Exosome Diagnostics Names New Director of Genetics Research

Exosome Diagnostics, a developer of proprietary genetics-based diagnostic tests with applications in oncology and endocrinology, has appointed Johan Skog as its new director of genetics research.

In this role, Dr Skog will oversee the research program that underlies the company’s development of its blood-based diagnostics that can identify cancer-specific genetic mutations.

Dr Skog is the primary discoverer and inventor of Exosome Diagnostics’s core technology that has been licensed exclusively to the company by Massachusetts General Hospital. Dr Skog has received his PhD specializing in gene therapy from Umea University in Sweden.

James McCullough, chairman and CEO of Exosome, said: “Dr Skog’s discoveries are the foundation of our development program to capture diagnostic quantities of genetic mutations in blood. His expertise as the inventor of the technology of isolating genetic mutations from circulating exosomes for use as diagnostic and prognostic tools will enable the company to rapidly move forward on its first program, a blood-based diagnostic for brain cancer.”

Aetna’s Initiatives to Reduce Health Disparities Recognized By the National Committee for Quality Assurance for Third Straight Year

Aetna (NYSE:AET) has been awarded the prestigious “Recognizing Innovation in Multicultural Health Care Award” by the National Committee for Quality Assurance (NCQA) for its prospective randomized study to determine if a telephonic culturally competent disease management program can improve the health of African American members with hypertension. Members in the study who received culturally competent disease management outreach and educational materials achieved a higher percentage of clinically acceptable blood pressure levels, increased their frequency of self blood pressure monitoring, and greater medication compliance when compared to a control group of members who received a light support program.

“Compared with white Americans, African Americans have an 80 percent higher rate of stroke mortality, a 50 percent higher rate of heart disease mortality, and a 320 percent higher rate of hypertension-related end-stage renal disease,” said Troyen A. Brennan, MD., chief medical officer at Aetna, citing statistics from the American Heart Association. “At Aetna, we believe in the power of culturally competent care to improve health care outcomes. Since 2002, we have asked members to voluntarily provide us with information on their race and ethnicity. We then combine this data with evidence about the most prevalent health conditions in diverse populations and use the information to create clinical programs that address disparities.”

“Aetna’s innovative effort to improve the lives of African Americans with hypertension is a model for health plans across the country,” said Margaret E. O’Kane, president of NCQA. “As a nation of diverse cultures, languages and lifestyles, it’s essential for health plans to recognize the health risks and vulnerabilities of special populations and design programs that reach out and improve the quality of those members’ lives.”

Aetna worked with Morehouse School of Medicine and Health & Technology Vector, Inc. to design and evaluate the effectiveness of a culturally competent disease management program relative to a lightly managed program. The light support program provided blood pressure monitors for members’ use and included initial and post-assessment interviews with Aetna staff. Members in the culturally competent disease management group received additional services including:

— Calls from disease management nurses to encourage life behaviors to improve hypertension health, blood pressure self-monitoring and medication compliance

— Culturally competent heart healthy educational materials

— Primary care physicians of these members received quarterly member-specific reports on self-reported blood pressure, as well as hypertension disease management goals and national guidelines on hypertension treatment

— Physicians also received an invitation to participate in free online cultural competency training provided by the Physician’s Practical Guide to Culturally Competent Care offered by the Office of Minority Health, U.S. Department of Health and Human Services.

Upon the study’s completion, members enrolled in the culturally competent program achieved a higher percentage of clinically acceptable blood pressure levels, increased the frequency of self blood pressure monitoring and improved medication compliance when compared with the light support control group.

Aetna will be recognized at a ceremony in San Francisco on September 18. The award, sponsored by The California Endowment with support from the Centers for Medicare & Medicaid Services and The Office of Minority Health, is part of NCQA’s efforts to improve the quality of health care in the U.S. through development of a truly multicultural health care system. This is the third consecutive year Aetna has received this award.

Aetna was honored in 2006 for its pioneering initiative to collect race, ethnicity and language preference data from members on a voluntary, self-identification basis, and again in 2007 for reaching out in a culturally sensitive manner to Latina and African American women who had not had annual screening mammograms to encourage them to get one and help them locate a convenient mammography center.

NCQA, a private, non-profit organization dedicated to improving health care quality, accredits and certifies health care organizations and recognizes physicians in key clinical areas. NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS) is the most widely used performance measurement tool in health care. For information about other innovative multicultural health plan programs recognized in recent years by NCQA, as well as upcoming conferences on multicultural health care, visit www.ncqa.org.

The California Endowment, a private, statewide health foundation, was established in 1996 to expand access to affordable, quality health care for underserved individuals and communities, and to promote fundamental improvements in the health status of all Californians. For more information, visit www.calendow.org.

Aetna is one of the nation’s leading diversified health care benefits companies, serving approximately 37.2 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities and health care management services for Medicaid plans. Our customers include employer groups, individuals, college students, part-time and hourly workers, health plans, governmental units, government-sponsored plans, labor groups and expatriates. www.aetna.com

UnitedHealthcare’s Asian Community Initiative Recognized By National Committee for Quality Assurance for Innovative Efforts to Reduce Health Care Disparities for Chinese Americans

UnitedHealthcare, a UnitedHealth Group (NYSE: UNH) company, received the prestigious Recognizing Innovation in Multicultural Health Care Award by the National Committee for Quality Assurance (NCQA) for the company’s efforts to provide its customers with culturally and linguistically appropriate health care services.

NCQA recognized UnitedHealthcare’s “In-Language Member and Public Outreach in New York’s Asian Community Initiative,” an outreach program by the company’s Asian Initiatives team designed to help Chinese Americans enrolled in the company’s SecureHorizons Medicare Advantage plans understand and utilize social welfare resources.

Central to the program is a dedicated staff of UnitedHealthcare social service professionals that offer information, counseling and application assistance for social benefit programs such as Medicare and Medicaid, prescription drug coverage, and supplemental security income, as well as assistance with telephone and utility bills, property taxes, rent-increase exemption and school tax credit. Also, the staff helps frail seniors with coordinated long-term home care, caregiver respite, meals-on-wheels and transportation services.

In addition, UnitedHealthcare established two in-language walk-in centers that serve more than 200 Chinese- as well as Korean-speaking seniors daily in the heart of New York City’s Chinatown and Flushing areas, partnered with local Chinese media to host public seminars, and have presented regularly at senior centers and community council meetings citywide.

“Many Chinese-speaking seniors are first-generation immigrants who do not know how to navigate the social-welfare system and often encounter language barriers that prevent them from accessing vital, needed benefits,” said Christopher Law, vice president of Asian Initiatives at UnitedHealthcare. “We developed the In-Language Member and Public Outreach program for Chinese-speaking seniors with the goal of becoming a trusted, one-stop source that understands their concerns and helps them utilize important social-welfare resources that are available to them.”

UnitedHealthcare data indicate the success of its effort to engage Chinese Americans to improve their health and quality of life. Since the program’s inception, UnitedHealthcare’s dedicated social service professionals have answered more than 10,000 phone calls through its customer-care hotline; helped more than 7,500 customers apply for government benefits and entitlement programs and save millions of dollars in medical premiums, prescription drug, food and transportation costs, utilities, rent and property taxes; and aided hundreds of customers in obtaining long-term home care and caregiver respite services to prevent premature institutional care and/or frequent hospitalization.

“These and other data reinforce the need for health plans to better engage multicultural and ethnic communities to improve health outcomes and enhance their quality of life,” said Law. “The In-language Member and Public Outreach program reflects UnitedHealthcare’s commitment to deliver culturally and linguistically relevant services that transcend traditional health care boundaries and to effectively address disparities in accessing health care resources. Our focus is the belief that everything we do is from the community, in the community and for the community.”

“UnitedHealthcare’s innovative effort to improve the lives of Chinese Americans is a model for health plans across the country,” said Margaret E. O’Kane, president of NCQA. “The gaps in care that persist for minorities and for non-English-speakers result in serious consequences: unnecessary disability and premature death for thousands.”

According to the landmark 2002 Institute of Medicine study, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” minorities in the U.S. tend to get lower quality health care than caucasians, even when such factors as medical conditions, insurance and economic status are equivalent.

UnitedHealthcare will be recognized at a ceremony Sept. 18 in San Francisco. The award, sponsored by The California Endowment with support from the Centers for Medicare & Medicaid Services and The Office of Minority Health, is part of NCQA’s efforts to improve the quality of health care in the U.S. through development of a truly multicultural health care system.

This is UnitedHealthcare’s third NCQA Recognizing Innovation in Multicultural Health Care Award. The company received an additional award this year for its “Enhanced Bilingual Service and Member Access Initiative” (see accompanying news release, “UnitedHealthcare’s Latino Health Initiative recognized by National Committee for Quality Assurance for innovative efforts to reduce health care disparities for Hispanics”). Last year, UnitedHealthcare was recognized for its interactive Asian-language provider directories.

For information about upcoming conferences on multicultural health care, visit www.ncqa.org

About NCQA

NCQA is a private, non-profit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations and recognizes physicians in key clinical areas. NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS) is the most widely used performance measurement tool in health care. NCQA is committed to providing health care quality information through the Web, media and data licensing agreements in order to help consumers, employers and others make more informed health care choices. For more information, visit www.ncqa.org.

About The California Endowment

The California Endowment, a private, statewide health foundation, was established in 1996 to expand access to affordable, quality health care for underserved individuals and communities, and to promote fundamental improvements in the health status of all Californians. For more information, visit www.calendow.org.

About UnitedHealthcare

UnitedHealthcare (www.unitedhealthcare.com) provides a full spectrum of consumer-oriented health benefit plans and services to individuals, public sector employers and businesses of all sizes, including more than half of the Fortune 100 companies. The company organizes access to quality, affordable health care services on behalf of more than 25 million individual consumers, contracting directly with more than 560,000 physicians and care professionals and 4,800 hospitals to offer them broad, convenient access to services nationwide. UnitedHealthcare is one of the businesses of UnitedHealth Group (NYSE: UNH), a diversified Fortune 50 health and well-being company.

Orqis(R) Medical Completes First in Man Implant of Revolutionary Exeleras Product

LAKE FOREST, Calif., Sept. 15 /PRNewswire/ — Orqis(R) Medical Corporation announced the first implant of the new Exeleras System in a 47 year old man suffering from NYHA Class III heart failure. The man was a moderately severe heart failure patient who, without the Exeleras device, would need to decline significantly to be considered a candidate for a more invasive ventricular assist device procedure. Within 48 hours of the minimally invasive Exeleras procedure being performed, the hemodynamics shifted from being classified as ‘moderately severe’ heart failure to near normal levels.

(Logo: http://www.newscom.com/cgi-bin/prnh/20080806/LAW519LOGO)

Exeleras is the first of its kind minimally invasive device that was successfully placed via a subcutaneous procedure in a hybrid cardiac interventional suite at Universitatsklinikum Essen, Germany. The device placement does not require a traditional operating room nor does it require the patient to undergo the hardship of an open-chest procedure. Ken Charhut, President and CEO commented, “Exeleras is well poised to provide long-term Aortic Flow Therapy to address the treatment gap where over 4 million NYHA Class III heart failure patients worldwide find themselves today. The success of the long-term Exeleras System, coupled with our short-term Cancion product, will enable physicians around the world to employ low-risk Aortic Flow Therapy to treat heart failure patients. This adoption will propel the company’s growth.

Dr Steven F. Bolling, Professor of Cardiac Surgery, University of Michigan was present for the procedure and added, “This is a transformational therapy with an easy to perform procedure which promises to provide a viable long-term solution to the large number of Class III heart failure patients who are far upstream of the disease progression that is typically associated with more invasive ventricular assist devices.” Dr Reynolds Delgado III, Medical Director, Mechanical Assist Devices in Heart Failure, Texas Heart Institute, contributed, “The procedure performed in Essen well-demonstrated the feasibility and hemodynamic efficacy of Aortic Flow Therapy with the Exeleras System in a patient who exemplifies the large number of patients who would directly benefit from this less-invasive approach.”

The first set of patients will be implanted with the Exeleras System to evaluate the short-term safety and performance attributes of the device. “The success of our initial clinical evaluations will allow us to best define the clinical protocols to properly study the potential long-term effect and benefit offered by this exciting new therapy,” stated Marvin Konstam, M.D. Medical Director, Orqis Medical, and Professor of Medicine, Tufts University.

About Heart Failure

Over 5 million Americans suffer from heart failure, a condition in which the heart becomes weakened and cannot pump blood efficiently. In the U.S., heart failure results in over 1 million hospitalizations annually and is responsible for over $33 billion in direct and indirect costs to the U.S. healthcare system each year.

About Orqis Medical Corporation

Orqis Medical Corporation is a privately held medical device company that develops and sells minimally invasive devices that unload the heart without touching the heart and improve cardiac performance. Orqis devices enable Aortic Flow Therapy to provide a low-risk treatment option for patients not responsive to optimal medical management but also not suitable candidates for more invasive procedures. The percutaneous Cancion product has secured the CE mark. The implantable Exeleras(R) System is in clinical development. For more information on Orqis Medical, please visit http://www.orqis.com/

Note: Orqis(R), Cancion(R), and Exeleras(R) are registered trademarks of Orqis Medical Corporation.

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Orqis Medical Corporation

CONTACT: financial inquiries, David Richards, Controller of OrqisMedical Corporation, +1-949-268-7866

Web site: http://www.orqis.com/

Betaseron(R) to Offer the Thinnest Needle in Multiple Sclerosis

Bayer HealthCare Pharmaceuticals Inc. today announced that Betaseron(R)* (interferon beta-1b), its treatment for relapsing forms of multiple sclerosis (MS), will soon be available with a new 30-gauge needle, which will be the thinnest needle of any injectable disease-modifying therapy for people with MS. The new needle is as thin as the needle commonly used for insulin and pediatric injections.

“One of the barriers that many people with multiple sclerosis face in starting an MS treatment is injection anxiety,” said Ludger Heeck, Vice President and General Manager, Specialty Medicine, Bayer HealthCare Pharmaceuticals Inc. “Betaseron is a safe and effective treatment for people with relapsing forms of MS, as well as those with the earliest signs of the disease. By introducing the thinnest needle of any injectable disease-modifying medication for MS, we are taking another important step in our commitment to continuously improve Betaseron and its use to help people start and stay on Betaseron long term, particularly those who may have resisted because of anxiety and concerns about injections.”

According to a recent North American survey of people with MS, “Injection Anxiety and Barriers to MS Treatment Commitment,” the majority of people with MS have, at some point, felt anxiety, nervousness, and fear associated with their injections. Also in the survey, which interviewed 220 people in the United States and Canada who have been diagnosed with MS in the past five years, the majority (56%) of respondents named at least one thing about injections that made them uncomfortable, most often the length (33%) and thickness (31%) of a needle. This was followed by “the thought of a needle” (28%) and “the sight of a needle” (21%).(1)

Additionally, two-thirds (67%) of participants in the survey agree they would be more comfortable injecting themselves if they knew they were using the thinnest needle possible, and about half of the patients surveyed who are not currently on therapy stated they would consider/reconsider taking an injectable MS drug if a thinner needle was shown to be less painful. Benefits cited by participants to using a thinner needle include less pain during injection (55%), less bruising (42%), less pain after injection (40%), and less anxiety immediately before injection (34%).(1)

“Discomfort and anxiety around injections affect many people with MS. Injection anxiety actually can be so high that it keeps people with MS from taking their medication consistently, which is essential to help slow disease progression,” stated Dr. Mark Cascione, Neurologist, Tampa Neurology Associates and Medical Director, South Tampa Multiple Sclerosis Center. “The new Betaseron 30-gauge needle is a welcome advancement for people with MS, and particularly for those with anxiety about their injections.”

Issues around injections, such as injection anxiety, injection fatigue and injection site pain, are among the top reasons patients cite for not starting or continuing an injectable medication.(1) Betaseron therapy requires half as many injections as Copaxone(R)* (glatiramer acetate) with a needle that is 25 percent thinner.(2),(3) Additionally, in a study, significantly more Betaseron than Rebif(R)* patients were pain-free at all time points measured (immediately after injection, and 30 and 60 minutes after injection) over the course of 15 injections.(4) Also in that same study, Betaseron patients using the new 30-gauge needle reported more than 50 percent of their injections were pain-free immediately after injection.+ ++ (4)

The new thinnest, 30-gauge needle will be introduced with an optional new autoinjector called BETAJECT(R) Lite.*Section In a survey of patients who used the new 30-gauge needle along with the new autoinjector, 98 percent were “satisfied” or “very satisfied” with the new thinner needle and autoinjector after their first injection,(5) and nearly all of the patients who tried the BETAJECT LiteSection said the new autoinjector was easy to use.(5)

There have been no changes to the formulation or the mixing process of Betaseron — it is still the same effective medication that patients and doctors have relied on for more than 15 years. People who are currently taking Betaseron can log onto www.betaseron.com/thinner for more information about the new needle and to request the optional BETAJECT Lite autoinjector.

About Betaseron

Betaseron is indicated for the treatment of relapsing forms of multiple sclerosis to reduce the frequency of clinical exacerbations. Patients with multiple sclerosis in whom efficacy has been demonstrated include patients who have experienced a first clinical episode and have MRI features consistent with multiple sclerosis.

The most commonly reported adverse reactions are lymphopenia, injection-site reaction, asthenia, flu-like symptom complex, headache and pain. Gradual dose titration and use of analgesics during treatment initiation may help reduce flu-like symptoms. Betaseron should be used with caution in patients with depression. Injection-site necrosis has been reported in four percent of patients in controlled trials. Patients should be advised of the importance of rotating injection sites. Female patients should be warned about the potential risk to pregnancy. Cases of anaphylaxis have been reported rarely. See “Warnings,””Precautions,” and “Adverse Reactions” sections of full Prescribing Information. More information, including the full Prescribing Information, is available at www.betaseron.com.

About Bayer HealthCare Pharmaceuticals Inc.

Bayer HealthCare Pharmaceuticals Inc. is the U.S.-based pharmaceuticals business of Bayer HealthCare LLC, a subsidiary of Bayer AG. Bayer HealthCare is one of the world’s leading, innovative companies in the healthcare and medical products industry, and combines the activities of the Animal Health, Consumer Care, Diabetes Care, and Pharmaceuticals divisions. Bayer HealthCare Pharmaceuticals comprises the following business units: Women’s Healthcare, Diagnostic Imaging, General Medicine, which includes Cardiology and Primary Care and Specialty Medicine, which includes Hematology, Oncology and Multiple Sclerosis. The company’s aim is to discover and manufacture products that will improve human health worldwide by diagnosing, preventing and treating diseases.

This news release contains forward-looking statements based on current assumptions and forecasts made by Bayer Group management. Various known and unknown risks, uncertainties and other factors could lead to material differences between the actual future results, financial situation, development or performance of the company and the estimates given here. These factors include those discussed in our public reports filed with the Frankfurt Stock Exchange and with the U.S. Securities and Exchange Commission (including Form 20-F). The company assumes no liability whatsoever to update these forward-looking statements or to conform them to future events or developments.

+ N=306; 211 patients used the BETAJECT(R) Lite autoinjector with the 30-gauge needle, 17 injected BETASERON(R) manually

++ Mean proportion of pain-free injections per patient

Section If you choose to use the BETAJECT Lite autoinjector, you can only use it with Betaseron with the new 30G needle. Use of Betaseron with an autoinjector other than BETAJECT LITE may result in patients not receiving their full recommended dose.

*Trademarks are the property of their respective owners: Betaseron(R) and BETAJECT(R) Lite are registered trademarks of Bayer HealthCare Pharmaceuticals. Copaxone(R) is a registered trademark of Teva Neurosciences, Inc. Rebif(R) is a registered trademark of EMD Serono, Inc.

_________________________

(1) “Injection Anxiety and Barriers to Treatment Commitment Survey.” Fielded by Russell Research. Funded by Bayer Healthcare Pharmaceuticals, Inc. March 25, 2008.

(2) COPAXONE(R) [Package Insert]. Kansas City, MO: Teva Neuroscience, Inc.; 2007.

(3) Data on file, Bayer HealthCare Pharmaceuticals; 2008

(4) K. Baum, C. O’Leary, F. Coret Ferrer, E. Klimova, L. Prochazkova, and J. Bugge for the BRIGHT Study Group. Comparison of injection site pain and injection site reactions in relapsing-remitting multiple sclerosis patients treated with interferon beta-1a or 1b. Mult Scler 2007 13: 1153-1160.

(5) Bugge JP, Rel L. Assessment of Betaferon Application Systems in Portugal: Patients’ Feedback. Study Poster. CMSC 2007

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 Media Contact: Marcy Funk Bayer HealthCare Pharmaceuticals 973-305-5385  

SOURCE: Bayer HealthCare

Dairyland Healthcare Solutions Changes Name to ‘Healthland’ and Acquires Advanced Professional Software, Inc.

Moving decisively to solidify its technology leadership among small community and critical access hospitals, Dairyland Healthcare Solutions today announced two significant developments: its acquisition of Advanced Professional Software, Inc. (APS) and the change of its company name to ‘Healthland.’

The acquisition of Waco, Texas-based APS–which becomes a division of the new Healthland–adds 140 new customers and makes Healthland the largest supplier of IT solutions to critical access and small community hospitals in America.

“This is a strategic acquisition for Healthland,” explained James Burgess, CEO of the newly combined companies. “By offering financial software, APS has gained a strong foothold in the rural healthcare market with an extremely loyal customer base. Now, these vital hospitals throughout rural America will have more technology choices to help them quickly advance their level of patient care and operational excellence. We are delighted to welcome APS to the Healthland family,” Burgess added. Healthland will operate through multiple business hubs including Glenwood and Minneapolis, MN, Louisville, KY and Waco, TX.

Both of these announcements mark key milestones in the company’s unfolding strategy to focus all of its resources on the small community and critical access hospital market. The name change to ‘Healthland’ is the end result of extensive research into the company’s strengths and core values. “Our people have very deep roots in the small towns of America and we are committed to these communities. We live there, we care about what happens there and we get involved in the issues that affect these communities–and that includes issues affecting their community hospitals,” explained Angie Franks, Healthland’s Senior Vice President of Marketing & Sales. “We wanted our name to express our commitment to helping these community hospitals provide the best healthcare to the people who live in their communities. After thorough analysis of the market, it was clear that the name ‘Healthland’ best communicates what we are all about and at the same time acknowledges our heritage,” Franks added.

Healthland: Laser Focus on Small Community Hospitals

Healthland, which operated under the Dairyland Healthcare Solutions name for nearly 30 years, has a solid reputation as a knowledgeable, committed technology partner to the country’s small community hospitals. Since its acquisition in June 2007 by Francisco Partners, Healthland’s focus on community hospitals has emerged as the company’s central operating strategy. Healthland is a three-time “Best in KLAS” award winner in the Community Hospital Information Systems category. KLAS is an independent market research firm that monitors vendor performance through the active participation of thousands of healthcare organizations.

“We are dedicated exclusively to these small community hospitals and that commitment is reflected in everything we do,” explained Burgess. “Our people care very much about the community hospitals they work with on a day-to-day basis. And our customers know they can count on us–whether it’s making sure we meet our commitment to them or helping them work-through an issue or a challenge. In fact, one customer recently said to me that he would not make any technology-related decisions without first checking with Healthland. That’s a high compliment and one that makes me very proud of our people,” Burgess added.

Given the unique needs and challenges that exist for small community and rural hospitals, Healthland stays focused on the standards, architecture and certification requirements that are emerging from the Bush Administration’s mandate to develop an industry and federal government-wide strategy for widespread adoption of health information technology. “As we move towards a goal of portable health records, it is essential that IT solutions providers stay up-to-date on evolving industry standards. Our solutions are CCHIT-certified and we follow guidelines from the Office of the National Coordinator for Health Information Technology so that we can tackle the complex EMR and Data Interchange requirements for our hospital partners,” Burgess explained.

To ensure that Healthland remains both culturally and strategically aligned with its community hospital partners’ direction and issues, Healthland recently created a new, executive level position–Vice President of Customer Experience–to ensure just that. The position will be entirely focused on the customer, making sure that Healthland continually provides value in important and emerging areas. Building on Healthland’s heritage of customer service and satisfaction, this new position will ensure that the customer’s experience with Healthland is positive throughout the continuum of care including sales, implementation, ongoing service and collaboration on future customer needs. According to Franks, “this position is an essential component in our strategy to transform community healthcare into a state-of-the-art model for the future. To achieve this with our hospital partners, we must work in lock-step with them and provide a seamless and positive experience.”

About Healthland

Founded in 1980 as Dairyland Healthcare Solutions, Healthland is America’s largest provider of IT solutions to the small community and critical access hospital market. Committed exclusively to this market, Healthland solutions enable these hospitals to deliver a high level of patient care and achieve operational efficiencies. A three-time “Best in KLAS” award winner in the Community Hospital Information Systems category, Healthland partners with community hospitals to help them improve efficiency, enhance profitability and ensure patient safety by providing solutions to manage, integrate and access key financial, clinical and patient information. The company employs 275 people, many of whom live in the small towns where their community hospital partners operate. Healthland maintains business hubs in Glenwood and Minneapolis, MN, Louisville, KY and Waco, TX. To learn more, visit: http://www.healthland.com.

Eye Institute of Marin’s Dr. Kathryn Najafi-Tagol Named “Best of the Bay”

Dr. Kathryn Najafi-Tagol, founder and CEO of the Eye Institute of Marin, has been nominated by KRON 4 TV’s “Best of the Bay” viewers as Marin County’s “Best Ophthalmologist.” She is the first ophthalmologist in the Bay Area to receive the prestigious designation and will be featured on KRON 4’s “Best of the Bay” television program on Saturday, Sept. 20 at 5:30 p.m. The program will air again on Wednesday, Sept. 24 at 1:30 p.m.

“This recognition is truly an honor for me and the Eye Institute of Marin,” Dr. Najafi said. “We strive to provide the highest quality of care in a setting that offers the most advanced technologies and treatments available today. This award is particularly meaningful because our patients are clearly pleased with the care they receive.”

A longtime Marin County resident, Dr. Najafi founded the Eye Institute of Marin in San Rafael in 2004 because she saw the need for a state-of-the art eye care center in the community. Dr. Najafi wanted to establish a private, solo practice where she could provide the highest level of care and personal attention, and offer her patients the latest technologies for detecting and treating eye conditions and diseases. At the Eye Institute of Marin, Dr. Najafi provides the latest in cataract and glaucoma surgeries and treatments including, LASIK, ReSTOR(R) multifocal Intra Ocular Lens (IOL), accommodating Crystalens(R), and Micropulse Diode Laser Trabeculoplasty.

“The rapid advancements in the field of ophthalmology over the past 10 years have been truly amazing,” Dr. Najafi said. “Patients who once suffered chronic poor vision as a result of conditions such as cataracts and glaucoma are now able to choose from a variety of treatment options for improving their eyesight, thanks to new technologies and treatments. I have had the privilege of treating many patients with glaucoma and nothing is more gratifying than knowing that the early treatment and detection we have provided them has saved their eyesight.”

The aging Baby Boomer generation is expected to create greater demands for eye care in the next 20 years. Age-related eye diseases including cataracts, diabetic retinopathy, glaucoma and age-related macular degeneration are expected to dramatically increase from 28 million to 43 million by 2020, according to the American Academy of Ophthalmology. By age 65, 1 in 3 Americans suffers from some form of vision-impairing eye disease and many do not know it.

Dr. Najafi is a board certified ophthalmologist and the only fellowship trained glaucoma surgeon in Marin County. She practices at Marin General Hospital, Novato Community Hospital and at California Pacific Medical Center in San Francisco, where she also is a faculty member. Prior to founding the Eye Institute of Marin, Dr. Najafi was a member and partner of the Solano Regional Medical Group and the Solano Regional Medical Foundation. She also is a founding member of the scientific advisory board of NovaBay Pharmaceuticals, Inc. (AMEX & TSX: NBY), where she has been instrumental in the development of an investigational treatment for eye infection.

Dr. Najafi completed her clinical fellowship at the prestigious Doheny Eye Institute at the University of Southern California. She earned her medical degree from the University of California, Los Angeles and completed her ophthalmology residency at Brookdale University Hospital and Medical Center in Brooklyn, New York.

About The Eye Institute of Marin

The Eye Institute of Marin is a solo practice, fully comprehensive eye care center in San Rafael, California run by Dr. Kathryn Najafi-Tagol. The practice provides the most advanced surgical and medical services, including LASIK, ReSTOR(R) multifocal Intra Ocular Lens (IOL), accommodating Crystalens(R), and Micropulse Diode Laser Trabeculoplasty. The Eye Institute of Marin’s staff members are highly skilled and knowledgeable professionals who are dedicated to patient education and strive to provide the highest quality care using the most modern, state-of-the-art technology available. For more information, please visit www.eyeinstituteofmarin.com.

South Bay Health Calendar

By From staff reports

Focus on good health with this week’s meetings

and events.

>TODAY

Bereavement

Torrance Memorial Home Health & Hospice drop-in bereavement support group. Health Conference Center, 3330 Lomita Blvd., Torrance, 6 to 7:30 p.m. Mondays. Call (310) 784-3754.

Eating Disorders

Overeaters Anonymous support group for those suffering from compulsive eating. 2222 Artesia Blvd., Redondo Beach, 6 p.m. Mondays. No dues or fees. Call (310) 374-8533.

Families Anonymous

A 12-step support group for families and friends of loved ones with substance abuse and related behavioral and emotional problems. Torrance Salvation Army Education Building, Room 25, 4223 Emerald St., Torrance, 7 p.m. Mondays. Call (310) 532-4018 or (800) 736- 9805.

TUESDAY

Al-Anon

Support group for families and friends of alcoholics. St. Peter’s Episcopal Church, 1648 E. Ninth St., San Pedro, noon Tuesdays. Call (310) 544-9668.

Breast Cancer

Refugio Spanish-speaking support group for breast cancer survivors, sponsored by the YWCA and the Susan G. Komen Foundation. Harbor-UCLA Medical Center, Trailer N-24, 1124 W. Carson St., Torrance, 9 a.m. to noon the second and fourth Tuesday of the month.

Walking Together support group for women who have had an abnormal mammogram and are waiting for test results; English and Spanish. Harbor-UCLA Medical Center, Trailer N-24, 1124 W. Carson St., Torrance, 1 to 3 p.m., second and fourth Tuesday of the month. Call Silvia at (310) 547-0831.

Diabetes

Informal diabetes networking group meets to learn the latest medical information about diabetes care from experts. Torrance Memorial Medical Center, 3330 Lomita Blvd., Health Conference Center Building, Medical Center Drive (one-story building at parking garage) west side of medical center (meeting rooms 1 or 4), 7 to 9 p.m. second and fourth Tuesday of the month. Free. Call (310) 370- 3228.

Multiple Sclerosis

Harbor/South Bay Multiple Sclerosis support group meeting. The Neighborhood Center, McMasters Park, 3612 Artesia Blvd., Torrance, 1 p.m. the second and fourth Tuesdays of the month. Call (310) 769- 0694.

Eating Disorder

Overeaters Anonymous support group for people who are recovering from compulsive overeating. Mary & Joseph Retreat House, 5300 Crest Road, Rancho Palos Verdes, 10 to 11:30 a.m. Tuesdays. Call Val at (310) 514-3025.

Weight Control

T.O.P.S. (Take Off Pounds Sensibly) Chapter 148. Harbor City Recreation Center, 24901 S. Frampton Ave., Harbor City, 9:30 to 11 a.m. Tuesdays. Call (310) 532-8795.

>WEDNESDAY

Bereavement

Open, ongoing bereavement support group offering friendship, insight and caring for those who have experienced a death from any cause. Beach Cities Health Center, 514 N. Prospect Ave., Redondo Beach, 5:30 p.m. Wednesdays. Registration required by calling the Gathering Place at (310) 374-6323.

Mental, Emotional

Beach Cities Alliance for the Mentally Ill support group meeting. Church of the Brethren, 2761 W. 190th St., Redondo Beach, 10 a.m. to noon the second Wednesday of the month. Free. Call (310) 378-6565.

>THURSDAY

Al-Anon

Support group for families and friends of alcoholics. St. Cross Church, 1818 Monterey Blvd., Hermosa Beach, noon Thursdays. Call (310) 544-9668.

Cancer Support

Leukemia, lymphoma and myeloma support group for adult patients, family and friends. The Wellness Community, 109 W. Torrance Blvd., Suite 100, Redondo Beach, 1 to 3 p.m. the second Thursday of the month. Call (310) 376-3550.

Nar-Anon

Support group for family members and friends of drug addicts. First Christian Church, 2930 El Dorado St., Torrance, 7:30 p.m. Thursdays. Call (310) 534-8188.

>FRIDAY

Breast-Feeding

La Leche League of South Bay offers support to breast-feeding mothers. Hayward Center, 2000 Artesia Blvd., Redondo Beach, 10 a.m. second Friday of the month. Call (310) 545-9600.

Cancer Support

Welcome to Wellness meeting sponsored by The Wellness Community- South Bay Cities. For those with cancer and their families and loved ones. Meeting provides an overview of the free group support programs and lectures. 109 W. Torrance Blvd., Redondo Beach, 11 a.m. Fridays. Call (310) 376-3550.

>SATURDAY

Al-Anon

Support group for families and friends of alcoholics. St. Cross Church, 1818 Monterey Blvd., Hermosa Beach, 10 a.m. Saturdays. Call (310) 544-9668.

Addictions

The Addictions & Recovery Ministry of Pacific Unitarian Church present “Supporting and Understanding the Addict in Your Life,” a free presentation given by clinical psychologist Donald R. H. Fridley. Pacific Unitarian Church, 5621 Montemalaga Drive, Rancho Palos Verdes, 10 a.m. Saturday. Call the church office at (310) 378- 9449 or e-mail [email protected].

Bipolar Disorder

The local chapter of the Depression and Bipolar Support Alliance (DBSA)hosts regular, confidential, peer-led, self-help support group meetings. Open to anyone who is diagnosed, or who they thinks they might have depression or bipolar disorder. Branch of Hope Orthodox Presbyterian Church, Santa Fe Business Park, 2370 W. Carson St., Suite 100, Torrance, 10 a.m. to noon the second and fourth Saturday of the month. Call (310) 891-3071 or email [email protected].

Fibromyalgia

Support group for those suffering from fibromyalgia. Torrance Memorial Hospital, West Towers, Conference Room B, 3325 Medical Center Drive (off of Lomita Boulevard) Torrance, 1 to 3 p.m. the second Saturday of the month. Call Roseanne at (310) 519-8961.

Nar-Anon

Support group for family members and friends of drug addicts. First Methodist Church, 1551 El Prado Ave., Torrance, 1 p.m. Saturdays. Call (310) 534-8188.

Eating Disorders

Overeaters Anonymous meeting. A support group for people recovering from compulsive overeating and food addictions. St. Mark’s Presbyterian Church, 24027 Pennsylvania Ave., Room 8, Lomita, 8:30 to 10 a.m. Saturdays. Call (310) 798-2126.

Parkinson’s Disease

Support group for patients and caregivers. Torrance Memorial Health Conference Center, Room 3, 3330 Lomita Blvd., Torrance, 3 to 4:30 p.m. the second Saturday of the month. Call (310) 316-7513 or (310) 329-7029.

>SUNDAY

Al-Anon

Support group for families and friends of alcoholics. St. Margaret Mary’s Church, 25511 Eshelman Ave., Lomita, 1:30 p.m. Sundays. Call (310) 544-9668.

– Sandy Gerety

Send Health Calendar items two weeks in advance to: Sandy Gerety c/o the Daily Breeze, 5215 Torrance Blvd., Torrance, CA 90503-4077. Fax: 310-540-6272. Or e-mail: [email protected].

(c) 2008 Daily Breeze. Provided by ProQuest LLC. All rights Reserved.

Modern Healthcare Recognizes 12 Rising Young Healthcare Management Stars

CHICAGO, Sept. 15 /PRNewswire/ — Add 12 healthcare executives to the list of rising healthcare management stars recognized by Modern Healthcare, the healthcare industry’s leading business publication.

“There are many challenges facing healthcare today and certainly in the future,” said David Burda, editor of Modern Healthcare. “We’re confident that the members of our Up & Comers class of 2008 are up to those challenges.”

The magazine’s annual recognition program drew a near-record 134 applicants from all sectors of the healthcare industry. The program is open to any executive age 40 or under working in the healthcare industry. An editorial review board composed of the magazine’s senior editors reviewed the nominations and selected this year’s 12 recipients. They are:

   -- Dawn Anuszkiewicz, 38, chief operating officer of St. Louis University      Hospital   -- Martin Bonick, 34, president and chief executive officer of Jewish      Hospital Medical Campus in Louisville, Ky.   -- Kira Carter, 33, president and chief executive officer of Sparrow      Specialty Hospital in Lansing, Mich.   -- James Dunlop, 38, senior vice president and chief financial officer of      Catholic Health System in Cheektowaga, N.Y.   -- David Entwistle, 39, chief executive officer of University of Utah      Hospitals and Clinics in Salt Lake City.   -- Don Fesko, 36, administrator of Community Hospital in Muncie, Ind.   -- Jena Hausmann, 37, senior vice president and chief operating officer of      Children's Hospital in Denver.   -- Christopher Hummer, 37, president of Carolinas Medical Center-Pineville      in Charlotte, N.C.   -- Kim Kalajainen, 40, vice president and chief information officer of      Lawrence & Memorial Hospital in New London, Conn.   -- Winjie Tang Miao, 30, president of Harris Methodist Northwest Hospital      in Azle, Texas.   -- Julie Sprengel, 37, assistant administrator of Providence St. Joseph      Medical Center in Burbank, Calif.   -- Jonathan Timmis, 35, vice president and chief strategy officer of St.      Vincent Health System in Little Rock, Ark.    

Profiles of the 12 executives appear in the Sept. 15 issue of Modern Healthcare. Readers can also read the profiles by visiting Modern Healthcare Online, the magazine’s Web site, at modernhealthcare.com. Modern Healthcare created its Up & Comers award program in 1987 to recognize rising young management talent in the healthcare industry. A total of 268 executives have earned that recognition since then, including this year’s recipients. Witt/Kieffer, an executive search firm, has sponsored the Up & Comers award program since 1997, but, per editorial policy, the firm is not involved in the nomination or selection process.

For more information on this year’s Up & Comers program, contact Editor David Burda at 312-649-5439 or [email protected].

Modern Healthcare is the industry’s most trusted, credible and relied-upon news source. In print and online, Modern Healthcare examines the most pressing healthcare issues and provides executives with the information they need to make the most informed business decisions and lead their organizations to success. It’s for this reason Modern Healthcare is deemed a “must-read publication” by the who’s who in healthcare. To subscribe to our products, please call Modern Healthcare at 888-446-1422 or e-mail us at [email protected] To advertise, please contact Ilana Klein at 312-649-5311 or [email protected].

Modern Healthcare

CONTACT: Brenda Stewart, +1-312-649-5499, [email protected], for ModernHealthcare

Web site: http://modernhealthcare.com/

Micromet Presents Data at ESMO 2008 on Anti-EpCAM Antibody Adecatumumab (MT201) in Combination With Chemotherapy

BETHESDA, Md., Sept. 15 /PRNewswire-FirstCall/ — Micromet, Inc. , a biopharmaceutical company developing novel, proprietary antibodies for the treatment of cancer, inflammation and autoimmune diseases, presented interim data from a study investigating its anti-EpCAM antibody adecatumumab (MT201) in combination with the chemotherapeutic docetaxel(1) on Saturday, September 13 at the 2008 meeting of the European Society of Medical Oncology (ESMO) held in Stockholm, Sweden.

Adecatumumab is an antibody that targets EpCAM, a tumor antigen known to be associated with poor prognosis for many solid cancers. A previous phase 2 trial investigating adecatumumab as a single agent in patients with metastatic breast cancer (MBC) suggested that treatment with adecatumumab was associated with fewer new metastases in patients with high EpCAM expression compared to patients with low EpCAM expression(2).

The ongoing phase 1b clinical trial presented at ESMO investigated the safety and tolerability of increasing doses of adecatumumab in combination with standard chemotherapy docetaxel in relapsed MBC patients who had a median of three prior chemotherapy regimens. Combining adecatumumab with docetaxel appears to be feasible with clinically manageable diarrhea being the main toxicity at higher doses. Other frequently observed adverse events included nausea, vomiting, stomatitis, constipation, fatigue, fever and chills. No increase in adverse events or laboratory abnormalities typically seen with docetaxel was observed.

The overall response rate according to RECIST has been reported to be 43 percent in patients with high expression of EpCAM, the target of adecatumumab (3 of 7 patients), whereas no responses were detected in patients with low EpCAM expression (0 of 8 patients).

“These data demonstrate that adding adecatumumab to standard chemotherapy is feasible and suggest that the combination with taxanes could be a valuable treatment option for patients with high EpCAM expression,” said Carsten Reinhardt, M.D., Ph.D., senior vice president and chief medical officer for Micromet. “The trend for a better outcome in patients with high EpCAM expression levels is in line with earlier observations and suggests a truly targeted effect of adecatumumab against EpCAM-positive tumor cells.”

In addition to the continued clinical development in patients with breast cancer, Micromet is also in the process of setting up a randomized phase 2 clinical trial in patients suffering from colorectal cancer (CRC) after complete resection of first liver metastases.

(1) First results from a Phase 1b study of the anti-EpCAM antibody adecatumumab (MT201) in combination with docetaxel in patients with metastatic breast cancer. M. Schuler et al. ESMO Meeting Abstract, Sep 2008; Abstract 485P.

(2) Highly reduced incidence of new breast cancer metastases during treatment with adecatumumab appears to be the major factor for longer time to tumor progression in patients with high-level EpCAM expression Ch. Dittrich et al. AACR Meeting Abstract, Oct 2007; A71.

About ESMO

The European Society for Medical Oncology (ESMO) is the leading European non-profit professional organization for medical oncology, with a focus on promoting multidisciplinary cancer treatment around the world.

Since its founding in 1975, ESMO has continuously expanded its mission, aiming to create a wider community of people involved in the multifaceted aspects and phases of cancer: a community of professionals who share the common goal of providing optimal care to all cancer patients.

Through the years, the Society has strived to meet the needs of both oncologists and patients. For oncology professionals, ESMO serves and offers support to its members in their daily practice and careers by sharing knowledge and expertise through scientific and educational activities. For patients, ESMO partners with cancer patient associations and groups, by promoting direct and pro-active involvement of patients in educational, political, and networking activities. For the benefit of both, professionals and patients, in 2006 ESMO became active at the political level in order to influence issues which could impact the oncology community.

About Micromet, Inc.

Micromet, Inc. (http://www.micromet-inc.com/) is a biopharmaceutical company developing novel, proprietary antibodies for the treatment of cancer, inflammation and autoimmune diseases. Four of its antibodies are currently in clinical trials, while the remainder of the product pipeline is in preclinical development. The BiTE(R) antibody blinatumomab (MT103/MEDI-538) is in a phase 2 clinical trial for the treatment of patients with acute lymphoblastic leukemia and in a phase 1 clinical trial for the treatment of patients with non-Hodgkin’s lymphoma. BiTE antibodies represent a new class of antibodies that activate a patient’s own cytotoxic T cells, considered the most powerful “killer cells” of the human immune system, to eliminate cancer cells. Micromet is developing blinatumomab in collaboration with MedImmune, Inc., a subsidiary of AstraZeneca plc. MT110 is the second BiTE antibody in clinical trials, and is being developed by Micromet in a phase 1 clinical trial for the treatment of patients with lung or gastrointestinal cancer. The third clinical stage antibody is adecatumumab, also known as MT201, a human monoclonal antibody that targets epithelial cell adhesion molecule (EpCAM)-expressing solid tumors. Micromet is developing adecatumumab in collaboration with Merck Serono in a phase 1b clinical trial evaluating adecatumumab in combination with docetaxel for the treatment of patients with metastatic breast cancer. The fourth clinical stage antibody is MT293 which is licensed to TRACON Pharmaceuticals, Inc. and is being developed in a phase 1 clinical trial for the treatment of patients with cancer. Three additional BiTE antibodies, targeting CD33, CEA and MCSP, respectively, are in preclinical development. In addition, Micromet has established a collaboration with Nycomed for the development and commercialization of MT203, a human antibody neutralizing the activity of granulocyte/macrophage colony stimulating factor (GM-CSF), which has potential applications in the treatment of various inflammatory and autoimmune diseases, such as rheumatoid arthritis, psoriasis, or multiple sclerosis.

Forward-Looking Statements

This release contains certain forward-looking statements that involve risks and uncertainties that could cause actual results to be materially different from historical results or from any future results expressed or implied by such forward-looking statements. These forward-looking statements include statements regarding the efficacy, safety and intended utilization of our product candidates, the development of our BiTE antibody technology, the conduct, timing and results of future clinical trials, expectations of the future expansion of our product pipeline and collaborations, and our plans regarding future presentations of clinical data. You are urged to consider statements that include the words “ongoing,””may,””will,””believes,””potential,””expects,””plans,””anticipates,””intends,” or the negative of those words or other similar words to be uncertain and forward-looking. Factors that may cause actual results to differ materially from any future results expressed or implied by any forward-looking statements include the risk that product candidates that appeared promising in early research, preclinical studies or clinical trials do not demonstrate safety and/or efficacy in subsequent clinical trials, the risk that encouraging results from early research, preclinical studies or clinical trials may not be confirmed upon further analysis of the detailed results of such research, preclinical study or clinical trial, the risk that additional information relating to the safety, efficacy or tolerability of our product candidates may be discovered upon further analysis of preclinical or clinical trial data, the risk that we or our collaborators will not obtain approval to market our product candidates, the risks associated with reliance on outside financing to meet capital requirements, and the risks associated with reliance on collaborators, including MedImmune, Merck Serono, TRACON and Nycomed, for the funding or conduct of further development and commercialization activities relating to our product candidates. These factors and others are more fully discussed in Micromet’s Annual Report on Form 10-K for the fiscal year ended December 31, 2007, filed with the SEC on March 14, 2008, as well as other filings by the company with the SEC.

