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The COVID-19 pandemic and global responses to this crisis reveal the changing landscape of global health governance. As countries around the world struggle to secure COVID-19 vaccines for their citizens, some non-Western powers have actively distributed vaccines internationally – an act broadly recognized as vaccine diplomacy. While existing literature suggests that geopolitical concerns affect the selection of recipient countries, it has yet to explain other aspects of vaccine diplomacy. Why are some countries focused on vaccine sales while others are more open to donation? Why do some prefer bilateral to multilateral channels in distributing vaccines? Through comparative analysis of China, India, and Russia, this article shows that political economic factors, in addition to geopolitics, shape the ways non-Western powers conduct vaccine diplomacy. We argue that these countries adjust their strategies in line with their relative advantages in development, manufacturing, and delivery of vaccines. Each country has unique strengths and weakness, which gives rise to the varied patterns in vaccine diplomacy. Our findings suggest that their strategies of vaccine diplomacy are enabled as well as constrained by their economic realities, and the rise of these countries in this field does not necessarily mean an outright challenge to the existing international system. [ABSTRACT FROM AUTHOR]

Developing countries are growing apart on environmental issues. International environmental negotiations are no longer characterized merely by the North–South conflict. Rising powers have come to divide the Global South and redefine the Common-But-Differentiated Responsibilities principle. This article explains the divergence of China and India at the Kigali Amendment to the Montreal Protocol, one of the first global environmental agreements to differentiate obligations between developing countries. China and India, the world's two largest hydrofluorocarbon producers, ended decades of collaboration and split the rest of the developing world behind them. I argue that developmental strategy and political institutions shape the preferences and influences of industrial, governmental, and social stakeholders, thereby explaining their negotiation behavior and outcome. This article explains why China moved faster and further than India on negotiations for hydrofluorocarbon regulation. It has important implications for the two rising powers' implementation of the Kigali Amendment and for their position formulations on other environmental issues. [ABSTRACT FROM AUTHOR]

Bryophytes play an important role in biogeochemical cycles and functions in forest ecosystems. Global climate changes have led to the population decline of bryophytes; however, the effects of bryophyte loss on the soil organic carbon stock and microbial dynamic remain poorly understood. Here, bryophytes were artificially removed to simulate the loss of bryophytes in two forests in Southwest China, i.e., evergreen broad-leaved forest and temperate coniferous forest. Soil physicochemical properties, microorganisms, and soil organic carbon stocks were analyzed and factors regulating soil organic carbon stocks were explored. Results showed that bryophyte removal significantly decreased soil organic carbon in the coniferous forest but had a negligible effect on the evergreen broad-leaved forest. Bryophyte removal had an insignificant effect on soil properties and microbial PLFAs except that soil nitrogen significantly increased in the 0–10 cm layer in the evergreen broad-leaved forest, while soil temperature and bulk density increased in the coniferous forest in the 0–10 and 10–20 soil layers, respectively. Soil organic carbon stocks increased by 14.06% in the evergreen forest and decreased by 14.39% in the coniferous forest. In the evergreen forest, most soil properties and microorganisms contributed to the change of soil organic carbon stocks, however, only soil organic carbon and depth had significant effects in the coniferous forest. Our findings suggest that soil physiochemical properties and microorganisms regulated the different responses of soil organic carbon stocks after bryophyte removal in the two forests. More research is needed to better understand the effects of understory plants on soil organic carbon stocks in various forest ecosystems. [ABSTRACT FROM AUTHOR]

