Department Of The Navy Research Articles

Energy Consumption Evaluation of U.S. Navy LEED-Certified Buildings

As of October 1, 2008, the Department of the Navy established the requirement that all new buildings constructed for the United States Navy (USN) and United States Marine Corps (USMC) obtain a Leadership in Energy and Environmental Design (LEED) Silver certification by the United States Green Building Council (USGBC). The goal of this requirement is to comply with Executive Order (EO) 13423, which mandates that all government departments reduce energy consumption by 30% by 2015. This research analyzes whether the 11 LEED-certified USN buildings have achieved the expected energy consumption savings. Energy data from LEED-certified buildings was compared with other USN and USMC non-certified buildings of comparable size, usage, and location. Statistical analysis shows that 9 of 11 LEED buildings did not achieve a 30% savings in electricity consumption, while seven of nine met the water consumption savings requirements set in place by EO 13423. Furthermore, this research concludes that the majority of the US...

Ink sick: Tattoo ink hypersensitivity vasculitis

This case describes a rare cause of vasculitis due to a hypersensitivity reaction to tattoo ink in a young man. This 21-year-old male sailor with no medical problems received a new tattoo on his right calf 2 weeks before presentation. He complained of a painful, pruritic rash on his legs for 1 week, most pronounced around the site of the tattoo. He also reported chills, arthralgias, and myalgias for the preceding 3 days. Despite treatment with loratadine and prednisone for presumed contact dermatitis by his primary care manager, the patient developed significant edema of his left hand and right ankle as well as rigors, prompting his presentation to the emergency department. The purpuric eruption was limited to his lower extremities (Figs. 1-3). His history and physical examination were unremarkable except where noted above. Although vasculitis is relatively common, tattoo ink hypersensitivity vasculitis is extremely rare. The most common complication of tattooing is cellulitis. Punch biopsy of this patient revealed leukocytoclastic vasculitis, which is consistent with previously published tattoo ink vasculidites [1,2]. The most common ink color precipitating cutaneous reactions to tattoos is red, as seen in this tattoo. Interestingly, the patient had previously received other less colorful tattoos without adverse effect. This presentation is similar to a case published by Hermida et al [3], which was the first of its kind. Our patient was admitted to the hospital and treated with systemic corticosteroids for 4 days. He was discharged with ☆ There was no financial support or grant for this paper. ☆☆ The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. ★ Government or non–copyright protected forum. I am a military service member. This work was prepared as part of my official duties. Title 17 USC 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 USC 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person's official duties.—MJH 0735-6757/$ – see front matter © 2011 Published by Elsevier Inc. prednisone and colchicine. Although his skin manifestations and arthralgias improved, he required crutches for ambulation 4 weeks after initial presentation. Fig. 2 Bilateral lower extremity purpuric lesions. Fig. 3 Close up of right ankle lesions. 1237.e4 Case Report Mary Josephine Hessert DO John Devlin MD Department of Emergency Medicine Naval Medical Center Portsmouth Portsmouth, VA USA E-mail address: maryjo.hessert@med.navy.mil doi:10.1016/j.ajem.2010.08.030

Comparison of Outcomes after Transplantation of G-CSF–Stimulated Bone Marrow Grafts versus Bone Marrow or Peripheral Blood Grafts from HLA-Matched Sibling Donors for Patients with Severe Aplastic Anemia

We compared outcomes of patients with severe aplastic anemia (SAA) who received granulocyte-colony stimulating factor (G-CSF)-stimulated bone marrow (G-BM) (n = 78), unstimulated bone marrow (BM) (n= 547), or peripheral blood progenitor cells (PBPC) (n = 134) from an HLA-matched sibling. Transplantations occurred in 1997 to 2003. Rates of neutrophil and platelet recovery were not different among the 3 treatment groups. Grade 2-4 acute graft-versus-host disease (aGVHD) (relative risk [RR] = 0.82, P = .539), grade 3-4 aGVHD (RR = 0.74, P = .535), and chronic GVHD (cGVHD) (RR = 1.56, P = .229) were similar after G-BM and BM transplants. Grade 2-4 aGVHD (RR = 2.37, P = .012) but not grade 3-4 aGVHD (RR = 1.66, P = .323) and cGVHD (RR = 5.09, P < .001) were higher after PBPC transplants compared to G-BM. Grade 2-4 (RR = 2.90, P < .001), grade 3-4 (RR = 2.24, P = .009) aGVHD and cGVHD (RR = 3.26, P < .001) were higher after PBPC transplants compared to BM. Mortality risks were lower after transplantation of BM compared to G-BM (RR = 0.63, P = .05). These data suggest no advantage to using G-BM and the observed higher rates of aGVHD and cGVHD in PBPC recipients warrants cautious use of this graft source for SAA. Taken together, BM is the preferred graft for HLA-matched sibling transplants for SAA.

