Consistent Definition Research Articles

Systematic review: Exploring the monitoring and reporting of unwanted events in psychotherapy trials for anorexia nervosa.

If a psychotherapeutic intervention has the capacity to produce positive change, the "deterioration effect" theory holds that it must also have the potential for negative effects. However, the definition, measurement, and reporting of unwanted events in psychotherapy is a topic of ongoing discussion. At present this area is under-explored in interventions for anorexia nervosa (AN), a severe mental illness associated with high medical and psychiatric risks. The aim of this article was to undertake a systematic review of published randomized controlled trials (RCTs) evaluating psychotherapeutic interventions for AN, and to assess how unwanted events were defined, monitored, and reported alongside the trial's key findings. Using a systematic review methodology, this article identified 23 RCTs through database searches meeting eligibility criteria. Results are presented using a narrative summary approach. Unwanted event reporting varied widely, both regarding definitions of key unwanted events (such as non-compliance or symptom deterioration) and in the amount of detail captured in each paper. The review identified two key issues: firstly, a lack of consistent definitions and unclear causality made it difficult to distinguish between unwanted events, and adverse events caused by the interventions. Secondly, it highlighted the difficulty of defining unwanted events where different studies have different populations and goals. Recommendations are made around how the area of defining, monitoring, and reporting unwanted events in RCTs for AN can be taken forward. Whilst psychotherapies can be effective in treating mental health conditions, negative or unwanted events can sometimes occur. This review explored how RCTs examining psychotherapy for AN report how they monitor the safety of participants, and how they report unwanted events. We found that the reporting was often inconsistent or hard to interpret, and we have made recommendations for how this can be improved in the future.

On Huber's contaminated model

Huber's contaminated model is a basic model for data with outliers. This paper aims at addressing several fundamental problems about this model. We first study its identifiability properties. Several theorems are presented to determine whether the model is identifiable for various situations. Based on these results, we discuss the problem of estimating the parameters with observations drawn from Huber's contaminated model. A definition of estimation consistency is introduced to handle the general case where the model may be unidentifiable. This consistency is a strong robustness property. After showing that existing estimators cannot be consistent in this sense, we propose a new estimator that possesses the consistency property under mild conditions. Its adaptive version, which can simultaneously possess this consistency property and optimal asymptotic efficiency, is also provided. Numerical examples show that our estimators have better overall performance than existing estimators no matter how many outliers in the data.

Multiplicative consistency analysis of interval-valued fuzzy preference relations

Interval-valued fuzzy preference relations (IVFPRs) have been applied to many real-life decision-making problems. However, most definitions of consistency of IVFPRs do not satisfy invariability to compared objects’ labels. To overcome this drawback, this paper mainly focuses on the multiplicative consistency analysis of interval-valued fuzzy preference relations (IVFPRs). Firstly, this paper proposes a new multiplicative consistency of complete IVFPRs. It is proved that this new multiplicative consistency is robust and invariable to compared objects’ labels. Then, the definition of acceptable incomplete IVFPRs (In-IVFPRs) is presented. To make full use of all direct and indirect evaluations of decision-makers, an algorithm is devised to evaluate the missing elements of an acceptable incomplete In-IVFPR. To comprehensively describe the closeness between any two complete IVFPRs, the total deviation of two complete IVFPRs is defined based on the p-norm of a vector. By minimizing the total deviation of two complete IVFPRs, a programming model is built to determine an interval weight vector from a complete IVFPR. Subsequently, a novel decision-making method with an In-IVFPR is proposed. Lastly, three practical and numerical examples and simulation-based comparative analyses are provided to further validate the practicability and advantages of the proposed method.

