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Most symptoms resolved rapidly on steroids but hematuria and proteinuria persisted for 1 year allergy shots not effective discount 10 ml astelin overnight delivery, making these symptoms unlikely to be vaccine related allergy symptoms shellfish discount 10 ml astelin visa. The frst two cases did not provide evidence beyond a temporal relationship between vaccination and development of symptoms allergy testing procedure codes generic astelin 10 ml fast delivery. Case 3 described a 19-year-old woman presenting with transient weakness of the left leg 3 months after receiving the second dose of a hepatitis B vaccine allergy symptoms wiki order astelin 10 ml without a prescription. Seven days after the third dose of a hepatitis B vaccine, the patient presented with arthralgias, left side hemihypesthesia, and an unstable gait. Narrowing of the right anterior cerebral artery, right middle cere bral artery, right posterior cerebral artery, left anterior cerebral artery, left middle cerebral artery, and basilar artery were detected by cerebral angio graphic studies. Laboratory results showed circulating immune complexes in one patient, cryoglobulins in two patients, and rheumatoid factor in one patient. Case one described an 18-year-old woman presenting with painful necrotic and bullous purpura of the legs 10 days after receiving the second Copyright National Academy of Sciences. Case 2 described a 36-year-old patient presenting with fever, pain, and bilateral purpura of the legs 30 days after receiving a booster dose of a hepatitis B vaccine. Weight of Mechanistic Evidence While rare, vasculitis, particularly polyarteritis nodosa, is associated with hepatitis B infections (Koziel and Thio, 2010). The committee considers the effects of natural infection one type of mechanistic evidence. In addition, the eight publications described above, when considered together, presented clinical evidence suggestive but not suffcient for the committee to conclude the vaccine may be a contributing cause of vascu litis after vaccination against hepatitis B. The evidence contributing to the weight of mechanistic evidence includes the latency of several days to 4 weeks between vaccination and development of symptoms, the resolution of symptoms after vaccination, positive tests for circulating immune com plexes or cryoglobulins, and recurrence or exacerbation of symptoms after revaccination against hepatitis B in two publications. The latency between administration of the second, third, or fourth doses of a hepatitis B vaccine and development of vasculitis in the publica tions described above ranged from several days to 4 weeks. The isolation of circulating immune complexes or cryoglobulins in several publications suggests immune complexes as the mechanism. In addition, autoantibod ies, T cells, and complement activation may contribute to the symptoms of vasculitis; however, the publications did not provide evidence linking these mechanisms to hepatitis B vaccine. The committee assesses the mechanistic evidence regarding an as sociation between hepatitis B vaccine and onset or exacerbation of vasculitis as low-intermediate based on knowledge about the natural infection and twelve cases. Described below are four publications reporting clinical, diagnostic, or experimental evidence that contributed to the weight of mechanistic evidence. Two cases described microscopic polyangiitis and are discussed in the section on vasculitis. Two cases reported latencies of between 4 and 8 months between the Copyright National Academy of Sciences. One case reported a temporal relationship between administration of a vaccine and development of symptoms, but the symptoms persisted beyond the time vaccine antigen would be present. Case 1 describes a 45-year-old man present ing with myalgia, joint pain, and morning stiffness 2 weeks after receiving the frst dose of a hepatitis B vaccine. After the second dose the patient presented with arthralgia, increased myalgia, an ulcer over the left lower limb, ischemic lesions over the fngertips, and ischemic discoloration distal to the second and third digits of the left hand. A skin biopsy of the lower left limb ulcer showed granulation tissue composed of fbroblasts with infammatory cells. A medium-sized vessel under the granulation tissue presented with fbrosis of the muscle wall with infltrating infammatory cells. The committee considers the effects of natural infection one type of mechanistic evidence. Furthermore, there is large variability in the latency between vaccination and the development of symptoms (1–32 weeks) and only one case of exacerbation of symptoms upon rechallenge with the vaccine. In addition, several of the publications report the persistence of symptoms beyond the time vaccine antigen would be present. In addition, autoantibodies, T cells, and complement activation may contribute to the symptoms of vasculitis; however, the publications did not provide evidence linking these mechanisms to hepatitis B vaccine. Mechanistic Evidence the committee identifed one report describing two cases of onset or exacerbation of psoriatic arthritis postvaccination