No conclusion could be reached about a possible effect of vitamin D and calcium dose man health cure order rogaine 2 on line amex. The effect of supplementation on postmenopausal women not on an energy restricted diet was of questionable clinical significance after 7 years prostate 73 60 ml rogaine 2 amex. The effect of supplementation for 15 weeks on overweight and obese premenopausal women (in an approximate age range of 32 to prostate 48 buy rogaine 2 60 ml with visa 54 years) on an energy restricted diet was relatively large (4 vs prostate oncology specialists marina buy discount rogaine 2 60 ml online. Placebo (various) (range), y group  Male (%) 0 Major 2007202 Overweight, Ca 704 mg/d Vit D + Ca nd Energy Health Quebec City, status healthy, pre carbonate vs. C om bined vitam inDand calcium and weigh t:R esults ofR C Ts A ge A uth orY ear Range, M ean Interventions, N o. No qualified systematic reviews evaluated the association between combined vitamin D and calcium, body stores, or serum concentrations, and total cancer incidence or mortality. Compared to the placebo group, the relative risk of developing cancer at the end of study was 0. On the hypothesis that cancers diagnosed early in the study would have been present, although unrecognized at entry, the analyses were restricted to women who were free of cancer at 1 year intervention. The relative risk of developing cancer at the end of study for the vitamin D3 plus calcium group changed to 0. No qualified systematic reviews evaluated the association between combined vitamin D and calcium, body stores, or serum concentrations, and colorectal cancer mortality or incidence. At 7 years vitamin D3 and calcium supplementation had no significant effect on colorectal cancer mortality (P=0. In a subgroup analysis, risks of colon cancer and rectal cancer were also not significantly different between the supplemented and unsupplemented groups (P=0. The study found no association between vitamin D and calcium intake and colorectal cancer mortality or incidence. No qualified systematic reviews evaluated the association between combined vitamin D and calcium, body stores, or serum concentrations, and incidence of intestinal adenoma. At 7 years, the incidence of adenoma was not significantly different between the supplement and placebo groups (p=0. All the adenoma cases were based on self reported data, not verified by medical record review or histopathology report. No subgroup data were available regarding sex, separate life stages, or other special populations. No statistically significant effect was found with combined vitamin D and calcium supplementation on incident breast cancer outcome. There were no significant effects of combined vitamin D and calcium supplementation on both outcomes. The authors concluded that invasive breast cancer incidence was similar in the two groups of healthy postmenopausal women: calcium and vitamin D supplementation and placebo groups. Findings per intake level No conclusions are possible regarding a dose effect from this single study, especially since the women in the intervention and placebo groups were allowed to take additional concurrent calcium and vitamin D supplements. Findings by age and sex the study investigated postmenopausal women 50 to 79 years old. We did not identify any eligible studies on the relationship of vitamin D with or without calcium and high blood pressure, preterm birth, or small for gestational age infant. The median dairy intake was <1 serving/day, which provided less than 300 mg of calcium. The combined supplementation significantly reduced the risk of stress fractures by 20 percent compared to placebo. However, women who had received vitamin D plus calcium supplementation showed less declines in walking time than those who had received placebo. Subgroup analyses showed a significant reduction in the risk of falls when only trials of postmenopausal women were combined. Most trials combined vitamin D and calcium supplementation; when used, calcium doses ranged between 500 and 1200 mg per day. Although the metaanalyses suggest decreased risk for allcause mortality with combined vitamin D and calcium supplementation, the relationship is not statistically significant in the performed analyses. As mentioned in the Methods section, we updated and reanalyzed published meta analyses of mortality outcomes. We also comment on the concordance of our conclusions with those of the published metaanalyses. As described in the vitamin D and allcause mortality section, we identified two 83, 84 potentially eligible systematic reviews, and selected one as the basis for our 83 reanalysis (Autier 2007). Table 37 in the “Vitamin D” section summarizes the findings of the Autier 2007 systematic review. As detailed below, we identified one additional trial of combined vitamin D and 209 calcium supplementation reporting allcause mortality. One publication 210 reported on the same trial as another publication in the Autier 2007 metaanalysis, and 209 was therefore excluded from our reanalysis. It included people older than 65 years, with chronically impaired mobility and stable general condition. We excluded 5 of 18 trials in the Autier 2007 