Incomplete Fermatean fuzzy preference relations and group decision-making

Abstract There may be cases where experts do not have in-depth knowledge of the problem to be solved in decision-making problems. In such cases, experts may fail to express their views on certain aspects of the problem, resulting in incomplete preferences, in which some preference values are not provided or are missing. In this article, we present a new model for group decision-making (GDM) methods in which experts’ preferences can be expressed as incomplete Fermatean fuzzy preference relations. This model is guided by the additive-consistency property and only uses the preference values the expert provides. An additive consistency definition characterized by a Fermatean fuzzy priority vector has been given. The additive consistency property is also used to measure the level of consistency of the information provided by the experts. The proposed additive consistency definition’s property is presented, as well as a model for obtaining missing judgments in incomplete Fermatean fuzzy preference relations. We present a method for adjusting the inconsistency for Fermatean fuzzy preference relations, a model for obtaining the priority vector, and a method for increasing the consensus degrees of Fermatean fuzzy preference relations. In addition, we present a GDM method in environments with incomplete Fermatean fuzzy preference relations. To show that our method outperforms existing GDM methods in incomplete Fermatean fuzzy preference relations environments, we have provided an example and compared it with some methods. It has been seen that our proposed GDM method is beneficial for GDM in deficient Fermatean fuzzy preference relation environments and produces meaningful results for us.

Normalizing crash risk of partially automated vehicles under sparse data

The safety of increasingly automated vehicles is of great concern to regulators, yet crash rates are generally reported by manufacturers using proprietary metrics with limited source data. Without consistent definitions of crashes and exposure, automated vehicle crash rates cannot be meaningfully compared with baseline datasets. The objective of this study was to establish methods to normalize automated vehicle crash rates using one manufacturer’s crash reports as a case study. The manufacturer’s quarterly crash rates for vehicles using SAE Level 1 and Level 2 automation were compared. Road type was controlled for using data from a naturalistic driving study with the same model vehicles, while driver age was controlled for using demographic ownership surveys. Although Level 2 vehicles were claimed to have a 43% lower crash rate than Level 1 vehicles, their improvement was only 10% after controlling for different rates of freeway driving. Direct comparison with general public driving was impossible due to unclear crash severity thresholds in the manufacturer’s reports, but analysis showed that controlling for driver age would increase reported crash rates by 11%. These results establish the need for detailed crash data, crash definitions, and exposure and demographic data in order to accurately assess automated vehicle safety.

Prosections in Anatomy Education: Establishing a Definition and Describing Preparation, Use, and Educator Perceptions.

There is an ongoing debate in anatomy education regarding the use of prosection versus student dissection in anatomy lab instruction. While there are plenty of studies comparing dissection and prosection, there are very few studies on how prosections are prepared and how they are used in anatomy instruction. Furthermore, there is no consistent definition of prosection used in the literature. This study used an anonymous questionnaire distributed to anatomy educators internationally and asked for educator views on defining, preparing, and using prosections in various course settings. One-hundred twenty-five completed responses representing fifteen countries and sixty-seven institutions underwent a thematic analysis to describe major themes in participant responses. From responses, a definition of prosection was developed, and the major perceived strengths and weaknesses of prosection use were described. Furthermore, quantitative data regarding the prevalence of prosection use as either a supplemental or primary resource and details pertaining to the perceived expertise of prosectors was collected. This study demonstrates the extensive reach of prosections in anatomy education and sets a foundation from which future studies on unique prosection preparation and use can stem from.

Safety of biological and targeted synthetic disease-modifying antirheumatic drugs for rheumatoid arthritis as used in clinical practice: results from the ARTIS programme

ObjectiveLongitudinal clinical registry-infrastructures such as Anti-Rheumatic Therapies in Sweden (ARTIS) allow simultaneous comparison of the safety of individual immunomodulatory drugs used in clinical practice, with consistent definitions of treatment cohorts,...

Attitudes of Maternal Fetal Medicine specialists on prenatal diagnosis, disability and termination

ObjectiveTo identify the key attitudes and opinions of Maternal-Fetal Medicine specialists (MFMs) who counsel expectant mothers with a prenatal diagnosis of fetal anomaly surrounding prenatal genetic testing, disability and termination. MethodsWe conducted in-depth semi-structured interviews with MFMs across the United States. Participants were recruited through the snowball method beginning with referrals from the MFM on our study team, AM. Interviews were audio-recorded, transcribed, and qualitatively analyzed for themes using modified grounded theory by three reviewers. Results2227 codes from 17 interviews were grouped into 18 themes, which were then characterized into six over-arching, topic-oriented clusters: 1) Physician Methodology; 2) Physician Perception of Disability; 3) Physician Experience; 4) Physician-Patient Relationship; 5) Patient Experience; and 6) Termination. Patients’ misunderstanding of prenatal genetic screening, diagnostic technology, the implications of certain genetic anomalies, and limited time to explain these factors were identified as major barriers to effective counseling. All MFMs described themselves as informants in the prenatal diagnostic process, and all offered their patients termination following a diagnosis of a severe or lethal congenital anomaly; however, MFMs did not identify a consistent definition of severe or lethal congenital anomaly. MFMs reported fears of being perceived as coercive by patients and a high degree of moral and emotional distress during consultations. Finally, MFMs identified legal, financial and structural barriers that prevented patients from accessing prenatal genetic diagnostic services and termination services. It was felt that these limitations ultimately inhibited autonomous decision making by patients. ConclusionsThese findings highlight important barriers faced by MFM providers when trying to provide effective counseling to expectant mothers carrying a prenatal diagnosis of fetal anomaly. Further exploration of these identified barriers may lead to the development of strategies to improve prenatal counseling.

