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Assistant Professor, University of Kansas School of Medicine

Sodium and chloride are normally consumed together as sodium chloride (salt) in food. For this reason, Chapter 6 presents data on recommended intakes and effects of sodium as sodium chloride and assumes it applies to chloride unless otherwise noted. While the minimal amount of sodium required to replace insensible losses is estimated to be 0. Approximately 98 percent of sodium chloride consumed is absorbed over a wide range of intakes, and approximately 90 to 95 percent of sodium excretion occurs through the urine, with losses in sweat being minimal among those who do not experience sweat loss due to exercise. For example, sweat losses during exercise in the heat may easily exceed 1 L/hour with a sodium concentration of greater than 35 to 50 mmol (0. Thus it would be prudent for individuals who exercise strenuously on a daily basis to carefully monitor their electrolyte intake as well as their water intake. Increased sodium chloride intake increases blood pressure, and it is associated with an increased risk of cardiovascular outcomes (particularly left ventricular hypertrophy and stroke), and possibly with an increased risk of asthma and gastric cancer. It also causes increased urinary excretion not only of sodium chloride, but also of calcium. At the lowest level of sodium intake, individuals consuming 1,600 kcal received 0. Of course, with restricted energy intake, careful dietary planning would be needed to meet recommended intakes for other nutrients. For example, use of diuretics has been reported to lead to hyponatremia, although this appears to be a consequence of impaired water excretion rather than of excessive sodium loss since it can be corrected by water restriction. Other clinical states that can lead to increased renal salt losses include adrenal cortical insufficiency, intrinsic renal disorders. In these situations, sodium should not be unduly restricted, and medical advice appropriate for the individual should be obtained. Number of days of food intake records required to estimate individual and group nutrient intakes with defined confidence. The relation between energy intake derived from estimated diet records and intake determined to maintain body weight. Inaccuracies in self-reported intake identified by comparison with the doubly labelled water method. Residual lifetime risk for developing hypertension in middle-aged women and men: the Framingham Heart Study. This chapter describes the approach used to develop the research agenda, briefly summarizes gaps in knowledge, and presents a list of research topics deemed of highest priority. Identified gaps in knowledge related to role of electrolytes and water in human health and their impact on functional and biochemical indicators used to assess requirements; methodological problems in measuring electrolyte and water intake and in assessing adequacy of intake; relationships of nutrient intake to chronic disease; and adverse effects from overconsumption of electrolytes and water. Considered the need to protect individuals with extreme or distinct vulnerabilities due to disease conditions or genetic predisposition. In predominantly short-term studies, a reduced sodium intake increased plasma renin activity, but the clinical relevance of increased plasma renin activity is uncertain. The best available evidence did not support adverse changes to lipid concentrations. Data were insufficient to determine whether chronic ingestion of sodium in clinically relevant ranges led to deterioration in insulin resistance. Achieving an adequate intake of other nutrients is a potential concern at extremely low levels of intake. Sodium imbalance, that is, sodium losses that exceed intake, might occur when sweat sodium losses are high, as in the setting of extreme heat or extreme physical activity, particularly in persons who are unacclimatized to these environmental conditions. Overall, there was no single indicator that could be used to assess adequacy of intake, and thus a combination of indicators was used. Requirements for sulfate are met by meeting dietary protein and sulfur amino acid recommendations. As an example, there is a paucity of data on the relationship of dietary sodium and potassium intakes early in life on blood pressure and markers of bone health during adulthood. For water, research studies commonly tested the effects of inadequate intake in men of military age, but not in broad populations. Methodology In free-living persons, accurate measurement of dietary water and electrolytes intake is difficult, as are measurements of total body water and electrolytes.