Hemodynamically Significant Gastrointestinal Bleeding after Mucosal Biopsy During Upper Endoscopy in an Anticoagulated Patient

Purpose: The periprocedural management of anticoagulated patients undergoing endoscopy remains an area of controversy. According to the American Society of Gastrointestinal Endoscopy (ASGE) 2009 guideline on the management of antithrombotic agents for endoscopic procedures, upper endoscopy with or without mucosal biopsy is considered a low-risk procedure for bleeding even in the setting of therapeutic warfarin. Methods: We present the case of a 32 year-old Asian female receiving anticoagulation therapy for a newly diagnosed right ovarian vein thrombosis who underwent upper endoscopy for 1 week of severe epigastric pain, nausea with emesis and weight loss. The patient was initiated on a weight based therapeutic dose of enoxaparin (Lovenox®) at 50 mg subcutaneously twice daily for the right ovarian vein thrombosis. Results: Due to her unremitting symptoms despite acid blockage and antiemetic therapy, upper endoscopy was performed. The patient was found to have a diffuse gastric erythema prompting mucosal biopsy, but with no evidence of active or recent bleeding. The patient experienced large volume hematemesis approximately 12 hours post procedure with the development of a relative tachycardia with hypotension. Anticoagulation was discontinued and the patient was transferred to the intensive care unit. Her baseline hemoglobin of 12.6 g/dl decreased over a 33 hour period to a hemoglobin of 6.3 g/dl. She required fluid resuscitation and a total of 6 units of packed red blood cells which eventually resulted in a normalization of her vital signs and raised her Hgb to 10.4 g/dl. A repeat upper endoscopy performed 48 hours after the initial endoscopy revealed a loosely formed clot at the initial mucosal biopsy site prompting placement of a hemastatic clip. Conclusion: The risk of upper gastrointestinal hemorrhage due to endoscopy with mucosal biopsy versus the risk of thromboembolic events in an anticoagulated patient remains an area of controversy. The literature suggesting that mucosal biopsy during endoscopy in the setting of anticoagulation is low risk was done primarily with patients receiving therapeutic warfarin. This report suggests that enoxaparin may pose an increased risk of gastrointestinal bleeding in the setting of endoscopy with mucosal biopsy. The views expressed in this abstract are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.

HLA-C Antigen Mismatch Is Associated with Worse Outcome in Unrelated Donor Peripheral Blood Stem Cell Transplantation

The association between HLA matching and outcome in unrelated-donor peripheral blood stem cell (PBSC) transplantation has not yet been established. In the present study, a total of 1933 unrelated donor-recipient pairs who underwent PBSC transplantation between 1999 and 2006 for acute myelogenous leukemia, acute lymphoblastic leukemia, myelodysplastic syndrome, or chronic myelogenous leukemia and received high-resolution HLA typing for HLA-A, -B, -C, -DRB1, -DQA1, and -DQB1 were included in the analysis. Outcomes were compared between HLA-matched and HLA-mismatched pairs, adjusting for patient and transplant characteristics. Matching for HLA-A, -B, -C, and -DRB1 alleles (8/8 match) was associated with better survival at 1 year compared with 7/8 HLA-matched pairs (56% vs 47%). Using 8/8 HLA-matched patients as the baseline (n = 1243), HLA-C antigen mismatches (n = 189) were statistically significantly associated with lower leukemia-free survival (relative risk [RR], 1.36; 95% confidence interval [CI], 1.13-1.64; P = .0010), and increased risk for mortality (RR, 1.41; 95% CI, 1.16-1.70; P = .0005), treatment-related mortality (RR, 1.61; 95% CI, 1.25-2.08; P = .0002), and grade III-IV graft-versus-host disease (RR, 1.98; 95% CI, 1.50-2.62; P < .0001). HLA-B antigen or allele mismatching was associated with an increased risk for acute GVHD grade III-IV. No statistically significant differences in outcome were observed for HLA-C allele (n = 61), HLA-A antigen/allele (n = 136), HLA-DRB1 allele (n = 39), or HLA-DQ antigen/allele (n = 114) mismatches compared with 8/8 HLA-matched pairs. HLA mismatch was not associated with relapse or chronic GVHD. HLA-C antigen-mismatched unrelated PBSC donors were associated with worse outcomes compared with 8/8 HLA-matched donors. The study's limited power due to small sample size precludesconclusions about other mismatches.

