Risk Factors for Lower Extremity Minor Amputation Conversion to Major Amputation.

BACKGROUND: Minor lower extremity amputations (LEAs) have become an important part of the limb salvage approach but are not as benign as previously thought. This study investigates the difference in outcome between toe/ray versus midfoot amputations and the risk factors for major amputation conversion associated with each procedure. METHODS: We performed retrospective chart review of foot amputation patients at a single tertiary care medical center with a primary end point of conversion to major amputation and secondary end points of 1-year wound healing and mortality rate. We collected data on relevant medical comorbidities, noninvasive vascular imaging, revascularization, repeat amputations, wound healing rate, and 1-year mortality. Patients were separated into toe/ray amputations versus midfoot amputation groups and compared using descriptive statistics, Chi-squared tests, Cox proportional hazards, and a multivariate logistic regression model. RESULTS: A total of 375 amputations were included in the analysis. 65.3% (245 patients) included toe/ray amputations and 34.7% (130 patients) included midfoot amputations. We compared these 2 cohorts with regard to their rate of conversion to repeat minor and/or major amputation in addition to overall mortality. The toe/ray group underwent more repeat minor amputations within 1 year after index amputation (34.7% vs. 21.5%, P = 0.008) and wound healing (epithelization) at 90 days was also higher in this group. The midfoot group had a higher conversion to major LEA within 1 year on univariate analysis (20.8 vs. 6.9%, P < 0.001). Overall 1-year mortality was 6.17% and there was no significant difference between groups. CONCLUSIONS: While there is a consistency with previous studies that found no significant overall difference in mortality between types of minor LEA, we have extended this previous work by demonstrating the independent risk factors for conversion to major amputation between types of minor LEA. Comparing these 2 groups will assist surgeons in choosing the appropriate level of amputations and will enhance patient's understanding of their chance of wound healing and risk of repeat amputation.

Host B cells escape CAR-T immunotherapy by reversible downregulation of CD19.

Anti-CD19-CAR-T cells are a successful clinical immunotherapy for B cell lymphomas, although some lymphomas can escape attack by downregulating surface CD19 levels. An undesirable consequence of this therapy is that it can also eliminate healthy B cells expressing CD19. Therefore, understanding the dynamics of CD19 expression in B cells under CAR-T cell immunotherapy can help mitigate both escape and adverse outcomes. Previous studies suggested that mechanisms responsible for the loss of CD19 expression in lymphomas usually involves genomic deletion or epigenetic modification which permanently removes CD19 as a therapeutic target in these cells. We examined if healthy B cells can use similar processes to lose CD19 expression and escape CAR-T attack. In the presence of CAR-T cells, untransformed B cells both when cultured in vitro or in vivo in non-tumor bearing animals downregulate expression of CD19. We then used adoptive transfer strategies to remove CD19-low B cells from αCD19-CAR-T pressure in vivo. Intriguingly, these B cells systematically recovered surface expression of CD19 comparable to wild-type levels. These data suggest that unlike many cases of lymphomas, healthy B cells downregulate CD19 in a reversible fashion. Taken together, these data suggest a dynamic regulatory process of CD19 surface expression on healthy B cells that could be exploited to modulate the expression of CD19 on cancer cells to improve immunotherapy or minimize the depletion of endogenous B cell compartment during treatment.

Migratory connectivity then and now: a northward shift in breeding origins of a long-distance migratory bird wintering in the tropics.

Temporal variation in the connectivity of populations of migratory animals has not been widely documented, despite having important repercussions for population ecology and conservation. Because the long-distance movements of migratory animals link ecologically distinct and geographically distant areas of the world, changes in the abundance and migratory patterns of species may reflect differential drivers of demographic trends acting over various spatial scales. Using stable hydrogen isotope analyses (δ2H) of feathers from historical museum specimens and contemporary samples obtained in the field, we provide evidence for an approximately 600 km northward shift over 45 years in the breeding origin of a species of songbird of major conservation concern (blackpoll warbler, Setophaga striata) wintering in the foothills of the eastern Andes of Colombia. Our finding mirrors predictions of range shifts for boreal-breeding species under warming climate scenarios and habitat loss in the temperate zone, and underscores likely drivers of widespread declines in populations of migratory birds. Our work also highlights the value of natural history collections to document the effects of global change on biodiversity.