Vitrification of human blastocysts with the Hemi-Straw carrier: application of assisted hatching after thawing. Metformin reduces pregnancy complications without affecting androgen levels in pregnant polycystic ovary syndrome women: results of a randomized study. Characteristics of ovarian and uterine cancers in a cohort of in vitro fertilization patients. The type of catheter has no impact on the pregnancy rate after intrauterine insemination: a randomized study. Three protocols for monitoring follicle development in 587 unstimulated cycles of in vitro fertilization and intracytoplasmic sperm injection. Low-dose aspirin in a short regimen as standard treatment in in vitro fertilization: a randomized, prospective study. Incidence of spontaneous abortion among pregnancies produced by assisted reproductive technology. Frozen-thawed embryo transfer: influence of clinical factors on implantation rate and risk of multiple conception. Cessation of low-dose gonadotropin releasing hormone agonist therapy followed by high-dose gonadotropin stimulation yields a favorable ovarian response in poor responders. A matched controlled study to evaluate the efficacy of acupuncture for improving pregnancy rates following in vitro fertilization-embryo transfer. Preterm birth and low birth weight after assisted reproductive technologyrelated pregnancy in Australia between 1996 and 2000. Sperm retrieval, fertilization, and pregnancy outcome in repeated testicular sperm aspiration. Pregnancy rates in varying age groups after in vitro fertilization: a comparison of follitropin alfa (Gonal F) and follitropin beta (Follistim). Minimal ovarian hyperstimulation for in vitro fertilization using sequential clomiphene citrate and gonadotropin with or without the addition of a gonadotropin-releasing hormone antagonist. Intracytoplasmic sperm injection with testicular spermatozoa in men with azoospermia. Comparative analysis of pregnancy rates after the transfer of early dividing embryos versus slower dividing embryos. Intrauterine insemination-ready versus conventional semen cryopreservation for donor insemination: a comparison of retrospective results and a prospective, randomized trial. In vitro fertilization and the cloacal-bladder exstrophy-epispadias complex: is there an association? Effect on clinical outcome of the interval between collection of epididymal and testicular spermatozoa and intracytoplasmic sperm injection in obstructive azoospermia. Reproductive potential of fresh and cryopreserved epididymal and testicular spermatozoa in consecutive intracytoplasmic sperm injection cycles in the same patients. Pregnancy potential of embryos from in vitro fertilization compared to intracytoplasmic sperm injection. Alternative embryo transfer on day 3 or day 5 for reducing the risk of multiple gestations. Prospective evaluation of the optimal time for selecting a single embryo for transfer: day 3 versus day 5. Ploidity and chromatin status of human oocytes after failed in vitro fertilization. Follicular aspiration during the selection phase prevents severe ovarian hyperstimulation in patients with polycystic ovary syndrome who are undergoing in vitro fertilization. Neonatal outcomes in triplet pregnancies: assisted reproduction versus spontaneous conception. B-39 Appendix C: Data Abstraction Forms (Questions 2-4) Question 2: Among women of reproductive age, what are the benefits and risks of Clomid and Pergonal (or other injectable super-ovulatory drugs), and Glucophage, and how do they vary in different patient populations? Is there evidence to link these adverse outcomes with the treatments and not the underlying maternal health or gestational age problems? Question 2 ­ Ovulation Induction without Assisted Conception Study Al-Fadhli, Sylvestre, Buckett, et al.

Metformin therapy throughout pregnancy reduces the development of gestational diabetes in women with polycystic ovary syndrome. Full Text: Exclude Q4-Outcomes not correlated with history or infertility or treatment. Follitropin-alpha versus human menopausal gonadotropin in an in vitro fertilization program. Multiple gestations in assisted reproductive technology: can they be avoided with blastocyst transfers? Effectiveness of two-step (consecutive) embryo transfer in patients who have two embryos on day 2: comparison with cleavagestage embryo transfer. Further considerations on natural or mild hyperstimulation cycles for intrauterine insemination treatment: effects on pregnancy and multiple pregnancy rates. A comparison of luteal phase support in graduated estradiol/progesterone replacement cycles using intramuscular progesterone alone versus combination with vaginal suppositories on outcome following frozen embryo transfer. Correctly timed coasting reduces the risk of ovarian hyperstimulation syndrome and gives good cycle outcome in an in vitro fertilization program. Overnight incubation improves selection of frozen-thawed blastocysts for transfer: preliminary study using supernumerary embryos. A meta-analysis and comparison with the Society for Assisted Reproductive Technology database. Selection of embryos for day-3 transfer at the pronuclear-stage and pronuclear-stage cryopreservation results in high delivery rates in fresh and frozen cycles. Practitioner reporting of birth defects in children born following assisted reproductive technology: Does it still have a role in surveillance of birth defects? Recombinant follicle stimulating hormone in in-vitro fertilization treatment-clinical experience with follitropin alpha and follitropin beta. Effect of aspiration vacuum on the developmental competence of immature human oocytes retrieved using a 20-gauge needle. Severe hypospermatogenesis in cases of nonobstructive azoospermia: should we use fresh or frozen testicular spermatozoa? Effects of letrozole on superovulation with gonadotropins in women undergoing intrauterine insemination. Defining women who are prone to have twins in in vitro fertilization-a necessary step towards single embryo transfer. Perinatal outcome of singletons and twins after assisted conception: a systematic review of controlled studies. Spontaneous conception after a successful attempt at in vitro fertilization/intracytoplasmic sperm injection. Patient attitudes towards twin pregnancies and single embryo transfer - a questionnaire study. Prospective study of parental choice for aneuploidy screening in assisted conception versus spontaneously conceived twins. Laser-assisted hatching of embryos is better than the chemical method for enhancing the pregnancy rate in women with advanced age. Clinical implications of intracytoplasmic sperm injection using cryopreserved testicular spermatozoa from men with azoospermia. Maternal serum pregnancy-associated plasma protein-A and free betahuman chorionic gonadotrophin in pregnancies conceived with fresh and frozen-thawed embryos from in vitro fertilization and intracytoplasmic sperm injection. Hydrosalpinx treated with extended doxycycline does not compromise the success of in vitro fertilization. A minimally monitored assisted reproduction stimulation protocol reduces cost without compromising success. Ultra-short metformin pretreatment for clomiphene citrate-resistant polycystic ovary syndrome. Combined approach as an effective method in the prevention of severe ovarian hyperstimulation syndrome. A simple, effective indicator of implantation and pregnancy in intracytoplasmic sperm injection. Impact of oocyte pre-incubation time on fertilization, embryo quality and pregnancy rate after intracytoplasmic sperm injection.