Open architecture, inventory pooling and maintenance modules

The adoption of open architecture has several economic implications in the life of an asset, including developmental, production, storage, training and maintenance costs. This research responds to an inquiry by the Program Executive Officer—Integrated Weapons System (US Department of the Navy) regarding the value of open architecture (OA) in the design of complex assets. With this intent, we evaluate how the inventory allocation of spare engines for the F-16 operations in the continental United States would be affected with and without the adoption of open architecture, focusing on the benefits of inventory pooling to meet the demand of many users from a small number of storage sites. We use a distance-constrained version of the Ardalan heuristic for solving the facility location problem, responding to practical limitations exposed by the model. This article shows that open architecture may provide substantial supply chain cost reduction, and simplification of the distribution network when combined with proper inventory storage policies.

Screening for Alcohol Misuse and Alcohol-Related Behaviors Among Combat Veterans

Screening for Alcohol Misuse and Alcohol-Related Behaviors Among Combat Veterans

Allogeneic Hematopoietic Cell Transplant for Prolymphocytic Leukemia

The poor prognosis of patients with prolymphocytic leukemia (PLL) has led some clinicians to recommend allogeneic hematopoietic cell transplant (HCT). However, the data to support this approach is limited to case-reports and small case series. We reviewed the database of the Center for International Blood and Marrow Transplant Research (CIBMTR) to determine outcomes after allotransplant for patients with PLL. We identified 47 patients with a median age of 54 years (range: 30-75 years). With a median follow-up of 13 months, progression-free survival (PFS) was 33% (95% confidence interval [CI] 20%-47%) at 1 year. The most common cause of death was relapse or progression in 49%. The cumulative incidence of treatment-related mortality (TRM) at 1-year posttransplant was 28%. The small patient population prohibited prognostic factor analysis, but these data support consideration of allotransplant for PLL. Further study of a larger population of patients is needed to determine which patients are more likely to benefit.

Race and Outcomes of Autologous Hematopoietic Cell Transplantation for Multiple Myeloma

Blacks are twice as likely to develop and die from multiple myeloma (MM), and are less likely to receive an autologous hematopoietic-cell transplant (AHCT) for MM compared to Whites. The influence of race on outcomes of AHCT for MM is not well described. We compared the probability of overall survival (OS), progression-free survival (PFS), disease progression, and nonrelapse mortality (NRM) among Black (N=303) and White (N=1892) recipients of AHCT for MM, who were reported to the Center for International Blood and Marrow Transplant Research (CIBMTR) from 1995 to 2005. The Black cohort was more likely to be female, and had better Karnofsky performance scores, but lower hemoglobin and albumin levels at diagnosis. Black recipients were younger and more likely to be transplanted later in their disease course. Disease stage and treatment characteristics prior to AHCT were similar between the 2 groups. Black and White recipients had similar probabilities of 5-year OS (52% versus 47%, P=.19) and PFS (19% versus 21%, P=.64) as well as cumulative incidences of disease progression (72% versus 72%, P=.97) and NRM (9% versus 8%, P=.52). In multivariate analyses, race was not associated with any of these endpoints. Black recipients of AHCT for MM have similar outcomes compared to Whites, suggesting that the reasons underlying lower rates of AHCT in Blacks need to be studied further to ensure equal access to effective therapy.

