Post-Ablation Cavity Evaluation: A Prospective Multicenter Observational Clinical Study to Evaluate Hysteroscopic Access to the Uterine Cavity 4 Years after Water Vapor Endometrial Ablation for the Treatment of Heavy Menstrual Bleeding.

STUDY OBJECTIVE: Patients who have undergone endometrial ablation may present a diagnostic challenge when they subsequently develop vaginal bleeding, pelvic pain, or postmenopausal bleeding. Extensive scarring of the uterine cavity often precludes evaluation and/or conservative treatment. For further research on this topic, we performed hysteroscopic examination in study subjects a mean duration of 4 years after they had undergone water vapor endometrial ablation. DESIGN: Prospective, multicenter, observational clinical study. SETTING: Eight private practice or outpatient sites in the United States and Mexico. PATIENTS: Seventy subjects who had completed their 36-month follow-up in the AEGEA Pivotal Trial. INTERVENTIONS: Diagnostic hysteroscopy. MEASUREMENTS AND MAIN RESULTS: The subjects were screened for general health and infection and underwent diagnostic hysteroscopy. Menstrual bleeding status was recorded. The video of the hysteroscopic examination was analyzed by an independent reviewer, who assessed uterine cavity access and visualization of the cornua and tubal ostia as well as characterized adhesions on the basis of the criteria by March et al. An independent reviewer also subjectively assessed whether Pipelle endometrial biopsy or intrauterine device placement would be feasible. Uterine cavity access was achieved in 90% (63/70) of subjects. Among subjects with cavity access, the cornua and ostia were visualized in 79% (50/63) and adhesions were absent in 75% (47/63), with only 2 women having severe adhesions (3%, 2/63). Biopsy was projected to be feasible in 86% (62/70) and intrauterine device placement in 60% (42/70) of all subjects. The subjects' bleeding statuses were not correlated with uterine cavity access. The results were consistent for subjects with large uterine cavities and International Federation of Gynecologic and Obstetrics type II to VI myomas ≤4 cm. CONCLUSION: Water vapor endometrial ablation preserved an accessible uterine cavity and visualization of the ostia in most subjects, with minimal incidence of severe adhesions, a mean of 4 years after the ablation procedure.

12-month outcomes of the US patient cohort in the SONATA pivotal IDE trial of transcervical ablation of uterine fibroids.

OBJECTIVE: The prospective SONATA pivotal Investigational Device Exemption (IDE) trial was performed in the United States (US) and Mexico to examine the safety and effectiveness of transcervical fibroid ablation (TFA) in the treatment of symptomatic uterine fibroids. This is an analysis of 12-month clinical outcomes in the US cohort. METHODS: TFA with the Sonata® System was performed on women with symptomatic uterine fibroids. The 12-month co-primary endpoints were reduction in menstrual blood loss and freedom from surgical reintervention. Symptom severity, quality of life, patient satisfaction, safety, and reductions in uterine and fibroid volumes were also evaluated. RESULTS: One hundred twenty-five patients were enrolled and treated in the US. Both co-primary endpoints were achieved in this US-based cohort, as 65.3% of patients reported ≥50% reduction in menstrual bleeding and 99.2% of patients were free from surgical reintervention. Symptom improvement was noted by 97.4% of patients and 98.3% were satisfied. Ninety-five percent of patients reported reduced menstrual bleeding at 12 months, and 86.8% noted >20% reduction. Significant mean improvements at 12 months were realized in both symptom severity and health-related quality of life (33.8 points and 45.8 points, respectively; all P<0.0001). Mean maximal fibroid volume reduction per patient was 63.8%. There was a 0% incidence of device related adverse events. Mean length of stay was 2.5 hrs and 50% of patients returned to normal activity within 1 day. CONCLUSION: This analysis of US patients in the SONATA pivotal IDE trial demonstrates results consistent with those in the full cohort. TFA with Sonata significantly reduced fibroid symptoms with a low surgical reintervention rate through 12 months. These results support the efficacy and safety of the Sonata system as a first-line treatment for women affected by symptomatic uterine fibroids.

Improved glycaemic control and treatment satisfaction with a simple wearable 3-day insulin delivery device among people with Type 2 diabetes.

