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Rondon-Berrios H. Edelman Gamblegrams: a tool to teach and learn disorders of water/plasma tonicity homeostasis. Adv Physiol Educ 2024; 48:200-204. [PMID: 38205519 DOI: 10.1152/advan.00253.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 01/12/2024]
Abstract
This article introduces an innovative teaching and learning tool called "Edelman Gamblegrams" that aims to help medical learners better understand disorders related to water/plasma tonicity homeostasis, i.e., hyponatremia and hypernatremia. Gamblegrams, named after physician James L. Gamble, are bar diagrams displaying the relative abundance of extracellular anions and cations and are commonly used in the analysis of acid-base disorders. The Edelman equation represents the physiological variables that determine plasma sodium concentration, namely, total body sodium mass, total body potassium mass, and total body water volume. Edelman Gamblegrams inspired by traditional Gamblegrams but using the components of the Edelman equation, visually demonstrate how sodium, potassium, and water contribute to plasma sodium concentration under normal and pathological conditions. Scenarios that lead to hypotonic hyponatremia and hypernatremia in Edelman Gamblegrams are also discussed. Furthermore, examples of how these visual aids can enhance understanding of the pathogenesis of dysnatremias are also presented. Overall, the use of Edelman Gamblegrams has the potential to improve comprehension and retention of concepts related to water/plasma tonicity homeostasis.NEW & NOTEWORTHY This article introduces a new teaching tool called "Edelman Gamblegrams," modeled after the conventional Gamblegrams used in acid-base disorder analysis and using the independent physiological variables that determine the plasma sodium concentration (Edelman equation), that aims to help medical learners understand disorders related to water/plasma tonicity homeostasis.
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Affiliation(s)
- Helbert Rondon-Berrios
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
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Buchkremer F, Schuetz P, Mueller B, Segerer S. Classifying Hypotonic Hyponatremia by Projected Treatment Effects - A Quantitative 3-Dimensional Framework. Kidney Int Rep 2023; 8:2720-2732. [PMID: 38106585 PMCID: PMC10719653 DOI: 10.1016/j.ekir.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 08/29/2023] [Accepted: 09/04/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction The diagnostic algorithms currently used for hypotonic hyponatremia focus primarily on impaired urinary dilution and often neglect the influence of free water intake and solute excretion. We hypothesized that, in each case of hypotonic hyponatremia different pathophysiological mechanisms play a role simultaneously. Methods Using clinical data of the previous observational Co-Med study, we defined each case of hypotonic hyponatremia concurrently in 3 dimensions as follows: (i) high net free water intake (HNFWI), (ii) impaired dilution of the urine (IDU), and (iii) low nonelectrolyte solute excretion (LNESE). For each dimension, a "standard delta sodium" (sdna) was calculated reflecting the expected difference to the serum sodium concentration, that would result from changing a dimension to a specific and equivalent target level. Results Results from 279 patients were used for this analysis. With target levels of free water intake and urine osmolality at the fifth percentile, and nonelectrolyte solute excretion at the 95th percentile, median (interquartile range) sdna values were 7.1 (4.8-10.2) for HNFWI, 11.8 (7.0-18.6) for IDU and 2.6 (1.6-4.2) mmol/l per 24 hours for LNESE. Sdna results in individual patients were highest with IDU in 68.5%, HNFWI in 30.8% and 0.7% with LNESE. At an sdna-level of at least 4mmol/l per 24 hours, the prevalence of HNFWI was 78.9%, IDU 87.1%, and LNESE 26.5%. 77.5% of patients had 2 or all 3 mechanisms present. Hyponatremia was mostly multifactorial in subgroups according to classic categories of hyponatremia and typical comorbidities as well. Conclusion Hypotonic hyponatremia can be quantitatively defined by 3 dimensions. Most cases should be considered multifactorial.
