Intrahepatic, Perihilar and Distal Cholangiocarcinoma: Management and Outcomes

Abstract: Introduction and aims. Cholangiocarcinomas are a heterogeneous group of tumors that can be classified into three clinically distinct types of cancers, intrahepatic, perihilar and distal cholangiocarcinoma. The inconsistent use of nomenclature for these cancers has obscured a true knowledge of the epidemiology, natural history and response to therapy of these cancers. Our aims were to define demographic characteristics, management and outcomes of these three distinct cancer types. Materials and methods. A retrospective study of patients enrolled in an institutional cancer registry from 1992 to 2010. Median survival was compared between different treatment modalities over three time periods for the three types of cholangiocarcinoma at different stages of the disease using Kaplan Meyer analysis. Results. 242 patients were identified. All cases were reviewed and classified into intrahepatic (90 patients), distal (48 patients) or perihilar (104 patients) cholangiocarcinomas. These cancers differed in median age of onset, gender distribution, median survival and stage. 13.8% of patients presented with stage I, 5.8% with stage II, 9.6% with stage III, 28% with stage IV, with 41.8% having unknown stage. The overall median survival was 15.8 months, and was 23, 25, 14, and 4.5 months for stages I, II, III, and IV respectively. Surgery improved survival in both early and advanced stages. Multimodality therapies further improved outcomes, particularly for perihilar cholangiocarcinoma. Conclusion. Perihilar, distal and intrahepatic cholangiocarcinoma vary in their presentation, natural history and therapeutic approach to management. A consistently applied classification is essential for meaningful interpretation of studies of these cancers.

Coral recruitment to two vessel grounding sites off southeast Florida, USA / Reclutamiento de coral en dos sitios de encallamiento de embarcaciones frente al sureste de Florida, EE. UU

Over the last two decades, more than 10 major vessel groundings have occurred on coral reefs offshore southeast Florida. Lack of any published information on coral settlement, post-settlement survival, and juvenile coral growth in the southeast Florida region inhibits efforts to determine if coral populations will be able to effectively re-establish themselves. The goal of this study was to examine these processes to obtain background data needed to determine the potential for natural recovery. Over a three year period annual coral recruitment, juvenile growth, and mortality rates were measured in 20 permanent quadrats at each of two ship grounding and two control sites. The density of new recruits was generally low, ranging from 0.2±0.1 (SE) to 7.1±1.0 recruits m-2. Although the density of coral recruits was generally higher at the grounding sites, mortality rates were high at all sites during the study period. Growth rates of individual colonies were highly variable, and many of the colonies shrank in size due to partial mortality. Results indicate that corals are able to recruit to the damaged reefs but that slow growth rates and high mortality rates may keep these areas in a perpetual cycle of settlement and mortality with little or extremely slow growth to larger size classes, thus inhibiting recovery.

En las dos últimas décadas, más de10 grandes encallamientos de embarcaciones se han producido en los arrecifes de coral mar afuera en el sureste de Florida. La falta de información publicada sobre el asentamiento de corales y sobrevivencia post-asentamiento y de los corales juveniles que crecen en la región, limita los esfuerzos para determinar si las poblaciones de coral serán capaces de restablecerse por ellas mismas. El objetivo de este estudio fue examinar estos procesos para obtener la información necesaria para determinar el potencial de recuperación natural. Se midió el reclutamiento anual de coral joven, el crecimiento y las tasas de mortalidad por un período de tres años, mediante 20 cuadrantes permanentes en cada uno de los dos encallamientos de barcos y dos sitios de control. La densidad de nuevos reclutamientos fue generalmente baja, de 0.2±0.1 a 7.1±1.0 reclutamientos m-2. Aunque la densidad del reclutamiento fue generalmente más alta en los sitios de encallamiento también hubo mayor mortalidad de corales juveniles en esos sitios durante el período de estudio. Las tasas de crecimiento de las colonias individuales fueron altamente variables, y muchas de las colonias se redujeron en tallas debido a mortalidad parcial. Los resultados indican que los corales presentan una disposición a reclutarse en arrecifes dañados, pero las lentas tasas de crecimiento y la alta mortalidad pueden mantener esas áreas en un perpetuo ciclo de asentamiento y mortalidad con poco o extremadamente lento crecimiento hacia las clases de tallas largas, por lo tanto inhibiendo la recuperación.