metaanalysis: One trial was on patients 85 86 with congestive heart failure, one was published only in abstract form, and in the last trial the controls also received supplementation with vitamin D, albeit with a smaller 87 88, 89 dose, and two used injections of vitamin D. Among the 12 trials, sample sizes ranged from 55 to 36, 282 participants, with 7 studies including more than 500 participants. There is little evidence for betweenstudy heterogeneity in 2 these analyses (P=0. It is unclear whether these findings are directly applicable to other life stages. We reviewed systematic reviews and primary studies that evaluated associations between combined vitamin D and calcium intake and incidence of hypertension or change in blood pressure. Studies of pregnancyrelated hypertension and blood pressure control are included in the “Pregnancyrelated outcomes” section. No qualified systematic reviews evaluated the association between combined vitamin D and calcium intake, body stores, or serum concentrations and incidence of hypertension. Over 7 years, combined vitamin D and calcium supplementation had no effect on the risk of hypertension. The women were allowed to take additional concurrent calcium and vitamin D supplements. The analysis of incident hypertension was reported briefly in a larger analysis of the blood pressure outcome (see Combined vitamin D and calcium and blood pressure, below). Among 17, 122 initially nonhypertensive women, 39 percent either were prescribed medication for hypertension or developed blood pressure above 140/90 mm Hg. Other subgroup analyses based on age, race or ethnicity, weight, or baseline total calcium intake did not find any interactions with the effect of the supplement intervention. This trial found no difference in (lack of) effect by age among postmenopausal women. No qualified systematic reviews evaluated the association between vitamin D and calcium intake, body stores, or serum concentrations, and changes in blood pressure. The 36, 282 women were postmenopausal (age 5079 y) with a background calcium intake on average of 211 about 1150 mg/day (from diet and supplements). On average, the women had normal blood pressure and were allowed to take additional concurrent calcium and vitamin D supplements. At 74 months, the women’s mean systolic blood pressure had risen and diastolic blood pressure had 199 fallen in both trial arms (by less than about 2 mm Hg each at 2 years). The absolute changes were not significantly different in the women assigned to the supplement than placebo (net difference 0. In subgroup analyses there was no differences in results by age, ethnicity, baseline total calcium intake, baseline diagnosis of hypertension, or a variety of other factors. The C quality trial of combined vitamin D and calcium, performed in Quebec City, recruited premenopausal women (mean age 43 y) with low calcium intake (800 mg calcium per day) who 202 did not have severe hypertension (blood pressure over 160/95 mm Hg). At 15 weeks, systolic and diastolic blood pressures were reduced in both study groups; systolic blood pressure was reduced by 2. The study was limited by a 25 percent dropout rate due to lack of compliance with the diet and exercise portion of the trial, without performing an intention to treat analysis, an adequate description of the study methods, or a complete statistical analysis. C om bined vitam inDand calcium and blood pressure:R esults ofR C Ts A uth orY ear A ge M ean Interventions, N o. The methodological quality of this study was rated C, due to underpower and low compliance rate. The evidence for this question comes from studies identified in our literature search that crossed vitamin D terms with various outcomes terms.
Cultural differences are noted with AsianAmerican girls prostate zero order cheap rogaine 2 on-line, on average man health hq buy rogaine 2 online from canada, developing last prostate medication purchase rogaine 2 on line, while African American girls enter puberty the earliest prostate 89 buy 60 ml rogaine 2 mastercard. Hispanic girls start puberty the second earliest, while EuropeanAmerican girls rank third in their age of starting puberty. Although African American girls are typically the first to develop, they are less likely to experience negative consequences of early puberty when compared to EuropeanAmerican girls (Weir, 2016). Research has demonstrated mental health problems linked to children who begin puberty earlier than their peers. For girls, early puberty is associated with depression, substance use, eating disorders, disruptive behavior disorders, and early sexual behavior (Graber, 2013). Early maturing girls demonstrate more anxiety and less confidence in their relationships with family and friends, and they compare themselves more negatively to their peers (Weir, 2016). Problems with early puberty seem to be due to the mismatch between the child’s appearance and the way she acts and thinks. Adults especially may assume the child is more capable than she actually is, and parents might grant more freedom than the child’s age would indicate. For girls, the emphasis on physical attractiveness and sexuality is emphasized at puberty and they may