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Affiliation(s)
| | - Philipp Schuetz
- Division of General Internal and Emergency Medicine, Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | - Beat Mueller
- Medical Faculty of the University of Basel, Basel, Switzerland
- Division of General Internal and Emergency Medicine, Department of Endocrinology, Diabetology & Metabolism, Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | - Stephan Segerer
- Division of Nephrology, Kantonsspital Aarau, Aarau, Switzerland
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Affiliation(s)
- Horacio J Adrogué
- From the Department of Medicine, Section of Nephrology, Baylor College of Medicine, and the Department of Medicine, Division of Nephrology, Houston Methodist Hospital - both in Houston (H.J.A.); and the Department of Medicine, Tufts University School of Medicine, and the Department of Medicine, Division of Nephrology, St. Elizabeth's Medical Center - both in Boston (N.E.M.)
| | - Nicolaos E Madias
- From the Department of Medicine, Section of Nephrology, Baylor College of Medicine, and the Department of Medicine, Division of Nephrology, Houston Methodist Hospital - both in Houston (H.J.A.); and the Department of Medicine, Tufts University School of Medicine, and the Department of Medicine, Division of Nephrology, St. Elizabeth's Medical Center - both in Boston (N.E.M.)
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Sasakawa Y, Tatematsu Y, Kato J, Fujii M, Okamoto N, Inaguma D. Relationship between serum sodium level at dialysis initiation and all-cause mortality. Clin Exp Nephrol 2023; 27:747-756. [PMID: 37264283 DOI: 10.1007/s10157-023-02363-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/24/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Hyponatremia is a common electrolyte disorder in patients with chronic kidney disease. In addition, hyponatremia is associated with mortality in patients with chronic kidney disease, including those on dialysis. However, few studies have examined this relationship in patients with incident dialysis. METHODS We used a database of multicenter prospective cohort studies that included 1520 incident dialysis patients. The baseline was set at the time of dialysis initiation. The enrolled patients were classified into five groups according to their serum sodium levels (< 130 mEq/L, 130-134 mEq/L, 135-139 mEq/L, 140-144 mEq/L, and ≥ 145 mEq/L). Multivariate Cox proportional hazards analysis was conducted to determine factors associated with all-cause mortality. RESULTS A total of 392 all-cause deaths occurred during the follow-up period. The ultrafiltration volume per body weight during the first dialysis session was more significant in the groups with the lowest and highest sodium levels. The percentage of patients using loop diuretics and thiazide was higher in the group with lower sodium levels (< 130 mEq/L and 130-134 mEq/L). All-cause mortality was significantly different among the five groups (p = 0.025). Multivariate analysis indicated that all-cause mortality was significantly higher in the group with the lowest sodium level compared to the group with a serum sodium level of 135-139 mEq/L (hazard ratio: 1.61, 95% confidence interval: 1.04-2.49). CONCLUSION Hyponatremia of < 130 mEq/L at dialysis initiation was significantly associated with all-cause mortality. We considered the results relevant to underlying conditions, including cardiovascular disease and medications.
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Affiliation(s)
- Yuji Sasakawa
- Department of Internal Medicine, Department of Nephrology, Fujita Health University Bantane Hospital, 3-6-10 Otobashi, Nakagawa, Nagoya, Aichi, 4548509, Japan
| | - Yoshitaka Tatematsu
- Department of Internal Medicine, Department of Nephrology, Fujita Health University Bantane Hospital, 3-6-10 Otobashi, Nakagawa, Nagoya, Aichi, 4548509, Japan
| | - Joichiro Kato
- Department of Internal Medicine, Department of Nephrology, Fujita Health University Bantane Hospital, 3-6-10 Otobashi, Nakagawa, Nagoya, Aichi, 4548509, Japan
| | - Maya Fujii
- Department of Internal Medicine, Department of Nephrology, Fujita Health University Bantane Hospital, 3-6-10 Otobashi, Nakagawa, Nagoya, Aichi, 4548509, Japan
| | - Naoki Okamoto
- Department of Internal Medicine, Department of Nephrology, Fujita Health University Bantane Hospital, 3-6-10 Otobashi, Nakagawa, Nagoya, Aichi, 4548509, Japan
| | - Daijo Inaguma
- Department of Internal Medicine, Department of Nephrology, Fujita Health University Bantane Hospital, 3-6-10 Otobashi, Nakagawa, Nagoya, Aichi, 4548509, Japan.