against hepatitis B. Aherne and Collins (1995) did not provide evidence beyond temporality in the two cases and did not contribute to the weight of mechanistic evidence. Weight of Mechanistic Evidence the committee assesses the mechanistic evidence regarding an as sociation between hepatitis B vaccine and onset or exacerbation of psoriatic arthritis as lacking. Weight of Epidemiologic Evidence the epidemiologic evidence is insuffcient or absent to assess an association between hepatitis B vaccine and onset or exacerbation of reactive arthritis. Mechanistic Evidence the committee identifed 10 publications reporting onset or exacerba tion of reactive arthritis postvaccination against hepatitis B. Described below are two publications reporting clinical, diagnostic, or experimental evidence that contributed to the weight of mechanistic evidence. The patient also complained of pain in the lumbar and cervical column, functional distress, fever, and malaise. Six weeks or more postvac cination the patient presented with arthritis and pain at the same sites. Symptoms developed after 2 and 12 days, and less than 1 month, 1 month, and 2 months postvaccination. Weight of Mechanistic Evidence Reactive arthritis is a clinical condition classifed among the group of spondyloarthropathies in which it is thought that infection triggers the de velopment of symptoms that persist after the infection itself is eradicated. The onset of arthritis typically occurs several days to several weeks follow ing either gastroenteritis or urethritis caused by certain specifc organisms (Chlamydia trachomatis, Yersinia, Salmonella, Shigella, Campylobacter, and possibly Clostridium diffcile and Chlamydia pneumoniae) (Toivanen and Toivanen, 2000). The two publications described above, when considered together, did not present evidence suffcient for the committee to conclude the vaccine may be a contributing cause of reactive arthritis after vaccination against Copyright National Academy of Sciences. The publications provide very little information that would sup port any particular mechanism for the development of reactive arthritis af ter vaccination against hepatitis B. Furthermore, the latency between vaccination and the presenta tion of symptoms varied considerably from 2 days to 2 months. Two days is short for the development of reactive arthritis based on the possible mechanisms involved. One patient was shown to have immune complexes; however, reactive arthritis is not considered to be an immune complex–mediated disease. In addition, molecular mimicry may contribute to the symptoms of reactive arthritis; however, the publications did not provide evidence linking this mechanism to hepatitis B vaccine. The committee assesses the mechanistic evidence regarding an as sociation between hepatitis B vaccine and onset or exacerbation of reactive arthritis as weak based on four cases. Exclusion criteria included pregnancy, past vaccination allergy, and positive screening for hepatitis B surface antigen, antihepatitis B surface, or antihepatitis B core antibodies above the normal ranges. Patients who declined vaccination were assigned to the unexposed group, and patients who accepted vaccination were assigned to the exposed group. The vaccinated group received three doses of hepatitis vaccine at 0, 1, and 6 months. Clinical assessments and routine laboratory tests were performed before vaccination, and 2 and 7 months after vaccination. The different measurements of disease activity (daytime pain, morning stiffness, number of tender joints, number of swollen joints, Westergren erythrocyte sedimentation rate, and C reactive protein levels) were not statistically different among the vaccinated and unvaccinated groups at 0 weeks, 1 month, or 7 months. Weight of Epidemiologic Evidence the committee has limited confdence in the epidemiologic evi dence, based on one study that lacked validity and precision, to assess an association between hepatitis B vaccine and exacerbation of rheumatoid arthritis. The epidemiologic evidence is insuffcient or absent to assess an association between hepatitis B vaccine and onset of rheumatoid arthritis. Mechanistic Evidence the committee identifed eight publications reporting the onset of rheu matoid arthritis postvaccination against hepatitis B. Geier and Geier (2004) did not provide evidence beyond temporality and did not contribute to the weight of mechanistic evidence. Described below are seven publications reporting clinical, diagnostic, or experimental evidence that contributed to the weight of mechanistic evidence. One month after receiv ing the third dose the patient presented with malaise, arthralgia, and heart rhythm disturbances. The symptoms worsened in four patients following subsequent vaccination; three after the second and third doses, one after the second dose. Two cases did not develop antibodies to hepatitis B; four were not tested; four were positive for antibodies. Two cases developed symptoms after the frst and second doses of hepatitis B vaccines. Soubrier and colleagues (1997) describe a 37-year-old patient present ing with hives days after administration of the frst dose of hepatitis B vaccine.