AIM: To evaluate the PAQ® (CeQur SA, Horw, Switzerland), a wearable 3-day insulin delivery device that provides set basal rates and bolus insulin on demand, in people with Type 2 diabetes. METHOD: Adults with Type 2 diabetes with HbA1c concentrations ≥53 and ≤97 mmol/mol (7.0 and 11.0%) while treated with ≥2 insulin injections/day were enrolled in two single-arm studies comprising three periods: a baseline (insulin injections), a transition and a PAQ treatment period (12 weeks). Endpoints included HbA1c , seven-point self-monitored blood glucose, total daily dose of insulin and body weight. Safety was assessed according to examination, hypoglycaemic episodes and adverse device effects. RESULTS: A total of 28 adults were enrolled (age 63 ± 7 years, 86% men, BMI 32.3 ± 4.3kg/m2 , Type 2 diabetes duration 17 ± 8 years, HbA1c 70 ± 12 mmol/mol (8.6 ± 1.1%), total daily insulin dose 58.7 ± 20.7 U), of whom 24 completed the studies. When transitioned to PAQ, 75% of participants continued on the first basal rate selected. After 12 weeks of PAQ wear, significant improvements from baseline were seen [HbA1c -16 ± 9 mmol/mol (95% CI -20, -12) or -1.5 ± 0.9% (95% CI -1.8, -1.1) P<0.0001], and at all seven self-monitored blood glucose readings time points (P ≤0.03). Total daily insulin dose increased by 12.1 ± 19.5 U (95% CI 3.9, 20.4; P=0.0058), the number of meal time boluses increased by 0.9 ± 1.5/day (95% CI 0.3, 1.5; P=0.0081) and body weight remained stable. Six participants had mild to moderate catheter site reactions and one mild skin irritation occurred. No participant experienced severe hypoglycaemia. CONCLUSIONS: Adults with Type 2 diabetes were safely transitioned from insulin injections to the PAQ and had significantly improved glycaemic control and treatment satisfaction with insulin therapy. (ClinicalTrials.gov identifiers: NCT02158078 & NCT02419859).

Atopy in people aged 40 years and over: Relation to airflow limitation.

BACKGROUND: Previous studies have reached conflicting conclusions about the role of atopy as a risk factor for COPD. In part, this is attributable to variation in the definitions of airflow limitation and the treatment of people with asthma. OBJECTIVE: To establish whether there is any independent association between atopy and post-bronchodilator airflow limitation in the general population aged 40 years and over. METHODS: A cross-sectional survey was conducted in a general population sample of 2415 people aged 40 years and over in Australia. A history of ever being diagnosed with asthma was elicited by questionnaire. Atopy was defined as any skin prick test weal to common aeroallergens ≥4 mm. Airflow limitation was defined as post-bronchodilator spirometric (FEV1 /FVC) ratio

Clinical effectiveness of very-low-energy diets in the management of weight loss: a systematic review and meta-analysis of randomized controlled trials.

Guidelines suggest that very-low-energy diets (VLEDs) should be used to treat obesity only when rapid weight loss is clinically indicated because of concerns about rapid weight regain. Literature databases were searched from inception to November 2014. Randomized trials were included where the intervention included a VLED and the comparator was no intervention or an intervention that could be given in a general medical setting in adults that were overweight. Two reviewers characterized the population, intervention, control groups, outcomes and appraised quality. The primary outcome was weight change at 12 months from baseline. Compared with a behavioural programme alone, VLEDs combined with a behavioural programme achieved -3.9 kg [95% confidence interval (CI) -6.7 to -1.1] at 1 year. The difference at 24 months was -1.4 kg (95%CI -2.6 to -0.2) and at 38-60 months was -1.3 kg (95%CI -2.9 to 0.2). Nineteen per cent of the VLED group discontinued treatment prematurely compared with 20% of the comparator groups, relative risk 0.96 (0.56 to 1.66). One serious adverse event, hospitalization with cholecystitis, was reported in the VLED group and none in the comparator group. Very-low-energy diets with behavioural programmes achieve greater long-term weight loss than behavioural programmes alone, appear tolerable and lead to few adverse events suggesting they could be more widely used than current guidelines suggest.

Current knowledge of US metal and nonmetal miner health: Current and potential data sources for analysis of miner health status.