The characteristics of stress cardiomyopathy in an ethnically heterogeneous population

OBJECTIVES: Stress cardiomyopathy is a cardiac syndrome that is characterized by transient left ventricular systolic dysfunction in the absence of obstructive coronary artery disease. Its epidemiology has been described in homogeneous Asian, Caucasian and Black populations, but its characteristics in heterogeneous populations are poorly understood. Our aim was to assess the characteristics of stress cardiomyopathy in a heterogeneous population that included a large percentage of Hispanics. METHODS: We reviewed 59 consecutive cases of stress cardiomyopathy that were confirmed by coronary angiography and were in agreement with the Mayo Clinic diagnostic criteria. RESULTS: The mean age of the patients was 74 years (range, 39-91 years), and 37 patients were female (62.7 percent). Twenty-nine patients (49.2 percent) were Latino/Hispanic, 26 (44 percent) were Caucasian, 3 (5 percent) were Asian, and 1 patient (1.7 percent) was Black. The most common chief symptom was dyspnea, followed by chest pain and an absence of symptoms in 54.2, 28.8, and 18.6 percent of the patients, respectively. The primary EKG abnormalities consisted of a T wave inversion, an ST segment elevation, and ST segment depression in 69.5 percent, 25.4 percent, and 15.3 percent of the patients, respectively. The stressor event was identified in 90 percent of the cases. In 32 cases (54 percent), the stressor event was physical stress or a medical illness, and in 21 cases (35.6 percent), the stressor event was emotional stress. The in-hospital mortality rate was 8.5 percent. CONCLUSIONS: In our heterogeneous study population, stress cardiomyopathy presented with a 3:2 female-to-male ratio, and dyspnea was the most common chief complaint. Stress cardiomyopathy exhibited a T wave inversion as the primary EKG abnormality. These findings differ from previous cases that have been reported, and further studies are needed.

Restoration and monitoring of a vessel grounding on a shallow reef in the Florida Keys

This paper summarizes the results of a monitoring event designed to track the recovery of a repaired coral reef injured by the M/V Alec Owen Maitland vessel grounding incident of October 25, 1989. This grounding occurred within the Florida Keys National Marine Sanctuary. Pursuant to the National Marine Sanctuaries Act, NOAA recovers money for injury to Sanctuary resources, and uses it to restore those resources. A monitoring program tracks patterns of recovery, in order to determine the success of restoration measures. To evaluate success, reference habitats adjacent to the restoration site are concurrently monitored to compare the condition of restored areas with natural areas. Restoration of this site was completed in September 1995 by means of cement and limestone rock, and the monitoring results from summer 2007 are presented. Monitoring consisted of omparison of the biological conditions in the restored area with the reference area. Monitored corals are divided into the Orders: Gorgonians, Milleporans, and Scleractinians. Densities at the restored and reference areas are compared, and are shown to be greater in the restored. Size-class frequency distributions for the most abundant Scleractinians are examined, and reveal that the restoration is converging on the reference area. Also, for the Scleractinians, number and percentage of colonies by species, as well as several common biodiversity indices are provided; measures for the restored area approximate the reference area. A quantitative comparison of colony substrate settlement preference in the restored area is provided for all Orders, and for Scleractinians is further broken down for the two most frequent Genera. Rev. Biol. Trop. 58 (Suppl. 3): 151-161. Epub 2010 October 01.

Este artículo sintetiza los resultados del seguimiento diseñado para medir la recuperación de un arrecife restaurado que fue impactado por el encallamiento del M/V Alec Owen Maitland el 25 de octubre de 1989. Este encallamiento ocurrió en el área que comprende el Santuario Marino Nacional de los Cayos de Florida. De acuerdo con la Ley de los Santuarios Marinos Nacionales, la NOAA cobra dinero por daños a los recursos del Santuario y los usa para restaurar dichos recursos. Un programa de seguimiento o monitoreo mide los patrones de recuperación para determinar el éxito de las medidas de restauración. Para evaluar el éxito, hábitats de referencia adyacentes al sitio de restauración son examinados para comparar las condiciones de las áreas restauradas con las naturales. La restauración de este lugar se completó en septiembre de 1995 utilizando roca de cemento y caliza y los resultados del seguimiento desde el verano del 2007 son presentados. Se compararon las condiciones biológicas entre el área restaurada y la de referencia. Los corales evaluados se dividieron en tres Órdenes: Gorgonios, Milleporinos y Escleractinios. Se compararon las densidades en las áreas de restauración y de referencia, siendo la densidad más grande en las áreas restauradas. Se examinaron las distribuciones de frecuencia de tamaño y clase para los Escleractinios más abundantes, lo que mostró que las áreas restauradas están convergiendo con las de referencia. Para los Escleractinios, también se presentan números y porcentajes de colonias por especie al igual que varios índices comunes de biodiversidad. Las medidas para el área restaurada se aproximan al área de referencia. Una comparación cuantitativa del sustrato preferido para el asentamiento de las colonias en el área de restauración se presenta para todos los Órdenes; para el caso de Escleractinios se presenta más detalle de los dos géneros más frecuentes.