The epi triad can capture how pathogen, host, and environment all affect each other. If sufficient data or information is available to prepare an ecology summary for the pathogen, it should focus on the appropriate exposure source 11 (water, food, other) and may include environments that the microorganisms encounter before they enter the media of concern. For example, biofilms create ecological niches that are important to consider because microbes often exhibit different properties in communities compared to the same species living in suspension. Protozoa can also harbor bacteria within their cell membranes, thereby protecting the bacteria from many environmental stresses. Legionella are known to reside within at least 20 species of amoebae, two species of ciliated protozoa, and one species of slime mold (Lau and Ashbolt, 2009). Species from the pathogens Vibrio, Mycobacterium, Helicobacter, Afipia, Bosea, Pseudomonas, and mimiviruses are also associated with protozoa in the environment. Virulence, Pathogenicity, Pathological Characteristics, and Host Specificity Virulence and pathogenicity refer to how easily and effectively a pathogen may cause disease in a host. Virulence is "the degree of intensity of the disease produced by a microorganism as indicated by its ability to invade the tissues of a host and the ensuing severity of illness. Pathogenicity of infectious agents is measured by the ratio of the number of persons developing clinical illness to the number exposed to infection" (U. Although both can be expressed numerically, the general definitions can be broader. Pathological characteristics are a description of the disease symptoms that result from exposure and infection by the pathogen (including strain variations). The known range of disease symptoms should be briefly reviewed and the specific health endpoint that the risk assessment addresses should be presented within the context of the broader range of health endpoints. Host specificity is a pathogen characteristic that is related to host susceptibility. Note that a species can still be considered a host even if no illness results from infection. For example, mild illness can occur in immune-competent persons resulting from 11 Exposure sources can be the media through which the contaminant is delivered, such as water or shellfish, or exposure sources can indicate the origin of the contaminant, such as point source, non-point sources, or naturally occurring. Exposure route indicates the sites of body contact that are relevant for access to sensitive tissues and organs, such as ingestion, inhalation, and dermal exposures. However, host specificity most often refers to the range of species that are infected by the pathogen. Wild and domestic animals may also be prone to infection and disease (zoonotic potential) and thus may be a source of pathogens for human exposure either directly or through transport in the environment. Some pathogens have non-human carriers, also known as vectors, which are important in the pathogen life cycle or serve as an environmental reservoir. These factors are also evaluated in greater detail in the health effects section of the risk assessment. The exposure routes 13 that will be included in the risk assessment are defined during problem formulation. Part of that definition should include identification of known routes that will not be part of the scope of the risk assessment. For example, in many waterborne pathogen risk assessments, the ingestion route of exposure is investigated and other routes of exposure. In cases where a pathogen is not known to be infectious through certain routes, such as the dermal route, discussion, including rationale, for not including the dermal exposure route should be included in the risk assessment documentation, particularly for risk assessments conducted to meet specific statutory requirements where reasons for excluding a route must be justified. Additional discussion of how the choice of included routes impacts the uncertainty, qualitative or quantitative, should be included in the risk characterization section. Infection without symptoms and the duration of infection are important attributes of the infection process because they contribute to the potential for secondary transmission via the shedding of pathogens into the environment. The majority of showerhead microbiota were comprised of genus- or species-level groups that are commonly found in water and soil. The showerhead environment strongly enriches for microbes that are known to form biofilms in water systems, including Mycobacterium spp. Legionella, which can cause Legionnaires disease and Pontiac fever, has been linked epidemiologically to hot water systems, cooling towers, evaporative condensers, humidifiers, whirlpool spas, respiratory devices, and decorative fountains. There may also be other opportunistic pathogens that are of interest to risk managers and assessors. Secondary Transmission the potential for secondary transmission will also contribute to human exposure. Secondary transmission refers to infection spreading from one infected person to another person.