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Objective: Although the endoscopic treatment of gastric stromal tumors is a recently accepted therapy, the long-term outcomes of this approach remain unknown. The aims of this study were to assess the long-term effectiveness and safety of endoscopic resection for gastric GISTs.Methods: A total of 60 consecutive patients undergoing endoscopic resection of gastric GISTs were enrolled in a retrospective single-center study. Clinical data, perioperative complications, histopathologic characteristics of the tumors, and long-term outcomes were recorded.Results: Sixty patients successfully underwent complete resection of lesions, including 25 cases of endoscopic submucosal dissection (ESD) and 35 cases of endoscopic full-thickness resection (EFTR), with an average tumor size of 1.76 ± 1.55 cm (range 0.5-7.6 cm). The average operation time was 43.97 ± 26.95 min (range 11.7-138.9 min). Two cases were observed with an intraoperative hemorrhage of 200 mL, which were successfully managed by hemostatic forceps. Perforations of 2-11 mm of ESD occurred in four cases (4/25) and were well closed with endoclips, with no conversions to surgical operation. Mucosal laceration of esophagus occurred in 1 case, when a large tumor was removed. The average length of hospitalization was 6.50 ± 3.06 days (range 3-21 days). Out of a total of 60 patients, 44 (73.3%) were at very low risk, 10 (16.7%) were at low risk, 5 (8.3%) were at intermediate risk, and 1 (1.7%) was at high risk. All patients were followed-up for 36.15 ± 12.92 months (range 14-73 months). Primary tumor recurrence occurred in 1 patient who underwent a second operation after 32 months, and no other cases were observed to have either tumor recurrence or metastasis.Conclusions: For long-term outcomes, endoscopic resection of ESD or EFTR is a safe and effective approach for removing gastric stromal tumors (<5 cm), and it can be a resection technique for them with no metastasis. [ABSTRACT FROM AUTHOR]

Conclusions:In this investigation, a large mammal, Rongchang pigs were used to successfully establish a research platform for cochlear implant study on the routine use of it in clinic. Objective:The aim of this study was to establish a standard method of cochlear implant in a large mammal—pig. Methods:Rongchang pigs were selected, then divided into two groups: normal-hearing group (Mitf +/+) and mutation group with hearing loss (Mitf −/−). Cochlear implants were used and ABR and EABR were recorded. The implanted electrodes were observed by X-ray and HE stains. Results:The success with cochlear implant and the best electrode position could be defined in all animals, the coiling of the cochlea reached 1.5–1.75 turns. Immediately after the operation of cochlear implants, the ABR threshold of the operated ear (right) could not be derived for each frequency at 120 dB SPL. Moreover, 7 days after surgery, the low-frequency ABR threshold of the operated ear (right) could be derived partly at 100 dB SPL, but the high-frequency ABR threshold could not be derived at 120 dB SPL. Immediately or 1 week after cochlear implants, the EABR threshold was 90 CL in the Mitf +/+ group. This was obviously lower than the 190 CL in the Mitf −/− group. [ABSTRACT FROM PUBLISHER]

Objective: The aim of this study was to analyze the safety and effectiveness of a new cochlear implant (CI) system developed in China, the Nurotron Venus device. Material and methods: Fifteen post-lingually deafened patients received Nurotron Venus CIs in our hospital. The safety and effectiveness of the devices were evaluated within 2 years after implantation. Patients' hearing thresholds were assessed. In addition, the speech perception performance of Nurotron Venus CI recipients was compared with that of 15 Cochlear Nucleus CI24 recipients. Results and conclusion: During 2 years of observation, all the Nurotron recipients used their devices regularly and effectively. The aided hearing thresholds of all the recipients were within the speech spectrum. The average scores of HOPE sentences and HOPE monosyllable words tests among Nurotron CI recipients were 82.88 ± 21.40% and 56.67 ± 9.77%, respectively. The average scores among Cochlear Nucleus CI24 recipients were 87.33 ± 14.44% and 52.8 ± 12.76%, respectively. There was no statistically significant difference in the speech test scores between these two groups when assessed using the t test. The Nurotron Venus cochlear implant system worked safely and effectively. The speech perception of Nurotron recipients was similar to that of the other CI system recipients. [ABSTRACT FROM AUTHOR]

Conclusions: It is impossible to make a diagnosis of temporal giant cell granuloma (GCG) before operation because of nonspecific clinical and imaging feature. Surgery is the first-line choice of treatment. Objective: To evaluate the diagnosis and treatment of temporal GCG. Methods: Eight patients with GCG receiving treatment in the Chinese PLA General Hospital between 2001 and 2010 were recruited for the study. These patients' clinical features, imaging and histopathological findings, types of surgery, and results of follow-up evaluations were noted. Results: The group was made up of four males and four females, with a median age of 37 years (range 21-50 years). Four patients had a granuloma on the left side and four on the right of the head. The median duration of the disease was 21 months (range 5-60 months). All patients, except one referred to us for recurring disease, were managed in our hospital. The main symptoms were: hearing loss ( n = 5), tinnitus ( n = 4), otalgia ( n = 3), dizziness ( n = 2), and local masses ( n = 2). Radiological examination of the masses revealed erosion of the temporal bone and base of the skull. There was no definitive diagnosis in any of the patients before surgery. All patients had surgical treatment, six of them by middle cranial fossa approach and two by combined cranio-auricular approach. Surgical complications included partial facial paralysis (three cases) and cerebral edema (one case) but they resolved soon after surgery. One patient was lost to follow-up, but the other seven were followed up over a mean period of 24 months; none has reported a recurrence. [ABSTRACT FROM AUTHOR]