Any forward-looking statements are made pursuant to Section 27A of the Securities Act of 1933, as amended, and Section 21E of the Securities Exchange Act of 1934, as amended, and, as such, speak only as of the date made. Micromet, Inc. undertakes no obligation to publicly update any forward-looking statements, whether as a result of new information, future events or otherwise.

Micromet, Inc.

CONTACT: US Media: Andrea tenBroek or Chris Stamm, +1-781-684-0770,[email protected]; European Media: Ludger Wess, +49 (40) 8816 5964,[email protected]; US Investors: Susan Noonan, +1-212-966-3650,[email protected]; or European Investors: Ines-Regina Buth,+49 (30) 2363 2768, [email protected], all for Micromet, Inc.

Web site: http://www.micromet-inc.com/

S.C. BlueCross to Present on Community Health Initiatives at ‘State of Our Health’ Conference

COLUMBIA, S.C., Sept. 15 /PRNewswire-USNewswire/ — Dr. Laura Long, vice president of clinical quality and health management at BlueCross BlueShield of South Carolina, will speak on a panel addressing Community Health and Wellness Best Practices in the “State of Our Health” conference to be held Tuesday in Columbia, S.C.

The panel also includes Vince Ford, senior vice president of Community Services for Palmetto Health Richland Hospital; Peter Leventis, S.C. Primary Health Care Association; and Judith Verona, manager of health and wellness at SCANA. This is one of several panel discussions in the conference.

Dr. Long will address how S.C. BlueCross works with employer groups to improve the health of their employees through wellness and disease management programs under BlueCross’ Total Population Health Management approach. BlueCross also works with community organizations to promote prevention and health education.

She also will discuss how BlueCross’ disease management program, implemented with its members since 2000, addresses seven chronic diseases that burden South Carolinians. Disease Management magazine recently published the results of a study showing that S.C. BlueCross members enrolled in the program were more compliant with their physicians’ orders for taking medication after receiving guidance, encouragement, or educational information from the program as a follow-up to their doctor’s visits.

“We try to address the whole health care continuum for our members, from the well and at-risk populations addressed through health risk assessments, onsite screenings and health coaching to the chronically ill. The biggest challenge is getting health plan groups’ management to buy into wellness initiatives and understand the cost justification,” says Dr. Long.

The conference, to take place at the Marriott Columbia Hotel, includes keynote presentations on “National Health Care Quality Measurement and How South Carolina Compares,” by Richard Sorian, National Committee for Quality Assurance; and “America’s Health Crisis,” by former Arkansas Gov. Mike Huckabee.

Headquartered in Columbia, S.C., BlueCross BlueShield of South Carolina (http://www.southcarolinablues.com/) is an independent licensee of the Blue Cross and Blue Shield Association. BlueCross BlueShield of South Carolina and its family of companies include more than 20 subsidiaries involved in health insurance services, U.S. DoD health plan and Medicare contracts, and other insurance and employee benefits services.

BlueCross BlueShield of South Carolina

CONTACT: Elizabeth Hammond of BlueCross BlueShield of South Carolina,+1-803-264-4626

Web site: http://www.southcarolinablues.com/

Cephalon Receives Complete Response Letter Regarding Request for Expanded FENTORA Label for Non-Cancer Breakthrough Pain

FRAZER, Pa., Sept. 15 /PRNewswire-FirstCall/ — Cephalon, Inc. announced today receipt of a complete response letter from the Food and Drug Administration (FDA) for its supplemental New Drug Application (sNDA) for FENTORA(R) (fentanyl buccal tablet) [C-II] as a treatment for opioid-tolerant patients with non-cancer breakthrough pain. In its letter, the FDA requested that Cephalon implement and demonstrate the effectiveness of proposed enhancements to the current FENTORA risk management program. These enhancements are consistent with the strategies the company presented at the FDA Advisory Board meeting on May 6, 2008. The agency also requested routine safety updates; no additional safety or efficacy studies were requested. In accordance with new FDA regulations, the company anticipates receiving a second communication from the agency requesting that the FENTORA Risk Minimization Action Plan (RiskMAP) be converted to incorporate the new standards for the Risk Evaluation and Mitigation Strategy (REMS) safety plan.

“The FDA request for revisions to the FENTORA risk management program was expected and over the last four months we have been working diligently to prepare for implementation of the program as soon as possible. We anticipate that the subsequent letter from the agency will provide useful guidance to finalize the timeline for and implementation of ongoing enhancements to the risk management program,” said Dr. Lesley Russell, Executive Vice President and Chief Medical Officer at Cephalon. “We intend to put into place a REMS that we hope will not only demonstrate effectiveness for mitigating the risks associated with FENTORA but also pave the way for a new industry standard for opioid pain medications.”

To address the FDA’s request in the complete response letter, Cephalon plans to implement COVERS(TM), a first-of-its-kind initiative designed to minimize the potential risk of overdose from an opioid through appropriate patient selection. This innovative component of the FENTORA REMS program will educate and engage physicians, patients and pharmacists to assure that patients prescribed FENTORA are opioid-tolerant. Additionally, the company will continue to enhance its existing programs to mitigate risks associated with abuse and misuse.

FENTORA is currently approved for the management of breakthrough pain in opioid-tolerant patients with cancer (for full prescribing information, visit http://www.fentora.com/). The FENTORA sNDA, submitted by Cephalon in November 2007, is based on data from three randomized, placebo-controlled clinical trials in patients with chronic non-cancer pain conditions and one long-term open-label safety study with a total of 941 patients. The patients in these trials were treated for up to 18 months and had a broad range of underlying chronic pain conditions, including chronic low back and chronic neuropathic pain. In these trials, opioid-tolerant patients with chronic pain treated with FENTORA experienced statistically significant improvements in relief from breakthrough pain with an onset and duration of relief similar to that seen in studies of FENTORA in patients with cancer.

Cephalon, Inc.

Founded in 1987, Cephalon, Inc. is an international biopharmaceutical company dedicated to the discovery, development and commercialization of innovative products in four core therapeutic areas: central nervous system, pain, oncology and addiction. A member of the Fortune 1000, Cephalon currently employs approximately 3,000 people in the United States and Europe. U.S. sites include the company’s headquarters in Frazer, Pennsylvania, and offices, laboratories or manufacturing facilities in West Chester, Pennsylvania, Salt Lake City, Utah, and suburban Minneapolis, Minnesota. The company’s European headquarters are located in Maisons-Alfort, France.

The company’s proprietary products in the United States include: TREANDA(R) (bendamustine hydrochloride) for Injection, AMRIX(R) (cyclobenzaprine hydrochloride extended-release capsules), PROVIGIL(R) (modafinil) Tablets [C-IV], FENTORA, TRISENOX(R) (arsenic trioxide) injection, VIVITROL(R) (naltrexone for extended-release injectable suspension), GABITRIL(R) (tiagabine hydrochloride), NUVIGIL(TM) (armodafinil) Tablets [C-IV] and ACTIQ(R) (oral transmucosal fentanyl citrate) [C-II]. The company also markets numerous products internationally. Full prescribing information on its U.S. products is available at http://www.cephalon.com/ or by calling 1-800-896-5855.

In addition to historical facts or statements of current condition, this press release may contain forward-looking statements. Forward-looking statements provide Cephalon’s current expectations or forecasts of future events. These may include statements regarding anticipated scientific progress on its research programs; development of potential pharmaceutical products; interpretation of clinical results, including the results of the FENTORA clinical trials; prospects for final regulatory approval of FENTORA; manufacturing development and capabilities; market prospects for its products, particularly with respect to FENTORA sales and earnings guidance; and other statements regarding matters that are not historical facts. You may identify some of these forward-looking statements by the use of words in the statements such as “anticipate,””estimate,””expect,””project,””intend,””plan,””believe” or other words and terms of similar meaning. Cephalon’s performance and financial results could differ materially from those reflected in these forward-looking statements due to general financial, economic, regulatory and political conditions affecting the biotechnology and pharmaceutical industries as well as more specific risks and uncertainties facing Cephalon such as those set forth in its reports on Form 8-K, 10-Q and 10-K filed with the U.S. Securities and Exchange Commission. Given these risks and uncertainties, any or all of these forward-looking statements may prove to be incorrect. Therefore, you should not rely on any such factors or forward-looking statements. Furthermore, Cephalon does not intend to update publicly any forward-looking statement, except as required by law. The Private Securities Litigation Reform Act of 1995 permits this discussion.

Cephalon, Inc.

CONTACT: Media, Stacey Beckhardt, +1-610-738-6198, or cell,+1-610-247-0212, [email protected], or Candace Steele, +1-610-727-6231, orcell, +1-484-318-0804, [email protected], or Investor Relations, ChipMerritt, +1-610-738-6376, [email protected], all of Cephalon

Web site: http://www.cephalon.com/http://www.fentora.com/

Company News On-Call: http://www.prnewswire.com/comp/134563.html

US Envoy Hopes Bangladesh Ex-PMs to Work Together for Democracy

Text of report headlined “Khaleda, Hasina Should Work Together for Democracy, Says Moriatry” published by Bangladeshi newspaper The Daily Star website on 15 September

US Ambassador to Dhaka James Moriarty yesterday said the US hopes a free, fair and credible election is held by December with participation of all major political parties according to the EC’s roadmap.

“An elected government to represent all in January, which is better for democracy,” he said.

Welcoming the release of BNP chief Khaleda Zia and Awami League chief Sheikh Hasina, he said they hope the major political parties including the two leaders will work together, which would be good for democracy.

He was talking to local journalists during his visit to Kumudini Hospital in Mirzapur upazila of Tangail yesterday.

USAID Mission Director Denise Rollins, Director of Kumudini Welfare Trust Protibha Mutsuddi and Managing Director of Kumudini Complex Rajib Prasad Saha were also there.

During his visit, the ambassador inaugurated a USAID-supported medical ward in Kumudini Hospital. The ward provides treatment and rehabilitation facilities to women with obstetric fistula.

The ambassador was highly impressed with the quality of service provided at the hospital. He also praised Kumudini’s leadership in providing opportunities to girls in education, training and employment through Bharateswari Homes School, Kumudini Nursing School and College, the Women’s Medical College and the hospital.

James Moriarty later watched a performance by students of Bharateswari Homes.

Originally published by The Daily Star website, Dhaka, in English 15 Sep 08.

(c) 2008 BBC Monitoring South Asia. Provided by ProQuest LLC. All rights Reserved.

Anthrax Emergency Declared in Southern Kyrgyz District

Text of report by privately-owned Kyrgyz AKIpress news agency website

Batken, 15 September: A state of emergency has been declared in Kadamdzhay District of Batken Region [in southern Kyrgyzstan] due to an outbreak of anthrax.

The Kadamdzhay district administration reported that two sources of the disease had been registered in the villages of Uchkorgon and Markaz.

“Now 11 residents of these villages have been taken to hospital with suspected anthrax. The anthrax diagnosis was confirmed in five of them, with one of them in a serious condition,” the deputy head of the district administration, Turgunay Aytmatova, said. The patients are provided with a sufficient amount of medicine necessary for the treatment, she added.

Originally published by AKIpress news agency website, Bishkek, in Russian 0403 15 Sep 08.

(c) 2008 BBC Monitoring Central Asia. Provided by ProQuest LLC. All rights Reserved.

Video: Keppra XR(TM) Approved in the U.S.

ATLANTA, Sept. 15 /PRNewswire/ — press release, regulated information: UCB announced today that the U.S. Food and Drug Administration (FDA) has approved Keppra XR(TM) (levetiracetam extended-release tablets) for use as an add-on to other antiepileptic treatments for people with partial-onset seizures who are 16 years of age and older. Keppra XR(TM) is expected to be available in U.S. pharmacies at the end of September 2008.

To view the Multimedia News Release, go to: http://www.prnewswire.com/mnr/keppra/34625/

The goal of therapy with antiepileptic drugs (AED) is freedom from seizures and minimal side effects. While many people with epilepsy are successfully treated with one or more of the currently available antiepileptic drugs, a significant percentage still live with uncontrolled seizures or intolerable side effects.

“With solid clinical trial data supporting Keppra XR(TM) efficacy and tolerability, this once-daily antiepileptic drug can play an important role in treating people with epilepsy,” said lead investigator Dr. Jukka Peltola, Department of Neurology, Tampere University Hospital, Finland. “We found in the clinical trial that Keppra XR(TM) provided significant partial onset seizure control in once-daily dosing when added to other antiepileptic drugs and that it was generally well-tolerated.”

Building On A Trusted Heritage

“This is one of many milestones at UCB to develop new treatment options for people with epilepsy,” said Troy Cox, Senior Vice President UCB & President CNS Operations. “Keppra XR(TM) provides a way to simplify treatment and offers another chance to achieve seizure control, which is an important goal for patients living with epilepsy.”

The immediate release tablet form of Keppra(R) (levetiracetam) was first approved by the FDA in 1999 as adjunctive therapy in the treatment of partial onset seizures in adults with epilepsy. Since then, Keppra(R) has become the leading antiepileptic drug in the U.S.

Important Safety Information

Keppra XR(TM) extended-release tablets are indicated as adjunctive therapy in the treatment of partial onset seizures in patients 16 years of age and older with epilepsy.

Keppra XR(TM) causes somnolence, dizziness, and behavioral abnormalities. The most common adverse reactions observed with Keppra XR(TM) in combination with other AEDs were somnolence and irritability.

The adverse reactions that may be seen in patients receiving Keppra XR(TM) are expected to be similar to those seen in patients receiving immediate- release Keppra(R) tablets.

Keppra(R) immediate-release tablets cause somnolence and fatigue, coordination difficulties, and behavioral abnormalities (e.g., psychotic symptoms, suicidal ideation, and other abnormalities), as well as hematological abnormalities. In adults experiencing partial onset seizures, the most common adverse reactions observed with Keppra(R) in combination with other AEDs were somnolence, asthenia, infection and dizziness.

Keppra XR(TM) should be gradually withdrawn to minimize the potential of increased seizure frequency.

Dosing must be individualized according to the patient’s renal function status. The dosage should be reduced in patients with impaired renal function receiving Keppra XR. In patients with end stage renal disease on dialysis, it is recommended that immediate-release Keppra(R) be used instead of Keppra XR(TM).

For full prescribing information, please see http://www.keppraxr.com/.

In order to ensure patient access to this valuable medication in the U.S., UCB is initiating a co-pay support program. For more information, contact U.S. UCB Medical Information at 1-866-822-0068 (press 9).

About Epilepsy

Epilepsy is a chronic neurological disorder affecting approximately three million people in the US-making it more common than multiple sclerosis and Parkinson’s disease combined. It is caused by abnormal, excessive electrical discharges of the nerve cells, or neurons, in the brain. Epilepsy is characterized by a tendency to have recurrent seizures and defined by two or more unprovoked seizures. There are many different seizure types and epileptic syndromes. Forty percent of patients taking only one AED continue to experience seizures, and approximately 30% of patients taking adjunctive therapy continue to experience seizures. This highlights the ongoing need for the development of new AEDs. For more information about epilepsy, visit http://www.epilepsyfoundation.org/, http://www.epilepsy.com/, or http://www.epilepsyadvocate.com/.

   Further information   Andrea Levin, Public Relations Manager, CNS, UCB U.S.   T +1.770.970.8352, [email protected]    Eimear O'Brien, Global CNS Communications Manager, UCB Group   T +32.2.559.9271, [email protected]   

Antje Witte, Vice-President Corporate Communications & Investor Relations, UCB Group

   T +32.2.559.9414, [email protected]    About UCB  

UCB (Brussels, Belgium, http://www.ucb-group.com/) is a global leader in the biopharmaceutical industry dedicated to the research, development and commercialization of innovative medicines with focus on the fields of central nervous system and immunology disorders. Employing around 12,000 people in over 40 countries, UCB achieved revenue of EUR 3.6 billion in 2007. UCB is listed on Euronext Brussels (symbol: UCB).

Forward looking statement

This press release contains forward-looking statements based on current plans, estimates and beliefs of management. Such statements are subject to risks and uncertainties that may cause actual results to be materially different from those that may be implied by such forward-looking statements contained in this press release. Important factors that could result in such differences include: changes in general economic, business and competitive conditions, effects of future judicial decisions, changes in regulation, exchange rate fluctuations and hiring and retention of its employees.

Video: http://www.prnewswire.com/mnr/keppra/34625

UCB

CONTACT: Andrea Levin, Public Relations Manager, CNS, UCB U.S.,+1-770-970-8352, [email protected], or Eimear O’Brien, Global CNSCommunications Manager, UCB Group, +32-2-559-9271,[email protected], or Antje Witte, Vice-President CorporateCommunications & Investor Relations, UCB Group, +32-2-559-9414,[email protected]

Web site: http://www.ucb-group.com/http://www.keppraxr.com/http://www.epilepsyfoundation.org/http://www.epilepsy.com/http://www.epilepsyadvocate.com/

An Alternative to Jail

By COURTNEY BLANCHARD

A numbers problem An estimated 16 percent of America’s prison inmates suffer from a mental illness, compared to 5 percent of the general population, according to 2002 data collected by the Criminal Justice/Mental Health Consensus Project. News You can use

Timothy Bribriesco stands more than 6 feet tall, and tattoos stretch over his 350-pound frame. But last week, the man’s voice wavered with an unexpected vulnerability. As he sat in the Dubuque County Jail, he called his mother and began to sob.

Another woman was vying for his attention: Lindsey.

“She tells me bad things, laughing at me,” Bribriesco, 32, told his mother, Deb Bykowsky. “She’s just evil.”

Lindsey appears as a suggestive tattoo on his right arm. With bright-red lips and yellow fishnet stockings, she resembles a tattoo parlor cliche, but her presence on Bribriesco’s arm is sinister to him.

Lindsey is a voice, a symptom of schizophrenia, which has haunted him since he was 14.

When she speaks, the big man nestles his chin into his right arm, and anger clouds his face, Bykowsky said. Lindsey once told him to run over a goat on a riding lawn mower at their farm in rural Linn County, Iowa, she said.

He stopped just short of it, knocking the animal off its feet.

Bykowsky worried about her son while he sat in jail, because he told her that he hadn’t received at least seven of his medications, including one for schizophrenia. Without it, she said, the voice gets worse.

But Dubuque County Jail officials say Bribriesco received all necessary medications. Dr. Norman Johnson, chief executive officer of the jail’s health care provider, Advanced Correctional Healthcare, said he received treatment based upon the jail doctor’s evaluation and recommendations from federal authorities.

“This guy is getting virtually everything. He’s manipulating, he’s violent,” Johnson said. “He’s actually swung at our nurses. He’s very difficult. In spite of all of this, our nurses are doing yeoman’s work. He is getting excellent care.”

Inmates like Bribriesco present a challenge to county jails, which are not equipped to deal with growing numbers of mentally ill inmates – especially those with violent tendencies.

However, mental illness of all varieties presents a strain on the corrections system. Law enforcement and community members address the problem with treatment options and alternatives to jail.

In Dubuque, the alternative is the jail diversion program.

Closing the revolving door

While violent, mentally ill inmates are rare at the Dubuque County Jail, many inmates have some kind of substance abuse problem or mental illness. About a third of Iowa’s prison inmates are mentally ill, and half of female inmates suffer from a mental illness, according to a 2006 report by the Iowa Department of Corrections.

When mentally ill inmates find treatment and support, they’re less likely to move in and out of jail, experts say. In Dubuque County, support programming evolved from a $1 million grant for a three-year jail diversion program, which kicked off in 2003.

Under the program, police officers learned to recognize the signals of a mental illness. When officers encountered someone with a possible mental illness, they called a mobile counselor to evaluate the person and, in some cases, referred the individual to a treatment center instead of the jail. Then, case managers guided the person through the judicial process and sought services to stabilize the person’s diagnosis.

Mood disorders, depression, bipolar disorder and anxiety topped the list of diagnoses, according to county data.

The varying forms of mental illness made everyday activities difficult, said Joel Lightcap, former director of the program. He remembers one participant who didn’t know how to get from his apartment to the doctor’s office. Lightcap bought a bus ticket and rode with him to the clinic. After his next appointment, the man stopped by Lightcap’s office.

“He comes in with a big smile on his face and he says,’I know how to get up there now!”” Lightcap said. “For him, it was a major accomplishment. For the average person, he got on a bus and went to a medical appointment. No big deal.”

When the grant ran out after three years, the county handed the reins to the Iowa Department of Corrections and eventually set aside around $72,000 annually to create a community treatment coordinator position, to find services for mentally ill inmates.

A question of control

Some worry that the slimmed-down funding doesn’t cut it.

Former Dubuque City Council member Ann Michalski said she expected local sources to keep the diversion program going at the same level of funding after the federal grant ran out.

“At the end of that three years, things were better but the system had not totally changed,” she said. “It really had the potential to do remarkable things if it had been funded fully.”

Lightcap said he was skeptical about the Department of Corrections’role.

“The Department of Corrections has the power to just throw (participants) in jail for violations,” he said. “You really can’t be an advocate if you’re tied into an agency that has that much ability to have control over people.”

Nathan Duccini begs to differ. Hired as the department’s community treatment coordinator in February 2007, Duccini has worked with nearly 100 clients. Fewer than a dozen went back to jail, he said.

“Almost all of them have wanted help, and they come in here desperate, wondering why they couldn’t get the help,” he said. “I have people who show up on a daily basis, and I don’t require it.”

Kyle Stewart, probation and parole supervisor, said the jail diversion program paved the way for unprecedented community collaboration. Agencies addressing homelessness, substance abuse, mental illness and job placement banded together to give Duccini the resources to help inmates acclimate to life outside of jail.

“We’re finally addressing the mental health issues within our own community and not just closing our eyes to what’s going on right in front of us,” Stewart said.

Saving money and lives

Dubuque Police Chief Kim Wadding said diversion efforts can appear costly and ominous for law enforcement agencies, but it saves time and money in the long run.

“We benefit not only ourselves, as far as saving resources, but we really, truly save the person,” he said.

Law enforcement officials point to voluminous data indicating that the costs of community-based programming such as jail diversion initiatives are significantly less than the cost of incarceration.

The Jail Diversion Committee, which has met regularly since the end of the federal grant, is considering establishing a Community Accountability Board, similar to a program run by Black Hawk County. Upon release, the inmate sits down with a group of corrections personnel, social service providers and people from the faith community to engage in an active discussion on his or her future, said Todd Lange, president of Dubuque National Alliance on Mental Illness, who recently observed a panel in Black Hawk County.

“It seemed like we’re dealing more with concrete problems and issues, there’s more solution-focus. You’re dealing with someone with more of a real-world situation,” Lange said.

A system’in transit’?

As communities continue to move forward with programming to help inmates with mental illness, there’s still a hole in the system for the most extreme cases.

Dubuque County Sheriff Ken Runde said most jails aren’t equipped to handle inmates with violent mental illness. Over the past few years, he sent two mentally ill and violent inmates to the Iowa Medical and Classification Center in Oakdale, Iowa, after a struggle over where to go.

“Corrections will be the first to tell you that the mentally ill shouldn’t be in our jails,” Runde said. “We can’t deal with them because we don’t have the medications to deal with them. When they’re on some of the particular medications they need, we don’t have the machines to monitor them, and we don’t have the restraining tools to restrain them if they need restraining.”

Bribriesco left the Dubuque County Jail and was listed “in transit” Friday, according to the Federal Bureau of Prisons. He’s been shuffled from facility to facility, and Bykowsky said she feels like people are just trying to get rid of her son.

When Bykowsky spoke to her son on Tuesday, she said his mental health medication had been replaced with an older psychiatric drug. He didn’t respond well to it.

“He’s decompensating (deteriorating mental health) really bad. I said just go to your bunk, think of pleasant things, take it a minute at a time,” she said. “He said he feels like he’s dying.”

Originally published by COURTNEY BLANCHARD TH staff writer/cblanchard@wcinetcom.

(c) 2008 Telegraph – Herald (Dubuque). Provided by ProQuest LLC. All rights Reserved.

Hospitals Face Bug Bust Hits

BUG buster teams are set to carry out hygiene spot-checks at Scots hospitals.

Health centres and GP clinics will also be subject to inspections, which will take place without advance warning.

The teams will ensure all health workers are keeping up cleanliness standards.

Nine people died after being infected with Clostridium difficile during an outbreak at the Vale of Leven Hospital in Alexandria, Dunbartonshire.

In total, 55 people were affected by the bug between December last year and June this year.

Health minister Nicola Sturgeon has said that higher standards of inspection and monitoring are required and has not ruled out a public inquiry.

She said: “The new method of assessment that NHS boards will now be required to follow is in the process of development but it must be independent, robust and transparent to all.”

(c) 2008 Daily Record; Glasgow (UK). Provided by ProQuest LLC. All rights Reserved.

Girling Health Care Employees and Patients Urged to Call for Instructions

AUSTIN, Texas, Sept. 14 /PRNewswire/ — Girling Health Care, a home health company with employees and patients throughout the areas affected by Hurricane Ike, are urged to follow the following procedures in order to reconnect patients with their caregivers.

Girling employees: Call your home office for instructions; all phones have been rolled over to a remote location and will be answered.

Girling patients: Call your local office; phones have been rolled over to a remote location and will be answered. If you have evacuated to another city, it is possible that care can be arranged by caregivers in that location.

If employees or patients have any problems with the local phone numbers, please call 1-800-GIRLING.

About Girling Health Care

Girling Health Care provides a variety of home health and personal care services for clients in Florida, Illinois, Iowa, Missouri, New York, Oklahoma, Tennessee, Texas and West Virginia. Services include skilled nursing, occupational therapy, medication management and cardiac pulmonary care, among others. Girling’s largest market is Texas, where it operates in more than 20 cities throughout the state. Girling Health Care is a member of the Harden Healthcare family of companies. For more information, visit http://www.girling.com/.

   Contact: Meg Meo            512-924-8932 or            [email protected]  

Girling Health Care

CONTACT: Meg Meo for Girling Health Care, +1-512-924-8932,[email protected]

Web site: http://www.girling.com/

Afghan Weekly Expects Further Food Price Hikes

Text of article in English by Muhsen Nazari entitled “Further food price hikes expected” published by independent Afghan newspaper Kabul Weekly on 10 September

The cost of food and fuel in Afghanistan shot up this year with some items even doubling in price from last year. Now importers are warning the government of a further 30 per cent rise by the end of the year.

Last December the government of Pakistan stopped the private sector from exporting wheat to Afghanistan after the increase in world food prices. Consequently, the price of flour, oil and rice doubled and prices of basic food items increased by 30 per cent to 50 per cent. According to the business sector, a further 30 per cent increase in prices would make it impossible for consumers to purchase goods and would create a crisis for the country.

The price of a 100kg bag of Pakistani wheat was 1,600 Afghanis last year, now the price is 3,500 Afghanis. Similarly the price of a five litre can of oil, which cost 250 Afghanis last year, now costs 550 Afghanis. The price of one litre of gas has doubled from last year. In the meantime, although the price of petrol and diesel has decreased in the international market in recent months, in Afghanistan it has remained the same. The price for one litre of petrol jumped from 28 Afghanis to 52 Afghanis during the last eighteen months. So the question is why is the private sector warning of another 30 per cent increase in prices by the end of the year?

While the Afghan government blames the private sector for the price increases, directly or indirectly, businesses say that the main reason for the increases is the lack of planning by government. “Since last year, our imports from Pakistan have been stopped. At the moment, we import food items, particularly wheat from Kazakhstan and the Ukraine. The harvest time for wheat in these countries is over and there are signs that these countries will decrease their exports next year”, said Engineer Mohammad Shafi Ahmadi, head of the Food Sellers Union.

Lack of strategic reserves and the deterioration of the security situation on highways are the main reasons for the price increases, said Ahmadi. The costs for transporting imported goods are now 40 per cent higher than last year. This does not include unofficial payments, which increase day by day. “Taking into account all these factors, we want the government to take appropriate action, otherwise a further 30 per cent increase will be unavoidable,” said Ahmadi.

In the past, all food items for government offices were supplied by the central silo and did not come from the markets. But at present, everyone is reliant on the markets. Even the Afghan National Army (ANA) buys its bread from the markets. This causes an increase in demand which in turn increases the prices.

Landlocked countries who import their basic needs, including food, from other countries are completely dependent on their neighbours, says deputy minister of commerce and industry, Ziaudin Zia. “Even the smallest political, transport and business issues can impact prices immediately. The warning from Afghan importers is more of a prediction, not a reality. We accept that the security situation has worsened, but the government has ordered the Defence and Interior Ministries to take appropriate action. Also, the surplus of food items in the city’s markets shows that price decreases are possible,” said Zia.

At the moment the majority of wheat supplies for Afghanistan are being smuggled from the other side of the Durand Line, (Miramshah, Khost border and Wazirestan). The recent unrest in the Northwest Frontier Province caused a fall in imports from Pakistan which negatively impacted prices.

But how can we control this situation? According to Khan Jan Alakozay, the deputy of ACCI, taking into account the free market policies of the government, prices cannot be controlled directly. “However, we can indirectly encourage businessmen to invest by importing food. This is an ongoing process. Some of our businessmen in Herat and Mazar-e Sharif have promised to sign contracts to import wheat from neighbouring countries. In the meantime, we have requested the government to build food reserves as soon as possible, so that in times of emergency ANA units will not empty the markets,” said Alokozay.

Originally published by Kabul Weekly in English 10 Sep 08.

(c) 2008 BBC Monitoring South Asia. Provided by ProQuest LLC. All rights Reserved.

Mass Casualty in an Isolated Environment: Medical Response to a Submarine Collision

By Jankosky, Christopher John

ABSTRACT On January 8, 2005, the U.S.S. SAN FRANCISCO (SSN 711), a nuclear-powered submarine, collided with a seamount in a remote Pacific Ocean location. The high-speed impact resulted in injuries to 90% of the crew. Subsequent emergency medical response is described as well as the 3-month physical and psychological morbidity. Recommendations for medical training, equipment, and policy for workers in isolated environments are discussed. INTRODUCTION

Developing medical guidance for a possible catastrophic event requires extensive planning. Within the past decade, events in major metropolitan areas have seen the health care system strain under unexpected events. These include the severe acute respiratory syndrome outbreak in Toronto, the health effects following the collapse of the World Trade Center in New York, and access to health care immediately following Hurricane Katrina in New Orleans. These events reinforce the need to provide adequate training and equipment for potential crises precipitated by accidents, man-made and natural disasters, and infectious diseases. Thus, contingency planning for a mass casualty event has taken on increased importance in recent years.1 In 2006, disaster preparedness and emergency management was added as a core competency in occupational and environmental medicine.2

Disaster preparedness becomes more difficult when a crisis occurs far from metropolitan areas. Response to events in remote locations, such as those that occurred following the 2004 Indian Ocean Tsunami, may be delayed by distance, transportation, and other political and logistical factors. Perhaps the most isolated health care environment is aboard a deployed submarine. U.S. Navy nuclear- powered submarines are designed to deploy for months at a time throughout the world’s oceans. Deployment duration is generally limited only by the amount of food that can be carried on board. It is recognized that during certain operational missions, such as traveling under the polar ice caps, patients are weeks or days away from additional medical care. To reduce the rate of seriously ill personnel, submariners are some of the most rigorously screened and monitored individuals in the military.3 The result is a young crew (average age mid-20s) with excellent baseline health.

While at sea, there is always a submarine-independent duty corpsman (IDC) on board. The IDC graduates from a 12-month course of clinical, laboratory, and radiological training at the Naval Undersea Medical Institute (Groton, Connecticut). Training includes 4 weeks of critical care at Yale-New Haven Medical Center (New Haven, Connecticut). On the submarine, an emergency medical assistance team (EMAT) assists the IDC in basic medical care, including activities such as patient transport and placing of intravenous lines. It is composed of crew members who are formally trained by the boat IDC. These skills are taught on a weekly basis, and proficiency is tested with periodic drills. Some EMAT members may have completed additional civilian training as emergency medical technicians (EMTs). Medical equipment carried on board includes basic laboratory equipment, an automatic defibrillator, over 200 different medications, and additional medical supplies. The IDC in most cases is able to communicate with a shore-based undersea medicine physician via satellite. Despite extensive planning to maintain a robust medical capability, unexpected events will continue to test the current system.

CASE REPORT

On January 8, 2005, the U.S.S. SAN FRANCISCO (SSN 711), a nuclear- powered submarine, collided with a seamount (a mountain rising from the ocean seafloor that does not reach to the water’s surface) in a remote Pacific Ocean location. The submarine’s homeport of Guam was the closest port, more than a 2-day sail. There were 138 individuals on board. There was no warning of a collision so the crew did not have an opportunity to brace themselves. The ensuing high-speed impact resulted in injuries to 90% of the crew. The intensity of the energy transfer can be visualized by the external damage to the bow of the submarine (Fig. 1).

On initial report, there were 2 severely injured personnel, 22 personnel requiring prompt medical attention, and 32 individuals with notable injuries not requiring prompt medical attention. Most of the remainder had only minor injuries. Approximately 10% of the crew was completely free of physical injury. Uninjured personnel were generally located in tightly enclosed spaces such as a bathroom stall or sleeping bunk.

The IDC was one of the uninjured. His attention was immediately drawn to the two most severely injured patients. Two crew members with some previous medical experience assisted him in caring for the other injured personnel. Injuries requiring the most urgent attention included head trauma, fractures, and lacerations (Table I). There were no initial reports of psychiatric casualties. All capable crew members manned their stations and ensured the continued operation of their boat.

One patient was thrown multiple feet at the time of the collision and suffered a fatal injury. He suffered immediate loss of consciousness from massive cerebral injury associated with a basilar skull fracture. He never regained consciousness. The IDC spent the majority of the next 24 hours tending to this patient as every effort was made to evacuate him for urgent neurosurgical care.

Adverse weather and sea state precluded transfer of medical personnel from a surface vessel that arrived ~18 hours postcollision. At ~24 hours postcollision, a helicopter arrived on the scene and was able to transport a medical team on board. They treated the crew until return to port the following day. A psychiatric team (consisting of a psychiatrist, a psychiatric technician, and a chaplain) boarded the submarine as it was coming in to the harbor in Guam. Before docking, the team interviewed individuals thought to be in need of immediate support. Upon arrival, 29 patients were transported to the emergency room at U.S. Naval Hospital Guam for further evaluation of physical injuries. Three patients were admitted to the hospital. One was admitted for a pneumocephaly with zygomatic and rib fractures. The second was admitted for a lumbar spine fracture, and the third for a fracture of the thyroid cartilage.

Three months after the collision, >85% of the crew was healthy and had no significant residual problems. Medical conditions precluding return to full duty were predominantly associated with mental health (Table II). After the 3-month evaluation was performed, it became more difficult to track all personnel. The boat completed a successful surface transit to Puget Sound Naval Shipyard for repairs, and much of the crew was dispersed to other commands at different locations. Most of the submariners disqualified for mental health reasons were transferred to nonsubmarine assignments. In the 2 years since the collision, all patients with physical injuries returned to submarine duty, although two additional crew members were disqualified from submarine duty due to psychiatric conditions.

DISCUSSION

Immediately after the ship’s return to Guam, a detailed evaluation of the medical response was initiated. Recommendations for improvements to submarine emergency preparedness and disaster response identified by the evaluation were implemented. New policies were directly applied to the entire U.S. submarine fleet, currently composed of 68 nuclearpowered submarines. Newly implemented policies have been tracked over the past 2 years to confirm completion and obtain feedback. The major policy changes can be placed in the following three categories: communications, training, and postcollision follow-on care.

Medical advice was provided to the U.S.S. SAN FRANCISCO from the Command Center at Submarine Force, U.S. Pacific Fleet (Pearl Harbor, Hawaii). The Command Center has decades of experience in responding to requests for medical advice from submarines. The force surgeon maintained a continuous physician rotating watch schedule for the 24- hour period before the physician team boarded the submarine. Often more than one physician was present, providing significant benefit since there were multiple simultaneous medical taskings. The most time-intensive tasking was to arrange care for the unconscious patient with the severe head injury. The situation was complicated by the fact that there was no neurosurgeon in the territory of Guam at the time of the collision. Plans were set in motion for a neurosurgeon to be flown to Guam (with equipment) from a base in Okinawa, Japan. Meanwhile, a general surgeon was identified to escort the patient via helicopter from the submarine to Guam Naval Hospital.

The demands of long duration medical communication via voice and naval message traffic are significant. Clear transfer of medical information, coupled witii confirmatory mechanisms, is required to avoid errors. Two approaches were taken to prepare for future incidents. First, a dedicated educational element was added to training at the Naval Undersea Medical Institute. All undersea medical officers, as well as all IDCs, are taught the basics of secure satellite communications, secure Internet chat groups, and other mechanisms that were used during this event. Second, a comprehensive Submarine Command Center Medical Guidebook was developed. The guidebook is updated annually to ensure contact information and communication procedures remain accurate. The medical response to this collision was outstanding, wim adequate medical supplies and appropriate care given to all casualties. Such success validated the annual update of required medical supplies currently in place, as well as the U.S. Navy’s submarine training pipeline for medical providers. However, there were some fortuitous events in this case. The event could have ended much differently. Most noticeably, the IDC was one of the few uninjured personnel. Additionally, there were two crew members wim some previous medical training (one as an EMT, one as a junior corpsman before he became a submarine officer). Although neither had been assigned as a member of the EMAT, these two individuals were essential in providing care to the injured crew. Following the collision, a survey of Hawaii submarines confirmed that on each boat there was generally only one nonIDC crew member who had an EMT level of knowledge. There was no mechanism to improve the availability of a backup for an injured corpsman, or one overwhelmed by a mass casualty.

A policy was initiated to require additional EMT-trained personnel on each submarine crew. At least one individual witii formal EMT training would then be available to assist the IDC. Volunteers for EMT training were drawn from that crew subset of young men with an interest in medicine, firefighting, or other emergency response fields. In 2006, 25 Hawaii submariners completed EMT training at Tripler Army Medical Center. Similar local EMT training programs were used at other submarine bases.

EMAT training requirements were increased, including a requirement for more frequent patient transport drills through the submarine and at all egress points out of the submarine. This was prompted by difficulties in maneuvering patients on stretchers following the collision. Because there are a variety of different submarine designs and modifications, the more inclusive annual drills have resulted in proactive solutions to solving difficult patient maneuvering problems specific to each individual submarine.

Detailed tracking of follow-on care was performed for all physical injuries sustained from the collision. This was of particular importance since patients with chronic intermittent musculoskeletal pain are often unable to tolerate submarine deployments. The submarine living spaces can cause strain to the human body. Sleeping areas are individual bunks stacked three high, with additional space limitations in working and living areas. Physical injuries were closely tracked so as to ensure appropriate and timely rehabilitation, allowing the return to work at 3 months by all but two patients with physical injuries.

Despite a robust proactive program to identify and treat mental health conditions associated with the collision, psychiatric disorders were the overwhelming reason for the departure of men at the 3-month point. Previously published reports have recognized the potential for the development of post-traumatic stress disorder and omer mental healtii conditions.4,5 Naval Hospital Guam dedicated all tiieir resources to the survivors, as well as arranging support for spouses and families with a school psychologist and licensed social workers from the U.S. Navy Fleet and Family Services Center.

After the collision, there were 17 submariners within the first 3 months who required follow-up psychiatric care for conditions that would possibly impact their ability to perform their submarine duties. There was no correlation between the degree of physical injury suffered during the collision and the development of a psychological condition. Despite efforts to retain all submariners in their current occupation, 3 months postcollision only 2 of 17 mental health patients had returned to full submarine duty.

The relatively large number of psychiatric casualties following the collision may be partially attributed to the strict psychiatric criteria for submariners. However, similar psychiatric morbidity was seen following an at-sea collision in 1975. The U.S.S. BELKNAP, a guided missile cruiser, suffered an at-sea collision resulting in the death of seven personnel.6 Eighteen of the surviving 329 men, none of whom had been hospitalized previously, required psychiatric hospitalization within the next 3 years. Thirteen of the men were hospitalized for neuroses, compared to only one man from a different guided missile cruiser used for comparison. Although each situation is unique, and the practice of psychiatry can vary over time and between geographic regions, it is likely that psychiatric diagnoses will continue to be common following future mass casualty events at sea.

CONCLUSIONS

This case offers insights into three areas that can be generalized to all disaster preparedness plans in isolated environments. First, update your plans according to advances in both verbal and Internet communication capabilities. There are now 3.3 billion worldwide mobile telephone subscriptions.7 Electrocardiogram strips, medical photographs, and patient videos can be sent via satellite from remote locations. Medical equipment previously thought too complex may now be reasonably deployed in an isolated environment if an expert can provide reliable long distance guidance. Second, ensure routine drills are performed for transport and evacuation of casualties. Medical personnel may not be informed when engineers or mechanics make alterations to the physical plant that affect passageways, ladders, and egress routes. Third, ensure that a written plan is in place to provide an early and robust medical response, including mental health resources for patients and their families. Physicians responsible for care of individuals in isolated environments are obligated to consider the potential for a worst case scenario, planning and drilling accordingly. These plans should be re-examined annually, so as to adjust to changes and maintain an effective emergency preparedness posture.

ACKNOWLEDGMENTS

I am grateful to Dr. Dwayne DePry for his provision of outstanding psychiatric care to the submarine community in Guam and his assistance in collection of the mental health data.

REFERENCES

1. Sklar DP, Richards M, Shah M, Roth P: Responding to disasters: academic medical centers’ responsibilities and opportunities. Acad Med 2007; 82: 797-800.

2. ACOEM Board of Directors: Disaster Preparedness and Emergency Management as a Core Competency in Occupational and Environmental Medicine. Elk Grove Village, IL, American College of Occupational and Environmental Medicine, January 28, 2006.

3. NAVMED P-117: Manual of the Medical Department. Change 126. Washington, DC, U.S. Navy, August 12, 2005.

4. Sokol RJ: Early mental health intervention in combat situations: the USS Stark. Milit Med 1989; 154: 407-9.

5. Campfield KM, Hills AM: Effect of timing of critical incident stress debriefing (CISD) on post traumatic symptoms. J Trauma Stress 2001; 14: 327-40.

6. Hoiberg A, McCaughey BG: The traumatic aftereffects of a collision at sea. Am J Psychiatry 1984; 141: 70-3.

7. Global cell phone use at 50%. Washington Post, November 29, 2007. Available at http://www.waslungtonrx)st.com/wp-dyn/content/ article/2007/ 11/29/AR2007112901242.html?sub=AR; accessed December 3, 2007.

CDR Christopher John Jankosky, MC USN

Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, Room A2056, 4301 Jones Bridge Road, Bethesda, MD 20814-4712.

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 U.S. government.

This manuscript was received for review in January 2008. The revised manuscript was accepted for publication in April 2008.

Copyright Association of Military Surgeons of the United States Aug 2008

(c) 2008 Military Medicine. Provided by ProQuest LLC. All rights Reserved.

Memorandum on Potential Marine Conservation Management Areas

By Bush, George W

August 25, 2008 Memorandum for the Secretary of Defense, the Secretary of the Interior, the Secretary of Commerce, and the Chairman of the Council on Environmental Quality

Subject: Potential Marine Conservation Management Areas

The Chairman of the Council on Environmental Quality has advised me there are objects of historic and scientific interest in areas under the jurisdiction of the United States that may be appropriate for recognition, protection, or improved conservation and management under available authorities including by executive order or action under the Magnuson-Stevens Fishery Conservation and Management Act (16 U.S.C. 1801 et seq.), Outer Continental Shelf Lands Act (43 U.S.C. 1331 et seq.), National Marine Sanctuaries Act (16 U.S.C. 1431, et seq.), or the Antiquities Act (16 U.S.C. 431). These objects include:

In the central Pacific, coral reefs, pinnacles, sea mounts, islands and surrounding waters of Johnston Atoll, Howland, Baker and Jarvis Islands, Kingman Reef, Palmyra Atoll, Wake Island, and Rose Atoll that are isolated from population centers, mostly uninhabited, and support endemic, depleted, migratory, endangered and threatened species of fish, giant clams, crabs, marine mammals, sea turtles, seabirds, migratory shorebirds and corals that are rapidly vanishing elsewhere in the world. The reefs in these areas support unique localized upwellingbased productivity, and two of the atolls are repositories of the larvae of many marine species transported from the biodiversity-rich western Pacific.

In the western Pacific Ocean, the marine waters around the northern islands of Commonwealth of the Northern Mariana Islands, including the Mariana Trench, that offer an exceptional and diverse collection of marine life and habitat.

Please provide to me your assessment, with relevant supporting information, including the views of the territorial and local governments and other interested parties, of the advisability of providing additional recognition, protection or improved conservation and management for objects of historic or scientific interest at these islands, coral reefs, geologic features and surrounding marine waters.

Because Johnston Atoll and Wake Island have supported active military bases, and the other areas in the Pacific include areas of strategic importance to the United States, any measures your assessment recommends should not limit the Department of Defense from carrying out the mission of the various branches of the military stationed or operating within the Pacific and shall be consistent with freedom of navigation and international law. Please also consider cultural, environmental, economic, and multiple use implications of any measures you recommend, including the extent to which they are compatible, if applicable, with sustaining access to: (1) recreational and commercial fishing; (2) energy and mineral resources; and (3) opportunities for scientific study.

With respect to each of these areas, your assessment should further identify whether there are opportunities and mechanisms for improved coordination of management among relevant agencies in accordance with Executive Order 13366 of December 17, 2004.

George W. Bush

Copyright Superintendent of Documents Sep 1, 2008

(c) 2008 Weekly Compilation of Presidential Documents. Provided by ProQuest LLC. All rights Reserved.