Little is known about the current health status of US metal and nonmetal (MNM) miners, in part because no health surveillance systems exist for this population. The National Institute for Occupational Safety and Health (NIOSH) is developing a program to characterize burden of disease among MNM miners. This report discusses current knowledge and potential data sources of MNM miner health. Recent national surveys were analyzed, and literature specific to MNM miner health status was reviewed. No robust estimates of disease prevalence were identified, and national surveys did not provide information specific to MNM miners. Because substantial gaps exist in the understanding of MNM miners' current health status, NIOSH plans to develop a health surveillance program for this population to guide intervention efforts to reduce occupational and personal risks for chronic illness.

Behavioural weight management programmes for adults assessed by trials conducted in everyday contexts: systematic review and meta-analysis.

This systematic review and meta-analysis of effectiveness trials comparing multicomponent behavioural weight management programmes with controls in overweight and obese adults set out to determine the effectiveness of these interventions implemented in routine practice. To be included, interventions must have been multicomponent, delivered by the therapists who would deliver the intervention in routine practice and in that same context, and must be widely available or feasible to implement with little additional infrastructure or staffing. Searches of electronic databases were conducted, and augmented by screening reference lists and contacting experts (November 2012). Data were extracted by two reviewers, with mean difference between intervention and control for 12-month change in weight, blood pressure, lipids and glucose calculated using baseline observation carried forward. Data were also extracted on adverse events, quality of life and mood measures. Although there were many published efficacy trials, only eight effectiveness trials met the inclusion criteria. Pooled results from five study arms providing access to commercial weight management programmes detected significant weight loss at 12 months (mean difference -2.22 kg, 95% confidence interval [CI] -2.90 to -1.54). Results from two arms of a study testing a commercial programme providing meal replacements also detected significant weight loss (mean difference -6.83 kg, 95% CI -8.39 to -5.26). In contrast, pooled results from five interventions delivered by primary care teams showed no evidence of an effect on weight (mean difference -0.45 kg, 95% CI -1.34 to 0.43). One study testing an interactive web-based intervention detected a significant effect in favour of the intervention at 12 months, but the study was judged to be at high risk of bias and the effect did not persist at 18 months. Few studies reported other outcomes, limiting comparisons between interventions. Few trials have examined the effectiveness of behavioural weight loss programmes delivered in everyday contexts. These trials suggest that commercial interventions delivered in the community are effective for achieving weight loss. There is no evidence that interventions delivered within primary care settings by generalist primary care teams trained in weight management achieve meaningful weight loss.

Cardiovascular effects of methacholine-induced airway obstruction in man.

Cardiovascular disease is the most frequent cause of death in people with chronic respiratory disease. The cause of this association has been attributed to airway obstruction leading to cardiovascular dysfunction (increased central blood pressure (BP) and aortic stiffness). However, this has never been experimentally tested. Methacholine is routinely used to stimulate airway function changes that mimic airway pathology. This study aimed to determine the cardiovascular effects of methacholine-induced airway obstruction. Fifteen healthy young adults (aged 22.9±2.5 years; 4 male; mean±S.D.) underwent a bronchial challenge test (randomized, blinded, cross-over design) in which they received nebulized methacholine inhalation in serially increasing concentrations (from 0.39 to 25 mg/ml) or saline (0.9%; control) on two separate days. Bronchoconstriction was assessed by forced expiratory volume at one second (FEV1) and cardiovascular effects by augmentation index, brachial BP, central BP, heart rate and aortic stiffness. Methacholine significantly decreased FEV1 from baseline to peak inhaled concentration compared with saline (-0.48±0.34 vs. -0.07±0.16 L; p<0.001), but there was no between-group change in augmentation index (1.6±7.0 vs. 3.7±10.2% p=0.49), brachial systolic BP (-3.3±7.6 vs. -4.7±5.7 mmHg; p=0.59), central systolic BP (-1.1±5.2 vs. -0.3±5.5 mmHg; p=0.73), heart rate (0.4±7.1 vs. -0.8±6.6 bpm; p=0.45) or aortic stiffness (0.2±1.3 vs. 0.8±1.8 m/s; p=0.20; n=12). Thus, methacholine induced airway obstruction does not acutely change brachial BP or central haemodynamics. This finding refutes the notion that airway obstruction per se leads to cardiovascular dysfunction, at least in healthy individuals in the acute setting.

Effect of behavioural techniques and delivery mode on effectiveness of weight management: systematic review, meta-analysis and meta-regression.