lack effective coping strategies to deal with the attention they may receive. Because the preadolescent time is one of not wanting to appear different, early developing children stand out among their peer group and gravitate toward those who are older. For girls, this results in them interacting with older peers who engage in risky behaviors such as substance use and early sexual behavior (Weir, 2016). According to Mendle, Harden, BrooksGunn, and Graber (2010), while most boys experienced a decrease in depressive symptoms during puberty, boys who began puberty earlier and exhibited a rapid Source tempo, or a fast rate of change, actually increased in depressive symptoms. The effects of pubertal tempo were stronger than those of pubertal timing, suggesting that rapid pubertal change in boys may be a more important risk factor than the timing of development. In a further study to better analyze the reasons for this change, Mendle, Harden, BrooksGunn and Graber (2012) found that both early maturing boys and rapidly maturing boys displayed decrements in the quality of their peer relationships as they moved into early adolescence, whereas boys with more typical timing and tempo development actually experienced improvements in peer relationships. The researchers concluded that the transition in peer relationships may be especially challenging for boys whose pubertal maturation differs significantly from those of others their age. Consequences for boys attaining early puberty were increased odds of cigarette, alcohol, or another drug use (Dudovitz, et al. Some girls who excelled at math or science in elementary school, may curb their enthusiasm and displays of success at these subjects for fear of limiting their popularity or attractiveness as girls (Taylor, Gilligan, & Sullivan, 1995; Sadker, 2004). Some boys who were not especially interested in sports previously may begin dedicating themselves to athletics to affirm their masculinity in the eyes of others. Some boys and girls who once worked together Source successfully on class projects may no longer feel comfortable doing so, or alternatively may now seek to be working partners, but for social rather than academic reasons. Such changes do not affect all youngsters equally, nor affect any one youngster equally on all occasions. An individual may act like a young adult on one day, but more like a child the next. Although it does not get larger, it matures by becoming more interconnected and specialized (Giedd, 2015). This results in an increase in the white matter of the brain and allows the adolescent to make significant improvements in their thinking and processing skills. For example, the brain’s language areas undergo myelination during the first 13 years. Completed insulation of the axons consolidates these language skills but makes it more difficult to learn a second language. With greater myelination, however, comes diminished plasticity as a myelin coating inhibits the growth of new connections (Dobbs, 2012). Even as the connections between neurons are strengthened, synaptic pruning occurs more than during childhood as the brain adapts to changes in the environment. This synaptic pruning causes the gray matter of the brain, or the cortex, to become thinner but more efficient (Dobbs, 2012). The corpus callosum, which connects the two hemispheres, continues to thicken allowing for stronger connections between brain areas. Additionally, the hippocampus becomes more strongly connected to the frontal lobes, allowing for greater integration of memory and experiences into our decision making. The limbic system is also related to novelty seeking and a shift toward interacting with peers. In contrast, the prefrontal cortex which is involved in the control of impulses, organization, planning, and making good decisions, does not fully develop until the mid20s. According to Giedd (2015) the significant aspect of the later developing prefrontal cortex and early development of the limbic system is the “mismatch” in timing between the two. The Source approximately ten years that separates the development of these two brain areas can result in risky behavior, poor decision making, and weak emotional control for the adolescent. Teens often take more risks than adults and according to research it is because they weigh risks and rewards differently than adults do (Dobbs, 2012). For adolescents the brain’s sensitivity to the neurotransmitter dopamine peaks, and dopamine is involved in reward circuits, so the possible rewards outweighs the risks. Adolescents respond especially strongly to social rewards during activities, and they prefer the company of others their same age. For example, adolescent drivers make risky driving decisions when with friends to impress them, and teens are much more likely to commit crimes together in comparison to adults (30 and older) who commit them alone (Steinberg et al. In addition to dopamine, the adolescent brain is affected by oxytocin which facilitates bonding and makes social connections more rewarding. With both dopamine and oxytocin engaged, it is no wonder that adolescents seek peers and excitement in their lives that could end up actually harming them. In