Atypical Presentation of a Retrorectal Ancient Schwannoma: A Case Report and Review of the Literature

By Santiago, Camilo Lucha, Paul A

ABSTRACT Retrorectal tumors are rare and frequently present either incidentally or with vague symptoms. Schwannomas of the presacral region are one variant described as benign tumors of neurogenic origin. The “ancient degenerative variant” is uncommonly reported. We present the case of a 37-year-old man presenting with symptoms of left renal colic, impotence, and left trochanteric pain. Computed tomography and magnetic resonance imaging of the pelvis showed a presacral mass with cystic changes and calcifications consistent with a schwannoma. The patient underwent an exploratory laparotomy with resection of the tumor, which subsequent analysis showed to be a schwannoma with ancient degenerative changes. INTRODUCTION

Retrorectal tumors present infrequently and comprise a variety of pathologic entities mat originate from the various tissue types present in the presacral space. These tumors represent ~1 in every 40,000 hospital admissions. In retrospective reviews, 50 to 57% were pathologically benign and 26% were asymptomatic.1,2 Presacral schwannoma is one of the described pathologic entities representing ~1 in 250 of all retrorectal tumors and is frequently present as a solitary mass.3 The most common presentation is as an incidental finding on routine rectal or pelvic examination; however, they may present with a variety of symptoms ranging from chronic pelvic and back pain, impotence, lower extremity pain and numbness, urinary incontinence and/or retention, and, rarely, renal colic symptoms. If the neurologist is asked to work up a radiculopathy, he or she might shift attention postelectromyelogram to proximal nerve roots and may choose a myelogram as the imagery of choice. Consideration should be addressed toward the abdominal cavity and a computed tomography (CT) or magnetic resonance imaging (MRI) addressing the abdomen and spinal chord should be entertained. This wide range of symptoms makes it difficult to suspect a retrorectal tumor based on clinical history and physical alone.4 Most patients do not experience symptoms until the mass has grown to a significant size; some experts estimate that symptoms may not occur for 7 years or more.5,6

Most schwannomas (85%) present as masses off midline arising along the course of any myelinated nerve and coursing into one of the sacral foramina; they are frequently palpable on rectal or pelvic examination.7 The patient should undergo a complete blood count, fecal occult blood examination, and a urinalysis with microscopic evaluation, to screen for the possibility of a gastrointestinal malignancy, a potential urologic malignancy or pathology, or gynecologic malignancy or pathology. Biopsy, transrectal or otherwise, is to be avoided to prevent sepsis, meningitis, abscess, or tumor seeding.1,2 Often mese laboratory studies are normal or inconclusive and imaging using CT or MRI is advised. The most common imaging study obtained is a CT scan, which often is unable to discern between malignant and benign presacral schwannoma. MRI can more frequently determine malignant vs. benign schwannoma.8,9 Most authors advocate performing MRI of the mass to try and better delineate the nerve roots involved.10-12

CASE REPORT

A 37-year-old man presented to the Emergency Department complaining of left flank pain, urinary hesitancy, and frequency wim associated dysuria. On further questioning, there was a history of left “hip” pain and impotence of unclear etiology. He had a previous medical history significant for urolithiasis. His laboratory evaluation was significant for a normal complete blood count and a normal urinalysis. CT for urolithiasis was obtained. This revealed no evidence of renal lithiasis and a 5.8- x 3-cm left-sided presacral mass at the level of S2 which had an enhancing capsule and distinct tissue planes. Further evaluation with a formal abdominal and pelvic CT scan and an MRI with contrast of the pelvic area demonstrated the presence of cystic and calcified areas within the mass (Figs. 1-3). There was no evidence of invasion to adjacent tissues. Based on this evaluation, the patient was taken to the operating room where a laparotomy was performed and the mass was resected en bloc. The mass was sent for frozen section which was inconclusive. Final histopathologic evaluation revealed an ancient degenerative benign schwannoma with cystic and associated calcific changes. At 1-year postoperation, he remains disease free with no neurological sequella.

CONCLUSION

An ancient schwannoma has a characteristic appearance on CT and MRI scanning consisting of encapsulated solid components with cystic areas, or appearing as cystic masses with marginal crescent-shaped or nodular solid components often containing calcifications.13,14 The ancient degenerative variant of presacral schwannoma often show stromal and vascular degenerative changes including cystic formation, central tissue loss, nuclear atypia, and calcification.15 These pathologic findings may be confused with sarcoma. This is the second report describing the clinical presentation of presacral schwannoma as possible renal colic.3 The treatment of all presacral schwannomas include en bloc resection of the mass, either via a transabdominal approach, a posterior sacral approach, or a combined procedure, entirely dependent on the sacral level at presentation. Retrorectal tumors, including presacral schwannoma, can be a diagnostic challenge due to the wide range of symptoms that may be present. Once the diagnosis is established, resection may provide marked improvement in patient symptoms if present. Resection is the recommended approach to establish the histological diagnosis.

REFERENCES

1. Lev-Chelouche D, Gutman M, Goldman G, et al: Presacral tumors: a practical classification and treatment of a unique and heterogeneous group of diseases. Surgery 2003; 133: 473-8.

2. Jao SW, Beart RW, Spencer RJ, Reiman HM, Ilstrup DM: Retrorectal tumors. Dis Colon Rectum 1985; 28: 644-52.

3. Andonian S, Karakiewicz PI, Herr HW: Presacral cystic schwannoma in a man. Urology 2003; 62: 551.

4. Hobson KG, Ghaemmanghami V, Roe JP, Goodnight JE, Khatri VP: Tumors of the retrorectal space. Dis Colon Rectum 2005; 48: 1964- 74.

5. Localio SA, Eng K, Ranson JH: Abdominosacral approach for retrorectal tumors. Ann Surg 1980; 191: 555-9.

6. Isobe K, Shimizu T, Akahane T, Kato H: Imaging of ancient schwannoma. AJR Am J Roentgenol 2004; 183: 331-6.

7. Maneschg C, Rogatsch H, Bartsch G, Stenzl A: Treatment of giant ancient pelvic schwannoma. Tech Urol 2001; 7: 296-8.

8. Cretella JP, Rafal RB, McCarron JP, Markisz JA: MR imaging in the diagnosis of a retroperitoneal schwannoma. Comput Med Imaging Graph 1994; 18: 209-12.

9. Schindler OS, Dixon JH, Case P: Retroperitoneal giant schwannomas: report on two cases and review of the literature. J Orthop Surg 2002; 10: 77-84.

10. Yano S, Hida K, Seki T, et al: Surgical treatment of retroperitoneal presacral large schwannoma by the anterior transabdominal approach: two case reports. No Shinkei Geka 2003; 31: 795-800.

11. Ogose A, Hotta T, Sato S, Takano R, Higuchi T: Presacral schwannoma with purely cystic form. Spine 2001; 26: 1817-9.

12. Wolpert A, Beer-Gabel M, Lifschitz O, Zbar AP: The management of presacral masses in the adult. Tech Coloproctol 2002; 6: 43-9.

13. Takeuchi M, Matsuzaki K, Nishitani H, Uehara H: Ancient schwannoma of the female pelvis. Abdom Imaging 2007; 33: 247-52.

14. Hughes MJ, Thomas JM, Fisher C, Moskovic EC: Imaging features of retroperitoneal and pelvic schwannomas. Clin Radiol 2005; 60: 886- 93.

15. Dodd LG, Marom EM, Dash RC, Matthews MR, McLendon RE: Fineneedle aspiration cytology of “ancient” schwannoma. Diagn Cytopathol 1999; 20: 307-11.

LT Camilo Santiago, MC USN*; CAPT Paul A. Lucha, MC USN[dagger]

* Department of General Surgery, Naval Medical Center, 620 John Paul Jones Circle, Portsmouth, VA 23708-2197.

[dagger] Division of Colon and Rectal Surgery, Naval Medical Center, 620 John Paul Jones Circle, Portsmouth, VA 23708-2197.

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. government. We are military service members. This work was prepared as part of our official duties. Title 17 U.S.C. 105 provides that “copyright protection under this title is not available for any work of the U.S. government.” Title 17 U.S.C. 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 that person’s official duties.

This manuscript was received for review in November 2007. The revised manuscript was accepted for publication in April 2008.

Copyright Association of Military Surgeons of the United States Aug 2008

(c) 2008 Military Medicine. Provided by ProQuest LLC. All rights Reserved.

Physical Fitness Influences Stress Reactions to Extreme Military Training

By Taylor, Marcus K Markham, Amanda E; Reis, Jared P; Padilla, Genieleah A; Potterat, Eric G; Drummond, Sean P A; Mujica-Parodi, Lilianne R

ABSTRACT Background: Physical fitness and physical conditioning have long been valued by the military for their roles in enhancing mission-specific performance and reducing risk of injury in the warfighter. It is not known whether physical fitness plays a causal role in attenuating acute military stress reactions or the evolution of post-traumatic stress disorder. Objective: The objective of this study was to determine whether physical fitness influences the impact of stressful events during military survival training in 31 men. Methods: Participants self-reported their most recent Physical Readiness Test scores and completed a trait anxiety measure before survival training. Participants also completed the Impact of Events Scale (IES) 24 hours after training. Results: Aerobic fitness was inversely associated with the total IES score (p

Post-traumatic stress disorder (PTSD) is an important public health and military problem, since PTSD symptoms are thought to occur in as many as 15 to 20% of individuals exposed to combat.1 However, the temporal course of PTSD development is difficult to quantify in an experimental setting. One important early marker of PTSD evolution in individuals exposed to extreme conditions concerns the impact of stressful events, including avoidance (avoiding situations that remind one of a previously experienced traumatic event), intrusion (experiencing intrusive or disturbing thoughts as a result of the event), and heightened arousal (experiencing anger, irritability, heightened startle response, and hypervigilance as a result of the event).2,3

There is a sustained interest in understanding characteristics that may serve as buffers against (or vulnerabilities for) acute stress reactions and subsequent PTSD development.4-6 One such factor has been termed resilience6,7 or psychological hardiness.5 These constructs are generally understood as an ability to “bounce back” from stressful or traumatic events. Research has shown that psychological hardiness buffers the effects of work-related stress in health care workers,8 athletes,9 casualty assistance workers,10 and Persian Gulf War soldiers.5 Other factors that may influence stress reactions and PTSD development include depression, anxiety,11,12 social support,13 and intelligence.12 Furthermore, proposed neurochemical, neuropeptide, and hormonal predictors include neuropeptide Y,14 Cortisol, dehydroepiandrosterone,15 dopamine, and benzodiazepine receptors.6 Finally, several neural mechanisms of reward and motivation (e.g., hedonia, optimism) and adaptive social behavior (e.g., altruism, teamwork) have also been suggested to serve protective roles.6

Physical fitness and physical conditioning have long been valued by the military for their roles in enhancing missionspecific performance and reducing risk of injury in the warfighter. It is not known whether physical fitness plays a causal role in attenuating acute military stress reactions or the evolution of PTSD. However, there is substantial literature documenting possible buffering effects of physical activity, exercise, and/or physical fitness with respect to stress reactivity,16,17 state and trait anxiety,18,19 and depression,20,21 as well as positive links to neurogenesis22-24 and cognitive function across a wide variety of populations.24 In light of this literature, it is plausible that physical fitness may influence stress reactions to intense military training.

The purpose of this study was to examine whether physical fitness influences the impact of stressful events during military survival training. We hypothesized that physical fitness would buffer these stress reactions, and that this observed effect would be mediated through attenuations in trait anxiety.

METHODS

The present study was part of a larger ongoing program of research examining individual differences in human performance and stress resilience in extreme military environments. The study was approved by the Institutional Review Board at the Naval Health Research Center (San Diego, California). Before participation, all prospective participants were informed of their rights as human subjects and each gave written, informed consent to participate.

Thirty-one male participants completed measures of physical fitness and trait anxiety ~3 weeks before participating in Survival, Evasion, Resistance, and Escape (SERE) training in the San Diego area. SERE training and our associated program of research have been described in detail elsewhere.25 Briefly, U.S. military members at high risk of capture are required to attend SERE training, which includes a period of confinement in a Resistance Training Laboratory (RTL). After an initial phase of classroom-based didactic training, students are taken to the field where they receive applied training in survival, evasion, resistance, and escape techniques. Students are then released into the field and tasked witii the goal of evading enemy captors. Upon eventual capture, students are taken to the RTL where they are expected to apply their recently learned skills of resistance to political indoctrination and captivity- related challenges. The structured, choreographed nature of this training platform provides a unique and unprecedented medium in which to examine human stress and performance in a realistic military context. Moreover, since a component of SERE training is designed to simulate the prisoner-of-war experience, it offers a unique medium in which to study the effects of mock captivity stress on many aspects of human functioning. Twenty-four hours after the conclusion of SERE training (i.e., release from RTL), participants completed me Impact of Events Scale-Revised (IES-R).3

Physical Fitness

Prior to SERE training, participants reported me results of their most recent Physical Readiness Test (PRT). Military personnel are required to maintain a standard level of physical fitness by scoring satisfactorily on the PRT, which is administered semiannually. The time required to complete a 1.5-mile run on a standardized course as part of the PRT was used as a measure of aerobic fitness (lower values indicate higher fitness). The maximum numbers of sit-ups and push-ups performed in 2 minutes were used as measures of core fitness and upper body fitness, respectively. Self-reported physical fitness test scores have been shown to correlate highly with objectively recorded scores. Specifically, Jones et al.26 found self- reported push-ups, sit-ups, and run time during an Army physical fitness test to be correlated to objectively recorded scores at 0.83, 0.71, and 0.85, respectively.

Trait Anxiety

Prior to SERE training, self-report of anxiety was assessed with the trait portion of the Spielberger State-Trait Anxiety Inventory. The 20-item trait anxiety inventory asks respondents to describe how they generally feel, using a 4-point Likert-type scale (almost never, sometimes, often, almost always). Examples of items include “I feel pleasant,””I worry too much about something that does not matter,” and “I make decisions easily.” The trait anxiety inventory is scored by reverse coding each positive item and then summing across all items. Scores range from 20 to 80, with lower scores indicating less anxiety and higher scores indicating a greater level of anxiety. The scale is widely used, and its reliability and validity has been established in several different populations.27,28 Internal reliability of the trait anxiety scale in me current study was acceptable (Cronbach’s alpha = 0.77).

Impact of Events Scale-Revised

The IES-R was administered 24 hours after the conclusion of SERE training. This self-report measure is designed to assess current subjective distress for any specific life event. The IES-R has 22 items, comprising three subscales corresponding to the Diagnostic and Statistical Manual of Mental Disorders-Fourth Editions- specified PTSD symptoms: avoidance (JES-avoidance; mean of eight items measuring the extent to which the respondent avoids situations that remind him or her of the stressful or traumatic event), intrusion (TES-intrusion; mean of eight items assessing the extent to which one experiences intrusive thoughts), and hyperarousal (IES- arousal; mean of six items measuring anger, irritability, heightened startle response, and hypervigilance). A total IES score (IES- total) is composed of the sum of the three subscales. With this scale, respondents are shown a list of difficulties people sometimes have after stressful life events and are asked to indicate how distressing each difficulty has been with respect to a stressful captivity-related problem on a scale of 0 (not at all) to 4 (extremely). Adequate reliability and predictive validity have been shown for this scale30,31 and Cronbach a reliabilities in the present sample were 0.73, 0.79, and 0.70 for IES-arousal, IES- avoidance, and IES-intrusion, respectively. Cronbach a reliability for IES-total was 0.89. Data Analysis

Preliminary analysis incorporated the use of normal probability and residual plots to assess compliance with the assumption of linear regression and screen for me presence of influential outlying data values. These plots revealed that the normal distribution was an appropriate assumption. Means (and SDs) and percentages were used to describe continuous and discrete characteristics, respectively. Linear regression was used to examine predictors of stressful events during SERE training. Pearson correlation coefficients compared the relative strength of these associations.

To assess confounding and the mediating influence of trait anxiety on the relation of aerobic fitness with the impact of stressful events during SERE training, we examined the change in the beta coefficient for run time (aerobic fitness) when each factor was added individually to a base model including only run time. SPSS Statistical Software System, version 15 (SPSS Inc., Chicago, Illinois) was used to perform all analyses. All tests of hypotheses were two-sided and based on a type I error rate of 0.05.

RESULTS

Characteristics of the Sample

Detailed sample characteristics are presented in Table I. Mean age, body mass index (BMI), and years of military service for this sample were 21.7 years (SD = 2.2), 24.2 kg/m^sup 2^ (SD = 1.6), and 1.8 years (SD = 0.9), respectively. Highest level of education reached was high school for most subjects (77.4%) and 22.6% were college educated. Most subjects were Caucasian (87.1%). Regarding military occupational specialty, 80.6% were students under instruction to become aviation warfare specialists/rescue swimmers, while the remaining 19.4% were students undergoing advanced instruction to become special warfare (SEAL) officers. Mean trait anxiety scores in the present sample were slightly lower than those found in a normative college-aged population.27

Predictors of Stressful Events during Survival Training

Univariate predictors of the impact of stressful events are indicated in Table II. Age and BMI were not associated with IES- total. Years of military service demonstrated a nonsignificant inverse relationship with IES-total (p = 0.08), although years of military service was fairly restricted in range (mean = 1.80, SD = 0.87, range = 4). Trait anxiety was positively associated with IES- total (p = 0.001). SEAL students demonstrated a notably lower IES- total than aviation warfare students (1.90 [SD = 1.70] versus 3.00 [SD = 1.53]) although these differences did not reach statistical significance (p = 0.18). Similarly, there was a trend for differences between participants with a high school (mean = 3.05, SD = 1.53) versus a college education (mean = 1.82, SD = 1.53) (p = 0.07).

Relationships between Physical Fitness and Impact of Stressful Events

Univariate relationships of measures of physical fitness with the impact of stressful events during survival training are shown in Table III. As indicated, upper body fitness as measured by number of push-ups performed in 2 minutes was inversely associated with IES- avoidance (p = 0.02) and IEStotal (p = 0.05). Core fitness as indicated by number of sit-ups performed in 2 minutes was inversely associated with IES-arousal (p = 0.04) as well as IES-total (p = 0.04). Aerobic fitness as indicated by number of minutes to run 1.5 miles (higher times indicating lower fitness) was inversely associated with IES-arousal (p = 0.007), IES-avoidance (p = 0.02), IES-intrusion (p = 0.05), and IES-total (p = 0.008).

Assessment of Mediating Role of Anxiety

Due to its robust relationship to impact of stressful events as well as substantial relationships with core (p = 0.07) and upper body fitness (p = 0.001), aerobic fitness was selected as the physical fitness variable with which to investigate possible confounding as well as the mediating influence of trait anxiety. An examination of models assessing these relationships is demonstrated in Table IV. Whereas aerobic fitness was significantly associated with IES-total in the regression model (p = 0.008), this relationship was not appreciably altered when adjusted for age, BMI, years of military service, education, or rnilitary occupational specialty. When adjusted for trait anxiety, however, this relationship was substantially attenuated and no longer significant (beta = 0.544, p = 0.10).

DISCUSSION

The present study was initiated to determine whether physical fitness influences the impact of events occurring during a stressful mock captivity phase of military survival training. We demonstrated that aerobic fitness was inversely associated with the impact of stressful events, and that mis relationship may be mediated via fitness-related attenuations in trait anxiety.

To the best of our knowledge, mis is the first study to link measures of physical fitness to acute military stress reactions, although the military has long valued physical fitness as a means of enhancing hardiness in the warfighter. Previous research has demonstrated convincing links between physical fitness and aspects of mental health in both clinical and healthy populations. As noted earlier, there is substantial literature documenting beneficial effects of physical activity, exercise, and/or fitness relative to stress reactivity,16,17 anxiety,18,19 depression,20,21 as well as neurogenesis,22-24 and cognitive function.24 Georgiades et al.,17 for example, studied the effects of exercise and weight loss on mental stress-induced cardiovascular responses in individuals with high blood pressure. After 6 months, participants in an exercise group and participants in a behavioral weight loss group (including exercise) had lower levels of systolic blood pressure, diastolic blood pressure, total peripheral resistance, and heart rate both at rest and during mental stress, compared with inactive controls.

In another randomized trial, Blumenthal et al.20 showed that 16 weeks of exercise treatment was as effective as antidepressant medication in reducing depression among patients with major depressive disorder. In a recent animal study, Pereira et al.22 showed that exercise had a direct impact on dentate gyrus cerebral blood volume, a hippocampal subregion known to support neurogenesis, in mice. These researchers then showed similar effects in humans and that these changes were correlated to cardiopulmonary and cognition function. Given the relationship of the hippocampus to memory and stress,32,33 this offers mechanistic insight into the possible link between exercise training, concomitant improvements in physical fitness, and stress resilience.

As an extension of these and related findings, Tsatsoulis et al.34 proposed that, since the stress response is a neuroendocrine mechanism that occurs in anticipation of physical action, physical activity should be the natural means to prevent the consequences of stress (i.e., strain). These authors offer additional mechanistic possibilities, including peripheral actions influencing metabolism such as insulin sensitivity and the partitioning of fuels toward oxidation rather than storage. The extent to which these metabolic processes are causally implicated in stress resilience awaits further research.

Limitations of this study should be addressed. We used a less- than-optimal measure of physical fitness-self-reported scores from a recent PRT. This, of course, is less desirable than “gold standard” measures such as peak volume of oxygen uptake (VO^sub 2^) using metabolic technology. However, the fact that we observed robust relationships between aerobic fitness and military stress reactions despite its crude measurement justifies additional research with more sophisticated tools. There are two important strengths of the current study. First, our findings regarding the link between physical fitness and military stress reactions is novel and may open the door to a new line of inquiry that may improve our understanding of prevention and treatment for combat stress and PTSD. Second, this study was conducted within the survival training environment, offering an unprecedented level of ecological validity. Specifically, SERE training is a standardized and systematic, yet realistic and intense, course of training modeled after the experiences of American prisoners of war from the Korean and Vietnam conflicts. Short of actual military combat, it is among the best forums in which to examine human reactions to acute military stress in a controlled fashion.

More research is needed to better understand the possible relationships between physical fitness and acute military stress reactions, including both resilience and vulnerability factors. Wherever possible, future research should employ more sophisticated measures of aerobic (e.g., peak VO^sub 2^ uptake) and muscular fitness (e.g., percentage of 1 repetition maximum or 10 repetition maximum). More research is also needed to test our proposed mediating role of trait anxiety in the physical fitness-stress reaction relationship as well as other possible mediating factors. Furthermore, it would be of interest to examine the relationship of physical fitness to other military stress endpoints, such as hormonal markers (e.g., Cortisol), dissociative symptoms (i.e., how perceptually connected or disconnected an individual is relative to his or her environment), as well as cognitive function and overt performance. Also, it would be particularly valuable to prospectively examine the effects of exercise training and concomitant fitness changes on military stress reactions in a randomized, controlled setting.

In summary, we examined the influence of physical fitness on the impact of events occurring during a stressful mock captivity phase of military survival training. We demonstrated that aerobic fitness was inversely associated with the impact of stressful events, and that this relationship may be mediated via fitness-related attenuations in trait anxiety. ACKNOWLEDGMENTS

The source of funding for this work was Office of Naval Research Award N0001406WX20141. This research has been conducted in compliance with all applicable federal regulations governing the protection of human subjects in research.

Appreciation is extended to Michelle Stoia for editorial expertise and to Sue Sobanski for fiscal expertise. Special appreciation is also extended to the students and staff at the Helicopter Squadron 10, Helicopter Squadron 41, and the Naval Special Warfare Center, San Diego, California. Finally, we wish to thank Center for Security Forces-SERE West (San Diego, CA) for support of our research and for “training the best for the worst.”

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6. Charney DS: Psychobiological mechanisms of resilience and vulnerability: implications for successful adaptation to extreme stress. Am J Psychiatry 2004; 161: 195-216.

7. Yehuda R, Flory JD, Southwick S, et al: Developing an agenda for translational studies of resilience and vulnerability following trauma exposure. Ann NY Acad Sci 2006; 1071: 379-96.

8. Keane A, Ducette J, Adler DC: Stress in ICU and non-ICU nurses. Nurs Res 1992; 34: 231-6.

9. Maddi SR, Hess M: Hardiness and success in basketball. Int J Sports Psychol 1992; 23: 360-8.

10. Bartone PT, Ursano RJ, Wright KM, et al: The impact of a military air disaster on the health of assistance workers: a prospective study. J Nerv Ment Dis 1989; 177: 317-28.

11. Storr CL, Ialongo NS, Anthony JC, et al: Childhood antecedents of exposure to traumatic events and posttraumatic stress disorder. Am J Psychiatry 2007; 164: 119-25.

12. Breslau N, Lucia VC, Alvarado GF: Intelligence and other predisposing factors in exposure to trauma and posttraumatic stress disorder: a follow-up study at age 17 years. Arch Gen Psychiatry 2006; 63: 1238-45.

13. Ringdal GI, Ringdal K, Jordhoy MS, et al: Does social support from family and friends work as a buffer against reactions to stressful life events such as terminal cancer? Palliat Support Care 2007; 5: 61-9.

14. Morgan CA, Rasmusson AM, Wang S, et al: Neuropeptide-Y, Cortisol, and subjective distress in humans exposed to acute stress: replication and extension of previous report. Biol Psychiatry 2002; 52: 136-42.

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16. Crews DJ, Landers DM: A meta-analytic review of aerobic fitness and reactivity to psychosocial stressors. Med Sci Sports Exerc 1987; 19: S114-20.

17. Georgiades A, Sherwood A, Gullette EC, et al: Effects of exercise and weight loss on mental stress-induced cardiovascular responses in individuals with high blood pressure. Hypertension 2000; 36: 171-6.

18. Petruzzello SJ, Landers DM, Hatfield BD, et al: A meta- analysis on the anxiety-reducing effects of acute and chronic exercise: outcomes and mechanisms. Sports Med 1991; 11: 143-82.

19. Taylor MK, Pietrobon R, Pan D, et al: Healthy People 2010 physical activity recommendations and psychological symptoms: evidence from a large nationwide database. J Phys Act Health 2004; 1: 114-30.

20. Blumenthal JA, Babyak MA, Craighead WE, et al: Effects of exercise training on older adults with major depression. Arch Intern Med 1999; 159: 2349-56.

21. Lindwall M, Rennemark M, Hailing A, et al: Depression and exercise in elderly men and women: findings from the Swedish National Study on Aging and Care. J Aging Phys Act 2007; 15: 41-55.

22. Pereira AC, Huddleston DE, Brickman AM, et al: An in vivo correlate of exercise-induced neurogenesis in the adult dentate gyrus. Proc Natl Acad Sci USA 2007; 104: 5638-43.

23. Redila VA, Christie BR: Exercise-induced changes in dendritic structure and complexity in the adult hippocampal dentate gyrus. Neuroscience 2006; 137: 1299-307.

24. Van der Borght K, Havekes R, Bos T: Exercise improves memory acquisition and retrieval in the Y-maze task: relationships with hippocampal neurogenesis. Behav Neurosci 2007; 121: 324-34.

25. Taylor MK, Sausen KP, Mujica-Parodi LR, et al: Neurophysiologic methods to measure stress during Survival, Evasion, Resistance, and Escape training. Aviat Space Environ Med 2007; 78: B224-30.

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LT Marcus K. Taylor, MSC USN*; Amanda E. Markham, MPH; Jared P. Reis, PhD[dagger]; Genieleah A. Padilla, BA*; CDR Eric G. Potterat, MSC USN[double dagger]; Sean P. A. Drummond, PhD[section]; Lilianne R. Mujica-Parodi, PhD[para]

* Stress Physiology Research Core, Department 162, Warfighter Performance, Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106.

[dagger] Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205.

[double dagger] Naval Special Warfare Center, 2446 Trident Way, San Diego, CA 92155.

[section] Veterans Affairs San Diego Healthcare System, 3350 La Jolla Drive, San Diego, CA 92161.

[para] Department of Biomedical Engineering, State University of New York at Stony Brook, Stony Brook, NY 11794.

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Navy, Department of Defense, or the U.S. government.

Address reprint requests to: LT Marcus K. Taylor, Naval Health Research Center, Stress Physiology Research Core, Dept 162 (Warfighter Performance), 140 Sylvester Rd, San Diego, CA 92106; [email protected]

This manuscript was received for review in November 2007. The revised manuscript was accepted for publication in April 2008.

Copyright Association of Military Surgeons of the United States Aug 2008

(c) 2008 Military Medicine. Provided by ProQuest LLC. All rights Reserved.

Dietary Intake of Pilots in the Israeli Air Force

By Stark, Aliza H Weis, Neta; Chapnik, Leah; Barenboim, Erez; Reifen, Ram

ABSTRACT The purpose of this study was to evaluate the dietary intake of pilots in me Israeli Air Force and to determine whether reported consumption met the Military Dietary Reference Intakes. Thirty-one pilots completed a 24-hour dietary recall and physical activity questionnaire. Blood parameter values were collected from medical records. Results showed that energy-adjusted sample mean intakes of nutrients met the military recommendations with the exceptions of dietary fiber (53% of the recommended level) and calcium (84% of the recommended level). Macronutrient distribution of energy was 17% from protein, 47% from carbohydrate, and 36% from fat. Although saturated fat consumption was not more than 10% of energy, cholesterol consumption was well above the 300 mg/d presently recommended. For all pilots, blood parameter values were in the normal range. Overall, the diet of Israeli pilots was found to be well balanced, but negative dietary patterns (i.e., high cholesterol intake and low fiber intake) characteristic of the general population were observed in this group. INTRODUCTION

Air Force pilots, because of the nature of their work, are selected and monitored to ensure that they are in excellent physical condition. Aircraft flying involves high levels of concentration and attentiveness and quick response times. Outstanding physical performance and mental performance are dependent on many factors, including proper nutrition. To guarantee that personnel receive a well-balanced diet, the U.S. military has established daily nutritional recommendations for healthy, 17- to 50-year-old, physically active, military men. These recommendations, commonly called Military Dietary Reference Intakes (MDRIs), are used as the basis for formulation of garrison and operational meals and rations and can be used for evaluations of the adequacy of food intake.1

It is well known that nutrient deficiencies can adversely affect physical and cognitive performance, as well as immune function and injury recovery.26 In the long term, a healthy diet is associated with lower risks of heart disease, stroke, obesity, and certain cancers.7-11 Therefore, to ensure that Air Force pilots are in the best of health, it is important to evaluate dietary intake and to make recommendations to improve rations if necessary.

Along with assessment of food consumption, numerous parameters can be used to determine overall physical condition and lifestyle patterns. Body weight within recommended limits is assumed to reflect good health.12 Blood parameters can also be used to assess physical condition. Lifestyle is considered to be an important factor in maintaining health. Therefore, nutritional data, physical activity practices, and breakfast consumption were evaluated to provide information regarding lifestyle.

Although several studies have been conducted in combat units, very few studies have assessed the dietary intake of Air Force pilots. The primary objective of this study was to evaluate the dietary intake of pilots in the Israeli Air Force and to determine whether reported consumption met MDRIs.

METHODS

Study Protocol

Interviews and questionnaires were completed either during scheduled annual physical examinations or at the squadron headquarters at various Air Force bases. Pilots were asked to volunteer for the study, and those who agreed to participate filled out a short questionnaire (self-report), followed by a 20-minute interview. The data were collected noninvasively over a 6-month period in 2004, during work hours, by using anonymous questionnaires.

Subjects

Thirty-one Israeli pilots, representing more than five different squadrons, volunteered for this study. The sample included jet fighter pilots, helicopter pilots, and military transport pilots. The study was approved by the internal medical review board of the Israeli Air Force Aeromedicai Center.

Interview

Individual interviews were conducted by a single interviewer with the aid of a questionnaire developed in collaboration witii the Israel Center for Disease Control and the Ministry of Health. The instrument was previously used in the First Israeli National Health and Nutrition Survey and included a validated 24-hour food consumption questionnaire. An atlas of photographs and measuring cups and spoons were used as aids for reporting portion sizes. Additional questions dealt with physical activity and personal preferences regarding foods served in the mess hall on each army base. The use of a single interviewer minimized variability in data collection.

Laboratory and Anthropometric Values

Data such as body weight and height and laboratory blood values were obtained from medical records from recent annual physical examinations. All blood parameters were determined in samples obtained after an overnight fast.

Data Analyses

Data are presented as mean +- SE. Daily nutrient consumption was computed with the aid of Tzemert 1 software (Israeli Ministry of Health), which was designed to calculate >30 nutrients and was developed specifically for use in Israel. The program includes a wide range of local products, with data from manufacturers or data calculated by using the U.S. Department of Agriculture Nutrient Database.13 Sample energy and nutrient means were compared with the MDRIs.1

RESULTS

Anthropometric and Laboratory Data

Table I summarizes descriptive data and biochemical parameters for the 31 male participants in this study. The majority (74%) of pilots had body mass index (BMI) values of

Evaluation of 24-Hour Recall of Food Consumption

The analysis of 24-hour dietary recall data appears in Table II. Self-reported energy intake was lower than calculated energy expenditure for this group of the population. The macronutrient composition of the diet was 17% of energy from protein, 36% of energy from fat, and 48% of energy from carbohydrate. Fatty acid intake was close to recommended values of up to 10% of energy from saturated fatty acids, at least 10% of energy from monounsaturated fatty acids, and ~10% of energy from saturated fats.15 Certain micronutrients were consumed in large quantities and, despite under- reporting, it was clear that these components of the diet were consumed in sufficient quantities (vitamin C, iron, and vitamin B12) or even in excess (cholesterol). To compensate for under-reporting, data were adjusted to energy intake (Table III). Energy-adjusted data showed that calcium and dietary fiber were consumed at levels significantly lower than recommended. Zinc consumption reached only 89% of the recommended value. The majority of the pilots reported that they did not take any dietary supplements; only two reported taking multivitamins, and another two reported taking vitamin C.

Physical Activity

Pilots reported their physical activity and energy expenditure by completing questionnaires regarding specific activities carried out at work and during leisure time. Pilots spent between 5 and 10 h/wk flying, depending on their specific jobs (e.g., helicopter pilot or military transport pilot). Eighty-one percent reported that, aside from actual flying time, the majority of the workday was spent sitting. Two pilots (6%) reported spending most of the workday standing, whereas four pilots (13%) described spending much of the workday walking. During leisure time, 84% of the participants habitually participated in sports, whereas 16% reported no regular physical activity.

Breakfast Frequency

Seventy-four percent of the pilots interviewed regularly ate breakfast in the squadron dining room. However, the energy content of the meal was commonly

DISCUSSION

The purpose of this study was to evaluate the dietary intake of pilots in the Israeli Air Force, to determine whether reported consumption met the MDRIs. It was hypothesized that pilots consumed a healthy diet, but dietary assessment was necessary to confirm or to dispute this assumption. Overall, adjusted sample means indicated that the pilots were consuming an adequate diet, with the exceptions of dietary fiber (53% of MDRI) and calcium (84% of MDRI). Cholesterol consumption was well above recommended levels. Results of blood parameters were in the normal range, and 84% of the participants reported regular physical activity. For the most part, the diet of Israeli pilots was found to be well balanced; however, some dietary habits could be improved. Recommendations include increasing consumption of dietary fiber and calcium, decreasing cholesterol intake, and including breakfast in the daily routine.

Participation in this survey was voluntary, and pilots were self- selected; therefore, a possibility for bias exists. However, the study did reach every branch of pilots in several squadrons and provides meaningful insights concerning the daily eating habits and nutrient consumption in the study population. It should be noted that very few studies have evaluated the nutritional status of Air Force pilots, and this article provides data that are not available elsewhere. As a group, the pilots were found to have optimal body weight, although 26% had BMI values greater than recommended values, with the highest value being 27 kg/m^sup 2^. It must be noted that using the BMI cutoff values for overweight can be problematic when individuals with high muscle mass are being assessed.18-20 A BMI value consistent with overweight does not always indicate that an individual has excess fat mass.

Averages of blood parameters indicated normal values for the Israeli Air Force pilots. In a similar study carried out in the Polish Air Force,21 78% of the 229 fighter pilots participating in the study were reported to have mild, moderate, or severe hyperlipidemia. It should be noted that the mean age for pilots in the Polish study was 36.0 +- 5.2 years, in contrast to the considerably younger pilots in this study. Data for U.S. fighter pilots indicated the average total cholesterol level to be 218 mg/ dL for the 30 men included in the study.22

Reported total energy consumption (2,657 +-168 kcal/d) was significantly lower than both recommended and calculated values for this group. It is well known that underestimation of food intake is pervasive when 24-hour recall methods are used.23,24 Under- reporting by pilots was also found in the work of Copp and Green,22 where an average of 2,585 kcal/d was reported, significantly lower than the recommended range of 2,800 to 3,600 kcal/d. Evaluation of diet adequacy was carried out by using energy-adjusted data, to compensate for under-reporting (Table III).

Macronutrient distribution was 17% of energy from protein, 47% from carbohydrate, and 36% from fat. Almost-identical data were collected in a study of fighter pilots in the U.S. Air Force; mean proportions of energy derived from carbohydrate, protein, and fat were 48.3%, 16.1%, and 34.2%, respectively.22 The MDRI system does not set specific recommendations for macronutrient content of the diet or cholesterol intake but suggests that 10% to 15% of energy be provided by protein, up to 30% of energy be provided by fat, and the remaining 55% to 60% of energy be provided by carbohydrate.1 More- recent standards for the general population have been set by the Institute of Medicine.15 These standards, known as the Dietary Reference Intakes (DRIs), were established in 2004 and set an acceptable range of dietary fat consumption for adults as 20% to 35% of energy intake, with

Evaluation of other dietary nutrients showed that, overall, the diet of fighter pilots provided close to 100% of the recommended values. With the exception of dietary fiber, calcium, zinc, and cholesterol, the consumption of nutrients was between 90% and 200% of the MDRI. According to the First Israeli National Health and Nutrition Survey carried out in 1999-2001,26 the average consumption of dietary fiber for Israeli men 25 to 29 years of age was ~18 g/d, almost identical with the amount reported by the pilots. After adjustment for energy intake, consumption values for dietary fiber were still only 53% of recommended levels.

Calcium consumption for pilots was 84% of recommended levels. This was significantly better than the national average for this age group, which was reported to be 535 mg/d, ~45% of the DRI.15 Dairy products are readily available in the Air Force mess halls and, whereas the national average is one serving of dairy products per day, the pilots consumed closer to two servings per day.

Zinc intake was close to recommended values (89%), and it is unlikely that zinc deficiency would occur at these levels of intake. McClung and Scrimgeour27 reviewed the potential benefits of zinc for soldiers, and from these results it is clear that care must be taken to ensure sufficient intake to prevent zinc status that is less than optimal. Cholesterol consumption was twice the recommended levels. This was largely attributable to high intake levels of both eggs and meat.

Dietary supplement use among the U.S. military has been reported to be high. One study found that 87% of U.S. Army Special Forces soldiers and 76% of support soldiers reported use of multivitamins, sports bars/drinks, and vitamin C.28 In Israel, similar to the United States, dietary supplements are readily available to the public. In marked contrast to the U.S. combat soldiers, Israeli pilots reported relatively low levels of supplement use.

Breakfast habits were variable, although almost all of the pilots ate or drank in the morning hours. Taking into consideration the demands and time constraints on fighter pilots, these data are encouraging. In the study by Copp and Green,22 63% of the pilots reported that they did not eat breakfast daily, and the authors concluded that the irregularity of breakfast consumption was of concern. However, this can easily be compensated for by providing nutritious late-morning snacks to overcome the barriers to consuming an adequate breakfast.

Pilots had 5 to 10 h/wk of flying time. Data on energy expenditure in flight are scarce, and there is insufficient information to accurately account for the amount of additional energy needed for this activity. It is beyond the scope of this study to make an accurate estimation of energy expenditure in this population. It is interesting that a surprising 16% of pilots reported that they did not participate in regular physical activity (>10 min/d).

In conclusion, the general dietary status of the fighter pilots interviewed in this project appeared to be satisfactory. A relatively large number of pilots had BMI values of >25 kg/m^sup 2^. In addition, several reported little or no physical activity beyond what was demanded of them at their jobs. Dietary patterns (i.e., high cholesterol intake and low fiber intake) characteristic of the general population were also observed in this group. This indicates that this population may benefit from a health promotion program that includes both nutrition education, to encourage consumption of a healthy diet, and a regular exercise plan.

ACKNOWLEDGMENTS

We thank Rivkah Goldsmith from the Israeli Ministry of Health for her help and advice concerning questionnaire preparation. In addition, we acknowledge the cooperation and help we received from Sergeant Estevan Malal and other members of the Aeromedicai Center of the Israeli Air Force.

REFERENCES

1. Baker-Fulco CJ, Bathalon GP, Bovill ME, Lieberman HR: Military Dietary Reference Intakes: Rationale for Tabled Values. U.S. Army Research Institute of Environmental Medicine Technical Note TN-00/ 10. Natick, MA, U.S. Army Research Institute of Environmental Medicine, 2001.

2. Tharion WJ, Lieberman HR, Montain SJ, et al: Energy requirements of military personnel. Appetite 2005; 44: 47-65.

3. Johnson AE: Iron supplementation and the female soldier. Milit Med 2006; 171: 298-300.

4. Keusch GT: The history of nutrition, infection, and immunity. J Nutr 2003; 133: 336S-40S.

5. Baker LB, Dougherty KA, Chow M, Kenney WL: Progressive dehydration causes a progressive decline in basketball skill performance. Med Sci Sports Exerc 2007; 39: 1114-23.

6. McCarthy MS, Fabling J, Martindale R, Meyer SA: Nutrition support of the traumatically injured warfighter. Crit Care Nurs Clin North Am 2008; 20: 59-65.

7. Lutsey PL, Steffen LM, Stevens J: Dietary intake and the development of the metabolic syndrome: the Atherosclerosis Risk in Communities study. Circulation 2008; 117: 754-61.

8. Lutsey PL, Jacobs DR Jr, Kori S, et al: Whole grain intake and its cross-sectional association with obesity, insulin resistance, inflammation, diabetes and subclinical CVD: the MESA Study. Br J Nutr 2007; 98: 397-405.

9. Huang CY: Nutrition and stroke. Asia Pac J Clin Nutr 2007; 16: 266-74.

10. Gonzalez CA, Riboli E: Diet and cancer prevention: where we are, where are we going. Nutr Cancer 2006; 56: 225-31.

11. Vainio H, Weiderpass E: Fruit and vegetables in cancer prevention. Nutr Cancer 2006; 54: 111-42.

12. Naghii MR: The importance of body weight and weight management for military personnel. Milit Med 2006; 171: 550-5.

13. U.S. Department of Agriculture: National nutrient database, 2007. Available at http://www.nal.usda.gov/fnic/foodcomp; accessed September 1, 2007.

14. Merck: Merck Manuals Online Medical Library. Available at http://www.merck.com/mmpe/index.html; accessed February 19, 2008.

15. Institute of Medicine: Dietary Reference Intakes (DRIs). Available at http://www.iom.edu/CMS/3788/4574/45132.aspx; accessed September 1, 2007.

16. Health tips: benefits of breakfast. Mayo Clin Health Lett 2005; 23: 3.

17. Nicklas TA, O’Neil C, Myers L: The importance of breakfast consumption to nutrition of children, adolescents, and young adults. Nutr Today 2004; 39: 30-9.

18. Ode JJ, Pivarnik JM, Reeves MJ, Knous JL: Body mass index as a predictor of percent fat in college athletes and nonathletes. Med Sci Sports Exerc 2007; 39: 403-9.

19. Vanderburgh PM: Correction factors for body mass bias in military physical fitness tests. Milit Med 2007; 172: 738-42.

20. Friedl KE, Leu JR: Body fat standards and individual physical readiness in a randomized Army sample: screening weights, methods of fat assessment, and linkage to physical fitness. Milit Med 2002; 167: 994-1000.

21. Zawadzka-Bartczak E, Kopka L, Gancarz A: Antioxidative enzyme profiles in fighter pilots. Aviat Space Environ Med 2003; 74: 654- 8. 22. Copp EK, Green NR: Dietary intake and blood lipid profile survey of fighter pilots at Tyndall Air Force Base. Aviat Space Environ Med 1991; 62: 837-41.

23. Tran KM, Johnson RK, Soultanakis RP, Matthews DE: In-person vs telephone-administered multiple-pass 24-hour recalls in women: validation with doubly labeled water. J Am Diet Assoc 2000; 100: 777- 83.

24. Jonnalagadda SS, Mitchell DC, Smiciklas-Wright H, et al: Accuracy of energy intake data estimated by a multiple-pass, 24- hour dietary recall technique. J Am Diet Assoc 2000; 100: 303-8.

25. National Cholesterol Education Program, Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults: Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel ??) final report. Circulation 2002; 106: 3143-421.

26. Israel Center for Disease Control: First Israeli National Health and Nutrition Survey, 1999-2001, Part 2: What Israelis Eat. Publication 228. Tel Hashomer, Israel, Israel Center for Disease Control, 2004.

27. McClung JP, Scrimgeour AG: Zinc: an essential trace element with potential benefits to soldiers. Milit Med 2005; 170: 1048-52.

28. Bovill ME, Tharion WJ, Lieberman HR: Nutrition knowledge and supplement use among elite U.S. Army soldiers. Milit Med 2003; 168: 997-1000.

Aliza H. Stark, PhD*; Neta Weis, BSc*; Leah Chapnik, BSc[dagger]; Erez Barenboim, MD[dagger]; Ram Reifen, MD*

* Faculty of Agricultural, Food, and Environmental Quality Sciences, School of Nutritional Sciences, The Hebrew University of Jerusalem, Rehovot, Israel.

[dagger] Aeromedical Center, Israeli Air Force, Tel HaShomer, Israel.

This manuscript was received for review in September 2007. The revised manuscript was accepted for publication in April 2008.