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Different arsenic compound produced and used in the industry such as allergy forecast minnesota generic astelin 10 ml amex, elementary arsenic allergy forecast baton rouge purchase 10 ml astelin fast delivery, Gallium arsenide allergy medicine makes my heart race buy discount astelin 10 ml, arsenic trioxide etc jewelry allergy treatment buy discount astelin 10 ml line. Arsenic trioxide, Arsenic pentaoxide, sodium arsenate and arsenite, Potassium arsenate and arsenate, Calcium arsenate are found in insecticides, pesticides, herbicides, fungicides, rodenticidies, wood preservatives, and other uses. Arsenic released form natural agencies such as weathering processes on a global scale is 4 4 estimated to be about 8*10 metric tones per year while man made activities account for 24*10 metric tones per year (Dara, 2002). Elemental arsenic is incorporated in some copper and lead base alloys to enhance their hardness and thermal resistance (Daran, 2002). There is so much variation in guideline value within different countries and institutes. The most toxic form is arsine gas, followed by inorganic trivalent compounds, organic trivalent compounds, inorganic pentavalent compounds, organic pentavalent compounds and elemental arsenic. This concentration is too low to induce any noticeable health effects by inhalation. Therefore, inhalation and skin contact are negligible source of entry for arsenic. The ingestion of arsenic containing food and/or water is the most important route of entry. Of the many food categories, fish and shellfish contain the highest level of arsenic. Fortunately, over 90% of the arsenic is in organic form, which is only very mildly toxic. In contrast, for arsenic contaminated drinking water, most of the arsenic is in the more toxic inorganic form. However, in areas with volcanic rock and sulphide mineral deposits, arsenic levels in excess of 3000 ug/L have been measured. Acute arsenic poisoning usually starts with a metallic or garlic like taste, burning lips and dysphagia. These gastrointestinal symptoms are a result of intestinal injury caused by dilatation of splanchnic vessels leading to mucosal vesiculation. After the initial gastrointestinal problems, multi-organ failures may occur, followed by death. Survivors of acute arsenic poisoning commonly incur damage to their peripheral nervous system. Acute poisoning has a mortality rate of 50-75% and death usually occurs within 48 hours. However, in the context of drinking water supply, acute poisoning is less common than chronic exposure. On the other hand, some believe that chronic toxicity at low arsenic levels, as found in most groundwater, is influenced only by total arsenic concentration, not speciation. No matter which hypothesis is correct, long-term exposure to arsenic has proven to cause dermal, vascular, and cancer effects. Hyperpigmentation is an alteration in color resulting in spots on the skin and keratosis is a hardening of skin bulges, usually found in palms and soles. Recent studies from West Bengal, India and Bangladesh in populations showed that that the age-adjusted prevalence of keratosis rose from zero in the lowest exposure level (< 50 µg/L) to 8. Studies have consistently shown high mortality risks from lung, bladder and kidney cancers among populations exposed to arsenic via drinking water. The characteristic of arsenicosis study in different stages (Bist, 2000; Shrestha and Maskey, 2001) which are as follows: Pre-clinical stage: Not-detectable by clinical manifestation. The work summarized in the following table: Table 5: Arsenic Level at Different Districts in Nepal as of November 2003 Samples with Arsenic Concentrations Percentage exceeding Max. Districts 0 10 ppb ppb > 50 ppb of tests ppb 10 ppb 50 ppb 1 Illam 4 0 0 4 0 0 2 Jhapa 493 77 1 571 79 14 0 3 Morang 339 260 4 603 70 44 1 4 Sunsari 646 241 4 891 75 27 0 5 Saptari 669 94 9 772 98 13 1 6 Siraha 245 235 104 584 90 58 18 7 Udaypur 3 0 0 3 5 0 0 8 Dhanusa 425 64 13 502 140 15 3 9 Mahhotari 177 21 4 202 80 12 2 10 Sarlahi 402 114 16 532 98 24 3 11 Rautahat 814 2289 262 3365 324 76 8 12 Bara 1983 550 51 2584 254 23 2 13 Parsa 1895 253 59 2207 456 14 3 14 Kathamndu 35 20 1 56 141 38 2 15 Chitwan 219 0 0 219 8 0 0 16 Nawalparasi 1385 1340 1108 3833 571 64 29 17 Rupandehi 2191 410 124 2725 2620 20 5 18 Kapilbastu 3471 466 162 4099 589 15 4 19 Palpa 26 0 0 26 0 0 20 Dang 639 25 3 667 81 4 0 21 Banke 2673 645 42 3360 270 20 1 