Two-Year Test-Retest Reliability of the Breastfeeding Duration Question Used By the Pregnancy Risk Assessment Monitoring System (PRAMS): Implications for Research.

INTRODUCTION: A large literature exists on positive sequelae of breastfeeding, relying heavily on maternal self-reported infant feeding behaviors. Many such studies use PRAMS data, though estimates of reliability for the breastfeeding duration question on PRAMS have not been published. METHODS: We used data from Oregon PRAMS (respondents are a median 3.5 months postpartum) and PRAMS-2 (median 25 months) to assess test-retest reliability of maternal self-reported breastfeeding duration, among women who had weaned prior to completing the PRAMS survey. RESULTS: The sample-wide kappa for the paired, self-reported breastfeeding duration was 0.014, and the intraclass correlation coefficient was 0.17, both of which indicate poor agreement. More than 80% of women reported a longer duration on PRAMS-2; the median (interquartile range) difference was +1.0 (0.31 - 2.1) months. DISCUSSION: Recent literature on this topic from high-income countries falls into two categories: entirely retrospective versus "prospective" reliability assessments. Entirely retrospective assessments (both inquiries occur well after weaning) universally report exceedingly high reliability, whereas "prospective" assessments (women report infant feeding behavior during infancy, immediately after weaning, and some years later are asked to replicate their original answer) universally report poorer reliability. Interestingly, all "prospective" reliability studies, including ours, found that women over-report past breastfeeding durations by about 1 month upon the second inquiry. Researchers need not refrain from using maternal self-reported breastfeeding durations, because participants are largely still ranked correctly, relative to each other. However, such research efforts must avoid attempting to determine any optimal threshold duration.

The Evolution of State-Based Dental Sealant Programs in Oregon Within the Context of the State Health Care Transformation Process.

CONTEXT: The 2007 Oregon Smile Survey of first, second, and third graders found that, since the first (2002) Smile Survey, all major measures of Oregon children's oral health had worsened. The Centers for Disease Control and Prevention recommends 2 interventions proven effective in preventing dental caries (cavities) in a population: community water fluoridation and school dental sealant programs. Repeated attempts at the state level to mandate water fluoridation had failed. State government therefore moved to increase the number of school dental sealant programs. OBJECTIVES: The objective of this article is to demonstrate how 2 interventions and subsequent statewide collaboration addressed the deterioration of children's oral health from 2002 to 2007. DESIGN: An 11-year observational study to increase the number of schools in Oregon with dental sealant programs in the state of Oregon during health care transformation. INTERVENTIONS: (1) Providing state general funds for a state school dental sealant program and (2) establishing an incentivized sealant metric for the Coordinated Care Organizations contracted to serve the Medicaid population. RESULTS: In school year (SY) 2006-2007, only 26% (n = 92) of the state's eligible elementary schools had dental sealant programs. By SY 2013-2014, the use of state general funds increased the number of schools served to 78% (363 schools). By SY 2017-2018, with the establishment of the sealant metric, state and local programs served 92% (n = 473) of the eligible early elementary grades and 65% (n = 172) of the newly eligible middle school grades. CONCLUSION: Providing state general funds and establishing a sealant metric increased the number of schools served by school dental sealant programs and may have contributed to recent improvements in oral health.

Mouse T cells express a neurotransmitter-receptor signature that is quantitatively modulated in a subset- and activation-dependent manner.

Neurotransmitters are known to modulate the course of an immune response by targeting cells in both the innate and adaptive immune systems. Increasing evidence suggests that T cells, by expressing specific neurotransmitter receptors (NR) are directly regulated by them, leading to altered activation and skewed differentiation of the adaptive immune response. Given that gene expression in T cells changes in lineage- and activation-dependent fashion, it is expected that sensitivity to neurotransmitters may also vary along these lines. Here we generate an important resource for further analysis of this tier of immunoregulation, by identifying the distinct profile of NR transcripts that are expressed by peripheral T cells in mice, at different states of activation and differentiation. We find that only about 15% of the total annotated NR genes are transcribed in these T cells and most of them do not change in different subsets of T cells (CD8, CD4 - Naïve vs Memory vs Treg), or even when T cells migrate to different tissues. We suggest that the T cell-expressed NRs, found across all these subsets identifies a core, constitutive NR signature for the T cell lineage. In contrast, a very limited number (<2) of NRs were observed to mark each of the post-activation T cell states, suggesting that very specific neurotransmitter signals are available to modulate T cell responses in vivo in these subsets.