• This multi-center RCT will provide evidence for the rational application of PPI in ESD. • Low-dose PPIs were sufficient for prevention post-ESD bleeding and its efficacy level was equivalent to high dose PPIs. • Artificial ulcer healing after ESD in low-dose PPIs was similar to high dose PPIs. Although proton pump inhibitors (PPIs) are widely used in the prevention of gastric bleeding caused by endoscopic submucosal dissection (ESD), there is no consensus on the optimal regimen for these patients. Therefore, we aim to investigate whether intermittent use of low-dose PPI is sufficient to prevent post-ESD bleeding. This multicenter, non-inferiority, randomized controlled trial was conducted at 9 hospitals in China. Consecutive eligible patients with a diagnosis of gastric mucosal lesions after ESD treatment were randomly assigned (1:1) to receive either intermittent low-dose or continuous high-dose PPIs treatment. After three days, all patients administered orally esomeprazole 40 mg once a day for 8 weeks. The primary endpoint was post-ESD bleeding within 7 days. Analysis was done according to the intention-to-treat principle with the non-inferiority margin (Δ) of 5%. 526 consecutive patients were assessed for eligibility from 30 September 2017 to 30 July 2019, of whom 414 were randomly assigned to low-dose (n = 209) or high-dose (n = 205) esomeprazole treatment group without dropouts within7 days. The total post-ESD bleeding is occurred in 13 (6.2 %, 95 % CI 3.3–9.6) of 209 within 7 days in the intermittent low-dose group, and 12 (5.9 %, 95 % CI 2.9–9.3) of 205 in the continuous high-dose group. The absolute risk reduction (ARR) was 0.4 % (−4.2, 4.9). One month after ESD, There are 44 patients (21.1 %, 95 % CI 15.8, 26.8) and 39 patients (19.0 % 95 % CI 13.7, 24.4) in scar stage respectively in low-dose group and high-dose group (P = 0.875).The hospital costs in the low-dose PPI group was lower than high -dose group (P = 0.005). The intermittent use of low-dose PPIs is sufficient to prevent post-ESD bleeding. It might be applied in clinical practice to prevent post-ESD bleeding and reduce the costs related to PPIs. [ABSTRACT FROM AUTHOR]

Background: Follow-up of cochlear implant effectiveness is mainly focused on 3 years postoperatively, and studies with more than 5 years of observation are rare, especially for local Chinese brands., Objectives: Nurotron (Chinese domestic cochlear implant brand) CI recipients who participated in the clinical trial in 2009 were followed-up for 10 years prospectively, providing data to guide doctors and patients., Material and Methods: From December 2009 to April 2010, 57 subjects underwent Nurotron Venus CI surgery at multiple-centers, and were continued to be followed up and assessed at 1, 2, 3, 4, 5, and 10 years after switch on., Results: All recipients were successfully implanted with CIs with no difficulty in subsequent use with one reported case of re-implantation at 9 years after implantation. The aided hearing thresholds were significantly improved at one month after switch on ( p  < 0.0001) and remained stable afterwards for 10 years. Speech recognition scores were significantly higher than pre-operative results ( p  < 0.05) and continued to improve till 3 years after switch on. At 10 years post-operation, most subjects had improved QOL scores in most sub-items., Conclusions and Significance: Nurotron Venus CI System provides long-term, stable results in hearing speech assistance capabilities and can improve the quality of life of CI recipients.