Reprint & Copyright (c) by Association of Military Surgeons of U.S., 2008.

Copyright Association of Military Surgeons of the United States Aug 2008

(c) 2008 Military Medicine. Provided by ProQuest LLC. All rights Reserved.

Diabetes, Dialysis, and Nutrition Care Interaction

By Schatz, Sharon R

Diabetes is present in the majority of patients who dialyze. If comprehensive care is to be delivered, the enormity of diabetes and its non-renal complications need to be appreciated. These influences on the treatment process, medical nutrition therapy, and glycemic control all interact with one another to determine dialysis adequacy, nutritional status, and degree of glycemic control. By gaining a further understanding of these dynamics, care management strategies can be improved and more thorough patient education provided to achieve better outcomes for this high-risk population. In 2007, the National Kidney Foundation’s (NKF) Kidney Disease Outcomes Quality Initiative (K/DOQI(TM)) released its evidence- based clinical practice guidelines for diabetes mellitus (DM) (NKF, 2007). These guidelines emphasized the management of DM for patients with chronic kidney disease (CKD) Stages 1 to 4, stating that evidence for management in Stage 5 was lacking or addressed in other guidelines. Practitioners in the dialysis setting may find themselves in a quandary since more than 50% of the dialysis population has DM (U.S Renal Data System [USRDS], 2005), although diabetic kidney disease may not have caused the kidney failure. The demands of dialysis have considerable implications on outcomes, since patients with DM have the lowest survival rate, poorest rehabilitation potential, highest incidence of hospitalizations, and a greater total cost of care (Locatelli, Pozzoni, & Del Vecchio, 2004; Lok, Oliver, Rothwell, & Hux, 2004; Pupim, Heimburger, Qureshi, Ikizler, & Stenvinkel, 20005). If comprehensive care is to be delivered, the enormity of DM and its non-renal complications need to be appreciated. These influences on the treatment process, medical nutrition therapy, and glycemic control all interact with one another to determine dialysis adequacy, nutritional status, and degree of glycemic control. This article provides insight into some of these issues to enhance practitioner perspectives.

Glycemic Control

Although good glycemic control in CKD Stage 5 cannot undo the kidney damage, it can slow the progression of retinopathy, neuropathy, and possibly macrovascular disease (American Diabetes Association [ADA], 2008; NKF, 2007). Studies by Oomichi et al. (2006) and Kalantar-Zadeh et al. (2007) associated worse prognosis and higher death risk with poorer glycemic control. Hyperglycemia triggers thirst, contributing to volume overload with adverse impact on cardiac status and less stable blood pressure dynamics. The KDOQI guidelines advocate using the ADA goals for glycemic control (glycosylated hemoglobin [HbA1C] less than 7.0%, preprandial capillary plasma glucose 70 to 130 mg/dL [3.9-7.2 mmol/L], and peak post-prandial capillary glucose less than 180 mg/dL {less than 10.0 mmol/L}), while individually considering any adverse effects of hypo- and hyperglycemia (ADA, 2008; NKF, 2007).

Glycemic control is best assessed by combining results of HbA1C and self-monitoring of blood glucose (SMBG) (ADA, 2008). Despite accuracy concerns regarding its use, HbA1C is deemed a reliable marker for the dialysis population, and monitoring this 2 to 4 times per year allows goal determination (ADA, 2008; NKF, 2007). HbA1C, the primary predictor of complications, is a weighted value of all glycemic changes over several months, and reaching the target goal may not be synonymous with consistently meeting pre- and post- prandial goals. Recent infection could skew the HbA1C value higher, and poor food intake could lower it. SMBG facilitates control by showing how food, exercise, and medication impact glycemia to enable adjustments. SMBG is especially useful to detect and deter asymptomatic hypo- and hyperglycemia. Post-prandial monitoring is helpful when the HbA1C goal is not being met or in determining insulin dosing with gastroparesis, and post-prandial glucose reduction may lessen cardiovascular risk (ADA, 2008; NKF, 2007). Unfortunately, glycemic monitoring in patients with end stage renal disease (ESRD) is still inadequate, based on frequency of A1c testing (USRDS, 2007) and prescribed diabetic test strips (USRDS, 2006). This signifies an opportunity for making a difference by promoting these tools to physicians, explaining relevance of results to patients, and encouraging patients to regularly do SMBG.

Pre-Diabetes

Insulin resistance exists in CKD Stage 5 but has not commonly been labeled in the renal literature as pre-diabetes. This official ADA (2008) term is defined as impaired fasting glucose (fasting plasma glucose 100 mg/dL [5.6 mmol/L] to 125 mg/dL [6.9 mmol/L]) and impaired glucose tolerance (2-hour plasma glucose 140 mg/dL [7.8 mmol/L] to 199 mg/dL [11.0 mmol/L]). Both are risk factors for future development of DM, cardiovascular disease (CVD), and stroke (ADA, 2008; Centers for Disease Control and Prevention [CDC], 2005); and lifestyle intervention may be warranted, including dietary modifications and exercise.

Complications of Diabetes

The USRDS Annual Data Report (2007) added information on disabilities, as defined by the decreased ability to perform activities of daily living (walking, eating, dressing, transferring, toileting, and bathing) and/or instrumental activities (cooking, shopping, and managing finances and medications). Four common disabilities in patients with ESRD are blindness, amputation, paresis or paralysis of one or more limbs, and dementia, and their risks are increased by DM’s microvascular (retinopathy progressing to blindness, peripheral vascular disease leading to amputation, small vessel cerebral disease contributing to dementia) and macrovascular (stroke leading to limb paresis and dementia) complications (USRDS, 2007). These have implications regarding food intake and nutritional adequacy, medication adherence, transportation to treatment, and increased patients’ needs, placing more demands on dialysis center staff. This also underscores the importance of regularly performing foot checks and advocating eye exams.

Diabetic neuropathy (autonomic and peripheral) affects multiple organ systems. The ADA Standards of Care (2008) address complications, and the CDC Diabetes Fact Sheet (2005) provides an overview of DM. The cardiovascular risk is detailed in the KDOQI guidelines. Gastrointestinal (GI) autonomic neuropathy may encompass the entire GI system, resulting in gastroparesis, gastroesophageal reflux disease, diabetic diarrhea, fecal incontinence, and constipation. Distal symmetric polyneuropathy treatment involves optimization and stabilization of glycemic control, although pharmacological management is usually required. Unfortunately, those medications may have anticholinergic, GI, and/or appetite side effects contributing to decreased food consumption with excessive fluid intake. Decreased salivary flow rates due to DM may also make the person more prone to symptoms of dry mouth.

Hemodialysis

Hemodialysis (HD) is the most common form of renal replacement therapy (RRT) for DM (USRDS, 2007). DM affects HD treatment due to:

* Advanced calcific atherosclerosis, leading to inadequate arterial flow, venous run-off problems, more likelihood of steal syndrome, and decreased survival of arteriovenous fistulas and grafts.

* Compromised adequacy due to vascular access management problems and increased frequency of intradialytic hypotension related to autonomic nervous system dysfunction, cardiac diastolic dysfunction, and susceptibility to over-hydration.

* Difficulty in achieving targeted dry weight, leading to poorer blood pressure control, cardiovascular accidents, and sudden death.

HD treatment, in turn, can affect glycemic control by disturbing the carbohydrate to medication balance and/or compromise nutritional status in the following ways.

* Treatment schedule may interfere with patient’s usual routine, including meal time and administration of medications, especially insulin-dosing time, which is additionally compounded by prolonged insulin action (if used).

* Post-treatment fatigue may alter amount of food intake or food choices.

* Transportation factors may compound issues.

Actions to consider include:

* Patient education regarding signs and symptoms of hypo- and hyperglycemic and mechanisms of diabetes medications.

* Pre- and post-dialysis treatment blood sugar testing.

* Encourage P.O. intake before coming to treatment and afterwards.

* Medication review – determines what the patient is actually taking and when.

* Encourage regular habits and times for medications and food intake.

* Adjust doses of diabetes medication or convert more traditional split doses of insulin to regimens with greater flexibility such as basal bolus dosing.

* If the patient has poor intake, lean body mass could be decreasing and not be detected when the dry weight targets remains unchanged. Routinely evaluate dry weight to deter volume overload. This is especially indicated when the patient has poor intake, since lean body mass could be decreasing and not be detected when the dry weight targets remain unchanged.

Peritoneal Dialysis

Underlying DM may compound or exacerbate several problems associated with intraperitoneal exposure to high glucose. These include inflammatory state, hyperlipidemia, fibrosis, enhanced protein loss, intra-abdominal fat accumulation, increased risk of CVD, weight gain, obesity, and acute hyperglycemic. Glycemic control in patients on peritoneal dialysis (PD) can be improved by emphasizing sodium and fluid control to deter ultrafiltration and allowing the use of less concentrated glucose dwells to decrease glucose absorption. Intraperitoneal insulin affords better glycemic control and does not necessarily increase risk of developing peritonitis. Calories absorbed from PD need to be considered as part of the person’s total energy intake. In the future, continuous glucose monitoring may play a role to better capture blood sugar changes than SMBG affords. Nutrition and Education Concerns

Modality choice drives the nutritional needs; with DM, there is extra emphasis on achieving a euglycemic state, minimizing dyslipidemia, and consuming a total energy intake that is appropriate for the personalized weight management goal. It is unlikely that one optimal mix of macronutrients exists. The key is balancing carbohydrate intake, including meal timing and spacing, while matching diabetic medications accordingly. Fluid and sodium control may have extra significance with patients with diabetes

A renal diabetic diet may seem like a jigsaw puzzle to many patients. They view the multiple and sometimes conflicting dietary restrictions and goals as separate pieces. They need to understand the why, what, and how, so they can put the separate pieces together and form a new, integrated way of eating. Health care providers should not assume that there is a good understanding of diabetes management and control just because an individual has long-standing diabetes. It is important to dispel any misconceptions that may exist and to instill the idea that all of this does matter.

Conclusion

More than half of those undergoing dialysis have diabetes. If nurses are to truly make a difference in the quality of their lives, nurses need to better understand the magnitude of diabetes, what glycemic control involves, nutritional issues, and the impact of dialysis impacts. This will enable nurses and other health care providers to improve management strategies and provide more thorough patient education, resulting in better outcomes for this high-risk population.

The Issues in Renal Nutrition in Nephrology Nursing department is designed to focus on nutritional issues for nephrology patients. Address correspondence to: Ann Cotton, Contributing Editor, Nephrology Nursing Journal; East Holly Avenue/Box 56; Pitman NJ 08071-0056; (856) 256-2320. The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of the American Nephrology Nurses’ Association.

References

American Diabetes Association (ADA). (2008). Standards of medical care in diabetes – 2008. Diabetes Care, 31, S12-S54.

Center for Disease Control and Prevention (CDC). (2005). National diabetes fact sheet. Retrieved July 6, 2008, from www.cdc.gov/ diabetes/pubs/pdf.ndfs_2005.pdf

Kalantar-Zadeh, K., Kopple, J.D., Regidor, D.L., Jing, J., Shinaberger, C.S., Aronovitz, J., et al. (2007). A1C and survival in maintenance hemodialysis patients. Diabetes Care, 30, 1049-1055.

Locatelli, F., Pozzoni, P., & Del Vecchio, L. (2004). Renal replacement therapyin patients with diabetes and ESRD. Journal of the American Society of Nephrology, 15, S25-S29.

Lok, C.E., Oliver, J.J., Rothwell, D.M., & Hux, J.E. (2004). The growing volume of diabetes-related dialysis: A population study. Nephrology Dialysis Transplantation, 19, 3098-3103.

National Kidney Foundation (NKF). (2007). KDOQI clinical practice guidelines and clinic practice recommendations for diabetes and chronic kidney disease. American Journal of Kidney Diseases, 49, S1- S182.

Oomichi, T., Emoto, M., Tabata, T., Morioka, T., Tsujimoto, Y., Tahara, H., et al. (2006). Impact of glycemic control on survival of diabetic patients on chronic regular hemodialysis. Diabetes Care, 29, 1496-1500.

Pupim, L.B., Heimburger, O., Qureshi, A.R., Ikizler, T.A., & Stenvinkel, P. (2005). Accelerated lean body mass loss in incident chronic dialysis patients with diabetes mellitus. Kidney International, 68(5), 2368-2374.

United States Renal Data System (USRDS). (2005). 2005 annual data report: Chapter 3 – Patient characteristics. Retrieved July 6, 2008, from http://www.usrds.org/2005/pdf/03_patient_charac_05.pdf

United States Renal Data System (USRDS). (2006). 2006 annual data report: Chapter 5 – Clinical indicators and preventive health. Retrieved July 6, 2008 from www.usrds.org/2006/pdf/ 05_clin_ind_prev_hlth_06.pdf

United States Renal Data System (USRDS). (2007). 2008 annual data report: Chapter 5 – Clinical indicators and preventive health. Retrieved July 6, 2008 from http://www.usrds.org/2007/pdf/ 05_clinical_care_07.pdf

Sharon R. Schatz, MS, RD, CSR, CDE, is a Renal Dietitian, Lumberton Dialysis/DaVita, Cherry Hill, NJ.

Copyright Anthony J. Jannetti, Inc. Jul/Aug 2008

(c) 2008 Nephrology Nursing Journal. Provided by ProQuest LLC. All rights Reserved.

Smoking Cessation Therapy Considerations for Patients With Chronic Kidney Disease

By Manley, Harold J Stack, Nicole M

Cigarette smoking is a readily modifiable cardiovascular and chronic kidney disease (CKD) risk factor. Smoking cessation aids include nicotine replacement therapy (NRT), bupropion, and varenicline. Several reports suggest that patients with CKD who use tobacco products be encouraged to stop; however, very little is offered to the healthcare provider as to how to successfully prescribe and monitor smoking cessation therapy for this patient population. This article reviews NRT, bupropion, and varenicline pharmacokinetics and dosing literature for patients with CKD. Evidence for the benefit of smoking cessation in patients with CKD is also reviewed. Goal:

To increase awareness about smoking cessation therapy for patients with chronic kidney disease.

Objectives

1. Explain how nicotine replacement therapy, bupropion, and varenicline are used as methods of smoking cessation therapy.

2. Describe the pharmacokinetics of bupropion and varenicline.

3. Discuss smoking cessation outcomes in patients with CKD.

Tobacco use is a common practice among Americans today. Nearly 47.5 million adults currently smoke, and this number has already increased from the estimated 46.2 million in 2001 (Centers for Disease Control and Prevention [CDC], 2002, 2003a,b). Tobacco use has numerous consequences and devastating health effects, but it also has large scale economic effects. Smoking leads to over 400,000 preventable deaths annually in addition to approximately $167 billion dollars lost annually in economic costs (CDC, 2005). According to the CDC, for every one person who dies, there are 20 individuals who also experience a serious illness secondary to smoking (CDC, 2002, 2003a,b). For each of the approximately 47 million smokers, more than $1,760 is lost in productivity, and $1,623 lost is in medical expenditures (CDC, 2005). The estimated annual economic costs of smoking are $75.5 billion in health care expenditures and $92 billion lost in productivity (CDC, 2005).

Cigarette smoking is associated with significant morbidity and mortality, and it places individuals at risk for developing numerous diseases, including cardiovascular disease, cancers, osteoporosis, and respiratory disorders, in addition to detrimental effects during pregnancy and further negative consequences in adolescents who smoke (Okuyemi, Ahluwalia, & Harris, 2000). Cigarette smoking substantially increases the risk of cardiovascular disease, such as stroke, sudden death, and heart attack (Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2001). Cigarette smoking is also associated with kidney disease and increases the risk and progression of chronic kidney disease (CKD) (Biesenbach & Zazgornik, 1996; Gambaro et al., 1998; National Kidney Foundation [NKF], 2002, 2003a; Orth, 2000; Yu, 2003). In the NKF’s Kidney Early Evaluation Program (KEEP), nearly half of KEEP participants had a smoking history; 14.0% were current smokers and 31.3% used to smoke. Of the current smokers, 23.6% had diabetes, 45% had hypertension, and 46% showed evidence of CKD (NKF, 2003a).

CKD is estimated to affect over 11% of the U.S. population (Coresh et al., 2005). In addition to kidney disease, patients with CKD may present with comorbid conditions, such as left ventricular hypertrophy, diabetes mellitus, coronary heart disease, anemia, and hypertension (Brown et al., 2003; Keith, Nichols, Gullion, Brown, & Smith, 2004). Patients with CKD Stage 5 (those on dialysis) have a mean of 5 to 6 co-morbid conditions that often require complex therapeutic regimens of up to 12 different medications (Manley et al., 2004; United States Renal Data System [USRDS], 2000). The number and severity of the aforementioned cardiovascular risk conditions increase as CKD worsens (Anavekar et al., 2004; NKF, 2002; Rahman et al., 2004). Cardiovascular-related hospitalizations and mortality also increase with worsening kidney function (Go, Chertow, Fan, McCulloch, & Hsu, 2004). Once a patient reaches CKD Stage 5, approximately 50% of deaths are cardiovascular-related (USRDS, 2004).

Since 1998, there has been a heightened awareness and call for research to reduce cardiovascular mortality in patients with CKD (Levey et al., 1998). Additionally, the NKF has published various clinical practice guidelines aimed at reducing the progression of kidney disease and cardiovascular mortality in patients with CKD through early detection and medical management of kidney disease, hyperphosphatemia, lipid abnormalities, anemia, hypertension, and cardiovascular disease (NKF, 2001, 2002, 2003b,c, 2004, 2005).

Cigarette smoking is a readily modifiable cardiovascular and CKD risk factor. It is generally accepted that smoking cessation decreases cardiovascular mortality in the general population. Smoking cessation may also decrease the progression of CKD (Chuahiun et al., 2004; Halami et al., 2000; Schiffl, Lang, & Fischer, 2002). Despite several reports suggesting that patients with CKD who use tobacco should be encouraged to stop their tobacco use (Brown & Keane, 2001; NKF, 2002, 2003b, 2004, 2005; St. Peter, Schoolwerth, McGowan, & McClellan, 2003; Yu, 2003), little is offered to the healthcare provider as to how to successfully prescribe and monitor smoking cessation therapy for this patient population.

Given the complexities of CKD and its affects on drug metabolism, distribution, and elimination, some clinicians may not be comfortable with or aware of the nuances of the medications prescribed for smoking cessation. In the context of CKD, this article reviews the dosing, pharmacokinetics, and side effect profiles of Food and Drug Administration-approved medications used in smoking cessation. It also reviews the literature of smoking cessation programs/clinics outcomes in patients with CKD.

Nicotine use is an addiction, and therefore, requires behavioral or nonpharmacologic interventions in addition to pharmacologic options. Many smokers report the desire to quit, whether secondary to health concerns or economics reasons, but the difficulty to quit highlights the habitual and physiological addiction (Hymowitz et al., 1997; Okuyemi et al., 2000). Effective smoking cessation programs typically include patient support programs and rely on medications to increase success. Tobacco cessation can be treated with the use of behavioral modifications in addition to drug therapy, such as nicotine replacement therapies (NRTs) bupropion, or varenicline. Behavioral strategies can include support groups, relaxation techniques, and follow-up phone calls, in addition to regular face-toface visits with the patient’s tobacco cessation provider. The effectiveness of each of the behavioral and medication therapies has been studied, and it is reported that no one therapy is better than another (Bollinger et al., 2000; Hajak et al., 1999; Hays et al., 2001; Herrera et al., 1995; Hurt et al., 1997, 1998; Setter & Johnson, 1998; Shiffman et al., 2002). A patient’s preference is typically what defines the option the patient chooses.

Nicotine Replacement Therapy

Nicotine is rapidly absorbed in the lung (Pomerleau & Pomerleau, 1998). On average, smokers absorb 1mg of nicotine per cigarette smoked; however, this can vary by the smoker and the level of inhalation. Nicotine then enters the pulmonary and arterial circulation. Nicotine is a weak base and is non-ionized, leading to easier absorption in alkaline environments. Nicotine undergoes extensive first pass metabolism when ingested orally (for example, with gum or lozenge). Nicotine is largely metabolized by the liver, with renal excretion depending on urinary pH and flow. The half- life (t1/2) is approximately two hours. The main metabolites include cotinine and nicotine-N-oxide.

The pharmacokinetics of intravenously administered nicotine (0.028 mg/kg) in nine healthy subjects (glomerular filtration rate [GFR], 84 to 143 mL/min/1.73m2), four patients with mild kidney failure (GFR, 63 to 73 mL/min/1.73m2), five patients with moderate kidney failure (GFR, 18 to 36 mL/min/1.73m2), and six patients with severe kidney failure (GFR, 1 to 10 mL/min/1.73m2) were reported (Pomerleau & Pomerleau, 1998). Three patients were on peritoneal dialysis. Nicotine and cotinine concentrations were measured in plasma, urine, and peritoneal dialysate from 0 to 24 hours after start of infusion. There were significant correlations between GFR and total clearance (p

Gum and the lozenge NRTs are similar in their administration and dosage availability (2mg and 4mg) (see Table 1). They are also available without a prescription. The most common side effects include gastrointestinal discomfort, but these products are generally tolerated well (Molander et al., 2000). Gum and lozenge NRTs are also useful in targeting the “handto-mouth” routine of many smokers; the gum or lozenge provides patients with something to place in their mouths where they would normally place a cigarette. These products have also been shown to assist in reducing weight gain, which can be a concern or potential barrier for many smokers trying to quit (Eliasson, Taskinen, & Smith, 1996; Herrera et al., 1995; Shiffman et al., 2002; Thompson & Hunter, 1998).

The NRT inhaler is another option that aims to target a patient’s “hand-to-mouth” routine. The inhaler is available as a 10mg cartridge that delivers 4mg of nicotine. It also provides flexible dosing for patients, who typically use 6 to 16 cartridges per day based on their level of nicotine dependence (Bollinger et al., 2000; Hjalmarson, Nilsson, Sjostrom, & Wiklund, 1997; Okuyemi et al., 2000).

The last NRT option is the nasal spray. The nasal spray is available as 0.5mg nicotine per spray. Patients are recommended to use 1 to 2 doses per hour (Henningfield et al., 2005). This formulation also provides flexible dosing and is the only NRT option that is closest to a cigarette in terms of the rapid rise in nicotine stimulation (Hurt et al., 1998; Okuyemi et al., 2000; Thompson & Hunter, 1998). Both the inhaler and nasal spray are well tolerated with mild side effects, such as coughing or nasal irritation, respectively.

Buproprion

The first non-nicotine-containing medication approved by the Food and Drug Administration for smoking cessation is bupropion. Bupropion is indicated for the treatment of depression and also as an aide to smoking cessation (GlaxoSmithKline, 2007). This option focuses more on reducing a patient’s craving rather than supplementing the need for nicotine, such as an NRT (Hays et al., 2001; Hurt et al., 1997). Bupropion use is warranted in patients who are willing to quit and have tried the NRTs without success, are unwilling to use an NRT, and have a potential precaution that precludes them from using one of the NRTs (such as cardiac conditions, pregnancy). The purported mechanism of bupropion in assisting patients in smoking cessation is unknown, but is probably related to inhibition of noradrenergic or dopa-minergic neuronal uptake (GlaxoSmith-Kline, 2007). The resultant increase in norepinephrine and dopamine attenuates nicotine withdrawal symptoms and cravings, respectively. Bupropion should be started 1 to 2 weeks prior to the patient’s chosen “quit day” because the onset of activity usually occurs after the first week of initiation. Patients who have not stopped smoking after seven weeks of bupropion therapy are generally considered non-responsive to this treatment (Glaxo- SmithKline, 2007). The most common side effect with bupropion use is dry mouth and insomnia. Bupropion increases the risk of seizure. Doses should not exceed 300mg per day, and bupropion should not be prescribed in patients with seizure disorder or who are at risk for seizures (GlaxoSmithKline, 2007; Henningfield et al., 2005).

The Pharmacokinetics Of Bupropion

Bupropion is rapidly absorbed after oral administration; however, only a small proportion of the oral drug reaches the systemic circulation intact. Bupropion is extensively protein bound (84%). The volume of distribution is 19 to 21 L/kg, and central nervous system concentrations are 10 to 25 times greater than in plasma concentrations (Findlay et al., 1981; Preskorn & Othmer, 1984). Buproprion undergoes extensive first-pass metabolism primarily by the CYP2B6 isoenzyme (GlaxoSmithKline, 2007). There are three active metabolites – hydroxybupropion, threohydrobupropion, and erythrohydrobupropion. The metabolite potentency, relative to bupropion, is estimated to be 50%, 20%, and 20% respectively (Glaxo- SmithKline, 2007). The kidney is responsible for 87% bupropion excretion; 10% is excreted via the feces (GlaxoSmithKline, 2007). With chronic administration, bupropion elimination half-life is 21 hours; metabolite elimination half-lives range from 20 to 37 hours. All half-lives are prolonged in patients with liver disease (GlaxoSmithKline, 2007).

In the general population, the recommended dose is 150mg daily for 3 days then increasing to 150mg twice a day (GlaxoSmithKline, 2007; Henningfield et al., 2005). Common adverse effects include general gastrointestinal discomfort, agitation, and insomnia (Henningfield et al., 2005). Patients prescribed bupropion should be advised to take the second dose earlier in the evening to minimize any associated insomnia.

The pharmacokinetics of bupropion and two of its major metabolites, hydroxybupropion and threohydrobupropion, were studied in eight patients on hemodialysis (HD) following a single oral dose of 150 mg bupropion hydrochloride sustained-release (Worrall, Almond, & Dhillon, 2004). The bupropion results were similar to those for individuals with normal renal function. The metabolites demonstrated increased areas under the curve, indicating accumulation. Dialysis clearance of hydroxybupropion is unlikely. The results suggest significant accumulation of the metabolites in patients with renal failure. Due to the uncertainty of the clinical importance bupropion metabolite accumulation and potential associated toxic plasma levels, the authors recommend that a dose of 150mg bupropion every three days in patients receiving HD may be more appropriate than the current manufacturer’s recommendation (in renalimpaired patients) of 150 mg daily then increased to twice daily after 3 days. Further investigation of the safety and efficacy of this dosing recommendation is warranted.

Varenicline

The latest non-nicotine containing medication approved and available for use in tobacco cessation is varenicline (Chantix(R)). Varenicline has a novel mechanism of action in targeting tobacco dependence. It works as a partial nicotinic receptor agonist selective for the alpha4beta nicotinic receptor. By binding to alpha4beta2 receptors, varenicline induces two results: 1) it signals the release of dopamine to create similar reinforcing effects due to its partial binding at the receptor, and 2) it acts as a physical antagonist by binding to the nicotine receptor to potentially block the effects of nicotine (Foulds, 2006; Pfizer, 2008). Varenicline’s dosing is 1mg twice daily for 12 weeks after a one-week dose titration. The recommended dosing titration is 0.5mg once daily for days 1 to 3, 0.5mg twice daily for days 4 to 7, and 1.0mg twice daily for day 8 through completion of treatment (Pfizer, 2008). Varenicline should be taken after eating and with a full glass of water to minimize possible side effects. The treatment duration may also be expanded to 24 weeks and has been shown increase efficacy and abstinence rates (Gonzales et al., 2006).

The most common adverse effects associated with varenicline include nausea, headaches, insomnia, and abnormal dreams (Pfizer, 2008). Nausea has been reported as primarily mild to moderate (Gonzales et al., 2006; Jorenby et al., 2006; Tonstad et al., 2006) and can be minimized by using the recommended dose titration.

The Pharmacokinetics Of Varenicline

Varenicline reaches maximum plasma concentrations within 3 to 4 hours after oral administration and typically achieves steady state within 4 days (Pfizer, 2008). Oral administration of varenicline has been shown to be unaffected by food or the time of administration (Faessel et al., 2006). Varenicline exhibits minimal metabolism with 92% of varenicline excreted unchanged in the urine and has a halflife of approximately 24 hours (Pfizer, 2008). Dosage adjustments have been recommended with varenicline in patients with severe renal impairment, which is defined as a creatinine clearance less than 30 mL/minute due to a 2-fold increase in varenicline levels (Pfizer, 2008). The recommended dosage adjustment is to titrate the patient from 0.5mg daily up to a maximum dose of 0.5mg twice daily. Currently, dosage adjustments have not been recommended for patients with hepatic impairment due to the minimal hepatic metabolism and are not recommended based on the age of the patient (Pfizer, 2008). Further data are still needed to evaluate the safety profile and potential for dosage adjustments in these special populations.

Smoking Cessation Outcomes In CKD: The Evidence

To date, only three studies were identified via a MEDLINE search that investigate the effects of smoking cessation on preservation of kidney function (Chuahirun et al., 2004; Halimi et al., 2000; Schiffl et al., 2002). Unfortunately, the trials do not mention whether or not nicotine or bupropion therapy was used to facilitate smoking cessation. Smoking cessation effects on GFR decline in patients with type 2 diabetes with and without macroalbuminuria were reported (Chuahirun et al., 2004). All patients had a normal plasma creatinine, were prescribed an angiotensin-converting enzyme inhibitor, and had adequate blood pressure control. Non-smokers and smokers with normo-, micro-, and macroalbuminuria (n = 157) and a separate cohort (n = 80) with microalbuminuria, were followed for six months. Urine excretion of transforming growth factor beta-1 (UTGF-beta1), measured as TGF-beta1, is associated with in the development of scarring and fibrous cresents in the glomerulus via activation of myofibroblasts from glomerular parietal epithelial cells (El Nahas, 1996; Ng et al., 1999). UTGF-beta1 increased in macroalbuminuric but not in nonmacroalbuminuric nonsmokers and UTGF- beta1 rate was higher in smokers than nonsmokers within each albuminuria group. In the separate microalbuminuric cohort, the rate of UTGF-beta1 change for quitting smokers was not different from nonsmokers (0.093 versus -0.123 ng/g of creatine/week, P = not significant) but for non-quitting smokers (0.970) was higher than non-smokers (P = 0.017). Patients with type 2 diabetes who are at high risk compared with low risk for nephropathy progression have progressive renal injury as measured by increasing UTGF-beta1. Cigarette smoking exacerbates renal injury in type 2 diabetes despite blood pressure control and ACEI, but its cessation in those with microalbuminuria ameliorates the progressive renal injury caused by continued smoking.

The second trial is a report of 45 patients with progressive primary nephropathies (glomerulonephritis or tubulointerstitial nephritis) and moderate renal failure (Schiffl et al., 2002). All patients were encouraged to stop cigarette smoking (1 to 2 packs per day); 26 patients refused to change their smoking habits (current smokers), and 16 successfully stopped (ex-smokers). Over a 24-month study period, carboxyhemoglobin and creatinine clearance were measured every six months. The primary end-point of the study was endstage renal disease requiring dialysis. Current smokers and ex- smokers had similar rates of creatinine clearance decline in the preceding 24 months prior to the investigation. Compared to ex- smokers or matched non-smoking patients with CKD, individuals who continued to smoke had a significantly faster decline in creatinine clearance during the 24-month study period. Dialysis therapy was started in seven individuals (6 smokers; 1 exsmoker) over the study period. The authors concluded that smoking cessation slowed the progression of renal failure but did not reverse any renal function caused by previous smoking.

Investigators determined creatinine clearance (Cockcroft-Gault formula) and proteinuria (dipstick) of an overnight urine sample in large observational trial (n = 28,409) in the general population of the la Sante region in France (Halimi et al., 2000). Adjusted creatinine clearance was higher in current smokers than in former smokers and never smokers (100.6 +- 13.6 vs. 98.8 +- 13.9 mL/min/ 1.73m2, P

Conclusion

Increased efforts should be made to encourage patients with CKD to stop smoking in order to preserve kidney function and potentially delay dialysis therapy. Clinicians recommending smoking cessation pharmacotherapy should use reduced doses of bupropion and varenicline, and may use recommended doses of NRT.

This offering for 1.9 contact hours is being provided by the American Nephrology Nurses’ Association (ANNA).

ANNA is accredited as a provider of continuing nursing education (CNE) by the American Nurses Credentialing Center’s Commission on Accreditation.

ANNA is a provider approved by the California Board of Registered Nursing, provider number CEP 00910.

This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continuing nursing education requirements for certification and recertification.

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Harold J. Manley, PharmD, FASN, FCCP, BCPS, is Director of Clinical Pharmacy, DaVita VillageHealth Disease Management, Vernon Hill, IL, and a Member, the Albany Nephrology Pharmacy Group (ANephRx).

Nicole M. Stack, PharmD, is an Assistant Professor, Albany College of Pharmacy, Albany, NY.

Disclosure Statement: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education article.

Copyright Anthony J. Jannetti, Inc. Jul/Aug 2008

(c) 2008 Nephrology Nursing Journal. Provided by ProQuest LLC. All rights Reserved.

Life’s Focus Much Different 70,000 Years Ago

By Wolfgang Niesielski

Just a mere 70,000 years ago humanity was on the brink of extinction, according to a recent study. At that time the entire population, which now numbers about 6.6 billion people, contained perhaps only about 2,000 individuals!

Just imagine at that time you probably knew just about each and every person on earth or at least one of his or her cousins. That pretty much means the six degrees of separation boiled down to almost zero. The expression that the entire world was watching the Olympics, for example, would have meant literally that at the time. You pretty well could easily fit the entire world’s population into any high school arena.

I wonder who would have sponsored athletes back then; good thing it wasn’t the tobacco industry. We can count ourselves extremely lucky that cigarette smoking was virtually unknown then because paper hadn’t been invented, or you can bet we’d be extinct for sure now. Come to think of it, with no knowledge of paper, as well as any modern tools, we also could not play the “paper, rock, and scissors” game because if you only have “rock” available, that practically cancels out anyone’s chances of winning. It makes you wonder what they did all night sitting around the campfire.

Raising kids must have been much easier in those days. For example, if teenagers wanted to borrow the family wheels for a joy ride, all a parent had to say was, “For crying out loud, wait until someone invents it first!” Talking about youth during the Stone Age, with rocks in abundance, rock music must have already been quite popular. But, of course, disco didn’t exist yet, which fortunately, decreased embarrassing moments of teens rolling around laughing while looking at pictures of their parents dressed in bell-bottom baby blue jumpsuits. Kids had a lot more respect for their parents back then.

Left only with plunking and twanging the entrails of an occasional moose, availability to first-class musical instruments was rare, which pretty much would have cut down most forms of musical expression, except maybe rapping. Unfortunately for rap artistes, the entire vocabulary range during those years of scarcity was probably limited to only a few dozen words. And perhaps half a dozen of those were already used up to describe different types of dung, expressions actually very practical for trackers to ascertain time and distance of prey during a hunt.

Even today with a dictionary at hand, how many words can you find that rhyme with mammoth manure? Facing fearsome audiences equipped with clubs and spears, rappers were eventually forced to invent record albums they could rhythmically scratch and scrape, to cover up awkward voids due to scant, inadequate terminology.

Obviously, though, life back then was less focused on celebrities and entertainment and more on cooking, an endeavor largely limited to tossing some living thing onto the fire and then munching on charred meat. This actually was an enormous improvement in the area of culinary achievements, standing head and shoulders above the previous practice of devouring the animal raw (progress that has been lost on today’s sushi crowd, by the way).

Certainly the inventor of fire must have been the world’s first celebrity. Good thing his or her identity has been lost in the annals of history because that name would soon be mud as this culprit set us on a downward-spiraling journey toward today’s climate change, due to escalating carbon emissions. Starting with the occasional wood fire back then, pollution has now accelerated to the point of almost total ecological collapse! So, if things continue we might end up where we started, with just a few of us surviving. But at least we can console ourselves with the fact that with access to today’s mammoth vocabulary, perhaps rap music will be improved.

Educating Generation Net-Can U.S. Engineering Woo and Win the Competition for Talent?

By Chubin, Daryl Donaldson, Krista; Olds, Barbara; Fleming, Lorraine

ABSTRACT U.S. engineering education needs to evolve if the country is to maintain its preeminence in science, technology, engineering, and mathematics fields. This paper, building on both national engineering student data and findings from the Academic Pathways Study, conjectures and reports on analyses of what matters to future generations of engineers. The paper compares the current generation of college students, Generation Net, with previous generations, explores motivations and choices along the engineering pathway (pre-college to the workforce), examines students’ knowledge and skills relative to faculty practices, and concludes with three scenarios of engineering education and the workforce, including the consequences of stasis or change.

Keywords: Gen Net, recruitment, workforce

I. WHAT IS AT STAKE (BEYOND ENGINEERING)?

Generations matter. However, they make more sense when viewed retrospectively than when one participates in the first-person. As U.S. higher education transitions to a new clientele, the “Gen Net,” many college freshmen today have Gen-X parents (born 1961-81). Are the educational values of Baby Boomer faculty consistent with those of these new students and their parents? Why is it important to consider the values and motivations of both the Gen Net (born 1982- 2002) and their Gen-X parents (Strauss and Howe, 2007)? Because the historic link between expectations and later pursuits-what to study, education and degrees earned, career choice-may determine how engineering as a broad field (with specific disciplinary variations) fares in the competition for student talent. The composition and quality of the future engineering workforce hangs in the balance.

There appear to be two distinct schools of thought regarding the global nature of engineering into the foreseeable future. One school focuses on the issue of global competitiveness and argues for the need to produce more “home grown” engineers to maintain a global competitive edge. Alarmists who fear globalization see U.S. innovation as the preeminent economic challenge of the twenty-first century (Wadhwa et al., 2007) and argue that the burden of leadership requires that our knowledge and inventiveness dominate the technological landscape. A key component of that leadership is the education and training of engineers in U.S. colleges and universities. Proponents cite statistics about the huge number of engineers graduating annually from Chinese and Indian universities as well as the declining number of U.S. citizens who are earning engineering degrees:

Even if the nation did everything that is needed, it will probably take 10 to 15 years before major benefits become apparent. Given the pace at which globalization is happening, by that time the United States would have lost its global competitive edge. The nation cannot wait for education to set matters right (Wadhwa et al., 2007).

A recent widely-discussed publication of the National Research Council, Rising Above the Gathering Storm (Committee on Science, Engineering, and Public Policy, 2007), for example, warns that “Although the U.S. economy is doing well today, current trends in each of those [competitiveness] criteria indicate that the United States may not fare as well in the future without government intervention. This nation must prepare with great urgency to preserve its strategic and economic security” (Augustine, 2005). The America Competes Act (Public Law 110-69, authorized Aug. 9, 2007) which was built on Above the Gathering Storm, encompasses the President’s American Competitiveness Initiative, and proposes incentives to increase the number of U.S. citizen science, technology, engineering, and madiematics (STEM) students and teachers (Carney, Chubin, andMalcom, 2007).

A different approach is taken by those who see the world as “flatter” and who argue for more international collaborations, often through the use of technology, as the way to maintain the U.S. edge in the global arena. Proponents of this view often argue that Americans are uniquely innovative and creative, our graduate programs are the best in the world, and that these qualities will preserve U.S. status in the global market through an endless flow of talent to our shores (Friedman, 2005). They cite a distinct qualitative difference in graduates of U.S. engineering programs and see a global picture more collaborative than competitive (Friedman, 2005).

On this the two groups converge: American engineering education needs to evolve if the country is to maintain its preeminence in STEM fields (Clough, 2004). Of approximately four million American high school students who graduate each year, less than two percent will earn an engineering degree from a U.S. engineering school (Orsak 2003). ABET, Inc., the accreditor for college and university programs in applied science, computing, engineering, and technology, has recognized the importance of a globallyaware engineering workforce, too-ABET Engineering Criterion 3h calls for “the broad education necessary to understand the impact of engineering solutions in a global, economic, environmental and societal context.” Many engineering programs have followed suit, developing international programs for their students ranging from brief overseas experiences to year-long exchanges and research opportunities (Downey, 2006).

If the Net Generation (also called the Digital Generation, Digital Natives, Millennials and the synonym we favor, Generation Net or Gen Net, for short) compose the pool of future engineers, then what “bait” should engineering institutions use to land needed and diverse talent (Howe and Strauss, 2000; Prensky, 2001)? If, as the evidence discussed in this special issue suggests, Gen Net students are more comfortable than their predecessors in interacting with diverse populations and with virtual communities, we predict that they will continue to work both formally and informally, with colleagues around the globe-but they need to be well-prepared through their engineering programs to do so. In traditional terms, how can engineering anticipate labor market “demand” and shape “supply” to ensure a better fit between what is learned in the classroom and what skills are sought for the workplace? What do we know about the Gen Net relative to our national and global competitiveness and collaborative needs?

Such questions are at once timeless, pragmatic, and vexing. Recognizing student propensities should give a competitive advantage to institutions who not only “fish smart,” but fill out their nets with a variety of “smart fish”-not just those traditionally attracted to engineering. This paper, building on both national engineering student data and findings from the Academic Pathways Study, casts about (theoretically) and seeks knowledge (empirically) of what matters to our future generations of engineers. Before we report what our sampled students thiruc, say, and do, we examine what previous generational analyses suggest about the specimens we covet.

II. GENERATION NET

Generational analyses are largely impressionistic-and therefore perilous. While contradictions in generalizations can always be found, we should not be perplexed by individuals who show few of the generational tendencies described (Ambrose, 2007; Hoover, 2007). The experiences of student affairs deans plus attitudinal data found in the 2007 National Survey of Student Engagement (Kuh, 2007) help paint a picture of current undergraduates and their parents. The defining characteristic of Generation Net is that they have never known life without the Internet and “can’t imagine life without it” (Oblinger and Oblinger, 2005). Gen Nets tend to be abundantly socially-connected, embrace new technologies, place value in immediacy and speed, and are ethnically diverse and involved in their community. In a learning environment, Gen Net students also differ from earlier generations: they prefer learning that is experiential (“learning by doing rather than being told what to do”), highly visual (as compared to text-based), fast-paced, and interactive (Roberts, 2005).

Universities are the frontline in attracting tomorrow’s engineers, and to do so, they must also attract their parents. The dynamic between parent and child differs by generation. Gen X, the parents of Gen Net, has been described as follows:

To get ahead, Gen Xers have had to work longer hours, take extra jobs, become dual-income families, go into business for themselves, or find new ways to economize. As a result, many Gen Xers have taken a pragmatic approach to the education of their children . . . demanded accountability from elementary and secondary schools, as well as bottomline cash value – the confidence that, in the end, what has been provided has been worth the investment of time and money (Strauss and Howe, 2007).

Gen Nets have been found to welcome the involvement of their parents in their lives, including their career planning. So-called “helicopter parents” hover and micromanage, often to their children’s delight (Andom, 2007; Merriman, 2007; Powers, 2007). Gen Net’s high expectations regarding overlapping boundaries of personal and professional life extend to future employers as well: they seek work-life balance, protection against risk, fairness, and the opportunity for teamwork Successful recruitment and retention on the job for this generation will have to focus not only on salary, but also on the importance of the work, the relations with colleagues (e.g., their preference for consultative decisionmaking), and the provision of appropriate supervision and mentoring. Corporate employers will have to manage Gen Net’s expectations for advancement, encourage them to take leadership roles, and cultivate responsible risk-taking. A need for structure will require a delicate balance with employers’ need for highly-motivated and committed self-starters. In universities, Gen Net’s characteristic approaches to learning are often not complementary with traditional teaching methods more aligned with those of earlier generations of faculty. Today’s students perceive technology, omnipresent in their Uves, not as hardware or software, but rather as the means to a desired end (Kvavlik 2005). Nevertheless, Slaughter (2007), of the National Action Council for Minorities in Engineering, identified a disconnect:

It seems counter-intuitive to me that with all the technological artifacts in our lives, young people are not more interested in science, engineering, and technology what with cell phones, digital cameras, MP-3 players, IPODs, PCs, CDs, PDAs, DDRs, VCRs, and TlVOs everywhere. Those of us in positions to help share much of the blame for not conveying to young people the excitement, satisfaction, and rewards to be found in science and engineering, and for not providing in some comprehensive manner, the outreach that will encourage and inspire more youth to prepare themselves for the opportunities that will be available to them.

In an interview, Charles Vest, the President of the National Academy of Engineering and President Emeritus of the Massachusetts Institute of Technology, similarly observed:

… this current generation of young people is actually very idealistic. They very much want to make the world a better place and very few of them see or understand engineering as a mechanism for doing that (Science and Government Report, 2007).

As Table 1 suggests, generational differences have been perceived throughout the twentieth century. While anecdotal, these comparisons do highlight some of the potential challenges of teaching, learning, and promoting student engagement. American faculty are adapting, but at a pace that appears to be too slow for many students who have been exposed to interactive, technologically-integrated curricula since elementary school (Clayton-Pedersen and O’Neill, 2005).

More technology does not necessarily enhance the learning environment. Research shows that technology, whether employing use of digital data-collection tools or computer simulations, must be integrated into an existing curriculum, rather than become the central feature of a course (Kvavlik, 2005). Getting immediate feedback on students’ basic understanding of concepts, for example using hand-held “clickers” in classrooms, improves the engagement of all types of learners (Davis, 2007; Chen, Lattuca, and Hamilton, 2008). Different styles of learning and processing information are here to stay. Indeed, the generation following Gen Net, composed of 8-18 year olds and sometimes called “Generation M(edia),” spends an average of nearly 6.5 hours a day with digital media (Rideout, Roberts, and Foehr, 2005).

The good news for university instructors, however, is that students still think that faculty expertise and passion are the keys to their learning (Roberts, 2005). That means the faculty role in engaging students remains unparalleled. As Chen et al. explore in this issue, certain institutional practices lead to high levels of student engagement. It is incumbent on faculty to organize learning opportunities on behalf of the institution (Chen, Lattuca, and Hamilton, 2008). In engineering education, they remind us, “systems thinking is . . . paramount; understanding . . . more conceptually driven . . . and the manipulation of ideas within design and odier problem-solving contexts is crucial.” Indeed, they find that satisfaction with instructors is significandy related to intent to major in engineering and their overall satisfaction with their collegiate experience. For example, engagement in undergraduate research is one way students can establish a personal relationship with faculty outside the classroom (Fortenberry, 2007). Yet evidence is lacking that institutions value-in deed if not in word-faculty commitment that takes curricular stewardship and student interactions seriously.