Global change and the distributional dynamics of migratory bird populations wintering in Central America.

Understanding the susceptibility of highly mobile taxa such as migratory birds to global change requires information on geographic patterns of occurrence across the annual cycle. Neotropical migrants that breed in North America and winter in Central America occur in high concentrations on their non-breeding grounds where they spend the majority of the year and where habitat loss has been associated with population declines. Here, we use eBird data to model weekly patterns of abundance and occurrence for 21 forest passerine species that winter in Central America. We estimate species' distributional dynamics across the annual cycle, which we use to determine how species are currently associated with public protected areas and projected changes in climate and land-use. The effects of global change on the non-breeding grounds is characterized by decreasing precipitation, especially during the summer, and the conversion of forest to cropland, grassland, or peri-urban. The effects of global change on the breeding grounds are characterized by increasing winter precipitation, higher temperatures, and the conversion of forest to peri-urban. During spring and autumn migration, species are projected to encounter higher temperatures, forests that have been converted to peri-urban, and increased precipitation during spring migration. Based on current distributional dynamics, susceptibility to global change is characterized by the loss of forested habitats on the non-breeding grounds, warming temperatures during migration and on the breeding grounds, and declining summer rainfall on the non-breeding grounds. Public protected areas with low and medium protection status are more prevalent on the non-breeding grounds, suggesting that management opportunities currently exist to mitigate near-term non-breeding habitat losses. These efforts would affect more individuals of more species during a longer period of the annual cycle, which may create additional opportunities for species to respond to changes in habitat or phenology that are likely to develop under climate change.

Tetanus, diphtheria, pertussis vaccination coverage before, during, and after pregnancy - 16 States and New York City, 2011.

In June 2011, the Advisory Committee on Immunizations Practices (ACIP) recommended 1 dose of a tetanus, diphtheria, and acellular pertussis (Tdap) vaccine during pregnancy for women who had not received Tdap previously. Before 2011, Tdap was recommended for unvaccinated women either before pregnancy or postpartum. In October 2012, ACIP expanded the 2011 recommendation, advising pregnant women to be vaccinated with Tdap during each pregnancy to provide maternal antibodies for each infant. The optimal time for vaccination is at 27-36 weeks' gestation as recommended by ACIP. In response to ACIP's Tdap recommendation for pregnant women in 2011, CDC added a supplemental question to the Pregnancy Risk Assessment Monitoring System (PRAMS) survey to determine women's Tdap vaccination status before, during, or after their most recent delivery. This report describes overall and state-specific Tdap vaccination coverage around the time of pregnancy using data from 6,852 sampled women who delivered a live-born infant during September-December 2011 in one of 16 states or New York City (NYC). Among the 17 jurisdictions, the median percentage of women with live births who reported any Tdap vaccination was 55.7%, ranging from 38.2% in NYC to 76.6% in Nebraska. The median percentage who received Tdap before pregnancy was 13.9% (range = 7.7%-20.1%), during pregnancy was 9.8% (range = 3.8%-14.2%), and after delivery was 30.9% (range = 13.6%-46.5%). The PRAMS data indicate a wide variation in Tdap vaccination coverage among demographic groups, with generally higher postpartum coverage for non-Hispanic white women, those who started prenatal care in the first trimester, and those who had private health insurance coverage. This information can be used for promoting evidence-based strategies to communicate the importance of ACIP guidelines related to Tdap vaccination coverage to women and their prenatal care providers.

Documenting stewardship responsibilities across the annual cycle for birds on U.S. public lands.