fact, 50% of the mental illness occurs by the age 14 and 75% occurs by age 24 (Giedd, 2015). Additionally, during this period of development the adolescent brain is especially vulnerable to damage from drug exposure. For example, repeated exposure to marijuana can affect cellular activity in the endocannabinoid system. Consequently, adolescents are more sensitive to the effects of repeated marijuana exposure (Weir, 2015). However, researchers have also focused on the highly adaptive qualities of the adolescent brain which allow the adolescent to move away from the family towards the outside world (Dobbs, 2012; Giedd, 2015). Novelty seeking and risk taking can generate positive outcomes including meeting new people and seeking out new situations. Separating from the family and moving into new relationships and different experiences are actually quite adaptive for society. The most recent Sleep in America poll in 2006 indicated that adolescents between sixth and twelfth grade were not getting the recommended amount of sleep. On average adolescents only received 7 fi hours of sleep per night on school nights with younger adolescents getting more than older ones (8. For the older adolescents, only about one in ten (9%) get an optimal amount of sleep, and they are more likely to experience negative consequences the following day. Additionally, they are at risk for substance abuse, car crashes, poor academic performance, obesity, and a weakened immune system (Weintraub, 2016). Reasons given for this include that those adolescents who stay out late, typically without parental supervision, are more likely to engage in a variety of risky behaviors, including risky sex, such as not using birth control or using substances before/during sex. An alternative explanation for risky sexual behavior is that the lack of sleep negatively affects impulsivity and decisionmaking processes. As adolescent go through puberty, their circadian rhythms change and push back their sleep time until later in the evening (Weintraub, 2016). This biological change not only keeps adolescents awake at night, it makes it difficult for them to wake up. Impairments are noted in attention, academic achievement, Source and behavior while increases in tardiness and absenteeism are also seen. Psychologists and other professionals have been advocating for later school times, and they have produced research demonstrating better student outcomes for later start times. More middle and high schools have changed their start times to better reflect the sleep research.
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The general principles of (pregnancy contraindicated) this classification are depicted in Table 6 mens health 4 week workout buy rogaine 2 60 ml fast delivery. A practical application Pulmonary arterial hypertension of any cause is given in Table 7 prostate cancer karyotype purchase generic rogaine 2. Neonatal complications occur in 20–28% of patients with heart Native severe coarctation 12 prostate ejaculaton purchase discount rogaine 2 line, 56 prostate cancer 8 out of 10 purchase rogaine 2 mastercard, 57, 75, 76 disease with a neonatal mortality between 1% and 12, 56, 57 57 73 4%. The risk may be lower with the mini women with heart disease mally invasive hysteroscopic techniques such as the Essure device. Three months after placement, correct device placement and bilateral tubal occlusion are confirmed 3. Multiple gestation12, 57 include the ability to perform the procedure in an outpatient 12 setting and without an incision. Use of oral anticoagulants during pregnancy 80 waiting period until tubal occlusion is confirmed. Mechanical valve prosthesis57 for the male partner is another efficacious option, but the long term prognosis of the female partner must be taken into Modified from Siu et al. The first trime Contraceptive methods include combined hormonal contracep ster is the safest time for elective pregnancy termination, which tives (oestrogen/progestin), progestogenonly methods, intrauter should be performed in hospital, rather than in an outpatient facil ine devices, and emergency contraception. Gynaecologists routinely medroxyprogesterone acetate are inappropriate for patients with advise antibiotic prophylaxis to prevent postabortal endometritis, heart failure because of the tendency for fiuid retention. It should be borne in mind that 5% of patients Up to 7 weeks gestation, mifepristone is an alternative to experience vasovagal reactions at the time of implant; therefore, for surgery. When prostaglandin E compounds are given, systemic those with highly complex heart disease. Antibiotic prophylaxis is not recommended at the time of Saline abortion should be avoided because saline absorption can insertion or removal since the riskof pelvic infection is not increased. Tubal ligation is usually accomplished safely, even in relatively high Thromboembolism may complicate in vitro fertilization when high 86 risk women. Because of the associated anaesthesia and abdominal oestradiol levels may precipitate a prothrombotic state. Congenital heart disease and pulmonary hypertension Table 9 General recommendations In many women with congenital heart disease, pregnancy