As engineering faculty are asked to better prepare their students to enter and thrive in the early twenty-first century workforce, the academic community must hope that institutions will invest in the pedagogy, technology, and professional development that supports engagement-teaching as well as learning.

III. THE ENGINEERING PATHWAY

A. Historical Trends on Choice of Major

Over the past 40 years, data on students enrolling in U.S. institutions of higher education present a moving picture of growth in number and diversity. Demographic pluralism has combined with policies to reduce inequities of race, ethnicity, gender, and disability, but the cost of attending college continues to rise. Meanwhile, the undergraduate student body, now represented in the aggregate by Gen Net, comes to college less academically prepared (needing remedial work especially in mathematics), but more socially accustomed to, if not adept in, living with “visible difference” (Hurtado and Pryor, 2007). Two in three say they have been “socialized with another race,” yet only one in five considers “racial discrimination no longer a major problem.”

What about those students in the STEM disciplines, and particularly those inclined to engineering? STEM degrees still represented only a third of all U.S. bachelors degrees awarded in 2004, the same proportion that they represented in 1966 (Babeo and Ellis, 2007). These percentages are remarkably stable, although gender ratios continue to be most imbalanced for engineering (as a whole) and computer science.

Whereas long-time trends of women’s high participation at the bachelors’ level approach parity in life and social/behavior sciences (Babeo and Ellis, 2007), The American Freshman (Pryor, 2007a) profiles show a continuing gender imbalance in interest among first-time, full-time freshmen in science and engineering majors- nine to one male in computer science and six to one in engineering. Today, five out of six engineering students and nine out often engineering professors are male. The vast majority are also white. These numbers are essentially unchanged over the last 30 years (Pryor, 2007a).

Contradictions and quandaries abound: in the total U.S. civilian workforce, STEM represents barely over 5 percent of the workers (Bureau of Labor Statistics, 2006). Yet science- and engineeringtrained personnel are suffused throughout all sectors of the economy, from manufacturing to service to health care and sales. Engineers may be part of a stealth technology and science workforce. Describing them as “stealth” attests to their capability of doing what employers value, now and in the future projected by the Bureau of Labor Statistics to 2030. Indeed, those with computer and mathematical science skills are among occupations with the lowest anticipated obsolescence in the U.S. (Cech, 2007). But how much of this luminous reality is communicated to undergraduates? Shouldn’t a technologicallyintensive and -savvy society be attracting more of its citizens to these opportunities? Why has there been no dramatic growth in STEM interest and degrees? Why is engineering attracting the students it gets? What is turning some on and turning others off? We start to consider these questions by looking at how American students might learn about engineering before arriving at college.

B. Pre-College Outreach: Laying an Engineering Foundation Before College

Pre-college engineering outreach programs largely aim to improve overall enrollment in undergraduate engineering, especially among women and underrepresented minorities (Orsak, 2003). Such programs started as early as 1956, and today over 300 operate nationally and locally (Douglas, Iversen, and Kalyandurg, 2004; Kimmel et al., 2006). Most American K-12 engineering programs target high school students and teachers, as compared to younger students: 77 percent focus on high school students and 46 percent on high school teachers (Project Lead The Way, 2007). Many universities, e.g., Maryland, Purdue, and MIT, also offer summer engineering programs where students attend classes on campus. Brophy et al. (2008) present several promising models in this issue for integrating engineering into P (pre-kindergarten)-12 curricula.

Programs in high schools generally introduce engineering concepts and fundamentals through one of two approaches: (1) as a “stand- alone” subject or program, or (2) integrated with related curriculum topics in math and science (Douglas, Iversen, and Kalyandurg, 2004). Project Lead the Way is an example of a standalone program that offers engineering fundamentals courses in over 1,500 U.S. schools in partnership with over 30 university affiliates. Summer programs at universities also tend to be “stand-alone,” and like their high school counterparts, tend to attract students already interested in engineering. Engineering Pathway, a digital library that resulted from the merging of the National Engineering Education Delivery System (NEEDS) and TeachEngineering, is an example of a program that integrates engineering topics and examples into related math and science curricula in K-12 institutions. Another example is The INFINITY Project, which partners engineering colleges with school districts in 34 states, and aims at increasing early exposure to engineering and improving students’ preparedness in math and science. This approach has the potential to reach all students in the classroom, not just those taking pre-engineering programs. Central to all of these efforts is the “teachability” of the curriculum by existing high school educators. Pre-engineering outreach programs tend to share many elements in recruiting and preparing students, particularly Gen Net, for majoring in engineering at the college level (Yoder et al., 2001; Schaefer, Sullivan, and Yowell, 2003):

* hands-on learning to promote discovery through inquirybased activities;

* lessons that bridge theory to reality (answering “Why is this important?”) and promoting preparedness in math and science;

* illustrations of the social relevance of engineering; and

* support for high school teachers teaching K-12, including training and mapping of curriculum to state standards.

However, evaluation of pre-engineering programs has largely focused on implementation and the process of engagement rather than on outcomes, including other professional experiences and degree attainment. In other words, the impact of any particular intervention and its contribution, in concert with other subsequent engineering experiences, to increasing the number of students enrolling in engineering programs is difficult to gauge. FIRST (For Inspiration and Recognition of Science and Technology, 2007), a stand-alone robotics competition with the vision to “create a world where science and technology are celebrated . . . where young people dream of becoming science and technology heroes,” may be an exception in that it reports outcomes based on longitudinal tracking of participants.

IV. GEN NET AT COLLEGE: DATA FROM THE ACADEMIC PATHWAYS STUDY

Adelman (1998), in his study of student pathways into and out of engineering, noted that curricular momentum can reinforce students’ trajectories within engineering and preferred pathways for students leaving engineering. His data are extensive: 11 years of college transcripts from the High School and Beyond/Sophomore Cohort Longitudinal Study, high school transcripts, standardized test scores, and surveys of undergraduate students. He found that an individual’s decision to study engineering was related to taking advanced mathematics and science classes in high school. Engineering students not only took higher level classes in high school, but also tended to be higher achieving there than their classmates. Once getting to college, however, for those who left engineering the “perception of overload” was found to be a factor in many students’ decisions to do so (Adelman, 1998).

Other papers in this special issue consider the multifaceted nature of the pathways of today’s students. For example, Ohland (2008) looks at choosing a major (asking how similar or different an engineering major is relative to other majors). Stevens (2008) examines how navigating an academic pathway involves matters of identity and knowledge acquisition (along with institutional opportunities and barriers). In this paper we look at four dimensions of the pathways to becoming an engineer:

* Knowledge of engineering prior to coming to college.

* Motivation to study engineering.

* Perceptions of needed knowledge and skills, and what is gained in undergraduate education.

* Post-baccalaureate plans.

Examining these four dimensions reveals the complexity of an engineering student’s life, and reinforces that there will be no “one size fits all” solution to excite more students about engineering. We use data from the Academic Pathways Study (APS) (described below) to address these dimensions. While we attempt to characterize Gen Net students largely in the aggregate, they are far from a monolithic group.

How do students identify career paths that genuinely fit their motivations, interests, and skills? The APS, part of the NSF-funded Center for the Advancement of Engineering Education, addresses questions about undergraduate student experiences and decisions to pursue an engineering degree relative to the development of their skills and knowledge, their self-perceptions, and needed skills as they enter the U.S. workforce (Sheppard et al., 2004). We present data from two cohorts of students who participated in the APS. The first cohort, the Longitudinal Cohort, is comprised of 160 students, 40 from each of the four core institutions (three had Carnegie 2000 classifications of Doctoral Research-Extensive, and one was Specialized Institution-Engineering). These students were followed from freshmen through senior years and participated in surveys, engineering activities, and interviews. The second cohort, the Broader Core Sample, is comprised of students from the larger population at the same four core APS institutions. Data of the Broader Core Sample come from their participation in the first deployment of the Academic Pathways for People Learning Engineering Survey (APPLES) in spring 2007. The goal of APPLES is to corroborate and generalize the Longitudinal Cohort findings to their broader population. The Academic Pathways Study and APPLES are described in greater detail in Sheppard et al. (2004), Donaldson et al. (2007), and Clark et al. (2008).

The students who participated in APS are quintessential Gen Net, born in the mid- to late-1980s. The year of birth for many in the Longitudinal Cohort, 1985, saw the introduction of Windows 1.0, Nokia’s 11-pound Talkman cell phone, the Commodore 128 (“with a whopping 128 KB RAM”), the Tandy 600 laptop, and Sony Discman D-50 MK2 (Rojas, 2005). Our data from the Longitudinal Cohort come from structured interviews in their first (freshmen) and second (sophomore) years; 128 subjects participated in their freshmen year and 91 subjects participated in their sophomore year. The structured interviews were approximately one hour in duration and conducted with subjects once a year for the first three years of the study at each of the four core APS institutions. These interviews were intended to collect specific information related to subjects’ engineering education experiences and their development of an identity as an engineer.

The Broader Core Sample is cross-sectional in that all undergraduate academic levels (freshmen through fifth-year+ seniors) are represented in the APPLES data. Specifically recruited were undergraduate students majoring in engineering, students thinking about majoring in engineering, and students who had intended to study engineering but decided to pursue a non-engineering major (“non-persisters”). Outreach to or over-sampling of women, ethnic minority, transfer, and internal students assured adequate statistical representation for analysis. The primary mode of subject recruitment was an e-mail solicitation from an engineering dean to students asking them to participate (Donaldson et al., 2007).

A. Gen Net’s Knowledge of Engineering Prior to Coming to College

Are the pre-college outreach programs that aim to expose students to engineering having an impact? The Broader Core Sample suggests, yes, but on a small scale. When asked “How did you gain your knowledge about the engineering profession?,” freshmen most commonly cited family members followed by (in order) having been a visitor and from a close friend. Figure 1 displays these and other sources of exposure to freshmen: intemship(s), university experiences (e.g., classes, activities, interaction with peers and faculty), “being an employee,” other (e.g., pre-college experiences, internet), and co- ops. “Other” experiences, which included K-12 programs such as Project Lead the Way, were cited by 6 percent of subjects in the Broader Core Sample.

Students who study engineering very often have parents who also studied engineering: one-third (33 percent) of the Broader Core Sample has an immediate family member who earned an engineering degree. Women students were more likely than their male counterparts (p

B. Gen Net’s Motivation to Study Engineering

Using data from the Broader Core Sample and the APPLE Survey, we looked at four different types of motivation that might spur Gen Net students to study engineering: financial, family, social good, and influence of a mentor. The survey asked students to rate whether they agree with several statements regarding each of the motivations. From these, an average variable score was computed for each of the four variables for all of the respondents who intended to complete an undergraduate engineering degree. Figure 2 shows how these four motivations compare for the Broader Core Sample: the strongest motivations were social good and financial, followed by mentor, and family. These motivations varied very little over time (as can be seen in Figure 2) and by institution. Gender differences were small: women showed a slightly higher level of mentor motivation than men, although there were no notable significant differences except for junior men (p

Given the reported influence of Gen Net’s parents in their children’s lives, we were surprised by the relative low level of motivation they provided in the APPLES data. However, this is consistent with findings by Pryor et al. (2007b) who found that while many American college students are happy with their parents’ involvement in their lives, significant percentages of students report “too little” parental involvement in their college decisions.

Table 2 shows what would be expected of those Gen Net students with an engineer as immediate family: they were likely to have higher family motivation to study engineering than other students. Having an immediate family member who is an engineer is also weakly correlated with social good and mentor motivations, but not financial motivation.

Structured interview data from the Longitudinal Cohort allowed us to explore motivations outside of the four focused on by the APPLE Survey. When freshmen and sophomores were asked what experiences have had a positive impact on their desire to become an engineer, they most frequently mentioned interaction with professors and teaching assistants, team projects, internships and extracurricular activities. These results complement findings by Chen et al. (2008) that student engagement in class and in extracurricular activities is tied to interaction and satisfaction with instructors. C. Gen Net’s Perceptions of Needed and Gained Knowledge and Skills

What is communicated to Gen Net engineering students at American universities in terms of their needed knowledge and skills? How are they gaining the knowledge they need? Table 3 summarizes Longitudinal Cohort and Broader Core Sample data on how undergraduate engineering students in the U.S. believe they gain their knowledge and skills. Taken together, these findings indicate that Gen Net students perceive their formal engineering education experience (for example, courses and interactions with faculty) as a primary source of their acquisition of engineering-related skills and knowledge. In contrast, they report that their understanding of engineering as a profession comes from more informal means (e.g., close relatives who have engineering degrees) and extracurricular activities (including internships and co-op experiences). We are relieved to see that seniors report knowing more about the engineering profession than freshmen. The fact that seniors report knowing less than freshmen about the engineering profession prior to matriculating may be due to seniors having a more realistic assessment of their prior knowledge anchored by their deeper understanding about engineering.

To understand students’ perceptions of their own skills, the Longitudinal Cohort was also asked: “What are the particular skills that you would say are important for an engineer to have?” Respondents (unsurprisingly) said that they needed “technical” skills-mathematics, science, and critical problem-solving-to be engineers. The students’ focus on technical skills parallels those of the larger engineering education community (Shuman, BesterfieldSacre, and McGourty, 2005, p. 43). However, Shuman et al. point to more than a century’s worth of reports on engineering education diat call for additional focus on what Shuman calls the “professional skills.” They cite the Accreditation Process Review Committee, which reported that “Employers were now emphasizing that success as an engineer required more than simply strong technical capabilities; also needed were skills in communication and persuasion, the ability to lead and work effectively as a team member, and an understanding of the non-technical forces that affected engineering decisions.” Industry and ABET recognize the need for these professional skills, but the engineering students as yet do not: less than 12 percent of 91 second-year Longitudinal Cohort students responded that it is important for engineers to possess the non-technical skills, such as communication skills, good work habits, and the ability to design, create, and build.

National Survey of Student Engagement (NSSE) data analyzed as part of APS reveal that engineering undergraduates participate as much as their non-engineering peers in extracurricular activities (despite spending more time studying), and 80 percent have had a practicum experience such as an internship and/or coop by their senior year (Puma and Lichtenstein, 2007). Puma and Lichtenstein’s findings on practicum experience are consistent with those from the Broader Core Sample. More than three out of four seniors had “real world experience”; they participated in an internship (52.2 percent), had been an employee (18 percent), or had participated in a co-op (7.8 percent). Gen Net seems particularly cognizant of the skills they develop while interning and participating in extracurricular activities, and they realize that they can serve to help focus their post-graduation plans. Almost three out of four engineering Broader Core Sample seniors who had participated in an internship program said they were “absolutely sure” or “pretty sure” about their plans after college.

“Ben,” a Longitudinal Cohort sophomore, interned for six months with an international engineering and architectural firm, working in the air conditioning and refrigeration department. He told APS researchers that he appreciated the problem-solving skills he acquired abroad, and greatly valued observing first-hand the commitment engineers displayed in completing their tasks in the field. He said that “people had passion for what they were doing and they stuck to it … , and it was the kind of thing that I was always looking forward to.” This student’s remark exemplifies the sense of purpose in Gen Net’s approach to learning.

Astin’s surveys of first- and fourth-year students over a twentyyear period led him to conclude that the degree to which a student is involved in his or her academic experience (typically on- campus) is directly proportional to his or her learning (1993). Similarly, we believe engagement in classes, as well as in campus Ufe, is pivotal to engineering students becoming engineers. Creating a balance between students’ in-class and out-of-class experiences enables them to develop the diverse skills needed to become engineers. Out-of-class experiences, extracurricular activities, and internships further assist students with an academic deficit or ambivalence about career goals by clarifying perceptions of the discipline and profession. Students are doing this, although not perhaps at the levels or in the areas we might expect.

Within the Broader Core Sample majoring in engineering or intending to major in engineering, two-thirds (66.5 percent) think it is “essential” or “very important” to be involved in non- engineering activities. Less than one-third (27.4 percent) of the same subjects are “extensively” or “moderately” involved in extracurricular engineering activities. The combination of such activities depicts a quality of life, both personally and professionally, that a future engineer may have and exposes them to mentors. Indeed, Felder and Brent (2005) posit that a balance between professional and technical skills correlates with the way students formulate goals and envision career pathways. Chen et al. (2008) show that extracurricular engineering involvement is positively tied to motivation to study engineering supplied by a mentor.

D. Gen Net’s Post-baccalaureate Plans

On the post-baccalaureate transition, national data are also instructive. NSF reports that one-half (51 percent) of all bachelor’s graduates of engineering programs did not pursue a graduate degree (National Science Foundation, 2006). Only one in eight engineering bachelor’s degree holders received an advanced degree in their field of study, 4 percent went on to earn doctorates.

Approximately 40 percent of the Broader Core Sample seniors majoring in engineering stated they were “absolutely sure” or “pretty sure” they would attend graduate school in engineering within three years following graduation. Another 5 percent stated they were “pretty sure” they would attend a wow-engineering graduate program in the next three years (none was “absolutely sure”). The APS data suggest the need to continue probing for changes in student perceptions of career opportunities, particularly relative to gender differences, skills to be learned, and possible career paths (Sheppard and Silva, 2001).

V. ENGAGING GEN NET

A. Gen Net Students and Baby Boomer Faculty

All teaching and learning combine content and pedagogy. How they mix, stylistically and otherwise, determines their effectiveness. If Gen Net’s learning style is not complemented by traditional teaching methods favored by earlier generations of faculty, then the advantages of active learning, where students learn more and more deeply, will be lost (Smith et al., 2005; Prince and Felder, 2007). Learning defies the neat compartments higher education has tended to make of disciplines, courses, credits, and semesters, and yet most STEM faculty persist in teaching as they were taught, wedded primarily to a lecture format (National Science Board, 2008, pp. 2- 4). This old formula is arguably counter-productive, stymieing more students in the pursuit of engineering because the packaging and delivery are mismatched to the audience (Tobias, 1990; Seymour and Hewitt, 1997).

Some are rethinking the meaning of learning and the faculty role in a digital age (Bourne, Harris, and Mayadas, 2005). While many professors remain “the sage on the stage,” others are inventing and adapting clever and effective ways of tapping into the interests of Gen Net students through such activities as simulations, modeling, digital libraries, and “serious games.” These latter, called “social impact games,” entertain but have non-entertainment goals (Social Impact Games, 2007).

In late 2004 and early 2005, the Computing Research Association (CRA) and the International Society of the Learning Sciences held a series of workshops to “explore where we are in the application of pervasive computing power to education, and where we need to be [Foreword].” In the resulting cyberinfrastructure for education and learning for the future, or CELF report (CRA, 2005), the authors assert that “Cyberinfrastructure has significant potential to radically influence educational practice,” though they also caution “it is common to overestimate the near-term effects of technology and to underestimate its long-term consequences.” Implementing their recommendations would necessitate significant changes in faculty roles and our familiar conceptions of education. How likely is change to occur, even despite repeated calls for reform from many quarters, including the influential National Academy of Engineering?

Although most new faculty have had at least rudimentary training in teaching if they were once teaching assistants, most engineering faculty are unaware of key research on how students learn engineering. Curriculum content “coverage” is still the operative paradigm in most engineering programs. Our hope is that this special issue of JEE will raise awareness about current research on the learning of engineering. Indeed, we believe every successful engineer can point to faculty members whose skill in teaching and/ or mentoring encouraged or inspired them. Knowledge of Gen Net students, how they think and how they learn, coupled with the APS research presented here, has the potential to profoundly alter the learning landscape, not just for learners, but for educators as well: Tn the higher education realm, new instructors, who often have little formal preparation as teachers, can become part of online communities where they can consult mentors, other instructors, practicing professionals, and others to find high-quality learning resources for their classes” (CRA 2005, p. 27).

Educators’ methods are not the only things that would help adapt to Gen Net. According to creativity researcher R. Keith Sawyer (2006), leading thinkers in a variety of fields believe that schools have to be redesigned for the new economy, and that the learning sciences are pointing the way to this new kind of school. In his concluding chapter of The Cambridge Handbook of the Learning Sciences, Sawyer offers some possibilities for such “new schools,” and while his focus is K-12, many of the suggestions have ramifications for higher education. If nothing else, the schools he describes will be radically different from the “old schools” that college students will attend if changes are not implemented (see Duderstadt, 2008).

B. Classroom Practices: What Matters

To “woo” talented students, many engineering educators are re- evaluating classroom practices and assessing the impact of outof- class programs on student learning (Fink, Ambrose, and Wheeler, 2005; Smith et al., 2005). They are supplementing or replacing traditional classroom lectures with activities such as Problem- based Learning (PBL) and cooperative learning experiences. More and more engineering curricula require that students participate in problem-solving teams, which often include a variety of individual assignments and team presentations (Froyd and Ohland, 2005). Some engineering educators are also moving beyond the standard technical disciplinary courses to create theme-based, and/or integrated curricula. These courses and curricula are characterized by a combination of non-technical courses, business, communication, ethics, culture, biology, and so on, with engineering coursework. By engaging diverse students with their unique intellectual perspectives and interests, educators are hoping to create engineers capable of devising holistic solutions to engineering problems dirough a dynamic learning process.

As students progress in their engineering programs, they encounter obstacles to and catalysts of learning. Satisfaction with instructors, as we know from Chen et al.’s (2008) analysis of the Broader Core Sample, is highly correlated with Gen Net’s overall satisfaction with their collegiate experience. Students’ frustration with professors’ teaching mirrors the dilemma facing engineering educators: how to convey critical engineering knowledge without unwittingly pushing talented students out of the field (a fundamental finding of Hewitt and Seymour 1997 a decade ago). Stevens et al. (2008) argue that what they call “navigation” (of the curriculum, of a program) is an important element in a student’s decision to stick with engineering. They describe both “unofficial” and “official” routes that students use, citing the example of a student taking a “required physics course at a nearby state university in order to avoid taking the class with a physics professor who had a very bad reputation among engineering students.””Navigational flexibility,” they found, however, differed markedly among the four institutions they studied.

The teaching quandary places engineering educators at a critical impasse. Not only do faculty members have the task of developing Gen Net’s skills and abilities as professional engineers, but they also have to shape them as life-long learners. What does that entail? Unlike previous generations, these Gen Nets are more self-directed learners, more technologically-sawy, more socially- aware, and more used to learning outside of die classroom. They enjoy the process of discovery. To complement this generation’s learning styles, educators must find other ways to utilize out-of-classroom resources inside the classroom.

VI. WHAT DOES THIS ALL MEAN?

Students gain fundamental knowledge from a variety of sources. While the influence of educators is largely classroom-bound, we know that the Gen Net students are self-directed learners who also seek enriching and compensatory experiences outside of the classroom. To retain talented students in engineering programs, educators must develop innovative ways to engage students and expose them to skills and knowledge beyond the university setting. While the days of lectures and rote are numbered, no one advocates that engineering classes consisting primarily of lectures and seminars be abandoned altogether. Research on the benefits of integrated curricula for engineering students suggests that traditional lectures coupled with hands-on opportunities represents a broader, more active (and satisfying) learning approach (Froyd and Ohland, 2005).

As the recent evaluation of the effectiveness of the EC2000 criteria commissioned by ABET concluded:

Finally, students’ undergraduate program experiences, both in- and outside-the-classroom, are clearly linked to what and how much students learn. Nine of 10 measures of their in- and out-of-class experiences have statistically significant, positive, and sometimes substantial influences on graduates’ reports of their ability levels on all nine of EC2000’s a-k learning outcome measures. The clarity of the instruction received, die amount of interaction widi and feedback from instructors, and the exposure to active and collaborative learning experiences are consistently die most powerful influences on learning of any factors in the study, all having a positive influence on learning. Out-of-class experiences, however, also shape student learning. . . cooperative education experiences, participation in design competitions, and … in a student chapter of a professional society or association. These experiences significantly and positively affect learning in six or more of the nine skill areas measured. The magnitudes of these effects, however, were smaller than those of students’ in-class experiences (Lattuca, Terenzini, and Volkwein, 2006).

Who will do engineering in the next generation and how will they differ, in style, interests, and career aspirations, from those who populate the current workforce? The Academic Pathways Study has provided some clues. Extrapolating from APS data and other research, we offer conjectures about alternative futures for engineering education. Some are more sobering than others.

Scenario 1-A Status Quo Culture and Workforce Erosion: In 2003, almost three out of four science and engineering workers with just a bachelor’s degree reported having a job related to their degree. Those who majored in engineering, mathematics, or computer sciences were the most likely to report a job related to their degree (Regets, 2006). If fewer than one in five science and engineering bachelor’s recipients go on to earn an advanced degree in science or engineering, what do they do with their deep knowledge? The main choices are research and development or management. Will these choices continue to suffice as career options, or will students gravitate to other disciplines and professions where their academic preparation and interests, for example, more readily connect with clearer opportunities for social good?

As a business systems manager in Virginia Beach, VA, recently wrote:

Every call that you make to the tech vendors is answered by someone in Bangalore. I don’t recommend that my kids go into IT, and I’ve been in it for 20 years and am paid well. If you scare them away from a career, you can’t blame them for not coming back (Stern, 2007).

While medical and law schools are now at gender parity, stereotypes, glass walls and ceilings, and old boys’ networks persist in engineering (Frehill, 2007). With 90 percent of the full- time engineering faculty male, retirements alone will not noticeably change this gender composition. Like it or not, a mostly-male, overwhelmingly white faculty is not a winning advertisement to an increasingly diverse undergraduate pool. And mass media coverage, which underscores the invisibility of engineers and technologists (especially women), does not help (Clark and Illman, 2006). More of the same will not attract a diverse talent pool to engineering. That is why ABET, which accredits 2,700 programs at more than 550 colleges and universities, revised its criteria at the turn of this century to make them less restrictive and more compatible with liberal arts curricula (Associated Press, 2007).

Scenario 2-An Influx of Women and A Resurgent Appeal of Engineering: Could engineering disciplines follow the lead of veterinary medicine (Maines, 2007)? Veterinary medicine has been highly successful in attracting women (three out of four doctoral “vet-med” students are women, despite only one out of eight vet college deans being a woman and a majority of the vet college faculty being male). But we do not know why with no organized efforts to diversify vet med, unlike programs in STEM to recruit those from underrepresented groups, the attraction of women remains unexplained. Such gender anomalies warrant research, especially in male-dominated fields. Surely engineering colleges that attract and graduate large fractions of women, for example, Yale and the University of Colorado at Colorado Springs, have created a welcoming culture and connected with female students still in high school who see engineering as solving social problems and impacting lives (Newsome, 2006). This is not just a matter of improving work-life balance or removing barriers to women’s advancement. It goes deeper than that, as an ongoing project devoted to intergenerational differences in STEM career development shows (Rayman, 2007). Women tend to gravitate to social, community, and global issues, as reflected in the choice of engineering discipline that current women engineering students make. Biomedical and environmental engineering, for example, tend to have greater percentages of women than other engineering disciplines (CPST, 2006). Clearly, engineering programs, either curricular or co-curricular, that promote a service ethic appear to attract female students. Examples of university programs include the Gordon Prize-winning EPICS program at Purdue and the Humanitarian Engineering Program at the Colorado School of Mines. To spur an influx, engineering programs must expand to address social, community, and global issues.

It is not just the women who will come. Gen Net in general appears to be much more outwardly oriented than previous generations. From their perspective, many may consider engineering with the question “How can I make a positive impact on the world?” There is no ready answer from the engineering profession or academia, though the APS interview data suggest that a “service ethic” runs deep with Gen Net, be it medicine (save/care for people), veterinary medicine (save/care for animals), or law (change inequality, fight injustice). Reconnecting engineering with the broader community, making explicit how technology enriches lives, could stimulate a surge of interest in engineering careers.

Scenario 3-Change the Curriculum and Diverse Students Will Come: Engineering has a storied history of curricular change (see the reports known eponymously as Mann, Wickenden, and Grinter) and today such an approach is favored by some. That is, the content of engineering education will lure more students to the profession for different reasons. But pedagogy and faculty attitudes must evolve as to who can do engineering, what represents excellence, and how classroom experiences reflect real-world problems and workplaces. Encouraging multiculturalism through project-based experiences in foreign countries could become the centerpiece of today’s “global engineering.” Current figures suggest that five percent of all undergraduates study abroad, but less than three percent of engineering students do, despite ABET’s endorsement of it as part of its accreditation criteria (Carlson, 2007).

One ongoing and noteworthy nation-wide effort to promote diversity in the student body in U.S. universities, through industrial partnerships, academic services, and the establishment of social networks, has produced modest gains. Since the early 1990s, NSF’s Louis Stokes Alliances for Minority Participation (LSAMP) have attracted underrepresented students to STEM majors and supported them through the completion of their baccalaureates. As an institutional program, however, LSAMP benefits all students by increasing diversity, though its impact has been uneven within and across the national set of alliances. Likewise, private scholarship programs such as the National Action Council for Minorities in Engineering (NACME) University Block Grant Program, based on two decades of direct engineering student grants, supports cohorts of students, including transfers, in engineering. But these funds are targeted at 20 universities that have developed the social and intellectual infrastructure to fill pedagogical and cultural gaps inside and outside the classroom. Recent evaluations of both LSAMP and NACME’s Block Grant indicate that investing in academically- prepared students through a range of financial, peer tutoring, internship, and mentoring activities builds both community and students’ engineering identity (Clewell et al., 2006; Educational Policy Institute, 2007).

The engineering faculty as a collective body, rather than a few committed outliers, holds the key to transforming the recruitment and retention of students. Advocates for change see rebuilding the undergraduate engineering curriculum, as opposed to boosting students’ performance in the existing curriculum, as the road to retaining salient technical material while enhancing the link between fundamentals and applications. The objective is to reduce critical path lengths in the course sequence, introduce team experiences into all courses, and create a climate of inclusion rather than exclusion, a process that “will require trial, assessment, and revision before it is ready for adoption” (Busch- Vishniac and Jarosz, 2004). This faculty-intensive approach must first demonstrate better learning outcomes, especially among a broader array of students, in some engineering disciplines and departments before we begin to harbor visions of wider buy-in. Early efforts look promising: a cadre of early-adopters is developing and testing the new courses in the core engineering curriculum.

An Invitation: Knowing Better and Doing Better: Chubin, May, and Babeo (2005) called for a research agenda in engineering education that informed “not only what we do, but more importantly, how we know what to do.” Through the Academic Pathways Study and related efforts, we have insight as to how to enhance the teaching and learning of engineering. These enhancements hold the promise to educate Generation Net, and to ultimately woo and win the competition for U.S. talent. Nevertheless, knowing better does not mean doing better.

Make no mistake about it: the future of the engineering workforce, both domestically and globally, remains in the hands of engineering educators. To attract the diverse and talented student needed for tomorrow’s technical leadership, educators must be savvy, flexible, and impassioned to engage a generation of learners with expectations and demands unlike those that preceded them. This is a test-not merely of technical knowledge or ingenuity, but of marketing, pedagogy, role models, and product development. Harnessing the gifts of Generation Net will become the legacy of the engineering educator pre-2020.

ACKNOWLEDGMENTS

The Academic Pathways Study is supported by the National Science Foundation under Grant No. ESI-0227558, which funds the Center for the Advancement of Engineering Education (CAEE). The authors gratefully acknowledge the input and assistance of Sheri Sheppard, Jim Pelligrino, Helen Chen, Mia Clark, Micah Lande, Janice McCain, Sabira Mohamed, and Andrene Taylor. We are also very thankful to the students, faculty and administrators who supported and/or participated in the Academic Pathways Study.

1 Mentor motivation as discussed in this paper differs from that discussed in Chen et al. (2008); in our paper we include mentoring by university and non-university mentors, whereas Chen et al. look largely at impacts of university mentors.

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Project Lead The Way (W

Poststress Left Ventricular Ejection Fraction is an Independent Predictor of Major Cardiac Events in Patients With Coronary Artery Disease and Impaired Left Ventricular Function

By De Winter, O Van De Veire, N; De Bondt, P; Van De Wiele, C; De Buyzere, M; De Backer, G; Gillebert, T C; Dierckx, R A; De Sutter, J

Aim. The aim of this study was to investigate the prognostic value of myocardial perfusion and function SPECT imaging in patients with coronary artery disease (CAD) and poor left ventricular (LV) function. Methods. We studied 261 patients (231 men, age 66+-10 years) with CAD and a resting LV ejection fraction (LVEF) =40% assessed during myocardial gated SPECT. Perfusion defect extent was calculated using 4D-MSPECT(R) software (Michigan University). Ischemia scoring was performed visually. Considered end points were: 1) major adverse cardiac events (MACE) (cardiac death, non-fatal myocardial infarction or late revascularization), 2) MACE or the need for hospitalization due to heart failure (MACE-HF) and 3) cardiac death or non-fatal myocardial infarction.

Results. During a median follow-up of 31 months, 52 patients (20%) died (35 cardiac deaths), 50 (19%) developed a MACE and 69 (26%) a MACE-HF. In a clinical model, diabetes and angina status were the only predictors of MACE (chi^sup 2^=19.3; P

Conclusion. In patients with impaired LV function and CAD, poststress LVEF is an independent predictor of future cardiac events.

KEY WORDS: Prognosis – Single photon emission tomography – Ischemia – Coronary artery disease – Heart failure, congestive.

Coronary artery disease (CAD) is the most common cause of heart failure in the Western world, accounting for 60-70% of the cases.1 Incidence and prevalence of congestive heart failure due to CAD are increasing worldwide as a result of increasing life expectancy in general and the longer survival of patients with CAD in particular.2 Although rates of death from most cardiovascular diseases are stable or declining, mortality data from heart failure are less clear.3 Patients with CAD and impaired left ventricular (LV) function are at very high risk for cardiac death and future cardiac events.4

Myocardial ischemia assessed by nuclear myocardial perfusion imaging is a well-known risk factor for future cardiac events in patients with known or suspected CAD.59 It is less clear whether ischemia is of prognostic importance in patients with depressed LV function. Revascularization procedures have shown to improve prognosis in patients with CAD and a depressed LV function,10 but some studies suggest no prognostic value for the presence of ischemia in patients with a poor systolic LV function.11 The favorable imaging characteristics of ^sup 99m^T/c bound ligands make it possible to perform electrocardiogram (ECG) gated cardiac single photon emission computed tomography (SPECT) during the acquisition of myocardial perfusion,12 which not only improves the specificity for detection of CAD 1^ but also permits the assessment of global LV functional parameters, including LV ejection fraction (LVEF) and LV volumes.14, 15 The predictive value of global LV functional parameters can be assessed using different imaging modalities and have shown predictive value in patients with known or suspected CAD. 16-21 The aim of this study was to investigate the predictive value of combined perfusion and function assessment during gated SPECT in patients with CAD and impaired LV function for prediction of future cardiac events.

Materials and methods

Study population

All patients with ischemic heart disease and a resting LVEF =40% determined by gated SPECT were prospectively evaluated (n=285) among 2 168 consecutive patients referred for a 2 day stress-rest gated myocardial perfusion SPECT imaging in the period from October 1998 until December 2001. The diagnosis of ischemic heart disease was based on a history of myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or angiographic significant CAD (at least one vessel with ?75% stenosis). Follow-up was achieved in 273 patients (95%). Twelve patients were excluded because they had an early revascularization procedure within 3 months following the myocardial SPECT.8 Therefore 261 patients (231 males) formed the study population.

STRESS TESTING

Bicycle stress testing was used in patients able to perform maximal physical stress (n=130, 50%). Each subject underwent maximal exercise testing on a computer-driven bicycle ergometer (Ergoselect, Ergoline GmbH, Bitz, Germany) using a ramp protocol starting at 50 Watts with gradual increase of 25 or 10 Watts according to the general condition of the patient. A standard 12-lead ECG was continuously recorded and the heart rate was followed. Blood pressure was measured by means of a mercury sphygmomanometer at each stage and at the peak of exercise. Subjects were exercised to their self-determined maximal capacity or until the physician stopped the test becau.se of significant symptoms, such as chest pain or dizziness, potential dangerous arrhythmias or ST-segment deviations, or marked systolic hypotension or hypertension.

When a patient was not able to perform maximal bicycle stress (n=27, 10%), an additional intravenous infusion of dipyridamole was given (infusion over a 4 min period, 0.142 mg/kg/min).

In patients who were not able to perform bicycle stress at all (n=104, 40%), only dipyridamole was given (infusion over a 4 min period, 0.142 mg/kg/min).

Patients were informed not to consume caffeinecontaining products for 24 h before testing. At peak stress 900 MegaBecquerel (MBq) Technetium-99m tetrofosmin was injected.

Gated SPECT acquisition and reconstruction

Stress and rest studies were performed in a 2-day protocol as described previously.22 In both stress and rest studies, 900 MBq (25 mCi) of technetium-99m tetrofosmin was injected intravenously. Imaging was started between 30-60 min after injection in the resting state and 15-30 min after injection at peak stress. A gated SPECT acquisition was performed over 360[degrees] in step-and-shoot mode (120 sectors of 3[degrees], 30 s/step, matrix size 64 x 64) using a triple-headed camera (Picker Prism 3000, Marconi, Philips, Cleveland, OH, USA) equipped with low energy all-purpose collimators. Acquisitions were gated for 8 frames per cardiac cycle. There was a 20% acceptance window around the 140 keV photon peak. Attenuation correction, background subtraction and beat rejection were not performed. The raw gated SPECT data were ungated and reconstructed using filtered back projection (ramp filter) and postfiltered using a low pass filter (order 5, cut-off frequency 0.21). The left ventricle was reoriented manually to obtain short axis gated and ungated images. The gated images were processed using Quantified Gated SPECT software (QGS*, CedarsSinai, Los Angeles, CA, USA) to obtain resting and poststress LVEF and LV volumes.

Scoring of the perfusion images

The ungated short axis images were used for semiquantitative detennination of myocardial defect extent on stress and rest myocardial perfusion images using 4D-MSPECT(R) software (University of Michigan, Ann Arbor, MI, USA) by comparison with a gender specific normal perfusion database generated at our institution. These stress and rest normal database files were made out of patients with a low cardiac risk (

Clinical data and follow-up

Demographic data at study entrance were collected by reviewing hospital records. Hypertension was defined as a blood pressure 140/ 90 mmHg or treatment with antihypertensive medication. Diabetes mellitus was defined as a fasting blood glucose level >140 mg/dL or the need for insulin or oral antidiabetic agents. Follow-up data were collected in 2003. One author (ODW) contacted patients’ general practitioners and reviewed hospital records. The author was blinded to scanning results at the time of follow-up. A standard questionnaire was used for follow-up interviews. The following cardiac events were taken into account: nonfatal acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, and the need for hospitalization because of heart failure, death and cause of death. Cardiac death was defined as death caused by acute myocardial infarction, refractory congestive heart failure, clinically important cardiac arrhythmias and sudden death without another explanation. The need for cardiac transplantation (n=2) was also considered as cardiac death. Myocardial infarction was defined according to the Joint European Society of Cardiology/American College of Cardiology Committee criteria.24 Patients who died from non-cardiac causes were censored on the day of their death. The time of the last patient contact was used to determine the end of the follow-up period in patients without events. Follow-up was limited to 36 months. Three combined cardiac end points were defined in advance and used for further analysis:

1) major adverse cardiac events (MACE): cardiac death, non-fatal myocardial infarction, percutaneous coronary intervention or coronary artery bypass grafting;

2) MACE-HF: MACE or the need for hospitalization due to heart failure-,

3) cardiac death or non-fatal myocardial infarction.

If a patient died from a cardiac cause, only cardiac death was considered. If there were 2 or more nonfatal events in one patient, only the event that came first in time was considered.

The study was approved by the local Ethics Committee of the Ghent University Hospital.

Statistical analysis

Statistical analyses were performed using SPSS 11.0.1 statistical software (SPSS Inc., Chicago, IL, USA). Data are shown as median (25th-75th percentile) or number (%). Non-parametric Mann- Whitney U testing or chi^sup 2^ testing was used to assess differences in clinical and SPECT variables between patients with and without events. Kruskal-Wallis testing was used to investigate trends in event rates between groups. Cumulative event free survival rates as a function over time were obtained by the Kaplan-Meier method. Differences in survival were analysed by log-rank testing. Clinical parameters significant by univariate analysis were forced into a stepwise multivariate Cox proportional hazards regression model to identify SPECT variables (functional parameters at rest and poststress, stress and rest defect extent and presence of reversibility) predicting cardiac events independently and incrementally above clinical parameters. Significance was set at

Results

Clinical characteristics of patients with and without events

Patients’ characteristics are summarized in Table I. Median age was 67 years. Of the 261 patients 231 (89%) were male. At the time of myocardial SPECT imaging 174 patients (67%) had a history of myocardial infarction, 45 patients (17%) a history of percutaneous coronary intervention and 58 patients (22%) previously underwent coronary artery bypass grafting. At the start of the follow-up period, 133 patients (51%) were taking ss-blockers and 188 (72%) angiotensinconverting enzyme inhibitors or angiotensin-II receptor blockers as medical treatment (Table I).

TABLE I. – Clinical characteristics of all patients and comparison between patients with and without MACE.

Gated SPECT variables inpatients with and without events

During a median follow-up of 31 months (interquartile range 21- 36 months), 52 patients (20%) died of which 35 deaths (13% of the total population) were considered cardiac. This means that 67% of the death causes in this population were cardiac. There were 50 patients (19%) who developed a MACE and 69 (26%) a MACE-HF. In the whole population, the annual event rate was 8.4% for MACE and 12.1% for MACEHF. Patients who developed a MACE during follow-up were more likely to be diabetic and to have angina complaints (Table I). When considering MACE-HF, the presence of diabetes mellitus was the only significant clinical variable in the univariate analysis (P

TABLE II. – Gated SPECT variables of all patients and comparison between patients with and without major cardiac events. Data are presented as median (25th- 73th percentile) or number (%).

TABLE III. – Annual cardiac event rate according to the presence of ischemia on myocardial perfusion imaging.

Multivariate predictors of cardiac events

With diabetes and the angina status as the major clinical variables included into the stepwise multivariate Cox regression model for MACE, adding of poststress LVEF provided a chi^sup 2^ gain of 6.4 (P=0.008). When the ischemia detection was added to this model, there was an additional chi^sup 2^ gain of 5.8 (P=0.018) (Figure 5).

In the clinical model of MACE-HF, only diabetes was significant and was forced in the multivariate analysis. Adding of poststress LVEF provided a ?2 gain of 5.5 (P=0.0 19) and ischemia detection on perfusion imaging an additive chi^sup 2^ gain of 4.3 (P=0.044) in this model (Figure 5).

Uni- and multivariate predictors of cardiac death or non-fatal myocardial infarction

Univariate predictors of cardiac death or non-fatal myocardial infarction were diabetes mellitus (P

Discussion

The results of this study indicate that the combined assessment of function and perfusion using technetium-99m tetrofosmin gated SPECT provides significant and independent predictive information regarding the subsequent risk of major cardiac events in patients with CAD and systolic LV dysfunction.

Figure 1. – Kaplan-Meier curves for MACE free survival according to the presence or absence of ischemia detected by myocardial perfusion imaging. MACE: major adverse cardiac event.

Figure 2. – Kaplan-Meier curves for MACE-HF free survival according to the presence or absence of ischemia. MACE-HF: major adverse cardiac event or hospitalization for heart failure.

Prognostic value of myocardial perfusion assessment

Multiple studies investigated the prognostic value of myocardial perfusion imaging in subjects with known or suspected CAD for predicting cardiac events and mortality.7, 9, 25-29 However, these prognostic data were all collected in patient populations with known or suspected CAD and only few data are available regarding the prognostic value of myocardial perfusion imaging in patients with impaired LV function and known CAD. The risk for subsequent cardiac events is much higher in this population than in the generally investigated populations.30 Therefore, results and risk factors found in other populations may not be extrapolated.31

Figure 3. – Kaplan-Meier curves for MACE free survival according to the poststress LVEF (in tertiles). LVEF: left ventricular ejection fraction; MACE: major adverse cardiac event.

Data on the prognostic value of myocardial perfusion imaging in patients with CAD and LV dysfunction are scarce. In concordance with our data, Miller et al. found a higher revascularization rate, but no difference in survival between patients with large ischemic defects versus patients with large fixed defects in 214 patients with a LVEF

Prognostic value of LV functional parameters

One of the most powerful prognostic parameters in patients with CAD is the LVEF. Multiple studies have demonstrated the important prognostic value of this parameter assessed using planar radionuclide angiography l921 or using other imaging modalities 16- 18 in patients with known or suspected CAD. Our data demonstrated that even in this population in which all patients had a depressed LVEF and the spreading of LVEF values was narrow, poststress LVEF was highly predictive for future cardiac events.

Figure 4. – Kaplan-Meier curves for MACE-HF free survival according to the poststress LVEF (in tertiles). LVEF: left ventricular ejection fraction; MACE-HF: major adverse cardiac event or hospitalization for heart failure.

Figure 5. – Chi-squares obtained by stepwise multivariate Cox regression analysis for MACE and MACE-HF. MACE: major cardiac event; MACE-HF: major cardiac event or the need for hospitalization due to heart failure; LVEF: left ventricular ejection fraction.

