Infant sustained attention differs by context and social content in the first 2 years of life.

Sustained attention (SA) is an endogenous form of attention that emerges in infancy and reflects cognitive engagement and processing. SA is critical for learning and has been measured using different methods during screen-based and interactive contexts involving social and nonsocial stimuli. How SA differs by measurement method, context, and stimuli across development in infancy is not fully understood. This 2-year longitudinal study examines attention using one measure of overall looking behavior and three measures of SA-mean look duration, percent time in heart rate-defined SA, and heart rate change during SA-in N = 53 infants from 1 to 24 months across four unique task conditions: social videos, nonsocial videos, social interactions (face-to-face play), and nonsocial interactions (toy engagement). Results suggest that developmental changes in attention differ by measurement method, task context (screen or interaction), and task stimulus (social or nonsocial). During social interactions, overall looking and look durations declined after age 3-4 months, whereas heart rate-defined attention measures remained stable. All SA measures were greater for videos than for live interaction conditions throughout the first 6 months, but SA to social and nonsocial stimuli within each task context were equivalent. In the second year of life, SA measured with look durations was greater for social videos compared to other conditions, heart rate-defined SA was greater for social videos compared to nonsocial interactions, and heart rate change during SA was similar across conditions. Together, these results suggest that different measures of attention to social and nonsocial stimuli may reflect unique developmental processes and are important to compare and consider together, particularly when using infant attention as a marker of typical or atypical development. RESEARCH HIGHLIGHTS: Attention measure, context, and social content uniquely differentiate developmental trajectories of attention in the first 2 years of life. Overall looking to caregivers during dyadic social interactions declines significantly from 4 to 6 months of age while sustained attention (SA) to caregivers remains stable. Heart rate-defined SA generally differentiates stimulus context where infants show greater SA while watching videos than while engaging with toys.

Multimodal study of the neural sources of error monitoring in adolescents and adults.

The ability to monitor performance during a goal-directed behavior differs among children and adults in ways that can be measured with several tasks and techniques. As well, recent work has shown that individual differences in error monitoring moderate temperamental risk for anxiety and that this moderation changes with age. We investigated age differences in neural responses linked to performance monitoring using a multimodal approach. The approach combined functional MRI and source localization of event-related potentials (ERPs) in 12-year-old, 15-year-old, and adult participants. Neural generators of two components related to performance and error monitoring, the N2 and ERN, lay within specific areas of fMRI clusters. Whereas correlates of the N2 component appeared similar across age groups, age-related differences manifested in the location of the generators of the ERN component. The dorsal anterior cingulate cortex (dACC) was the predominant source location for the 12-year-old group; this area manifested posteriorly for the 15-year-old and adult groups. A fMRI-based ROI analysis confirmed this pattern of activity. These results suggest that changes in the underlying neural mechanisms are related to developmental changes in performance monitoring.

Frontal asymmetry assessed in infancy using functional near-infrared spectroscopy is associated with emotional and behavioral problems in early childhood.

Frontal asymmetry (FA), the difference in brain activity between the left versus right frontal areas, is thought to reflect approach versus avoidance motivation. This study (2012-2021) used functional near-infrared spectroscopy to investigate if infant (Mage  = 7.63 months; N = 90; n = 48 male; n = 75 White) FA in the dorsolateral prefrontal cortex relates to psychopathology in later childhood (Mage  = 62.05 months). Greater right FA to happy faces was associated with increased internalizing (η2  = .09) and externalizing (η2  = .06) problems at age 5 years. Greater right FA to both happy and fearful faces was associated with an increased likelihood of a lifetime anxiety diagnosis (R2 > .13). FA may be an informative and early-emerging marker for psychopathology.

The MCH Library: Leveraging Learning to Leadership.

A library to support maternal and child health programs has existed in many forms from the founding of the Children's Bureau in 1912 to the current MCH Digital Library. The overarching goal of the library remains to serve the MCH community with accurate, reliable, and timely information and resources. Like the field of MCH, championed into existence by dedicated activists and nurtured by passionate, gifted people over the decades that followed, today's library is the result of the work of an unbroken chain of individuals devoted to its cause and with a vision for its future. The library website is a critical tool for the field where MCH stakeholders can access the work and wisdom of content experts in the field. All materials, whether in print or digital, are vetted, organized, and curated by librarians devoted to providing the field of MCH with the most relevant evidence-based, implementation-focused resources, links, and tools.