Distribution and abundance of natural parasitoid (Hymenoptera: Pteromalidae) populations of house flies and stable flies (Diptera: Muscidae) at the University of Florida Dairy Research Unit

From September 2001 through September 2002, house fly and stable fly pupae were collected weekly from three fly habitats at the University of Florida Research dairy in northcentral Florida and evaluated for parasitism. Varying parasitism percentages were observed throughout the study but they were not affected by temperature, precipitation or fly abundance. Of the 6,222 house fly pupae and 1,660 stable fly pupae that produced either a host fly or a parasitoid, 26.9 percent and 26.7 percent were parasitized, respectively. Ten parasitoid species were recovered, with the genus Spalangia accounting for 85.7 percent of the total; the most common parasitoids attacking house fly and stable fly pupae were Spalangia endius Walker (33.9 percent and 27.3 percent), S. cameroni Perkins (27.9 percent and 40.6 percent), and S. nigroaenea Curtis (21.0 percent and 24.8 percent), respectively. Other parasitoids included one specimen of S. erythromera Fõrster and four specimens of Phygadeuon fumator Gravenhõrst (Ichneumonidae). The percentage parasitism of pupae collected from bunker silos was higher than that of pupae from calf pens and open pastures. Spalangia cameroni was consistently recovered through the entire year. Spalangia nigroaenea was predominant in July, August, and September. Spalangia endius was most active from October to May with a peak of relative abundance in January.

Human Papillomavirus infection in men residing in Brazil, Mexico, and the USA / Infección por Virus de Papiloma Humano en hombres de Brasil, México y EUA

OBJECTIVE: To assess Human Papillomavirus (HPV) type distribution among men ages 18 years and older recruited from three different countries utilizing a common protocol for sampling HPV detection, and to evaluate whether HPV detection differs by age and country. MATERIAL AD METHODS: The study protocol includes a pre-enrollment run-in visit, a baseline (enrollment) visit, and nine additional visits after enrollment scheduled six months apart. For this analysis, the first 1160 men who completed both the run-in and baseline visit were included. To maximize sampling and prevent fraying of applicators, three different applicators were utilized to sample the external genitalia of participants among different anatomic sites. These samples were later combined to form a single sample for the detection of HPV using polymerase chain reaction (PCR) for amplification of a fragment of the HPV L1 gene. RESULTS: Among 1160 men from Brazil, Mexico, and the United States (U.S.), overall HPV prevalence was 65.2 percent; with 12.0 percent oncogenic types only, 20.7 percent non-oncogenic types only, 17.8 percent both oncogenic and non-oncogenic, and 14.7 percent unclassified infections. Multiple HPV types were detected in 25.7 percent of study participants. HPV prevalence was higher in Brazil (72.3 percent) than in the U.S. (61.3 percent) and Mexico (61.9 percent). HPV 16 (6.5 percent), 51 (6.5 percent), and 59 (5.3 percent) were the most commonly detected oncogenic infections, and HPV 84 (7.7 percent), 62 (7.3 percent), and 6 (6.6 percent) were the most commonly detected non-oncogenic infections. Overall HPV prevalence was not associated with age. However, significant associations with age were observed when specific categories of oncogenic, non-oncogenic, and unclassified HPV infections were considered. CONCLUSIONS: Studies of HPV type distribution among a broad age range of men from multiple countries is needed to fill the information gap internationally ...