Inpatient boarding definitions and mitigation strategies: A cross-sectional survey of academic emergency departments in the United States

ObjectiveConceptually, inpatient boarding is a result in the delay of admitting patients from the Emergency Department (ED) to inpatient units, but there is no consistent definition across academic EDs. The purpose of this study was to evaluate the definition of boarding across academic EDs, and to identify mitigation strategies used by EDs to alleviate crowd management. MethodsThis was a cross-sectional survey of boarding-related questions (i.e., boarding definitions and practices) that were embedded into the annual benchmarking survey conducted by the Academy of Academic Administrators of Emergency Medicine and the Association of Academic Chairs of Emergency Medicine. Results were descriptively assessed and tabulated. ResultsOf the 130 eligible institutions, 68 participated in the survey. Approximately 70% of institutions reported starting the boarding clock at the time of ED admission, while 19% reported that the clock started with the completion of inpatient orders. Approximately 35% of institutions considered patients boarded within 2 h, while 34% considered patients boarded >4 h after admission decision. In response to ED overcrowding brought on by inpatient boarding, 35% reported using hallway beds for patient care. Surge capacity measures reported included having a high census/surge capacity plan (81%), going on ambulance diversion (54%), and institutional use of a discharge lounge (49%). ConclusionsWe found that definitions for boarding varied widely. Inpatient boarding has serious consequences to patient care and well-being, suggesting the need for standardized definitions to describe inpatient boarding.

The Unique Role of Father Involvement in Child Socioemotional Development

The role of fathers in the modern households has significantly changed, prompting scholarly interest in the uniqueness of paternal influences. The early childhood development literature is thereby no longer limited to focus solely on the effects of maternal behaviors. In particular, father involvement is regarded to have distinct mechanisms of influence on children's early social-emotional development that relatively independent of motherhood. However, there is not even a consistent definition of father involvement yet, and the current literature has received little attention within the pathways of how its influence on early childhood development. To bridge this gap, this paper aims to explore aspects of father involvement and the mechanisms of its impact on children's social-emotional behavior. Grounded on attachment theory and activation relationship theory, this paper presents that father involvement can build high-quality father-child attachments both through sensitive affection engagement and the challenges and activations that common in physical play, thus having a unique impact on children's social-emotional behavior that is different from that of their mothers. This paper can serve as an inspiration for future directions in father involvement research and has potential practical implications for policymakers and families with newborns. There remains ambiguities and gaps in the research on the parenting literature, such as there are very few studies have yet considered the dynamic and reciprocal nature of the father-child relationship, which need to be addressed by future research.

Public Transport Management - where do we stand?

The key function of Public Transport Management (PTM) is to merge behavioural science and systems engineering to determine how to improve the flow of passengers on mass public transport. The efficiency of a transport system depends on several elements, such as available technology, governmental policies, the planning process, and control strategies. The key element lies in the digitalisation approach of all public transport services as well as real-time information, thus standardization is necessary for a consistent and comprehensive definition of how data is to be reported.

Examining the Peer-Reviewed Published Literature Regarding Low Back Pain in Rowing: A Scoping Review.