Exertional Rhabdomyolysis in Athletes: Systematic Review and Current Perspectives.

OBJECTIVE: Exertional rhabdomyolysis results from a breakdown of skeletal muscle cells after intense exercise in otherwise healthy patients, causing increased levels of creatine kinase (CK) or myoglobin, as well as urine dipstick positive for blood, and may result in kidney insufficiency. The aim of this study was to outline the current perspectives of exertional rhabdomyolysis in athletes and subsequent treatment based on the current literature. DATA SOURCES: We searched the MEDLINE/PubMed and Google databases for ([exercise] OR [exertional]) AND rhabdomyolysis following the PRISMA guidelines. All abstracts were reviewed by 2 independent examiners. Inclusion criteria consisted of original articles presenting studies on exertional rhabdomyolysis or exercise-induced rhabdomyolysis with 7 or more cases. All case reports, case series, or editorials were excluded. MAIN RESULTS: A total of 1541-abstracts were screened, leaving 25 studies for final inclusion and analysing 772patients. Especially, young male patients were affected at a mean age of 28.7 years (range 15.8-46.6 years). Most of the athletes performed running, including marathons in 54.3% of cases (n = 419/772), followed by weightlifting in 14.8% (n = 114/772). At the time of presentation, the mean creatine kinase was 31 481 IU/L (range 164-106,488 IU/L). Seventeen studies reported the highest level of CK, which was 38 552 IU/L (range 450-88,496 IU/L). For treatment, hydration was the most common method of choice reported by 8 studies. CONCLUSIONS: Exertional rhabdomyolysis seems to be underestimated, and it is essential to screen patients who present with muscle soreness/cramps and/or dark urine after heavy endurance events to avoid any further complications. LEVEL OF EVIDENCE: II; systematic review.

Polygenic risk score as a possible tool for identifying familial monogenic causes of complex diseases.

PURPOSE: The study aimed to evaluate whether polygenic risk scores could be helpful in addition to family history for triaging individuals to undergo deep-depth diagnostic sequencing for identifying monogenic causes of complex diseases. METHODS: Among 44,550 exome-sequenced European ancestry UK Biobank participants, we identified individuals with a clinically reported or computationally predicted monogenic pathogenic variant for breast cancer, bowel cancer, heart disease, diabetes, or Alzheimer disease. We derived polygenic risk scores for these diseases. We tested whether a polygenic risk score could identify rare pathogenic variant heterozygotes among individuals with a parental disease history. RESULTS: Monogenic causes of complex diseases were more prevalent among individuals with a parental disease history than in the rest of the population. Polygenic risk scores showed moderate discriminative power to identify familial monogenic causes. For instance, we showed that prescreening the patients with a polygenic risk score for type 2 diabetes can prioritize individuals to undergo diagnostic sequencing for monogenic diabetes variants and reduce needs for such sequencing by up to 37%. CONCLUSION: Among individuals with a family history of complex diseases, those with a low polygenic risk score are more likely to have monogenic causes of the disease and could be prioritized to undergo genetic testing.

Neural correlates of inhibitory control and associations with cognitive outcomes in Bangladeshi children exposed to early adversities.

There is strong support for the view that children growing up in low-income homes typically evince poorer performance on tests of inhibitory control compared to those growing up in higher income homes. Unfortunately, the vast majority of the work documenting this association has been conducted in high-income countries. It is not yet known whether the mechanisms found to mediate this association would generalize to children in low- and middle-income countries, where the risks of exposure to extreme poverty and a wide range of both biological and psychosocial hazards may be greater. We examined relations among early adversity, neural correlates of inhibitory control, and cognitive outcomes in 154 5-year-old children living in Dhaka, Bangladesh, an area with a high prevalence of poverty. Participants completed a go/no-go task assessing inhibitory control and their behavioral and event-related potential responses were assessed. Cortical source analysis was performed. We collected measures of poverty, malnutrition, maternal mental health, psychosocial adversity, and cognitive skills. Supporting studies in high-income countries, children in this sample exhibited a longer N2 latency and higher P3 amplitude to the no-go versus go condition. Unexpectedly, children had a more pronounced N2 amplitude during go trials than no-go trials. The N2 latency was related to their behavioral accuracy on the go/no-go task. The P3 mean amplitude, behavioral accuracy, and reaction time during the task were all associated with intelligence-quotient (IQ) scores. Children who experienced higher levels of psychosocial adversity had lower accuracy on the task and lower IQ scores.

