The little pool in my backyard is busier than the Atlanta airport. In the late afternoon, bumblebee bombers are landing and taking off four and five at a time. Their landings are not quite touch and go. They seem to be tanking up. They rest on the water just long enough for a drink.

They are showing remarkable traits, and raising more questions than they answer.

It is urban legend that bumblebees cannot fly – a legend disproved by the obvious evidence. Nevertheless, it is true that bumblebees do not have the characteristics we normally connect to aerodynamic flight.

They seem large for their wings – somewhat like a small stone with cobwebs. They are not sleek, but covered with hairs and dragging pollen buckets on their legs. They do not seem very hydrodynamic either. Their fat little bodies look as if they should immediately sink when touching the water.

A close look reveals they are relying on surface tension to rest lightly on the water surface, denting it, but not breaking through the outer layers of water molecules enough to sink.

Upon takeoff, they seem to fly up nearly vertically, with no taxiing and no smooth, flat climb.

They can fly faster than a person can run. Recently, scientists have begun to understand more about bumblebee flight.

Bumblebee wings (two pair, lightly attached in sets on each side) are rather rigid on the leading edge, but with very flexible surfaces and trailing edges. In this, they are rather like costumer wings for kindergarten butterflies – a stick or wire with cloth attached.

Bumblebees rely on their wings for lift and propulsion, unlike modern fixed-wing aircraft. The motion of the wings is rather subtle: out, twist and return. The result is to generate vortexes in the air in a way that provides lift, thrust and directional control.

Some scientists have studied this motion by attaching small slivers of mirror to bumblebees and tracking their motion with laser light.

Military scientists are interested in this peculiar style of flight, because small insect-size robotic fliers have military uses for observation.

Bumblebee landings on water raise some questions I need to answer with further study. Do bumblebees drink from ponds and streams regularly? Is this just a dry weather and drought phenomenon?

Would bumblebees normally get enough moisture from the flowers whose nectar they harvest? Are the flowers too dry to provide enough moisture?

How curious it is that in a bumblebee hive, all the bees except the queen die off in the winter. In the spring, the queen lays eggs and begins a new hive.

Virginia’s science Standards of Learning encourage students to apply scientific concepts, skills, and processes to everyday experiences (Goal 4) and to develop scientific dispositions and habits of mind including curiosity. The study of animal behavior and habitat begins in first grade (1.7) and continues in 2.7, 3.4, and higher grades.

On the Web

Bumblebee facts: www.bumblebee.org/

Plight of the Bumblebee:

http://science.the-environmentalist.org/2007/10/plight-of-bumble- bee.html

Bumblebees around the house: http://hgic.clemson.edu/factsheets/ hgic2500.htm

Bumblebee flight research: www.physorg.com/news89459870.html

Walter R.T. Witschey is professor of anthropology and science education at Longwood University.

ILLUSTRATION: PHOTO

MEMO: SCI-KIDS

Originally published by WITSCHEY; SPECIAL CORRESPONDENT.

(c) 2008 Richmond Times – Dispatch. Provided by ProQuest LLC. All rights Reserved.

By Day, Matthew

doi: 10.1017/S0009640708000863 Monkey Trials and Gorilla Sermons: Evolution and Christianity from Darwin to Intelligent Design. By Peter Bowler. New Histories of Science, Technology, and Medicine. Cambridge, Mass.: Harvard University Press, 2007. x + 258 pp. $24.95 cloth. Rummaging around for a title to his now-classic study of the religious movements that rocked central and western New York state during the first half of the nineteenth century, Whitney Cross decided that he could do no better than to lean on Charles Grandison Finney. These territories represented a burned-over district, he concluded, a land exhausted by decades of religious fervor and creativity.

Almost a century and a half has passed since the publication of Origin of Species, and in many ways the historiography of religious responses to Darwin’s “dangerous idea” represents another kind of bumed-over district. The tales of how Christian communities have assimilated, resisted, or ignored Darwinian evolution have been told so often and by so many different parties that one might be excused for doubting that there is much left to say about the matter. Because of this, I don’t believe it is a criticism of Peter Bowler’s latest book to observe that while it occasionally gestures toward new terrain-such as the counter-cultural ties that bind Scientific Creationism and Immanuel Velikovsky’s work on the veracity of ancient myths (205-208)-it never quite breaks new ground. Nevertheless, because Bowler knows the features of this landscape so well, Monkey Trials and Gorilla Sermons is a notable achievement.

The book’s structure is admirably clear and efficient. Chapter 1 (“The Myths of History”) offers a survey of the key historical developments with an eye toward undermining the passe notion that religion and science are ineluctably at war. Chapter 2 (“Setting the Scene”) explores the intellectual trends that prepared the way for Darwin’s theoretical innovations, including very useful discussions of Robert Chambers, Jean-Baptiste Lamarck, and William Paley. Chapter 3 (“Darwin and His Bulldog”) examines the structure of Darwin’s evolutionary gambit, the philosophical ambitions of the firstgeneration “Darwinians,” and the liberal Protestant willingness to see divine purpose in evolutionary progress. Chapter 4 (“The Eclipse of Darwinism”) analyzes the apparent collapse of Darwinian selection theory during the early days of the “genetical” revolution and the liberal Christian embrace of nonmaterialist models of evolution. Chapter 5 (“Modern Debates”) argues that appreciating the historical complexity of the engagement between Christianity and evolutionary theory necessarily undermines the rhetorical simplicity of both hard-line Darwinians who belittle religious people and unrepentant creationists who ridicule scientists.

As one might gather from this brief outline, Monkey Trials and Gorilla Sermons does not set out to radically re-imagine the historical contours of the continuing struggle over evolution. Yet, because it assembles the crucial figures and events in an easily accessible and wonderfully economical package, the book is exceptionally well-crafted for its intended general authence. Indeed, reading Bowler’s book is a bit like watching a major league baseball player take batting practice. Even when routine, it is satisfying to watch a professional make something difficult look easy.

Matthew Day

Florida State University

Copyright American Society of Church History Jun 2008

(c) 2008 Church History. Provided by ProQuest LLC. All rights Reserved.

By Behrman, Stephen W Zarzaur, Ben L

Intra-abdominal sepsis (IAS) following pancreatectomy is associated with the need for therapeutic intervention and may result in mortality. We retrospectively reviewed patients developing IAS following elective pancreatectomy. Risk factors for the development of sepsis were assessed. The microbiology of these infections was ascertained. The number and type of therapeutic interventions required and infectious-related mortality were recorded. One hundred ninety-six patients had a pancreatectomy performed, 32 (16.3%) of who developed IAS. Infected abdominal collections were diagnosed and therapeutically managed at a mean of 11.8 days after the index procedure (range, 4-33). Eleven of 32 (34%) of these infections were diagnosed on or before postoperative day 6, 10 of who had Whipple procedures. Statistically significant risk factors included an overt pancreatic fistula (18.8% vs 5.5%) and a soft pancreatic remnant (74.2% vs 42.3%), but not the lack of intra-abdominal drainage, an antecedent immunocompromised state, postoperative hemorrhage, or the preoperative placement of a biliary stent. Fifty-five per cent had polymicrobial infections and 26 per cent of isolates were resistant organisms. Nineteen per cent and 48 per cent of patients had an isolate positive for fungus and a Gram-positive organism, respectively. Fortyseven therapeutic interventions were used, including 10 reoperations. Length of stay was significantly prolonged in those with IAS (28.5 vs 15.2 days) and mortality was higher (15.6% vs 1.8%). We conclude: 1) septic morbidity after pancreatectomy is associated with a soft pancreatic remnant and an overt pancreatic fistula and in this series resulted in a prolonged length of stay and a significant increase in procedure-related mortality; 2) infected fluid collections may occur very early in the postoperative period before frank abscess formation, and an early threshold for diagnostic imaging and/or therapeutic intervention should be entertained in those with clinical deterioration; and 3) these infections are often polymicrobial and frequently include resistant and nonenteric organisms. MORBIDITY FOLLOWING PANCREATIC resection remains common and has been reported in up to 50 per cent of patients in recent series.1-4 Pancreatic and biliary fistulae as well as delayed gastric emptying are most prevalent and have been the focus of study in the majority of the literature.1, 5-10 While these complications increase hospital length of stay, they rarely require further diagnostic and/or invasive therapeutic procedures and mortality is exceptional. Intraabdominal sepsis occurs less frequently but remains important.1-8, 11 In contrast to other morbidity following pancreatectomy, abscess and/or other infected abdominai fluid collections are most often associated with the need for nonoperative and operative intervention, a prolonged hospital length of stay, and an increase in mortality. The pathogenesis and microbiology associated with these infections has received relatively little attention. Furthermore, management and outcome that impact so significantly on this patient population, most of who have carcinoma, have been poorly described. We reviewed our experience with intra-abdominal sepsis following pancreatic resection with a focus on the diagnosis, bacteriology, and management of this problematic and sometimes catastrophic complication in hopes of improving future patient outcome and survival.

Methods

The records of patients developing intra-abdominal sepsis following elective pancreatic resection at the University of Tennessee, Memphis, affiliated hospitals from 1997 to 2007 were retrospectively reviewed. Data examined included disease process and type of resection. Risk factors for the development of intraabdominal abscess or intra-abdominal sepsis (IAS), including preoperative biliary stenting, a pre-existing immunocompromised state (other than carcinoma), the presence or absence of intraperitoneal drainage, the need for blood transfusion, the development of a pancreatic fistula, postoperative hemorrhage, and the consistency of the remnant pancreas, were examined. An immunocompromised state included diabetes, steroid use, and a history of neoadjuvant therapy. Blood transfusions were recorded within the first 24 hours of surgery. A pancreatic fistula was defined according to the International Study Group of Pancreatic Fistula consensus.12 The time from operation until the clinical development of intra-abdominal sepsis was noted. We specifically focused on the offending microbiologic pathogens recovered during treatment and note was made of resistant organisms or unexpected flora if present. The type (operative vs nonoperative) and number of invasive procedures used in an attempt to eradicate the septic focus were evaluated critically. The impact of postoperative IAS is on hospital length of stay and procedure-related mortality was assessed.

For the purposes of this study, IAS was categorized as follows. An intra-abdominal abscess was defined as a discrete, rim-enhancing fluid collection with or without the presence of gas occurring on or after postoperative day 7. An infected fluid collection was considered as ill-defined, localized, or diffuse, nonrimenhancing fluid noted on or before postoperative day 6. Peritonitis was defined as diffuse abdominal tenderness with rebound on physical examination within the clinical context of sepsis. Patients with a frank pancreaticoenteric anastomotic breakdown (Grade C fistula defined by the International Study Group of Pancreatic Fistula) were included as a result of the ensuing sepsis that developed.

All patients received routine prophylactic perioperative antibiotics for 24 to 48 hours at the time of the index procedure. In addition, during the last 3 years, we have maintained rigid glucose control (80 to 120 mg/dL) in the operating room with hourly blood glucose monitoring. Such levels are maintained in the postoperative period with the use of an insulin drip in the intensive care unit if necessary.

Comparisons between groups were made using Student’s t test for continuous variables and chi^sup 2^ analysis for discrete variables. Significance was assessed at the 95m percentile. Univariate and multivariate logistic regression analysis was used to determine the relationship between potential risk factors and the development of IAS following elective pancreatic resection. Potential risk factors were first assessed with univariate logistic regression. Risk factors with a P

Results

One hundred ninety-six patients underwent pancreatic resection during the 10-year time period with 32 patients (16.3%) developing postoperative IAS (Table 1). Of those with infections, 24 had Whipple procedures with seven and one having distal and total pancreatectomy, respectively. Twenty-four of 32 patients (75%) developing postoperative sepsis had operations performed for carcinoma or premalignant conditions, and this was not different from those avoiding infectious sequelae. The mean age of those with postoperative abdominal infection was 58.3 years and was not different from those without sepsis. Those developing infectious complications had a female predominance in contrast to those without postoperative sepsis; however, this difference was not significant.

Risk factors for the development of postoperative IAS were analyzed by univariate analysis (Table 2). Postoperative infection was not associated with age, operating time, the need for blood transfusion, preoperative biliary stenting, the presence or absence of abdominal drainage, perioperative hemorrhage, the type of procedure performed (distal vs proximal resection), or a preoperative immunocompromised state. In addition, there was no decrease in the incidence of postpancreatectomy sepsis with the institution of rigid glucose control (Fig. 1). In contrast, a pancreatic fistula and a soft pancreatic remnant were predictive of future infectious complications. Pancreatic duct stenting, fibrin glue application to the pancreaticoenteric anastomosis, and the perioperative use of octreotide did not prevent the development of postoperative sepsis. Only the development of a pancreatic fistula following elective pancreatic resection was associated with IAS on multivariate analysis.

TABLE 1. Patient Demographics

TABLE 2. Risk Factors for the Development of Intra-abdominal Sepsis

FIG. 1. Number of pancreatic resections and intra-abdominal sepsis per year.

Intra-abdominal infections were diagnosed at a mean of 11.8 days following the index procedure. Clinical and laboratory findings at the time of diagnosis of IAS are presented in Table 3. Notably, peritonitis and abdominal pain were uncommon. In contrast, more subtle findings such as oliguria, mental status changes, and an increase in the percentage of bands on differential analysis of the white blood cell count were not unusual. Eleven of 32 (34%) patients developing infectious sequelae were diagnosed on or before postoperative day 6 before the development of a frank abscess. This included three patients with a Class C pancreatic fistula. Ten of these 11 with infected fluid collections had Whipple procedures. Six of the 11 patients (55%) developing early infection ultimately required open surgical drainage to eradicate the septic focus versus four of 21 (19%) developing infection (abscess) on or after postoperative day 7. TABLE 3. Clinical Assessment and Laboratory Analysis Prompting Intervention

Fifty-eight pathogens were recovered on culture from these 32 patients (Table 4). Twenty-eight (48%) of these isolates were Gram- positive organisms. Eleven of 58 pathogens (19%) were fungi. Fifteen isolates (26%) comprised resistant organisms, including methicillin- resistant Staphylococcus aureus, vancomycin-resistant Enterococcus faecalis, and extendedspectrum beta-lactamase-producing Gram- negative bacteria. Fifty-four per cent of patients with IAS had polymicrobial infections. Four of 32 patients developing postoperative infections had placement of a preoperative biliary stent. There was no correlation between stent placement and the development of nonenteric or resistant organisms on final culture.

Forty-seven therapeutic interventions were used in an attempt to eradicate the septic focus on this study population (Table 5). Procedures used included percutaneous drainage of infected collections (26 of 32 [81%]) and open surgical drainage (10 of 32 [31%]). Up-front surgical drainage was used in six patients. Four of these six had Whipple procedures and required repeat laparotomy for severe sepsis before postoperative day 6 (including two with Class C fistulas). Two patients having up-front surgery developed subphrenic abscesses following distal pancreatectomy that were not amendable to percutaneous drainage. Twenty-one of 32 patients had one procedure alone, but 11 patients (34%) required multiple procedures. Four of 11 patients requiring multiple therapeutic interventions had open surgical drainage following failed percutaneous drainage. These four patients all had infected fluid collections diagnosed on or before postoperative day 6, including one with a Class C fistula. In total, only four of 26 patients (15%) developing IAS following pancreatic resection failed initial percutaneous, non-operative drainage. Six patients avoiding reoperation required more than one percutaneous drain placement for definitive eradication of sepsis.

TABLE 4. Microbiology of Intra-abdominal Sepsis (n = 32)

TABLE 5. Therapeutic Interventions (n = 47)

Length of stay was significantly prolonged in those who developed IAS versus those who did not (28.5 vs 15.2 days; P

Discussion

Mortality following pancreatic resection has diminished significantly in the past decade, especially when performed in high- volume centers with multispecialty expertise.13-15 In contrast, morbidity following pancreatectomy remains substantial ranging from approximately 30 per cent to 60 per cent in recent series with the vast majority involving an intra-abdominal process. The surgical literature has primarily focused on the incidence, management, and sequelae of pancreatic anastomotic complications as well as delayed gastric emptying. 9, 10, 16 While important in terms of a prolongation in length of stay and a delay in recovery, in the absence of a Class B or C pancreatic fistula, which are uncommon, these complications infrequently require invasive therapeutic intervention or result in mortality.12 Intra-abdominal sepsis following pancreatic resection has received relatively little attention. While less common than other complications, postoperative septic fluid collections or frank abscess formation mandate therapeutic drainage either by the percutaneous route or, not infrequently, repeat laparotomy.1, 4, 5, 11, 16 In addition, the development of IAS increases the cost associated with pancreatic resection, delays recovery, and has a distinct associated mortality rate, especially if reoperation is required in an attempt to eliminate the septic focus.1, 5, 16

The incidence of IAS ranges from 5 per cent to 16 percent inclusive of this study.1, 2, 5, 6, 11, 16, 17 Unfortunately, this rate of infection has not changed significantly in the last two decades despite a myriad of refinements and technical adjuncts involved in pancreatic resection and reconstruction. While a Class C pancreatic fistula remains uncommon, it is almost universally associated with sepsis that requires aggressive nonoperative and operative management.12, 18 In this scenario, sepsis results not so much from leakage of pancreatic juice, but from leakage of enteric contents within the peritoneal cavity. Three of 32 patients in this series developed a Class C fistula as defined by the International Study Group of Pancreatic Fistula classification scheme. All occurred after reconstruction to a soft gland. These patients became septic very early in their postoperative course (before day 6) and all required reoperation (including one after failed percutaneous drainage) for definitive control of their infection. Aggressive intervention failed to prevent one death in this group.