22 Bardiya 472 160 20 652 181 28 3 23 Kailali 149 106 44 299 213 50 15 24 Kanchanpur 167 21 12 200 221 17 6 Total 19522 7391 2043 28956 Total % 67% 26% 7% 100% Source: (National Arsenic Steering Committee, Nepal. In this method coagulation, oxidation, co precipitation followed by filtration occurs to remove arsenic from water. In this filter, a black colored arsenic removal powder is used, which is a specially prepared mixture of coagulant, activated carbon and oxidizing agent for removing arsenic from the water. Agencies working in arsenic have been providing this filter to the arsenic affected community in Terai region. This system does not use any chemicals for arsenic removal but uses locally available material like sand, brick and charcoal. The natural filtration process removes arsenic, iron and other unnecessary chemicals. This filter has been introduced in the Terai region previously 31 for removal of iron and bacteriological contamination. Since this filter system is durable and considering the iron removal efficiency, it is expected that it will also remove arsenic with some modifications. This system removes iron arsenic as well as bacterial contamination without using any chemicals. This filter was introduced at the end of 2002 and is provided to few communities as pilot phase in Terai. Beginning in the early 1800s, sand beds were used in Europe to treat cholera infected waters. Several research studies revealed that the removal rate of fecal coliforms from the drinking water is very good (more than 90%) (Ngai. The arsenic removal unit is consisted of plastic diffuser basin, iron nails and some brick chips. Cross section of Improved Bio Sand Filter is shown in fig; 32 Diffuser Basin Lid Arsenic Iron Nails & Removal Unit Container Brick Chips Air Space Water Fine Sand Pathogen Pipe Removal Unit Coarse Sand Gravel Figure 6: Cross section of Arsenic Biosand Filter. They are: Oxidation/Reduction Precipitation Adsorption In adsorption process, arsenic is strongly attracted to sorption sites on the surfaces of the solid materials like iron and aluminum hydroxide flocs and is effectively removed from the solution by subsequent physical filtration. Arsenic removal technology of ArsenicBio Sand Filter is based upon the adsorption process as it consists of iron nails, which is found to be an excellent adsorbent for Arsenic. In Arsenic Bio Sand Filter, the iron nails are exposed to air and water, and are rust quickly, producing ferric hydroxide particles. When arsenic contaminated water is poured into the filter, 33 arsenic is quickly adsorbed onto the surface of the ferric hydroxide particles. These arsenic loaded ferric hydroxide particles are trapped on top of the fine sand layer. Most of the arsenic is already adsorbed on to the ferric hydroxide, and almost all ferric hydroxide is trapped on the top of fine sand layer, as a result, arsenic is effectively removed from the water. During the process of arsenic removal, iron dissolved in water is also removed through co precipitation and filtration process. A tightly packed bed of the sand grains can detain particles about 5% of the grain diameter. This is extensively larger than many particles to be removed from surface water such as cysts (1-20µm). Viruses are much less than 1 µm, so must be removed by other means, such as biological mechanisms. When water is passed through the sand bed, the particles it contains-large and small collide with individual grains of sand. Water that requires filtration usually contains various kinds of organic matter, including living organisms. These particles and organisms accumulate in the uppermost layers of a sand bed, since this is where most of the collision takes place, and eventually develop into a dense biological population, which is known as the biological layer of biofilm. The biofilm consists of threadlike algae, and many other organisms including plankton, protozoa and bacteria. The biofilm needs stability, continuous water environment, diffuser level and basic nutrients, such as organic matter and oxygen. The 5 cm resting water level is the optimum heights as at this height the biology surviving in the biofilm receives maximum oxygen. Moreover, this resting water level serves a constant aquatic environment necessary for the organisms present in the layer to survive. The water should not be allowed to flow freely or directly on to the sand as it disturbs the biofilm, which may results incapability of pathogen removal.