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Barajas Galindo DE, Ruiz-Sánchez JG, Fernández Martínez A, de la Vega IR, Ferrer García JC, Ropero-Luis G, Ortolá Buigues A, Serrano Gotarredona J, Gómez Hoyos E. Consensus document on the management of hyponatraemia of the Acqua Group of the Spanish Society of Endocrinology and Nutrition. ENDOCRINOL DIAB NUTR 2023; 70 Suppl 1:7-26. [PMID: 36404266 DOI: 10.1016/j.endien.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/09/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Hyponatremia is the most prevalent electrolyte disorder in the outpatient and inpatient settings. Despite this frequency, hyponatremia, including severe hyponatremia, is frequently underestimated and inadequately treated, thus highlighting the need to produce consensus documents and clinical practice guidelines geared towards improving the diagnostic and therapeutic approach to it in a structured fashion. MATERIAL AND METHODS Members of the Acqua Group of the Spanish Society of Endocrinology and Nutrition (SEEN) met using a networking methodology over a period of 20 months (between October 2019 and August 2021) with the aim of discussing and developing an updated guideline for the management of hyponatraemia. A literature search of the available scientific evidence for each section presented in this document was performed. RESULTS A document with 8 sections was produced, which sets out to provide updated guidance on the most clinically relevant questions in the management of hyponatraemia. The management of severe hyponatraemia is based on the i.v. administration of a 3% hypertonic solution. For the management of chronic euvolemic hyponatraemia, algorithms for the initiation of treatment with the two pharmacological therapeutic options currently available in Spain are presented: urea and tolvaptan. CONCLUSIONS This document sets out to simplify the approach to and the treatment of hyponatraemia, making it easier to learn and thus improve the clinical approach to hyponatremia.
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Affiliation(s)
- David E Barajas Galindo
- Sección de Endocrinología y Nutrición, Complejo Asistencial Universitario de León, León, Spain.
| | | | | | | | | | | | - Ana Ortolá Buigues
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Emilia Gómez Hoyos
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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Workeneh BT, Meena P, Christ-Crain M, Rondon-Berrios H. Hyponatremia Demystified: Integrating Physiology to Shape Clinical Practice. Adv Kidney Dis Health 2023; 30:85-101. [PMID: 36868737 PMCID: PMC9993811 DOI: 10.1053/j.akdh.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 10/05/2022] [Accepted: 11/07/2022] [Indexed: 12/24/2022]
Abstract
Hyponatremia is one of the most common problems encountered in clinical practice and one of the least-understood because accurate diagnosis and management require some familiarity with water homeostasis physiology, making the topic seemingly complex. The prevalence of hyponatremia depends on the nature of the population studied and the criteria used to define it. Hyponatremia is associated with poor outcomes including increased mortality and morbidity. The pathogenesis of hypotonic hyponatremia involves the accumulation of electrolyte-free water caused by either increased intake and/or decrease in kidney excretion. Plasma osmolality, urine osmolality, and urine sodium can help to differentiate among the different etiologies. Brain adaptation to plasma hypotonicity consisting of solute extrusion to mitigate further water influx into brain cells best explains the clinical manifestations of hyponatremia. Acute hyponatremia has an onset within 48 hours, commonly resulting in severe symptoms, while chronic hyponatremia develops over 48 hours and usually is pauci-symptomatic. However, the latter increases the risk of osmotic demyelination syndrome if hyponatremia is corrected rapidly; therefore, extreme caution must be exercised when correcting plasma sodium. Management strategies depend on the presence of symptoms and the cause of hyponatremia and are discussed in this review.