The use of preoperative biliary stenting and the lack of peritoneal drainage following pancreatectomy have been associated with infectious morbidity in some but not all studies and their relationship to septic morbidity remains controversial.2, 19-21 In this study, LAS was not associated with either the preoperative placement of a bile duct stent or the lack of peritoneal drainage. Other risk factors, including intraoperative blood loss, the need for perioperative blood transfusion, and a preoperative immunocompromised state, were not associated with IAS in this study. Only a soft pancreatic remnant and the development of a postoperative pancreatic fistula were significantly associated with the development of IAS by univariate analysis and just the development of a fistula by multivariate analysis. This finding is in common with most, but not all, studies in the literature.1-3, 5, 6, 10, 11, 16, 22

Measures potentially protective of the pancreatic anastomosis such as stenting, fibrin glue application, and the perioperative use of octreotide had no impact on the prevention of septic complications. Despite mese latter results, we continue to use these adjuncts to pancreatic reconstruction in those with a soft pancreatic remnant. Finally, data from the general and cardiac literature suggest that rigid glucose control in the perioperative period reduces infectious morbidity and indeed, this has become a quality initiative monitored by the Center for Medicare and Medicaid Services.23, 24 Despite the implementation of a rigid protocol for normalization of glucose in the perioperative period in the last 3 years, we did not appreciate any decrease in the incidence of IAS in this study. It may be that a 5 per cent to 15 per cent risk of postoperative IAS is inevitable following pancreatectomy with reconstruction to, or closure of, a soft gland. We feel further study might better focus on the early diagnosis of intra-abdominal infections, the recognition of commonly encountered pathogens, and the application of aggressive therapeutic intervention.

The diagnosis of IAS can usually be suspected based on clinical criteria, including fever and tachycardia. Abdominal tenderness and/ or peritonitis may or may not be present, especially if sepsis occurs early in the postoperative period. In addition, more subtle clues such as mental status changes and evidence of renal failure were noted in older patient populations in our review. When suspected, a manual differential has been particularly helpful demonstrating a shift to immature forms even in the face of a normal or depressed white blood cell count. We have been impressed with the rapidity with which these infections develop in the postoperative period. One-third of our patients developed infected fluid collections documented by percutaneous aspiration or reoperation on or before postoperative day 6. The development of an early infected fluid collection following pancreatic resection prior to frank abscess formation (7 to 10 days) has been suggested by others.11, 22 Our three Class C pancreatic fistulas occurred in this group suggesting that when these fistulas occur, they do so early in the postoperative period. Ten of 11 infected fluid collections developing early occurred following reconstruction to a soft gland and in all but one case following a Whipple procedure. Thus, early sepsis, especially following pancreaticoduodenectomy and reconstruction to a soft pancreas, should mandate immediate diagnostic imaging. Our review of patient records for mis study was noteworthy for the frequency with which early sepsis following pancreatic resection was mistakenly attributed to other etiologies such as atelectasis, pneumonia, line sepsis, and urinary tract infection by the treating surgeon as a result of the absence of abdominal physical findings. Our data suggest that if sepsis occurs early in the postoperative period, it is imperative mat an intra- abdominal source should be excluded with early CT scan. In patients with postresection sepsis, we recommend that any free fluid noted on CT be treated with at least percutaneous drainage.

To our knowledge, no prior study has specifically addressed the pathogens associated witii abdominal infections developing after elective pancreatic resection. In contrast to enteric pathogens that might be anticipated in these infections, over one-half of isolates obtained from our 32 patients included either a Gram-positive or fungal organism with no correlation noted between early and late infections or the preoperative placement of a biliary stent. Furthermore, the early presence of resistant organisms was not uncommon. The flora encountered in this study are more common in those developing tertiary peritonitis following laparotomy for secondary peritonitis.25, 26 All of our patients received prophylactic perioperative antibiotics alone, suggesting mat there was little selection pressure for these tertiary padiogens. One- fourth of isolates from patients with postoperative sepsis were resistant organisms and one-half had polymicrobial infections. Importantly, of the five deaths in those with IAS, three patients had fungal pathogens and one had methicillin-resistant S. aureus. We believe mat confirmation of these results from other centers performing pancreatic resection is clearly necessary. However, in the absence of further data and although it is difficult to speculate that earlier treatment would positively impact on outcome, we recommend the institution of broad-spectrum antibacterial coverage, including empiric antifungal therapy and treatment directed at methicillin-resistant S. aureus in those witii postpancreatectomy sepsis until final cultures are obtained. Not unexpectedly, all patients in this series developing postoperative IAS required therapeutic intervention. Although the vast majority of abscesses/fluid collections were amendable to percutaneous drainage, approximately one-tiiird of these infections ultimately required repeat laparotomy and open drainage as has been reported by other centers.1, 11, 16 Six of seven patients avoiding reoperation required more than one drain placement in common with results reported by Sohn et al.11 This was most often necessary as a result of noncontiguous fluid collections. We are aggressive in monitoring clinical improvement after drain placement as well as performing early follow-up CT scans to identify those that might require more than one percutaneous intervention. Four of 32 patients (12.5%) failed initial percutaneous drainage, greater than the 0.5 per cent reported by Sohn. This may simply reflect the smaller number of patients in this study. Open drainage was uniformly required in the three patients with Class C pancreatic fistulas, one after failed percutaneous drainage. Seven of 10 patients requiring reoperation had a pancreaticoduodenectomy as their index procedure, five of whom had reconstruction to a soft gland.

As might be anticipated, length of stay was prolonged in those developing IAS following pancreatic resection and in this study was nearly double that of those who did not have an infectious complication. This prolongation in hospitalization was not different than that previously reported in a series of patients requiring postoperative radiologic intervention for a variety of complications, including IAS following the Whipple procedure.11 More disturbing was a significant increase in procedure-related mortality in those with infectious complications. Our death rate related to infectious morbidity following pancreatic resection was slightly higher than that reported elsewhere.11, 16

The need for therapeutic intervention, the exaggerated length of stay, and the increase in mortality following the development of IAS after pancreatectomy emphasizes the need for early recognition and aggressive treatment of these infections. Based on our data and that of others, one must anticipate infectious complications, especially if a soft pancreas is managed or if a clinically relevant pancreatic fistula develops following surgical excision. Septic morbidity may develop very early in the postoperative period with subtle clinical and laboratory signs before the time period typical of abscess formation. We recommend the institution of early diagnostic imaging in those with clinical deterioration in the early perioperative period. Urgent operative and nonoperative intervention to drain intra-abdominal fluid collections should be used even if there is not a suggestion of frank abscess formation. Our review of the microbiology of these infections suggests a significant per cent is associated with nonenteric and resistant organisms. Early diagnosis, broad initial antimicrobial coverage, and prompt intervention to eradicate septic foci will hopefully ameliorate the morbidity and mortality associated with intra-abdominal infections after pancreatic resection.

REFERENCES

1. Yeo CJ, Cameron JL, Sohn TA, et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990’s. Ann Surg 1997;226:248-57.

2. Conlon KC, Labow D, Leung D, et al. Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection. Ann Surg 2001;234:419-29.

3. Satoi S, Takai S, Matsui Y, et al. Less morbidity after pancreaticoduodenectomy of patients with pancreatic cancer. Pancreas 2006;33:45-52.

4. Behrman SW, Rush BT, Dilawari RA. A modern analysis of morbidity after pancreatic resection. Am Surg 2004;70:675-82; discussion 682-3.

5. Miedema BW, Sarr MG, van Heerden JA, et al. Complications following pancreaticoduodenectomy. Arch Surg 1992;127: 945-50.

6. Grace PA, Pitt HA, Tompkins RK, et al. Decreased morbidity and mortality after pancreatoduodenectomy. Am J Surg 1986; 151:141-9.

7. Trede M, Schwall G. The complications of pancreatectomy. Ann Surg 1998;207:39-47.

8. Stephens J, Kuhn J, O’Brien J, et al. Surgical morbidity, mortality and long-term survival in patients with peripancreatic cancer following pancreaticoduodenectomy. Am J Surg 1997;174: 600- 4.

9. Yeo CJ, Lillemoe KD, Sauter PK, et al. Does prophylactic octreotide really decrease the rates of pancreatic fistula and other complications following pancreaticoduodenectomy? Ann Surg 2000;232:419-29.

10. Yeo CJ, Cameron JL, Maher MM, et al. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Ann Surg 1995;222: 580-8.

11. Sohn TA, Yeo CJ, Cameron JF, et al. Pancreaticoduodenectomy: Role of interventional radiologists in managing patients and complications. J Gastrointest Surg 2003;7:209-19.

12. Bassi C, Dervenis C, Buttarmi G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005;138:8-13.

13. Birkmeyer JD, Warshaw AL, Finlayson SR, et al. Relationship between hospital volume and late survival after pancreaticoduodenectomy. Surgery 1999;126:178-83.

14. Sosa JA, Bowman HM, Gordon TA, et al. Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg 1998;228:429-38.

15. Rosemurgy AS, Bloomston M, Serafini FM, et al. Frequency with which surgeons undertake pancreaticoduodenectomy determines length of stay, hospital charges and in-hospital mortality. J Gastrointest Surg 2001;5:21-6.

16. Buchler MW, Wagner M, Schmied BM, et al. Changes in morbidity after pancreatic resection. Arch Surg 2003;138:1310-4.

17. Crist DW, Sitzmann JV, Cameron JL. Improved hospital morbidity, mortality and survival after the Whipple procedure. Ann Surg 1987;206:358-65.

18. Pratt WB, Maithel SK, Vanounou T, et al. Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme. Ann Surg 2007;245: 443-51.

19. Howard TJ, Yu J, Greene RB, et al. Influence of bactibilia after biliary stenting on postoperative infectious complications. J Gastrointest Surg 2006;10:523-31.

20. Pisters PW, Hudec WA, Hess KR, et al. Effect of preoperative biliary decompression on pancreaticoduodenectomy-associated morbidity in 300 consecutive patients. Ann Surg 2001; 234:47-55.

21. Povoski SP, Karpeh MS, Conlon KC, et al. Preoperative biliary drainage: Impact on intraoperative bile cultures and infectious morbidity and mortality after pancreaticoduodenectomy. J Gastrointest Surg 1999;5:496-505.

22. Grobmyer SR, Pieracci FM, Allen PJ, et al. Pancreaticoduodenectomy: Use of a prospective complication grading system. J Am Coll Surg 2007;204:356-64.

23. Pomposelli JJ, Baxter JK III, Babineau TJ, et al. Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. J Parenter Enteral Nutr 1998;22:77-81.

24. Furnary AP, Zerr KJ, Grandemeier GL, et al. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg 1999;67:352-60.

25. Evans HL, Raymond DP, Pelletier SJ, et al. Tertiary peritonitis (recurrent diffuse or localized disease) is not an independent predictor of mortality in surgical patients with intraabdominal infection. Surg Infect (Larchmt) 2001;2:255-63.

26. Nathens AB, Rotstein OD, Marshall JC. Tertiary peritonitis: Clinical features of a complex nosocomial infection. World J Surg 1998;22:158-63.

STEPHEN W. BEHRMAN, M.D., BEN L. ZARZAUR, M.D., M.P.H.

From the Department of Surgery, University of Tennessee, Memphis, Tennessee.

Presented at the Annual Scientific Meeting and Postgraduate Course Program, Southeastern Surgical Congress, Birmingham, AL, February 9-12, 2008.

Supported in part by the Herb Kosten endowment for pancreatic cancer research and care at the University of Tennessee, Memphis.

Address correspondence and reprint requests to Stephen W. Behrman, M.D., F.A.C.S., Associate Professor of Surgery, University of Tennessee, Memphis, Department of Surgery, 910 Madison Avenue, Suite 208, Memphis, TN 38163. E-mail: sbehrman@ utmem.edu.

DISCUSSION

JOHN R. GALLOWAY, M.D. (Atlanta, GA; Opening Discussion): This single institution review of 196 elective pancreatectomies for both benign and malignant diseases focused on the postoperative intra- abdominal sepsis that occurred in 16 per cent. Soft pancreas is identified as a major risk factor for postoperative leak and postoperative infection. Fever, tachycardia, altered mental status, oliguria, and hemodynamic changes are signs of developing intraabdominal sepsis. The authors appropriately advocate early CT imaging to effectively diagnose and treat infected fluid collections and abscesses. Based on their analysis, the bacterial flora obtained from such collection, the early institution of broadspectrum antimicrobial antibiotics against methicillinresistant S. aureus, Gram-negative rods, and antifungal agents are recommended. This is certainly in keeping with the sepsis protocol guidelines put forth by the Society of Critical Care Medicine. The authors accurately note the valuable role of CT drainage using multiple drains, if necessary, and the early follow-up CT scan to document efficacy. In those patients who cannot be safely drained or fail drainage, they advocate the expeditious role of surgical intervention.

Despite this aggressive program of management, postpancreatectomy intra-abdominal sepsis remains a terrible, devastating problem for the patient. Length of stay in the successfully treated patients is more than doubled, and mortality increases from 2 per cent to 16 per cent. Short of never cutting into the soft pancreas, are there any other ways to prevent this complication?

The authors state their own data does not support the use of intraoperative drainage, stenting of the pancreaticojejunostomy, fibrin glue application, or the use of perioperative octreotide. Nevertheless, in their discussion, when confronted with a soft pancreas, they do indeed use these techniques. Do these measures aid in preventing sepsis in a soft gland? How do you handle the cut edge of the pancreas in your patient with distal pancreatectomy?

STEPHEN W. BEHRMAN, M.D. (Memphis, TN; Closing Discussion): Other series, as well as our own results, suggest with a soft pancreas, a 10 per cent to 15 per cent leak rate will occur. My approach is to do everything in a soft gland: fibrin glue, octreotide, omentum, and so on.

I will typically invaginate those anastomoses. With a cut edge, I will individually ligate the duct of Wirsung and then place vertical mattress sutures across the cut edge. In addition, I will place fibrin glue and omentum over it.

JOSE J. DIAZ, JR., M.D. (Nashville, TN): Have you looked at any intraoperative differences during those cases that did and did not develop an intra-abdominal infection (that is, periods of hypotension, length of operation, perioperative antibiotic, timing, redosing during the procedure, and so on)?

STEPHEN W. BEHRMAN, M.D. (Memphis, TN; Closing Discussion): In the uni- and multivariate analyses, we did not find any difference. We have not been able to get our rate of sepsis below the 10 per cent to 15 per cent level.

TAD KIM, M.D. (Gainesville, FL): Do abscesses occur despite having intraperitoneal drains placed intraoperatively?

STEPHEN W. BEHRMAN, M.D. (Memphis, TN; Closing Discussion): I stopped draining pancreatic resections approximately 3 to 4 years ago. One of the things I wanted to look at was whether that made an impact on whether or not these patients developed sepsis. In our analysis, it had no impact on the development of this complication after pancreatectomy.

ROBERT MAXWELL, M.D. (Chattanooga, TN): I would like to get your thoughts on the soft gland and ligating or stapling the gland off.

STEPHEN W. BEHRMAN, M.D. (Memphis, TN; Closing Discussion): That has been reported in the surgical literature; the pancreatic fistula rate is higher when stapled versus hand-sewn.

GARY C. VITALE, M.D. (Louisville, KY): I think if you can convert these to a fistula, you are less likely to have sepsis that leads to death. Does it not make sense even though placing drains may promote fistulization and you end up with a higher fistula rate, that it might lead to less sepsis collections that need to be reoperated early? Could you comment about those in whom you did place drains and whether there was a little higher fistula rate but lower sepsis and collection rate?

STEPHEN W. BEHRMAN, MD. (Memphis, TN; Closing Discussion): I noted in the abstract that the sepsis postoperative sepsis rate was higher in mose who did not have intraperitoneal drains placed. I was very disturbed by that. For the subsequent follow up, I then placed drains in the 16 patients who I added to this series. The data showed there was no difference whether or not they had placement of intraperitoneal drains. My preference is to still not drain these patients because the drains are not effective in evacuating these fluid collections.

DAVID FELICIANO, M.D. (Atlanta, GA): Would it not be safer to put a JP drain in? I may be naive because I do not do pancreatic resections everyday, but although there is a fixed leak rate, I am not convinced that everyone has a high rate of abscesses.

STEPHEN W. BEHRMAN, M.D. (Memphis, TN; Closing Discussion): I have tried all sorts of drainage, and I have still not found one that works. I still place drains occasionally, but I am not sure if the intraperitoneal drain is the panacea to preventing this underlying complication. In all of our patients, the fistula probably occurred before postoperative day 6. We are really aggressive in investigating these patients early, so perhaps we are detecting collections earlier than we had in the past. These are not frank abscesses, but appear to be ascites or postoperative fluid that can accumulate after any operation. Because of the clinical condition of the patient, we are very aggressive with early percutaneous drainage.

Copyright Southeastern Surgical Congress Jul 2008

(c) 2008 American Surgeon, The. Provided by ProQuest LLC. All rights Reserved.

By Clauser, Steven B Arora, Neeraj K; Bellizzi, Keith M; Haffer, Samuel C (Chris); Topor, Marie; Hays, Ron D

Health plan member survey and cancer registry data were analyzed to understand differences in health-related quality of life (HRQOL) among cancer survivors and those without a cancer diagnosis enrolled in Medicare managed care. HRQOL was measured by the physical component summary score (PCS) and mental component summary score (MCS) of the Medical Outcomes Study SF-36(R), version 1.0. Cancer survivors enrolled in Medicare managed care have lower PCS and MCS scores than those enrollees who have never been diagnosed with cancer. PCS scores are worse than the MCS scores, and lowest for cancer survivors who are Hispanic, Medicaid enrollees, and those who have low income or education. HRQOL disparities are greatest among cancer survivors diagnosed with lung cancer and those with multiple primary cancer diagnoses. The influence of these variables persists when controlling for multiple variables including comorbidity status. Health plans should focus on addressing these disparities. INTRODUCTION

Advances in cancer screening and treatment enable many elderly cancer patients to survive their diagnosis and live much longer than their peers 10-20 years ago. However, increased survival brings new challenges and implications for older cancer patients. A diagnosis of cancer in older adults is often superimposed on existing comorbid conditions, and can exacerbate acute and chronic, physical, and emotional effects of the disease and treatment (Garman, Pieper, and Seo, 2003; Smith et al., 2008). Research suggests that unless many of these sequellae are promptly identified and effectively managed by individuals, families, and health care providers, these factors can negatively influence the HRQOL of cancer survivors for years after treatment (Bellizzi and Rowland, 2007).

This article addresses the issue of disparities in HRQOL among cancer and noncancer survivors in Medicare managed care plans. Disparities are defined as differences in the burden of cancer (as measured by HRQOL) that exist among specific population groups in these plans, including groups characterized by age, sex, ethnicity, education, and income1. Little populationbased information is available to document the differences in HRQOL among older cancer survivors and those who have never been diagnosed with cancer to assist health care providers in addressing this issue. One study Baker and colleagues (2003), based on data from the late 1990s, showed in a managed care setting that cancer survivors had lower physical and mental health as measured by the SF-36(R) than enrollees who did not report a cancer diagnosis. Bierman and colleagues (2001) and Cooper and Kohlman (2001) found that chronic diseases had a large impact on self-reported health although other evidence suggests the burden of cancer may not be as great as other comorbid conditions (Ko and Coons, 2005). However, with the exception of Baker’s study, research has not focused on the HRQOL of cancer survivors compared with individuals without a history of cancer in managed care organizations.