Evaluating Head Models for Cortical Source Localization of the Face-Sensitive N290 Component in Infants.

Accurate cortical source localization of event-related potentials (ERPs) requires using realistic head models constructed from the participant's structural magnetic resonance imaging (MRI). A challenge in developmental studies is the limited accessibility of participant-specific MRIs. The present study compared source localization of infants' N290 ERP activities estimated using participant-specific head models with a series of substitute head models. The N290 responses to faces relative to toys were measured in 36 infants aged at 4.5, 7.5, 9, and 12 months. The substitutes were individual-based head models constructed from age-matched MRIs with closely matched ("close") or different ("far") head measures with the participants, age-appropriate average template, and age-inappropriate average templates. The greater source responses to faces than toys at the middle fusiform gyrus (mFG) estimated using participant-specific head models were preserved in individual-based head models, but not average templates. The "close" head models yielded the best fit with the participant-specific head models in source activities at the mFG and across face-processing-related regions of interest (ROIs). The age-appropriate average template showed mixed results, not supporting the stimulus effect but showed topographical distributions across the ROIs like the participant-specific head models. The "close" head models are the most optimal substitute for participant-specific MRIs.

Videofluoroscopic swallow study training for radiologists-in-training: a survey of practice and training needs.

BACKGROUND: There is a lack of formal, published videofluoroscopic swallow study (VFSS) training targeting radiologists, yet radiology senior medical officers and resident medical officers (i.e., radiologists-in-training, known in Australia as "registrars") are expected to be involved in VFSS interpretation of anatomical anomalies and reporting. This study investigated whether VFSS training is delivered to registrars during their specialist radiology training, whether it is a perceived need and, if so, to determine the desired content for inclusion in a targeted training package. METHODS: A cross-sectional, mixed methods study design was used. An internet-based survey was circulated via convenience and snowball sampling to radiologists (both senior medical officers and registrars) and speech-language pathologists across Australia in October-November 2017. Surveys also were distributed to practitioners based in New Zealand and the United Kingdom, as they practised within similar health systems, and it was anticipated they may have similar VFSS training practices. The radiology survey contained 36 questions and the speech-language pathology survey contained 44 questions. Participants were asked the following: (1) Report their current VFSS radiology registrar training environment; (2) Advise whether radiology registrars need VFSS training; (3) Recommend the content, format, training intensity, and evaluation methods for an effective radiology registrar training package. Demographic data were analysed descriptively, and open-ended responses were analysed using qualitative content analysis. RESULTS: 21 radiology senior medical officers and registrars and 150 speech-language pathologists predominantly based at Australian tertiary hospital settings completed the survey. Most respondents (90.6%) identified that VFSS training is needed for radiology registrars. Only one speech-language pathologist respondent reported that they deliver VFSS training for radiology registrars. Specific content and teaching modalities for a VFSS training package, including diagnosing anatomical anomalies associated with dysphagia were recommended. CONCLUSION: While most of the radiologists and speech-language pathologists surveyed did not deliver VFSS training to radiology registrars, they identified that targeted training is needed to improve radiology registrars' effectiveness and engagement in VFSS clinics. The training package content, format and evaluation methods recommended by participants will inform the development of a VFSS training package targeting radiology registrars to be piloted at an Australian tertiary hospital.

Emergency Department Hallway Care From the Millennium to the Pandemic: A Clear and Present Danger.

BACKGROUND: Emergency department (ED) crowding and hallway care has been a serious problem for the past three decades in the United States and abroad. Myriad articles highlighting this problem and proposing solutions have had little impact on its progression. OBJECTIVES: To discuss reasons for ED crowding leading to hallway care, the impact of the coronavirus disease (COVID-19) pandemic, potential solutions, and why little has changed despite widespread awareness. DISCUSSION: ED crowding has been a public health issue for the past three decades, leading to patient care and boarding of admitted patients in ED hallways with limited resources. This care is often substandard and precarious. The COVID-19 pandemic placed further strain on the ED safety net, especially in certain urban areas. Despite recognition of the problem, publication of studies, and proposals offering many solutions, this problem continues to worsen. Corporate and hospital leadership must be made aware of the financial and legal ramifications for failure to address potential solutions, such as inpatient hallway boarding, provision of flexible expansion care areas, smoothing of elective admissions/surgeries, and efficient inpatient discharge flow. State and federal legislation may also be required to motivate this process. CONCLUSIONS: ED crowding and hallway care will continue to worsen unless hospital leadership is willing to listen to ED staff concerns and address the problem on all levels of the hospital using previously proposed solutions. Emergency physicians should not fear termination for discussing this issue and its potential for poor clinical outcomes and ED staff morale.