In the face of global environmental change, the importance of protected areas in biological management and conservation is expected to grow. Birds have played an important role as biological indicators of the effectiveness of protected areas, but with little consideration given to where species occur outside the breeding season. We estimated weekly probability of occurrence for 308 bird species throughout the year within protected areas in the western contiguous USA using eBird occurrence data for the combined period 2004 to 2011. We classified species based on their annual patterns of occurrence on lands having intermediate conservation mandates (GAP status 2 and 3) administered by the Bureau of Land Management (BLM) and the United States Forest Service (USFS). We identified species having consistent annual association with one agency, and species whose associations across the annual cycle switched between agencies. BLM and USFS GAP status 2 and 3 lands contained low to moderate proportions of species occurrences, with proportions highest for species that occurred year-round or only during the summer. We identified two groups of species whose annual movements resulted in changes in stewardship responsibilities: (1) year-round species that occurred on USFS lands during the breeding season and BLM lands during the nonbreeding season; and (2) summer species that occurred on USFS lands during the breeding season and BLM lands during spring and autumn migration. Species that switched agencies had broad distributions, bred on high-elevation USFS lands, were not more likely to be identified as species of special management concern, and migrated short (year-round species) to long distances (summer species). Our findings suggest cooperative efforts that address the requirements of short-distance migratory species on GAP status 2 lands (n = 20 species) and GAP status 3 lands (n = 24) and long-distance migratory species on GAP status 2 lands (n = 9) would likely benefit their populations. Such efforts may prove especially relevant for species whose seasonal movements result in associations with different environments containing contrasting global change processes and management mandates.

Influenza vaccination of pregnant women: attitudes and behaviors of Oregon physician prenatal care providers.

In spite of increased risk of influenza complications during pregnancy, only half of US pregnant women get influenza vaccination. We surveyed physician prenatal care providers in Oregon to assess their knowledge and behaviors regarding vaccination of pregnant women. From September through November 2011, a state-wide survey was mailed to a simple random sample (n = 1,114) of Oregon obstetricians and family physicians. The response rate was 44.5 %. Of 496 survey respondents, 187 (37.7 %) had provided prenatal care within the last 12 months. Of these, 88.5 % reported that they routinely recommended influenza vaccine to healthy pregnant patients. No significant differences in vaccine recommendation were found by specialty, practice location, number of providers in their practice, physician gender or years in practice. In multivariable regression analysis, routinely recommending influenza vaccine was significantly associated with younger physician age [adjusted odds ratio (AOR) 2.01, 95 % confidence interval (CI) 1.29-3.13] and greater number of pregnant patients seen per week (AOR 1.95, 95 % CI 1.25-3.06). Among rural physicians, fewer obstetricians (90.3 %) than family physicians (98.5 %) had vaccine-appropriate storage units (p = 0.001). Most physician prenatal care providers understand the importance of influenza vaccination during pregnancy. To increase influenza vaccine coverage among pregnant women, it will be necessary to identify and address patient barriers to receiving influenza vaccination during pregnancy.

Increased Food Insecurity Among Mothers of 2 Year Olds with Special Health Care Needs.

The objective of this study is to explore the association between having a child with special health care needs (CSHCN) and food insecurity when the child is 2 years old. We studied women who had a live birth in 2004-2005 and responded to Oregon's Pregnancy Risk Assessment Monitoring System (PRAMS) survey 3 months postpartum (Time 1) and the follow-up survey (PRAMS-2), when the child was 2 years old (Time 2). Women answering affirmatively to the PRAMS-2 question, "In the last 12 months, did you ever eat less than you felt you should because there was not enough money for food?" were considered food insecure. CSHCN status was identified by affirmative responses to questions about needs for ongoing services (Time 2). PRAMS and PRAMS-2 responses were weighted for study design and non-response. Results report weighted analyses, unless noted. Among 1812 mothers completing PRAMS-2, 13.6 % (unweighted) had a 2-year-old CSHCN and 11.9 % (unweighted) were food insecure at Time 2. The estimated prevalence of food insecurity at 2-year follow-up was 20.7 % among families of CSHCN and 9.7 % for others. After adjustment for Time 2 marital status, education, lifetime U.S. residence, income and health conditions, multivariable logistic regression revealed that odds of food insecurity were more than two times as great for CSHCN mothers 2 years post-partum compared to non-CSHCN mothers (adjusted odds ratio 2.6, 95 % confidence interval 1.3, 4.6). Families of CSHCN face increased risk for food insecurity. Improved understanding of causal determinants of food insecurity among households of CSHCN is needed.

Evaluation and treatment of sex addiction.

There have been several diagnostic labels for persistent, excessive sexual behaviors, often referred in the popular media as sex addiction. Two related diagnoses, Internet addictive disorder and hypersexual disorder, were considered for, but not included in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders. However, most clinicians, even those trained in sexual disorders or addiction medicine, have little to no training in treating sexual compulsivity and cybersex addiction. The authors present the historical context, proposed diagnostic criteria, evaluation protocols, comorbid disorders, speculations about the neuroscience, and treatment recommendations.