Evidence also exists that significant differences in cancer outcomes are associated with age, race, poverty, insurance status, and education, although findings are inconsistent across studies. A population-based study of 703 breast cancer patients in California found significant ethnic differences in HRQOL, with the Latino population reporting greater role limitations and lower emotional well-being than the White, African-American, and AsianAmerican populations (Ashing-Giwa et al., 2007). A study of 804 females with breast cancer who participated in the Health, Eating, Activity and Lifestyle study found that Black females reported statistically significantly lower physical functioning, but higher mental health than White and Hispanic females (Bowen et al., 2007).

Another study, focused on long-term breast cancer survivors, found socioeconomic, but not ethnicity differences in HRQOL outcomes (Ashing-Giwa, Ganz, and Peterson, 1998). Ganz and colleagues (1998) studied 864 breast cancer survivors in the District of Columbia and Los Angeles and found significant increases in emotional functioning and decreases in physical functioning with age. Knight and colleagues (2007) found that lower education was associated with poorer emotional well-being in 248 prostate cancer patients cared for in the U.S. Department of Veterans Affairs, after controlling for demographic and other factors. A cancer registry-based study of 1,307 females with breast cancer from Detroit and Los Angeles found that among females with advanced breast cancer, those who were more highly educated felt better emotionally and were better able to function socially than were females with low education (Lanz et al., 2005). Penson and colleagues (2001) found that inadequate or lack of insurance had a strong negative effect on physical functioning and emotional well-being among prostate cancer patients (Penson et al., 2001). Despite the contribution of these studies to our understanding of the HRQOL impacts of cancer in older survivors, they are mostly confined to survivors of breast or prostate cancer, do not typically include non-cancer controls, and do not examine HRQOL disparities in the context of specific health care delivery systems accountable for the health of cancer survivors.

To further clarify the relationships between demographic and socioeconomic variables with HRQOL among cancer survivors and those without a cancer diagnosis in Medicare managed care, we linked patient survey data collected from Medicare managed care enrollees with population-based cancer registry data containing clinical information on those with cancer. The objectives of this study were to examine whether the findings in these smaller studies would be replicated in a large population-based sample of Medicare managed care enrollees, and specifically test: (1) to what extent HRQOL among cancer survivors is lower than in individuals who have never been diagnosed with cancer, (2) whether physical and mental health varies in cancer survivors based on their cancer status (i.e., type of diagnosis and number of primary cancer diagnoses), and (3) whether age, race/ethnicity, sex, marital status, education, income, and severity of cancer (i.e., stage of disease) and comorbidity, are associated with reduced HRQOL.

METHODS

Study Design

Data for this study were collected as part of a larger national study of HRQOL in cancer patients, called the Surveillance Epidemiology, and End Results (SEER)-Medicare Health Outcomes Survey (MHOS) study, undertaken by NCI (2007) and CMS. This study examined the HRQOL of more than 170,000 enrollees of Medicare managed care who resided in 1 of 13 SEER cancer registry regions from 1998-2001. Data were collected from two sources, including the MHOS (Jones, Jones, and Miller, 2004), which randomly surveys 1,000 health plan members annually in each participating Medicare Advantage plan, and SEER, which is a standardized population-based cancer registry that documents detailed clinical and histological characteristics of individuals newly diagnosed with cancer in the region, as well as information on their initial treatment (Ries et al., 2007). The data set represents 27 percent of all Medicare Advantage enrollees.

The methods for linking the SEER and MHOS data have been described by Ambs and colleagues (2008). SEER registries in San Francisco (California), Connecticut, Michigan, Hawaii, Iowa, New Mexico, and Utah link cancer diagnoses back to 1973; Atlanta (Georgia) back to 1975; rural Georgia back to 1992; Los Angeles and San Jose (California) back to 1988; and the expansion registries in Greater California, Kentucky, Louisiana, and New Jersey that were added to SEER in 2000, link cancer diagnoses back to 1988, 1995, 1995, and 1979, respectfully. MHOS response rates averaged 67 percent over the four cohorts and all MHOS respondents were successfully linked either as cancer survivors (SEER) or non-cancer controls, with the exception of 719 cases that were eliminated because their date of death was prior to the date of survey administration.

The study was approved by NCI’s Institutional Review Board and both participating government agencies2. These analyses use data from both sources.

Study Population

From the SEER-MHOS files, we created a pooled cross-sectional data set that includes all survey respondents from 19982001. For the single cancer and tumor specific analyses, we restricted the cancer sample to the four cancer types with the highest incidence: breast, colorectal, prostate, and lung. These four cancers account for more than 50 percent of all incident cancers in the U.S. and more than one-half of incident cancers in males and females over age 65 (Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey, 2007). We also identified and examined individuals who had multiple primary cancer diagnosesthat is, people originally diagnosed with one cancer type (e.g., breast cancer) and then later diagnosed with a second or even third cancer (e.g., colorectal cancer and/ or lung cancer). In all analyses, cancer survivors are defined as individuals who were diagnosed with cancer (as verified in the SEER cancer registry) before they took the MHOS. We did not use the self-report survey responses on whether or not an individual had been ever diagnosed with cancer or whether they were under active treatment for breast, colorectal, prostate, or lung cancer because the samples are not equivalent, since some survey respondents were diagnosed with cancer before they moved into the SEER region or before SEER began collecting diagnosis data and because of our interest in multiple primary cancer diagnoses, which are not captured in the MHOS. These decisions resulted in 21,504 incident cancers in the analytic data set, with 4,549 breast cancer cases, 5,422 prostate cancer cases, 968 lung cancer cases, and 2,916 colorectal cancer cases. Of these incident cancers, 2,810 survey respondents had multiple primary cancer diagnoses. The sample of survey respondents without cancer included individuals in the same health plans as the cancer respondents (i.e., from the 13 SEER regions) who self-reported no previous cancer diagnosis (other than non-skin melanoma) and had no record of a cancer diagnosis in the SEER registry or were diagnosed with cancer after their first MHOS as reported by the SEER registry. Al study respondents appear only once in the data set; we took the first completed MHOS in instances where individuals appear in multiple MHOS cohorts. There were 150,766 survey respondents who did not have a cancer diagnosis and serve as controls in the analytic data set. Approximately 12 percent of surveys were answered by proxies, such as family or caregivers living in the same household.

Measures

We describe the HRQOL of survey respondents with and without cancer using the Medical Outcomes Study SF-36(R), version 1.0 PCS and MCS scores (Ware and Kosinski, 2001). The PCS and MCS are scored on a T-score metric such that a score of 50 represents the U.S. general population average. A score that is 10-points above or below the mean score of 50 represents a difference of one standard deviation (SD) from the national average.

We evaluated the associations of the PCS and MCS with respondent age, race/ ethnicity, sex, marital status, educational attainment, income, and poverty status (Table 1). Respondent’s age was derived by subtracting date of birth in the Medicare Enrollment Files from the date of the MHOS. Age was categorized into three groups: (1) 65- 74 years, (2) 75-84 years, and (3) 85 years or over. Race/ethnicity was organized into five mutually exclusive categories: (1) White, (2) Black or African-American, (3) Hispanic, (4) AsianAmerican, (5) other. Sex was coded as a dummy variable (male = 1; female = 0) for all analyses. Marital status had four categories: (1) married, (2) divorced/separated, (3) widowed, and (4) single and never married). Education had four categories: (1) 8th grade or less, (2) high school graduate, (3) some college, and (4) college graduate with 4 or more years of college education. Four income categories were used: (1)

We further classified cancer respondents by whether they had one cancer diagnosis or multiple primary cancer diagnoses, and by whether they had one of the four leading cancer diagnoses-breast, prostate, colorectal cancer, or lung cancer. We also created a comorbidity index for use in the multivariate regression analyses based on a simple count of the following 12 medical conditions assessed in the MHOS: (1) hypertension or high blood pressure, (2) coronary artery disease, (3) congestive heart failure, (4) myocardial infarction or heart attack, (5) other heart conditions, (6) stroke, (7) chronic obstructive pulmonary disease, (8) inflammatory bowel disease, (9) arthritis of the hip or knee, (10) arthritis of the hand or wrist, (11) sciatica, and (12) diabetes.

Statistical Analysis

We conducted three sets of analyses. First, we calculated bivariate associations between the sociodemographic characteristics of interest and the PCS and MCS. We retained all patient variables with p

Although all results of the bivariate and multivariate analyses are reported, we characterize PCS and MCS differences of three points or more between the PCS and MCS scores of cancer survivors and controls as a disparity. This threshold of 0.30 SD was chosen because it exceeds Cohen’s (1988) small effect size and is consistent with previous estimates of the minimally important statistical difference for the SF-36(R) in large samples (Kosinski et al., 2000), and with existing literature that concludes the minimal clinically important difference for the SF-36(R) is typically in the range of 3-5 points (Samsa et al., 1999).

RESULTS

The mean age of each cancer status group varies from 74 years for respondents who have never been diagnosed with cancer to 77 years for individuals diagnosed with two or more cancers (Table 1). More respondents with two or more cancers report their own race as White. Sex differences exist in the sample to the extent that the percentage of females exceeds males for two of the three groups- those who have never been diagnosed with cancer and those with two or more primary cancer diagnoses. The groups are relatively similar in their marital, educational, and income status, although the poverty status (as measured by Medicaid enrollment) is about one- quarter of the national average for Medicare beneficiaries (Lied and Haffer, 2004).

Table 2 shows the association between the sociodemographic variables of interest in the sample and PCS and MCS. All variables were statistically significant, reflecting in part, the large sample sizes in the data set. As a result, all variables were retained in the subsequent multivariate analyses.

Physical Health and Cancer Status

Noteworthy variations in PCS existed by personal characteristic and whether survivors were diagnosed with one or multiple primary cancer diagnoses (Table 3). In almost all cases, a cancer diagnosis was associated with lower PCS, with typically a 3-point or greater difference between those individuals with no cancer diagnosis and those with two or more primary cancer diagnoses. A clear grathent between HRQOL and cancer status existed, with a 4-point difference in PCS for those age 65-74 diagnosed with two or more primary cancer diagnoses. However, for those age 85 or over, the effect of cancer was attenuated.

Similar differences in PCS exist by race/ ethnicity and the number of cancer diagnoses. White, Hispanic, Asian-American, and others who have two or more primary cancer diagnoses have a 4-point or greater difference in PCS; in contrast, Black beneficiaries who have never been diagnosed with cancer and those who have been diagnosed with two or more primary cancers show a 2-point difference. Interestingly, Asian-American’ PCS is consistently higher than any other race/ethnic group and, among those with two or more cancers, is 3-points higher than Hispanic or Black beneficiaries.

Similar results appear for sex, marital status, and income, with each category having 3-4 point deterioration or greater in PCS depending on whether they had been diagnosed with two or more primary cancers. In contrast, the data show considerable differences across cancer groups depending on educational attainment, with a 4- point or greater difference in PCS for those who did not receive a high school degree or equivalent and those who graduated college.

Although PCS differences for the Medicare-only enrollees is consistent with the other results (i.e., a 4-point difference for those diagnosed with two or more primary cancers), the PCS differences for those enrollees also receiving Medicaid benefits are much smaller, ranging less than 2-points between cancer groups. However, those with poverty status (Medicaid beneficiaries), did report 5-8 point lower levels of PCS compared to Medicare only respondents if they were diagnosed with multiple primary cancers.

Mental Health and Cancer Status

The relationship between the MCS, personal characteristics and cancer status is different than the PCS results, with mean differences being much smaller, even for survivors diagnosed with two or more cancers (Table 4). MCS scores tend to be uniformly higher than PCS scores, with some of the single cancer diagnosis groups (e.g., age 65-74, White, Asian-American, males, high school degree or higher, income groups exceeding $20,000 annually, Medi- care-only group) having MCS meeting or slightly exceeding the general U.S. popula- tion mean of 50. MCS is higher for those single people with multiple primary can- cer diagnoses than those with a single cancer-in all other categories MCS goes down as the number of cancer diagnoses increases. Interestingly, MCS disparities within cancer status category are greater for some sociodemographic characteristics than across cancer diagnoses, with racial differences between Hispanic, Asian, or White cancer survivors equaling or exceeding 3-points. Education and income disparities within cancer status categories are even greater, with MCS differences exceeding 6-points between those with less than a high school degree or income below $20,000 and those with a college degree or incomes in excess of $50,000. The disparity in MCS between poor Medicare health plan enrollees (as measured by enrollment in Medicaid), and enrollees only enrolled in Medicare exceeds 7- points. Multivariate Analyses of Sociodemographic Variables

The results reported in Tables 5 and 6 confirm the relationship between cancer status, age, education, income, poverty status, and MCS and PCS. All coefficients are in the same direction as the threeway contingency table analyses and are of similar relative magnitude.3 However, the influence of race/ethnicity on HRQOL was moderate in the multivariate model, with only Asian Americans having significantly higher PCS (0.91) than White and Hispanic beneficiaries having lower PCS (-0.70) and MCS (-1.05) compared to White beneficiaries.

Comorbidity was highly negatively associated with PCS (-3.13) and MCS (-1.30) compared to those without comorbidity. Further, it appeared that proxy respondents were significantly more likely to report poor physical and mental functioning for cancer survivors (- 3.80 and -4.48, respectively) than were cancer survivor respondents themselves. Finally, in a separate model, we added two-way interaction effects for age, race, education, and cancer status.4 The interaction terms were in the correct direction and in the same relative magnitude of the differences observed in the main effects model. They suggest that although Asian-Americans report better HRQOL than other race/ ethnicity groups overall, younger Asian Americans have higher PCS (1.50) and younger African-Americans have lower PCS (-1.19) than older Asian-Americans or African-Americans, respectively. Also, cancer survivors who are younger than age 85 and have one or more cancers have significantly lower PCS than their older counterparts; confirming the contingency table analyses comparing age, cancer status, and HRQOL.

Regarding mental health, Asian-Americans who are educated at the college level or higher, have much lower MCS than their counterparts who have not gone to college.

Tumor Type

Cancer status based on number of diagnoses appears to be a useful factor in explaining differences in HRQOL within the sample. However, for the cancer status group, we also examined differences by tumor type to see if these relationships could be explained in part by differences in the type of cancer. Tables 7 and 8 present relationships between respondent sociodemographics, tumor type, and PCS and MCS for the four most prevalent cancersbreast, prostate, colorectal, and lung. Although PCS and MCS scores for health plan cancer survivors diagnosed with breast, prostate, colorectal, or lung cancer tend to be substantially lower than U.S. population norms of 50, the differences across tumor types appear to be small (i.e., less than a 2-point PCS difference). In contrast, several MCS scores equal or exceed U.S. population norms of 50 with the highest scores for cancer survivors who had gone to college or had incomes exceeding $50,000 annually. The major exception are lung cancer survivors who average greater than a 5-point lower score in PCS than other tumor types depending on personal characteristic, and greater than a 3-point lower score in MCS. Part of these differ- ences may reflect differences in severity of cancer, which is commonly reflected by the stage of cancer at diagnosis. Additional analyses (not reported here) were per- formed examining the relationship between tumor type, stage, personal characteristics, and HRQOL, and the results were inconsistent for both PCS and MCS. These results may reflect in part the large number of missing values for stage of disease in the SEER-MHOS data set.5

DISCUSSION

We examined the relationship of sociodemographics, cancer status, and HRQOL among cancer survivors enrolled in Medicare managed care. HRQOL disparities were greater for PCS than for MCS, and for survey respondents with multiple primary cancer diagnoses. Research has been conducted on the HRQOL implications of recurrent cancers, very little research has focused on individuals with multiple primary cancers (Curtis et al., 2006). This study showed that more than 13 percent of cancer survivors in the sample had multiple primary diagnoses. These individuals tended to be older, White, and of lower income and educational status than individuals with a single cancer diagnosis, and consistently had lower PCS and MCS. Cancer survivors with multiple primary cancer diagnoses may differ in many important respects from other cancer survivors of a single primary incident. As the elderly continue to survive longer with a diagnosis of cancer, the likelihood of multiple cancer diagnoses will increase in the elderly population. More research should be done to further investigate the reasons for these large differences in HRQOL between those with multiple cancer diagnoses and those without a cancer diagnosis and the potential for inter- ventions in health plan settings to improve their HRQOL.

One potential area to focus on is the effect of cancer diagnosis on different sociodemographic groups. These data replicate findings from the studies previously described suggesting that three sociodemographic factors-(1) age, (2) education, and (3) household income-are uniquely associated with HRQOL beyond cancer diagnosis in Medicare managed care enrollees. The differences in HRQOL were consistently 3 or more points after controlling for cancer status. However, the results were not uniform across physical and mental health, and differed for certain patient characteristics. For example, the data also show that when the oldest old (those age 85 or over) cancer survivors are compared to those without a cancer diagnosis, the influence of cancer on HRQOL disappears, suggesting other aspects of advancing age may overwhelm cancer in describing differences in HRQOL MHOS respondents, whether diagnosed with one or more primary cancers, tended to consistently report higher MCS than PCS. A potential explanation is that as individuals’ age, they adjust their expectations for functional recovery from illness. As a result, they learn to adapt in terms of their mental health, despite having poor physical health (Baltes, 1997). The multivariate models also point to the importance of comorbidity in explaining differences in HRQOL among cancer survivors. This is consistent with the work of Bierman and others, who argue that factors such as chronic medical conditions and declining functional abilities play more dominant roles in physical and mental health than do factors related to the initial medical diagnosis among the elderly in advancing age (Bierman, Lawrence, Haffer and Clancy, 2001; Bierman, Haffer, and Hwang, 2001). Yet, few of these studies have samples sufficient to investigate the transitions among elderly cancer survivors as they age. How advancing age interacts with multiple cancer diagnoses, comorbidity, and other clinical characteristics of this population in explaining HRQOL merits further research.

