Human factors enablers and barriers for successful airway management - an in-depth interview study.

Human factors are the individual, team, environmental and organisational aspects of the anaesthetic environment that affect performance and decision-making of anaesthesia teams. This study aimed to identify which human factors were enablers and/or barriers to anaesthesia teams during airway management challenges. Sixteen interviews were conducted with experienced anaesthetists and anaesthetic nurses using an in-depth interview technique (the Critical Decision Method) to identify human factors enablers and/or barriers during successful management of a significant airway challenge. Thematic analysis identified three overarching enablers: equipment location and storage; experience and learning; teamwork and communication. Five overarching barriers were also identified: time and resource limitations; teamwork and communication; equipment location and storage; experience and learning; insufficient back-up planning; and equipment preparation. This study showed that a variety of human factors issues affect the handling of airway challenges, ranging from individual and team to organisational and environmental aspects. Recommendations for the design of airway management decision support tools that relate to equipment standardisation, decision support complexity, inclusive mutual learning and teamwork are discussed.

BMI loci and longitudinal BMI from adolescence to young adulthood in an ethnically diverse cohort.

OBJECTIVE: The association of obesity susceptibility variants with change in body mass index (BMI) across the life course is not well understood. SUBJECTS: In ancestry-stratified models of 5962 European American (EA), 2080 African American (AA) and 1582 Hispanic American (HA) individuals from the National Longitudinal Study of Adolescent to Adult Health (Add Health), we examined associations between 34 obesity single-nucleotide polymorphisms (SNPs) with per year change in BMI, measured by the slope from a growth-curve analysis of two or more BMI measurements between adolescence and young adulthood. For SNPs nominally associated with BMI change (P<0.05), we interrogated age differences within data collection Wave and time differences between age categories that overlapped between Waves. RESULTS: We found SNPs in/near FTO, MC4R, MTCH2, TFAP2B, SEC16B and TMEM18 were significantly associated (P<0.0015≈0.05/34) with BMI change in EA and the ancestry-combined meta-analysis. rs9939609 in FTO met genome-wide significance at P<5e-08 in the EA and ancestry-combined analysis, respectively [Beta(se)=0.025(0.004);Beta(se)=0.021(0.003)]. No SNPs were significant after Bonferroni correction in AA or HA, although five SNPs in AA and four SNPs in HA were nominally significant (P<0.05). In EA and the ancestry-combined meta-analysis, rs3817334 near MTCH2 showed larger effects in younger respondents, whereas rs987237 near TFAP2B, showed larger effects in older respondents across all Waves. Differences in effect estimates across time for MTCH2 and TFAP2B are suggestive of either era or cohort effects. CONCLUSION: The observed association between variants in/near FTO, MC4R, MTCH2, TFAP2B, SEC16B and TMEM18 with change in BMI from adolescence to young adulthood suggest that the genetic effect of BMI loci varies over time in a complex manner, highlighting the importance of investigating loci influencing obesity risk across the life course.

No relevant impact of ambient temperature on disability measurements in a large cohort of patients with multiple sclerosis.

BACKGROUND AND PURPOSE: Many patients with multiple sclerosis (MS) report a worsening of symptoms due to high ambient temperatures, but objective data about this association are rare and contradictory. The aim of this study was to investigate the influence of ambient temperature on standard clinical tests. METHODS: We extracted the Symbol Digit Modality Test, Nine Hole Peg Test, Timed 25 Foot Walk (T25FW), Timed Tandem Walk, Expanded Disability Status Scale (EDSS) and quality-of-life items on cognition, fatigue and depression from our clinical database and matched them to historical temperatures. We used linear mixed-effect models to investigate the association between temperature and outcomes. RESULTS: A total of 1254 patients with MS (mean age, 42.7 years; 69.9% females; 52.1% relapsing-remitting MS, mean EDSS, 3.8) had 5751 assessments between 1996 and 2012. We observed a worsening in the T25FW with higher ambient temperatures in moderately disabled patients (EDSS ≥ 4) but not in less disabled patients. However, an increase of 10°C prolonged the T25FW by just 0.4 s. Other outcomes were not associated with ambient temperatures. CONCLUSIONS: Higher ambient temperature might compromise walking capabilities in patients with MS with a manifest walking impairment. However, effects are small and not detectable in mildly disabled patients. Hand function, cognition, mood and fatigue do not appear to be correlated with ambient temperature.