OBJETIVO: Evaluar la distribución tipo específica de infección por Virus del Papiloma Humano (VPH) entre hombres de 18 años o más de tres países con un protocolo común para el muestreo de la detección de VPH, y evaluar si la detección de VPH varía de acuerdo con la edad y el país. MATERIAL Y MÉTODOS: El estudio incluye diversas etapas que inician con la identificación de hombres susceptibles, una medición basal (visita de enrolamiento) y nueve visitas adicionales programadas cada seis meses. En este artículo, se presenta el análisis de los primeros 1160 hombres que fueron incluídos en el estudio. Para maximizar la posibilidad de detección de VPH se utilizó un cepillo de dacrón que muestreó en forma combinada diferentes sitios anatómicos. Para la determinación de ADN de VPH se utilizó ión en cadena de polimerasa (PCR) por amplificación de un fragmento del gen de VPH L1. RESULTADOS: Entre 1160 hombres de Brasil, México y EUA, la prevalencia global de VPH fue de 65.2 por ciento, con solamente 12 por ciento de tipos oncogénicos, 20.7 por ciento de tipos de VPH no oncogénicos, 17.8 por ciento de muestras positivas a tipos oncogénicos y no oncogénicos; y finalmente 14.7 por ciento de infecciones no clasificadas. Múltiples tipos de VPH fueron detectados en 25.7 por ciento de los participantes en el estudio. La prevalencia de VPH fue más alta en Brasil (72.3 por ciento), comparada con la observada en EUA (61.3 por ciento) y México (61.9 por ciento). Los tipos de VPH 16 (6.5 por ciento), 51 (6.5 por ciento) y 59 (5.3 por ciento) fueron los más comúnmente observados con poder oncogénico. El VPH 84 (7.7 por ciento), 62 (7.3 por ciento) y 6 (6.6 por ciento) fueron las infecciones no oncogénicas más comunes. CONCLUSIONES: Son necesarios estudios de la distribución de VPH en un amplio margen de edad entre hombres de múltiples países, para establecer con mayor precisión, el conocimiento de la historia natural de la infección por VPH en hombres.

HIV risk behaviors of Latin American and Caribbean men who have sex with men in Miami, Florida, USA / Comportamientos de riesgo de infección por el VIH en hombres latinoamericanos y caribeños que tienen sexo con hombres en Miami, Florida, EUA

OBJECTIVE: The goal of this study is to describe the sexual practices, drug use behaviors, psychosocial factors, and predictors of unprotected anal intercourse (UAI) in a sample of Hispanic men who have sex with men (MSM) born in Latin American and Caribbean (LAC) countries who currently reside in Miami-Dade County, Florida. METHODS: Hispanic MSM (N = 566) recruited from community and Internet venues completed a computer-assisted self-interview assessing sociodemographic factors, drug use, sexual behaviors, and psychosocial factors. We focused on the 470 men who were born in LAC countries, including Puerto Rico. We first examined separately, by country of origin, the sexual practices, drug use behaviors, and psychosocial factors of the sample. We then collapsed the groups and examined the factors associated with UAI in the previous 6 months for the entire sample of Hispanic MSM from LAC countries. RESULTS: In the previous 6 months, 44 percent of the sample engaged in UAI, and 41 percent used club drugs. At the multivariate level, psychological distress, higher number of sexual partners, club drug use, HIV-positive status at the time of immigration, and greater orientation to American culture were significantly associated with UAI in the previous 6 months. CONCLUSIONS: Many MSM born in LAC countries engage in HIV-related risk behaviors in the AIDS epicenter of Miami-Dade County, Florida. Culturally appropriate interventions should address these risk behaviors in this underserved population.

OBJETIVO: Describir las prácticas sexuales, el consumo de drogas y los factores psicosociales y de predicción del coito anal sin protección (CASP), en una muestra de hombres nacidos en América Latina y el Caribe (ALC) residentes actualmente en el Condado de Miami-Dade, Florida, que tienen sexo con hombres. MÉTODOS: En total, 566 hispanos que tienen sexo con hombres (HSH), captados en la comunidad y sitios de Internet, completaron una encuesta autoaplicada por computadora que abordaba los factores socioeconómicos, el consumo de drogas, el comportamiento sexual y los factores psicológicos. El estudio se centró en 470 hombres nacidos en ALC, incluido Puerto Rico. La muestra se analizó por país de origen, prácticas sexuales, consumo de drogas y factores psicológicos. Luego se unieron los grupos y se analizaron los factores asociados con el CASP en los 6 meses previos en toda la muestra. RESULTADOS: En los 6 meses previos, 44 por ciento de la muestra tuvo CASP y 41 por ciento consumió drogas de las llamadas recreativas. Según el análisis multifactorial, los factores asociados significativamente con el CASP en los 6 meses previos fueron: los problemas psicológicos, el mayor número de parejas sexuales, el consumo de drogas recreacionales, la positividad al VIH en el momento en que inmigró y el mayor grado de orientación hacia la cultura estadounidense. CONCLUSIONES: Muchos HSH nacidos en ALC incurren en comportamientos de riesgo de infección por el VIH en el epicentro de sida del Condado de Miami-Dade, Florida. Se deben aplicar intervenciones culturalmente apropiadas para combatir estos comportamientos de riesgo en la población marginada estudiada.

