2002.

SUBJECTS/METHODS

A nationally representative survey was conducted in 2002 (1023 women, 15-49 years of age; 1059 children, 12-59 months of age) and a second survey in 2010 (2035 women; 940 children). Venous blood samples were used to measure hemoglobin, ferritin and red blood cell folate (the latter on a subsample of 393 women).

RESULTS

Among women in 2010, the prevalence of folate deficiency and insufficiency was 13.6% and 82.9%, respectively. Geometric mean serum ferritin was higher in 2010 compared with 2002 (21.3 ng/ml vs 18.3, P=0.01); there was no significant change in the prevalence of iron deficiency (35.1% vs 38.7%, P=0.17), iron deficiency anemia (19.1% vs 20.0%, P=0.61) or anemia (29.2% vs 29.3%, P=0.96). Among children, a significantly lower prevalence was observed in 2010 compared with 2002 for iron deficiency (13.7% vs 26.2% P<0.001) and iron deficiency anemia (4.8% vs 10.1%, P<0.001); a nonsignificant lower prevalence was observed for anemia (16.6% vs 20.2%, P=0.09).

CONCLUSIONS

In 2010, approximately one of seven women was folate deficient and six out of seven were folate insufficient for the prevention of neural tube defects. Between 2002 and 2010, significant improvement was observed in the prevalence of iron deficiency in children, but not in women.

SOX20, a new member of the SOX gene family, is located on chromosome 17p13

SOX genes share a high sequence identity with the HMG box present in the testis determining gene SRY. We have identified a HMG box-like sequence motif on six contiguous cosmids, which cross-hybridize to a SOX9 cDNA probe. A data base search revealed a high similarity of the deduced amino acid sequence to the human SOX12 and the murine Sox16 HMG domains. The cosmids were assigned to chromosome 17p13 by FISH analysis.

Molecular cloning of the critical region for glomerulopathy with fibronectin deposits (GFND) and evaluation of candidate genes

Glomerulopathy with fibronectin deposits (GFND, MIM 601894) is an autosomal dominant kidney disease that leads to terminal renal failure at a median age of 47 years. It represents a distinct entity of membranoproliferative glomerulonephritis (MPGN) type III and is characterized by the unique feature of massive glomerular deposits of fibronectin. We have recently localized a gene locus for GFND to human chromosome 1q32 by total genome linkage analysis in a large kindred, within a 4.1-cM critical interval between markers D1S2872 and D1S2891. This interval contains a cluster of genes for "regulators of complement activation" (RCA), which represent strong candidates for GFND. To identify positional candidate genes for GFND within the critical genetic interval, we here report the cloning of the entire critical GFND region in a complete YAC and partial PAC contig. We constructed a high-resolution transcriptional map, thereby defining positional and functional candidate genes for the disease. To evaluate their role in GFND, we performed functional studies on RCA proteins in GFND patients from the large kindred, as well as mutational analysis of the genes for complement receptor-2 (CR2), membrane cofactor protein (MCP), and decay accelerating factor (DAF). Although no loss-of-function mutation has been identified as yet, these data provide a basis for the examination of candidate genes for GFND and other genes for MPGN, which localize to the vicinity of the GFND region.

Molecular cytogenetic analysis of a de novo balanced X;autosome translocation: Evidence for predominant inactivation of the derivative X chromosome in a girl with multiple malformations

We report on the characterization of a de novo, apparently balanced translocation t(X;15)(p11.3;q26) detected in a girl with multiple congenital malformations. Replication banding studies on Epstein-Barr virus transformed peripheral blood lymphocytes revealed non-random X chromosome inactivation with predominant inactivation of the derivative X chromosome. Using chromosomal fluorescence in situ hybridization (FISH), we located the breakpoints to a 30 kb region on the short arm of the X chromosome band p11.3 and to a 160 kb region defined by BAC RP11-89K11 on the long arm of chromosome 15. Our data suggest that the disruption/disturbance of plant homeo domain (PHD) zinc finger gene KIAA0215 or of another gene (RGN, RNU12, P17.3, or RBM10) in the breakpoint region on the X chromosome is not well tolerated and leads to the selection of cells with an active non-rearranged X chromosome.

Research competencies in the dietetics curricula

Investment in dietetics research has the potential to improve general health; increase work performance and learning capacity; extend disease-free life; reduce birth defects, infections, and chronic diseases; and decrease health care costs. Opportunities exist for research in the areas of solid waste management, global environment, health care reform, and foodservice systems management. Research efforts can focus on cost-effectiveness and medical efficacy of dietary services to improve third-party reimbursement. Educators have a stake in creating the future by conducting research, teaching research to dietetic students, and investigating the effectiveness of education.