Structural templates for imaging EEG cortical sources in infants.

Electroencephalographic (EEG) source reconstruction is a powerful approach that allows anatomical localization of electrophysiological brain activity. Algorithms used to estimate cortical sources require an anatomical model of the head and the brain, generally reconstructed using magnetic resonance imaging (MRI). When such scans are unavailable, a population average can be used for adults, but no average surface template is available for cortical source imaging in infants. To address this issue, we introduce a new series of 13 anatomical models for subjects between zero and 24 months of age. These templates are built from MRI averages and boundary element method (BEM) segmentation of head tissues available as part of the Neurodevelopmental MRI Database. Surfaces separating the pia mater, the gray matter, and the white matter were estimated using the Infant FreeSurfer pipeline. The surface of the skin as well as the outer and inner skull surfaces were extracted using a cube marching algorithm followed by Laplacian smoothing and mesh decimation. We post-processed these meshes to correct topological errors and ensure watertight meshes. Source reconstruction with these templates is demonstrated and validated using 100 high-density EEG recordings from 7-month-old infants. Hopefully, these templates will support future studies on EEG-based neuroimaging and functional connectivity in healthy infants as well as in clinical pediatric populations.

The Influence of the Head Model Conductor on the Source Localization of Auditory Evoked Potentials.

The accuracy of EEG source analysis reconstruction improves when a realistic head volume conductor is modeled. In this study we investigated how the progressively more complex head representations influence the spatial localization of auditory-evoked potentials (AEPs). Fourteen young-adult participants with normal hearing performed the AEP task. Individualized head models were obtained from structural MRI and diffusion-weighted imaging scans collected in a separate session. AEPs were elicited by 1 k Hz and 4 k Hz tone bursts during a passive-listening tetanizing paradigm. We compared the amplitude of the N1 and P2 components before and after 4 min of tetanic-stimulation with 1 k Hz sounds. Current density reconstruction values of both components were investigated in the primary auditory cortex and adjacent areas. Furthermore, we compared the signal topography and magnitude obtained with 10 different head models on the EEG forward solution. Starting from the simplest model (scalp, skull, brain), we investigated the influence of modeling the CSF, distinguishing between GM and WM conductors, and including anisotropic WM values. We localized the activity of AEPs within the primary auditory cortex, but not in adjacent areas. The inclusion of the CSF compartment had the strongest influence on the source reconstruction, whereas white matter anisotropy led to a smaller improvement. We conclude that individualized realistic head models provide the best solution for the forward solution when modeling the CSF conductor.

Peak selection and latency jitter correction in developmental event-related potentials.

Event-related potentials (ERPs) provide great insight into neural responses, yet developmental ERP work is plagued with inconsistent approaches to identifying and quantifying component latency. In this analytical review, we describe popular conventions for the selection of time windows for ERP analysis and assert that a data-driven strategy should be applied to the identification of component latency within individual participants' data. This may overcome weaknesses of more general approaches to peak selection; however, it does not account for trial-by-trial variability within a participant. This issue, known as ERP latency jitter, may blur the average ERP, misleading the interpretation of neural mechanisms. Recently, the ReSync MATLAB toolbox has been made available for correction of latency jitter. Although not created specifically for pediatric ERP data, this approach can be adapted for developmental researchers. We have demonstrated the use of the ReSync toolbox with individual infant and child datasets to illustrate its utility. Details about our peak detection script and the ReSync toolbox are provided. The adoption of data processing procedures that allow for accurate, study-specific component selection and reduce trial-by-trial asynchrony strengthens developmental ERP research by decreasing noise included in ERP analyses and improving the representation of the neural response.

A single-session behavioral protocol for successful event-related potential recording in children with neurodevelopmental disorders.