A systematic review, meta-analysis and meta-regression were conducted to evaluate the effectiveness of behavioural weight management programmes and examine how programme characteristics affect mean weight loss. Randomized controlled trials of multicomponent behavioural weight management programmes in overweight and obese adults were included. References were obtained through systematic searches of electronic databases (conducted November 2012), screening reference lists and contacting experts. Two reviewers extracted data and evaluated risk of bias. Thirty-seven studies, representing over 16,000 participants, were included. The pooled mean difference in weight loss at 12 months was -2.8 kg (95% confidence interval [CI] -3.6 to -2.1, P < 0.001). I(2) indicated that 93% of the variability in outcome was due to differences in programme effectiveness. Meta-analysis showed no evidence that supervised physical activity sessions (mean difference 1.1 kg, 95% CI -2.65 to 4.79, P = 0.08), more frequent contact (mean difference -0.3 kg, 95% CI -0.7 to 0.2, P = 0.25) or in-person contact (mean difference 0.0 kg, 95% CI -1.8 to 1.8, P = 0.06) were related to programme effectiveness at 12 months. In meta-regression, calorie counting (-3.3 kg, 95% CI -4.6 to -2.0, P = 0.027), contact with a dietitian (-1.5 kg, 95% CI -2.9 to -0.2, P < 0.001) and use of behaviour change techniques that compare participants' behaviour with others (-1.5 kg, 95% CI -2.9 to -0.1, P = 0.032) were associated with greater weight loss. There was no evidence that other programme characteristics were associated with programme effectiveness. Most but not all behavioural weight management programmes are effective. Programmes that support participants to count calories or include a dietitian may be more effective, but the programme characteristics explaining success are mainly unknown.

Plerixafor and G-CSF for autologous stem cell mobilization in patients with NHL, Hodgkin's lymphoma and multiple myeloma: results from the expanded access program.

Before US regulatory approval, an expanded access program provided plerixafor to patients with non-Hodgkin's lymphoma (NHL), Hodgkin's lymphoma (HD) or multiple myeloma (MM) who had not previously failed mobilization and were otherwise candidates for auto-SCT. Patients received granulocyte-CSF (G-CSF) 10 mcg/kg daily and plerixafor 0.24 mg/kg starting on day 4 with apheresis on day 5; all repeated daily until collection was complete. Overall, 104 patients received 1 dose of plerixafor. The addition of plerixafor to G-CSF resulted in a median threefold increase in peripheral blood CD34+ cell count between days 4 and 5. Among 43 NHL patients, 74% met the target of 5 × 10(6) CD34+ cells/kg (median, 1 day apheresis, range 1-5 days); among 7 HD patients, 57% met the target of 5 × 10(6) CD34+ cells/kg (median, 2 days apheresis, range 1-3); and among 54 MM patients, 89% met the target of 6 × 10(6) CD34+ cells/kg (median, 1 day apheresis, range 1-4). Overall, 93% of patients had 2 × 10(6) CD34+ cells/kg collected within 1-3 days. Plerixafor-related toxicities were minimal. Engraftment kinetics, graft durability and transplant outcomes demonstrated no unexpected outcomes. Efficacy and safety results were similar to results in phase II and III clinical trials.

Hysterectomy subsequent to endometrial ablation.

STUDY OBJECTIVE: To estimate the incidence of and factors associated with hysterectomy subsequent to endometrial ablation. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Gynecology practice. PATIENTS: Women who underwent endometrial ablation from January 2003 to June 2010, with a minimum follow-up of 9 months. INTERVENTIONS: Endometrial ablation and hysterectomy. MEASUREMENTS AND MAIN RESULTS: Of 1169 women, 157 (13.4%) underwent hysterectomy subsequent to endometrial ablation. Women who underwent subsequent hysterectomy were significantly younger at ablation (mean [SD; 95% CI] 39.0 [6.8; 38.0-40.1] years vs 41.4 [7.0; 41.0-41.9] years; p < .001) and were more likely to have previously delivered via cesarean section (26.3 vs 18.1%; p = .02). The rate of hysterectomy was significantly associated with the type of ablation performed: 33.0% for rollerball vs 16.5% for thermal balloon (p = .003), 11.0% for radiofrequency (p < .001), and 9.8% for cryoablation (p < .001). Time to hysterectomy also differed significantly based on the type of ablation performed (p = .006). Adenomyosis was present in 44.4% of hysterectomy specimens. CONCLUSION: With a mean follow-up of 39 months, 13.4% of women underwent hysterectomy subsequent to ablation. Women who were younger at ablation had an increased likelihood of hysterectomy. Rate and time to hysterectomy were associated with the type of ablation performed.