Gauging differential health among the sexes at Windover (8Br246) using the Western Hemisphere Health Index

Assessment of intrapopulation human health provides information concerning social structure, division of labor, and lifestyle. Differential health among the sexes can provide clues to social roles, resource acquisition and status within prehistoric populations. Windover (8Br246) is an Archaic mortuary pond located in eastern central Florida. Its occupation spans over 500 years and dates to 7000 years BP. Over 168 well-preserved individuals were excavated, providing a glimpse into life during Florida's Archaic. Through the application of the Western Hemisphere Health Index, we find that males within the group experienced better overall health than females. Males outscore females in quality of life, percent of maximum scores, stature, anemia, dental disease, and infection. Females out-score males in enamel hypoplasia and degenerative joint disease. Causative factors for observed differential health are examined and include activity levels, sexual division of labor, access to resources, and the physiological demands of childbearing.

Coral recruitment patterns in the Florida Keys

This study examines scleractinian zooxanthellate coral recruitment patterns in the Florida Keys to determine if differences in density or community composition exist between regions. From July to September 2002, nine patch reefs, three in each of the upper, middle and lower Keys, were surveyed for coral recruits (colonies <5 cm in diameter) using randomly placed quadrats and transects. Coral recruits were enumerated, measured, and identified to genus. Fourteen genera of corals were observed across all sites and ranged from five to 13 per site. Densities ranged from 6.29 +/- 1.92 (mean +/- SE) to 39.08 +/- 4.53 recruits m(-2), and there were significant site and regional differences in recruit densities. The density of recruits in the upper Keys was significantly lower than in the middle and lower Keys. In addition, the upper Keys were less diverse and had a different recruit size-frequency distribution. The majority of recruits were non-massive scleractinian species that contribute relatively little to overall reef-building processes, a finding that is similar to previous studies. Fewer recruits of massive species were found in the upper Keys compared to the middle and lower Keys. The recruitment patterns of the reefs in the upper Keys could potentially hinder their ability to recover from stress and disturbances

Determination of the distribution of shallow-water seagrass and drift algae communities with acoustic seafloor discrimination

The spatial distribution of seagrass and algae communities can be difficult to determine in large, shallow lagoon systems where high turbidity prevents the use of optical methods like aerial photography or satellite imagery. Further complications can arise when algae are not permanently attached to the substratum and drift with tides and currents. A study using acoustic seafloor discrimination was conducted in the Indian River Lagoon (Florida, USA) to determine the extent of drift algae and seagrass. Acoustic surveys using the QTC View V system based on 50 and 200 kHz transducers were conducted near Sebastian Inlet. Results indicate that areas of seagrass can be identified, and are mixed with a high abundance of drift algae. Nearest-neighbor extrapolation was used to fill in spaces between survey lines and thus obtain spatially cohesive maps. These maps were then ground-truthed using data from towed video and compared using confusion matrices, The maps showed a high level of agreement (60%) with the actual distribution of algae, however some confusion existed between bare sand and algae as well as seagrass

Assessing the accuracy of acoustic seabed classification for mapping coral reef environments in South Florida (Broward County, USA)