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Affiliation(s)
- Biruh T Workeneh
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Priti Meena
- All India Institute of Medical Sciences, Bhubaneswar, India
| | - Mirjam Christ-Crain
- Departments of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
| | - Helbert Rondon-Berrios
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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Barajas Galindo DE, Ruiz-sánchez JG, Fernández Martínez A, Runkle de la Vega I, Ferrer García JC, Ropero-luis G, Ortolá Buigues A, Serrano Gotarredona J, Gómez Hoyos E. Documento de consenso sobre el manejo de la hiponatremia del Grupo Acqua de la Sociedad Española de Endocrinología y Nutrición. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
Hypernatraemia is most commonly caused by excessive loss of solute-free water or decreased fluid intake; less often, the aetiology is salt intoxication. Especially infants, young children and individuals with a lack of access to water are at risk of developing hypernatraemia. Diagnosis is based on detailed history, physical examination and basic laboratory tests. Correction of hypernatraemia must be slow to prevent cerebral oedema and irreversible brain damage. This article reviews the aetiology, differential diagnosis and management of conditions associated with paediatric hypernatraemia. Distinguishing states with water deficiency from states with salt excess is important for proper management of hypernatraemic patients.
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Affiliation(s)
- Jakub Zieg
- Department of Paediatrics Second Medical Faculty Motol University HospitalCharles University Prague Czech Republic
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Abstract
Novel immunotherapy drugs have changed the landscape of cancer medicine. Immune checkpoint inhibitors and chimeric antigen receptor T cells are being used and investigated in almost all solid cancers. Immune-related adverse events have been associated with immunotherapies. Acute kidney injury has been the most commonly associated kidney adverse event. In this review, we showcase the several associated electrolyte disorders seen with immunotherapy. Immune checkpoint inhibitors can lead to hyponatremia by several mechanisms, with the syndrome of inappropriate antidiuresis being the most common. Endocrine causes of hyponatremia are rare. Hypokalemia is not uncommon and is associated with both proximal and distal renal tubular acidosis. Hypercalcemia associated with immune checkpoint inhibitors has led to some interesting observations including immune checkpoint inhibitor-induced parathyroid hormone - related peptide production, sarcoid-like granulomas, and hyper-progression of the disease. Hypocalcemia and hyperphosphatemia may be seen with immune checkpoint inhibitor-induced tumor lysis syndrome. Chimeric antigen receptor T cell therapy-associated electrolyte disorders are also common. This is associated chiefly with hyponatremia, although other electrolyte abnormalities can occur. Early recognition and prompt diagnosis may help providers manage the mechanistically varied and novel electrolyte disorders associated with immunotherapy.
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Affiliation(s)
- Nupur N. Uppal
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, New York
| | - Biruh T. Workeneh
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Helbert Rondon-Berrios
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, New York
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Selvaraj S, Rodrigues D, Krishnamoorthy N, Fakhro KA, Saraiva LR, Lemos MC. Clinical, Genetic and Functional Characterization of a Novel AVPR2 Missense Mutation in a Woman with X-Linked Recessive Nephrogenic Diabetes Insipidus. J Pers Med 2022; 12:118. [PMID: 35055433 PMCID: PMC8779739 DOI: 10.3390/jpm12010118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 12/27/2021] [Accepted: 01/05/2022] [Indexed: 11/28/2022] Open
Abstract
Nephrogenic diabetes insipidus (NDI) is a rare disorder characterized by renal unresponsiveness to the hormone vasopressin, leading to excretion of large volumes of diluted urine. Mutations in the arginine vasopressin receptor-2 (AVPR2) gene cause congenital NDI and have an X-linked recessive inheritance. The disorder affects almost exclusively male family members, but female carriers occasionally present partial phenotypes due to skewed inactivation of the X-chromosome. Here, we report a rare case of a woman affected with X-linked recessive NDI, presenting an average urinary output of 12 L/day. Clinical and biochemical studies showed incomplete responses to water deprivation and vasopressin stimulation tests. Genetic analyses revealed a novel heterozygous missense mutation (c.493G > C, p.Ala165Pro) in the AVPR2 gene. Using a combination of in-silico protein modeling with human cellular models and molecular phenotyping, we provide functional evidence for phenotypic effects. The mutation destabilizes the helical structure of the AVPR2 transmembrane domains and disrupts its plasma membrane localization and downstream intracellular signaling pathways upon activation with its agonist vasopressin. These defects lead to deficient aquaporin 2 (AQP2) membrane translocation, explaining the inability to concentrate urine in this patient.