is well tolerated. The risk of pregnancy depends on the underlying Recommendations Classa Levelb heart disease as well as on additional factors such as ventricular Prepregnancy risk assessment and counselling and valvular function, functional class, and cyanosis. The miscar is indicated in all women with known or riage rate is higher in more complex disease ure 1). High risk patients should be treated in I C Offspring complications, including offspring mortality (4%), are specialized centres by a multidisciplinary team. Diagnosis Echocardiography should be performed in any pregnant patient with unexplained or new I C Usually, congenital heart diseases will be known and diagnosed cardiovascular signs or symptoms. Prepregnancy assessment including medical Before cardiac surgery a full course of history, echocardiography, and exercise testing is indicated in all corticosteroids should be administered to the I C patients, with other diagnostic tests indicated on an individual mother whenever possible. Functional status before pregnancy and history of For the prevention of infective endocarditis in pregnancy the same measures as in non I C previous cardiac events are of particular prognostic value (see pregnant patients should be used. Diagnostic procedures that can be used during pregnancy are When gestational age is at least 28 weeks, 21 outlined in Section 2. This occurs even in patients with little or no dis hypoxia, and acidosis which may precipitate refractory heart ability before or during pregnancy. Supplemental oxygen therapy should be given if there is are: late hospitalization, severity of pulmonary hypertension, and 87 hypoxaemia. The risk probably increases with more elev occasionally used antenatally and peripartum to improve haemody ated pulmonary pressures. In patients where the indication for anticoagulation basis of all available diagnostic modalities in a specialized centre. In portal hypertension, anticoagulation is not recommended in view of the risks of anaesthesia this should be performed in a patients with increased risk of bleeding. It oxygen saturation is, 85%, a substantial maternal and fetal mor should be recognized that potentially significant drug interactions tality risk is expected and pregnancy is contraindicated. Planned the degree of maternal hypoxaemia is the most important predic caesarean delivery and vaginal delivery are favoured over emer tor of fetal outcome. If, however, maternal oxygen saturation is, 85%, the chance of a live birth is 91 3. Maternal risk Eisenmenger patients need special consideration because of the Management association of pulmonary hypertension with cyanosis due to the Followup. Systemic vasodilatation increases the plemental oxygen (monitoring oxygen saturation) are rec righttoleft shunt and decreases pulmonary fiow, leading to ommended. Because of the increased risk of paradoxical increased cyanosis and eventually to a low output state. The litera embolism, prevention of venous stasis (use of compression stock ings and avoiding the supine position) is important. For prolonged ture reports a high maternal mortality of 20–50%, occurring most 91 bed rest, prophylactic heparin administration should be con often in the peri or postpartum period. Thromboembolism is a major risk for Obstetric and offspring risk cyanotic patients, therefore patients should be considered for pro Cyanosis poses a significant risk to the fetus, with a live birth unli phylaxis after haematology review and investigations for blood kely (, 12%) if oxygen saturation is, 85%. When pregnancy occurs, the risks should be discussed cated and managed in the same way as in patients with Eisenmen and a termination of pregnancy offered; however, termination ger syndrome. If the patient wishes to continue with preg nancy, care should be based in a specialist unit. Thromboembolism is a major risk for cyanotic patients, fetal condition deteriorates, an early caesarean delivery should be therefore patients should be considered for prophylaxis after hae planned. In view of the risks of anaesthesia this should be per matology review and investigations for blood haemostasis. Antic formed in a tertiary centre experienced in the management of oagulation must be used with caution, as patients with these patients. In others, timely hospital admission, planned elec Eisenmenger syndrome are also prone to haemoptysis and throm tive delivery, and incremental regional anaesthesia may improve maternal outcome. The risks and benefits of anticoagulation must there fore be carefully considered on an individual patient basis. It may be valvular, supravalvular, or caused by oxygen saturation measurement and full blood count are indicated. The manage ment of supravalvular and subvalvular stenosis is only described in Delivery. If the maternal or fetal condition deteriorates, an early case reports during pregnancy and is probably similar to the man caesarean delivery should be planned. In view of the risks of anaes thesia this should be performed in a tertiary centre experienced in agement of patients with valvular stenosis, although balloon valvu 92 the management of these patients. Although patients need pregnancy evaluation