Background: Recurrent bleeding from the small intestine accounts for 5 to 10% of cases of gastrointestinal bleeding and remains a therapeutic challenge. Thalidomide has been evaluated for the treatment of recurrent bleeding due to small-intestinal angiodysplasia (SIA), but confirmatory trials are lacking., Methods: We conducted a multicenter, double-blind, randomized, placebo-controlled trial to investigate the efficacy and safety of thalidomide for the treatment of recurrent bleeding due to SIA. Eligible patients with recurrent bleeding (at least four episodes of bleeding during the previous year) due to SIA were randomly assigned to receive thalidomide at an oral daily dose of 100 mg or 50 mg or placebo for 4 months. Patients were followed for at least 1 year after the end of the 4-month treatment period. The primary end point was effective response, which was defined as a reduction of at least 50% in the number of bleeding episodes that occurred during the year after the end of thalidomide treatment as compared with the number that occurred during the year before treatment. Key secondary end points were cessation of bleeding without rebleeding, blood transfusion, hospitalization because of bleeding, duration of bleeding, and hemoglobin levels., Results: Overall, 150 patients underwent randomization: 51 to the 100-mg thalidomide group, 49 to the 50-mg thalidomide group, and 50 to the placebo group. The percentages of patients with an effective response in the 100-mg thalidomide group, 50-mg thalidomide group, and placebo group were 68.6%, 51.0%, and 16.0%, respectively (P<0.001 for simultaneous comparison across the three groups). The results of the analyses of the secondary end points supported those of the primary end point. Adverse events were more common in the thalidomide groups than in the placebo group overall; specific events included constipation, somnolence, limb numbness, peripheral edema, dizziness, and elevated liver-enzyme levels., Conclusions: In this placebo-controlled trial, treatment with thalidomide resulted in a reduction in bleeding in patients with recurrent bleeding due to SIA. (Funded by the National Natural Science Foundation of China and the Shanghai Municipal Education Commission, Gaofeng Clinical Medicine; ClinicalTrials.gov number, NCT02707484.)., (Copyright © 2023 Massachusetts Medical Society.)

Background: The prevention and treatment of presbycusis becomes a serious health challenge and socio-economic problem., Objectives: We performed a cross-sectional analysis of the audiometry results of all elderly patients who visited our department throughout the year of 2018., Material and Methods: A total of 5520 people aged 60 and over were included and divided into three groups: young-old group (60-74 years old), old-old group (75-89 years old), and longevous group (over 90 years old). Pure-tone audiometry results of all patients were analyzed., Results: Among the 5520 patients, there were 4445 cases in the young-old group, 1029 cases in the old-old group, and 46 cases in the longevous group, accounting for 80.53, 18.64, and 0.83%, respectively. In the young-old group, normal hearing and mild-moderate hearing loss were the most common, while moderate and severe hearing loss were more common among the old-old group and the longevous group. The hearing curve showed typical age-related hearing loss with a drop at high frequencies., Conclusions: With an increase in age, patients tend to suffer from more serious hearing disorders. Presbycusis was associated with specific frequency and age characteristics. Understanding these characteristics is of great significance for the prevention and treatment of age-related hearing loss.