Low back pain (LBP) is highly prevalent in the rowing population. The body of existing research variously investigates risk factors, prevention, and treatment methods. The purpose of this scoping review was to explore the breadth and depth of the LBP literature in rowing and to identify areas for future research. Scoping review. PubMed, Ebsco and ScienceDirect were searched from inception to November 1, 2020. Only published, peer-reviewed, primary, and secondary data pertaining to LBP in rowing were included for this study. Arksey and O'Malley's framework for guided data synthesis was used. Reporting quality of a subsection of the data was assessed using the STROBE tool. Following the removal of duplicates and abstract screening, a set of 78 studies were included and divided into the following categories: epidemiology, biomechanics, biopsychosocial, and miscellaneous. The incidence and prevalence of LBP in rowers were well mapped. The biomechanical literature covered a wide range of investigations with limited cohesion. Significant risk factors for LBP in rowers included back pain history and prolonged ergometer use. A lack of consistent definitions within the studies caused fragmentation of the literature. There was good evidence for prolonged ergometer use and history of LBP to constitute risk factors and this may assist future LBP preventative action. Methodological issues such as small sample size and barriers to injury reporting increased heterogeneity and decreased data quality. Further exploration is required to determine the mechanism of LBP in rowers through research with larger samples.

The role of telemedicine in emergency situations with the provision of medical care in hard-to-reach areas of the North Caucasus

This article presents the scientific merits of telemedicine interventions in primary health care in hard-to-reach areas of the North Caucasus. Although there is no single and consistent definition of primary health care, most sources agree that it is central to the healthcare system as it is the first contact for patients seeking medical care. Growing concerns about sustainability and an expected shortage of primary care physicians have sparked interest in exploring the potential of telemedicine to address many of the challenges facing primary health care in the Nor th Caucasus.

P887 Epidemiology of perianal fistulising Crohn’s disease: a systematic literature review

Abstract Background Complex Crohn’s perianal fistulas (CPF) are a debilitating complication of Crohn’s disease (CD). Data about the epidemiology of complex CPF are limited. This systematic literature review (SLR) aimed to understand the epidemiology of CPF in adult and paediatric CD populations globally. Methods Electronic databases (MEDLINE, Embase, EBM Reviews, EconLit) were searched. PICOS-T (population, interventions, comparators, outcomes, study design, time) selection criteria were used to identify relevant studies, and two reviewers independently screened and extracted data. Articles included observational studies with >50 patients published in English from 1 Jan 2015 to 17 Feb 2022. The study was still included if complex CPF was not defined. The NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to assess the risk of bias/quality of studies (good, fair or poor). Outcomes of interest were the prevalence and incidence of CPF. Studies reporting epidemiology as an objective were considered primary epidemiology studies. Data were summarized using descriptive statistics. Results In total, 140 studies were included, of which most were of good (n=14) or fair (n=98) quality regarding risk of bias. Few studies (n=24) defined complex CPF; hence, outcomes included all types of CPF. An epidemiology outcome was reported in 86 studies (covering all major geographic regions and age groups; Table 1), including 36 population-based studies and 20 primary epidemiology studies. CPF prevalence, reported in 84 studies, varied widely (Table 2). For adult studies (including those not reporting an age range; n=44) and paediatric-only studies (n=15), CPF prevalence (interquartile range) was in the range 1.5–81.0% (10.5–30.1%) and 5.5–47.3% (13.1–19.9%), respectively. Complex CPF prevalence (range) was reported in 18 studies and varied widely (3.4–54.6%); of these, four were primary epidemiology studies (3.4–29.3%). CPF incidence was reported in 15 studies: two studies reported incidence in person-years (PY) as 133.83 per 100 000 PY and 1100 per 100 000 PY. Of studies reporting cumulative CPF incidence at specific timepoints, incidence at 1 year after CD diagnosis was most frequently reported (n=8, range 3.5–50.1%; Table 3). Conclusion This SLR highlights a wide range in prevalences and incidences of CPF, potentially due to a lack of standardized definitions for CPF alongside a range of reported timepoints. Prevalences were up to 81.0% for CPF and 54.6% for complex CPF, and CPF incidences reached 1100 per 100 000 PY. This SLR demonstrates that understanding the burden of CPF in CD populations globally is challenging and consistent definitions are required to permit cross-study comparisons. Funding: Takeda Pharmaceuticals USA, Inc.

Ovarian Real-World International Consortium (ORWIC): A multicentre, real-world analysis of epithelial ovarian cancer treatment and outcomes.