Outbreak of Half disease in the Brazilian Amazon

Haff disease, first reported along the Baltic coast in 1924, is unexplained rhabdomyolysis in a person who ate fish in the 24 hours before onset of illness (1). Outbreaks resembling Haff disease were described in Sweden and the Soviet Union between 1934 and 1984 (2, 3). In the United States, only three reports have been published to date (4). Haff disease remains a rare clinical syndrome for which there is no physiologic explanation. Outbreaks of Haff disease have never been reported in Brazil. But in June 2008, a 39-year-old female medical doctor was admitted by the emergency service of a public hospital in Manaus, Amazonas State, Brazil, with diffuse myalgia and chest pain. The plasma creatine kinase (CK) activity levels were 6 252 units per liter (U/L) and no history of classic risk factors for rhabdomyolysis was detected. Her mother had been admitted 1 week before, presenting the same symptoms. Both women reported eating fish 24 hours before the onset of symptoms; further inquiry revealed that two residents from the same household who had not eaten fish did not become sick. The attending physician at the hospital was intrigued by the diagnosis of the two familial cases of Haff disease and began an epidemiologic investigation, looking for similar cases and potential risk factors. A case report form was designed and distributed along with a technical note to all hospitals in Manaus, instructions on how to report suspected cases, and suggestions for their management. The cases were defined as those who were hospitalized on or after 1 June 2008 with a diffuse myalgia of sudden onset who ate fish in the 24 hours before onset of illness and CK serum activity that exceeded five times the upper limit of normal. Patients with a classic risk factor for rhabdomyolysis were not included. The results of the investigation are reported here. Twenty-five cases of Haff disease were identified in Manaus between June and September 2008. All reported consumption of fried or roasted pacu—silver dollars (Mylossoma spp.), tambaqui—black-finned colossoma (Colossoma macropomum), or pirapitinga—freshwater pompano (Piaractus brachypomus), three river fishes of the region, within 24 hours before the onset of symptoms. All patients were older than 13 years of age (range 13–80 years); there were a similar number of males and females (59% and 41%, respectively). Three patients came from rural areas surrounding Manaus and nine patients were clustered in four families: the initial mother–daughter pair, a brother–sister pair, a husband–wife pair, and a family of three (husband, wife, and daughter). Five other members of these four families, who did not eat fish, did not fall ill. All patients were hospitalized (range 3–6 days) with myalgia of sudden onset, mostly localized at the beginning of symptoms and followed by generalized spreading within a few hours. Nineteen patients reported chest pain, among other symptoms (see Table 1). No fever or kidney damage was observed. TABLE 1 Symptoms of Haff disease cases, Amazon, Brazil, 2008 Predominant laboratory abnormalities were elevated CK serum activity (mean = 12 795 U/L, range 1 444–36 896 U/L). Serum activities of transaminases and lactate dehydrogenase were also elevated. In two patients, myoglobin was measured and found to be higher than 700 U/L. Serology for leptospirosis and hepatitis A and B was negative. Patients were treated with intravenous fluid hydration and bicarbonate infusion. No deaths were observed. In only 4 months, 27 cases of Haff disease were reported in Manaus and surrounding municipalities of the Brazilian Amazon. The diagnosis of Haff disease was made based on the fact that none of the cases could be explained by classic causes of rhabdomyolysis; all patients reported consumption of fish within 24 hours before the onset of symptoms; some cases occurred in family clusters and no cases were observed after the beginning of the period of prohibition of fishing in the region that occurs every year from October to March. This possible association between fish eating and rhabdomyolysis in the Amazon region may have an important impact, as fish is a major source of protein in the Brazilian Amazon (5). Active surveillance of this supposedly uncommon condition is necessary to corroborate its frequency in the region and enhance our understanding of this elusive disease. This paper is part of the doctoral thesis of Marcelo Cordeiro dos Santos of Amazonas State University, Amazonas State Tropical Medicine Foundation. The views expressed here are those of the authors and do not necessarily reflect the official policy or position of the Brazilian Government, the U.S. Government, Department of the Navy, or Department of Defense.