Eighteen- to 30-year-olds more likely to link to hepatitis C virus care: an opportunity to decrease transmission.

Hepatitis C virus (HCV) infection incidence among 18- to 30-year-olds is increasing and guidelines recommend treatment of active injection drug users to limit transmission. We aimed to : measure linkage to HCV care among 18- to 30-year-olds and identify factors associated with linkage; compare linkage among 18- to 30-year-olds to that of patients >30 years. We used the electronic medical record at an urban safety net hospital to create a retrospective cohort with reactive HCV antibody between 2005 and 2010. We report seroprevalence and demographics of seropositive patients, and used multivariable logistic regression to identify factors associated with linkage to HCV care. We defined linkage as having evidence of HCV RNA testing after reactive antibody. Thirty two thousand four hundred and eighteen individuals were tested, including 8873 between 18 and 30 years. The seropositivity rate among those ages 18-30 was 10%. In multivariate analysis, among those 18-30, diagnosis location (Outpatient vs Inpatient/ED) (OR 1.78, 95% CI 1.28-2.49) and number of visits after diagnosis (OR 5.30, 95% CI 3.91-7.19) were associated with higher odds of linking to care. When we compared linkage in patients ages 18-30 to that among those older than 30, patients in the 18-30 years age group were more likely to link to HCV care than those in the older cohort even when controlling for gender, ethnicity, socioeconomic status, birthplace, diagnosis location and duration of follow-up. Eighteen- to 30-year-olds are more likely to link to HCV care than their older counterparts. During the interferon-free treatment era, there is an opportunity to prevent further HCV transmission in this population.

Decisional stage distribution for colorectal cancer screening among diverse, low-income study participants.

Colorectal cancer (CRC) screening uptake among minorities and those with lower incomes is suboptimal. Behavioral interventions specifically tailored to these populations can increase screening rates and save lives. The Precaution Adoption Process Model (PAPM) allows assignment of a decisional stage for adoption of a behavior such as CRC screening. Here, we characterize the PAPM decisional stage distribution among 470 low income, racially and ethnically diverse study participants at intake into a behavioral intervention study designed to increase CRC screening uptake. We staged participants for stool blood test (SBT) and colonoscopy separately and used the highest stage for the two tests as the 'overall' stage for CRC screening. For SBT, sex, language (English versus Spanish) and doctor recommendation were significantly related to PAPM stage for CRC screening. For colonoscopy, language, education level, doctor recommendation and self-efficacy were related to stage. For overall CRC screening stage, all the variables associated with either SBT or colonoscopy, with the exception of language were significant. This study suggests attending to these key variables in designing interventions to promote CRC screening, particularly with respect to medically underserved populations.

Lipoprotein lipase variants interact with polyunsaturated fatty acids for obesity traits in women: replication in two populations.

BACKGROUND AND AIMS: Lipoprotein lipase (LPL) is a candidate gene for obesity based on its role in triglyceride hydrolysis and the partitioning of fatty acids towards storage or oxidation. Whether dietary fatty acids modify LPL associated obesity risk is unknown. METHODS AND RESULTS: We examined five single nucleotide polymorphisms (SNPs) (rs320, rs2083637, rs17411031, rs13702, rs2197089) for potential interaction with dietary fatty acids for obesity traits in 1171 participants (333 men and 838 women, aged 45-75 y) of the Boston Puerto Rican Health Study (BPRHS). In women, SNP rs320 interacted with dietary polyunsaturated fatty acids (PUFA) for body mass index (BMI) (P = 0.002) and waist circumference (WC) (P = 0.001) respectively. Higher intake of PUFA was associated with lower BMI and WC in homozygotes of the major allele (TT) (P = 0.01 and 0.005) but not in minor allele carriers (TG and GG). These interactions were replicated in an independent population, African American women of the Atherosclerosis Risk in Communities (ARIC) study (n = 1334). CONCLUSION: Dietary PUFA modulated the association of LPL rs320 with obesity traits in two independent populations. These interactions may be relevant to the dietary management of obesity, particularly in women.

Loss of retinal nerve fibre layer axons indicates white but not grey matter damage in early multiple sclerosis.