Much drug development and published analysis for epithelial ovarian cancer (EOC) focuses on early-line treatment. Full sequences of treatment from diagnosis to death and the impact of later lines of therapy are rarely studied. We describe the establishment of an international network of cancer centers configured to compare real-world treatment pathways in UK, Portugal, Germany, South Korea, France and Romania (the Ovarian Real-World International Consortium; ORWIC). 3344 patients diagnosed with EOC (2012-2018) were analysed using a common data model and hub and spoke programming approach applied to existing electronic medical records. Consistent definition of line of therapy between sites and an efficient approach to analysis within the limitations of local information governance was achieved. Median age of participants was 53-67 years old and 5-29% were ECOG >1. Between 62% and 84% of patients were diagnosed with late-stage disease (FIGO III-IV). Sites treating younger and fitter patients had higher rates of debulking surgery for those diagnosed at late stage than sites with older, more frail patients. At least 21% of patients treated with systemic anti-cancer therapy (SACT) had recurrent disease following second-line therapy (2L); up to 11 lines of SACT treatment were recorded for some patients. Platinum-based SACT was consistently used across sites at 1L, but choices at 2L varied, with hormone therapies commonly used in the UK and Portugal. The use (and type) of maintenance therapy following 1L also varied. Beyond 2L, there was little consensus between sites on treatment choice: trial compounds and unspecified combinations of other agents were common. Specific treatment sequences are reported up to 4L and the establishment of this network facilitates future analysis of comparative outcomes per line of treatment with the aim of optimizing available options for patients with recurrent EOC. In particular, this real-world network can be used to assess the growing use of PARP inhibitors. The real-world optimization of advanced line treatment will be especially important for patients not usually eligible for involvement with clinical trials. The resources to enable this analysis to be implemented elsewhere are supplied and the network will seek to grow in coverage of further sites.

Approaches for Measuring Inclusive Demographics Across Youth Enjoy Science Cancer Research Training Programs.

The National Cancer Institute's (NCI) Youth Enjoy Science Program (YES) funds initiatives to support the cancer research training and career ambitions of middle school through undergraduate students from populations underrepresented in the biomedical sciences. The program has funded 16 institutions nationally as of January 2022. Given the program's focus on increasing diversity within the cancer research workforce, demographic characteristics of YES trainees provide essential information about the populations being served and program effectiveness. Six programs formed an interest group focused on trainee demographics and surveyed all YES grantees about their demographic data practices. Fifteen programs (94%) completed the survey. Survey data were analyzed through descriptive statistics and thematic coding. Findings revealed considerable variability in programs' approach to demographic data, including which demographics were measured, how they were operationalized, and when and how the data were collected. Half of YES programs (53%) could report underrepresented populations in biomedical research among trainees using consistent definitions. Most programs described efforts to improve their demographic data practices; however, challenges remained for the vast majority. In consideration of these findings, we offer recommendations for inclusive demographic data practices to better define and retain underrepresented populations in biomedical sciences.

Cultural safe healthcare initiatives, implementations, and recommendations, for Indigenous peoples of Canada: a systematic review

The health of Indigenous peoples across Canada continues to be significantly impacted by experiences of racism when seeking healthcare. Implementing cultural safety was identified by the Truth and Reconciliation Commission of Canada as a critical way to mitigate these negative health consequences. This systematic review aims to outline cultural safety and its associated derivatives in academia, what cultural safety is, and why it is important in the context of indigenous healthcare. A systematic search of PubMed was carried out refining searches to Canadian contexts, published after December of 2015, and limited to peer-reviewed reviews and systematic reviews. A thematic review of the articles identified four central ideas of importance regarding the information presented in the papers; definitions of cultural safety and associated derivatives, the importance of including culture in healthcare, recommendations to healthcare settings, and evaluation methods of cultural safety initiatives. It is clear that there is a need for an explicit and consistent definition of cultural safety with the inclusion of Indigenous peoples in the creation of this definition. To determine effectiveness, gaps and areas for improvement, evaluation methods inclusive of the unique Indigenous worldviews are imperative to develop culturally safe healthcare practices and institutions.