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And then the place I had to bank the sperm was upstairs as well so I had to squeeze into a little lift and then I was a bit of a wreck by the time I got there allergy medicine rite-aid discount astelin 10 ml with visa. And she explained like everything and any questions I had which was really good cos it set us at ease allergy testing your baby order astelin 10 ml online. Teenage male 18:19 Another of the wheelchair users was so ill with severe headaches that he could not physically sit up at any stage of the journey allergy treatment emedicine purchase astelin 10 ml visa. He had to lie on the back seat of the car and be tilted backwards in the wheelchair from the entrance of the hospital through to the sperm bank before transferring to the bed to produce the sample allergy medicine enlarged prostate discount astelin 10 ml line. Being accompanied Three were accompanied by their mothers (2 teenagers, one adult), one by mother and an uncle (one teenager), 3 by fathers (all now adults), two by female nurses (both teenagers), two went unaccompanied (one adult, one teenager) and one by a social worker (one adult). It is interesting to see that there was a complete shift from fathers to mothers or nurses. The majority were given the choice as to who should go with them and expressed satisfaction with the arrangements. However, at least one who was offered a choice by the consultant did not feel that he could do other than accept his fathers offer to go with him, even though he would have preferred to go alone or with a nurse. This echoes sentiments expressed elsewhere in the study about the difficulties faced by 58 teenagers being offered a choice (or rather, making the decision that they want to make) in the presence of their parents. Several could not remember having a choice but were nevertheless satisfied with the arrangements. For one, this was fortuitous as he was told that he would be accompanied by a professional rather than his parents – and he, like several others, was finding it difficult to cope with his parents at times. Another valued the fact that he and his mother could talk openly on the journey without worrying about strangers (even if they were professionals) being party to their private discussion. The presence of this young mans mother at the sperm bank also resulted in him being supported to make a crucial decision to return one more time to provide another sample – and one that turned out to be much better quality (and a great comfort to him now). Being accompanied brought its constraints, with an acute awareness of the nature of the task awaiting them at the end of the journey. Adult male 16:22 Even those who reported favourably on being accompanied by family members or professionals did not want them to be seated nearby when they were in the semen collection room. The consent process Although many talked about the consent process, the level of detail that was recalled varied and tended to be lower than about other aspects of the banking process. A few would have preferred the consent process to take place on the paediatric oncology ward. Some found the consent consultation to be repetitive of what they had been told prior to going to the sperm bank and/or delivered in too much detail and complexity or with too little clarity. Although some found the approach of the staff at the sperm bank eased the consent process considerably others found that their approach contributed to making it more difficult to handle. I think that was one of the things cos I was pretty up tight and, you know, het up about things. And him saying, going through all that with you – are you thinking about having kids For some, this reinforced their belief that it would have been easier for them to have gone through the consent process on the ward and then gone on to produce the sample at a time that felt right for them. Several could remember receiving a copy of the consent form and appeared reasonably aware of its main features such as the option of extended storage and of disposal arrangements in the event of their death. While some had not been upset by the need to decide about the latter and seemed to take it in their stride (especially those who had not considered their situation to be life threatening), others had found this distressing. Several also thought that they had agreed for it to be used for research if they were to die. Only one could remember being asked for, and signing, consent to disclose information about whether or not they had banked to staff outside the licensed centre (a legal requirement). This included those who had since had written contact with the sperm bank over renewal of storage. In keeping with this, few seemed aware that they could put their partners name onto the form at a later stage to facilitate posthumous use even though a number knew that posthumous use by a partner was an option. Finally, while some spoke of there being a mass of paperwork to complete, others remembered there being very little. One or two thought that their parents had given written consent rather than them but the majority were clear that the consent had been made by them alone. Physical attributes of the semen collection room There were a number of physical aspects of the