BACKGROUND AND PURPOSE: Optical coherence tomography (OCT) has shown thinning of the retinal nerve fibre layer (RNFL) and total macular volume (TMV) in multiple sclerosis (MS) patients. Measures of retinal atrophy are associated with the brain parenchymal fraction (BPF) assessed by magnetic resonance imaging (MRI). However, in MS, data on the relation of OCT measures and grey and white matter volumes are contradictory. We performed a prospective cross-sectional study with a statistically pre-defined endpoint to test our hypothesis that OCT measures of neuro-axonal degeneration are related to global and partial brain atrophy in early forms of MS. METHODS AND RESULTS: Forty-four patients with clinically isolated syndrome (n = 10) or relapsing-remitting MS (n = 34; mean disease duration = 3.2 years, median EDSS = 1.5) were enrolled in the study. Peripapillary- and volumetric OCT scans of the macula were performed using latest spectral-domain OCT technology. BPF as well as white and grey matter fractions (WMF/GMF) were assessed by 1.5 Tesla MRI scans. Generalized estimating equation models adjusted for age and linear regression statistics were used to assess the association between OCT and MRI measures. RNFL thickness, TMV and age were significantly associated with BPF. RNFL thickness and TMV independently predicted WMF (P = 0.003 and P = 0.032) but not GMF (P = 0.717 and P = 0.357) when corrected for age. In contrast, age was strongly associated with GMF (P < 0.001) but not WMF. CONCLUSION: Our study suggests that, in early MS, OCT measures of retinal atrophy are related to volumetric changes in the white but not grey matter compartment as assessed by MRI. It further substantiates the association of retinal thinning and brain tissue loss in MS.

Deterring illegal smartphone use while driving: Are perceptions of risk information associated with the impact of informal sanctions?

Advertising campaigns have used threat appeals to increase the perceptions of risk associated with dangerous driving behaviours. Building on recent research that suggests increasing the pertinence of informal sanctions (sense of guilt, fear of peer disapproval, or fear of hurting oneself and others) decreases the likelihood of illegal smartphone engagement while driving, this study aimed to determine if perceptions of risk information, that is, how effective drivers believe the information is in deterring their illegal use, is associated with perceptions of informal sanctions. An online survey of 1027 Victorians who self-reported illegal smartphone use while driving asked participants to rate the personal deterrent effectiveness of five types of risks associated with illegal smartphone use while driving. A hierarchical linear regression model explored the associations between the most effective risks and each informal sanction. Female drivers were more likely than male drivers to experience guilt, fear of social loss and fear of physical loss when using their smartphones illegally. More frequent illegal smartphone engagement while driving was associated with decreased impact of informal sanctions. Female drivers were more likely than male drivers to perceive each risk as effective. The most effective piece of information was, "Contributes to 16% of Victorian road deaths and serious injuries annually"; it was also the least known (32.7% males, 26.7% females). This message, alongside, "Increases risk of a crash comparable to those associated with driving under the influence of alcohol or cannabis" and, "A 2 s glance at your phone while driving at 50 km/h effectively means driving blind for 27 m", were associated with stronger perceptions of guilt, fear of peer disapproval, or fear of hurting oneself and others when thinking about using a smartphone illegally while driving. These results suggest tailoring and targeting these specific risk information may be effective in deterring illegal smartphone use while driving.

"Does that mean I can't use my phone to pay when I'm in the Maccas drive thru?": Younger drivers' uncertainty and attitude toward smartphone law and punishment.

This study employed a mixed methods approach (a survey [n = 2,774] and focus groups [n = 16]) to understand the perceptions of younger drivers (18-25) on current smartphone laws in the Australian state of Victoria. First, by analysing quantitative data gathered from an online survey regarding smartphone laws, perceptions of punishment when breaking the law, and attitudes to both the law and fines, this study found younger drivers were less likely to understand the law around phone use while driving, even after direct or indirect experience with police. Additionally, the severity and impact of fines were perceived as more impactful and severe among younger drivers, women, and those on lower incomes, and the most common types of illegal use younger drivers engaged with were navigation, music applications, and hands-free calling, mostly facilitated through Bluetooth with their device placed out of sight. Consequently, focus groups were conducted with a subset of these younger drivers to explore these findings in more depth. It was revealed that smartphone laws were perceived to be ambiguous, at times unreasonable, and difficult to access conclusive information regarding the law or receive information throughout the Graduated Licencing Program. Additionally, of full licenced drivers breaking smartphone laws (n = 807), 61.7 percent never used a cradle. Among probationary drivers breaking the law (n = 209), 76.1 percent never used a cradle. This suggests rampant surreptitious illegal use. As such, younger drivers learning to drive are also learning methods to avoid punishment while breaking smartphone laws. This included not using a cradle and opting instead for Bluetooth connectivity or engaging in hand-held use, a choice that continued into Full Licensed driving. The severity of punishment was not common knowledge and was perceived to be incommensurate to the risks associated with certain types of use. In their opinion all of these factors reduced the legitimacy of the law. Addressing these factors with evidence-based countermeasures may increase compliance and road safety.