Importance of combined perfusion and function assessment in patients with CAD and poor LV function using gated SPECT

The addition of LV ventricular functional data to myocardial perfusion imaging has shown benefit in diagnostic settings by increasing specificity and decreasing the number of borderline interpretations.13- 33, 34 Another potential diagnostic use is in identifying patients with multivessel disease who might be otherwise missed by myocardial perfusion imaging.35

There are however limited data on the prognostic value of LVEF as assessed by gated SPECT in patients with impaired LV function. As part of a larger study, Sharir et al.36 investigated a subgroup of 277 patients with suspected CAD and a LVEF /=70 mL. In our study group, there was a trend towards a higher resting (P=0.084) and poststress (P=0.010) LV end systolic volume in patients with a subsequent hard event (cardiac death or non-fatal myocardial infarction). However, once the poststress LVEF was added to the model, there was no further predictive value for LV volumes. Since myocardial perfusion imaging is used in daily clinical practice for diagnosis and follow-up of patients with CAD and LV dysfunction and ECG gating during the acquisition of myocardial SPECT can be easily performed in daily practice, gated SPECT could be an ideal tool for risk stratification in this patient population.

Limitations of the study

Because only 130 (50%) of the 261 patients were able to perform maximal bicycle exercise stress, a possible incremental prognostic value of nuclear imaging variables above parameters obtained during bicycle stress (stress electrocardiography changes, maximum workload or blood pressure change) could not be assessed.

Conclusions

This study showed the significant incremental power of nuclear imaging data over clinical data in predicting cardiac events in patients with a depressed systolic LV function due to CAD. A lower poststress LVEF is an independent predictor of future cardiac events in patients with CAD and impaired systolic LV function.

This work was made possible by a Special Research Grant of the Ghent University and the Flemish Government (BOZF 01100400). J. De Sutter is a senior clinical investigator and N. Van de Veire is a research fellow of the Fund for Scientific Research – Flanders (Belgium) (FWO – Vlaanderen).

Received on June 14, 2005.

Accepted for publication on 9 February, 2006.

Epub ahead of print on January 15, 2007.

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35. Yamagishi H, Shirai N, Yoshiyama M, Teragaki M, Akioka K, Takeuchi K et al. Incremental value of left ventricular ejection fraction for detection of multivessel coronary artery disease in exercise (20I)Tl gated myocardial perfusion imaging. J Nucl Med 2002;43:131-9. 36. Sharir T, Germano G, Kavanagh PB, Lai S, Cohen I, Lewin HC et al. Incremental prognostic value of post-stress left ventricular ejection fraction and volume by gated myocardial perfusion single photon emission computed tomography. Circulation 1999; 100: 1035-42.

O. DE WINTER1, N. VAN DE VEIRE2, P. DE BONDT1, C. VAN DE WIELE L M. DE BUYZERE2, G. DE BACKER3 T. C. GILLEBERT2, R. A. DIERCKX1, J. DE SUTTER2

1Nuclear Medicine Division

Ghent University Hospital Ghent, Belgium

2Department of Cardiovascular Diseases

Ghent University Hospital. Ghent, Belgium

3Cardiac Rehabilitation Center

Ghent University Hospital. Ghent. Belgium

Address reprint requests to: O. De Winter, MD. Nuclear Medicine Division, Ghent University Hospital. De Fintelaan 185, 9000 Ghent. Belgium. E-mail: [email protected]

Copyright Edizioni Minerva Medica Sep 2008

(c) 2008 Quarterly Journal of Nuclear Medicine, The. Provided by ProQuest LLC. All rights Reserved.

Evolution’s Ear

By Bower, Bruce

Recent changes in hearing-related genes may have influenced language development Imagine, for a moment, that you are smaller than a speck of dust and in the mood for some teeny-tiny sightseeing. It’s a perfect opportunity to take a scenic trip to the inner ear.

First, stroll up the ear canal. This is a fantasy, so no waxy buildup blocks the way. At the end of the fleshy tunnel, squeeze around the huge, circular membrane better known as the eardrum. Gingerly sidestep the precariously balanced, oddly shaped middle ear bones and proceed into the inner ear. Up ahead, rising like skyscrapers from a flat landscape, looms a cluster of stereocilia. These slender, interconnected projections sit atop the basic sensory elements of hearing- the inner ear hair cells. Bundles of gently waving stereocilia serve as receptacles for sound waves delivered from hair cells, transforming those waves into electrical signals that travel to the brain to be interpreted.

But the inner ear is more than just the mediator of hearing. As a core player in the human system for receiving and creating spoken language, it’s a hotbed of recent evolutionary change as well.

In a new study, anthropologist John Hawks of the University of WisconsinMadison finds that eight hearing-related genes show signs of having evolved systematically in human populations over the past 40,000 years. Some alterations on these genes took root as recently as 2,000 to 3,000 years ago.

“Hawks makes a compelling case that not only is human evolution ongoing in the past 10,000 years, but it has sped up,” says anthropologist Clark Larsen of Ohio State University in Columbus.

Seven genes identified by Hawks produce proteins that make stereocilia and the membrane that coats them. The eighth gene assists in building middle ear structures that transmit sound frequencies to the inner ear.

It all points to the evolutionary sensitivity of at least one part of the human language system in the post-Stone Age world, Hawks reported in April in Columbus at the annual meeting of the American Association of Physical Anthropologists. Language depends not just on a vocal tract capable of making certain speech sounds but on ears designed to hear particular sound frequencies, as well as on a variety of other brain and body features. Relatively recently in evolutionary history, genetic revisions within populations have upgraded ear structures needed for discerning what other people say, he proposes.

“It takes a long time for a biologically complex system like language to evolve,” Hawks says. “We’re still genetically adapting to language.”

His findings challenge the influential idea that the way humans now talk emerged full-blown about 50,000 years ago thanks to a single genetic mutation that improved vocal articulation. Hawks’ results instead play into a growing appreciation that rapid population growth toward the end of the Stone Age, followed by the rise of agriculture and village life around 10,000 years ago, triggered cultural changes that prompted genetic accommodations.

Speak up speedup

Speech-related genes must have succumbed to evolutionary pressures for improved communication in the expanding populations of the late Stone Age and at the dawn of farming, Hawks reasons.

He wanted to test whether certain genes that foster the ability to hear what others say might have become more common as more and more people lived year-round in one place.

To do that, Hawks analyzed a database of 3.9 million single nucleotide polymorphisms – regularly occurring variations of individual DNA letters within genetic sequences – that researchers had earlier identified in 90 Europeans, 90 Africans, 45 Chinese and 45 Japanese.

These single letter mutations are passed down as part of a larger chunk of DNA, a section of chromosome with a characteristic pattern of other nearby DNA alterations. These sections, along with their sets of mutations, break down over time due to the remixing of DNA that occurs each time a sperm and egg fuse during conception. It’s thus possible to estimate how long ago a specific mutation arose based on the pattern of accompanying mutations.

Consider a gene necessary for forming filaments that join stereocilia into sound-transmitting bundles. A particular mutation of this gene appears frequently in Chinese and Japanese people and probably originated in the past 10,000 to 15,000 years, Hawks says.

Other common variants of genes required for making stereocilia occur either in Europeans or Africans. These DNA changes emerged as early as 40,000 years ago and as late as 2,000 years ago.

“I have no idea why certain variants show up in some populations and not in others,” Hawks remarks.

It nonetheless appears that evolution has increasingly promoted genes that mediate the ability to hear speech sounds. Hawks suggests that as social life became more demanding in the late Stone Age, these particular gene variants must have aided survival and reproduction. People who inherited them may have developed special proficiency at detecting subtle emotions conveyed by a speaker’s vocal tone or recognizing familiar voices in a chattering crowd.

Hawks initially suspected that the need to counteract hearing loss in aging populations spurred much recent evolution in genes involved in hearing. But to his surprise, genes that have been implicated in aging-related hearing loss showed no evidence of systematic change in the past 40,000 years.

In contrast, the systematic changes of the hearing- and speech- related genes echo those of a 2007 paper in which Hawks and his colleagues – using the same genetic database from Europeans, Africans and Asians – concluded that late- Stone Age population surges spurred abevy of rapid evolutionary changes. The pace of such changes has sped up ever since, the researchers propose.

About 1,800 genes, roughly 7 percent of the human total, show signs of survival-enhancing change in the past 80,000 years, Hawks’ team estimates. Around 80,000 years ago, human groups left Africa and adapted to a series of new habitats and climates. In a second wave of change, the agricultural revolution reshaped physical and cultural environments with particular vigor.

That may explain the researchers’ finding that gene variants related to several forms of disease resistance have spread through populations in different parts of the world. Agricultural groups witnessed sharp increases in mortality from contagious epidemic diseases, including smallpox, malaria, yellow fever and tuberculosis, Hawks notes.

Similarly, a switch to milk drinking by farmers fostered the spread of a gene variant involved in efficiently metabolizing lactose, a sugar found in milk. This lactose-tolerance gene flourished independently in Europe and in Africa, allowing its inheritors to drink milk without unpleasant side effects.

Other recent evolutionary changes defy explanation. For instance, Chinese, Japanese and Europeans display systematic alterations to a couple of serotonin transporter genes. These genes produce a protein necessary for regulating serotonin, a mood-related chemical messenger in the brain. Any emotional or behavioral consequences of tweaks to these genes remain unknown.

Although apparently adaptive mutations such as these arose in the past 10,000 years, some geneticists doubt that the agricultural revolution jump-started the pace of genetic evolution. Accurate techniques for identifying and dating the single DNA letter variants characteristic of certain populations are still being developed. Hawks and his associates’ analysis may have missed many ancient instances of genetic evolution, leading them to overestimate the pace of recent evolution, remarks geneticist Sar ah Tishkoff of the University of Pennsylvania in Philadelphia.

“We have to be cautious in making inferences about the rate of selective change in human populations,” she says.

Fossil talk

Hawks sees a greater need for caution in evaluating the recent suggestion, based on fossil discoveries, that humanlike speech emerged long before modern Homo sapiens did about 200,000 years ago.

Throat and ear bones of a Neandertal ancestor that lived at least 530,000 years ago in northern Spain point to a remarkably advanced speech capacity, say paleontologist Ignacio Martinez of the University of Alcala near Madrid, Spain, and his colleagues.

In the January Journal of Human Evolution, the scientists describe two hyoid bones from this ancient Homo species, a possible common ancestor of later European Neandertals and modern humans. A cave in Spain’s Atapuerca mountains yielded the fossils. The hyoid, a horseshoe-shaped bone in the neck, supports the tongue and larynx and is the only bone in the skeleton not connected to any other bone.

Some researchers regard hyoid shape in humans as an indicator of a vocal tract designed for speaking. Others argue that the hyoid contains no reliable clues to vocal tract functions.

What’s beyond debate is that the Atapuerca hyoids look like those of people today, the researchers say. But hyoids from chimpanzees, gorillas and 3- to 4-millionyear-old human ancestors differ substantially from the Spanish fossils.

Human-looking hyoids alone don’t prove that Atapuerca folk gabbed with one another a half million years ago. But add earlier finds of humanlike outer and middle ear structures in five skulls from the same site and the possibility of ancient speech at Atapuerca gains some traction, according to Martinez’s group. Neandertal ancestors in northern Spain had ears specialized for transmitting midrange sound frequencies used in speech today, the Spanish scientists reported in 2004.

But skeletal similarities such as these tell a limited story about language evolution, Hawks argues. Recent genetic modifications to nonfossilizing stereocilia in the inner ear suggest that modern humans produce and hear speech differently than ancient Atapuercans did, in Hawks’ view.

Anthropologist Robert McCarthy of Florida Atlantic University in Boca Raton agrees. McCarthy studies head and neck fossils in order to reconstruct the vocal tracts of ancient members of the human evolutionary family.

Neandertals and other Stone Age species must have spoken, only not as clearly as people now do, he says. At the physical anthropology meeting, McCarthy played synthesized re-creations of what a Neandertal speaker would have sounded like making vowel sounds, based on earlier reconstructions of vocal tracts.

The combination of a long face, short neck, unequally proportioned vocal tract and large nose would have decreased the intelligibility, at least to modern human ears, of Neandertals’ vowel sounds, according to his analysis.

A transition to facial and neck traits needed for modern speech occurred in H. sapiens between 100,000 and 40,000 years ago, McCarthy estimates.

Even then, languages continued to change and assume different structures. For instance, Asian languages came to rely on musical- sounding tonal shifts for meaning and some African tribes adopted clicking sounds in place of vowels.

In a volatile linguistic world, it makes sense to McCarthy that language-related hearing genes still attract evolutionary adjustments. “Hawks has done a nice job of showing that all kinds of genes have been changing at a faster rate in the last 50,000 years, so it’s not surprising that genes related to hearing are on that bandwagon,” he says.

Cultivating problems

The biggest bandwagon in human evolutionary history started rolling around 10,000 years ago, when sedentary farming rapidly replaced nomadic hunting and foraging, the anthropologists agree. On the plus side, the spread of agriculture and animal domestication provided enough food for growing populations. On the minus side, farming’s rise caused many people to suffer marked declines in health and well-being, says Ohio State’s Larsen.

Larsen’s unpleasant picture of the agricultural lifestyle stems from analyses of human skeletons excavated at a variety of prehistoric farming villages. Crowds of villagers acted as petri dishes for infectious diseases. Water sources near villages became contaminated by parasites, which also infected people. Infants and young children died more frequently than they had at the height of the Stone Age.

A newfound emphasis on eating domesticated plants prompted deficiencies in nutrients formerly obtained from meat, such as iron, zinc, vitamin A and vitamin B12. As a result, people grew increasingly smaller and shorter. Size reductions of the face and jaw outpaced those of the teeth, often resulting in dental misalignments. To top it off, competition for fertile land encouraged the rise of organized warfare and mass slaughters.

A brave new agricultural world of deteriorating health must have provoked unprecedented adaptive changes in human genes, Larsen asserts.

Recent genetic evolution bolstered immune defenses in response to epidemic diseases that ravaged farming populations, hypothesizes anthropologist George Armelagos of Emory University in Atlanta.

Hawks agrees but adds that postStone Age evolution has not been solely a race against death and disease. The need to communicate in groups of expanding size and complexity sparked genetic changes in humans’ ability to hear what others say, he maintains.

As genetic data from people around the world continue to accumulate, Hawks will keep his eye on the ear for further signs of language evolution. If you know how to listen, even DNA can talk.

This scanning electron micrograph shows sensory hair cells in the cochlea of the inner ear. As sound enters the ear, waves cause the stereocilia (orange) on the hair cells to move. This movement is converted to an electrical signal, which passes to the brain.

The modern hyoid bone, found in the human neck, supports the root of the tongue. The bone In the skeleton (left) Is held up by wires since It Is not connected to any other bones. The fossilized hyoid bones (below) belong to an early Homo species. Found In Atapuerca, Spain, they date back to the Stone Age.

Explore more

* John Hawks et al. “Recent acceleration of human adaptive evolution.”

Proceedings of the National Academy of Sciences. December 26, 2007.

Copyright Science Service, Incorporated Aug 30, 2008

(c) 2008 Science News. Provided by ProQuest LLC. All rights Reserved.

A Comparative Study of Self-Perceived Public Health Competencies: Practice Teachers and Qualifying SCPHNs

By Poulton, Brenda Lyons, Agatha; O’Callaghan, Anne

Abstract There is evidence to suggest that population-focused public health nursing is more rhetoric than reality. This quantitative study compares the self-perceived public health competence of qualifying student specialist community public health nurses (SCPHNs) (n=35) with those of the practice teachers (PTs) facilitating their practice learning (n=31).

Findings suggest that PTs felt more competent than qualifying students on leadership and management for public health, working with communities, and communication skills. However, the qualifying students self-rated higher than the PTs on principles and practice of public health, suggesting that the PTs in this study felt less competent than their qualifying students in key public health skills, such as epidemiology, population health needs assessment, research and evidence-based decision-making.

It is recommended that the triennial review of PTs should address not only educational skills but knowledge and skills in contemporary public health practice, a continuing professional development framework for SCPHNs should be developed and funded, providers should assist PTs in keeping up with contemporary public health, and the role of the PT should be recognised and given appropriate support and remuneration.

Key words

Public health nursing, education, practice teachers, professional regulation

Community Practitioner, 2008; 81(9): 31-4.

Introduction

Recent policy documents promote the role of health visitors and school nurses in the delivery of the public health agenda.1,2 While community-focused public health practice has long been seen as part of these roles, there is evidence to suggest that this is more rhetoric than reality. In a review of the literature exploring the public health roles of health visitors and school nurses, Hawksley et al3 concluded that there was little evidence of population- focused activity. This is supported by earlier study findings in one area of the UK,4,5 that public health activity concentrated largely on intervention at an individual and small group level.

Although there are a range of models for implementing the public health nursing role,6,7 nurses often experience constraints in fulfilling family-centred public health roles. Smith8 conducted focus groups with health visitors in England and found that the key factors in the development of the public health nursing role were:

* Leadership in clarifying the role

* Development of public health networks

* Support for change in practice.

These mirror the findings of Plews et al,9 that practitioners reported limitations in their public health skills. Refocusing the public health role of health visitors and school nurses requires not only robust academic models, but also experienced and committed practice teachers (PTs) who feel competent in their public health role.

The opening of the specialist community public health nurse (SCPHN) part of the NMC register in 200410 constituted a radical change to the delivery of health visiting, school nursing and occupational health nursing educational programmes. Not only were these programmes extended to 52 weeks in length, with 10 weeks’ consolidation of practice, but their educational standards have a broader public health focus based on specific national occupational standards (NOS).11 The NOS are divided into 10 broad public health areas, including population needs assessment and surveillance, health promotion and health protection, tackling health inequalities, partnership working and community development.

A recent study12 designed to evaluate qualifying SCPHN students’ self-perceived competence found that they reported a significant improvement in public health skills following exposure to a populationbased public health programme. This study developed and validated a questionnaire based on the NOS that was administered to students before and after the programme.

Educational preparation of competent SCPHNs who are ‘fit for purpose’ and ‘fit for practice’ requires competent PTs, who must have advanced public health and research skills in addition to being effective practitioners. The NMC have developed revised standards for learning and assessment in practice13 that require all SCPHN students to be facilitated by a PT on a live register, maintained by the local health provider. To be registered, PTs must have undertaken a dedicated PT programme that meets NMC standards. PTs who have undertaken an earlier preparation programme must successfully map across their knowledge and experience to demonstrate that they meet present NMC standards. Furthermore, PTs must be reviewed every three years to ensure that only those who continue to meet the standards remain on the local register. The PT standards are arranged in eight domains (see Box 1). While these domains and related competencies reflect contemporary practice, a study of 35 community PTs14 found that they required educational updating in order to fulfil their public health role.

This paper reports on a study that used a previously validated measure to enable PTs and qualifying SCPHNs to self-assess their public health competencies, the results of which were then compared.

Aim

To investigate PTs’ self-assessed knowledge and skills in the 10 key areas of public health practice, and to compare the results with those of qualifying SCPHN students.

Method

A quantitative study design was used, employing a questionnaire validated in a previous study.12 This questionnaire was developed using the NOS, NMC standards for SCPHNs and the public health skills audit tool developed by the Health Development Agency.15 A questionnaire design was considered appropriate due to the specific nature of nursing competencies, which require practitioners to assess knowledge and skills against a required standard of practice. Furthermore, a questionnaire study affords anonymity to respondents16 and is less time-consuming.

Participants

The sample comprised students registered on the BSc/postgraduate diploma in community and public health nursing at one university (n=98). They were enrolled on the specialist public health core module, but then followed one of two routes:

* Specialist community nursing – district nursing, community mental health nursing, community children’s nursing or community learning disability nursing

* SCPHN – health visiting, occupational health nursing or school nursing.

Additionally, qualified practitioners acting as PTs for these students were invited to participate (n=86).

Questionnaire

The questionnaire asked for respondents’ background details, including their specialist area of practice. Competency statements were divided into six categories:

* Personal skills

* Professional skills

* Underpinning public health principles

* Policy and strategy

* Leadership

* Management.

Respondents were asked to rate on a fivepoint Likert scale, in which five signified ‘highly competent’, four ‘competent’, three ‘average’, two ‘barely competent’ and one ‘not at all competent’. The questionnaire was distributed to the students prior to and on completion of the public health programme. It was also distributed and completed during a study day for PTs.

Ethical considerations

This study forms part of a larger study, for which ethical approval was granted by the university ethics committee prior to implementation of the new Research Governance Framework, which was implemented in the study area later than in the rest of the UK. Participants were assured that completion of the questionnaire was a matter of personal choice, that anonymity and confidentiality would be maintained throughout the study, and that results would only be published in aggregated form so that no individuals could be identified. Anonymity was important in order to encourage participants to self-assess honestly.

Data analysis

Data were analysed using the Statistical Package for Social Sciences (SPSS) version 11. Descriptive statistics were generated initially to check the data for errors and to describe the characteristics of the sample. The distribution of the scores for the questionnaire scales were assessed and found to be normally distributed, so parametric analyses were completed throughout.16 The questionnaire comprised 54 variables (see Table 1), and in the previous study12 these were subjected to factor analysis and reduced to three scales. Two variables did not load on to any of the scales. One was omitted from the analysis, but the other (working with communities) was considered important and treated as a discrete variable. These scales all demonstrated acceptable levels of scale reliability.

t-tests were used to compare scores between PTs and qualifying students. While the t-test can indicate a statistically significant difference between the two groups that it has not occurred simply by chance – it does not measure the degree to which the variables are associated with one another. Pallant16 advocates calculating the ‘effect size’, which is the amount of the total variance in the dependant variable (selfperceived competence) that is predictable from the independent variable (PT or qualifying student). Therefore, the partial etasquared was calculated for statistically significant results.

Results

Of the 98 questionnaires distributed to qualifying students, 59 were returned completed (response rate=60%). Of the 86 PTs invited to participate, 58 returned completed questionnaires (response rate=67%). As this paper relates to SCPHN students and PTs, data were analysed only for this group (n=35). This included students qualifying as health visitors (n=23), school nurses (n=8) and occupational health nurses (n=4). Of the SCPHN PT respondents (n=31), 25 were health visitors, four school nurses and two occupational health nurses. Comparison of post-course assessments

Achievement of professional competencies assumes that qualifying students are ‘fit for’ practice and purpose. To explore this assumption, qualifying SCPHN students’ self-perceived competence in public health was compared with that of the PT group using an independent sample t-test (see Table 2).

Although the PTs rated themselves higher than qualifying students did on the dimensions of leadership and management for public health practice and working with communities, the difference between these ratings was not significant. Not surprisingly, the PTs rated themselves significantly higher than the qualifying students did on communication skills (p=

This latter finding suggests that the PTs in this study felt less competent than their qualifying students in key public health skills, such as epidemiology, population health needs assessment, research and evidence-based decision-making.

Discussion

Due to the small sample size and restricted geographical location, the results of this study cannot be generalised to all SCPHNs. However, the results support previous research3’8 that has demonstrated that the community-focused public health role of SCPHNs is not being enacted in line with national policy.

The previous study12 found that qualifying SCPHNs rated themselves to be more competent in the principles and practice of public health following exposure to a dedicated public health programme. In this study, although PTs rated themselves more competent in leadership and communication skills, they felt less competent in the more specific skills of public health practice than the qualifying students they supervised during the SCPHN programme. This might call into question the ‘fitness to practice’ of the existing SCPHN workforce, as clearly they are not confident in some crucial elements of public health practice. The reverse argument is that the legacy of GP fund-holding, high caseloads and understaffing5 renders them ‘fit for purpose’ in a climate that offers limited scope for the acquisition and development of public health skills.

These results are in keeping with those of Byers,14 who found that mentors for district nursing, health visiting and school nursing required an updating programme to equip them to move from a caseload approach to one that was public health focused. The skills deficits identified by Byers are similar to those within the principles and practice dimension of this study. These include population health needs assessment, developing and sustaining partnership working, and research skills. Such identified skills deficits imply that qualified SCPHN practitioners are not engaging in true public health practice, and supports the results of other studies that suggest inconsistent interpretation of public health nursing, poor interprofessional and interagency collaboration, and a reactive rather than proactive approach to practice.

While the revised standards for teaching and assessment in practice are to be commended, it could be argued that they focus on educational facilitation of students rather than pushing forward the boundaries of practice in order to meet public health challenges. If the triennial review of PTs is to be effective, it needs to assess their practice as well as educational skills, and any good appraisal system should do this. Furthermore, there is a responsibility on higher education institutions (HEIs) providing SCPHN programmes to facilitate study days for PTs in order to address the perceived deficits in their knowledge and skills. The majority of PTs are committed practitioners who take a pride in their role and dedicate huge amounts of time in providing a broad range of experiences and learning opportunities for students. Many do this while carrying large caseloads and without additional remuneration.

Conclusions

In spite of the rhetoric that surrounds community-focused public health nursing, many SCPHNs still practice in the traditional way, working at individual and family level. If they become PTs, they consequently do not feel competent in key public health skills. Conversely, students qualifying on the new SCPHN programmes have acquired these skills, but there is a danger that they will lose them if they are employed within a culture that does not support community-focused public health practices.

Recommendations

* The triennial review of PTs should address not only educational skills but knowledge and skills in contemporary public health practice

* Essential skills clusters18 should be developed for each SCPHN pathway, and used in the development of a continuing professional development (CPD) framework for qualified practitioners similar to that proposed by the American Nurses’ Association19

* Such CPD should be supported and funded by employers/ commissioners and delivered by HEIs

* HEIs should work in partnership with PTs to assist them in keeping up to date with contemporary public health practice, not only by organising study days as appropriate, but allowing access to student learning materials and learning alongside students in the sharing of experiences and ideas

* The role of the PT should be recognised as crucial and given the support and remuneration that it deserves

* Extension of the study to a wider population of SCPHNs across the UK, to get a better national picture of the public health skills of PTs, would enhance this research.

Box 1. PT standards

Adapted from NMC standards:13

* Enabling effective working relationship

* Facilitation of learning

* Assessment and accountability

* Evaluation of learning

* Creating an environment for learning

* Content of practice

* Evidence-based practice

* Leadership

Key points

* Evidence suggests that population-based public health nursing is more rhetoric than reality

* Use of a tool developed and validated to measure self- perceived competence in public health skills found a small group of qualifying SCPHNs to rate their competence in public health principles and practice more highly than their practice teachers rated their own

* Practice teachers who work at an individual and family level may not feel competent in key public health skills, and qualifying SCPHNs who possess these skills risk losing them if they are not utilised in practice

* Review of practice teachers should address knowledge and skills in contemporary practice, and they should be better supported, recognised and remunerated

References

1 Department of Health. Facing the Future: a review of the role of health visitors. London: Department of Health, 2007.

2. Department of Health. School nurse: practice development resource pack 2006. London: Department of Health, 2006.

3. Hawksley, B, Carwell, R, Callwood I. A literature review of the public health roles of health visitors and school nurses. British Journal of Community Nursing, 2003; 8(10): 447-54.

4. Poulton BC, Mason C, McKenna H, Lynch C, Keeney S. The contribution of nurses, midwives and health visitors to the public health agenda. Belfast: Department of Health, Social Services and Public Safety, 2000.

5. Turner J, Poulton B, Lazenbatt A, Patton L, Curran C. Community health nursing: current practice and possible futures. Belfast: Department of Health, Social Services and Public Safety, 2003

6. Carr SM. Refocusing health visiting: sharpening the vision and facilitating the process. Journal of Nursing Management, 2005; 13(3): 249-56.

7. Smith K, Bazinini-Barakat N. A public health nursing practice model: melding public health principles with the nursing process. Public Health Nursing, 2003; 20(1): 42-8.

8. Smith MA. Health visiting: the public health role. Journal of Advanced Nursing, 2004; 45(1): 17-25.

9. Plews C, Billingham K, Rowe A. Public health nursing: barriers and opportunities. Health and Social Care in the Community, 2000; 8(2): 138-46.

10.NMC. Standards of proficiency for specialist community public health nurses. London: NMC, 2004.

11.Skills for Health. National occupational standards for the practice of public health. Bristol: Skills for Health, 2004.

12.Poulton B, McCammon V. Measuring self-perceived public health nursing competencies: a quantitative approach. Nurse Education Today, 2007; 27: 238-46.

13.NMC. Standards to support learning and assessment in practice. London: NMC, 2006.

14.Byers P. Report on the Practice Educator Project. London: Amicus/CPHVA, 2002.

15.Burke S, Meyrick J, Speller V. Public health skills audit 2001: research report. London: Health Development Agency, 2001.

16.Parahoo K. Nursing research: principles, process and issues. Basingstoke: Macmillan Press, 2006.

17.Pallant J. SPSS survival guide (third edition). Maidenhead: Open University, 2007.

18.NMC. Guidance for the introduction of essential skills clusters for pre-registration nursing programmes. London: NMC, 2007.

19.American Nurses Association. The Framework, Concepts and Methods of the Competency Outcomes and Performance Assessment Model. Silver Spring, Maryland: American Nurses Association, 2000. Available at: www.nursingworld.org/mods/archive/mod110/ copafull.htm#copa (accessed 14 August 2008).

Brenda Poulton PhD, BA, MSc, RGN, RSCPHN, CertEd

Professor of community health nursing,

University of Ulster

Agatha Lyons PGCertEd, BSc, RGN, RSCPHN SCPHN lecturer and course director, University of Ulster

Anne O’Callaghan PGCertEd, BSc, RGN, RSCPHN

SCPHN lecturer, University of Ulster

Copyright TG Scott & Son Ltd. Sep 2008

(c) 2008 Community Practitioner. Provided by ProQuest LLC. All rights Reserved.

A Goodbye From a Former NPC Member

By Beswick, Kate

Letter of the month Dear editor,

I am contacting you so that I can express my thanks to Unite/ CPHVA for all the support, fun and hard work I have so enjoyed during my years as a member of the association. I have decided that it is time to retire and enjoy the next few years with my husband.

Health visiting has been a fantastic job and way of life, but I think is now so changed that it is time for me to leave and let the younger generation find out for themselves the joys and sorrows of the job. Public health and family visiting will always be there, and they need the excellence of the health visiting service.

The HVA and then the CPHVA became my life for years. I was so proud to be part of the fantastic progress and implementation of exciting changes that the association was managing at the time.

I am going to try to maintain my interest and contact with the prison service. This will not be as a paid employee of the NHS, but I hope to do voluntary work with the independent monitoring board of one of the local prisons or detention centres. I am expecting to use my public health skills in the new work, but I shall have to wait and see.

I am sorry that the Oxfordshire Centre has closed. I hope it will manage to merge with the local health branch, however there will always be a loss of clinical updating with a health visiting or child health focus.

Very best wishes for the future,

Kate Beswlck Retiring as an Oxford health visitor, former head of health care at HMYOI Huntercombe, Oxfordshire and former Unite/ CPHVA National Professional Committee (NPC) member

Kate Beswick Retiring as an Oxford health visitor, former head of health care at HMYOI Huntercombe, Oxfordshire and former Unite/ CPHVA National Professional Committee (NPC) member

Copyright TG Scott & Son Ltd. Sep 2008

(c) 2008 Community Practitioner. Provided by ProQuest LLC. All rights Reserved.

‘Towelhead’ is Meant to Provoke

By Bob Strauss

“Towelhead’s” title is considered insensitive and definitely provocative. The film’s sexualization of a 13-year-old girl makes Miley Cyrus look like a kindergartner. It also questions basic assumptions about physically abusive parents, good Samaritans and even Saddam Hussein.

Lucky thing this is a really terrific movie or it might be banned across the country.

Many people will still find a lot about “Towelhead” to get upset about, and they’re perfectly welcome to. It was designed to push buttons, but also to make you think about prejudices, morals and judgments that we may not need to examine but would probably benefit from doing so.

It’s also absolutely hilarious in the truest, behavior-based way – – and in that kind of passionately deadpan manner that Alan Ball, the writer of “American Beauty” and creator of HBO’s “Six Feet Under” and “True Blood” can do so well.

For his feature directing debut, Ball chose to adapt the perceptive, semi-autobiographical novel by Alicia Erian, an Arab- American woman. Her takes on the wonderful, alarming weirdness of teen sexuality and suburban discontent are right in tune with Ball’s sensibility. Substitute ignorant and/or hypocritical racism for homophobia, and it’s easy to see why Ball cottoned to this material like it was his own life story.

In “Towelhead,” Jasira Maroun (Summer Bishil) is what you might call an early developer — so much so that her mother’s boyfriend finds it necessary to help her trim her bikini line. When Mom (Maria Bello) gets wind of this, she immediately packs off Jasira to her father Rifat’s (Peter Macdissi) new place on a cul-de-sac outside Houston.

A Lebanese Christian, an apparently respectable NASA engineer and quite the bimbo hound, Rifat nonetheless has some serious, Old World double standards regarding his daughter’s blooming womanliness. He also has a completely weird personality. So it’s little wonder when, once Jasira discovers the joy of self-pleasuring, she invites male attention from dubious sources. There’s the Army reservist next door, Travis Vuoso (“Dark Knight’s” Aaron Eckhart), and a nice but one-track-minded African-American kid, Thomas Bradley (Eugene Jones), from the new school where everybody else calls Jasira racist names.

This is during the winter of 1991 when the first Gulf War is on. Even though Rifat hates Saddam more than anyone and Jasira barely even realizes she is part Arab, they’re suddenly the neighborhood’s questionable “others.” A competition to show who’s most patriotic on the block ensues, and it outlandishly mirrors Jasira’s sexual explorations. But embattled ethnic pride also bonds her and Rifat closer together for the first time in their lives.

Ball is merciless toward — yet immensely understanding of — every adult character, and that’s a major accomplishment for any movie. But he goes so much further with Jasira, presenting a naive adolescent who, yes, lets herself be terribly exploited, but also insists on learning, growing and gaining more control from every outrageous situation she gets herself into. This girl may not be as smart-mouthed as Juno (though some of her lines are better), but she’s a lot smarter. And she refuses to consider herself a victim against some pretty strong encouragement otherwise.

Bishil was 18 at the time she made “Towelhead,” so anyone inclined to scream kiddie porn is out of luck (besides, director of photography Newton Thomas Sigel frames everything so we never actually see Jasira in the act). Much more importantly, she’s one of the finest natural film actresses to emerge in years. As strong as many of its other aspects are, the movie would not have succeeded without the perfectly calibrated confusion, intelligence and, yes, lust Bishil conveys, and the complex emotions she appears to effortlessly make crystal clear.

“Towelhead” is tough stuff. It’s also brilliant stuff. Proceed, with caution, accordingly.

Bob Strauss, (818) 713-3670

[email protected]

TOWELHEAD – Four stars

>R: sex, nudity, violence, racism, language, children in peril.

>Starring: Summer Bishil, Aaron Eckhart, Peter Macdissi, Toni Collette, Maria Bello, Eugene Jones.

>Director: Alan Ball.

>Running time: 1 hr. 56 min.

>Playing: ArcLight, Hollywood; Landmark, West L.A.

>In a nutshell: There’s something to upset everyone in this dark comedy about a 13-year-old Arab-American girl’s coming of age; it also happens to be one of the smartest, best-acted movies of the year.

(c) 2008 Daily News; Los Angeles, Calif.. Provided by ProQuest LLC. All rights Reserved.

Reporters’ Notebook / Bits and Pieces of News…

OLAF FUB SEZ: According to journalist and social critic H.L. Mencken, born on this date in 1880, “A celebrity is one who is known to many persons he is glad he doesn’t know.”

***

CLEAN MACHINE — Take your dirty vehicle out to the Herschell Carrousel Factory Museum, 180 Thompson St., North Tonawanda, between 10 a.m. and 1 p.m. today and get more than a car wash. The occasion includes live music from Beats Me and Jimmy Pirate. Hot dogs and soft drinks will be available. Crafts by People Inc., which is co- sponsoring the fundraiser, will be available. Proceeds benefit the children’s gallery at the museum.

***

SALE ITEMS — The Elma Fire Company Auxiliary will hold a fall flea market from 9 a.m. to 2 p.m. Saturday at the fire hall, 2945 Bowen Road.

Unity Church, 1243 Delaware Ave., will hold a silent auction and 50/50 split raffle from 11 a.m. to 1 p.m Saturday. Proceeds benefit Farm Sanctuary.

***

EATING AROUND — The Village of Lancaster Citizens Party will hold a steak roast from 6 to 9 p.m. today in the Elks Lodge, 13 Legion Parkway. Tickets, $20, include dinner, beer, wine and pop.

*The Amherst Lions Club will be selling hot dogs from 11 a.m. to 3 p.m. Saturday outside Valu Home Center at 3275 Sheridan Drive. Proceeds will benefit the Lions Diagnostic Imaging Center in the Ross Eye Institute in Buffalo.

*St. Stephen’s Tamburitzans and Dancers will host a chicken and lamb barbecue from 4 to 8 p.m. Saturday in St. Stephen’s Serbian Orthodox Church, Abbott and Weber roads, Lackawanna, Chicken dinners are $8, lamb is $10, both meats are $12. Djuro Klipa will provide music for listening and dancing from 7 to 11 p.m.

*Habitat for Humanity’s 16th annual chicken barbecue takes place from 11:30 a.m. to 1 p.m. Sunday at Holy Trinity Lutheran Church, 1080 Main St. near North Street. Dinners are $8 for adults, $4 for children. To reserve tickets, call Sue Fayle at 882-4348.

*St. Philip the Apostle Church, 950 Losson Road, Cheektowaga, holds a chicken barbecue by Wendel Farms from 11 a.m. to 3 p.m. Sunday in the parish center. Tickets are $8, $7.50 presale after weekend Masses.

***

HAPPY BIRTHDAY — Christine Zanghi, Chesley McNeil, Tom Borrelli, Janet Meiselman, Justine Welch, Oneal Fields, Elizabeth Harris, Jane Brennan, Raymond Hampton, Ray Pilarski, Gloria Marino, Gene Drebot, John Mickler, Sister Mary Catherine Raczkowski, Ray Wrazen, Donna Kokotajlo, Tom Amodeo, Keith Halt, Sue Bifaro, Peter Gerace, Matthew Pfeifer, Jean Riley, Keenan Toohey, Katen Damstetter, Julie Schictel, Suzanne Mackey, Dan Paul, Leona Grogg.

SATURDAY — Chandler Hamilton Edbauer, Ken Madell, Matthew Crist, Anna Marie Cellino, Steve Watson, Peter Ulrich, Chelsea Ulrich, Michael Herr, Sharon Hodur, Sister Mary John Lawicki, Karen Drebot, Sister Mary Edwardine Machnica, Gary Weiss, Michelle Giblin, Janet Bettinger, Jack McGrady, Colleen Kruzicki, Tiffany Pulci, Devonia Santucci, Mike Sabo, Joey Stein, Cheryl Nicotera.

AND SUNDAY — Elizabeth Hanson, Mary Jo Sheldon, Mitch Flynn, Nadia Pizarro, Tysheka Long, Nancy Naples, Pat Nicotera, Timmy Sands, Stephanie Snyder, Brandon Tobias Panek, Sister Mary Marcelette Bogonieski, Frani Walters, Billy Wasielewski, Donna Clark, Jane Brennan, Jennifer Louth, Lumen Brown, Mary Baty.

e-mail: [email protected]

(c) 2008 Buffalo News. Provided by ProQuest LLC. All rights Reserved.

Tips for Coping With the Suddenly Empty Nest

By Jackie Burrell

Penny Warner recalls saying goodbye on the steps of daughter Rebecca’s dorm at CSU Chico as if it were yesterday. She held it together through the farewell kisses and the fluttered waves through the car windows. And then she remembers driving home, crying so hard she could barely catch her breath.

“I cried so hard,” she says, “I threw up. I remember it vividly – – trying to let go. It’s your whole life for 18 years.”

When it comes to parenting, those sleep-deprived toddler years seem to take forever. Then, whoosh, you’re standing tiptoe in a university parking lot — or on the tarmac at a military base — trying not to weep all over your child’s college hoodie or their fatigues. And what happens next is different for every parent.

Some return tearfully to a silent, empty nest. Some rush home to gleefully redecorate. And some, like Ann Allen, head straight for the airport, ready for adventures of their own.

Allen just finished helping her youngest daughter, Karina Race, move into her dorm at San Francisco State. Now, the Concord resident is packing for a seven-week trip to India to discover new experiences and get her mind off her impending empty nest.

It was a support group that helped new empty-nester Julie Renalds — that and her crying towel.

“The first year when Amy went away I really struggled,” Renalds says. “I’ve got sisters and good women friends, but no one really understood how hard it was. It just was a huge transition.”

After muddling her way through the first year in tears so copious, she gave up on tissues, the Oakland mom put a notice in the Montclarion newspaper, looking for parents interested in forming a “discussion group.” Calls came in immediately, some from parents in the thick of the experience, and others anticipating what lay ahead.

Now, that support group has inspired a book, “Writin’ on Empty: Parents Reveal the Upside, Downside and Everything in Between When Children Leave the Nest,” edited by Renalds, college admissions counselor Risa Nye and support group co-founder Joan Cehn, with essays sharing the experiences of 26 moms, dads and grandparents from all walks of life.

Empty nest syndrome, says Renalds, has struck this generation and its helicopter parents particularly hard.

“They have trouble letting go,” she says, “because they’ve been so involved in every facet of their (children’s) lives.”

Of course, not everyone is appalled at the sudden quiet that settles over a house without kids. Some people aren’t dismayed by the lack of dirty laundry, or the unravished refrigerator. They enjoy the newfound freedom, reconnect with their spouses, or, like Linda Lee Peterson, one of the contributors to “Writin’ on Empty,” they swim naked and pad through the house in their underwear.

It can be a time to rediscover oneself, says Nye: “While you’re letting go, start looking toward yourself. They’re moving into a new phase and so are you. What are those thing have always wanted to do? Hopefully, you have a list.”

And it helps to have friends or family who have gone through the same thing. Philip Weingrow sympathized when his wife went through the process with her daughter, but it wasn’t until his son left that he fully understood.

“I didn’t get it at all,” he writes in “Writin’ on Empty.””Oh sure, I understood that (my wife) would miss her bright, fun-loving daughter. But I didn’t get it like I did when I was losing my son. And that’s the way it felt: like I was losing a part of myself.”

Carol Penskar can relate. Her son graduated from Orinda’s Miramonte High in 2005 and headed for West Point. But when the prospect of losing her daughter — now a sophomore at Northwestern – – loomed, Penskar made plans.

“We knew we’d see her less,” Penskar said. “So I had thought about it some ahead of time.”

Penskar ramped up her work schedule. She began playing more tennis. And as a longtime classroom and youth sports volunteer, Penskar looked for opportunities to shift her spirit of volunteerism into the community. She joined the board of her homeowners association, and Orinda’s citizens budget committee.

But it was the social aspect that surprised her most.

“You make all these friends and see them regularly at (sports) practice and preparing for the prom,” she says, “and all of a sudden, you don’t have that regular contact anymore. So you have to make that happen. You have to seek those people out, look for ways to be involved in the community. Tennis has been great for me because all of my tennis friends are empty nesters or approaching it. We talk about this stuff and check in.”

That helped Warner, too. She and her husband reconnected with their old babysitting co-op.

“When the kids grew up, we realized we missed those people,” she says. “We started inviting those people back for dinner. It’s the babysitting group without the babies.”

Contact Jackie Burrell at [email protected] for empty

nesters– PLAN AHEAD: Saying goodbye to your last child is a major life transition for both of you. Make plans to sustain you in the years to come. Nurture your marriage and rekindle that romance. Ramp up your work schedule. Explore volunteer opportunities. Plan to stay busy. — VOLUNTEER: Many parents spent years volunteering in the classroom. Now, shift that spirit of volunteerism into the community. Joining a volunteer group gives you an instant circle of new friends and keeps you busy.– RECONNECT WITH OLD FRIENDS: Just because the inspiration behind the old babysitting co-op or swim team parent social have gone off to college doesn’t mean you can’t still see those parents. Throw a party, schedule a coffee date, renew old friendships with parents going through the same stage of life.– REDISCOVER YOURSELF: Dig out that old list of things you always wanted to try — hobbies, career paths, cuisines, travel destinations, whatever — and start working on it.

Book talks

“Writin’ on Empty: Parents Reveal the Upside, Downside, and Everything In Between When Children Leave the Nest” edited by Risa Nye, Joan Cehn and Julie Renalds ($19.95, www.writinonempty.com). Meet the authors and hear their stories at these upcoming book talks:– TOWNE CENTER BOOKS: Oct. 6 at 7:30 p.m., 555 Main St., Pleasanton– ORINDA BOOKS: Oct. 28 at 4 p.m., 276 Village Square, Orinda– DIESEL BOOKS: Oct. 30 at 7 p.m., 5433 College Ave., Oakland- – LAFAYETTE LIBRARY: Nov. 13 at 7:30 p.m., 952 Moraga Rd., Lafayette

Originally published by Jackie Burrell, Contra Costa Times.

(c) 2008 Oakland Tribune. Provided by ProQuest LLC. All rights Reserved.

Accident Victim Very Ill

A MAN struck by a train remained seriously ill in hospital today.

He is in the intensive care unit at Newcastle General Hospital after suffering a head injury and collapsed lung.

He was struck after running in front of a Hexham to Middlesbrough Northern Rail train on Wednesday morning at the rear of the Davy Roll factory in Gateshead.

Police have not revealed the victim’s identity, but he is 22 and from the Gateshead area.

The section of the track where he was hit is near Coulthards Lane and the Gateshead College campus.

It is believed the man was taking a short cut across the line from the Davy Roll side to Saltmeadows.

British Transport Police are investigating the incident.

A spokesman said: “He has been stabilised, but remains seriously injured in hospital. We are continuing inquiries.”

(c) 2008 Evening Chronicle – Newcastle-upon-Tyne. Provided by ProQuest LLC. All rights Reserved.

HHS Provides Prescription Drug and Durable Medical Equipment Assistance for Uninsured Texas Victims of Hurricane Ike

HHS Secretary Mike Leavitt today announced up to $2 million in individual assistance for victims of Hurricane Ike from affected counties in Texas, through a new Emergency Prescription Assistance Program (EPAP) administrated by the Centers for Medicare and Medicaid Services (CMS).

The program, which has begun providing benefits, is an efficient way for pharmacies to process claims for prescription medications and certain durable medical equipment items for individuals who do not have any form of health insurance coverage and who are from the Texas emergency area declared by the President.