Discarded Military Munitions Case Study: Ordnance Reef (HI-06), Hawaii

AbstractIn 2006, the U.S. Department of the Army and Department of the Navy funded a survey of Site HI-06, locally known as Ordnance Reef, Oahu, Hawaii, an area of shallow fringing nearshore reef that was used as a disposal area for discarded military munitions following World War II. This study determined site boundaries; the quantity, type, and locations of munitions present, collected and analyzed sediment and fish samples; and generated a screening-level survey of the data suggesting that contamination from munitions did not pose a threat to human health. Subsequent review of the 2006 study by community members as well as state and Federal resource agencies identified several data gaps requiring further investigation. The U.S. Army Corps of Engineers Pacific Ocean Division identified remaining study questions and engaged local experts to design and conduct the follow-on investigation. The University of Hawaii, with assistance from Environet Inc., is conducting a remedial investigation and risk assessment of Ordnance Reef. The National Oceanic and Atmospheric Administration is also contributing to the ongoing research effort by deploying sensors that will monitor ocean currents in the area. Data from the sensors will be used to model current patterns and pollutant transport mechanisms to determine potential migration paths should contaminant releases occur from the munitions.

To Protect and Serve

To Protect and Serve

The SAFE CARE model

Ferguson, Cynthia CNM, MSN, FNE-A, SANE-A, D-ABMDI1; Faugno, Diana MSN, RN, CPN, SANE-A, SANE-P, FAAFS2 Author Information

The Long Goodbye

The Long Goodbye

Alveolar Rhabdomyosarcoma of the Paranasal Sinuses

Disclaimer The opinions and assertions expressed herein are those of the author and are not to be construed as official or representing the views of the Department of the Navy or the Department of Defense.

Improving Afghanistan Pharmacy Practices and Services

The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, the Department of Defense, nor the US Government. I am a military service member. This work was prepared as part of my official duties. Title 17, USC, 105 provides that “copyright protection under this title is not available for any work of the United States Government.” Title 17, USC, 101 defines a US Government as part of that person's official duties.

Assessment and Management of Hospitalized Suicidal Patients

Suicide in inpatient psychiatric settings is a critical problem. A comprehensive literature review was performed to determine risk factors for inpatient suicide, instruments for assessing suicide, and treatment of hospitalized suicidal patients. Findings suggested that root causes of inpatient suicide were factors related to the treatment environment, failure to assess patient behavioral characteristics, and staff reliance on no-suicide contracts. Recommendations include assessing suicide risk regularly throughout hospitalization, including on admission, during changes in a patient's mental or physical status, after a change in observation level, and before discharge. Orientation and inservice education for all staff and additional research on the psychometric properties of available suicide assessment instruments are also essential.

Safety of Surgeon-Directed Conscious Sedation in Nasal Surgery

Safety of Surgeon-Directed Conscious Sedation in Nasal Surgery

The Impact of Nurse Case Management Home Visitation on Birth Outcomes in African-American Women

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Uniformed Services University of the Health Sciences, Department of the Navy, Department of Defense or the U. S. government. Dr. Wells is a military service member (employee of the U.S. government). This work was prepared as a part of her official duties. Title 17, USC Section 101 defines a U.S. government work as a work prepared by a military service member or employee of the U.S. government as part of the person's official duties. Despite substantial reductions in U.S. infant mortality rates, racial disparities persist, with black Americans experiencing 2.4 times the rate of their white counterparts. Low birthweight and preterm delivery contribute to this disparity. To examine the association between antepartum nurse case management home visitation and the occurrence of low birthweight and preterm deliveries in African-American women in Montgomery County, MD, a retrospective cohort study was conducted using existing data from 109 mothers who were enrolled in the Black Babies Start More Infants Living Equally Healthy (SMILE) program. Logistic regression analysis was used. Women who received antepartum home visits were 0.37 (CI 0.15-0.94) times less likely to experience preterm delivery than women who did not receive antepartum home visits. The effect of antepartum home visits on preterm delivery was independent of level of prenatal care, negative life events and number of prior live births. There was no significant association between antepartum home visits and low birthweight. Antepartum home visits appeared to be protective against preterm delivery and could contribute to reducing racial disparities in infant mortality. Further study is needed to understand and replicate specific program components that may contribute to improved birth outcomes in African-American women.