Understanding the deterrent impact formal and informal sanctions have on illegal smartphone use while driving.

The illegal use of a smartphone while driving increases the risk of crashes. As such, road authorities rely on countermeasures to reduce illegal smartphone use. Deterrence-based methods dominate road safety, however, perceptions and impact of formal (legal) and informal (non-legal) methods to deter illegal smartphone use in Australia have not yet been explored. The current study reports on a survey of 2774 drivers (47.0 % males) that own and regularly use a smartphone. The survey analysed the self-reported frequency of illegal smartphone use while driving, perceptions of formal and informal deterrence mechanisms, differences between perceived and informed deterrence, and deterrent predictors of illegal use. The findings revealed that illegal smartphone use is increasing in Victoria, Australia. Drivers that break the law perceive deterrent mechanisms significantly different from drivers that abide by the law, however, both groups view the prospect of hurting oneself as most impactful. Additionally, drivers tend to underestimate the consequences of illegal use, yet overestimate the certainty of apprehension. A binary logistic regression analysis revealed that only age, gender and informal sanctions such as social loss (stigma/peer disapproval), internal loss (shame/guilt/embarrassment), and physical loss (injury/property damage) were significant predictors of illegal use. None of the formal mechanisms were significant. Based on these findings, road safety interventions and future research should consider exploring the psychological characteristics of young people's perceptions of informal sanctions such as social loss (shame/embarrassment) and internal loss (guilt).

Self-reported mindfulness, cyclist anger and aggression.

Anger is a common behaviour exhibited by road users when one's goals are perceived to have been blocked by another. Recent research has demonstrated that, generally, cyclists tend to deal with anger in constructive ways. However, when anger does manifest, it can result in behaviours that increase their crash risk. Amongst motor vehicle drivers, mindfulness levels have been associated with less anger and appear to mediate anger and associated aggression. The current study sought to understand whether mindfulness has similar associations with anger and aggression in a sample of cyclists. A total of 583 cyclists (males = 68 %) completed an online questionnaire that sought information on their levels of mindfulness, current mindfulness practices and tendencies for anger and aggression while cycling. The relationships between these were then examined using structural equation modelling. The results showed that cyclists with higher mindfulness levels tended to report less anger across a range of situations (e.g., interactions with pedestrians, cyclists, motor vehicle drivers and police). Both direct and indirect (through anger) relationships were found between mindfulness and aggression, again showing that more mindful cyclists tended to engage in less frequent aggression. These findings align with recent research investigating this relationship amongst motor vehicle drivers and suggest that mindfulness may be a promising strategy to reduce or avoid anger and aggression in cyclists.

Necrotizing enterocolitis associated with in utero and breast milk exposure to the selective serotonin reuptake inhibitor, escitalopram.

A term neonate presenting with necrotizing enterocolitis following in utero and breast milk exposure to the newest serotonin selective reuptake inhibitor, escitalopram, is described.

Toward best practice in Human Machine Interface design for older drivers: A review of current design guidelines.

Older adults are the fastest growing segment of the driving population. While there is a strong emphasis for older people to maintain their mobility, the safety of older drivers is a serious community concern. Frailty and declines in a range of age-related sensory, cognitive, and physical impairments can place older drivers at an increased risk of crash-related injuries and death. A number of studies have indicated that in-vehicle technologies such as Advanced Driver Assistance Systems (ADAS) and In-Vehicle Information Systems (IVIS) may provide assistance to older drivers. However, these technologies will only benefit older drivers if their design is congruent with the complex needs and diverse abilities of this driving cohort. The design of ADAS and IVIS is largely informed by automotive Human Machine Interface (HMI) guidelines. However, it is unclear to what extent the declining sensory, cognitive and physical capabilities of older drivers are addressed in the current guidelines. This paper provides a review of key current design guidelines for IVIS and ADAS with respect to the extent they address age-related changes in functional capacities. The review revealed that most of the HMI guidelines do not address design issues related to older driver impairments. In fact, in many guidelines driver age and sensory cognitive and physical impairments are not mentioned at all and where reference is made, it is typically very broad. Prescriptive advice on how to actually design a system so that it addresses the needs and limitations of older drivers is not provided. In order for older drivers to reap the full benefits that in-vehicle technology can afford, it is critical that further work establish how older driver limitations and capabilities can be supported by the system design process, including their inclusion into HMI design guidelines.