Race or ethnicity had a somewhat limited influence on overall HRQOL in this population. The contingency table results were not consistently replicated in the multivariate models where only Hispanic respondents were found to have significantly lower PCS and MCS than other racial groups. This is consistent with the findings from Ashing-Giwa and colleagues (2007) who also found that Latino respondents as reported the lowest physical (role limitations) and mental (emotional wellbeing) status in a multiethnic sample of females with breast cancer. However, the PCS scores of Asian- American cancer survivors were higher than for other respondents in our sample and U.S. population norms. It is unclear from these results why certain variables are strong predictors for some groups, but not for others, and why Asian-Americans have higher PCS compared to all other race and ethnic groups. Our findings also demonstrate that the positive association of the Asian race is more pronounced among the less educated than among college graduates. Litwin and colleagues (1999) also noted that among Asians higher education was independently associated with worse HRQOL following treatment in certain disease domains. Others have hypothesized that social support, doctor-patient relationships, and the effects of differential life stress may explain some of these differences (Ashing-Giwa et al., 2007). Studies of HRQOL among multiple ethnic groups of the elderly with and without cancer are rare (Ashing-Giwa et al., 2004). More work is needed to investigate the underlying reasons for these differences, due to their potential for more effective targeting of HRQOL interventions by managed care plans to select subgroups of cancer patients.

These results also suggest that using the SF-36(R) to target interventions to address health outcome disparities based on specific cancer diagnoses may be challenging. The associations between tumor type and HRQOL presented in Tables 7 and 8 were inconsistent across most major tumor types. The exception was lung cancer which was often associated with much greater reductions in PCS and MCS compared to U.S. population norms than were breast, prostate, or colorectal cancer. This is consistent with the Baker (2003) study previously described and in accordance with the broader literature on lung cancer, which has found that males and females diagnosed with the disease commonly report significant distress with their diagnosis and family relationships, difficulties with sexual function, and reductions in other aspects of HRQOL (Sarna et al., 2002). Also, poor physical health may be due to the significant rehabilitation problems that survivors of lung cancer have after treatment (Schag, Ganz, and Wing, 1994). Our knowledge of the HRQOL of lung cancer survivors beyond the treatment phase is very limited (Earle and Weeks, 2005). Medicare beneficiaries diagnosed with lung cancer appear to be at high risk of deteriorating HRQOL and merit special attention by researchers and health plans. Previous work on social disparities in health outcome has found that those of lower socioeconomic status experience poor HRQOL outcomes and greater symptom burden (Parker, Baile, de Moor et al., 2002). These results were replicated in this study. Our study suggests that cancer survivors with low educational attainment and low incomes are a highly vulnerable group even within an equal access setting like a Medicare health plan. This suggests that socioeconomic status may have a unique effect on HRQOL among the elderly independent of insurance status.6 Several potential explanations are possible. Knight and colleagues (2007) posit that individuals with less education may have greater difficulty understanding complex information about their cancer, its treatments, and posttreatment care. Poor understanding of the self-care instructions or poor understanding of post treatment resources available to manage symptoms and other sequelae accompanying cancer survivorship may contribute to difficulties in the management of symptoms, worry about disease burden and recurrence, and difficulty in adjusting one’s lifestyle to treatment regimens and symptoms.

Low income may present transportation barriers and result in greater isolation or reduced access to services among the elderly. Because level of education is easy to ascertain in health plan records or in the clinical setting, this could be an interventional opportunity for health plans to improve outcomes of cancer survivors. Further research is needed to understand the role of education and income as factors influencing the HRQOL of cancer survivors and potential strategies for health plans to mitigate the impact of survivorship on the lives of Medicare enrollees they serve.

This study has several limitations. First, these analyses do not include data on domains that measure the specific effects of treatments and length of survivorship on health outcomes. This may overstate the influence of diagnoses with high mortality rates like lung cancer where PCS and MCS differences among MHOS respondents may reflect more of a treatment effect than a diagnosis effect per se. Thus, it does not provide the richness of information that one would like to have in order to guide welldelineated areas for intervention. Second, because this is a pooled cross-sectional sample, relationships between variables are descriptive and do not imply causality. Future research should model how these variables affect the change in HRQOL among cancer survivors with respect to a closely matched non-cancer control group; SEER-MHOS provides such an opportunity through examination of the longitudinal cohorts of cancer survivors and those without a cancer diagnosis contained in the data set. In particular, sorting out the influence of lung cancer and possibly rarer cancers, such as bladder cancer and stomach cancer, may be useful for identifying the unique influence of tumor type on disparities in HRQOL among Medicare managed care enrollees. Third, approximately 13 percent of the sample reflects proxy responses. Proxies reported health tends to be worse than that reported directly by the elderly, especially in the area of mental health (Yip et al., 2001). A final limitation of the study design is that the survey respondents in this sample come from health plans located in the 13 SEER regions of the U.S. Although the SEER regions account for over 25 percent of all Medicare managed care enrollment, these results may not be generalizable to all health plans in the Medicare Advantage program.

These analyses illustrate the potential for the SEER-MHOS to inform our understanding of the variation in health outcomes as reflected in HRQOL and the sociodemographic factors associated with these differences. Future work to examine these differences over time, and incorporate utilization variables such as differences in initial treatment, may suggest intervention opportunities to address these variations in health outcomes. The SEER-MHOS offers important and relevant data to facilitate the monitoring, planning and targeting of health plan intervention strategies to improve the HRQOL of cancer survivors.

ACKNOWLEDGMENT

The authors would like to thank Yongwu Shao for his assistance with the multivariate statistical analyses.

1 NCI’s definition of health disparities includes other elements of cancer burden not measured in this article, such as the incidence, prevalence, and mortality of disease, and other population characteristics not captured in the Medicare Health Outcomes Survey, such as children.

2 The National Institute of Health, Office of Human Subjects Research approval number is OHSR 2620, February 19, 2004.

3 Although not reported in this article, sex and marital status were not significantly associated with either PCS or MCS.

4 Again, we did not estimate interaction effects for sex and marital status because they were not significantly associated with either PCS or MCS in the main effects models.

5 SEER data indicates that the cancer staging variables were not available and coded unstaged for more than 25 percent of the cancer survivors. Prostate cancer cases had large numbers of unstaged cases, which resulted in eliminating almost one-half of the cases from the stage of disease analyses.

6 Low PCS and MCS scores for poor cancer survivors enrolled in both Medicare/Medicaid should be taken with caution. Extremely low HRQOL respondents enrolled in Medicaid may largely reflect their severe disability status, which is a condition of Medicaid enrollment for Medicare beneficiaries living in the community.

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Garman, K.S., Pieper, C.F., Seo, P., et al: Function in Elderly Cancer Survivors Depends on Comorbidities. The Journal of Gerontology Series A: Biological Sciences and Medical Sciences 58:11191124, 2003.

Jemal, A., Siegel, R., Ward, E., et al: Cancer Statistics. CA Cancer Journal 57:43-66, 2007.

Jones, N., Jones, S.L., and Miller, N.A.: The Medicare Health Outcomes Survey Program: Overview, Context, and Near-Term Prospects. Health and Quality-of-Life Outcomes 2:33, July 2004.

Knight, S.J., Latini, D.M., Hart, S.L., et al: Education Predicts Quality-of-Life Among Men With Prostate Cancer Cared for in the U.S. Department of Veterans Affairs. Cancer 109(9):1769-1776, 2007.

Ko, Y. and Coons, S.J.: An Examination of SelfReported Chronic Conditions and Health Status in the 2001 Medicare Health Outcomes Survey. Current Medical Research and Opinion 21(11):18011808, November, 2005.

Kosinski, M., Zhao, S. Z., Dedhiya, S., et al.: Determining the Minimally Important Changes in Generic and Disease-Specific Health- Related Quality-of-Life Questionnaires in Clinical Trials of Rheumatoid Arthritis. Arthritis and Rheumatism 43:1478-1487, 2000. Lanz, N.K., Mujahid, M., Lantz, P.M., et al.: Population-Based Study of the Relationship of Treatment and Socio-demographics on Quality- ofLife for Early Stage Breast Cancer. Quality-of-Life Research 14:1467-1479, 2005.

Lied, T.R. and Haffer, S.C.: Health Status of Dually Eligible Beneficiaries in Managed Care Plans. Health Care Financing Review 25(4):59-74, Summer 2004.

Litwin, M.S., McGuigan, K.A., Shpall, A.L., et al.: Recovery of Health-Related Quality-of-Life in the Year After Radical Prostatectomy: Early Experience. Journal of Urology 161(2):515-519, 1999.

National Cancer Institute: SEER-Medicare Health Outcomes Survey. Internet address: http://outcomes. cancer.gov/surveys/seer-mhos/ (Accessed 2008.)

Parker, P.A., Baile, W.F., de Moor, C. et al.: Psychosocial and Demographic Predictors of Quality-of-Life in a Large Sample of Cancer Patients. Psycho-Oncology 12(20):183-193, 2002.

Penson, D.F., Stoddard, M.L., Pasta, D.J., et al.: The Association Between Socioeconomic Status, Health Insurance Coverage, and Quality-of-Life in Men with Prostate Cancer. Journal of Clinical Epidemiology 54:350-358, 2001.

Ries, L.A.G., Melbert, D., Kraphcho, M., et al: SEER 2006 Data Submission – Posted to the SEER Web site by Howlader, N., Eisner, M.P., Reichman, M., and Edwards, B.K. (eds.): SEER Cancer Statistics Review, 1975-2004. National Cancer Institute. Internet address: http://seer.cancer. gove/csr/1975_2004/ (Accessed 2008.)

Samsa, G., Edelman, D., Rothman, M. I., et al.: Determining Clinically Important Differences in Health Status Measures: A General Approach With Illustration to the Health Utilities Index Mark II. Pharmacoeconomics 15(2):141-155, 1999.

Sarna, L., Padilla, G., Colmes, C., et al.: Qualityof-Life of Long Term Survivors of Non-Small-Cell Lung Cancer. Journal of Clinical Oncology 20:29202929, 2002.

SAS Institute Inc.: Base SAS(R) 9.1.3 Procedures Guide, Second Edition. Volumes 1-4. SAS Institute, Inc. Cary, NC. 2006.

Schag, C.A., Ganz, P.A., Wing, D.S., et.al.: Quality-ofLife in Adult Survivors of Lung, Colon, and Prostate Cancer. Quality-of- Life Research 3:127-141, 1994.

Shavers, V.L. and Brown, M.L.: Racial and Ethnic Disparities in the Receipt of Cancer Treatment. National Cancer Institute 94(5): 334-357, March 2002.

Smith, AW, Reeve, B.B., Bellizzi, K.M., et al.: Cancer, Comorbidities, and Health-Related Qualityof-Life of Older Adults. Health Care Financing Review 29 (4) ,41-56, Summer 2008.

Ware, Jr., J.E. and Kosinski, M.: SF-36(R): Physical and Mental Health Summary Scales: A Manual for Users of Version 1 (2nd Edition). QualityMetric, Inc. Lincoln, RI. 2001.

Yip, J.Y., Wilber, K.H., Myrtle, R.C., et al: Comparison of Older Adult Subject and Proxy Responses on the SF-36(R) Health Related Quality-ofLife Instrument. Aging and Mental Health 5(2):136142, 2001.

Steven B. Clauser, Ph.D., M.P.A., Neeraj K. Arora, Ph.D., Keith M. Bellizzi, Ph.D., M.P.H., Samuel C. (Chris) Haffer, Ph.D., Marie Topor, and Ron D. Hays, Ph.D.

Steven B. Clauser, Neeraj K. Arora, and Keith M. Bellizzi are with the National Cancer Institute (NCI). Samuel C. (Chris) Haffer is with the Centers for Medicare & Medicaid Services (CMS). Marie Topor is with Information Management Services, Inc. Ron D. Hays is with the University of California, Los Angeles (UCLA). He was supported by the National Cancer Institute under the Intergovernmental Personnel Act and in part by a POl Grant Number AG020679-01 from the National Institute on Aging and by UCLA under Grant Number 2P30-AG-021684. The statements expressed in this article are those of the authors and do not necessarily reflect the views or policies of NCI, CMS, Information Management Services, Inc., or UCLA.

Reprint Requests: Steven B. Clauser, Ph.D., M.P.A., National Cancer Institute, Division of Cancer Control and Population Sciences, Bethesda, MD 20892-7344. E-mail: [email protected]

Copyright Superintendent of Documents Summer 2008

(c) 2008 Health Care Financing Review. Provided by ProQuest LLC. All rights Reserved.

KANSAS CITY, Mo., Aug. 28 /PRNewswire/ — Truman Medical Centers (TMC) became one of the first hospitals in the United States to install the Siemens SOMATOM Definition AS 128 slice CT scanner this week. The 128-slice CT scanner is a highly adaptive scanner, providing exceptional image quality with minimal radiation exposure to the patient.

“To be one of the first medical facilities in the country to have this, truly, first of its kind, state-of-the-art technology cements TMC’s commitment to providing the highest quality care to our patients with the best medical technology available,” said TMC President/CEO John W. Bluford.

The Siemens SOMATOM Definition AS 128 slice CT scanner was recently approved by the FDA and released from the Siemens Corporation. The scanner has been developed with all the latest technological advances in the world of Computed Tomography. Some of these advances include the Adaptive Dose Shielding technology which eliminates unnecessary radiation exposure to the patient through the pre and post scan range. This means that the only radiation dose the patient is exposed to will be for clinically relevant imaging.

“TMC patients can be assured that with this state-of-the-art technology they will be provided with the safest and fastest CT imaging available, ensuring exceptional care,” said Dr. Lawrence Ricci, TMC Chairman of Radiology.

The AS 128 will also allow the performance of perfusion imaging of the entire brain which will demonstrate blood flow throughout the organ over a short period of time. Other angiographic techniques will be able to be used for assessment of vascular pathways throughout the body, including the coronary arteries. With speed of the scanner being faster than the average human heartbeat it will be able to accurately visual the heart vessels allowing for a safer, more precise scan.

The relatively compact design of the system and small foot print allows for installation in smaller areas. The Siemens SOMATOM Definition AS 128 slice CT scanner is installed in the TMC Hospital Hill Emergency Department just steps away from trauma rooms. The availability of accurate and rapid scanning of trauma patients makes its placement in the emergency department ideal for managing the needs of critically ill patients without having to move them from floor to floor for radiological imaging.

“With the speed, the small footprint of its design and the adaptive technology available this CT scanner will provide the most ideal imaging capabilities to deliver a rapid diagnosis and improve overall quality and efficiency of patient care,” said Dr. Mark Steele, TMC Chief Medical Officer.

TMC expects to begin accepting patients and physician referrals for the SOMATOM Definition AS 128 slice CT Scanner as early as September 1.

About TMC

Truman Medical Centers is a not-for-profit two acute-care hospital health system in Kansas City. The TMC Health System includes TMC Hospital Hill, TMC Lakewood, TMC Behavioral Health, the Jackson County Health Department and a number of primary care practices throughout Eastern Jackson County. Recently named one of the nation’s top academic medical centers, TMC is the primary teaching hospital for the University of Missouri-Kansas City Schools of Health Sciences and specializes in asthma, bariatrics, diabetes, women’s health, and trauma services. For more information, please call (816) 404-3785 or visit http://www.trumed.org/ .

For More Information, contact:

Shane Kovac, Media Relations Manager, (816) 404-3786

Truman Medical Centers

CONTACT: Shane Kovac, Media Relations Manager, Truman Medical Centers,+1-816-404-3786

Web site: http://www.trumed.org/

The new September issue of Guideposts magazine features a cover story by Angie Harmon, actress, TV star and mother about learning the virtues of patience. Why would someone in the fast-paced world of show business even care to think about being patient? Angie tells readers, however, that it’s in her personal life where being patient has given her the most rewards. Once thinking of herself as the “most impatient person on the planet,” Angie wanted to be married, have kids and kept wondering why that “right guy” hadn’t come along. Ex-NY Giant football player, Jason Sehorn, was that guy and when a mutual friend introduced them, Angie knew it right away. He was just what she’d waited for. Angie tells Guideposts readers that a happy family life with Jason, their two girls, Finley Faith and Avery Grace – and a third child on the way – has taught her that good things truly come to those who wait.

September’s Guideposts continues its inspiring new series about people who are surviving and living with cancer with a story by Tiffini Dingman-Grover of Sterling, VA who faced hopeless odds that her 8-year old son would survive a very aggressive form of cancer. The doubts, anger, fear and above all hope of a parent’s emotional journey are vividly brought to life in Tiffini’s personal story of her son’s ordeal. Stories that help round out Guideposts September issue include: Tennis star James Blake tells about the inspiration his father provided that helped make him a champion; the work of Farm Rescue volunteers to save a North Dakota family farm; a nurse’s dedication to helping heal New Orleans despite her 280 mile commute to work there; how books helped a daughter and step-dad bond; secrets to a long-lasting marriage from Guideposts co-founder the late Ruth Stafford Peale; a family project to build a Peace Table; one woman’s recollection of meeting Beatle John Lennon at her church; healthy and fun family meal planning for a whole week; how an American wife learned to cook her Italian husband’s favorite dishes… there’s even a great recipe for his mother’s spaghetti alla puttanesca; and much more. (To read more about these stories and others in this issue, please visit www.guidepostsmag.com).

“Our readers love a great story and Guideposts stories really connect with readers because the person the story is about – even celebrities like Angie Harmon and James Blake – actually tell their own true story,” says Edward Grinnan, Guideposts Editor-in-Chief. Ranked #1 by a major national survey as “favorite magazine” overall for the past 6 years in a row and one of the top 25 magazines in America, Guideposts brings its popular, engaging, and life-changing true stories of hope and inspiration to millions of readers. Guideposts September issue is on sale at major retailers, food & drug chains, bookstores, newsstands, and other magazine outlets nationwide at a cover price of $2.99.

Guideposts’ stories reflect today’s culture, where the desire for a sense of hope and interest in spiritual well being has never been more important. Recognized for over 60 years as “America’s Source for Inspiration,” Guideposts contains articles, from everyday people and celebrities alike, covering topics such as: relationships, health issues, family, self-help, heroism, survival, and rescue. Regular departments and on-going series focus on subject like: Making Marriage Work, Health Breakthroughs, Caregivers, Communities in Action, Positive People, and Pets & Healing.