Aims: It remains unknown whether the treatment of hypertension influences the mortality of patients diagnosed with coronavirus disease 2019 (COVID-19)., Methods and Results: This is a retrospective observational study of all patients admitted with COVID-19 to Huo Shen Shan Hospital. The hospital was dedicated solely to the treatment of COVID-19 in Wuhan, China. Hypertension and the treatments were stratified according to the medical history or medications administrated prior to the infection. Among 2877 hospitalized patients, 29.5% (850/2877) had a history of hypertension. After adjustment for confounders, patients with hypertension had a two-fold increase in the relative risk of mortality as compared with patients without hypertension [4.0% vs. 1.1%, adjusted hazard ratio (HR) 2.12, 95% confidence interval (CI) 1.17-3.82, P = 0.013]. Patients with a history of hypertension but without antihypertensive treatment (n = 140) were associated with a significantly higher risk of mortality compared with those with antihypertensive treatments (n = 730) (7.9% vs. 3.2%, adjusted HR 2.17, 95% CI 1.03-4.57, P = 0.041). The mortality rates were similar between the renin-angiotensin-aldosterone system (RAAS) inhibitor (4/183) and non-RAAS inhibitor (19/527) cohorts (2.2% vs. 3.6%, adjusted HR 0.85, 95% CI 0.28-2.58, P = 0.774). However, in a study-level meta-analysis of four studies, the result showed that patients with RAAS inhibitor use tend to have a lower risk of mortality (relative risk 0.65, 95% CI 0.45-0.94, P = 0.20)., Conclusion: While hypertension and the discontinuation of antihypertensive treatment are suspected to be related to increased risk of mortality, in this retrospective observational analysis, we did not detect any harm of RAAS inhibitors in patients infected with COVID-19. However, the results should be considered as exploratory and interpreted cautiously., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Background: A set of Chinese Mandarin monosyllable test lists has been widely used in clinical diagnosis, while the performance of the Mandarin-speaking patients with auditory neuropathy (AN) in the monosyllable tests was still unknown. Objectives: To analyze the characteristics of monosyllable recognition in Mandarin-speaking patients with AN. Materials and methods: Nineteen Mandarin-speaking patients diagnosed with AN were recruited to obtain the performance-intensity (P-I) functions. They were divided into two paired groups according to two conditions: (1) the rising-slope (RS) and the non-rising-slope pattern (NRS) group for the audiogram; or (2) the male and the female group for gender. Results: The performance at 20 and 30 dB SL showed negative correlation with the pure tone-averaged thresholds of 0.5, 1.0, 2.0 and 4.0 kHz (4FA). We found significant differences between the P-I functions of the RS and the NRS group, and surprisingly found that between the male and female as well although there was no difference in 4FA between the paired groups. A notable rollover phenomenon in P-I functions was detected in each group. Conclusions: The monosyllable recognition scores of Mandarin-speaking AN patients showed numerous particular characteristics reflected by P-I functions. Acquiring the complete P-I functions at multiple presentation levels and the rollover index may give us more information about the diagnosis and prognosis.

Background: Until now, little is known about the role of miRNAs in the invasion and metastasis of Laryngeal squamous cell carcinoma (LSCC)., Objectives: This study aimed to explore the relationship between microRNA and the invasion and metastasis of LSCC., Material and Methods: The highly metastatic laryngocarcinoma cells were obtained from the established animal model with spontaneous lymph node metastasis of LSCC in our previous study. MicroRNA expression profiling and bioinformatic analysis were performed to analyze the microRNA expression changes in the highly metastatic laryngocarcinoma cells and the parental tumor cells (HEP-2). RT-PCR was performed for further validation of the result of microarray., Results: A total of 40 microRNAs were found to be significantly altered in the highly metastatic laryngocarcinoma cells compared to controls. Bioinformatic analysis identified that 19 key microRNAs might involve in LSCC development. Moreover, RT-PCR confirmed that miR-25, miR-100, miR-125b-5p and let-7g were differentially expressed in different laryngocarcinoma cells and human tumor specimens., Conclusions and Significance: Our findings suggest that microRNA play an important role in the invasion and metastasis of LSCC, and provide the clues for studying the function of microRNA as well as opportunities to analyze the complex molecular abnormalities driving LSCC progression.

Although the cochlear implant has been widely acknowledged as the most successful neural prosthesis, only a fraction of hearing-impaired people who can potentially benefit from a cochlear implant have actually received one due to its limited awareness, accessibility, and affordability. To help overcome these limitations, a 26-electrode cochlear implant has been developed to receive China's Food and Drug Administration (CFDA) approval in 2011 and Conformité Européenne (CE) Marking in 2012. The present article describes design philosophy, system specification, and technical verification of the Nurotron device, which includes advanced digital signal processing and 4 current sources with multiple amplitude resolutions that not only are compatible with perceptual capability but also allow interleaved or simultaneous stimulation. The article also presents 3-year longitudinal evaluation data from 60 human subjects who have received the Nurotron device. The objective measures show that electrode impedance decreased within the first month of device use, but was stable until a slight increase at the end of two years. The subjective loudness measures show that electric stimulation threshold was stable while the maximal comfort level increased over the 3 years. Mandarin sentence recognition increased from the pre-surgical 0%-correct score to a plateau of about 80% correct with 6-month use of the device. Both indirect and direct comparisons indicate indistinguishable performance differences between the Nurotron system and other commercially available devices. The present 26-electrode cochlear implant has already helped to lower the price of cochlear implantation in China and will likely contribute to increased cochlear implant access and success in the rest of the world. This article is part of a Special Issue entitled ., (Copyright © 2014 The Authors. Published by Elsevier B.V. All rights reserved.)