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Workeneh BT, Jhaveri KD, Rondon-Berrios H. Hyponatremia in the cancer patient. Kidney Int 2020; 98:870-882. [DOI: 10.1016/j.kint.2020.05.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/28/2020] [Accepted: 05/11/2020] [Indexed: 02/08/2023]
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Brady SS, Berry A, Camenga DR, Fitzgerald CM, Gahagan S, Hardacker CT, Harlow BL, Hebert-Beirne J, LaCoursiere DY, Lewis JB, Low LK, Lowder JL, Markland AD, McGwin G, Newman DK, Palmer MH, Shoham DA, Smith AL, Stapleton A, Williams BR, Sutcliffe S. Applying concepts of life course theory and life course epidemiology to the study of bladder health and lower urinary tract symptoms among girls and women. Neurourol Urodyn 2020; 39:1185-1202. [PMID: 32119156 PMCID: PMC7659467 DOI: 10.1002/nau.24325] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/23/2020] [Indexed: 01/18/2023]
Abstract
AIMS Although lower urinary tract symptoms (LUTS) may occur at different periods during the life course of women, a little research on LUTS has adopted a life course perspective. The purpose of this conceptual paper is to demonstrate how life course theory and life course epidemiology can be applied to study bladder health and LUTS trajectories. We highlight conceptual work from the Prevention of Lower Urinary Tract Symptoms Research Consortium to enhance the understanding of life course concepts. METHODS Consortium members worked in transdisciplinary teams to generate examples of how life course concepts may be applied to research on bladder health and LUTS in eight prioritized areas: (a) biopsychosocial ecology of stress and brain health; (b) toileting environment, access, habits, and techniques; (c) pregnancy and childbirth; (d) physical health and medical conditions; (e) musculoskeletal health; (f) lifestyle behaviors; (g) infections and microbiome; and (h) hormonal status across the life span. RESULTS Life course concepts guided consortium members' conceptualization of how potential risk and protective factors may influence women's health. For example, intrapartum interventions across multiple pregnancies may influence trajectories of bladder health and LUTS, illustrating the principle of life span development. Consortium members also identified and summarized methodologic and practical considerations in designing life course research. CONCLUSIONS This paper may assist researchers from a variety of disciplines to design and implement research identifying key risk and protective factors for LUTS and bladder health across the life course of women. Results from life course research may inform health promotion programs, policies, and practices.
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Affiliation(s)
- Sonya S Brady
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Amanda Berry
- Department of Surgery, Division of Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Deepa R Camenga
- Department of Emergency Medicine and Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Colleen M Fitzgerald
- Department of Obstetrics and Gynecology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - Sheila Gahagan
- Department of Pediatrics, Division of Academic General Pediatrics, University of California San Diego School of Medicine, San Diego, California
| | | | - Bernard L Harlow
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Jeni Hebert-Beirne
- Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - D Yvette LaCoursiere
- Department of Obstetrics, Gynecology, and Reproductive Sciences, UC San Diego School of Medicine, San Diego, California
| | - Jessica B Lewis
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Lisa K Low
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Jerry L Lowder
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Alayne D Markland
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, School of Medicine, University of Alabama, Birmingham, Alabama
- Geriatric Research, Education, and Clinical Center, Birmingham VA Medical Center, Birmingham, Alabama
| | - Gerald McGwin
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama
| | - Diane K Newman
- Department of Surgery, Division of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary H Palmer
- School of Nursing, University of North Carolina, Chapel Hill, North Carolina
| | - David A Shoham
- Department of Public Health Sciences, Loyola University Chicago, Maywood, Illinois
| | - Ariana L Smith
- Department of Surgery, Division of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ann Stapleton
- Department of Medicine, Division of Allergy and Infectious Disease, University of Washington, Seattle, Washington
| | - Beverly R Williams
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, School of Medicine, University of Alabama, Birmingham, Alabama
| | - Siobhan Sutcliffe
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri
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