LEWISTON – A new course, “Cancer and Society,” will be offered during the fall semester at the University of Southern Maine’s Lewiston-Auburn College from 1 to 3:30 p.m. Tuesdays, beginning Sept. 2.

The seminar course will examine what has been learned about the origin, treatment, survivorship and death from cancer.

Beginning with President Nixon’s declaration of “War on Cancer” in 1971, cancer has emerged from the shadows and become a focus of the American people.

The instructors for the course are Blake Whitaker, PhD, and Sallie Nealand, EdD. Whitaker’s area of expertise is cellular biology and infectious diseases. His research focus is on the genetic effects of pollution and on the immunophysiology of reproduction.

Nealand is a retired USM professor of nursing who has worked as a community nurse in Pennsylvania and has taught at the University of Delaware, Neumann College in Aston Pa., as well as the University of Southern Maine.

Registration is open through the first class meeting.

The course has no prerequisites. For more information or to register, call 753-6500. The complete fall semester USM LAC course schedule is online at www.usm.maine.edu/lac/schedules.

(c) 2008 Sun-Journal Lewiston, Me.. Provided by ProQuest LLC. All rights Reserved.

Support for people with cancer and their families is provided by the Cancer Society of New Zealand from its Christchurch office in Manchester Street.

Josie Cowen, a support services staff member, and Meg Biggs, a cancer information nurse, who work from the Cancer Society office in Manchester Street, are two members of a dedicated team which provides answers for those affected by the diagnosis of cancer.

The support services staff offer regular contact for people with cancer, their families and friends.

“Our service offers care and support that complements the health care services,” Cowen says.

“Referrals come from health professionals or people can also drop in to the office or telephone us to make the initial contact.

“We support people from early diagnosis, through their treatment, and for some, we remain in contact to support them and their families through the later stages of their disease. These services are all free.

“Support is provided by health professionals.We offer emotional and practical support. We have time to listen. We recognize and respect that everyone’s needs are different.”

The Cancer Society also offers a turban service, prosthesis fittings, and Look Good Feel Better workshops.

It is also an agent for Total Mobility, a scheme that provides subsidised taxi service for people with serious mobility constraints.

Support groups and programmes are offered, including educational sessions and self-care with activities such as relaxation, nutrition and exercise. These sessions are an opportunity to meet with others who are having a similar experience.

“Our trained volunteers are a vital part of the service we offer. They offer companionship, home visits, baking, transport to medical appointments and outings,” Cowen says.

The Cancer Society Information Service is available to answer questions that people have about cancer.

The Christchurch information team is available Monday to Friday from 8.30am to 5pm. It can be contacted by phoning (03) 379 5835 or 0800 226 237 (CANCER).

The team is part of the National 0800 cancer information service that is serviced from Auckland, Wellington and Christchurch. The Christchurch team also has an open- door policy for people in the local area to come in and talk face to face if they prefer.

“The object of the 0800 number is to make cancer information as equitable and available to people in New Zealand wherever they live,” Biggs says.

“We respond to calls about cancer prevention, screening, investigations, diagnosis, treatment, decision making, after treatment issues, survivorship, through to the late stages of disease and palliative care.

“When a cancer is diagnosed, things happen very quickly. People often find it useful to have someone outside their family or support network to talk to. We can help to clarify people’s understanding and provide information around their type of cancer, its treatments and their situation.”

The team is able to provide information through booklets, brochures, from websites (or recommend reputable websites), books from the Cancer Society library, or audiovisual material that can be mailed or sent by to individuals.

Much of the information is translated into Maori and it is planned to translate key information into other languages commonly used in New Zealand.

The Cancer Society’s Cancer Connect NZ programme arranges telephone peer support calls for people living with cancer and for caregivers. Each Cancer Connect peer supporter has had a cancer or cared for a loved one living with cancer. It is a free support service that provides a listening ear, practical information and the opportunity to talk to someone whose life has been affected by cancer.

“It is a privilege to be a part of people’s lives and we all have a passion for what we do,” Biggs says.

The Canterbury West Coast Division of the Cancer Society of NZ is located at 246 Manchester St, Christchurch, Ph (03) 379 5835. The Cancer Information Service may be contacted on Toll Free 0800 226 237 (CANCER).

——————–

(c) 2008 Press, The; Christchurch, New Zealand. Provided by ProQuest LLC. All rights Reserved.

CHICAGO, Aug. 28 /PRNewswire/ — Carol Cottrill, M.D., a pediatric cardiologist at the University of Kentucky’s Kentucky Children’s Hospital in Lexington, KY, has been named the 2008 recipient of the Catholic Church Extension Society’s Lumen Christi Award for her lifesaving ministry in the mission areas of Appalachia and her generous presence in caring for poor families in desperate need of medical care.

The national award (which means “Light of Christ”) is presented annually by Catholic Extension to recognize outstanding missionary work in America. This year marks the 31st annual Lumen Christi Award given by Catholic Extension.

Rev. John J. Wall, President of Catholic Extension, will present the Lumen Christi Award to Dr. Cottrill in Chicago Sept. 27, followed by Mass at Holy Name Cathedral. Catholic Extension will further honor Dr. Cottrill with a gift of $25,000, and the Diocese of Lexington, which nominated her for the honor, will also receive $25,000.

Over the past 30 years, Dr. Cottrill has saved the lives of hundreds of children, bringing a missioner’s compassionate heart to families with children facing life-threatening illness. Cottrill’s fourth child, Crystal, was born with a serious heart condition and died at the age of 6. Dr. Cottrill and her husband Tom have served as foster parents to more than 24 children, 19 of which had heart disease. For the past 2 1/2 years Dr. Cottrill has worked from a wheelchair because of rheumatoid arthritis.

Her Catholic Faith plays an important role in Dr. Cottrill’s professional and personal life. An active member of the Newman Center at the University of Kentucky, she is a long-time participant in parish activities, especially as a member of the Newman Foundation Board of Directors. She is committed to the health of the needy in eastern Kentucky, where she runs two monthly cardiac care clinics in Pikeville and Somerset. They have never turned away any families in need.

“We at Catholic Extension are privileged to recognize and honor missionaries like Dr. Cottrill,” Rev. Wall said. “She exemplifies the ‘Light of Christ’ in the way she has continued to reach out to offer excellent medical care and a caring, understanding empathy to folks who rely on her in the Diocese of Lexington. Having lost a child to heart disease herself, she feels deeply and compassionately what is in the hearts of the families she serves and is a real gift to them.”

“Dr. Cottrill exemplifies how the Light of Christ shines in so many ways,” said Most Reverend Ronald W. Gainer, Bishop of Lexington, who nominated her for the award. “Through her thorough and professional care of the youngest and most vulnerable cardiac patients, through her understanding and compassion for their families, through her role as a teacher and mentor to medical students, and through her tireless service to the wider community.”

Nominations for the Lumen Christi Award are put forward by home mission bishops and then judged by a prestigious panel. This year’s panel included television’s Bob Newhart, Chicago Bears owner and Board of Directors Secretary Virginia McCaskey, radio and television personality Father Albert Cutie, Sister Maria Elena Gonzalez, RSM, former president of the Board of Directors of the Mexican American Cultural Center, “Our Sunday Visitor” Associate Publisher Monsignor Owen Campion, and retired Bishop of Biloxi Most Reverend Joseph L. Howze.

For more than 100 years, the Chicago-based Catholic Church Extension Society has supported Catholic missions in the U.S. by funding church construction, religious education and seminary formation, campus and outreach ministries, evangelization, and salaries for missionaries. Catholic Extension is the leading supporter of Catholic missions in the U.S. and has distributed more than $450 million over its history.

Read more about Dr. Cottrill in the September issue of EXTENSION Magazine. Sign up to receive a full year of EXTENSION Magazine free of charge. Call 1-800-842-7804 or visit http://www.catholicextension.org/.

(For high-resolution photos of Dr. Carol Cottrill for reprinting, please email Mark Andel at [email protected] or call 312-795-6074.)

    Mark Andel    Director of Communications    Catholic Church Extension Society    150 South Wacker Drive, 20th Floor    Chicago, IL 60606    Phone: (312) 795-6074    Web: http://www.catholicextension.org/    email: [email protected]  

Catholic Church Extension Society

CONTACT: Mark Andel, Director of Communications of Catholic ChurchExtension Society, +1-312-795-6074, [email protected]

Web site: http://www.catholicextension.org/

Aurora Imaging Technology Inc. today announced that the Aurora(R) 1.5Tesla Dedicated Breast MRI System is now available to patients in northern Massachusetts and southern New Hampshire at Aurora Breast MRI of Beverly Hospital. The Aurora System is the only Food and Drug Administration (FDA) cleared dedicated breast MRI system specifically designed for the detection, diagnosis and management of breast disease.

Aurora Breast MRI of Beverly Hospital is located within the Breast Health Center at Beverly Hospital at Danvers, providing specialized service and easy access to advanced imaging technology for its patients. Since the Aurora System’s installation earlier this summer, the center has scheduled patients daily for breast MRI screening.

“MRI is an emerging technology and we are proud to add a dedicated breast MRI to our Breast Health Center with the installation of the Aurora System,” said Peter Curatolo, M.D., radiologist and acting medical director, Aurora Breast MRI of Beverly Hospital. “The Aurora System plays a valuable role in the diagnosis of breast cancer at our facility, and has been instrumental in the staging and treatment planning of patients with recent diagnoses of breast disease. The Aurora System is an integrated component of our multidisciplinary center and the feedback we’ve received from patients regarding our new service has all been very positive.”

The Aurora System’s table design captures full coverage of both breasts, the chest wall and axillae in a single scan, without any compromise in image contrast or resolution. Its feet-first entry also minimizes feelings of claustrophobia, and patients rest comfortably on the massage-type table contoured specifically for breast anatomy. Such patient comfort also greatly minimizes the risk of patient movement and thus, motion artifacts on the images are reduced. Patients lie prone, with arms forward and down for comfort, with their breasts suspended away from their chest.

“We’re very pleased to offer the convenience and comfort provided by the Aurora System,” said Christine Aiello, director, Radiology and Imaging Services, Beverly Hospital. “Since the Aurora System was designed specifically with a woman’s anatomy in mind, it is more appealing to our clientele of female patients as the Aurora System is more sensitive to their needs and concerns.”

Unique to the Aurora System is a computer-automated and fully integrated MRI-guided biopsy technology, which virtually eliminates human error by accurately determining needle placement for a seamless procedure. The Aurora System also delivers industry-leading, ultra-thin 1mm slices for superior resolution and clarity, ideal for detecting cancers that may be missed through mammography or clinical examination. These features are only a fraction of the Aurora Systems’ advancements, all helping to detect cancers at earlier stages of development, thus directly aiding in the fight against breast disease.

“Early detection of cancer, through the help of advanced imaging technologies like the Aurora System, is the key to eradicating mortalities associated with breast disease,” said Olivia Ho Cheng, president and chief executive officer, Aurora Imaging Technology Inc. “Breast health centers nationwide are continually discovering the benefits of this important imaging modality. We proudly partner with Beverly Hospital to offer additional access to the Aurora System, to reach our mutual goal of winning the battle against breast disease.”

Over the years, breast cancer statistics have steadily declined in Massachusetts. However, according to the American Cancer Society (ACS), breast cancer is the second leading cause of female cancer mortalities in the state. The availability of the Aurora System at Aurora Breast MRI of Beverly Hospital supports the most recent ACS guideline, recommending breast MRI for women at high risk of breast cancer. This installation marks the fourth Aurora System in the state of Massachusetts.

About Beverly Hospital

Beverly Hospital is a full service, community hospital providing quality, patient-centered care to North Shore and Cape Ann residents. Services include maternity, pediatrics, surgical, orthopedics, cardiology, as well as other specialties. The hospital boasts a medical staff of more than 570 physicians and its service area includes some 13 communities. Beverly Hospital has been nationally recognized by Solucient Institute as a 100 Top Hospital five times in the past seven years. Beverly Hospital is a member of Northeast Health System. For more information on Beverly Hospital, visit www.beverlyhospital.org.

About Aurora Imaging Technology Inc.

Aurora Imaging Technology Inc. is a private company based in North Andover, Mass. committed to expanding the fight against breast cancer. Aurora strives to manufacture the highest quality and most cost-effective breast MRI solutions, and partners with a growing number of the nation’s finest breast care centers to provide the ultimate in the detection, diagnosis, biopsy and treatment of breast cancer. The Aurora System is in clinical use at a rapidly growing number of leading breast care centers in the United States, Europe and Asia. To find an Aurora Dedicated Breast MRI System near you, visit www.auroramri.com.

CELSION CORPORATION (NASDAQ: CLSN) announced today that the interim results from its second Phase I liver cancer confirmation study of ThermoDox(R) used in combination with Radio Frequency Ablation (RFA) for the treatment of patients with primary and metastatic liver cancer will be presented at a Poster Presentation session at the International Liver Cancer Association (ILCA) Annual Conference in Chicago, IL, from September 5-7, 2008. This annual conference is recognized as a premier multidisciplinary gathering of cancer researchers dedicated to the exchange of knowledge and innovative approaches to liver cancer research and care. For more information on the ILCA, visit their website: http://www.ilca-online.org/.

The abstract presentation, titled “Phase I Dose Escalation Study of Thermally Sensitive Liposomal Doxorubicin (ThermoDox(R)) in combination with Radiofrequency Ablation (RFA) of Primary and Metastatic tumors to the liver: Interim Report” will be delivered by Dr. Thanjavur S. Ravikumar, MD Professor and Chairman, Department of Surgery, North Shore Hospital, Albert Einstein Medical School. The presentation will provide interim Phase I results regarding safety, dosage and pharmacokinetic summaries supporting the company’s pivotal global trial for Hepatocellular Carcinoma, which is currently enrolling patients.

The ILCA Annual Conference 2008 marks the fifth time this year that Phase I results from ThermoDox(R) trials have been presented at a major medical conference. In February of this year, Dr. Ronnie T. Poon, Professor of Surgery at the Queen Mary Hospital, Hong Kong presented our Phase I liver cancer study results at the International Hepato-Pancreato-Biliary Association (IHBPA) Conference in Mumbai, India at the Oral Paper Awards Session. In March, Dr. Bradford J. Wood’s abstract titled “Imaging Features in Patients undergoing Liver RFA plus Heat Deployed Nanoparticles” was selected for Oral presentation at the Society for Interventional Radiology. Also in March, Dr. Zeljko Vujaskovic, Associate Clinical Professor at Duke University, on behalf of Dr. Ellen Jones, presented interim progress and evidence of safety and suggested efficacy from our second indication under study, Recurrent Chest Wall breast cancer, at the ICHO Conference in Munich, Germany. Finally, in June Dr. Ravikumar presented at WCIO 2008 & Best of ASCO.

Michael H. Tardugno, Celsion’s President and Chief Executive Officer, commented, “The medical and scientific communities’ interest in our innovative treatment approach and the results that ThermoDox(R) has shown in early phase trials is most encouraging and reinforces our commitment to bringing our promising technology to market as rapidly as possible. Accordingly, we continue to make progress in our pivotal Phase III HCC program. We have enrolled patients in four out of the seven countries for which we have Clinical Trial Agreements and have announced our plans for clinical development in Japan, funded and led by Yakult Honsha. Yakult is a leading Japanese healthcare company with a rapidly growing oncology focus. Through this partnership agreement, our goal is to ensure ThermoDox(R)’s presence in the promising Japanese HCC market, which is currently the 2nd largest global market based on incidence.”

About ThermoDox(R): ThermoDox(R) is Celsion’s proprietary heat-sensitive liposomal encapsulation of doxorubicin, an approved and frequently used anti-cancer drug used in the treatment of various cancers. Localized heat (at 40-42 degrees Celsius and above) releases the entrapped doxorubicin from the liposome. This delivery technology enables high concentrations of doxorubicin to be deposited preferentially in a targeted tumor.

About Celsion: Celsion is dedicated to the development and commercialization of oncology drugs including tumor-targeting treatments using focused heat energy in combination with heat-activated drug delivery systems. Celsion has research, license or commercialization agreements with leading institutions such as the National Institutes of Health, Duke University Medical Center, University of Hong Kong, Cleveland Clinic, North Shore Long Island Jewish Health System.

For more information on Celsion, visit our website: http://www.celsion.com.

Celsion wishes to inform readers that forward-looking statements in this release are made pursuant to the “safe harbor” provisions of the Private Securities Litigation Reform Act of 1995. Readers are cautioned that such forward-looking statements involve risks and uncertainties including, without limitation, unforeseen changes in the course of research and development activities and in clinical trials by others; possible acquisitions of other technologies, assets or businesses; possible actions by customers, suppliers, competitors, regulatory authorities; and other risks detailed from time to time in the Company’s periodic reports filed with the Securities and Exchange Commission.

The central role of receptor tyrosine kinases (RTKs) in cellular processes, especially in cancer, has made them an important target for several antibody- and small molecule-based inhibitors specific for various RTKs for the treatment of different tumour entities. The electrical impedance detection method with Roche’s real-time cell microelectronic sensor-based platform xCELLigence system is a facile, high content, and cell based kinase assay allowing for monitoring short term RTK activation and the long term biologic effect of the activation in real time in a single well. The novel technology has improved utility over existing in vitro and cell based assay in the identification and characterization of selective and potent kinase inhibitors, as shown in a recent study.

Several approaches have been developed to identify RTK inhibitors such as antibody-dependent and independent technologies. However, most of these current approaches are end point, in vitro based assays that require substantial reagent optimization, and are inadequate in providing information on their effective intracellular activity. Roche Applied Science’s xCELLigence System – originally invented by the US-based ACEA Biosciences and co-developed by Roche and ACEA – addresses several of these limitations. Unlike other RTK assays, this technology is cell-based, label-free, capable of monitoring cellular changes in real-time, and non-invasive. The method utilizes an electronic readout of impedance to quantify cellular status, including cell number, viability, morphology, and cytoskeletal dynamics. Cells are seeded in E-Plate microtiter plates, which are integrated with microelectronic sensor arrays. The interaction of cells with the microelectrode surface leads to the generation of a cell-electrode impedance response, which indicates the status of the cells in terms of morphology, quality of adhesion and number.