Choosing The &lt;cite&gt;Bright Futures Guidelines&lt;/cite&gt;: Lessons from Leaders and Early Adopters

&lt;P&gt;The &lt;cite&gt;Bright Futures Guidelines for the Health Supervision of Infants, Children and Adolescents&lt;/cite&gt;, third Edition was developed under a cooperative agreement between the Maternal and Child Health Bureau of the U.S. Department of Health and Human Services and the American Academy of Pediatrics (AAP). More than 50 experts and more than 1,000 reviewers — pediatricians and family physicians, nurse practitioners, mental health colleagues, pediatric dentists, nutritionists, and families — worked collaboratively to assure completeness and accuracy. When published in 2008, it became the uniform guideline for the health supervision care for U.S. youth.&lt;/P&gt;&lt;H4&gt;ABOUT THE AUTHORS&lt;/H4&gt;&lt;P&gt;Gregory S. Blaschke, MD, MPH, FAAP, is Associate Professor of Pediatrics at Uniformed Services University, Bethesda, MD; practices at Naval Medical Center, San Diego, CA; and is a Captain in the Medical Corps of the United States Navy. Joseph O. Lopreiato, MD, MPH, FAAP, is Associate Professor of Pediatrics at Uniformed Services University, Bethesda, MD; practices at Naval Medical Center, San Diego, CA; and is a Captain in the Medical Corps of the United States Navy. Bruce Bedingfield, DO, FAAP, FACOP, is a private practitioner in Hoffman Estates, IL. Francis C. Rash, MD, FAAP, is Clinical Professor of Pediatrics at Uniformed Services University, Bethesda, MD; practices at Naval Medical Center, San Diego; and is a Captain (retired) in the Medical Corps of the United States Navy. Ann E. Burke, MD, FAAP, is Program Director of Pediatrics and practices inpatient and outpatient general pediatrics at Dayton Children’s Hospital, Wright State University, Dayton, OH. Rick Goldstein, MD, FAAP, is Assistant Professor of Pediatrics at Boston University School of Medicine; Associate Program Director of the Boston Combined Residency Program; and practices in a group practice in Cambridge, MA, and Boston Medical Center. Timothy R. Shope, MD, MPH, FAAP, is Associate Professor of Pediatrics at Uniformed Services University, Bethesda, MD; practices at Naval Medical Center, Portsmouth, VA; and is a Captain in the Medical Corps of the United States Navy. Christine Johnson, MD, FAAP, is Assistant Professor of Pediatrics at Uniformed Services University, Bethesda, MD; practices at Naval Medical Center, San Diego, CA; and is a Commander in the Medical Corps of the United States Navy. Frances E. Biagioli is an Associate Professor of Family Medicine at Oregon Health &amp; Science University; sees patients and serves as the Medical Director at the OHSU Gabriel Park Family Health Center and is the Family Medicine Associate Residency Director. Nathaniel S. Beers, MD, MPA, FAAP, is Assistant Professor of Pediatrics at George Washington University, Washington, DC, and practices at Children’s National Medical Center. Joseph F. Hagan, Jr., MD, FAAP, is Clinical Professor of Pediatrics at University of Vermont College of Medicine, Burlington, VT; co-editor of &lt;cite&gt;Bright Futures&lt;/cite&gt;, third edition; and primary care pediatrician in Burlington, VT.&lt;/P&gt;&lt;P&gt;The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.&lt;/P&gt;&lt;P&gt;The Bright Futures Text is published by the American Academy of Pediatrics. Since its inception in 1990, the ongoing development of this guideline has been funded by the U.S. Department of Health and Human Services, the Health Resources and Services Administration, the Maternal Child Health Bureau. Editors, authors, contributors and reviewers of Bright Futures, third edition do not benefit from the sale or dissemination of the guidelines. Most invited authors have had varying involvement in formulating, leading, informing, writing, reviewing, researching, disseminating and/or implementing Bright Futures; none has any financial benefit to this specific guideline’s incorporation into health supervision practice. &lt;/P&gt;&lt;P&gt;Address correspondence to: Gregory S. Blaschke, MD, MPH, FAAP, Captain, Medical Corps, United States Navy, Naval Medical Center, Pediatrics, San Diego, CA, 92134-2100; fax 619-532-9902; e-mail &lt;a href="mailto:Gregory.Blaschke@med.navy.mil"&gt;Gregory.Blaschke@med.navy.mil&lt;/a&gt;.&lt;/P&gt;&lt;P&gt;Dr. Blaschke, Dr. Lopreiato, Dr. Bedingfield, Dr. Rash, Dr. Burke, Dr. Goldstein, Dr. Shope, Dr. Johnson, Dr. Biagioli, Dr. Beers, and Dr. Hagan have disclosed no relevant financial relationships. &lt;/P&gt;