of the presence of a (residual) defect, to be informed about the (often small) additional risk, pregnancy cardiac dimensions, and an estimation of pulmonary pressures is should not be discouraged. The Obstetric and offspring risk followup plan should be individualized taking into account the Preeclampsia may occur more often than in the normal complexity of the heart disease and clinical status of the patient. The risk of heart failure is low and only exists in women with severe regur gitation or impaired ventricular function. Offspring mortality has been reported in 6%, primarily due to the occurrence of complex con 99 genital heart disease. For a secun Management dum defect, catheter device closure can be performed during preg Followup. Followup during pregnancy is advisable at least once nancy, but is only indicated when the condition of the mother is each trimester. Clinical and echocardiographic followup is indi deteriorating (with transoesophageal or intracardiac echocardio cated monthly or bimonthly in patients with moderate or severe graphic guidance). For rec Because of the increased risk of paradoxical embolism, in ommended preventive measures for thromboembolism, see women with a residual shunt, prevention of venous stasis (use of Section 3. Pregnancy is often well tolerated in women after repair of coarcta Spontaneous vaginal delivery is in most cases appropriate. Other risk factors for this complication include aortic dilatation and bicuspid aortic valve, and they 3. The Obstetric and offspring risk rate of progression of stenosis in these young patients is lower 107 An excess of hypertensive disorders and miscarriages has been than in older patients. Hypertension should be treated, undergo imaging of the ascending aorta before pregnancy, and although aggressive treatment in women with residual coarctation surgery should be considered when the aortic diameter is must be avoided to prevent placental hypoperfusion. The use of covered stents may lower the risk In unrepaired patients, surgical repair is indicated before preg of dissection.
Vitam inDand cardiovascularoutcom es:R esults ofcoh ortstudies F ollowup A uth orY ear A ge O utcome Duration VitD Concentration prostate cancer 3 monthly injection order rogaine 2 with a mastercard, N o prostate cancer 9 value best buy rogaine 2. C Inasubgroupanalysisofparticipantsonnoch olesterolloweringdrugsatbaseline prostate and masurbation buy cheap rogaine 2 60 ml, comparingth e h igh estserum 25(O H)Dconcentrationcategory(>75 nmol/L)toth e lowest(fi37 prostate number range purchase 60 ml rogaine 2 fast delivery. Cardiovascular outcomes risk stratified by vitamin D concentration 56 Vitamin D and Body Weight We searched for systematic reviews and primary studies that evaluated associations between vitamin D intake or body stores and incidence of overweight or obesity; no such studies were found. The study participants also varied: they were postmenopausal women, obese men and women, or only obese men. In the Finnish and Norwegian studies, the participants on average, gained weight in all groups over 1 or 3 years; in the Indian study weight remained mostly stable over 6 weeks. All studies found no difference in weight change with or without vitamin D supplementation. Two of the study arms included hormone replacement treatment and are not further discussed here. Women on cholesterollowering medication at any point during the trial were excluded. After 3 years, women, on average, gained weight in both study arms (about 12 kg). The study had a methodological quality of C due to an uneven distribution of body weights between study arms at baseline (means 71. The second trial was conducted in Norway among healthy overweight and obese women and 50 men. Compared to the placebo group, those taking the larger dose of vitamin D had less weight gain than those taking the smaller dose, but none of the differences among study groups were statistically significant. The study was rated methodological quality B, primarily due to the high dropout rate (25 percent), which was not explained. The trial compared vitamin D3 120, 000 given under supervised conditions every 2 weeks and placebo in 100 men, of whom 71 were analyzed; most dropouts occurred because of refusals for subsequent blood draws (to assess the primary outcome). The study was rated methodological quality B because of the high dropout rate; for weight (in kg), the study was of quality C because baseline weights were not reported. There was a lack of effect found in studies both of men mostly in their 40s, somewhat older people of both sexes, and postmenopausal women. No significant effect was found on weight from vitamin D supplementation for 1 or 3 years. Vitam inDand weigh t:R esults ofR C Ts A ge A uth orY ear Range, M ean Interventions, Daily N o. No qualified systematic reviews have evaluated relationships between vitamin D and total cancer incidence or mortality. Only the comparison between the combined vitamin D and calcium versus the calcium alone groups is discussed here. The other comparisons are described in the calcium and combined vitamin D and calcium sections. A total of 1179 postmenopausal women, aged more than 55 years