According to experimental data, the xCELLigence System provides a facile, easy platform for identification and further characterization of RTK inhibitors. In a recent study(1), the kinetic of epidermal growth factor (EGF)-mediated changes of COS7 cells pretreated with epidermal growth factor receptor (EGFR) inhibitor and insulin were monitored using the xCELLigence System.

As the authors concluded, the electrical impedance detection method was able to screen, identify, and characterize a potent and selective EGF receptor inhibitor from a compound library. The assay quantified morphological changes in response to growth factor treatment and therefore mimics proximal events in kinase activation. Additionally, the xCELLigence System provided valuable information about the state of the cell and the signalling pathways being activated. Furthermore, the technology does not require intensive optimization or special reagents such as peptides, antibodies, or probes, nor suffers from assay component interference. Since the readout is non-invasive, multiple treatments can be performed in the same well. The assay can also be used in conjunction with other existing cell-based assays for RTK. More important, because the assay is cell based, the studies are done in a physiologically relevant environment, allowing for concurrent assessment of a compound’s solubility, stability, membrane permeability, cytotoxicity, and off-target interaction effects. Finally, the system requires very little user training, making this assay amenable for use in both primary and secondary screens.

For more information on the technology, please visit www.xcelligence.roche.com

(1) xCELLigence System, Application Note No. 4, 2008, Roche Applied Science.

About Roche

Headquartered in Basel, Switzerland, Roche is one of the world’s leading research-focused healthcare groups in the fields of pharmaceuticals and diagnostics. As the world’s biggest biotech company and an innovator of products and services for the early detection, prevention, diagnosis and treatment of diseases, the Group contributes on a broad range of fronts to improving people’s health and quality of life. Roche is the world leader in in-vitro diagnostics and drugs for cancer and transplantation, and is a market leader in virology. It is also active in other major therapeutic areas such as autoimmune diseases, inflammatory and metabolic disorders and diseases of the central nervous system. In 2007 sales by the Pharmaceuticals Division totalled 36.8 billion Swiss francs, and the Diagnostics Division posted sales of 9.3 billion francs. Roche has R&D agreements and strategic alliances with numerous partners, including majority ownership interests in Genentech and Chugai, and invested over 8 billion Swiss francs in R&D in 2007. Worldwide, the Group employs about 80,000 people. Additional information is available on the Internet at www.roche.com.

XCELLIGENCE is a trademark of Roche.

E-PLATE, RT-CES, and ACEA BIOSCIENCES are registered trademarks of ACEA Biosciences, Inc. in the US.

REDCAR’S most famous triplets are about to embark on their first day at school.

Lewis, Lilly-Sue and Taylor-Jean Butters, all four, start reception at Greengates Primary next Tuesday.

Parents Sammie, 22, and David, 29, year-and-a-half-old-brother Alfie, and Ruby, five months, will wave them off.

The triplets first made headlines when they were born in Scunthorpe on July 24, 2004.

Sammie was whisked there due to a lack of incubators at the James Cook Hospital.

Last year they appeared on TV programme, the House of Tiny Tearaways.

Now they are preparing to start school and mum and dad say they have mixed feelings about the big day.

Sammie said: “They tried their school uniform on and I nearly cried. They looked so small. The girls are tiny, so we had to wash their new jumpers at a high temperature to try to shrink them to fit.

“We had to have their pinafores taken up as well.

It feels like yesterday when they were born and now they are off to school – before we know it they’ll be doing their GCSEs!”

The triplets will be in the same class and although they look alike and share a passion for painting, they have very different personalities.

Lewis is shy and loves jigsaws and can concentrate for long periods on a task. Taylor-Jean loves any type of sport and is often seen kicking a ball. Lilly-Sue loves nursery rhymes and playing with dolls.

David said: “We are so used to having them with us all day long that it will be strange when they go to school.”

But the kids aren’t the only ones getting on the learning ladder. Sammie starts her access to nursing course at Redcar College on September 15. She will be training as a nurse before becoming a midwife.

(c) 2008 Evening Gazette – Middlesbrough. Provided by ProQuest LLC. All rights Reserved.

By NORA FIRESTONE

By Nora Firestone

Correspondent

LYNNHAVEN

“Listen to your body,” he told me.

I figured that when my quadriceps screamed, “Lunge for the heating pad!” I’d quietly withdraw into the August evening, sip Gatorade and take notes as the sun set beyond Mount Trashmore Lake.

But that never happened.

Fitness coach Andre Owens designs his three-day-a-week exercise program to serve at every level.

Owens, who is a trainer at Fitness 24/7 in Virginia Beach when he’s not leading his evening classes at Trashmore, even has the patience to deal with me, a Beacon correspondent who hasn’t “had time” to workout since last century.

Everyone – from architect Maureen McElfresh, who recently gave birth, to Navy man Derek Rankin and his wife, Noelle, a veterinary technician – seemed strangely satisfied, despite their panting and grunting.

Masochists? No, they looked normal.

Okay, maybe normal’s not the word. How many people do pushups on the incline of a mountain, facing downward? Or delight in running uphill backward, sidestepping to a set of orange cones and cheering when one cone is lifted to reveal the next task: a seven-second “Chicken Dance?”

I counted 12.

But they were kind – like a dozen “good eggs,” and up for a challenge. Each encouraged the others. They strove for better stretches than the day before or for one more backward downhill skip than they’d landed (upright) last week.

“You should try it,” newbie Kevin Thompson had urged. Having recently recovered from an injury, the “40-ish” human resources consultant from Kempsville had just started working fitness back into his lifestyle.

I should, I thought.

All hands met mid-huddle. Owens’ brief pep talk seemed to strike a different chord within each individual.

As Ann Cleland of Chick’s Beach later said: “He’s very positive. He makes everybody comfortable. No matter where you are in physical fitness, he makes you better.”

“Hard work!” we shouted, and headed for our mats.

Owens’ initial advice came back to me: “Whenever your body’s saying ‘I need to shut it down right now,’ shut it down. Don’t try to keep up,” he said. “Everyone here’s at different fitness levels.”

Prep meant jumping jacks, squats and several contortions designed to elongate targeted muscles. Twenty-one “butt-kickers” had us jogging in place, kicking our own glutei with our heels.

Twenty-one, not 20, Owens said, because “We can always do one more.” He’d named his business, Pro 14:23, for a biblical proverb. “All hard work leads to profit. But mere talk leads to nothing,” he said.

A California native and personal trainer since 1989, Owens sets the standard high for the advanced folks, but his group says he has a knack for individualized affirmation and encouragement.

McElfresh and I felt no shame “shutting it down” now and then.

“It’s not easy stuff that Andre puts them through,” Thompson said, nodding toward the “veterans.””These things are for athletes. My first night, I didn’t even finish.”

But this hour had passed quickly, marked by good company, great instruction, fresh air and a natural backdrop of kite-flying children fading to silhouette at the hill’s horizon.

The class broke with another huddle: “Results!”

“You should come back,” Cleland said.

I should.

Nora Firestone, [email protected]

going?

What Andre Owens’ outdoor fitness program

Where Mount Trashmore Park, 310 Edwin Drive

When 7-8 p.m. Mondays, Tuesdays and Wednesdays.

Cost $10

Info Wear comfortable workout clothes. Bring a towel or mat and sugary fruit and water or an electrolytes drink.

Call Andre Owens to reserve a spot: 660-2886, www.pro1423.com

Originally published by BY NORA FIRESTONE.

(c) 2008 Virginian – Pilot. Provided by ProQuest LLC. All rights Reserved.

By Theresa Harrington

Together, John Muir Medical Center’s campus expansions in Walnut Creek and Concord comprise one of the largest construction projects under way in Contra Costa County.

With holes dug and steel frames beginning to take shape, the John Muir Health Foundation has merged the capital campaigns for both projects, increasing its overall goal to $56 million by 2011 to help pay for $800 million in costs.

So far, the foundation is slightly more than halfway toward meeting this commitment, with $28.6 million raised.

“We’re working with possible donors in the Concord area on soliciting a major lead gift,” said Susan Woods, foundation president.

About $27.6 million has been earmarked for the Ygnacio Valley Road facility in Walnut Creek, while $1 million is designated for a new patient room building at the East Street hospital in Concord.

For a $9.5 million lead gift in Walnut Creek by the Thomas J. Long Foundation, the new five-story, 350,000-square foot addition will be named the Thomas J. and Muriel T. Long Patient Care Tower.

Naming opportunities in Concord range from $10 million for the five-story, 174,000-square-foot cardiovascular patient care tower to $25,000 for emergency department treatment rooms, Woods said.

Capital campaign director Kimberly Low is optimistic about raising the remaining $27.4 million in the next three years. Up until now, she said, the foundation has focused on large donors and internal fundraising.

Recently, Low and board members have begun giving presentations and tours to civic leaders, in the hopes that they will become strong advocates for the hospital projects. In the fall, the foundation will launch its public campaign, asking patients and others to help support the locally-run, not-for-profit institutions.

“I think the public will respond very positively,” Low said. “To our knowledge, there has not been any broad-based fund-raising in the Concord community (toward the medical center). It’s been there 70 years. No one’s ever said, ‘Show your support for our Concord hospital.’ “

Dr. Michael Levine, a Concord campus cancer specialist, said he recently joined the foundation board to ensure high-quality medical facilities now and in the future.

“It’s kind of an extension of what I do every day, personally improving the health of my patients,” Levine said. “This gives me a special opportunity to make a broader impact on health care in Contra Costa County and hopefully to inspire others to give back to this effort.” Both expansions, slated to open in late 2010, are on schedule, said Michael Monaldo, vice president for facilities development.

Theresa Harrington covers Walnut Creek. Reach her at 925-945- 4764.MORE INFORMATION:

Details about the John Muir Health Foundation’s capital campaign are at 925-947-4449 or www.johnmuirhealthfoundation.org.

Originally published by Theresa Harrington, Contra Costa Times.

(c) 2008 Oakland Tribune. Provided by ProQuest LLC. All rights Reserved.

By Ambs, Anita Warren, Joan L; Bellizzi, Keith M; Topor, Marie; Haffer, Samuel C (Chris); Clauser, Steven B

The Surveillance, Epidemiology, and End Results (SEER)-Medicare Health Outcomes Survey (MHOS) links cancer registry data with survey data from Medicare managed care enrollees. The linked file includes clinical information about the cancer with self-reported data about symptoms, functional status and health-related quality of life (HRQOL) for Medicare managed care enrollees. This article provides a description of the SEER-MHOS data as a tool to study cancer among Medicare enrollees. In order to highlight the strengths of the database, we also present some descriptive statistics from the database. INTRODUCTION

Although cancer strikes both young and old, it is well recognized in the medical community that the disease disproportionately affects the elderly. Almost 60 percent of incident cases (all sites combined) occur in males and females age 65 or over (Surveillance Research Program, National Cancer Institute, 2003). Of the 10.8 million prevalent cancer population, 60 percent (6.5 million) of cancer survivors are age 65 or over (Surveillance, Epidemiology, and End Results Program, 2007). Forty-three percent of these 6.5 million elderly males and females with cancer survive more than 10 years and 17 percent of them survive more than 20 years from their initial diagnosis (Surveillance, Epidemiology, and End Results Program, 2007). Although age-adjusted cancer incidence rates in the U.S. have declined significantly from 1995-2004 (Ries et al., 2007), the number of people newly diagnosed with cancer is expected to increase because of population growth and the aging of the U.S. population. It is estimated that the number of persons with cancer will double by the year 2050 (Edwards et al., 2002).

The burden that cancer places on the U.S. population has resulted in much interest in assessing cancer treatment and outcomes, especially for older persons. A number of population-based studies have used secondary data to evaluate patterns and quality of care, outcomes, and health care costs for elderly persons with cancer. One aspect of the cancer experience of older people that cannot be addressed with studies based on available secondary data, however, is HRQOL. Data from pediatric and young adult cancer populations show that cancer and its treatment can result in years of physical and mental distress for some individuals (Robison, 2005; Zabora et al., 2001; Oeffinger et al., 2006), but little is known about how cancer treatment affects HRQOL in the elderly. Moreover, the elderly population differs from younger groups in a number of respects, including the fact that they have higher levels of comorbidities that may affect HRQOL even in the absence of a cancer diagnosis. The addition of a cancer diagnosis to other health conditions may have an interactive affect on HRQOL. The role of comorbidity on HRQOL is an emerging area of research interest only recently receiving attention among investigators (Bellizzi and Rowland, 2007; Lichtman, Balducci, and Aapro, 2007; Rao and Demark-Wahnefried, 2006; Aziz and Bellizzi, 2008; Yancik et al., 1996; Extermann, 2007; Hewitt, Rowland, and Yancik, 2003).

In 1998, CMS began to monitor the quality-of-care provided by Medicare managed care plans through the MHOS. The MHOS was designed to gather valid, reliable, and clinically meaningful data on health outcomes, including functional status, comorbid conditions, symptoms, and HRQOL for the approximately 8.3 million Medicare managed care enrollees, who account for 19 percent of Medicare beneficiaries in 2007 (U.S. Department of Health and Human Services, 2008). MHOS data provide a unique opportunity to assess HRQOL for patients with selected clinical conditions, including cancer.

To assess HRQOL for cancer patients, NCI and CMS have collaborated to link the MHOS with cancer registry data from the SEER program of population-based registries (Espey et al., 2007). This linked dataset provides a powerful and efficient way to collect data on HRQOL of older cancer patients enrolled in health maintenance organizations (HMOs).

OVERVIEW

Data Sources

SEER

The SEER program collects information about all newly diagnosed cancer (incident) cases in populations within defined geographic areas. The program, which began in 1973, now includes registries that cover about 26 percent of the U.S. population. Detailed information can be found at http://seer.cancer.gov/. The SEER areas include Connecticut, Hawaii, Iowa, New Mexico, Utah, Kentucky, Louisiana, New Jersey, California, the metropolitan areas of Detroit, Atlanta, Seattle-Puget Sound, and rural Georgia. Data collection for some registries, Kentucky, Louisiana, New Jersey, and greater California, began in 2000. The information collected by the registries includes patient’s age, sex, race, and marital status. Information about the cancer consists of the month and year of diagnosis, the site, behavior, and stage. Staging in the SEER data is based on classification schemata that vary by cancer site and year of diagnosis. These methods include SEER historic staging and American Joint Committee on Cancer staging system, the latter available for all cancers other than lymphoma and leukemia. The SEER historic staging variable consists of the categories of in situ, localized, regional, distant and unstaged and can be used to track trends in stage over time. SEER registries also collect information about surgical and radiation treatment recommended or provided within 12 months of diagnosis. Information about chemotherapy is not reported because of concerns about under ascertainment. Followup is limited to vital status, and cause of death, if applicable. The data collected by the registries comes primarily from medical records and reports from health professionals. The registries do not collect information on non-melanoma skin cancer, use of screening, or how the cancer was detected, cancer recurrence or progression, sequela of disease or treatment, or cancer-specific symptoms related to HRQOL (Warren et al., 2002).

MHOS

The National Committee for Quality Assurance began the MHOS in 1996 under contract to CMS. The original intent of the MHOS was to measure health outcomes of Medicare beneficiaries who are enrolled in Medicare Advantage (previously Medicare+Choice) health plans for use in monitoring plan performance and improving health outcomes. The MHOS includes a 95-item core questionnaire that is administered to 1,000 randomly selected beneficiaries including institutionalized and disabled beneficiaries who were members of the participating managed care organization (MCO) in the Medicare Advantage program. In plans with fewer than 1,000 enrollees, all eligible members were surveyed. A baseline survey was administered to the first cohort in May 1998, and a followup survey was administered to the same cohort in spring 2000. A new cohort is randomly selected each year for baseline measurement and a 2-year followup assessment.

Since 1998, CMS has conducted 10 baseline surveys and 8 followup surveys. The MHOS data used for the SEER-MHOS project include people who were selected to respond to the MHOS between 19982001 and their 2-year followup surveys, if available. These years were selected as it allowed us to use an established link between Medicare enrollment data and persons in SEER. The core MHOS survey contains questions related to demographics, socio-economic status, health problems, functional status (activities of daily living [ADLs]), and symptoms1. It also assesses measures of HRQOL through the Medical Outcomes Study Short Form-36 (SF-36(R), version 1). This instrument is widely used and has been validated in several studies, including many that have assessed cancer care (Turner-Bowker et al., 2002). As shown in Table 1, the SF-36(R) has eight scales, with each representing a separate construct of HRQOL (Jones, Jones, and Miller, 2004). The eight scales provide the basis for calculating two summary measures, the physical component summary (PCS) and the mental component summary (MCS). Scores on the two summary measures include data from all eight scales, but vary by the order in weight applied to each scale. The PCS score is mostly determined by the physical functioning, role-physical, bodily pain, and the general health scales. The MCS is mostly determined by the mental health, role-emotional, social functioning, and vitality scales.

The SF-36(R) uses norm-based scaling, meaning that scores on the instrument are standardized using an algorithm that builds in normative values for the U.S. population. Thus, all scores above or below 50 can be interpreted as above or below the general population norm. Moreover, because the standard deviations for each scale are equalized at 10, it is relatively easy to see exactly how far above (or below) the mean any particular score is in standard deviation units (Ware et al., 2004). This aspect of the SF-36(R) is a major advantage over other HRQOL instruments used in this type of research, because other instruments typically do not allow direct comparisons to U.S. population norms. The extensive self-reported information on the MHOS can be used to compare HRQOL differences between cancer survivors, cancer patients, and the general elderly population enrolled in MCOs, as well as differences within these groups by demographic, socio-economic status, and type of MCO health plan. The available information on the MCO health plans include type of plan, the plan’s State, name, and organization name, Medicare product name, and CMS region. It also includes information on the population of people it served by MCO. In addition, information on the health plan’s start date, duration of the plan contract, and duration of the health plan categories are also available. The MHOS contains limited information about cancers; there are only questions that ask if the person has been diagnosed with any of the major cancers (colorectal, lung, breast, and prostate). Other than this, the survey instrument does not identify persons with specific cancers. Additionally, no questions related to the nature of initial treatment, length of time between diagnosis and survey administration, and severity of cancer as measured by stage of disease are included in the survey.