service that were seen as a hindrance to the experience. Six of the twelve who tried to bank said that the room was too small and impersonal. Two at least had been able to hear voices outside very clearly and hence it had not felt private enough. Others were pleased to find that the room had a lock on the inside which improved their sense of privacy a little. Some thought the room should have been less clinical and would have preferred it to contain, for example, comfortable chairs, a television, pictures on the walls, provision of food and drink (or the knowledge beforehand that they could take food and drink in with them) and so on. For one of those who failed to ejaculate, the memory of the clinical surroundings was vivid as he recalled his acute discomfort acted out by wandering around the room until finally abandoning the attempt. Another, who was in accord with the general sentiment of wanting the room to be more pleasant, suggested particular attention should be paid to cleanliness because that would have made him feel less conscious that others may have used the room for similar purposes before him. He had had to use what appeared to be a consulting room with a trolley and computer in it and found this off-putting. Another found the clinical nature of the room to be an inhibitor in part because he associated clinical with cleanliness and felt that reinforced his sense of masturbation as being inappropriate in that context. Seven of the twelve supported the provision of pornographic magazines in the semen collection room. All thought that they were potentially useful at any age even those that did not make use of them themselves. One of the teenage males who failed to bank wondered whether access to magazines or a video might have helped 61 (although he also thought it was related to his tension at being there, the fact that he did not like the room and found it too hot, and that he was already on treatment). Another teenage male thought that their availability the second time around contributed to his higher sperm count on that occasion. However there were also hints that their presence contributed to at least three feel that they were doing something smutty or shameful. Adult male 20:22 One found the container itself very difficult to manage as it did not have a wide enough opening. Only one reported that no-one had prepared him before he left the paediatric oncology centre by checking that he knew that he had to masturbate in order to produce a sample. When he got to the sperm bank, he was simply given a bottle and shown to a room but, again, given no instructions about what to do. Getting the results All but one could recall having been given the results though one was hazy about the timing (which suggests that, for him, the timing was unproblematic) and another did not talk at all about getting the results. Some of the nurses might know, young impressionable, so the nurses might know, it might say what my sperm count is in that file in front of them…. Adult male 15:30 Among the others, there were variations in the timing of giving results. This was viewed very positively as it enabled them to move forward with the reassurance of having successfully banked. One got the results of the first sample when going for the second appointment but then did not get the results from the second sample until he went back for a consultation after chemotherapy finished. He would have preferred to have the results sooner and commented on the reassurance that came from knowing that his first sample was of very good quality. No I would yeah, that actually made me quite happy that you know because I knew it before I had chemo, so it made me quite happy that that was sorted. Adult male 20:22 Another left the clinic without any idea of the timescale for getting the results and when they were given three weeks later it was to say that no sperm had been detected. However, one had been given the results by a nurse on the paediatric oncology ward who had been asked to pass on the message. For those for whom completing the banking process marked a step on the way to treatment, a piece of business that was finished and done with that enabled them to keep moving forward, getting the results marked the end of this task. As such they were an important marker in a process where it frequently felt difficult to have any sense of achievement in these early stages. Storage Issues A number of issues came up about storage: Knowledge about storage facilities Although detailed knowledge seemed patchy, this did not appear to present anxieties with many feeling that they knew enough. A number were very clear about the facilities and appeared to appreciate knowing matters such as where and how their sperm was going to be stored (two were offered the chance to see the storage facility – one declined but appreciated having the opportunity, the other had a look). Charging A few expressed concern and a sense of unfairness that they might be charged for storage (and for any associated assisted conception treatment) in the future. Indeed one of the adults had been prompted to go for testing because the bank where his sample was stored was intending to move it to another site where storage costs would be incurred (and he would have struggled to find the costs).