Event-related potentials (ERPs) are an ideal tool for measuring neural responses in a wide range of participants, including children diagnosed with neurodevelopmental disorders (NDDs). However, due to perceived barriers regarding participant compliance, much of this work has excluded children with low IQ and/or reduced adaptive functioning, significant anxiety symptoms, and/or sensory processing difficulties, including heterogeneous samples of children with autism spectrum disorder (ASD) and children with fragile X syndrome (FXS). We have developed a behavioral support protocol designed to obtain high-quality ERP data from children in a single session. Using this approach, ERP data were successfully collected from participants with ASD, FXS, and typical development (TD). Higher success rates were observed for children with ASD and TD than children with FXS. Unique clinical-behavioral characteristics were associated with successful data collection across these groups. Higher chronological age, nonverbal mental age, and receptive language skills were associated with a greater number of valid trials completed in children with ASD. In contrast, higher language ability, lower autism severity, increased anxiety, and increased sensory hyperresponsivity were associated with a greater number of valid trials completed in children with FXS. This work indicates that a "one-size-fits-all" approach cannot be taken to ERP research on children with NDDs, but that a single-session paradigm is feasible and is intended to promote increased representation of children with NDDs in neuroscience research through development of ERP methods that support inclusion of diverse and representative samples.

Comparison of Video Versus Direct Laryngoscopy: A Prospective Prehospital Air Medical Services Study.

OBJECTIVE: Videolaryngoscopy (VL) in the prehospital setting remains controversial, with conflicting data on its utility. We compared C-MAC VL (Karl Storz, Tuttlingen, Germany) versus direct laryngoscopy (DL) in the prehospital setting, recording the grade of the glottic view, first pass success (FPS), overall success, and equipment functionality. METHODS: We conducted a prospective observational study with a convenience sample of 49 adult patients who were intubated by flight crew nurses and paramedics using the C-MAC videolaryngoscope from April to November 2013. We compared Cormack-Lehane (CL) grades of view for DL and VL, intubation success rates, and equipment functionality. RESULTS: CL grades 1 or 2 were obtained with 24 patients (49%) with DL and 45 patients (92%) with VL. Of the 25 patients (51%) who had a CL grade 3 or 4 view on DL, 22 of those patients (88%) converted to a CL grade 1 or 2 with VL (P < .001). There was an overall success rate of 96% and an FPS rate of 71%. The C-MAC videolaryngoscope was functional during intubation 100% of the time. CONCLUSION: VL improved glottic visualization compared with DL. The FPS and overall intubation success rates were similar to other published prehospital studies using VL. The C-MAC provided reliable, high-quality video despite demanding prehospital conditions.

Constrained instruments and their application to Mendelian randomization with pleiotropy.

In Mendelian randomization (MR), inference about causal relationship between a phenotype of interest and a response or disease outcome can be obtained by constructing instrumental variables from genetic variants. However, MR inference requires three assumptions, one of which is that the genetic variants only influence the outcome through phenotype of interest. Pleiotropy, that is, the situation in which some genetic variants affect more than one phenotype, can invalidate these genetic variants for use as instrumental variables; thus a naive analysis will give biased estimates of the causal relation. Here, we present new methods (constrained instrumental variable [CIV] methods) to construct valid instrumental variables and perform adjusted causal effect estimation when pleiotropy exists and when the pleiotropic phenotypes are available. We demonstrate that a smoothed version of CIV performs approximate selection of genetic variants that are valid instruments, and provides unbiased estimates of the causal effects. We provide details on a number of existing methods, together with a comparison of their performance in a large series of simulations. CIV performs robustly across different pleiotropic violations of the MR assumptions. We also analyzed the data from the Alzheimer's disease (AD) neuroimaging initiative (ADNI; Mueller et al., 2005. Alzheimer's Dementia, 11(1), 55-66) to disentangle causal relationships of several biomarkers with AD progression.

Face-sensitive brain responses in the first year of life.