Linkage of MHOS and SEER

The linkage of MHOS and SEER data was accomplished by using an existing file that links persons in the SEER data to Medicare’s Master Enrollment File. This existing file was initially constructed for the SEER-Medicare linked database, another collaborative project between CMS and NCI (http://healthservices.cancer.gov/ seermedicare/ ). The linkage of SEER cases to Medicare’s Enrollment File is based on an algorithm that involved a match of a respondent’s Social Security number (SSN), sex, last name, first name, and month of birth. In the absence of a match on the SSN, respondents were matched on their last name, first name, sex, and month of birth. This algorithm required an agreement between 7 or 8 digits of the SSN or a match on two or more of the following identifiers: year of birth, day of birth, middle initial, and date of death (month and year). For persons in the SEER data age 65 or over, 93 percent were matched to Medicare’s enrollment data. For persons found in both data sources, a SEER-Medicare crosswalk file was created that linked each person’s unique SEER case number to their Medicare health insurance claim number (HICNUM).

To create the SEER-MHOS linked database, we took the HICNUMs from MHOS respondents and attempted to match these numbers to HICNUMs for persons in the SEER-Medicare crosswalk file. Persons found in the MHOS group who were found in the SEER-Medicare crosswalk were classified as cancer cases. Those who were not matched to the SEER- Medicare data were considered possible controls.

SEER-MHOS Analytic File

Using this linked SEER-MHOS database, NCI and CMS have constructed a file that is designed to meet the analytical needs of investigators who wish to use the MHOS data to examine cancer- related issues. This file includes only persons who have responded to at least one MHOS survey for persons with and without cancer. Up to eight records per person may be available in this file, in the case of individuals who were included in the MHOS sample every year and responded to all four baseline and followup surveys. Figure 1 provides a flow chart that describes the number of people included in the file. For persons with cancer, the chart provides information about the timing of surveys in relation to the cancer diagnosis.

Not everyone who was selected for inclusion in the MHOS cohort agreed to participate in the survey. Table 2 provides information on the total number of surveys included in the MHOS sample and the percentage of surveys completed at baseline or followup. A completed survey was defined as one in which 80 percent of all questions had been answered. Followup surveys were only provided for people who were alive and still in the plan at the 2-year followup. MHOS respondents who had discrepancies on sex or a difference of more than 6 months on date of birth or date of death were deleted from the linked cohort (n=88). In addition, because the MHOS survey could have been completed by a proxy (such as a family member or friend), an additional verification was done to confirm that the respondent was alive at the time of survey administration. A small number of respondents were deleted because their date of death was before their survey date (n=82). MHOS respondents not found in the crosswalk file (i.e., respondents without cancer) also were checked for consistency between date of death (if any) and MHOS survey date administration. As a result, an additional 719 respondents were deleted from the sample because their date of death was before their survey date. The number of postmortem surveys appears to be relatively large, but is still a very small fraction of the MHOS respondents (0.07 percent). Approximately one-half of those postmortem surveys were completed by the respondents themselves, indicating an erroneous survey date. Thus, most of the discrepancies could be due to an erroneous survey date or date of death in the Medicare file, and it was decided to exclude all patients with a survey date after date of death.

The SEER-MHOS Analytic File includes demographic information obtained from several sources including the Enrollment Data Base (EDB) File maintained by CMS for Medicare enrollees, SEER files, and self-reported information. For persons with cancer, information from the SEER data is provided about the date of diagnosis and clinical information for up to 10 cancers, vital status information, and some census tract information, such as median household income and education at time of first cancer diagnosis at age 65 or over (Warren et al., 2002). The file has been constructed in a way to facilitate the creation of cohorts. Respondents can be selected on a number of factors including cancer status, residency in SEER area, and a variety of other survey and cancer-related indicators. In addition, to support both cross-sectional and longitudinal study designs, the file allows investigators to identify individuals who participated in multiple surveys. (A file layout with a data dictionary is available on request from the NCI authors.)

Data Confidentiality

The SEER-MHOS data is a valuable resource. However, it is not in the public domain at this time and is available only to Federal Government scientists and collaborators. SEER-MHOS region-specific data are available to SEER principal investigators. Before the data become available to the general public, safeguards to protect patient and provider confidentiality, such as de-identification of the data, and establishing data use agreements, must be taken. NCI intends to work with CMS to develop a public use resource for these data in the near future.

DESCRIPTIVE DATA FROM THE SEER-MHOS

Table 3 presents information on selected characteristics of all MHOS respondents, comparing those persons who never had a cancer diagnosis with cancer patients and stratifying by those who had completed surveys before and following a cancer diagnosis. Respondent’s age, sex, and race/ ethnicity, were collected on the MHOS survey, as well as on the EDB File and the SEER database for cancer cases. A respondent’s age was derived by subtracting the date of birth from the survey administration date. If available, a respondent’s race/ ethnicity was constructed based on their self- reported information from the MHOS survey. Otherwise, race/ ethnicity was obtained from the CMS database or the SEER File. In instances where respondents have multiple MHOS surveys (i.e., a baseline and a followup survey), race/ethnicity information was retained from the first survey. The race/ethnicity variable is a six- category variable; patients of Hispanic origin receive the Hispanic classification regardless of race. All others fall into one of the other categories: White, Black (or African-American), Asian (or Pacific Islander), American Indian (or Alaskan Native), and another race or multiracial (also referred to as other). It should be noted that the number of subjects is low from certain population groups, e.g., American Indian/Alaskan Native, that participated in the MHOS survey. Because of this, stratification of an analysis by race/ ethnicity may have resulted in less reliable estimates for those groups than for better represented groups, even after combining all cancer sites in an analysis. Marital status, income, and education were self-reported by the respondent.

To measure the health condition of participants in the MHOS survey, a comorbidity score was developed from a series of questions on pre-existing chronic conditions, at the time of the survey, including hypertension, coronary artery disease, congestive heart failure, heart attack, other heart conditions, stroke, pulmonary disease, bowel disease, arthritis, diabetes, sciatica, and any cancer other than skin cancer. To be sure the answers were based on a clinical diagnosis, the questions were prefaced with “Has a doctor ever told you that you had: … the condition.” Each positive response was assigned a point. The comorbidity score is the sum of all responses, and ranges from 0 (fewest comorbidities) to 12 (most comorbidities). The comorbidity score was reset to unknown if any one of the disease condition questions was not answered (data not shown) (Smith et al, 2008).

Survey respondents were categorized into four smoking groups: (1) non-smoker, (2) former smoker, (3) smoker, or (4) those with unknown smoking status. Respondents who reported smoking less than 100 cigarettes in their lifetime were categorized as a non-smoker. Former smokers were those who reported smoking 100 cigarettes or more over their lifetime but were not currently smoking and had not smoked in the past 6 months (Hays et al, 2008).

Table 3 presents data on the number of respondents with and without cancer. For persons with cancer, the data are divided into those who completed a survey before and after a cancer diagnosis. The non-cancer group includes only persons who lived in a SEER area at the time of the baseline survey. The non-cancer group in the SEER area is similar to non-cancer cases living in non-SEER areas other than those people in the SEER area are more likely to be Latino or Asian and less likely to be White. In addition to demographic information, Table 3 includes information about the mean range of scores for the PCS and MCS. The PCS mean score ranges from 39.9 to 42.3, below the general population mean of 50. The MCS mean score is slightly above the general population mean and ranges from 50.0 to 51.3. Table 3 also notes the percentage of unknown values in each variable in the table. Item non-response for most variables is less than 2 percent, except for income, which has a non-response averaging about 21 percent, and smoking status, which is missing in approximately 9 percent of cases. Work by McCall and colleagues (2004) have noted that non-response bias in the survey is relatively modest, in spite of differences in response rates in baseline and followup surveys, and differential item non-response. Table 4 includes information about the number of persons who have responded to at least one MHOS survey by specific type of cancer. The table presents information for all cancer patients who completed a baseline survey as well as the number of cancer patients who completed a baseline survey prior to their cancer diagnosis. For persons with multiple cancers, data are presented for the first cancer reported in the SEER data. Data on the number of cancer cases is presented differently in Table 5. This table provides information about the number of respondents that have completed the survey by stage for persons with colorectal, lung, breast, and prostate cancers. Tables 4 and 5 show that the SEERMHOS Analytic File has a sufficiently large sample size to examine some questions related to cancer treatment and outcomes both cross-sectionally and longitudinally. This is especially true for the most common cancers, prostate, breast, colorectal, and lung.

We provide three examples of functional measures available in the SEER-MHOS data. In Figure 2, we used information from MHOS to compare the self-reported ADL status of cancer respondents who completed the survey before their cancer diagnosis to those who completed the survey after their cancer diagnosis. The data show that ADLs are more difficult to perform for persons who completed the survey after a cancer diagnosis. We performed a similar analysis of self-reported depression in relation to the timing of the cancer diagnosis and compared with Medicare beneficiaries who do not have cancer (Figure 3). The data show that those who completed the survey after their first cancer diagnosis were slightly more depressed than their pre-diagnosis status or compared with non-cancer cases. Figure 4 presents information on comorbidity scores based on a count of selected chronic conditions. One can see that among those who completed the survey after their first cancer diagnosis, the percent of respondents who reported having four or more comorbidities was somewhat higher compared with cancerfree patients and patients who did not have cancer at the time of survey administration. Smith et al. (2008) further discuss the role of comorbidity and HRQOL for cancer patients. These examples show how MHOS data from a group of elderly Medicare beneficiaries who do not have cancer can be used to evaluate the status of elderly beneficiaries with cancer.

SEER-MHOS STRENGTHS

The SEER-MHOS data are a unique resource. The information it contains, such as HRQOL and comorbidities, can be used for analyses that cannot be performed on other secondary data. Because the dataset uses the SF-36(R), it enables investigators to compare across populations of cancer survivors, as well as to compare individuals with and without cancer. Analyses of the SEER-MHOS data can explore behavioral issues (e.g., smoking behavior) as well as treatment issues (e.g., surgery or radiation oncology).

Existing research on health outcomes of older adults with cancer often examines this population as one homogeneous group. Longitudinal studies of health and aging clearly demonstrate the existence of heterogeneity in respect to the health status of the elderly population (Baltes and Smith, 2003), however, suggesting that differences in health outcomes by cancer status could also exist. The SEER-MHOS data are derived from a large sample, which permits examination of data by age strata for males and females age 65 or over. The large samples also enable investigators to stratify the elderly population by other important factors, such as race/ ethnicity, and socio-economic status. Further, few HRQOL datasets exist that facilitate comparisons across multiple tumor types as well as comparisons with individuals who were never diagnosed with cancer.

Another strength of the SEER-MHOS is the inclusion of a 2-year longitudinal panel of respondents in the dataset. Many of the most important HRQOL research questions have to do with changes in health status among cancer survivors, especially in response to treatment, to the diagnosis of cancer, or in response to other health events, such as a second primary cancer diagnosis. The SEER-MHOS potentially enables the exploration of these types of research questions, at least within the 2-year window of the followup sample.

Finally, as described in Table 4, the SEERMHOS data can be used to explore HRQOL issues in tumor sites beyond breast, prostate, colorectal, and lung. The dataset has more than 1,000 cases each of gynecological cancers, bladder cancers, melanomas, and head and neck cancers. It also includes more than 2,000 individuals who have been diagnosed with multiple primary cancers (Clauser et al., 2008) and a limited number of respondents with rare cancers. Little is currently known about the HRQOL of survivors for rare or multiple cancers, and continued efforts to expand the dataset with additional cohorts of survey respondents will increase the power to examine HRQOL issues with these respondents.

SEER-MHOS Limitations

The SEER-MHOS data also have limitations that users should consider before working with them. The SEER-MHOS is designed to allow standard comparisons across different types of cancers and other clinical characteristics of the study population (e.g., other diseases, individuals who self-report being disease free). However, cancer-specific HRQOL measures would likely be more sensitive than the SF-36(R) to the impact of cancer but they would not allow comparisons to those in the sample who do not have cancer. Many researchers would recommend using these refined HRQOL instruments in studies or interventions of selected tumor types where they are available and valid. Despite this limitation, SEER-MHOS studies can still complement the use of other HRQOL instruments by providing a comparative assessment, thereby highlighting opportunities in which researchers and health plans could conduct detailed research and intervention using more sensitive instruments.

Another limitation of the SEER-MHOS is its lack of representativeness of the Medicare Program in general. The primary purpose of the MHOS is to serve as a program monitoring and accountability mechanism for the Medicare managed care program. Therefore, it is not used to collect HRQOL information on Medicare beneficiaries in the fee-for-service program where the vast majority of Medicare beneficiaries are enrolled. An earlier study by Riley (2000) found that Medicare beneficiaries with feefor-service coverage had more risk factors and lower functional status. Also, because the data are limited to managed care, no administrative claims or utilization data are available from Medicare on this population. Utilization data are limited to what is available in SEER and to specific services associated with initial cancer treatment, such as surgery and radiation. Some types of cancer treatment, i.e., chemotherapy and hormonal therapy, are not reported by the SEER program because of concerns about under ascertainment. Nevertheless, the SEER-MHOS dataset does provide the potential to evaluate selective issues related to HRQOL and receipt of initial cancer treatment, especially with respect to surgical interventions and radiation therapy.

The SEER-MHOS dataset also is not representative of the Medicare Advantage program. Medicare Advantage allows beneficiaries to obtain their Medicare services from HMOs and preferred provider organizations. Overall, the SEER regions in this dataset represent about 27 percent of all Medicare Advantage enrollees (Kaiser Family Foundation, 2007). Certain regions-Florida and Minnesota, for example-that have a large proportion of Medicare managed care enrollees are not included in SEER. Conversely, Medicare Advantage plans are not represented in all SEER regions. The SEER regions with the largest overlap with the Medicare Advantage program are California, Detroit, and Seattle. Nevertheless, these SEER regions account for approximately 1.5 million Medicare health plan enrollees annually and reflect areas that are racially and ethnically diverse. Methods for weighting these data to improve their generalizability in the Medicare Advantage program have not been developed. As an interim measure, Medicare enrollment numbers available at the plan level that might be used to adjust for different plan sizes.

CONCLUSIONS

The SEER-MHOS data are a potentially valuable resource that combines healthrelated quality of life, sociodemographic, and clinical data for Medicare health plan enrollees. The data are population-based, with a large number of cancer cases and controls, and the dataset allows for both cross-sectional and longitudinal studies. The inclusion of control cases of individuals who were never diagnosed with cancer is a major advantage, because it allows investigators to evaluate HRQOL in individuals before and after a cancer diagnosis, as well as between cancer survivors and individuals never diagnosed with cancer. The strength of the dataset is its ability to reveal insights about HRQOL, both across different types of cancers and between respondents with and without cancer (Clauser et al., 2008; Smith et al., 2008; Hays et al., 2008). Finally, because survey respondents are representative of the health plans in which they enroll, the data may serve important policy research functions as well. The SEER-MHOS provide an attractive window into examining the HRQOL of cancer survivors enrolled in Medicare managed care. Improved cancer therapies and cancer screening technology is allowing Medicare beneficiaries diagnosed with cancer to live longer with the disease. Increased survival will place even greater emphasis on the need for Medicare managed care plans to assist cancer survivors in dealing with quality of life implications of living with cancer. The SEER-MHOS is one tool to inform health care plans on gaps in health status and intervention opportunities that can improve the HRQOL of cancer patients and survivors for whom they are accountable.

ACKNOWLEDGMENTS

The authors wish to thank Gigi Yuan, Bryce Reeve, Ron Hays, Neeraj Arora, Ashley Smith, Arnold Potosky, and Anne Rodgers for their help with this SEERMHOS effort.

1 The full survey is available on CMS’ Web site at http://www. cms.hhs.gov/.

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Clauser, S.B., Arora, N.K., Bellizzi, K.M., et al.: Disparities in HRQOL of Cancer Survivors and Non-Cancer Managed Care Enrollees. Health Care Financing Review 29(4):23-40, Summer 2008.

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Espey, D.K., Wu, X.C., Swan, J., et al: Annual Report to the Nation on the Status of Cancer, 1975-2004, Featuring Cancer in American Indians and Alaska Natives. Cancer 110:2119-2152, 2007.

Extermann, M.: Interaction Between Comorbidity and Cancer. Cancer Control 14:13-22, 2007.

Hays, R.D., Smith, A.W., Reeve, B.B., et al.: Cigarette Smoking and Health-Related Quality of Life in Medicaid Beneficiaries. Health Care Financing Review 29(4):57-68, Summer 2008.

Hewitt, M., Rowland, J.H., Yancik, R: Cancer Survivors in the United States: Age, Health, and Disability. Journal of Gerontology: Medical Sciences 58:82-91, 2003.

Jones, N., Jones, S.L., and Miller, N.A.: The Medicare Health Outcomes Survey Program: Overview, Context, and Near-Term Prospects. Health and Quality of Life Outcomes. 12(2):33, July 2004.

Kaiser Family Foundation: State Health Facts.Org Total Medicare Advantage (MA) Enrollment. 2007. Internet address: http:// www.statehealthfacts.org/ comparetable.jsp?ind=327&cat=6 (Accessed 2008.)

Lichtman, S.M., Balducci, L, and Aapro, M.: Geriatric Oncology: A Field Coming of Age. Journal of Clinical Oncology 25:1821-1823, 2007.

McCall, N., Bonito, A, and Trofimovich, L: Estimation and Analysis of Non-response Bias in Medicare Surveys. RTI International. Durham, NC. 2004.

Oeffinger, K.C., Mertens, A.C., Sklar, C.A., et al.: Chronic Health Conditions in Survivors of Childhood Cancer. New England Journal of Medicine 355:1572-1582, 2006.

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Ries, L.A.G., Melbert, D., Krapcho, M., et. al.: SEER Cancer Statistics Review, 1975-2004. National Cancer Institute. Bethesda, MD. Based on November 2006 SEER Data Submission Posted to the SEER Web Site, 2007. Internet address: http://seer.cancer.gov/csr/ 1975_2004/ (Accessed 2008.)

Riley, G.: Two-Year Changes in Health and Functional Status among Elderly Medicare Beneficiaries in HMOs and Fee-for-Service. Health Services Research 35(5 Pt 3):44-59, December 2000.

Robison, L: The Childhood Cancer Survivor Study: A Resource for Research of Long-Term Outcomes among Adult Survivors of Childhood Cancer. Minnesota Medicine 88(4):45-49, April 2005.