Cultural safe healthcare initiatives, implementations, and recommendations, for Indigenous peoples of Canada: a systematic review

The health of Indigenous peoples across Canada continues to be significantly impacted by experiences of racism when seeking healthcare. Implementing cultural safety was identified by the Truth and Reconciliation Commission of Canada as a critical way to mitigate these negative health consequences. This systematic review aims to outline cultural safety and its associated derivatives in academia, what cultural safety is, and why it is important in the context of indigenous healthcare. A systematic search of PubMed was carried out refining searches to Canadian contexts, published after December of 2015, and limited to peer-reviewed reviews and systematic reviews. A thematic review of the articles identified four central ideas of importance regarding the information presented in the papers; definitions of cultural safety and associated derivatives, the importance of including culture in healthcare, recommendations to healthcare settings, and evaluation methods of cultural safety initiatives. It is clear that there is a need for an explicit and consistent definition of cultural safety with the inclusion of Indigenous peoples in the creation of this definition. To determine effectiveness, gaps and areas for improvement, evaluation methods inclusive of the unique Indigenous worldviews are imperative to develop culturally safe healthcare practices and institutions.

Polatuzumab vedotin in previously untreated DLBCL: an Asia subpopulation analysis from the phase 3 POLARIX trial

AbstractIn the phase 3 POLARIX study in previously untreated diffuse large B-cell lymphoma, polatuzumab vedotin combined with rituximab plus cyclophosphamide, doxorubicin, and prednisone (Pola-R-CHP) significantly improved progression-free survival (PFS) compared with rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) with similar safety. Patients were randomized 1:1 to 6 cycles of Pola-R-CHP or R-CHOP plus 2 cycles of rituximab alone. For registration of POLARIX in China, consistency of PFS in an Asia subpopulation (defined as ≥50% of the risk reduction in PFS expected in the global population) was evaluated. Overall, 281 patients were analyzed: 160 patients from Asia in the intention-to-treat (ITT) population of the global study and 121 from an ITT China extension cohort. Of these, 141 were randomized to Pola-R-CHP and 140 to R-CHOP. At data cutoff (28 June 2021; median follow-up 24.2 months), PFS met the consistency definition with the global population, and was superior with Pola-R-CHP vs R-CHOP (hazard ratio, 0.64; 95% confidence interval [CI], 0.40-1.03). Two-year PFS was 74.2% (95% CI, 65.7-82.7) and 66.5% (95% CI, 57.3-75.6) with Pola-R-CHP and R-CHOP, respectively. Safety was comparable between Pola-R-CHP and R-CHOP, including rates of grade 3 to 4 adverse events (AEs; 72.9% vs 66.2%, respectively), serious AEs (32.9% vs 32.4%), grade 5 AEs (1.4% vs 0.7%), AEs leading to study treatment discontinuation (5.0% vs 7.2%), and any-grade peripheral neuropathy (44.3% vs 50.4%). These findings demonstrate consistent efficacy and safety of Pola-R-CHP vs R-CHOP in the Asia and global populations in POLARIX. This trial was registered at https://clinicaltrials.gov/ct2/home as # NCT03274492.

Longitudinal Assessment of Serum 25-Hydroxyvitamin D Levels during Pregnancy and Postpartum-Are the Current Recommendations for Supplementation Sufficient?

(1) Background: Pregnant women are at risk of vitamin D deficiency. Data on pregnancy outcomes in women with vitamin D deficiency during pregnancy are controversial, and prospective longitudinal data on vitamin D deficiency with consistent definitions in pregnant women are scarce. (2) Methods: The aim of this prospective longitudinal cohort study was to investigate 25-hydroxyvitamin D levels over the course of pregnancy and postpartum in singleton and twin pregnancies with regard to dietary and supplemental vitamin D intake and environmental factors influencing vitamin D levels, evaluated by a standardized food frequency questionnaire. (3) Results: We included 198 healthy singleton and 51 twin pregnancies for analysis. A total of 967 study visits were performed over a 3-year period. Overall, 59.5% of pregnant women were classified as vitamin D deficient in the first trimester, 54.8% in the second trimester, 58.5% in the third trimester, 66.9% at birth, and 60% 12 weeks postpartum, even though 66.4% of the study population reported daily pregnancy vitamin intake containing vitamin D. Dietary vitamin D intake did not affect vitamin D levels significantly. (4) Conclusions: The majority of pregnant women evaluated in this study were vitamin D deficient, despite administration of pregnancy vitamins containing vitamin D. Individualized vitamin D assessment during pregnancy should be considered to ensure adequate supplementation and prevention of hypovitaminosis D.