A Rational Hierarchy to Capture Raw Material Attribute Variability in the Pharmaceutical Drug Product Development and Manufacturing Lifecycle.

Assessing the robustness of a drug product formulation and manufacturing process to variations in raw material (RM) properties is an essential aspect of pharmaceutical product development. Motivated by the need to demonstrate understanding of attribute-performance relationships at the time of new product registration and for subsequent process maintenance, we review practices to explore RM variations. We describe limitations that can arise when active ingredients and excipients invariably undergo changes during a drug product lifecycle. Historical approaches, such as Quality-by-Design (QbD) experiments, are useful for initial evaluations but can be inefficient and cumbersome to maintain once commercial manufacturing commences. The relatively miniscule data sets accessible in product development - used to predict response to a hypothetical risk of variation - become less relevant as real-world experience of actual variability in the commercial landscape grows. Based on our observations of development and manufacturing, we instead propose a holistic framework exploiting a hierarchy of RM variability, and challenge this with common failure modes. By explicitly incorporating higher ranking RM variations as perturbations, material-conserving experiments are shown to provide powerful and enduring robustness data. Case studies illustrate how correctly contextualizing such data in formulation and process development can avoid the traps of historical QbD approaches and become valuable for evaluating changes occurring later in the drug product lifecycle.

Consumption of soda and other sugar-sweetened beverages by 2-year-olds: findings from a population-based survey.

OBJECTIVE: To determine risk factors for consumption of soda and other sugar-sweetened beverages (SSB) among 2-year-old children. DESIGN: The analysis was performed using three linked data sets: the 2004-2005 Oregon Pregnancy Risk Assessment Monitoring Survey (PRAMS); its longitudinal follow-up, 2006-2007 Oregon PRAMS-2; and 2004-2005 Oregon birth certificates. SETTING: PRAMS is a surveillance programme supported by the federal Centers for Disease Control and Prevention and implemented by participating state health departments. Using mixed methods, PRAMS surveys women 2-6 months after a live birth. Oregon PRAMS-2 re-interviews respondents shortly after the index child's second birthday. Oregon PRAMS oversamples minority women. SUBJECTS: Using monthly cohorts, we randomly selected 5851 women from the 2004-2005 birth certificates. In total 1911 women completed both PRAMS and PRAMS-2. The weighted response rate of PRAMS-2 was 43.5%. RESULTS: Almost half of mothers (49.9%) reported that their child drank SSB on at least 1 d/week. Mothers whose children drank SSB at least once weekly were more likely to have low income (adjusted OR=2.83, 95% CI 2.09, 3.83) and to eat out on ≥2 d/week (OR=2.11 %, 95% CI 1.66, 2.70). Hispanic and non-Hispanic black women were most likely to report that their child drank SSB at least once weekly. CONCLUSIONS: Half of mothers reported that their 2-year-old children drank SSB at least once weekly. Public health interventions and policies should address childhood SSB consumption including educating health-care providers and parents.

Is maternal food security a predictor of food and drink intake among toddlers in Oregon?

Food insecurity has detrimental effects on the mental, physical, and behavioral health of developing children. Few studies, however, have sought to determine whether associations exist between food insecurity and intake of vegetables, fresh or canned fruit, candy or cookies, French fries, fast food, water, milk, fruit juices, fruit drinks, soda, and sports drinks. To identify independent associations that exist between maternal food insecurity and food and drink intake among toddlers, population-based data from the 2006-2008 Oregon Pregnancy Risk Assessment Monitoring System follow-back survey (Oregon PRAMS-2) of 1,522 mothers of 2-year-old children were analyzed. Maternal food insecurity was defined as mothers' report of eating less because of lack of money for food. Typical weekly child food and drink intake was examined using polytomous logistic regression: 0-1 days/week, 2-3 days/week, and 4-7 days/week. Maternal food insecurity prevalence was 11.7 %. Compared to toddlers of food secure mothers, toddlers of food insecure mothers consumed vegetables (adjusted odds ratio [AOR] for 4-7 days/week = 0.31; 95 % confidence interval [CI] 0.12, 0.79) and fruit (AOR for 4-7 days/week = 0.25; 95 % CI 0.08, 0.75) fewer days of the week. Toddlers of food insecure mothers consumed soda (AOR for 4-7 days/week = 3.21; 95 % CI 1.12, 9.14) more days of the week. Maternal food insecurity is associated with weekly intake of certain foods and drinks. Among toddlers, consumption of fewer vegetables and fruit, and more soda may help explain the link between food insecurity and poor health.