Improved Lesion Detection by Using Axial T2-Weighted MRI with Full Spinal Cord Coverage in Multiple Sclerosis.

BACKGROUND AND PURPOSE: Identification of lesions in specific locations gains importance in multiple sclerosis imaging diagnostic criteria. In clinical routine, axial scans are usually exclusively obtained to depict the cervical spinal cord or used to confirm suspected lesions on sagittal scans. We sought to evaluate the detection rate for MS lesions on axial T2WI scans with full spinal cord coverage in comparison with sagittal scans. MATERIALS AND METHODS: One hundred fifteen patients with definite or suspected MS underwent an MR imaging examination including 3-mm sagittal and 3.5-mm axial T2-weighted images with full spinal cord coverage. T2WI lesions were identified on axial and sagittal scans independently by 2 raters. Axial diameter, craniocaudal extension, lesion intensity, and location were analyzed. RESULTS: Four hundred forty-nine of 509 (88.2%) lesions were detected on axial and 337/509 (66.2%) on sagittal scans. Only 277/449 (61.7%) axial lesions were also detected on sagittal images. The number of lesions visible on sagittal and axial images was dependent on the axial lesion diameter (P < .001). CONCLUSIONS: Axial T2WI scans with full spinal cord coverage showed 22% more lesions in patients with MS in comparison with sagittal scans, especially for lesions with small axial diameters. We suggest including biplanar spinal MR imaging with full spinal cord coverage for lesion detection in MS in clinical routine and for clinical studies.

Chronic T2 Lesions in Multiple Sclerosis are Heterogeneous Regarding Phase MR Imaging.

PURPOSE: Phase imaging provides additional information on multiple sclerosis (MS) lesions and may in combination with mean diffusivity (MD) and magnetization transfer ratio (MTR) help differentiating heterogeneity of MS lesion pathology. METHODS: Magnetic resonance imaging (MRI) was performed in 23 MS patients including diffusion tensor imaging (DTI), magnetization transfer imaging (MTI), and SWI. Mean values (MTR, MD, and homodyne filtered phase) from 138 chronic MS lesions and normal appearing white matter (NAWM) were obtained and correlations examined. For explorative analysis, a divisive hierarchical clustering algorithm was applied. RESULTS: Phase characteristics were an independent characteristic of chronic T2 lesions, as MTR and MD were not correlated with phase values (R = - 0.23, R = - 0.18). Dependent on MTR, MD, and phase, cluster analysis led to five lesion groups. Of the two groups with phase values close to NAWM, one presented with highest MD and most severe MTR decrease (p = 0.01), the other with slight MD increase and MTR decrease. Two lesion groups with highest phase values (p = 0.01) displayed slightly increased MD and moderate decrease in MTR. Clinical data including EDSS, disease duration, and age did not differ significantly between groups. CONCLUSIONS: Increased phase is predominantly detectable in lesions with clear MTR decrease but only moderate MD increase. Phase images seem to represent an independent parameter for MS lesion characterization and may provide additional information on MS lesion heterogeneity.

Influence of SNP*SNP interaction on BMI in European American adolescents: findings from the National Longitudinal Study of Adolescent Health.

BACKGROUND: Adolescent obesity is predictive of future weight gain, obesity and adult onset severe obesity (body mass index [BMI] ≥40 kg m(-2) ). Despite successful efforts to identify Single Nucleotide Polymorphisms (SNPs) influencing BMI, <5% of the 40-80% heritability of the phenotype has been explained. Identification of gene-gene (G-G) interactions between known variants can help explain this hidden heritability as well as identify potential biological mechanisms affecting weight gain during this critical developmental period. OBJECTIVE: We have recently shown distinct genetic effects on BMI across the life course, and thus it is important to examine the evidence for epistasis in adolescence. METHODS: In adolescent participants of European descent from wave II of the National Longitudinal Study of Adolescent Health (Add Health, n = 5072, ages 12-21, 52.5% female), we tested 34 established BMI-related SNPs for G-G interaction effects on BMI z-score. We used mixed-effects regression, assuming multiplicative interaction models adjusting for age, sex and geographic region, with random effects for family and school. RESULTS: For 28 G-G interactions that were nominally significant (P < 0.05), we attempted to replicate our results in an adolescent sample from the Childhood European American Cohort from Philadelphia. In the replication study, one interaction (PRKD1-FTO) was significant after correction for multiple testing. CONCLUSIONS: Our results are suggestive of epistatic effects on BMI during adolescence and point to potentially interactive effects between genes in biological pathways important in obesity.