old, were randomized. On the hypothesis that cancers diagnosed early in the study would have been present, although unrecognized on entry, the analyses were restricted to women who were free of cancer at 1 year intervention. Total cancer mortality and incidence were evaluated as two of multiple secondary endpoints. This trial was rated B because it did not report in sufficient detail the randomization method, and the outcome ascertainment was based on death certificates or self reported data, not verified with another objective documents. Vitam inDand totalcancer:R esults ofcoh ortstudies A uth orY ear F ollowup O utcome 25(O H)D, N o. No qualified systematic reviews have evaluated the association between serum vitamin D concentrations and incidence of prostate cancer. The time between blood drawn and the diagnosis of prostate cancer varied from 2 to 16 years. The methodological quality of three studies was rated B and nine studies were rated C. This study adjusted for factors related to insulin resistance syndrome but not those potentially related to prostate cancer. Even though this study used a conditional logistic regression in its analysis to maintain matching status, it was unclear if additional factors potentially relevant to prostate cancer were also entered into the regression analysis. When stratified by age and race, this association was only found in men above the median age of 57 years at time of blood drawn but not in younger men; the association was similar in black and white men. Vitam inDand prostate cancer:R esults ofnested casecontrolstudies A uth orY ear L ife O utcome (no. Detailed presentation of supplemental vitamin D and colorectal caner (Tables 20 & 21). Colorectal cancer mortality and incidence were evaluated as two of multiple secondary endpoints. At 5 years vitamin D3 supplementation had no significant effect on the prevention of colorectal cancer mortality (P=0. This trial was rated B because it did not report in sufficient detail the randomization method, and the outcome ascertainment was based on death certificates or selfreported data, not verified with another objective documents. The same British trial reported no significant difference in colorectal cancer mortality or incidence between the vitamin D supplements group and the placebo at 5 years in men (P=0. In women, the trial also found no significant difference in colorectal cancer incidence between the two groups (P=0. The number of pairs of cases and controls in these studies ranged from 101 to 588. Time between blood drawn and the diagnosis of colorectal cancer incidence or mortality ranged from less than 1 year to 17 years. Common reasons for downgrading the quality ratings included exclusion of participants without available blood samples, no verification of cancer diagnosis, and lack of adequate 53 statistical adjustments. The cohort study was rated B because it was unclear whether cases were verified and there was no statistical adjustment for family history. Another study that exclusively 72 included white population also found no association. The trial found no difference in colorectal cancer mortality or incidence between supplemental vitamin D and no supplements. Vitam inDand colorectalcancer:R esults ofobservationalstudies A uth orY ear L ife Stage O utcome F ollowup 25(O H)D N o. C Resultswere notnotablych angedwh encasesdiagnosedwith inth e firstyearafterbloodcollectionwere excluded(P fortrend notreported). This study was rated B because it excluded more than 50 percent of participants of the original cohort because their blood samples were not available. However, no unique conclusions are possible for this life stage separate from those for people 51 to 70 years. Vitam inDand colorectaladenom a:R esults ofobservationalstudies A uth orY ear L ife O utcome F ollowup 25(O H)D N o. The study included 71 percent nonHispanic white, 14 percent nonHispanic black, 6 percent Mexican American, and 9 percent from other races. The breast cancerspecific mortality was one of many cancerspecific mortality outcomes reported in this study. However, in the second study, when compared with the lowest quintile, quintiles 3 to 5 were associated with nonsignificantly elevated risks. In the one nested casecontrol study (methodological quality B) including both premenopausal and postmenopausal women, no relationship was found between vitamin D levels and risk of breast cancer. Vitam inDand breastcancer:R esults ofobservationalstudies A uth orY ear L ife Stage O utcome F ollowup VitD Concentration, N o. No qualified systematic reviews evaluated associations between serum vitamin D concentrations and the incidence of pancreatic cancer. The result was adjusted for age, month of blood drawn, years smoked, number of cigarettes smoked per day, reporting to have quit smoking more than three consecutive visits (>1 y) during the trial (19851993), occupational physical activity, education, and serum retinol. The study authors excluded islet cell carcinomas from analysis because the etiology for their pathogenesis might be different from that of exocrine tumors. The association was not significantly modified by season of blood collection (P for interaction > 0.