Racial/ethnic discrepancies in the metabolic syndrome begin in childhood and persist after adjustment for environmental factors.

BACKGROUND AND AIMS: Evaluation of metabolic syndrome (MetS) characteristics across an age spectrum from childhood to adulthood has been limited by a lack of consistent MetS criteria for children and adults and by a lack of adjustment for environmental factors. We used the pediatric and adult International Diabetes Federation (IDF) criteria to determine whether gender-specific and race-specific differences in MetS and its components are present in adolescents as in adults after adjustment for socio-economic status (SES) and lifestyle factors. METHODS AND RESULTS: Waist circumference, blood pressure, triglycerides, HDL cholesterol, and fasting glucose measures were obtained from 3100 adolescent (12-19 years) and 3419 adult (20-69 years) non-Hispanic white, non-Hispanic black, and Mexican-American participants of the 1999-2006 National Health and Nutrition Examination Surveys. We compared odds of having MetS and its components across racial/ethnic groups by age group, while adjusting for income, education, physical activity and diet quality. After adjusting for possible confounding influences of SES and lifestyle, non-Hispanic-black adolescent males exhibited a lower odds of MetS and multiple components (abdominal obesity, hypertriglyceridemia, low HDL, hyperglycemia) compared to non-Hispanic-white and Mexican-American adolescents. Compared to non-Hispanic-white adolescent males, Mexican-American adolescent males had less hypertension. There were no differences in MetS prevalence among adolescent females, though non-Hispanic-black girls exhibited less hypertriglyceridemia. CONCLUSION: Racial/ethnicity-specific differences in MetS and its components are present in both adolescence and adulthood, even after adjusting for environmental factors. These data help strengthen arguments for developing racial/ethnic-specific MetS criteria to better identify individuals at risk for future cardiovascular disease.

Anacetrapib, a novel CETP inhibitor: pursuing a new approach to cardiovascular risk reduction.

Cholesteryl ester transfer protein (CETP) inhibition is a promising experimental strategy to raise high-density lipoprotein cholesterol (HDL-C) and reduce cardiovascular risk. This review focuses on the highly selective and potent CE TP inhibitor anacetrapib and discusses the available preclinical and clinical information pertaining to it. We also describe strategies to target HDL-C, discuss the mechanism underlying CETP inhibition and its effects on lipid biology, and give an overview of other CETP inhibitors that are currently in development.

Can hysterosalpingo-contrast sonography replace hysterosalpingography in confirming tubal blockage after hysteroscopic sterilization and in the evaluation of the uterus and tubes in infertile patients?

OBJECTIVE: The objective of the study was to assess the accuracy of hysterosalpingo-contrast sonography (HyCoSy) in establishing tubal patency or blockage and evaluating the uterine cavity by comparing it with hysteroscopy laparoscopy (HLC) or hysterosalpingography (HSG). STUDY DESIGN: This study was a chart review evaluating infertility patients and patients who had undergone hysteroscopic sterilization who underwent both HyCoSy and HLC or HyCoSy and HSG at private offices associated with university hospitals. Sensitivity, specificity, positive predictive value, and negative predictive value of HyCoSy were calculated. RESULTS: HyCoSy compared with HLC had a sensitivity of 97% and specificity of 82%, and HyCoSy compared with HSG was 100% concordant. Uterine cavities evaluated by sonohysterography and hysteroscopy were 100% concordant. CONCLUSION: HyCoSy is accurate in determining tubal patency and evaluating the uterine cavity, suggesting it could supplant HSG not only as the first-line diagnostic test in an infertility workup but also in confirming tubal blockage after hysteroscopic sterilization.

Poor lung function and tonsillectomy in childhood are associated with mortality from age 18 to 44.