Binding-site geometry and flexibility in DC-SIGN demonstrated with surface force measurements.

The dendritic cell receptor DC-SIGN mediates pathogen recognition by binding to glycans characteristic of pathogen surfaces, including those found on HIV. Clustering of carbohydrate-binding sites in the receptor tetramer is believed to be critical for targeting of pathogen glycans, but the arrangement of these sites remains poorly understood. Surface force measurements between apposed lipid bilayers displaying the extracellular domain of DC-SIGN and a neoglycolipid bearing an oligosaccharide ligand provide evidence that the receptor is in an extended conformation and that glycan docking is associated with a conformational change that repositions the carbohydrate-recognition domains during ligand binding. The results further show that the lateral mobility of membrane-bound ligands enhances the engagement of multiple carbohydrate-recognition domains in the receptor oligomer with appropriately spaced ligands. These studies highlight differences between pathogen targeting by DC-SIGN and receptors in which binding sites at fixed spacing bind to simple molecular patterns.

Acute effects of FLT3L treatment on T cells in intact mice.

Peripheral T cells express a diverse repertoire of antigen-specific receptors, which together protect against the full range of pathogens. In this context, the total repertoire of memory T cells which are maintained by trophic signals, long after pathogen clearance, is critical. Since these trophic factors include cytokines and self-peptide-MHC, both of which are available from endogenous antigen-presenting cells (APC), we hypothesized that enhancing APC numbers in vivo can be a viable strategy to amplify the population of memory T cells. We evaluated this by acutely treating intact mice with FMS-like tyrosine kinase 3 ligand (Flt3l), which promotes expansion of APCs. Here we report that this treatment allowed for, an expansion of effector-memory CD4+ and CD8+ T cells as well as an increase in their expression of KLRG1 and CD25. In the lymph nodes and spleen, the expansion was limited to a specific CD8 (CD44-low but CD62L-) subset. Functionally, this subset is distinct from naïve T cells and could produce significant amounts of effector cytokines upon restimulation. Taken together, these data suggest that the administration of Flt3L can impact both APC turnover as well as a corresponding flux of specific subsets of CD8+ T cells in an intact peripheral immune compartment.

Geometry and adhesion of extracellular domains of DC-SIGNR neck length variants analyzed by force-distance measurements.

Force-distance measurements have been used to examine differences in the interaction of the dendritic cell glycan-binding receptor DC-SIGN and the closely related endothelial cell receptor DC-SIGNR (L-SIGN) with membranes bearing glycan ligands. The results demonstrate that upon binding to membrane-anchored ligand, DC-SIGNR undergoes a conformational change similar to that previously observed for DC-SIGN. The results also validate a model for the extracellular domain of DC-SIGNR derived from crystallographic studies. Force measurements were performed with DC-SIGNR variants that differ in the length of the neck that result from genetic polymorphisms, which encode different numbers of the 23-amino acid repeat sequences that constitute the neck. The findings are consistent with an elongated, relatively rigid structure of the neck repeat observed in crystals. In addition, differences in the lengths of DC-SIGN and DC-SIGNR extracellular domains with equivalent numbers of neck repeats support a model in which the different dispositions of the carbohydrate-recognition domains in DC-SIGN and DC-SIGNR result from variations in the sequences of the necks.

New options for child health surveillance by state health departments.

Until recently there were no child health surveillance instruments available to state health departments for children 1-14 years old. In recent years, several states have developed new surveillance instruments. This article includes information about examples of four types of child health surveys: (1) Behavioral Risk Factor Surveillance System (BRFSS) follow-back survey [phone-based in Colorado]; (2) Pregnancy Risk Assessment Monitoring System (PRAMS) re-interviews [PRAMS-based in Rhode Island]; (3) elementary school child health survey combined with dental screening and physical measurements of height and weight [school-based in Maine]; and (4) freestanding elementary school survey [school-based in Oregon]. The PRAMS-based survey was moderate in expense but addressed only issues related to 2 year olds. The phone-based survey was the most expensive but addressed issues of children 1-14 years old. The school-based surveys were moderate in expense, logistically complex, and were least likely to provide robust generalizable data.