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Calcium may be poorly absorbed from foods rich in oxalic acid (such as spinach allergy medication for dogs order astelin 10 ml line, sweet potatoes allergy symptoms cold buy 10 ml astelin free shipping, rhubarb allergy symptoms august astelin 10 ml on-line, and beans) and from foods rich in phytic acid (such as un leavened bread allergy symptoms to pollen buy 10 ml astelin, raw beans, seeds, nuts, grains, and soy isolates). Although soy beans contain large amounts of phytic acid, calcium absorption from these le gumes is relatively high compared with other foods rich in phytic acid. Com pared with calcium absorption from milk, calcium absorption from dried beans is about half; from spinach it is about one-tenth. Dietary Reference Intakes: the Essential Guide to Nutrient Requirements. Tablet disintegration of supplements is crucial, and the efficiency of calcium absorption from supplements is greatest when calcium is taken in doses of 500 mg or less. Dietary Interactions There is evidence that calcium may interact with certain other nutrients and dietary substances (see Table 2). During chronic calcium deficiency, the mineral is resorbed from the skeleton to maintain a normal circulating concentration, thereby compromis ing bone health. Consequently, chronic calcium deficiency is one of several important causes of reduced bone mass and osteoporosis. The po tential effects of calcium deficiency include the following: •O steopenia (lower than normal bone-mineral density) •O steoporosis (very low bone-mineral density) •A n increased risk of fractures Special Considerations Amenorrhea: Induced by exercise or anorexia nervosa, amenorrhea results in reduced calcium retention and net calcium absorption, respectively, along with lower bone mass. Menopause: Decreased estrogen production at menopause is associated with accelerated bone loss for about 5 years. Lower levels of estrogen are accompa nied by decreased calcium absorption efficiency and increased rates of bone turnover. However, available evidence suggests that the calcium intake require ment for women does not appear to change acutely with menopause. Lactose intolerance: People with lactose intolerance who avoid dairy products and do not consume calcium-rich lactose-free foods may be at risk for cal cium deficiency. Although lactose intolerance may influence intake, lactose intolerant individuals absorb calcium normally from milk. Dietary Reference Intakes: the Essential Guide to Nutrient Requirements. Magnesium Magnesium deficiency may In general, magnesium deficiency must become cause hypocalcemia. However, a 3-week study of dietary-induced experimental magnesium depletion in humans demonstrated that even a mild degree of magnesium depletion may result in a significant decrease in serum calcium concentration. Oxalic acid Oxalic acid may inhibit Foods rich in oxalic acid include spinach, sweet calcium absorption. Phosphorus Excess intake of phosphorus this is less likely to pose a problem if calcium intake is may interfere with calcium adequate. Phytic acid Phytic acid may inhibit Foods rich in phytic acid include unleavened bread, calcium absorption. Protein Protein may increase urinary the effect of dietary protein on calcium retention is loss of calcium. Available evidence does not warrant adjusting calcium intake recommendations based on dietary protein intake. Sodium Moderate and high sodium High sodium chloride (salt) intake results in an intake may increase urinary increased loss of urinary calcium. However, direct evidence linking sodium intake with bone loss and fracture is lacking. Available evidence does not warrant different calcium intake requirements for individuals based on their salt consumption. Dietary Reference Intakes: the Essential Guide to Nutrient Requirements. However, the available human data fail to show cases of iron deficiency or even reduced iron stores as a result of calcium intake. Magnesium High intakes of calcium may Most human studies of the effects of dietary calcium decrease magnesium on magnesium absorption have shown no effect, but absorption. Calcium intakes of as much as 2,000 mg/day (in adult men) did not affect magnesium absorption. Calcium intakes in excess of 2,600 mg/day have been reported to decrease magnesium balance. Several studies have found that high sodium and