Cortical areas in the ventral visual pathway become selectively tuned towards the processing of faces compared to non-face stimuli beginning around 3 months of age and continuing over the first year. Studies using event-related potentials in the EEG (ERPs) have found an ERP component, the N290, that displays specificity for human faces. Other components, such as the P1, P400, and Nc have been studied to a lesser degree in their responsiveness to human faces. However, little is known about the systematic changes in the neural responses to faces during the first year of life, and the localization of these responses in infants' brain. We examined ERP responses to pictures of faces and objects in infants from 4.5 months through 12 months in a cross-sectional study. We investigated the activity of all the components reported to be involved in infant face processing, with particular interest to their amplitude variation and cortical localization. We identified neural regions responsible for the component through the application of cortical source localization methods. We found larger P1 and N290 responses to faces than objects, and these components were localized in the lingual and middle/posterior fusiform gyri, respectively. The amplitude of the P400 was not differentially sensitive to faces over objects. The Nc component was different for faces and objects, was influenced by the infant's attentional state, and localized in medial-anterior brain areas. The implications of these results are discussed in the identification of developmental ERP precursors to face processing.

The developmental trajectory of fronto-temporoparietal connectivity as a proxy of the default mode network: a longitudinal fNIRS investigation.

The default mode network (DMN) is a network of brain regions that is activated while we are not engaged in any particular task. While there is a large volume of research documenting functional connectivity within the DMN in adults, knowledge of the development of this network is still limited. There is some evidence for a gradual increase in the functional connections within the DMN during the first 2 years of life, in contrast to other functional resting-state networks that support primary sensorimotor functions, which are online from very early in life. Previous studies that investigated the development of the DMN acquired data from sleeping infants using fMRI. However, sleep stages are known to affect functional connectivity. In the current longitudinal study, fNIRS was used to measure spontaneous fluctuations in connectivity within fronto-temporoparietal areas-as a proxy for the DMN-in awake participants every 6 months from 11 months till 36 months. This study validates a method for recording resting-state data from awake infants, and presents a data analysis pipeline for the investigation of functional connections with infant fNIRS data, which will be beneficial for researchers in this field. A gradual development of fronto-temporoparietal connectivity was found, supporting the idea that the DMN develops over the first years of life. Functional connectivity reached its maximum peak at about 24 months, which is consistent with previous findings showing that, by 2 years of age, DMN connectivity is similar to that observed in adults.

Team triathlon effects on physiological, psychological, and immunological measures in women breast cancer survivors.

PURPOSE: Exercise after breast cancer diagnosis and treatment improves cancer-related outcomes, although the mechanisms involved are not clear. This study evaluated the impact of exercise on body composition, strength, endurance, quality of life (QOL), fatigue, and endocrine and inflammatory biomarkers in breast cancer survivors participating in a highly monitored, clinically supervised, moderate-intensity exercise program. The association of hormonal and inflammatory biomarkers with the observed physiological changes was assessed. METHODS: Female breast cancer survivors (BCS; n = 46) who engaged in a goal-oriented 14-week triathlon exercise training program were compared to an untrained control group of female BCS (n = 16). Psychosocial metrics, QOL, cancer-related fatigue, and exercise self-efficacy were evaluated via pre- and post-exercise intervention questionnaires. Serum estradiol and inflammatory biomarkers (C-reactive protein (CRP), sTNFR1a, estradiol, leptin, and adiponectin) were measured prior to the exercise training program start and after the completion of the goal triathlon. RESULTS: After exercise training, the exercise group had lower BMI and arm circumferences. Greater positive change was noted in the trained group for QOL, fatigue, and self-efficacy questionnaires. Functional endurance improved in the trained but not the control group. Knee and elbow strength were not different between the groups, except that knee flexion at 180 degrees∙sec-1 was higher in trained. The only significantly different biomarker was adiponectin, which decreased in the trained group. CONCLUSIONS: Group triathlon exercise training may be beneficial to BCS by significantly improving their psychosocial measures, functional endurance, and BMI.

Bodybuilding supplements leading to copper toxicity, encephalopathy, fulminant hepatic failure and rhabdomyolysis.

Millions of people worldwide use nutritional and dietary supplements, such as vitamins and minerals. These and other performance-enhancing substances are also used by high school, college, and professional athletes, bodybuilders, and amateur sports enthusiasts. The constituents of these supplements and their metabolites may be harmful and not listed on the product label. We present a case report of a 32-year-old bodybuilder using myriad nutritional, performance-enhancing, and weight-loss supplements with life-threatening encephalopathy, hepatic failure, rhabdomyolysis, and copper toxicity mimicking Wilson's disease. Emergency physicians and nurses should be aware of these potential deleterious effects and inquire about supplement use by patients with unexplained multiorgan failure. Family, friends, or acquaintances should be asked to bring the actual products to the hospital for analysis.