The Atlantic coast of Broward County, Florida (USA) is paralleled by a series of progressively deeper, shore-parallel coral reef communities. Two of these reef systems are drowned early Holocene coral reefs of 5 ky and 7 ky uncorrected radiocarbon age. Despite the case of access to these reefs, and their major contribution to the local economy, accurate benthic habitat maps of the area are not available. Ecological studies have shown that different benthic communities (i.e. communities composed of different biological taxa) exist along several spatial gradients on all reefs. Since these studies are limited by time and spatial extent, acoustic surveys with the QTCView V bottom classification system based on a 50 kHz transducer were used as an alternative method of producing habitat maps. From the acoustic data of a 3.1 km(2) survey area, spatial prediction maps were created for the area. These were compared with habitat maps interpreted from in situ data and Laser Airborne Depth Sounder (LADS) bathymetry, in order to ground-truth the remotely sensed data. An error matrix was used to quantitatively determine the accuracy of the acoustically derived spatial prediction model against the maps derived from the in situ and LADS data sets. Confusion analysis of 100 random points showed that the system was able to distinguish areas of reef from areas of rubble and sand with an overall accuracy of 61%. When asked to detect more subtle spatial differences, for example, those between distinct reef communities, the classification was only about 40% accurate. We discuss to what degree a synthesis of acoustic and in situ techniques can provide accurate habitat maps in coral reef environments, and conclude that acoustic methods were able to reflect the spatial extent and composition of at least three different biological communities.

The prevalence of human immunodeficiency virus type 1 and hepatitis C virus among injection drug users who use high risk inner-city locales in Miami, Florida

In order to estimate the prevalence of human immunodeficiency virus type 1 (HIV-1) and hepatitis C virus (HCV) co-infection in hard-to-reach intravenous drug users, 199 subjects from high-risk inner-city locales, the so called "shooting galleries", were consented, interviewed, and tested in Miami, FL, US. Positive HIV-1 status was based on repeatedly reactive ELISA and confirmatory Western Blot. Positive HCV status was based on reactive ELISA and confirmatory polymerase chain reaction techniques. Overall, 50 (25 percent) were not infected with either virus, 61 (31 percent) were HIV-1/HCV co-infected, 17 (8 percent) infected by HIV-1 only, and 71 (36 percent) infected by HCV only. The results of the multivariable analyses showed that more years using heroin was the only significant risk factor for HCV only infection (odds ratio = 1.15; 95 percent confidence interval = 1.07, 1.24) and for HIV-1/HCV co-infection (odds ratio = 1.17; 95 percent confidence interval = 1.09, 1.26). This paper demonstrates that HIV-1/HCV co-infection is highly prevalent among so called "shooting galleries".

Colonization potential of banana leaves for growth of pleurotus species

Um teste de colonizaçäo por Pleurotus sp. Florida, P. ostreatoroseus e P.sajor-caju, fungos comestíveis, foi realizado visando conhecer a potencialidade da palha de folha de bananeira (PB), resíduo lignocelulósico, como substrato para o cultivo desses fungos. Utilizou-se a PB e esta misturada ao bagaço de cana (PBBC) ou sabugo de milho (PBSM). A palha de trigo (PT) foi empregada como parâmetro de comparaçäo por ser o resíduo tradicionalmente empregado. As palhas picadas, em partículas de aproximadamente 0,5 cm de comprimento, foram reumedecidas até alcançar aproximadamente 70 por cento de umidade; em seguida foram esterilizadas, em placas de Petri, a 120ºC por 2 horas. O pH dos substratos

Nutritional status of institutionalized elderly in south Florida

To assess the nutritional status of an elderly nursing home population of South Florida, forty-seven persons with ages ranging from 65 to 96 years were studied. Complete clinical examination and anthropometric measures were performed, along with blood cell count, biochemical blood parameters and assessment of water-soluble vitamins levels. The most common clinical finding were edentulous (67%), general pallor (44%), hyperpigmentation (33%), dry skin (26%) and arcus corneitis (26%). Thirty-five percent of the studied population had cholesterol levels greater than 220 mg/dl. Triglyceride levels were also significantly elevated in a considerable subset of our subjects, with 30% having levels above threshold value of 150 mg/dl. Small proportions of subjects showed low levels of albumin (6%), total protein (28%), ascorbic acid (2%), and thiamin (9%). Forty-five percent of males were pyridoxine deficient, while 63% of the females presented such deficiency. This study underscores the need to define, with greater precision, the nutritional status of aged populations as well as improve our inadequate standards associated with the normal aging process. Nutritional intervention--only possible when appropriate standards are defined--can potentially serve not only to prevent the occurrence of significant morbidity and mortality, but can also be employed to enhance quality of life in the elderly individuals