Claims for individuals with private insurance, such as employer-sponsored coverage or an individual health insurance policy, are not eligible for payment under the EPAP. Nor are claims for individuals with public insurance, such as Medicare or Medicaid.

“This program is an example of the public and private sector working together to improve our nation’s ability to respond to emergencies,” Secretary Leavitt said. “People without health insurance affected by this storm will be able to more easily get their needed prescriptions no matter where they evacuate to.”

EPAP covers one-time, 30-day supplies of medications and certain durable medical equipment, such as canes, walkers, wheelchairs and diabetic supplies.

With a written prescription, eligible individuals may receive assistance for essential pharmaceutical and durable medical equipment lost as a direct result of Ike. The supply can be used to treat an acute condition and to replace maintenance prescription drugs or medical equipment.

For the eligible individuals, the program also would cover, at no cost to the patient, replacements for needed drugs or equipment lost or damaged while in transit, such as from an emergency site to a designated shelter facility.

To assist in the determination of eligibility, pharmacies must check at the point of sale for other forms of health insurance coverage. Only claims with a date of service between Sept. 12 and Sept. 22, 2008 are eligible under for processing under the EPAP-Ike Activation at this time.

Eligible individuals must have a new prescription from a licensed health care practitioner, a current prescription bottle, a prescription phoned in by a licensed health care practitioner, or proof of an existing prescription in order to receive a prescription fill and/or certain durable medical equipment.

Pharmacies must dispense the generic form of medication unless otherwise indicated as brand medically necessary by the licensed health care practitioner.

Eligibility for the EPAP – Ike Activation is limited to individuals who meet the criteria above and are a resident of the following counties in Texas: Aransas, Bexar, Brazoria, Brooks, Calhoun, Cameron, Chambers, Cherokee, Collin, Comal, Dallas, Denton, El Paso, Ellis, Fort Bend, Galveston, Hardin, Harris, Hidalgo, Hunt, Jackson, Jefferson, Jim Wells, Kenedy, Kleberg, Kaufman, Liberty, Lubbock, Matagorda, Navarro, Nueces, Orange, Refugio, San Patricio, Smith, Van Zandt, Victoria, Walker, Waller, Wharton, Willacy, and Wood.

The HHS Web site is featuring a link to public health and safety information specifically related to hurricanes at www.hhs.gov/hurricane. The EPAP-Ike Activation can be accessed at http://www.cms.hhs.gov/Emergency/Downloads/EPAP_PublicComm_Ike.pdf.

Note: All HHS press releases, fact sheets and other press materials are available at http://www.hhs.gov/news.

Death Rate for Infective Endocarditis Up

The death rate for infective endocarditis — an infection where bacteria destroy the heart — has increased, a British cardiologist warns.

Despite medical improvements, the rate for infective endocarditis has been virtually unchanged for last 20 years, and now seems to be rising again, Dr. Bernard Prendergast of Oxford, England’s John Radcliffe Hospital told a meeting of the Society for General Microbiology held at Trinity College, in Dublin, Ireland.

“Now that people live so long, degenerative heart valve disease is a more common problem. We’re also seeing complications in patients who have received replacement heart valves and infections as a result of intravenous drug use,” Prendergast said in a statement. “On top of that, aggressive Staphylococcus infections are now common, and conventional antibiotic treatments are becoming less effective because of drug-resistant bacteria.”

Presently, early surgery to treat valve infection is controversial as is preventative antibiotic treatment, Prendergast said.

“We just don’t have the results from properly conducted and randomized clinical trials to know whether routine prophylactic antibiotics are helpful or not,” Pendergast said. “Improved dental health and skin hygiene are probably at least as important as blanket antibiotic treatment.”

Battling the Baby Weight

By THERESA WINSLOW Staff Writer

Elicia Brand-Leudemann thought she’d lost her body.

After the delight of having twins 8 months ago came the realization that her body had changed dramatically.

She’d gained almost 80 pounds on her petite 5-foot-1-inch frame during her pregnancy, had a Caesarean section, and was now giving all of herself to her children. A first-time mother, the 38-year- old was a bit depressed about her physical condition.

“After the C-section, I thought it was all over,” the Eastport resident said last week. “I felt so lost. I’d see myself in the mirror and didn’t know who I was.”

One day this spring, though, she made up her mind to change that, and took the first step to getting her body back. She enrolled in a two-week workout program at Premier Fitness in Annapolis, and since then has been more diligent about exercise. Now down to 134 pounds (about 15 more than before she was pregnant), she’s just begun a more intensive fitness regimen at the health club under the guidance of personal trainer Nathalie King.

“I’m not going to give up getting my body back,” Ms. Brand- Leudemann said after getting weighed, having her body fat percentage measured, and having Mrs. King show her some exercises. “I want it to be healthier.”

What she’s learned over the past few months is something that Mrs. King, a mother of two herself, tells lots of clients: A healthier body and attitude make for a better mom.

“Don’t feel guilty about taking time for yourself,” the trainer said. “It’s so important to get out and feel you’re not the only person going through this. There is life after baby.”

Exercising your options

The key to taking off baby weight, according to Mrs. King and other fitness experts, is patience.

“You didn’t put the weight on in a day, you’re not going to take it off in a day,” said Price Booker, co-owner of Fitness Together in Annapolis.

“Be realistic,” added Erin Horst, owner of Evolutions Body Clinic in Annapolis and a new mom who got back to her prebaby weight just five months after giving birth. “A lot of people, it’s going to take nine months. I was lucky.”

A patient attitude also helps when a woman is eager to start working out immediately after giving birth. Typically, it’s recommended that women wait about six weeks postpartum before starting an exercise program. But that varies and can depend on whether or not the mom was working out while pregnant and how intensive a regimen she undertook, the experts said.The bottom line is that a start date should be left to the mother and her doctor, Mr. Booker said.

Once a mom has been given the OK, it’s also important to start gradually. “You’re not going to pick up where you left off,” said Jeff Miyamoto, the other owner of Fitness Together. “Work up slowly; pick up at a basic level (and) listen to your body.”

That’s exactly what Kristin Legg of Annapolis did when she began working out again just recently. Her son is 6 weeks old, and she began walking and doing light work on an elliptical machine four weeks after he was born. Ms. Legg, who works at Evolutions, increased her workouts from there.

“I don’t stress about it,” she said of taking off baby weight. “I know it will happen. I know I’m dedicated. You want to go right back down, but it’s hard. But the little baby is definitely worth it.”

Like many new moms, Ms. Legg’s biggest issue is finding the time to exercise. But she’s had the support of her husband and family, which she said makes it a lot easier. Danielle Cavallo of Annapolis agreed.

“Finding the time is tricky,” said Mrs. Cavallo, who has a 4- month-old son. “It’s about the baby now. It’s much more challenging, but I’ve had a lot of support. I can see how (you’d) forget yourself. (But) my time working out is my time. I cherish it and it refuels me.”

Her routine mixes strength training with cardiovascular work, and of course she watches what she eats. Ms. Horst said nutrition has been the biggest reason why her baby weight came off so quickly. (Of course, women who are breast-feeding need to eat a bit more than those who aren’t, but the additions to their diet should be healthy, experts said.)

A large part of Ms. Brand-Leudemann’s current program encompasses nutrition, and she’s supposed to eat six small meals a day. It’s based on Bill Phillips’ popular “Body for Life.”

“When you become a mom, you need to give yourself the gift of health,” she said, smiling. “The gym has to be part of your life.” {Corrections:} {Status:}

EXPERTS ADVISE NEW MOMS TO START SLOWLY, PAY ATTENTION TO NUTRITION

(c) 2008 Capital (Annapolis). Provided by ProQuest LLC. All rights Reserved.

Girl Scouts to Hold Registration

BETHEL – Girl Scouts of Maine will hold local parent information and registration meetings during September.

Those wishing may register for Girl Scouts on one of the following dates and find out about Girl Scout activities taking place in the community:

Bethel: Monday, Sept. 22, at 6 p.m. at the Bethel Alliance Church.

Woodstock: Tuesday, Sept. 23, at 6 p.m. at Woodstock Elementary School.

Girl Scouts of Maine serves more than 14,000 girls ages 5 to 17 statewide. The registration fee to become a member is $10, payable by check. Financial assistance is available.

Girl Scouts of Maine also has many volunteer options for adults. For more information, contact Heather Carver at 824-0778 or Jeanie Duguay at 364-3639, 1-888-922-GSME (4763) or [email protected].

(c) 2008 Sun-Journal Lewiston, Me.. Provided by ProQuest LLC. All rights Reserved.

Pupils Turn Teacher for Technology Conference

By GILLESPIE, Sean

SOMETIMES teaching isn’t just an adult’s job.

About 80 pupils from six Invercargill primary schools converged on Bluff Community School yesterday for an ICT (information communication technology) conference partially run by pupils.

A group of specially chosen pupils held workshops for the other children, teaching them how to use computers for making movies, music and other practical applications.

The schools involved were Salford, Windsor North, St Theresa’s (Invercargill), Otatara, Sacred Heart and Bluff Community School.

ICT facilitator Pania McVay-Stewart said the concept helped to promote self-directed learning and problem solving.

“Students should be taking more roles in the classroom — the teacher shouldn’t be the fountain of all knowledge,” Ms McVay- Stewart said.

The pupils teaching the workshops were accompanied by teachers and had been given training beforehand.

Eleven-year-old Daniel Kapene from the host school taught rotating groups of his peers how to create digital comics.

He said teaching people he had not met before was a lot easier than he had expected and it was a good experience.

[email protected]

——————–

(c) 2008 Southland Times, The. Provided by ProQuest LLC. All rights Reserved.

Remedies in Our Food

By MORGAN, Jon

The next big thing: food that switches off bad genes.

——————–

IMAGINE going to a doctor with severe arthritis and instead of being prescribed a drug you are told to eat a special kiwifruit grown only in New Zealand.

It’s not impossible. Food that may be able to help mend the health problems caused by our genetic makeup is being explored by a team of New Zealand scientists.

The research hopes to take what we now know as functional food — food that is linked to disease prevention, such as broccoli to colon cancer — and connect it directly with the gene map of an individual or group of people.

The idea is to find the gene “switch” that makes people susceptible to a disease and discover the food — or a potent nutrient in the food — that turns the switch off. The potential benefit for New Zealand is that if our scientists can intensify the active ingredient through selective breeding they can claim the exclusive plant variety rights.

Other countries are also involved in research and eventually it is hoped this science — nutrigenomics — will be refined to apply to the treatment of all illnesses that have a genetic base.

At present, this is still a long way away. It is believed that 10 million genetic differences between individuals exist and so far only around 20 are understood.

The potent food ingredients are micronutrients, dietary compounds such as vitamins and minerals that are required in small amounts in the diet, or macronutrients, organic compounds, like proteins, amino acids, carbohydrates and lipids, which are needed in large amounts.

Professor Bruce Ames, of the University of California, Berkeley, argues that micronutrient deficiencies are widespread and may be a key preventable cause of the diseases of ageing. His theory is that the degenerative diseases which accompany ageing, such as immune dysfunction, cancer, dementia and stroke, might be delayed by the inexpensive intervention of micronutrients.

In Australia, research into micronutrient deficiencies that damage dna has led to a simple diagnostic blood test to discover damage to a type of white blood cell and to the micronutrients that can reduce it.

At Tufts University, Massachusetts, Jim Joseph is investigating “berrying” the aged brain. His findings suggest that berries may improve learning and memory and protect against Alzheimer’s, Parkinson’s, heart disease, vascular dementia, cancer and arthritis.

IN New Zealand, scientists are working on gut health. A 50- strong group from the government science institutes AgResearch, HortResearch and Crop & Food Research and Auckland University is spending $3.2 million a year. Known as Nutrigenomics New Zealand, the group is four years into an initial six-year funded term and expects to need another six years.

It is slow work.

The leader, Professor Lynn Ferguson, who heads the university’s nutrition department, says “we’ve reached a point on how to study it”. “We understand some of the science we didn’t understand when we started out.”

The group’s focus is on Crohn’s disease, where foods are known to play a role in triggering the genes that cause this inflammatory bowel disease. Some overlap with genes associated with asthma and arthritis has also been found.

The scientists are looking for two things, the gene “switch” that make people susceptible to inflammation and a nutrient that turns it off.

About 1000 Crohn’s patients are taking part and have begun by listing the foods they can and cannot tolerate. Energy and carbonated drinks, hot curries, salami, grapefruit, cream, fruits with small seeds, alcohol, coffee and corn are bad. Bananas, ginger, starchy vegetables and couscous are good.

Cabbage has sprung a surprise. Crohn’s people with a certain gene find they can’t eat it but other patients without the gene find it beneficial.

Findings of a low level of selenium in the blood serum of Crohn’s patients were to be expected. Selenium and folate are two nutrients that are naturally low in the New Zealand diet. Selenium is found in wheat-based cereals imported from Australia and Brazil nuts and deficiencies have been associated with prostate cancer. A diet lacking in folate, which is in green-leafed vegetables, has been linked to a risk of cardiovascular disease.

Professor Ferguson says the science so far is showing that the well- known food pyramid of dietary priorities may be too simplistic. “Recommendations may need to be fine-tuned, particularly for people who have a susceptibility to a disease or who are just not in optimal health.”

An example is the 20 per cent of the population who need twice as much folate. “It’s not going to be a life or death situation for them but it will enhance their health, performance and general state of well- being.” Another is the people whose genes produce a bad reaction to too much of the polyunsaturated acids in oily fish that are generally considered beneficial.

Ultimately, mapping a person’s unique genetic makeup will mean any one person’s dietary requirements can be far more finely tuned, she says. “It could also mean that not only would someone know which foods to avoid, but they could also learn what foods are good for them and should be included in their regular diet.”

In the meantime, the Crohn’s patients are first in line. She says a clear picture is still to emerge, but it appears the genes involved are in clusters, not scattered across the genome, which helps to simplify treatment. “It looks like some of the dietary advice will depend on which of those groups of genes is affected.”

It is expected this work will lead on to other inflammatory illnesses and other nutrients that turn off harmful gene “switches”.

HortResearch biochemist William Laing’s job is to find foods high in the key nutrients. Asked what foods he has been looking at, he replies: “Everything and anything we can think of.”

This includes a wide variety of fruit and vegetables as well as milk products, green tea, red wine and chocolate. HortResearch’s wide germplasm base of kiwifruit and apples is a rich source.

“The idea is to obtain value for New Zealand. It’s pretty hard to protect a food component in terms of intellectual property, but one way is to breed a fruit or a vegetable that is naturally high in the active ingredient and then you can protect it through plant variety rights.”

AGRESEARCH scientist Warren McNabb, who leads a team that tests promising nutrients on rats and mice, says the science is still little understood. “Knowledge is rapidly growing, but we’re only scratching the surface.”

As more genes are found to be nutrient-sensitive it gives hope that treatment will be of broad population groups, based on ethnicity or a tendency to heart disease or cancers, rather than individuals, he says.

This might be a way around issues of personal security that arise over having people’s genomes stored in a database somewhere. It is a question exercising scientists, he says.

“In Singapore, where they are seeing an increase in western diseases as their diet changes, all babies are genotyped. But in other countries that is a privacy issue.”

Progress might be slow, but he says it is essential that New Zealand actively participates in the science.

“What’s happening is a transformational change about how we’re going to be talking about foods in the future and New Zealand, a food export-driven country, can’t be left out. Farmers have to be aware of this. They can’t be pumping out that same old stuff all the time.”

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(c) 2008 Dominion Post. Provided by ProQuest LLC. All rights Reserved.

Young Men Increasingly Affected By Eating Disorders

Anorexia and bulimia are on the rise among men as a new study shows one in five young men are unhappy with their body.

“One in five young men have some degree of quite extreme distress,” said Dr John Morgan, who runs the Yorkshire Center for Eating Disorders in Leeds.

While the official estimate for the number of men with an eating disorder stands at around 10-15 percent of all sufferers, the real figure is much higher.

“We know that 1 in 20 young people suffer from some degree of disordered eating and that at least 15% of them are men and yet that’s a tip of an iceberg,” he said.

“There are men who have problems with compulsive exercise and excessive bodybuilding who have an illness, but we haven’t defined them. Our definitions of illness have been focused on women, rather than men.”

Eight years after a report for the Eating Disorder Association showed that not enough help was available for men dealing with eating disorders, Dr. Morgan said matters have gotten worse.

“When the report was written there were some units that had dedicated expertise in male eating disorders. A couple of these have now closed down,” he said.

“There’s a lack of funding, a lack of interest. You’re dealing with a situation where you’re trying to develop a national service for men across the country, but the Health Service is now more focused on the local.”

At the age of 13, George was affected by anorexia. Doctors were unable to identify the problem as they tested for cancer, Aids, gluten allergies and a variety of disorders.

“I knew deep down, were completely irrelevant,” George said.

When he was admitted to a clinic, he was told he had four weeks to live.

His body had started to eat its own muscles and organs to survive.

“Everything that your healthy mind says is right, ‘You can eat this, it wont make you fat at all, in fact, it’s completely healthy, it’s what normal people do’.

“But then anorexia would jump in straight off and be like – ‘What are you doing, this is terrible. You’re driven by an evil, deceiving affliction that’s not good, it’s really wrong’.”

Dr Morgan points to images in the media of male beauty which pressure young men as much as young women to look slim.

“The ideal male body image has changed into quite an unhealthy shape,” he said.

“In the past blokes have been comfortable with beer bellies. Now, men and boys are under huge pressures to look good.”

“It’s completely unhealthy, and to achieve that sort of shape you’ve got to be either working out for hours in a gym, making yourself sick, or taking certain kinds of illegal drugs.”

Marcus O’Donovan is an actor who’s been in Holby City and the recent Narnia film, Prince Caspian.

He said getting in shape for a role and enjoying a normal life is very difficult.

“The pressure is increasing on everyone to look better and better and better,” Marcus said.

“I like to eat, it’s that simple, I love my food, and I do find that I’m quite worried. I have to watch what I eat and make sure that I train. It’s quite difficult to balance that and a really happy lifestyle.”

On the Net:

Scientists Say Antarctic Winter Ice Is Growing

Experts reported on Friday that the amount of sea ice around Antarctica has grown in recent Septembers in what could be an unusual side-effect of global warming.

Since the late 1970s, in the southern hemisphere winter, when emperor penguins huddle together against the biting cold, ice on the sea around Antarctica has been increasing, perhaps because climate change means shifts in winds, sea currents or snowfall.

But Arctic sea ice at the other end of the planet is now close to matching a September 2007 record low at the tail end of the northern summer in a threat to the hunting lifestyles of indigenous peoples and creatures such as polar bears.

“The Antarctic wintertime ice extent increased…at a rate of 0.6 percent per decade” from 1979-2006, said Donald Cavalieri, a senior research scientist at the NASA Goddard Space Flight Center.

He said at 19 million sq kms (7.34 million sq mile), it is still slightly below records from the early 1970s of 20 million. The average year-round ice extent has risen too.

Skeptics point to the differing trends at the poles as a sign that worries about climate change are exaggerated. However, experts say they can explain the development.

“What’s happening is not unexpected…Climate modelers predicted a long time ago that the Arctic would warm fastest and the Antarctic would be stable for a long time,” said Ted Maksym, a sea ice specialist at the British Antarctic Survey.

The U.N. Climate Panel says it is at least 90 percent sure that people are stoking global warming — mainly by burning fossil fuels. But it says each region will react differently.

For instance, Arctic ice floats on an ocean and is warmed by shifting currents and winds from the south. By contrast, Antarctica is an isolated continent bigger than the United States that creates its own deep freeze.

“The air temperature in Antarctica has increased very little compared to the Arctic,” said Ola Johannessen, director of the Nansen Environmental and Remote Sensing Center in Norway. “The reason is you have a huge ocean surrounding the land.”

Some computer models indicate a reduction in the amount of heat coming up from the ocean around Antarctica as one possible explanation for growing ice, Cavalieri said.

He said another theory was that warmer air absorbs more moisture and means more snow and rainfall. That could mean more fresh water at the sea surface around Antarctica — fresh water freezes at a higher temperature than salt water.

Maksym said there has been a strengthening of the winds that circumnavigate the Antarctic. That might be linked to a thinning of the ozone layer high above the continent, blamed in turn on human use of chemicals used in refrigerants.

Stronger winds in some places might blow ice out to sea to areas where ice would not naturally form.

Maksym predicted that global warming would eventually warm the southern oceans, and shrink the sea ice around Antarctica.

“A lot of the modelers are predicting the turning point to be right about this time,” he said.

On the Net:

OmniSonics Medical Technologies Announces Licensing and Development Agreement With Boston Scientific

WILMINGTON, Mass., Sept. 12 /PRNewswire/ — OmniSonics Medical Technologies, Inc., a developer of advanced medical devices for use in the treatment of vascular disease, announced today that it has entered into a licensing and development agreement with Boston Scientific Corporation for technology to treat thromboembolic acute ischemic stroke. Treatment of this type of stroke represents a significant unmet clinical need, as only 10 percent of the more than 600,000 stroke patients in the United States receive therapy each year.

Under the terms of the agreement, the two companies will work jointly to develop an application of OmniSonics’ OmniWave(TM) technology for the treatment of acute ischemic stroke. The OmniWave technology, which delivers low-power ultrasonic energy to remove thrombus (or a blood clot), recently launched in the U.S. for the treatment of clots in the peripheral vasculature. Boston Scientific will provide funding based on the achievement of development milestones and has an option to acquire the technology as well as exclusive rights to the intellectual property for the treatment of acute stroke.

“OmniSonics is excited to enter into this agreement with Boston Scientific,” said Richard Ganz, President and CEO of OmniSonics Medical Technologies. “We are hopeful our OmniWave technology will prove to be an effective option for patients suffering from acute stroke.”

About OmniSonics Medical Technologies, Inc.

OmniSonics Medical Technologies, Inc., based in Wilmington, MA, is a venture-backed medical device company focused on developing breakthrough products for the treatment of vascular disease. The Company’s products are based on its patented OmniWave technology, the first technology capable of delivering low-power ultrasonic energy around the active length of a small diameter wire in a diseased blood vessel. OmniWave technology is designed to have broad applications in vascular disease.

   Contact:   OmniSonics Medical Technologies, Inc.   Len Farris   (978) 657-9980 x501   [email protected]  

OmniSonics Medical Technologies, Inc.

CONTACT: Len Farris of OmniSonics Medical Technologies, Inc.,+1-978-657-9980 ext. 501, [email protected]

Web site: http://www.omnisonics.com/

Company Profile for Lebanon Cardiology Associates, PC

Lebanon Cardiology Associates, PC, has been providing care for patients in Lebanon County since 1988. Offering our patients innovative and state of the art treatment including cardiac imaging, interventional cardiology, electrophysiology, peripheral vascular disease, and heart failure.

LCA now offers advanced cardiac heart rhythm evaluation, intracardiac arrhythmia ablation (including atrial fibrillation) and implantation of pacemakers and defibrillators. The Invasive Electrophysiology Laboratory at Good Samaritan Hospital offers the most advanced 3D intracardiac mapping system and intracardiac echocardiography available and is the only center in Central PA to offer jet ventilation for advanced ablation to ensure the safest possible procedures.

  Company:                Lebanon Cardiology Associates, PC  Headquarters Address:   775 Norman Drive Lebanon, PA 17042  Main Telephone:         717-274-5500  Website:                www.lebanoncardiology.com  Type of Organization:   Private  Industry:               Health  Key Executives:         President: Thomas Clemens  Public Relations Contact:              Linda Ehrenfeld Phone:                717-274-5500 Email:                [email protected] 

The American Nurses Association Endorses Senator Barack Obama

SILVER SPRING, Md., Sept. 12 /PRNewswire-USNewswire/ — The American Nurses Association (ANA) announces its endorsement of Senator Barack Obama (D-IL) in the 2008 Presidential Election. The ANA represents the interests of the nation’s 2.9 million registered nurses.

“As President, Barack Obama will bring real change to our health care system,” said ANA President Rebecca M. Patton, MSN, RN, CNOR. “Nurses are consistently voted the most trusted profession by the American people, and we, as a profession, trust that Barack Obama will see that affordable quality health care is made available to everyone.”

“I am honored to receive the endorsement of the American Nurses Association,” said Sen. Barack Obama. “The nurses of America serve our country tirelessly, and I share their belief that we must bring affordable and accessible health care to all Americans. My plan lowers health care costs for the average American family by up to $2500 and finally makes health care work better for American families than it does for the drug and insurance companies.”

“Both Senator Obama and Senator Clinton spoke at ANA’s House of Delegates in June about the need to move forward in unity to bring about real, much needed change to our health care system, and our nurses responded: ‘Yes we can'” Patton added. “Nurses represent the largest group of health care professionals in this country, and working together, we can use our power in the voting booth to make health care a priority, and make Barack Obama the next President of the United States.”

Senator Obama is committed to signing universal health legislation by the end of his first term in office that ensures all Americans have high-quality, affordable health care coverage. Barack Obama recognizes that nurses play a critical role in every aspect of patient care, and the nursing shortage ranks as one of the most pressing issues facing our health care system. Obama’s health care plan includes expanded funding to improve the primary care and public health practitioner workforce; including loan repayments, improved reimbursement and training grants.

Barack Obama has a history of advocacy for nurses and patients. In the Illinois senate, he helped lead efforts to protect nurses and improve the quality of health care. In the U.S. Senate, he cosponsored the Safe Nursing and Patient Care Act, which limits mandatory overtime for nurses to true emergency situations, and as President, he has promised to sign this important legislation into law.

ANA has been making presidential endorsements since 1984. The endorsement process includes sending a questionnaire on nursing and health care issues to all of the Democratic and Republican candidates, an invitation to all of the democratic and republican candidates for a personal interview and an online survey of ANA’s membership regarding which candidate is most supportive of nursing’s agenda.

The ANA is the only full-service professional organization representing the interests of the nation’s 2.9 million registered nurses through its 54 constituent member nurses associations. The ANA advances the nursing profession by fostering high standards of nursing practice, promoting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on health care issues affecting nurses and the public.

American Nurses Association

CONTACT: Mary McNamara, +1-301-628-5198, [email protected], or MaryStewart, +1-301-628-5038, [email protected], both of the American NursesAssociation

Web Site: http://www.nursingworld.org/

Sisters Oregon Harvest Faire

The Sisters Oregon Chamber of Commerce today announced the 27th annual Harvest Faire. This event will be held October 11 and 12th in Sisters Oregon from 10AM to 4PM. Over 200 vendors selling quality handcrafted items will be in attendance with items such pottery, metal art, photography, painting, jewelry, clothing, furniture, home decor and much more.

If you have interest in fresh local food, gardening, supporting a local economy, improving the environment, or having a good time, then you will not want to miss the Sisters Oregon Harvest Faire. This event boasts two full days of hands-on activities, educational opportunities, great food and good old-fashioned fun.

Flute maker Charles Littleleaf will be a special guest. Littleleaf was featured in the September 2007 issue of Cowboys and Indians magazine. He creates custom-ordered flutes that can take up to several months to complete, and he is currently making a flute for Willie Nelson. Saturday’s entertainment will be Rodrigo Espinoza, a 5-year veteran of the harvest faire. He will be entertaining guests with his music that is classified as easy listening, but carries with it a South American beat. Tyler Spencer will be featuring his Didjeridoo, an Australian instrument often used for healing purposes. Michael and Linda Soeby will be featuring their handcrafted Father Christmas figurines. Don Zylius, a local Sisters artist will be featuring his watercolors, and Linda Jacobsen will be displaying her unique form of pleated fabric art. Another popular artist that will be featured is Mitch Deadrick, who will display his pottery. David Johns will be selling his salt-free spices and sauces from the Oregon Flavor Rack, and Carol Morrison will be featuring her and her daughter’s wares from “Handmade by Mom and Me.”

A poster designed by Sisters Artist Barbara Berry commemorating the event will be available for $5. Of course, you will want to buy some tasty snacks or a delicious meal from the local food vendor, and the Harvest Faire is a great place to shop for unique, local, goods of all sorts. For more information about the Harvest Faire, visit our website at: www.sisterschamber.com

 Contact: Jeri Buckmann Phone: 541-549-0251 Email: Email Contact

SOURCE: Sisters Oregon Chamber of Commerce

Abstracts and Case Studies From the College of American Pathologists 2008 Annual Meeting (CAP ’08)

By Anonymous

Abstract and case study poster sessions will be conducted during the College of American Pathologists Annual Meeting (CAP ’08), which is scheduled for September 25 to September 28, 2008. The meeting will take place at the Manchester Grand Hyatt, San Diego, Calif. The poster sessions will occur in the Connection Cafe and Exhibits Hall. Specific dates and times for each poster session are listed below. Also shown below each poster session listing are the subject areas that will be presented during that session. POSTER SESSION 100: THURSDAY, SEPTEMBER 25, 2008, 10:00 AM-12:30 PM

Hematopathology

Posttransplant Lymphoproliferative Plasma Cell Myeloma With t(8;14) and Epstein-Barr Virus Association

(Poster No. 1)

Rebecca M. Wilcoxon, MD ([email protected]); Michel R. Nasr, MD; Nancy Rosenthal, MD. Department of Pathology and Laboratory Medicine, University of Iowa Hospitals and Clinics, Iowa City.

Although posttransplant lymphoproliferative disorders are not rare, those presenting as plasma cell myeloma, particularly with plasmablastic morphology, are exceedingly uncommon. In this case, cytogenetic studies also revealed a t(8;14) translocation, which to our knowledge has not been previously reported in this setting. The patient was a 57-year-old man and cardiac transplant recipient who presented with lytic bone lesions and an IgG-lambda monoclonal protein. Bone marrow examination revealed 60% atypical plasma cells with blastic morphology (Figure 1). Flow cytometric analysis of the atypical plasma cells showed CD38, CD138, and CD19 expression with surface lambda light-chain restriction. CD56 was negative. Additionally, the tumor cells were Epstein-Barr virus-encoded RNA positive, and cytogenetics showed a t(8;14) translocation and trisomy 22. Despite aggressive therapy, the patient had a rapidly progressive disease course and died within 3 months of diagnosis. Posttransplant lymphoproliferative disorders presenting as plasma cell myeloma are exceedingly rare, with fewer than 20 cases reported in the literature. Furthermore, few of the reported posttransplant plasma cell myelomas are documented as being related to Epstein- Barr virus infection, and none of the cases describe cytogenetic abnormalities. The c-myc oncogene dysregulation of the cell cycle associated with the t(8;14) translocation may have led to the blastic morphology and may have contributed to the aggressive nature of the malignancy in this patient. This case contributes to the spectrum of diseases that may be seen in immunosuppressed patients after transplantation.

Gastric Extranodal Marginal Zone Lymphoma in Histologic Remission With a Recurrent Clonal B-Cell Population Detected in the Thyroid by Polymerase Chain Reaction

(Poster No. 2)

Kenneth E. Youens, MD ([email protected]); Jennifer H. Crow, MD; Michael B. Datto, MD, PhD. Department of Pathology, Duke University Medical Center, Durham, NC.

Extranodal marginal zone lymphoma of lymphoid tissue (MALToma) is an indolent B-cell neoplasm that is thought to arise as a result of chronic antigenic stimulation of mucosa-associated lymphoid tissue, which is frequently caused by infection in or inflammation of the affected site. In this setting, antigenic stimulation results in a polyclonal T-cell response that is thought to promote a monoclonal B- cell proliferation via a cytokinemediated mechanism. The most common chromosomal abnormality associated with MALToma is t(11;18)(q21;q21). It results in fusion of the inhibitor of apoptosis gene on chromosome 11 with the MALT lymphoma-associated translocation gene on chromosome 18, resulting in a more aggressive lymphoma that is less responsive to antibiotic treatment. We present a case in which gastric MALToma with a monoclonal t(11;18) Bcell population was brought to histologic remission by radiotherapy. Two years later, in the absence of further clinically malignant behavior, a monoclonal B-cell population with t(11;18) and an identical immunoglobulin heavy-chain rearrangement size to the gastric MALToma was identified in the thyroid gland in the setting of Hashimoto thyroiditis. This finding raises questions about the pathophysiology of MALToma. Speculatively, suppression of the accompanying polyclonal T cells by antibiotic or radiation therapy may decrease the cytokine-fueled proliferation of the clonal B-cell population, resulting in indolent posttherapy behavior of the B- cell clone. It may be plausible that in the setting of autoimmune disease, the residual monoclonal B cells can find an alternative inflammatory milieu that allows them to continue to proliferate.

Primary Cutaneous Precursor B-Cell Lymphoblastic Lymphoma: A Report of 2 Cases

(Poster No. 3)

Yvonne S. Noronha, MD ([email protected]); Jun Wang, MD. Department of Pathology, Loma Linda University Medical Center, Loma Linda, Calif.

Extramedullary precursor B-cell lymphoblastic lymphoma (pre B- LBL) is uncommon and tends to involve skin, soft tissues, and bones. We present 2 cases of primary cutaneous pre B-LBL. Case 1 was from a 6-yearold girl with a right cheek mass. Case 2 was from an 8-year- old boy with a left forehead mass. Both lesions were biopsied. Microscopically, both tumors showed a monotonous population of medium-sized lymphoid cells diffusely infiltrating the dermis with extension into the underlying subcutis and muscle. These lymphoid cells had high nuclear-cytoplasmic ratios, round to irregular nuclei with dispersed chromatin, multiple small nucleoli, and scant cytoplasm (Figure 2). Immunohistochemically, the neoplastic cells in case 1 expressed CD45, CD79a, PAX-5, CD10, CD34, and CD43 but not TdT or CD20. The neoplastic cells in case 2 expressed CD20, CD79a, PAX-5, CD10, and TdT but not CD3. Based on thorough physical examination and radiologic survey, peripheral blood and bone marrow involvement were not evident in either case; there was also no lymphadenopathy or other extranodal/medullary lesions. A diagnosis of primary cutaneous pre B-LBL was made in both cases. Pre B-LBL must be considered in the differential diagnosis of cutaneous “small round blue cell tumors,” which includes primitive neuroectodermal tumor, rhabdomyosarcoma, neuroendocrine malignancies, granulocytic sarcoma, and other lymphomas. Pre B-LBL may show negative staining with commonly used panlymphoid markers like CD45 and B-cell markers like CD20 (case 1). Very rarely, TdT may be negative as well (case 1). Careful morphologic analysis along with appropriate immunophenotyping by flow cytometry and/or immunohistochemistry is essential in arriving at the right diagnosis.

Diagnosis of Copper Deficiency Myelodysplasia

(Poster No. 4)

Kathrina Alexander, MD ([email protected]); Yongsheng Ren, MD, PhD; Vishnu Reddy, MD. Department of Pathology, University of Alabama-Birmingham.

Context: Copper deficiency has been cited as a rare and reversible cause of myelodysplasia, and the frequency of copper deficiencymyelodysplasia is unknown. Presently, clinical suspicion for copper deficiency as a cause of myelodysplasia is low. Additionally, the routine workup for myelodysplastic syndrome (MDS) does not include serum copper testing, creating the potential for misdiagnosis of MDS.

Design: During the first 4 months of 2007, bone marrow biopsies were performed on 56 patients, testing for possible MDS.

Results: In this cohort, 3 patients demonstrated marrow morphology that we believe to be consistent with copper deficiency, including cytoplasmic vacuolization of early erythroid and early myeloid precursors, left-shifted granulopoiesis, and granular iron deposits within plasma cells (Figure 3). Serum copper measurements performed on each of these 3 patients revealed undetectable or markedly deficient levels of copper. In each case, hematologic remission was rapidly achieved with copper supplementation.

Conclusions: We conclude that the frequency of copper deficiency myelodysplasia is higher than previously thought. Given the lack of routine serum copper testing in the evaluation of MDS, copper deficiency may be overlooked as the etiology of myelodysplasia and misdiagnosed as MDS, and patients with this curable condition may undergo unnecessary bone marrow transplantation. We suggest that the presence of vacuolization in both early erythroid and early myeloid lineage cells, and the presence of granular iron deposits within plasma cells, together represent hallmark morphologic features of copper deficiency. In our opinion, serum copper testing should be routinely performed in the evaluation for MDS in the presence of these morphologic features.

Spontaneous Tumor Lysis Syndrome and Secondary Thrombotic Thrombocytopenic Purpura in Early Stage Colorectal Cancer

(Poster No. 5)

Husain A. Saleh, MD, MBA1 ([email protected]); Saad Z. Usmani, MD2; Joel Apple, MD1; Zainab Shahid, MD.1 1Department of Pathology, Wayne State University, Detroit, Mich; 2Department of Hematology- Oncology, University of Connecticut Health Center, Farmington.

Spontaneous tumor lysis syndrome and secondary thrombotic thrombocytopenic purpura are oncologic emergencies that can occur at the onset of hematologic malignancies prior to treatment. They have been very rarely documented in solid tumors. We report a case of a 60-year-old woman with limited stage colorectal cancer presenting with these complications. The patient presented with a history of diarrhea with blood clots and leftsided abdominal pain. Computed tomography scan of the abdomen and pelvis showed diffuse colitis. Colonoscopy revealed a fungating mass obstructing the sigmoid colon, and the histopathology of the biopsy showed well-to moderately differentiated colonic adenocarcinoma. The patient rapidly developed spontaneous tumor lysis syndrome, including acute renal failure. She also developed thrombotic thrombocytopenic purpura with low hemoglobin and platelet levels and with a blood smear showing a microangiopathic hemolytic picture. Distal colectomy revealed stage IIA disease. Her renal function and blood counts returned to normal after surgery. To our knowledge, there are only 4 reported cases of spontaneous tumor lysis syndrome and 8 reported cases of secondary thrombotic thrombocytopenic purpura in solid tumors, all presenting with advanced stage metastatic disease. We report the first case of limited stage colorectal cancer presenting with both spontaneous tumor lysis syndrome and secondary thrombotic thrombocytopenic purpura. Abnormal B-Cell Populations in 2 Patients With Whipple Disease

(Poster No. 6)

Leonard Grosso, MD, PhD; Emily S. Popovic, DO ([email protected]). Department of Pathology, Division of Hematopathology, St Louis University Hospital, St Louis, Mo.

Patients with Whipple disease (WD), a rare systemic disorder caused by the bacillus Tropheryma whippleii, most commonly exhibit gastrointestinal symptoms; however, lymph node involvement has been described. We present flow cytometric analysis of 2 lymph node biopsies in individuals ultimately diagnosed with WD. Analysis of the first lymph node (at an outside institution) identified a monoclonal population of B cells expressing kappa light chain (moderate), CD19, CD20, CD22, CD38 (dim), CD45 (bright), and CD71 (subset) and representing 24% of cells of the retroperitoneal node. This population lacked CD5, CD10, CD11c, and CD23 and was identified by flow cytometry as a minor component of a bone marrow biopsy. Flow cytometic analysis of a mesenteric node in the second case identified an abnormal population of B cells (43% of cells) lacking surface light-chain expression. In both cases, polymerase chain reaction did not identify a monoclonal population of B cells, and there was no morphologic evidence of malignant lymphoma. Histiocytes containing T whippleii were identified by diastase-resistant periodic acid-Schiff staining and electron microscopy. Speculation on the pathogenesis of WD has suggested an immune derangement; the aberrant B-cell populations identified in these 2 cases (and in a previous report) may be reflective of this problem. Few cases of WD have been analyzed by immunophenotyping; therefore, the frequency of this aberrant response is unknown, and further study is necessary to confirm this hypothesis. Because of the potential misinterpretation of flow cytometric data in a patient with lymphadenopathy, caution should be exercised when that patient may have WD.

8p11 Stem Cell Leukemia: Simultaneous Presentation With Precursor B-Acute Lymphoblastic Leukemia, Precursor T-Lymphoblastic Lymphoma, and Myeloproliferative Syndrome

(Poster No. 7)

Ian M. Bovio, MD ([email protected]); Robert W. Allan, MD. Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville.

The 8p11 stem cell leukemia/lymphoma syndrome is a rare, aggressive hematopoietic malignancy that is typically characterized by the coexistence of a chronic myeloproliferative disorder with hypereosinophilia and lymphoblastic lymphoma usually of T-cell type. We report the first case of myeloproliferative disorder occurring simultaneously with hypereosinophilia, precursor B-lymphoblastic leukemia, and precursor T-lymphoblastic lymphoma involving the bone marrow in a patient with a t(8; 13)(p12;q12) translocation. A 56- year-old previously healthy man presented with extensive lymphadenopathy and leukocytosis (white blood cell 30 000/[mu]L). The peripheral blood was remarkable for eosinophilia (17%) and leukoerythroblastic features; flow cytometry was negative for an abnormal T- or B-lymphoblast population. A bone marrow biopsy and aspirate were performed, which revealed a precursor B-lymphoblastic leukemia (CD19^sup +^, CD10^sup ++^, CD20 dim/partial^sup +^, CD34^sup +^, TdT^sup +^), a small abnormal precursor T-cell population (surface CD3^SUP -^, cytoCD3^sup +^, CD7^sup +^, CD4^sup +^, CD8^sup +^, CD1a^sup +^), and a striking increase in eosinophils with myeloid predominance (myeloid-erythroid ratio of 10:1) that is consistent with a myeloproliferative disorder. The lymph node was extensively involved by precursor T-lymphoblastic lymphoma with the same immunophenotype of the marrow infiltrate and contained numerous eosinophils; precursor B-lymphoblastic lymphoma was not detected. Cytogenetic analysis on the bone marrow and peripheral blood and lymph node specimens revealed a t(8;13)(p12;q12) translocation. This case highlights the importance of careful morphologic and flow cytometric analysis, even when a singular diagnosis is prominent, to expand the spectrum of presentations of the 8p11 stem cell leukemia syndrome.

Cytotoxic T-Cell Lymphomas in Patients With B-Cell Chronic Lymphocytic Leukemia Appear to Be Derived From the Acquired Immune System

(Poster No. 8)

David A. Barrett, MD ([email protected]); Andrew Feldman, MD; William Morice, MD, PhD; William Macon, MD. Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn.

Context: Cytotoxic peripheral T-cell lymphomas (PTCLs) have been described as second lymphoid neoplasms in patients with B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma. To further characterize PTCLs associated with B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma, we studied 6 such cases from the surgical pathology files of the Mayo Clinic.

Design: Clinical data, histopathology, and immunochemistry results were reviewed for all 6 cases. Granzyme M staining was performed at the Mayo Clinic using a home-brewed antibody.

Results: The PTCLs were classified as follows: PTCL unspecified (4), subcutaneous panniculitis-like T-cell lymphoma (1), and anaplastic large cell lymphoma (1). All had an activated cytotoxic lymphocyte phenotype (TIA-1 and granzyme B positive), and most had T- cell phenotypic aberrancy (Table). None had granzyme M-positive tumor cells. However, some nonneoplastic T cells within the cellular reaction were granzyme M positive. Cytotoxic T-cell lymphomas in patients with B-cell chronic lymphocytic leukemia appear to be derived from the acquired immune system.

Conclusions: In this series, all PTCLs associated with B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma had an activated cytotoxic T-cell phenotype. None of the cytotoxic PTCLs expressed granzyme M, which suggests they had an origin from the acquired immune system. Of interest, reactive T cells included a subset that was granzyme M positive, suggesting these cells had an origin from the innate immune system.

Bone Marrow Granulomata and Hemophagocytosis in a Patient With Epstein-Barr Virus Infection

(Poster No. 9)

Anna D. Castiglione Richmond, MD ([email protected]); Wei Feng, MD; Meredith Reyes, MD; Andy Nguyen, MD. Department of Pathology, University of Texas-Houston.

Epstein-Barr virus (EBV) infection is known to cause hemophagocytic syndrome. Granulomata in the bone marrow have also been associated with viral infections, such as EBV. However, it is rare to have both hemophagocytic syndrome and granulomata in the bone marrow due to an EBV infection. We present a case of hemophagocytic syndrome and bone marrow granulomata after primary EBV infection. The patient, a previously healthy 13-year-old girl, presented with fevers for 2 weeks. A peripheral blood smear showed pancytopenia and microcytic hypochromic anemia with minimal reticulocytosis. The bone marrow was normocellular with increased erythropoiesis. The bone marrow aspirate demonstrated many macrophages containing phagocytosed erythrocytes and myelocytes. Focal granulomata were also seen in the bone marrow biopsy. Neither acid-fast bacilli nor fungal organisms were identified on acid-fast and Gomori methenamine-silver stains, respectively. However, EBV- latent membrane protein immunohistochemical stain, and EBV in situ hybridization performed on the bone marrow biopsy, showed positivity within the granulomata. The nongranulomatous areas of the biopsy were negative. Serology for EBV indicated a latent infection, with positive EBV immunoglobulin (Ig) G antibodies to viral capsid antigen and EBV IgG antibodies to nuclear antigen while being negative for EBV IgM antibodies to viral capsid antigen and EBV IgG antibodies to early antigen. The constellation of clinicopathologic findings are consistent with EBV-induced hemophagocytosis and granulomata resulting in pancytopenia. To our knowledge, the presentation in a patient with EBV infection of concurrent findings of hemophagocytosis and granulomata on the bone marrow biopsy, with positivity for EBV latent membrane protein and Epstein-Barr-encoded ribonucleic acids, has never been described.

Immunoglobulin D-Positive Lymphocytic and/or Histiocytic Reed- Sternberg Cell Variants in Nodular Lymphocyte-Predominant Hodgkin Lymphoma

(Poster No. 10)

Syed S. Ahmed, MD ([email protected]); Majd Jundi, MD. Department of Pathology, Al-Hada and Taif Military Hospital, Taif, Saudi Arabia.