The interaction between physical activity and obesity gene variants in association with BMI: Does the obesogenic environment matter?

Little is known about how obesity susceptibility single nucleotide polymorphisms (SNPs) interact with moderate to vigorous physical activity (MVPA) in relation to BMI during adolescence, once obesogenic neighborhood factors are accounted for. In race stratified models, including European (EA; N=4977), African (AA; N=1726), and Hispanic Americans (HA; N=1270) from the National Longitudinal Study of Adolescent to Adult Health (1996; ages 12-21), we assessed the evidence for a SNPxMVPA interaction with BMI-for-age Z score, once accounting for obesogenic neighborhood factors including physical activity amenities, transportation and recreation infrastructure, poverty and crime. Eight SNPxMVPA interactions with suggestive significance (p<0.10; three in each EA, and AA, two in HA) were observed showing attenuation on BMI-for-age Z score in adolescents with ≥5 versus <5 bouts/week MVPA, except for rs10146997 (near NRXN3). Findings were robust to the inclusion of neighborhood-level variables as covariates. These findings suggest that any attenuation from MVPA on a genetic susceptibility to obesity during adolescence is likely not operating through obesogenic neighborhood factors.

Introducing a new method to assess vision: Computer-adaptive contrast-sensitivity testing predicts visual functioning better than charts in multiple sclerosis patients.

BACKGROUND: Impaired low-contrast visual acuity (LCVA) is common in multiple sclerosis (MS) and other neurological diseases. Its assessment is often limited to selected contrasts, for example, 2.5% or 1.25%. Computerized adaptive testing with the quick contrast-sensitivity function (qCSF) method allows assessment across expanded contrast and spatial frequency ranges. OBJECTIVE: The objective of this article is to compare qCSF with high- and low-contrast charts and patient-reported visual function. METHODS: We enrolled 131 consecutive MS patients (mean age 39.6 years) to assess high-contrast visual acuity (HCVA) at 30 cm and 5 m, low-contrast vision with Sloan charts at 2.5% and 1.25%, qCSF and the National Eye Institute Visual Functioning Questionnaire (NEIVFQ). Associations between the different measures were estimated with linear regression models corrected for age, gender and multiple testing. RESULTS: The association between qCSF and Sloan charts (R2 = 0.68) was higher than with HCVA (5 m: R2 = 0.5; 30 cm: R2 = 0.41). The highest association with NEIVFQ subscales was observed for qCSF (R2 0.20-0.57), while Sloan charts were not associated with any NEIVFQ subscale after correction for multiple testing. CONCLUSION: The qCSF is a promising new outcome for low-contrast vision in MS and other neurological diseases. Here we show a closer link to patient-reported visual function than standard low- and high-contrast charts.

Dietary status of trained female cyclists.

Dietary status was evaluated in eight highly trained female cyclists. Each cyclist kept a 3-day weighed food record. Diets were analyzed for nutrient content using a computerized software package. Blood was also obtained and evaluated for hemoglobin, hematocrit, and albumin. For an athletic group, the cyclists' diets were found to be low in energy (85% RDA) and carbohydrate (4.4 gm/kg body weight per day). Mean daily dietary intakes were well below the RDAs for folacin (76% RDA), magnesium (81%), iron (59%), and zinc (48%). In addition, more than one-third of the cyclists failed to consume 67% of the RDA for the following micronutrients: pyridoxine, folacin, cobalamin, vitamin E, magnesium, iron, and zinc. Hemoglobin (135 gm/L), hematocrit (0.39), and albumin (45 gm/L) values were all normal, although most hemoglobin values were in the lower 50% of normal range. Foods such as meats, poultry, fish, beans, peas, and nuts were low or absent from the diets of most athletes. Dietary quality in this group of female cyclists could have been greatly improved with the addition of more of those foods. These athletes could benefit from nutrition education and diet counseling.