BACKGROUND: The aim of this analysis was to examine associations between lung health in childhood and mortality between ages 18 and 44 years in the Tasmanian Longitudinal Health Study (TAHS). METHODS: The 1961 Tasmanian birth cohort who attended school in 1968 (n=8583) were linked to the Australian National Death Index (NDI) to identify deaths. Additional deaths were notified by families through a 37 year follow-up postal questionnaire. Information on lung health at age 7 years and on potential confounders was obtained from the original 1968 TAHS survey and school medical records. Cox proportional hazards modelling was used to assess determinants of mortality. RESULTS: A total of 264 (3%) deaths were identified. The principal causes of death were external injury (56.1%, n=97) and cancer (17.9%, n=31). Males were more likely than females to have died (p=<0.1). Only two (1.1%) participants had died from respiratory conditions. Having an FEV(1)<80% predicted at 7 years of age was associated with a 2-fold increased incidence of death. Tonsillectomy before age 7 years was associated with a 1.5-fold increase in mortality (p=0.05); being male with a 3.6-fold increase in mortality (p=0.0001); and repeated chest illnesses at age 7 years causing >30 days confinement in the last year, was associated with a 2.2-fold increase in mortality (p=0.03). CONCLUSIONS: Childhood lung health appears to be associated with increased mortality in adulthood, perhaps by affecting the ability to survive trauma, major illnesses and other physical stresses.

Adherence to asthma management guidelines by middle-aged adults with current asthma.

BACKGROUND: With the increasing burden of asthma worldwide, much effort has been given to developing and updating management guidelines. Using data from the Tasmanian Longitudinal Health Study (TAHS), the adequacy of asthma management for middle-aged adults with asthma was investigated. METHODS: Information about spirometry, medication history and current asthma status was collected by the most recent TAHS when participants were in their mid 40s. Only those who reported ever having asthma were eligible for analysis. RESULTS: Of the 702 participants who reported ever having asthma, 50% had current asthma (n = 351) of whom 71% were categorised as having persistent asthma (n = 98 mild, n = 92 moderate, n = 58 severe). The majority (85.2%) of participants with current asthma had used some form of asthma medication in the past 12 months, but the proportion of the use of minimally adequate preventer medication was low (26%). Post-bronchodilator airflow obstruction increased progressively from mild to severe persistent asthma for those inadequately managed, but not for those on adequate therapy. CONCLUSION: Appropriate use of asthma medication by this middle-aged group of adults with current asthma was inadequate, especially for those with adult-onset moderate or severe persistent disease and without a family history of asthma. These results suggest that proper use of preventer medication could protect against the progressive decline in lung function associated with increasing severity. This has implications not just for poor quality of life, but also for the development of fixed airflow obstruction.

Translating ecological risk to ecosystem service loss.

Hazardous site management in the United States includes remediation of contaminated environmental media and restoration of injured natural resources. Site remediation decisions are informed by ecological risk assessment (ERA), whereas restoration and compensation decisions are informed by the natural resource damage assessment (NRDA) process. Despite similarities in many of their data needs and the advantages of more closely linking their analyses, ERA and NRDA have been conducted largely independently of one another. This is the 4th in a series of papers reporting the results of a recent workshop that explored how ERA and NRDA data needs and assessment processes could be more closely linked. Our objective is to evaluate the technical underpinnings of recentmethods used to translate natural resource injuries into ecological service losses and to propose ways to enhance the usefulness of data obtained in ERAs to the NRDA process. Three aspects are addressed: 1) improving the linkage among ERA assessment endpoints and ecological services evaluated in the NRDA process, 2) enhancing ERA data collection and interpretation approaches to improve translation of ERA measurements in damage assessments, and 3) highlighting methods that can be used to aggregate service losses across contaminants and across natural resources. We propose that ERA and NRDA both would benefit by focusing ecological assessment endpoints on the ecosystem services that correspond most directly to restoration and damage compensation decisions, and we encourage development of generic ecosystem service assessment endpoints for application in hazardous site investigations. To facilitate their use in NRDA, ERA measurements should focus on natural resource species that affect the flow of ecosystem services most directly, should encompass levels of biological organization above organisms, and should be made with the use of experimental designs that support description of responses to contaminants as continuous (as opposed to discrete) variables. Application of a data quality objective process, involving input from ERA and NRDA practitioners and site decision makers alike, can facilitate identification of data collection and analysis approaches that will benefit both assessment processes. Because of their demonstrated relationships to a number of important ecosystem services, we recommend that measures of biodiversity be targeted as key measurement endpoints in ERA to support the translation between risk and service losses. Building from case studies of recent successes, suggestions are offered for aggregating service losses at sites involving combinations of chemicals and multiple natural resource groups. Recognizing that ERA and NRDA are conducted for different purposes, we conclude that their values to environmental decision making can be enhanced by more closely linking their data collection and analysis activities.