Immunoglobulin D (IgD)-positive lymphocytic and/or histiocytic Reed-Sternberg cell variants (L&H cells) are a unique subset of nodular lymphocyte-predominant Hodgkin lymphoma. A 5-year-old boy presented with enlarged solitary submandibular lymph node of 6 months’ duration. There were no associated B symptoms, such as fever or weight loss. Excision biopsy of the lymph node showed diffuse effacement of the nodal architecture by proliferation of atypical lymphocytes containing abundant Reed-Sternberg-like L&H cells. Focal residual lymphoid follicles were present. The L&H cells were positive for CD20, IgD, Oct2, Bcl-6, and Bob.1 and were negative for CD15 and CD30. There was an abundance of CD3-positive T lymphocytes in the background. IgD is usually coexpressed in the naive B cells (CD27 positive) and centroblast (CD38 positive). Approximately 25% of the nodular lymphocyte-predominant Hodgkin lymphoma show IgD- positive L&H cells in the interfollicular regions. These cases differ from IgD-negative nodular lymphocyte-predominant Hodgkin lymphoma in which the L&H cells are present in the disrupted B-cell follicles and are Pu.1 positive. Clinically, both IgD-positive and IgD-negative cases present as a solitary mass, but the IgD-positive cases are more prevalent in younger patients (21 vs 44 years) and have a striking male predominance (male-female ratio, 23:1 vs 1.5:1). Derivative (16;17): A Novel Poor Outcome Indicator

(Poster No. 11)

Paula Andrea Rodriguez Urrego, MD1 ([email protected]); Daphne Ang, MD1; Malca Kierson, DO1; Vathany Sriganeshan, MD2; Lauri Goodell, MD1; Hana Aviv, PhD.1 1Department of Pathology, Robert Wood Johnson Medical School/University of Medicine and Dentistry of New Jersey, New Brunswick; 2Department of Pathology, Mount Sinai Medical Center, Miami Beach, Fla.

Previous karyotypes involving chromosomes 16 and 17 have been associated with prognostic significance in acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS). There has generally been favorable response to therapy in patients with AML with inversion 16 or translocation (16;16) and unfavorable prognosis in cases of MDS and AML with deletions del(17p) and del(16q22). We present 3 AML patients, 1 therapy related and 2 with history of MDS, who shared the same abnormal karyotype detected by G-banding stain: 46,XY,der(16;17)(p10;q10),-17. This derivative chromosome resulted in simultaneous del(16q) and del(17p). Flow cytometry, bone marrow biopsy, demographics, clinical history, and outcome were compared. Morphologic changes associated with del(16q) or del(17p) were noted. Patients were followed with fluorescence in situ hybridization probe, core binding factor beta subunit, for the persistence of del(16q). All patients were men, ranging in age from 69 to 80 years (Table). Flow cytometry in all patients was positive for CD34, CD117, CD13, CD33, and cytoplasmic myeloperoxidase with an average blast count of 22%. Although MDS abnormalities with poor prognosis were absent, the outcome was similar. To our knowledge, the clinical significance of der(16; 17) has not yet been described.

Verification and Establishment of Reference Intervals for Hematology and Biochemistry Parameters: A Study of Indian Men

(Poster No. 12)

Preeti Kabra, MD1 ([email protected]); Jagruti Desai, MSc2; Madhura Joshi, BSc, DMLT1; Neela Asarkar, BM Tech1; Jaikant Gaikwad, BSc, DMLT1; Ashwini Patil, BSc, DMLT1; Eileen Daniel, BA.1 1Central Laboratory and 2Department of Early Development, Reliance Clinical Research Services, Navi Mumbai, India.

Context: Few data are available in literature for reference intervals for healthy Indian populations. We conducted retrospective analyses of data from samples analyzed at our laboratory to establish reference intervals for Indian men.

Design: Analyses were conducted for 21 hematology parameters and 14 chemistry parameters using samples from 120 healthy men with body mass index ranging from 18 to 25 and with no significant disease or blood donation in the last 3 months. Criteria for verification were as follows: After mean and standard deviation calculations, if 10% or less of data points fell outside the manufacturer’s proposed reference interval, then the interval was verified. If more than 10% of data points fell outside the manufacturer’s proposed reference interval, the reference interval was established using parametric/ nonparametric methods by applying the Anderson Darling test.

Results: The proposed reference interval was verified for most parameters. The eosinophil percentage in the Indian population differed significantly. The proposed reference interval for eosinophils was 0.8% to 7.0%. The interval established in Indians was 0.0% to 12.4%. For hemoglobin, the proposed reference interval was 13.0 to 18.0 g/dL. The established reference interval was 11.9 to 16.4 g/dL. For routine chemistry parameters, the manufacturer’s proposed reference interval was verified for all parameters, except for total protein and serum urea nitrogen. Serum urea nitrogen was slightly lower in the Indian population.

Conclusions: Eosinophil percentages in healthy Indian men was significantly higher, possibly due to environmental factors. Hemoglobin and serum urea nitrogen levels were lower compared with other populations, possibly due to nutritional factors and the Indian physique. We are planning studies using larger samples to verify the same from different geographical areas within India.

Bronchioloalveolar Lung Circulating Tumor Cells Retain Cytomorphologic Features of Primary Tumor Type

(Poster No. 13)

Dena Marrinucci, BS1 ([email protected]); Kelly Bethel, MD2; Jennifer Fisher, MD3; Daniel Lazar, BS1; Madelyn Luttgen, BS1; Peter Kuhn, PhD.1 1Department of Cell Biology, The Scripps Research Institute, La Jolla, Calif; Departments of 2Pathology and 3Oncology, Scripps Clinic, La Jolla, Calif.

Circulating tumor cell (CTC) detection and characterization could provide a valuable tool for stratifying cancer patients and aiding with individualized treatment strategies. We study a nonsmoking 47- year-old woman who was diagnosed with stage IIIB non-small cell lung cancer in 2003. She was treated with chemoradiation and consolidative Taxotere, but the cancer recurred locally in January 2005, and the patient subsequently received multiple agents secondary to progression. In 2007, 67 CTCs were identified using an immunofluorescent staining protocol and fiberoptic array scanning technology and then stained with Wright-Giemsa. The CTCs are larger than surrounding white blood cells, often appear in clusters, and have low to moderate nuclear-cytoplasmic (N/C) ratios and a generous cytoplasmic domain (Figure 4). Compared with the cells of the patient’s original lung biopsy, which shows a well-differentiated bronchoalveolar carcinoma, the CTCs retain the morphologic features of large size in comparison to white blood cells and low N/C ratios with voluminous cytoplasm. The striking cytomorphologic difference between the CTCs in this patient with very well-differentiated adenocarcinoma, versus previously studied patients with less well- differentiated tumors of breast and colon, suggests that cytomorphologic features of primary tumors are retained when cells enter the bloodstream. The additional images demonstrate primary tumor and correlating CTC features in a breast cancer (cuboidal cells in tissue, round high N/C ratio cells in circulation), a colon cancer (columnar cells in tissue, elongated cells with eccentric cytoplasm in circulation), and this well-differentiated lung cancer (moderate to low N/C ratio cells in tissue, moderate to low N/C ratios in circulation).

Diffuse Large B-Cell Lymphoma With Aberrant T-Cell-Associated Antigen Expression

(Poster No. 14)

Archana M. Agarwal, MD ([email protected]); Jeremy Wallentine, MD; Kristi Smock, MD; David Bahler, MD, PhD; Sherrie Perkins, MD, PhD. Department of Pathology, University of Utah, Salt Lake City.

Diffuse large B-cell lymphoma (DLBL) is the most common type of non-Hodgkin lymphoma. Although, aberrant expression of T-cell- associated antigens (exclusive of CD5) on diffuse large B-cell lymphoma has been described in the literature, it is rare with few published reports. We describe 2 well-characterized cases of diffuse large B-cell lymphoma, 1 with aberrant coexpression of CD3 and the other showing aberrant expression of both CD2 and CD7. The literature of diffuse large B-cell lymphoma with aberrant T-cell- associated antigen expression was also reviewed. Case 1: A 9-year- old boy presented with a 2-month history of swelling in his left forearm. The left forearm biopsy showed a polymorphic background with scattered larger pleomorphic tumor cells. The tumor cells were positive for CD20, CD79a, PAX-5, and MUM-1 and also coexpressed CD3. Case 2: A 54-year-old woman presented with right inguinal lymphadenopathy. Immunohistochemical analysis on the paraffin sections revealed sheets of larger atypical cells positive for CD20, CD79a, and PAX-5 that also coexpressed CD2 and CD7. The expression of T-cell-associated antigens CD3, CD2, and CD7 by DLBL is important to recognize because it can greatly complicate diagnoses. To the best of our knowledge, CD3 expression by DLBL has not been previously reported in pediatric patients with DLBCLs. Although rare cases of B-cell lymphomas with expression of either CD2 or CD7 have been previously described, coexpression of both CD2 and CD7 by a DLBL also has not been previously described.

An Unusual Case of Acute Intravascular Hemolysis

(Poster No. 15)

Amanda C. Mullins, MD1 ([email protected]); Ted S. Strom, MD, PhD.2 1Department of Pathology, University of Tennessee-Memphis; 2Department of Pathology and Laboratory Medicine Service, Memphis VA Medical Center, Memphis, Tenn.

Hemolysis is a common problem in laboratory medicine and is a frequent cause of rejected specimens. The dilemma for pathologists lies in determining which case of hemolysis is in vitro and which is in vivo. The patient was a 53-year-old African American man with a medical history significant for end-stage renal disease on dialysis, hypertension, and hepatitis C. He presented from dialysis with a complaint of dull, substernal chest tightness, elevated blood pressure, and shortness of breath. Initial laboratory evaluation was hampered by severe, gross hemolysis of sampled blood. The results were remarkable for a total bilirubin level of 17.9 mg/dL, an aspartate aminotransferase level of 723 U/L, a hemoglobin level of 8.30 g/dL, a hematocrit concentration of 15.2%, and a lactate dehydrogenase level of 16 764 U/L. A direct antiglobulin test was negative. A peripheral smear was reviewed and showed moderate anisocytosis the red cell line with frequent polychromasia and occasional microspherocytes. No schistocytes, bite cells, or blister cells were seen. Leukocyte and platelet morphologies were unremarkable. Extensive evaluation the patient was negative for alternative sources of blood loss to account the precipitous drop in hematocrit concentration. This patient’s acute intravascular hemolysis was attributed to a kink and/or clot in a dialysis line. Acute intravascular hemolysis induced by a kink and/or clot in a hemodialysis machine is rare. It is distinguished from other causes mainly history. Recognition of this entity by pathologists may prevent extensive evaluation and unnecessary procedures. Primary Mucosa-Associated Lymphoid Tissue Lymphoma of the Breast With Localized Amyloidosis

(Poster No. 16)

Fadi Habib, MD ([email protected]); Koichi Maeda, MD. Department Clinical and Anatomic Pathology, Henry Ford Health System, Detroit, Mich.

Primary non-Hodgkin lymphoma of the breast is a rare disease; however, the association between mucosa-associated lymphoid tissue lymphoma with localized amyloidosis makes it exceptional. We report on a 72-year-old woman who presented to the surgery clinic for consultation after abnormal mammogram. The screen mammogram detected a 10-mm area of asymmetry in the left breast. An ultrasound-guided needle biopsy showed extramedullary plasmacytoma with amyloid deposition, and excisional biopsy was advised. Initial evaluation revealed proliferation of small neoplastic lymphocytes, plasmacytoid lymphocytes, and plasma cells with focal deposits of amyloid-like material (Figure 5). In immunohistochemical stains, the lymphoid infiltrate included areas in which CD20-positive/CD79a-positive B cells and VS38-positive plasma cells predominated and other areas in which CD3-positive/CD5-positive/CD43-positive T cells were more numerous. The B cells were CD20 positive, CD5 negative (with no CD20/ CD5 coexpression), CD43 negative, cyclin negative, and CD10 negative. The plasma cells were predominantly kappa positive, and the amyloid-like material was Congo red positive. A clonal IGH gene rearrangement/monoclonal B-cell population was detected by molecular analysis. Cytogenetic study was normal. Subsequent abdominal fat- pad biopsy was done to rule out systemic amyloidosis. Serum protein electrophoresis was normal; however, urine protein electrophoresis and immunofixation showed traces of free kappa light chain (

Synchronous Lymphoblastic Lymphoma and Chronic Eosinophilic Leukemia With FIP1L1-PDGFRA Gene Fusion and Deletion of CHIC2

(Poster No. 17)

Summer L. Bohman, MD ([email protected]); John H. Irlam, DO; Robert L. Booth, MD. Department of Pathology, University of Toledo, Toledo, Ohio.

The association of the CHIC2 deletion with FIP1L1-PDGFRA fusion and primary eosinophilic disorders has gained recent interest as a group of disorders that appear to respond favorably to imatinib. We present a patient with synchronous lymphoblastic lymphoma and chronic eosinophilic leukemia, both with the CHIC2 gene deletion. Peripheral blood smears with bone marrow and lymph node biopsies were evaluated to diagnose synchronous malignancies. Flow cytometry and TdT stain were used to confirm lymphoma. Both blood myeloid cells and lymph node were tested for CHIC2 deletion by fluorescence in situ hybridization. The peripheral blood showed a chronic increase of eosinophils, approximately 30%. The bone marrow was hypercellular. The patient had evidence of heart valve disease and no other cause for eosinophilia could be found. The lymph node revealed complete effacement by malignant cells, which by flow cytometry was of a population of abnormal T cells. These cells were strongly positive for TdT, consistent with lymphoblastic lymphoma. Both the blood sample and the lymph node were positive for the CHIC2 deletion. Reactive eosinophilia is a common finding with lymphoblastic lymphoma. The CHIC2 deletion in both lymphoma and myeloid cell lines indicates a stem cell origin of bilineal chronic eosinophilic leukemia and lymphoblastic lymphoma. The importance of identifying patients with this mutation lies in the high reported rate of molecular remissions following imatinib treatment, which targets an abnormal tyrosine kinase that is created by the FIP1L1- PDGFRA gene fusion. This may lead to a decreased morbidity and mortality in these patients with early identification and treatment.

Small Lymphocytic Lymphoma Developed in an Anaplastic Astrocytoma in the Brain

(Poster No. 18)

Xiaohong M. Zhang, MD, PhD ([email protected]). Department of Pathology, Geisinger Northeastern Medical Center, Wilkes-Barre, Pa.

Anaplastic astrocytoma is usually solitary. We report a case of a 72-year-old man with mixed tumors of anaplastic astrocytoma and small lymphocytic lymphoma in the brain. The patient had a history of B-cell chronic lymphocytic leukemia in peripheral blood with immunophenotypic features of positivity for CD19, CD20 (weak), coexpressing CD5 and CD23 with kappa light-chain restriction by flow cytometry study. He was treated with Fludarabine and Rituxan twice. He developed moderate to severe headaches and unstable gait. A computed tomography scan of the brain showed a 7.7 x 5.3-cm mass with enhancing area in the right temporal lobe. Physical examination revealed neither peripheral lymphadenopathy nor hepatosplenomegaly. Neurologic examination showed equal pupils reactive to light and normal motor strength of all muscles. Laboratory tests revealed a white blood cell count of 15 810/[mu]L with 94% lymphocytes. Temporal craniotomy was performed. The specimen revealed an anaplastic astrocytoma admixed with small lymphocytic lymphoma (Figure 6). The anaplastic astrocytoma showed marked nuclear atypia and some mitotic activity, but no necrosis or microvascular glomerulus. Small lymphocytic lymphoma had monotonous small lymphocytes with mature chromatin. Immunostains revealed astrocytoma positive for glial fibrillary acidic protein and small lymphocytic lymphoma positive for CD79a, CD5, and CD23. CD20 expression was weak. No other site of lymphoma was noted after careful examination. The patient recovered from craniotomy. To our knowledge, this finding has not been previously reported. This case demonstrates small lymphocytic lymphoma developed in an anaplastic astrocytoma and provides the evidence of brain histopathology in this rare situation.

A Collision Tumor: Central Nervous System B-Cell Lymphoma and Anaplastic Astrocytoma

(Poster No. 19)

Kun Ru, MD, PhD ([email protected]); Cufeng Pu, MD, PhD; Katherine Jasnosz, MD; Jan Silverman, MD; Shahid Bokhari, MD. Department of Pathology, Allegheny General Hospital, Pittsburgh, Pa.

Second malignancies are relatively common among long-term survivors following chemotherapy or radiation for the primary neoplasm. However, central nervous system (CNS) collision tumors in immune competent patients are extremely rare. We report a CNS collision tumor consisting of a primary CNS B-cell lymphoma and an anaplastic astrocytoma in a 29-year-old man without any significant medical history. The patient presented with a 4-week history of headaches, altered mental status, nausea, and vomiting. A computed tomography scan revealed a complex mass with surrounding edema at the left parietal lobe. Microscopically, the tumor showed 2 distinct histologic patterns. The predominant component consisted of anaplastic astrocytoma with gemistocytic appearance in the background of numerous lymphocytes. Multiple foci of perivascular lymphocytic aggregates were present, including many small lymphocytes with scattered large atypical cells. Immunostains highlighted that the large cells were CD20-positive B cells with a high proliferation index. In situ hybridization demonstrated that the neoplastic cells were kappa restricted and Epstein-Barr virus positive, and molecular studies showed a clonal rearranged immunoglobulin gene. After the surgery and 5 cycles of methotrexate therapy, the patient is neurologically asymptomatic. The positive Epstein-Barr virus favors a virus-driven process in terms of the tumorigenesis. The diagnostic challenge in this case is the differential diagnosis between the reactive lymphocytes surrounding an existing glioma versus a lymphoproliferative disorder. We believe this is the first report of a simultaneous CNS collision tumor consisting of a primary CNS lymphoma and an anaplastic astrocytoma.

Precursor T-Lymphoblastic Lymphoma With Coexpression of T- and B- Cell Antigens: A Very Rare Occurrence

(Poster No. 20)

Christopher Dadisman, MD ([email protected]); RobertW. Allan, MD. Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville.

Precursor T-lymphoblastic lymphomas often express aberrant myeloid markers, in particular CD13, CD33, and less frequently C- kit. The aberrant expression of markers of B-cell lineage by these tumors is extremely unusual and would make diagnosis difficult. We report a case of a precursor T-lymphoblastic lymphoma that aberrantly expressed the B-cell marker CD19 by flow cytometry and CD79a by immunohistochemistry. The patient was a 13-year-old girl who presented with cervical lymphadenopathy. A lymph node biopsy revealed an effaced lymph node composed of small cells with immature chromatin and scant cytoplasm. Flow cytometry was performed, which showed a homogenous blast population with a precursor T-cell phenotype: CD3^sup +^, CD2 dimly^sup +^, CD7^sup +^, CD5^sup +^, CD34^sup +^, CD33^sup +^, C-kit^sup +^, CD45 moderately^sup +^, CD56^sup +^, TdT^sup +^, myeloperoxidase^sup -^, CD1a^sup -^, and CD10^sup -^. The tumor aberrantly expressed surface CD19 and CD22 dimly (Figure 7). Immunohistochemical stains were positive for CD79a and negative for Oct-2. The bone marrow and peripheral blood were negative for leukemia. According to the European Group for the Immunological Characterization of Leukemias criteria, the case met criteria for biphenotypic leukemia based on the expression of CD19 and CD79a, although the latter is not infrequently observed in precursor Tlymphoblastic neoplasms. She was treated for precursor T- lymphoblastic lymphoma with vincristine, daunorubicin, prednisone, and asparaginase and maintenance 6-mercaptopurine. One year later she is in complete remission. In summary, we report a very rare lymphoblastic lymphoma with coexpression of T-cell and B-cell antigens, which highlights the lineage ambiguity that may occur in these neoplasms. Biphenotypic Acute Leukemia in a Patient With Waldenstrom Macroglobulinemia After Long-Term Treatment With Chlorambucil

(Poster No. 21)

Mikako Warren, MD1; Stacey A. Honda, MD, PhD2; Jane H. Uyehara- Lock, MD2 ([email protected]). 1Department of Pathology, University of Hawaii Residency Program, Honolulu; 2Department of Pathology, Kaiser Moanalua Medical Center and University of Hawaii, John A. Burns School of Medicine, Honolulu.

Waldenstrom macroglobulinemia is a rare malignant lymphoproliferative disorder with immunoglobulin M monoclonal gammopathy. Chlorambucil, an alkylating agent, is commonly used to treat Waldenstrom macroglobulinemia; however, like other alkylating agents, there is a risk to the patient of developing myelodysplastic syndrome or in rare cases leukemia. We report the first case of a 75- year-old man who developed biphenotypic acute leukemia after 4 1/2 years of treatment with chlorambucil for Waldenstrom macroglobulinemia. After 4 1/2 years of treatment with chlorambucil, this 75-year-old patient presented with fever, weakness, and respiratory infection. His fever workup revealed a white blood cell count of 4300/[mu]L, with a differential showing 46% poorly differentiated cells and 12% blasts. A bone marrow biopsy revealed a hypercellular marrow consistent with acute leukemia and residual lymphoplasmacytic infiltrate. The flow cytometric analysis was characteristic of a biphenotypic acute leukemia with residual lymphoplasmacytic lymphoma. It is unclear if the biphenotypic leukemia developed as a result of chlorambucil treatment or if this case represents de novo formation of leukemia in Waldenstrom macroglobulinemia.

Ceftriaxone-Induced Hemolysis: A Case Report of a Rare But Potentially Fatal Complication

(Poster No. 22)

Syed T. Hoda, MD ([email protected]). Department of Pathology, North Shore-Long Island Jewish Medical Center, New Hyde Park, NY.

Cephalosporins are among the most widely used antibiotics in the hospital setting. Considering the number of patients given antibiotics such as ceftriaxone, severe complications resulting from these antibiotics are a rare event. A 6-year-old girl was admitted to the emergency department with fever and was positive for methicillin-resistant Staphylococcus aureus. She was subsequently being treated for methicillin-resistant S aureus with ceftriaxone. Twenty-four hours after the ceftriaxone was started and then discontinued, the patient experienced a large decrease in hemoglobin and hematocrit levels. Within 24 hours, the patient’s hemoglobin/ hematocrit levels went from 10.3/32.6 to an extremely low 1.3/4.3. A direct Coombs test was positive for C3d complement activity. A sample of blood from the severely anemic test was sent for antibody analysis. The results showed a positive antibody response to ceftriaxone on the red blood cells from this sample. This positive finding may have contributed to the low hemoglobin/hematocrit levels found in the patient’s laboratory test results. Autopsy findings also documented cardiopulmonary anomalies in this patient. A literature search indicated that there are fewer than 40 known and documented cases of ceftriaxone-induced hemolysis. The positive antibodies to ceftriaxone found in this patient’s blood make this antibiotic a very likely contributor to her death. If severe structural and congenital anomalies are combined with a severely traumatic drug-associated hemolytic reaction, as witnessed in this case, it is difficult to conceive of a good patient prognosis. Drug- induced hemolysis is a severe complication and should be considered when there is evidence of a rapid hemolytic reaction.

Acquired Expression of CD56 in Recurrent Diffuse Large B-Cell Lymphoma

(Poster No. 23)

Emily C. Maambo, MD ([email protected]); Frank X. Zhao, MD; Christine McMahon, MD. Department of Anatomic Pathology, University of Maryland Medical Center, Baltimore.

Context: CD56, or neural cell adhesion molecule, plays a primary role in the regulation of homophilic interactions between neurons and muscle. It is also commonly expressed on the surface of natural killer cells. It is regarded as a poor prognostic marker in plasma cell myeloma and anaplastic large T-cell lymphomas. However, CD56 is usually negative in diffuse large B-cell lymphomas (DLBCL). Only 4 cases of CD56-positive DLBCL have been reported in the English literature. We identified a case of recurrent DLBCL that acquired CD56 expression in the second recurrence.

Design: To evaluate the relationship between the aberrant CD56 expression and the recurrence of DLBCL, we analyzed all the DLBCLs diagnosed at the University of Maryland Medical Center from 2004 to February 2008 (44 primary and 5 recurrent DLBCLs) using immunohistochemistry for CD56.

Results: Our study showed that CD56 expression was only detected in the second recurrent DLBCL sample of our index case. In addition, p53 was also positive in both the first and second recurrent biopsy samples for our index case.

Conclusions: We conclude that CD56 expression is rare in both the primary and possibly recurrent DLBCL. Because CD56 was acquired during the second recurrence of this DLBCL, it may play a role in the progression of DLBCL. In addition, the relationship between CD56 and p53 expression deserves further investigation in recurrent DLBCL.

A Case of True Thymic Hyperplasia Associated With Graves Disease

(Poster No. 24)

John J. Nelson, MD, MPH ([email protected]); Jacek M. Polski, MD. Department of Pathology, University of South Alabama, Mobile.

Mass lesions in the mediastinum are clinically worrisome and often of neoplastic origin; they include lymphoma, thymoma, and germ cell tumors. Thymic hyperplasia is not common but sometimes presents with a mediastinal mass. Thymic hyperplasia can involve normal thymic tissue (true thymic hyperplasia) or lymphoid follicles (follicular hyperplasia). Thymic hyperplasia is often associated with autoimmune phenomena, and the association of follicular thymic hyperplasia with myasthenia gravis is well known. Association of symptomatic true thymic hyperplasia with Graves disease has been reported only in rare case reports. We describe a single case report of true thymic hyperplasia associated with Graves disease. A 40- year-old white man presented with 4 days of difficult breathing. He reported a 20-lb weight loss during the last 6 months. Chest radiographs showed an enlarged cardiac silhouette. Computed tomography scan of the chest showed an anterior mediastinal mass adherent to the pericardium. The patient underwent excision of the mass. Postoperative laboratory workup documented Graves disease. The mass measured 11.5 x 7.0 x 2.0 cm and weighed 73 g. The microscopic examination showed thymic tissue with preservation of cortex and medulla with often enlarged Hassall corpuscles. This case illustrates an association of symptomatic true thymic hyperplasia with Graves disease. In most cases of Graves disease, the thymic hyperplasia is minimal and reversible on treatment. This reversible consequence of Graves disease should not be overlooked in the differential diagnosis, because we have the ability to treat the patient medically and to avoid sometimes unnecessary surgical intervention.

Extent of Bone Marrow Hemophagocytosis in Hemophagocytic Lymphohistiocytosis

(Poster No. 25)

Suman Goel, MD, MPH1 ([email protected]); Hamayun Imran,MD2; Jacek M. Polski, MD.1 Departments of 1Pathology and 2Pediatrics, University of South Alabama, Mobile.

Context: Hemophagocytic lymphohistiocytosis (HLH) is a rare and potentially fatal disease characterized by abnormal activation of immune system T lymphocytes and macrophages leading to hemophagocytosis. Currently, the diagnosis of HLH can be established based on a family history of HLH and/or evidence of genetic defects or by satisfying 5 of 8 clinicopathologic criteria. This case- control study aims to examine the extent of hemophagocytosis in the bone marrow examinations of patients satisfying diagnostic criteria for HLH.

Design: Hemophagocytosis in 6 bone marrow aspirates from 3 patients satisfying criteria for HLH was compared with 20 random bone marrow controls. Macrophages with hemophagocytosis were counted in fields containing approximately 9000 nucleated cells by 2 authors using a Miller disc. Unpaired t test was used for statistical analysis.

Results: Mean hemophagocytosis count in the HLH cases was estimated at 0.081717% (range, 0%-0.31%), whereas in the controls the mean hemophagocytosis count was 0.00855% (range, 0%-0.04%). The difference was statistically significant (P = .01). However, there was a large overlap between HLH and control groups.

Conclusions: This study documents that rare hemophagocytosis can be seen in random bone marrow aspirates without clinical diagnosis of HLH. Although the hemophagocytosis counts are significantly higher in HLH than controls, overlap of the counts precludes diagnosis of HLH by morphology alone. This supports the clinical practice of relying on many clinicopathologic criteria. Further studies in different populations are needed to understand the impact of this study. Pure Red Cell Aplasia in HIV/AIDS Spontaneously Remits After Intravenous Immunoglobulin Therapy

(Poster No. 26)

Cleve O. James, PhD1; Payam Arya, MD2 ([email protected]); Lekidelu Taddesse-Heath, MD2; Amy Sitapati, MD1; Wanghai Zhang, MD.2 Departments of 1Internal Medicine and 2Pathology, Howard University Hospital, Washington, DC.

We present a 37-year-old man with HIV/AIDS and a 3-month history of anemia that is refractory to treatment with erythropoietin, iron, and multiple blood transfusions. Complete blood count showed a hemoglobin level of 4.1 g/dL with normal white blood cells, platelets, and mean corpuscular volume. Bone marrow biopsy and aspirate smear revealed markedly hypercellular marrow with nearly 100% cellularity, a myeloid-erythroid ratio greater than 20:1, and marked erythroid hypoplasia with rare erythroid precursors and mature forms. The myeloid and megakaryocytic series were progressively maturing. Evidence of parvovirus infection was not appreciated. The special stains showed adequate iron stores and normal reticulin fiber pattern. On bone marrow analysis, the patient was diagnosed with pure red cell aplasia, a rare variant of aplastic anemia in which erythroid precursors and reticulocytes are selectively absent from the bone marrow but all other cell lineages are functionally present. Pure red cell aplasia has an autoimmune basis in most cases. It is typically treated with corticosteroids or immunosuppressive or cytotoxic drugs. However, treatment with intravenous immunoglobulin therapy represents an attractive alternative because it enhances protection against opportunistic infections without suppressing the host’s immune system, and this function is desirable in patients with HIV/AIDS. Intravenous immunoglobulin therapy resulted in an amazing resolution of the anemia and its symptoms within 2 weeks of administration, including amplification of erythroid precursors and metamyelocyte numbers and a marked increase in reticulocyte count by 1 log unit. As late as 1 month after intravenous immunoglobulin therapy, the patient’s complete blood counts were within reference range.

Diffuse Follicle Center Lymphomas

(Poster No. 27)

Kelly N. Mizell, MD ([email protected]); John J. Nelson, MD, MPH; Jacek M. Polski, MD. Department of Pathology, University of South Alabama, Mobile.

Follicular lymphoma is one of the most common non-Hodgkin lymphomas. Follicular lymphomas typically involve lymph nodes, have a nodular growth pattern, and are composed of centrocytes and centroblasts. However, rare cases of lymphomas derived from centrocytes and centroblasts have a diffuse pattern. Such cases are designated as diffuse follicle center lymphoma (DFCL) in the World Health Organization classification. We report 3 cases of DFCL that were recently diagnosed at our institution. The patients’ ages ranged from 57 to 83 years. Two patients had orbital masses. One had a spinal tumor with meningeal involvement. The orbital biopsies were small, ranging from 0.6 to 1.5 cm. The spinal tumor resection specimen was relatively large. All cases had involvement of fibrous tissue by a dense lymphoid infiltrate composed of small, variably irregular lymphocytes. The process was diffuse in all cases. Variable numbers of preserved germinal centers were seen in both orbital mass biopsies. The lymphoma cells were positive for CD10, CD20, and Bcl-2 in all cases by flow cytometry or immunoperoxidase stains. Fluorescence in situ hybridization performed on the 2 orbital biopsies and polymerase chain reaction performed on the spinal tumor indicated the presence of BCL2 rearrangements. This small series documents that DFCL can be encountered in extranodal sites, especially in the orbit. DFCL is rare but should be considered in the differential diagnosis when dealing with lymphoid infiltrates in soft tissue. The diffuse nature of these lymphomas makes them a diagnostic challenge. Close attention to the immunophenotype and molecular findings helps to confirm the diagnosis of DFCL.

Evaluation of Peripheral Blood Flow Cytometry as a Screening Tool for Non-Hodgkin Lymphoma

(Poster No. 28)

Tonialatoya Eley, MD ([email protected]); Mohammad Alsawah, MD; Jozef Malysz, MD; Vonda Douglas-Nikitin, MD. Department of Clinical Pathology, William Beaumont Hospital, Royal Oak, Mich.

Context: Peripheral blood flow cytometry (PBFC) is an ancillary tool that is of great utility in the diagnosis of non-Hodgkin lymphoma (NHL). However, its use to randomly screen for NHL is often misunderstood. Recommended guidelines for PBFC in screening for NHL have been published, but they are often not observed. We examined the indications for PBFC ordered at our institution to assess their rate of positivity in detecting NHL.

Design: We reviewed 605 PBFC samples analyzed from January to December 2007 using a standard lymphoma panel and recorded the following: indication for PBFC, sex, age, ordering physician, PBFC diagnosis, previous diagnosis, biopsy findings, radiology, complete blood count parameters, and peripheral smear review. The percentage of cases with positive PBFC findings was recorded for each indication and was subdivided in the Table.

Results: A positive result was either a monoclonal B-cell population or an aberrant B-, T-, or NK-cell population. See the Table for the most common reasons for PBFC requests. Overall, 25% of the 605 cases were positive. Eighty-four percent of all cases had accepted medical indications; of these, 26% were positive. Twenty- eight percent of cases had nonaccepted indications; of these, 13% were positive. The highest percentages of positive cases were seen with the accepted medical indications.

Conclusions: Accepted medical indications for PBFC produced the highest yield for diagnoses of NHL. Conversely, the nonaccepted indications yielded a low rate of positive results. Considering the cost of flow cytometric testing, this study confirmed the use of the recommended paradigm of decision making for ordering PBFC.

Histiocytic Sarcoma

(Poster No. 29)

Fadi Habib, MD ([email protected]); Osama Alassi, MD. Department of Clinical and Anatomic Pathology, Henry Ford Health System, Detroit, Mich.

Histiocytic sarcoma is rare neoplasm characterized by malignant proliferation of cells showing morphologic and immunophenotypic features similar to mature tissue histiocytes. A 76-year-old woman presented with a left groin expansile mass. Magnetic resonance imaging of the abdomen and positron emission tomography scan showed hypermetabolic mediastinal masses encasing the thoracic and descending aorta, as well as masses in both adrenal glands, liver, pancreatic head, and along the left anterior pelvis soft tissues. Left groin mass biopsy revealed epithelioid cells with abundant delicate cytoplasm and foci of spindling. The cells showed malignant nuclear features with frequent mitotic figures, including abnormal forms (Figure 8). Foci of coagulative necrosis were seen. The tumor was positive for vimentin, CD163, and CD10, focally positive for CD68 (KP1), and negative for epithelial markers (keratin cocktail, epithelial membrane antigen, cytokeratin [CK] 7, CK20, CAM 5.2, and CK5/6), muscle markers (myogenin, desmin, and smooth muscle actin), hematolymphoid markers (leukocyte common antigen, BerH2, myeloperoxidase, CD1a, CD21, CD34, and ALK-1), melanocytic markers (S100 and HMB-45), and for mammoglobin and C-kit. T- and B-cell gene rearrangements were negative. The patient was not a candidate for aggressive chemotherapy, and palliative treatment was started. The patient died 6 weeks after the diagnosis. The pathologic diagnosis of histiocytic sarcoma is often challenging and requires histologic, immunohistochemical, andmolecular studies. In our case, we reached the diagnosis of histiocytic sarcoma based on the exclusion of other sarcomas and carcinomas including other members of the histiocytic sarcoma/dendritic cell sarcoma group.

Histopathologic Characterization of 11 Cases of Primary Breast Marginal Zone Lymphoma

(Poster No. 30)

Mohamed E. Salama, MD1 ([email protected]); Jonathan L. Hecht, MD, PhD2; SaWang, MD3; Monika Pilichowska,MD4; Rajan M. Mariappan, MD, PhD.2 1Department of Pathology, University of Utah/ ARUP, Salt Lake City; 2Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Mass; 3Department of Pathology, University of Massachusetts Medical School, Worcester; 4Department of Pathology, Tufts-New England Medical Center, Boston, Mass.

Context: Our independently performed previous studies support the notion that primary breast lymphoma (PBL) is a distinct entity. One subtype, marginal zone lymphoma (MZL), occurring primarily or exclusively in the breast, has interesting features such as bilaterality (2/7 cases in the Stanford series). An in-depth morphologic study of PBL-MZL is lacking.

Design: We morphologically and phenotypically characterized 11 cases of PBL-MZL. Lymphoma involving skin overlying breast was excluded. Lymphoma exclusively involving intramammary nodes was included. Diagnostic criteria included B-cell lymphoproliferation with predominantly small lymphocytes with marginal zone differentiation including monocytoid features and cytoplasmic clearing. All cases were CD5/CD10 negative. Parameters evaluated included presence of nodal versus extranodal disease, architectural patterns, and epithelial involvement versus parenchymal involvement. Cases with epithelial involvement were evaluated for ductal or lobular epithelial involvement. Information regarding demographics and antigenic profile were collected from patient charts. Results: This study included 1 man and 10 women. Age ranged from 31 to 78 years (mean, 59.2 years). Morphologic features identified were as follows: PBL-MZL is predominantly an extranodal disease with only 2 of 11 cases primarily intramammary nodal MZL. Lymphoepithelial lesions were seen in 5 of 11 cases. All 5 cases with epithelial involvement were predominantly terminal ductal-centric. Most cases involved atrophic breast tissue. CD43 immunohistochemical staining was performed on 4 of 11 cases, and coexpression was noted in 3 (75%).

Conclusions: PBL-MZL, unlike ocular or MALT type MZL, is mainly a parenchymal disease. Epithelial involvement, when present, is predominantly around terminal ducts with lymphoepithelial lesions. CD43 is frequently coexpressed.

Relapsed Acute Myelogenous Leukemia Presenting as Histiocytic Sarcoma

(Poster No. 31)

Phillip E. Starshak, MD1 ([email protected]); Carol Richman, MD1; Maxwell Fung, MD1; Kavita S. Reddy, MD2; Denis Dwyre, MD.1 1Department of Pathology, University of California Davis Medical Center, Sacramento; 2Department of Molecular Pathology, Genzyme Genetics, New York, NY.

Histiocytic sarcoma is a rare malignancy with a poor prognosis and presents as nodal or extranodal tumors with a predilection for the skin and gastrointestinal tract. These tumors are of histiocytic origin with only a few case reports documenting an association with acute myelogenous leukemia (AML). We report a case of a 33-year-old woman who presented 2 years prior with AML with monocytic antigen expression and a rearrangement involving the MLL gene (11q23). The patient was treated with multiagent chemotherapy followed by stem cell transplant from a male sibling. After 18 months of clinical remission, the patient presented with multiple subcutaneous nodules. Hematoxylin-eosin-stained slides of the nodules along with immunohistochemical stains were consistent with histiocytic sarcoma. Fluorescence in situ hybridization using a MLL breakapart probe (Abbott Molecular Inc) and a Y probe on paraffin-embedded tissue showed a MLL gene rearrangement with absence of a Y signal in ~78% of interphases and normal MLL signals with the presence of a Y signal in ~20% of interphases. Cytogenetics confirmed these findings (46,XX with MLL rearrangement). Concurrent bone marrow biopsy showed no evidence of relapse by histologic and flow cytometry analysis. Cytogenetics of the bone marrow was 46,XY (100% donor origin). This represents a unique case of relapsed AML presenting solely as histiocytic sarcoma. It suggests that leukemic stem cells survive in microenvironments outside the bone marrow. The presence of a MLL rearrangement in both the acute monoblastic leukemia and subsequent histiocytic sarcoma provided the evolutionary link.

CD5^sup -^/CD23^sup +^ Primary Splenic Mantle Cell Lymphoma: A Mimic of Splenic Marginal Zone Lymphoma

(Poster No. 32)

John M. Childs, MD ([email protected]); Elizabeth N. Pavlisko, MD; Barbara K. Goodman, PhD; Anand S. Lagoo, MD, PhD. Department of Pathology, Duke University Medical Center, Durham, NC.

Primary splenic mantle cell lymphoma is uncommon and the characteristic CD5^sup +^/CD23^sup -^ immunophenotype of mantle cell lymphoma is usually present. We report a case of a CD5^sup -^/ CD23^sup +^ splenic mantle cell lymphoma in a 54-year-old man who presented with epigastric pain and massive splenomegaly. A computed tomography scan showed minimal abdominal and retroperitoneal lymphadenopathy. His blood count was significant for anemia and thrombocytopenia. Flow cytometric immunophenotyping of peripheral blood demonstrated a kappa-restricted monoclonal B-cell population constituting 14% of total white cells that expressed CD19, CD20, CD22, CD25 (dim), and CD23, but did not express CD5, CD10, or CD103. A bone marrow biopsy showed 10% involvement by an immunophenotypically similar process. The primary differential diagnosis was splenic marginal zone lymphoma, and subsequently splenectomy was performed for confirmation. The spleen revealed white pulp expansion by monocytoid B cells with an immunophenotype similar to that in the blood and marrow, leading to a diagnosis of splenic marginal zone lymphoma. Subsequent single agent treatment with Fludarabine for worsening lymphadenopathy was followed by pancytopenia. A repeat bone marrow biopsy found extensive involvement by lymphoma, raising doubts about the initial diagnosis. A cyclin D1 stain was performed on the marrow and was found to be positive. The lymphoma in the splenectomy specimen also proved to be cyclin D1 positive. Despite additional treatment, the patient died approximately 14 months after diagnosis. CD5-negative primary splenic mantle cell lymphoma can closely mimic splenic marginal zone lymphoma and pose a significant diagnostic challenge.

C-myc Gene Rearrangement in a Case of B-Cell Lymphoproliferative Disorder With Prolymphocytic Morphology

(Poster No. 33)

Shourong Zhao, MD1 ([email protected]); Phillip Cason, MT(ASCP)1; Andrew Pippas, MD.2 Departments of 1Pathology and 2Medical Oncology, Columbus Regional Healthcare System, Columbus, Ga.

A 55-year-old man presented with fatigue, headaches, nausea, and gingival bleeding. His complete blood cell count showed a white blood cell count of 205 000/[mu]L, a platelet count of 79 103/ [mu]L, and a hemoglobin level of 11.3 g/dL. His examination revealed enlarged peripheral adenopathy and dramatic splenomegaly. Peripheral blood smear demonstrated increased medium-sized lymphocytes with open nuclear chromatin, prominent nucleoli, and abundant basophilic cytoplasm. Themorphologic features were consistent with prolymphocytes. Bone marrow bi

CareView Communications, Inc. Announces Success of SouthCrest Hospital Deployment

CareView Communications, Inc. (“CareView” or the “Company”) (Pink Sheets:CRVW), an information technology provider to the healthcare industry, announced today the successful deployment of the CareView System(TM) at SouthCrest Hospital, a 180-bed hospital and #1 provider of coronary interventional procedures and cardiac surgery, maternity and general healthcare services in Tulsa, Oklahoma.

The CareView System(TM) is a suite of products that brings the information technology of the 21st century directly to patients, families and healthcare providers by connecting them through one easy-to-install and simple-to-use system. SouthCrest Hospital is now able to provide:

— Doctors, nurses and other healthcare providers with the ability to efficiently and cost-effectively monitor, treat and visit their patients.

— Family members and friends with the ability to use the Internet to monitor, visit and correspond with their loved ones in SouthCrest.

— Patients and their visitors with direct access to on-demand high-speed Internet and first run movies in their rooms.

— The ability to implement audit tools to insure that quality standards are being met and safety measures are being complied with, while both are used to further educate caregivers to continually enhance quality and safety.

“The CareView System allows our nurses to visually monitor patients in their rooms every minute of every day which improves patient care and ultimately provides an even safer hospital environment. In addition to providing patients with Internet access, they can also have their family and friends for a video visit and watch first run movies in their rooms. So, if a grandparent is in the hospital, family members out-of-state can view the patient in their room and talk with them via the CareView system. Family members and even our soldiers overseas have the ability to view new infants via BabyView. With this system, patients have complete control over when the camera in their room is on and can turn it off at any time,” said Tony Young, President and CEO of SouthCrest Hospital.

“We are proud to be a part of the SouthCrest team and are extremely excited to make today’s announcement. This deployment not only expands our network, but it gives us the continuing privilege to work with the dedicated healthcare professionals at SouthCrest who are the first to promote improvements in the care, safety and environment of their patients,” stated Samuel A. Greco, CareView’s CEO.

Governor Tommy G. Thompson, the Company’s Chairman of the Board and former Secretary of Health and Human Services stated, “I have long been a staunch advocate of improving technology in our hospitals and SouthCrest is a leader in bringing the healthcare industry into the Information Age.”

About CareView Communications, Inc.

CareView has created a proprietary high-speed data network system that may be deployed throughout a healthcare facility using the existing cable television infrastructure. This network supports CareView’s Room Control Platform (RCP) and complementary suite of software applications designed to streamline workflow and improve value-added services offered to customers. Real-time bedside monitoring and point-of-care video monitoring and recording improve efficiency while limiting liability, and entertainment packages and education enhance quality of stay. This technology may also act as an interface gateway for other software systems and medical devices moving forward. CareView is dedicated to working with all types of hospitals, nursing homes, adult living centers and selected outpatient care facilities domestically and internationally.

Corporate offices are located at 5000 Legacy Drive, Suite 470, Plano, TX 75024. Questions may be directed to John R. Bailey, Chief Financial Officer at (972) 943-6044. More information about the Company is available on the Company’s website at www.care-view.com.

This press release shall not constitute an offer to sell or a solicitation of an offer to buy securities of CareView Communications, Inc. Certain statements in this release and other written or oral statements made by or on behalf of the Company are “forward looking statements” within the meaning of the federal securities laws. Statements regarding future events and developments and our future performance, as well as management’s expectations, beliefs, plans, estimates or projections relating to the future are forward-looking statements within the meaning of these laws. The forward-looking statements are subject to a number of risks and uncertainties including market acceptance of the Company’s services and projects and the Company’s continued access to capital and other risks and uncertainties. The actual results the Company achieves may differ materially from any forward-looking statements due to such risks and uncertainties. These statements are based on our current expectations and speak only as of the date of such statements. The Company undertakes no obligation to publicly update or revise any forward-looking statement, whether as a result of future events, new information or otherwise.