To identify genetic markers for laryngeal squamous cell carcinoma (LSCC), we conducted a genome-wide association study (GWAS) on 993 individuals with LSCC (cases) and 1,995 cancer-free controls from Chinese populations. The most promising variants (association P < 1 × 10(-5)) were then replicated in 3 independent sets including 2,398 cases and 2,804 controls, among which we identified 3 new susceptibility loci at 11q12 (rs174549), 6p21 (rs2857595) and 12q24 (rs10492336). The minor alleles of each of these loci showed protective effects, with odds ratios (95% confidence intervals) of 0.73 (0.68-0.78; P = 1.00 × 10(-20)), 0.78 (0.72-0.84; P = 2.43 × 10(-15)) and 0.71 (0.65-0.77; P = 4.48 × 10(-14)), respectively. None of these variants showed an interaction with smoking or drinking. This is the first GWAS to our knowledge solely on LSCC, and the findings might advance understanding of the etiology of LSCC.

Conclusions: The commonest manifestation of facial nerve tumours was facial paralysis, followed by hearing loss. During tumour resection facial nerve continuity should be maintained and reconstructed in one stage wherever possible. If this is not a viable option, second-stage surgery should be performed as soon as possible after surgery., Objective: To summarize the clinical characteristics of tumours of the facial nerve and discuss their diagnosis and treatment., Patients and Methods: Twenty-two cases of primary facial nerve tumours were reviewed. These cases were confirmed pathologically and treated in the Chinese PLA General Hospital during the period 1986-2003, where the clinical manifestations, diagnosis and treatment of this series were analysed., Results: Among the 22 cases, 14 were facial neurilemmomas, 6 were facial neurofibromas and 2 were facial nerve haemangiomas. The commonest presenting symptom in all cases was facial paralysis (14/22) followed by hearing loss (10/22). Facial paralysis was also the commonest sign of a facial nerve tumour (18/22), followed by a swollen mass in the tympanic cavity (8/22) and a swollen mass in the external auditory canal (5/22). The 22 tumours were totally resected surgically. The function of the facial nerve was normal (grade I) in two cases where the integrity of the nerve was preserved during the operation, grade II in one case and grade III in another case where it was possible to maintain partial continuity of the facial nerve. The facial nerve was reconstructed in one stage when the tumours were resected, with facial-great auricular-facial nerve cable grafting (10 cases) and facial-lateral femoral cutaneous-facial nerve cable grafting (1 case). The facial nerve function consequently recovered to grade II-IV. The second stage facial-hypoglossal nerve anastomosis was carried out in two cases, and facial function consequently recovered to grade II in one case at 3 years and grade III in another with 2 years follow-up. In five cases, the facial nerve remained discontinuous and the facial nerve function showed no recovery (grade VI).

Objective: To investigate the effect of different levels of iodine intake on the prevalence of hyperthyroidism and the impact of universal salt iodization on the incidence of hyperthyroidism., Design: A comparative cross-sectional and longitudinal survey was conducted in three areas with borderline iodine deficiency, mild iodine excess (previously mild iodine deficiency) and severe iodine excess. Universal salt iodization had been introduced 3 years previously except in the area with borderline iodine deficiency., Methods: In total 16 287 inhabitants from three areas answered a questionnaire concerning the history of thyroid disease. Among them 3761 unselected subjects received further investigations including thyroid function, thyroid autoantibodies, thyroid ultrasonography and urinary iodine excretion., Results: Among areas with median urinary iodine excretion of 103 microg/l, 375 microg/l and 615 microg/l (P<0.05), the prevalence of hyperthyroidism did not differ significantly (1.6%, 2% and 1.2%). The prevalence of subclinical hyperthyroidism was higher in areas with borderline iodine deficiency and mild iodine excess than in the area with severe excess iodine intake (3.7%, 3.9% and 1.1%, P<0.001). The prevalence of Graves' disease and its proportion in hyperthyroidism did not differ among areas. The incidence of hyperthyroidism did not significantly increase after the introduction of universal salt iodization., Conclusion: Different iodine intakes under a certain range do not affect the prevalence and type of hyperthyroidism. Subclinical hyperthyroidism is more prevalent in the iodine deficient area than in the severe iodine excessive area. In the area with mild iodine deficiency, the introduction of universal salt iodization may not be accompanied by an increased incidence of hyperthyroidism.