calcium intake may result in increased renal magnesium excretion. Overall, at the dietary levels recommended in this publication, the interaction of magnesium with calcium is not of concern. Phosphorus Pharmacological doses of Calcium in the normal adult intake range is not likely calcium carbonate may to pose a problem for phosphorus absorption. Zinc Calcium may decrease zinc Dietary calcium may decrease zinc absorption, but absorption. Human studies have found that calcium phosphate (1,360 mg/day of calcium) decreased zinc absorption, whereas calcium in the form of a citrate–malate complex (1,000 mg/day of calcium) had no statistically significant effect on zinc absorption. Data suggest that consuming a calcium-rich diet does not lower zinc absorption in people who consume adequate zinc. The effect of calcium on zinc absorption in people with low zinc intakes has not been extensively studied. Dietary Reference Intakes: the Essential Guide to Nutrient Requirements. Mothers who breastfeed multiple infants: Due to the increased milk produc tion of a mother while breastfeeding multiple infants, increased intakes of cal cium during lactation, as with magnesium, should be considered. Of the many possible adverse effects of excessive calcium intake, the three most widely stud ied and biologically important are the following: •Kidney stones •H ypercalcemia and renal insufficiency (also known as milk-alkali syndrome) •The interaction of calcium with absorption of other minerals (see Table 2) Although these are not the only adverse effects associated with excess calcium intake, they do constitute the vast majority of reported effects. Special Considerations Individuals susceptible to adverse effects: Some people may be at greater risk for adverse effects related to calcium. They include those with renal failure, those who take thiazide diuretics, and those with low intakes of minerals that interact with calcium (see Table 2). Dietary Reference Intakes: the Essential Guide to Nutrient Requirements. However, this increased efficiency of calcium absorption is generally not sufficient to offset the loss of absorbed calcium that occurs with a decrease in dietary calcium intake. During chronic calcium deficiency, the mineral is resorbed from the skeleton to keep the circulating concentration normal, thereby compromising bone health. Calcium may be poorly absorbed from foods that are rich in oxalic acid or phytic acid. Dietary Reference Intakes: the Essential Guide to Nutrient Requirements. Dietary Reference Intakes: the Essential Guide to Nutrient Requirements. The clinical signs and symptoms of defi ciency include impaired plasma glucose utilization and an increased need for insulin. Few serious adverse effects have been associated with excess intake of chromium from foods. Early studies identified chromium as the element that restores glucose tolerance in rats. A number of studies have demonstrated beneficial effects of chromium on circulating glu cose, insulin, and lipids, although the potential mechanisms of action are still being investigated. Progress in the field has been limited by the difficulty in producing chromium deficiency in animals and also by the lack of a simple, widely accepted method for identifying subjects who are chromium depleted and, thus, who would be expected to respond to chromium supplementation. Dietary Reference Intakes: the Essential Guide to Nutrient Requirements. Some studies suggest that chromium absorp tion increases with exercise, but further research is necessary. Most absorbed chromium is excreted rapidly in the urine, and most unabsorbed chromium is excreted in the feces. Dietary Reference Intakes: the Essential Guide to Nutrient Requirements. No adverse effects have been con vincingly associated with excess intake from food or supplements, but this does not mean that there is no potential for adverse effects resulting from high in takes. Determining the chromium content of foods requires rigorous contamination control because standard methods of sample preparation contribute substantial amounts of chromium to the foods being analyzed. In addition, the chromium content of individual foods widely varies and may be influenced by geochemical factors. Consequently, dietary chromium intakes cannot be determined using any existing databases.

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