Smith, A.W., Reeve, B.B., Bellizzi, K., et al.: Cancer, Comorbidities, and Health-Related Quality of Life of Older Adults. Health Care Financing Review 29(4):41-56, Summer 2008.

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Turner-Bowker, D.M, Bartley, PJ., et al.: SF-36(R) Health Survey &”SF” Bibliography: Third Edition (1988-2000). QualityMetric Incorporated. Lincoln, RI. 2002.

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Ware, J.E., Gandek, B., Sinclair, S.J., et al.: Measuring and Improving Health Outcomes: An SF-36(R) Primer for the Medicare Health Outcomes Survey. Health Assessment Lab and Quality Metric Incorporated. Waltham MA. 2004.

Warren, J.L., Klabunde, C.N., Schrag, D., et al.: Overview of the SEER-Medicare Data: Content, Research Applications, and Generalizability to the United States Elderly Population. Medical Care 40(8 Suppl):LV-3-18, August 2002.

Yancik, R, Havlik, R.J., Wesley, M.N., et al: Cancer and Comorbidity in Older Patients: A Descriptive Profile. Annals of Epidemiology 6:399-412, 1996.

Zabora, J., BrintzenhofeSzoc, K., Curbow, B., et al: The Prevalence of Psychological Distress by Cancer Site. Psycho- Oncology 10(1):19-28, January/February 2001.

Anita Ambs, M.P.H., Joan L. Warren, Ph.D., Keith M. Bellizzi, Ph.D., M.P.H., Marie Topor, Samuel C. (Chris) Haffer, Ph.D, and Steven B. Clauser, Ph.D., M.P.H.

Anita Ambs, Joan L. Warren, Keith Bellizzi, and Steven B. Clauser are with the National Cancer Institute (NCI). Marie Topor is with IMS. Samuel C. (Chris) Haffer is with the Centers for Medicare & Medicaid Services (CMS). The statements expressed in this article are those of the authors and do not necessarily reflect the views or policies of NCI, IMS, or CMS.

Reprint Requests: Anita Ambs, M.P.H., National Cancer Institute, EPN 4005, 6130 Executive Blvd., MSC 7344 Bethesda, MD 20892-7344. E- mail: [email protected]

Copyright Superintendent of Documents Summer 2008

(c) 2008 Health Care Financing Review. Provided by ProQuest LLC. All rights Reserved.

By Monaco, John E

For a decade I have committed myself to raising the consciousness of one of the greatest public health crises ever to face the children of this country and much of the industrialized world. Not only is this problem still with us, but also it has actually worsened, to the point that overweight kids now have become the “new normal.” Illnesses related to obesity have increased in frequency, new complications have been revealed, and for the first time in modern history, the life span of today’s children may be shorter than their parents. I was reminded of this trend recently when we cared for a ten-year-old girl who presented to the emergency room with abdominal pain, fever and intermittent vomiting. The pain was located primarily in the right lower quadrant of the abdomen and the ER doc appropriately suspected appendicitis. I should also mention that this young lady was significantly overweight. Her belly fat made her physical exam difficult since it was hard to localize the pain and accurately assess its character and severity.

So before he consulted the surgeons, the ER doc obtained a CT scan of the abdomen to hopefully help him make the diagnosis. The study was inconclusive and the comment was made that the degree of her obesity may have contributed to the inconclusive test results.

The surgeon was consulted and also experienced difficulty examining this chubby patient. The decision was made to admit her to pediatrics and watch her closely for the evolution of her abdominal pain. So for two days she languished on the pediatric floor, in and out of severe pain, the diagnosis difficult because of her obesity. When she was finally taken to the operating room mainly out of frustration, after yet another inconclusive scan, the surgeon found that not only did she have appendicitis, but also the appendix had ruptured and she now had severe peritonitis, or infection of the abdominal cavity. What had initially been a localized infection was now much worse and generalized throughout her abdomen.

After a week in the hospital with intensive IV antibiotics, she was released, only to be readmitted five days later, having developed an abscess within her abdominal cavity, the result of the initial appendix rupture. She required another operation, and, as I write this narrative, she remains in the hospital with IV antibiotics and intensive hospital care. Essentially, this young lady endured two operations, two weeks in the hospital, days of antibiotics, pain and emotional trauma primarily because of her obesity. Even though she will most likely fully recover, the costs and the trauma this patient and her family have experienced have been extraordinary.

What further haunts me is that if this adolescent does not turn her life around and combat her obesity, she is in for so much more trouble. Will she be the next teenage girl, like so many I have seen over the last few years, who will need gall bladder surgery – a procedure once considered common in fat, forty-year-old women? Will she develop hypertension and early coronary artery disease? Will she develop arthritis much earlier than her mother and hip problems that require surgery before the age of 35? Will the asthma that runs in her family suddenly become much worse due to the strain of the many pounds of extra weight on her lungs? Will she develop diabetes in college, the kind her grandmother was diagnosed with at the age of 67?

These possible – probable – conditions are the scope of the problem we now face with the state of childhood obesity, and the fact that it gets worse every day. There are solutions, but they will take time. And they will take the dedication of families, schools, churches and the government. That’s right, this problem is just that important. Yet, aside from an occasional Oprah episode, or the YouTube video I recently saw of a 400-pound five year old, shamelessly little attention is given to this problem.

My ten-year-old patient will get better, she will go home and her family will be relieved that her present health crisis has been met and successfully defeated. But while they may have won this battle, they are still at a horrible disadvantage in the overall war. And they have no chance of winning that war without the cooperation of all of us. So I ask you, don’t we owe this girl our support, research and understanding? After all, she is the future. She is our future.

By John E. Monaco, MD

John E. Monaco, MD, is board certified in both pediatrics and pediatric critical care. He has published two books: Moondance to Eternity and Slim and Fit Kids: Raising Healthy Children in a Fast Food. He lives and works in Tampa, Florida. He welcomes your comments, suggestions, and thoughts on his observations.

Copyright Pediatrics for Parents, Inc. Jul 2008

(c) 2008 Pediatrics for Parents. Provided by ProQuest LLC. All rights Reserved.

By Taghdiri, Celia

Many people are shocked to learn that arthritis isn’t just “an old person’s disease.” The reality is about 300,000 U.S. children, or one in 250, have joint inflammation that causes pain, redness, heat and swelling. Juvenile arthritis occurs before age 16. The most common is juvenile idiopathic arthritis (JIA). Idiopathic means arising from an unknown cause. Targeting the body’s joints, JIA is more frequent in girls and occurs generally from one to three years of age, and later from eight to twelve years. According to the Arthritis Foundation, there are three different kinds of JIA: oligoarticular, poliarticular and systemic onset.

Causes

Scientists are unsure of what causes JIA but some studies suggest there may be a genetic predisposition to the disease. With JIA, the immune system, which normally helps to fight off harmful, foreign substances such as a virus or bacteria, identifies some of its own cells and tissues as foreign and begins to attack healthy cells and tissues. The result is inflammation.

According to the National Institute of Arthritis, Musculoskeletal and Skin Diseases, one of the earliest signs of JIA may be limping in the morning because of an affected knee. There are periods when the symptoms are better and times when children experience flareups. Some children with arthritis may have growth problems, depending on the severity of the disease and the joints affected. Juvenile arthritis may cause joints to grow unevenly.

Three Types of JIA

Oligoarticular is the most common form of JIA in young children, and affects four or fewer joints. This type of JIA usually damages larger joints such as the knees, ankles and/or elbows.

Polyarticular JIA is a more severe form of the disease and affects five or more joints, usually the small joints of the fingers and hands but also the knees, hips, ankles and feet. It can cause bumps on the body on areas subjected to pressure from sitting or leaning, and low-grade fever. Joints from the neck and jaw may also be affected.

The least-common form of JIA is systemic onset, which affects 20% of all children with JIA. In addition to joint swelling and inflammation, systemic JIA causes high fevers that may last for weeks, and a light skin rash appears on the child’s chest, thighs and other body parts. It may also affect the heart, liver, spleen and lymph nodes. In most cases, this form of JIA is chronic and these children require regular evaluations and X-Rays.

Eye Complications

Eye inflammation can also occur with JIA. Uveitis, or the inflammation of the iris (the colored area of the eye), may occur with or without active joint symptoms. The inflammation can lead to scarring of the pupil; if the scarring deteriorates and is not treated, it can lead to blindness.

Fortunately, arthritis-related eye problems are highly treatable. Typically, they are treated with a steroid eyedrop to reduce the inflammation. A pediatric ophthalmologist can detect uveitis early and would need to examine the eyes every three to four months after diagnosis, then follow up for years afterwards.

Diagnosing JIA

There is not one single test doctors use for diagnosis. Rather, they conduct a physical exam, study the patient’s medical history, X- Rays and laboratory test results. A physical exam looks for joint inflammation, rash, nodules and eye problems that may suggest the presence of juvenile arthritis. A complete medical history helps determine the length of time symptoms have been present. Joint swelling or pain must last at least six weeks for the physician to consider a diagnosis of juvenile arthritis. The physician also needs to be aware if other family members have had arthritis conditions. X- Rays may be needed if the doctor suspects injury to the bone or unusual bone development.

Lab tests may include erythrocyte sedimentation rate (sed rate or ESR), antinuclear antibody test (ANA) and a rheumatoid factor test (RF). Lab results, however, are not used solely as diagnostic factors. A child can manifest JIA symptoms but have normal or near- normal lab test results.

ESR measures how quickly red blood cells fall to the bottom of the test tube. It is a non-specific inflammatory indicator. If the test reveals elevated inflammation, JIA is just one possibility. ANA detects autoimmunity and it is also useful in predicting which children are likely to have eye disease with JIA. The RF test helps the doctor to differentiate among the three types of JIA, particularly with adolescents.

Medical Treatments for JIA

Robert Sheets, MD, pediatric rheumatologist at Rady Children’s Hospital in San Diego, CA, says treatment is key. “Early diagnosis and appropriate aggressive therapy can frequently lead to a good prognosis.”

Treatment options include oral and injected medication along with physical therapy to strengthen the muscles and joints. Non- steroidal anti-inflammatory drugs (NSAIDs), such as Ibuprofen and naproxen, are commonly used to treat the disease’s pain and inflammation.

In some cases, doctors will prescribe “disease-modifying” drugs such as methotrexate, in addition to an NSAIDs, to limit the progression of JIA. Usually, small doses of methotrexate are prescribed to relieve arthritis symptoms. Physicians are likely to prescribe it when an NSAID alone is not controlling joint inflammation.

“Treatment has tremendously improved,” Sheets says. “Twenty years ago, we did not have the drugs we have today, so children were taking aspirin as their pain reliever.”

Emotional Treatments for JIA

Children usually do not like to be considered “different” and may feel sad or angry about having arthritis. It is also difficult for youngsters, especially teens, to seek assistance with simple tasks such as getting dressed. Some kids are forced to discontinue some of their favorite activities. They may resent other children, including their siblings, for not having the disease.

Parents can help manage the child’s disease by administering their medication and supervising some physical activities. For most patients, activities such as muscle-strengthening exercises need to be done regularly. But it is vital to remain cautious of some activities such as biking because it may put weightbearing stress on the joints.

Psychologists and social workers can help by emphasizing to the child that he did not cause the arthritis. They help kids cope, lead a healthy social life and continue with their activities. Therapy can assist children with pain management because children and teens often prefer discussing their illness with someone other than a family member.

Conclusion

Childhood arthritis continues into adulthood for most patients. For some, the pain and stiffness go into remission, a period when the disease isn’t cured but instead seems to disappear. This period, however, doesn’t last and symptoms manifest during a flare.

According to Dr. Sheets, most children with oligoarticular arthritis, the type with the best prognosis, remit and the majority are able to continue everyday activities. For some other forms of childhood arthritis, however, the chance of remission and the long- term prognosis are more difficult to predict.

Celia Taghdiri is afreelance writer who lives in California. This article was adapted from her original piece that was published in the San Diego Union-Tribune.

Copyright Pediatrics for Parents, Inc. Jul 2008

(c) 2008 Pediatrics for Parents. Provided by ProQuest LLC. All rights Reserved.

By Cockey, Linda

The items marked with this symbol can be ordered via the MTNA website through our affiliation with Amazon.com. Go to www.mma.org and choose Member Services from the Membership option in the main menu bar for more information. INTRODUCTION

Included for each annotation is a brief description of the content of the resource and the intended audience. Publishing information is included. Most books can be bought directly from the publisher, through amazon.com or can be obtained at a university library or inter-library loan service. Books go quickly out of print these days.

Selections are chosen that are specifically useful to musicians, even if it does not specifically address the musician. Materials are screened to include only items that are relevant to specific musicians with regard to wellness issues. Topics include prevention of medical problems, meditation, performance anxiety, performance preparation, healthy practicing techniques, learning theories and physiological and psychological issues related to overall musicianship.

UPDATE

Shockley, Rebecca Payne. (1997) Mapping Music: For Faster Learning and Secure Memory A Guide for Piano Teachers and Students. A-R Editions, Onc, 8551 Research Way, Ste. 180, Middletown, WI 53562; (608) 836-9000; www.areditions.com 122pp. ISBN: 0-889579-39

MOST RECENT BOOKS

Cook, Orlanda. (2004) Singing with Your Own Voice: A Practical Guide to Awakening and Developing the Hidden Qualities in your own Singing Voice. Routledge, 270 Madison Ave., New York, NY 10016- 0602; www.routledge-ny.com. 224 pp. ISBN: 0-87830-182-8

Published posthumously, this manual is comprehensive with practical suggestions for all singers, particularly actors, about how to improve performances in a healthy way. Written by a vocal coach and director who worked all over Europe, the aim of the book is to provide the reader with her tips and tools from the trade.

There is a total of six parts. Each part offers a combination of theory, ideas to ponder and practical exercises. The parts begin with an overview and ends with a summary. Within each section, there are three key words: Explore-indicating an active exercise that involves moving, standing up or getting down onto the floor; Discover-indicating additional ideas and exercises for self- discovery, which can be read and considered without necessarily having to move; and Develop-indicating further exercises to increase, over a period of time, your practical understanding of the physical structure explained or the activity proposed. The parts are titled with “additive” titles as will be seen below.

“Part One-Voice: Mind and Heart” is about “Singing Who We Are,””The Natural Voice,””First Voices,””The Singing Voice,””The Individual Voice,” and Gold in the Cracks. This serves as an introductory section where the author discusses vocal inhibition and confidence and singing as a natural and pleasurable sound.

“Part Two-Voice: Mind, Heart and. . .Body” is about “Activating the Body,””A Power Base for the Voice,””PVE, Laughter and the Jaw,””A Body Made for Breathing,” and “The Magic Cords.” This part examines the body as the “ground” for all feelings, thoughts and songs and how every structure of our anatomy that is component of helping to create vocal sound can be influenced through a combination of thought, imagination and muscular action.

“Part Three-Voice: Mind, Heart, Body and… Sound” examines “Vibration and Resonance,””The Harmonics of Sound,””Singing in Tune,””Working with a Piano,””Facing the Music,” and “Shaping the Sounds of Speech.” Good vocal sound is the result of a combination of breath, vibration and resonance.

“Part Four-Voice: Mind, Heart, Body, Sound and… Imagination” is about “Freeing the Imagination,””Characters in and for the Voice,””Animal Arias,” and the “Whole Voice-Broken Sound.” Here, the author discusses one’s imagination and how it is the connecting fluid that joins everything. She suggests ways of discovering the many different qualities in your voice through different characters, images of animals and birds. The union between the voice and body through felling and imagination is paramount in the development of a good singing voice.

“Part Five-Voice: Mind, Heart, Body,””Sound and Imagination into Song” review “The Creative Voice” and provide the reader with a song- learning checklist. In summary, the creative voice is one that is totally present and responsive to the moment and able to call on any part of your voice to express what you want and how you want it.

“Part Six-The Singer and the Song” discusses how to face audiences, work with support groups for feedback and ends with a section about 10 different students the author worked with to help explore their voice and guide them towards finding new energy and interpretative ideas for their singing.

The book ends with an “Epilogue Voice and Soul,” where the author explains that singing with our soul is about “giving” not “getting.” She discusses important characters from Greek mythology and relates to the extremes of one’s character. A bibliography is included and an index of exercises and where they can be found in the text is incorporated at the end.

Audience: singers and actors

David, Catherin. (1996) The Beauty of Gesture: The Invisible Keyboard of Piano & T’ai Chi. North Atlantic Books, P.O. Box 12327, Berkelery, CA 94712; 166 pp. ISBN 1-55643-219-4

This short book explores and compares the art of playing the piano with the aesthetics of practicing t’ai chi. Both disciplines require the development of technical skill to make difficult tasks seem simpie and obstacles seem an ordinary part of the artistic skill. The author depicts the meditation of discipline through these two skills and how body and mind connect.

There are 26 short chapters where David compares a gesture one would use to play the opening of a particular piano piece (for example, Mozart’s Sonata in B-flat Major (K.570)) with a gesture one would use in t’ai chi. She goes on to compare both arts as relying on mental imagery for technical mastery. An interesting read for any musician interested in the mind/body connection and does any form of meditation such as yoga and t’ai chi.

This is a translation from an awardwinning French edition, La Tribune de Geneve. David draws on works from philosophy, art and literature to examine and compare playing the piano with t’ai chi. Bibliography not included; however, there is a section titkd “notes” at the end.

Audience: all musicians

Dawson, William J. (2008) Fit as a Fiddle: The Musicians Guide to Playing Healthy. Rowman & Littlefield Education Publishing Group, Inc., 4501 Forbes Blvd., Ste. 200, Lanham, MD 20706; (800) 462- 6420, fax: (717) 794-3803; www.rowmaneducation.com. 158 pp. ISBN: 978-1-57886-683-0 (hardback); 978-1-57886-684-7 (paperback)

Dawson is a retired hand surgeon, a symphonic bassoonist and private teacher, as well as president of the Performing Arts Medicine Association and professor emeritus of orthopedic surgery at Feinberg School of Medicine, Northwestern University. Dawson’s diverse background makes this clearly written book an important contribution to the basic resources on musician wellness and the physical problems of instrumental musicians.

Dawson states in his introduction that his purpose for writing is to “improve the availability, quantity, and quality of health care for all performers,” and that the special needs of musicians and other performing artists are unique. He compares the medical problems of musicians with the medical problems of athletes, where diagnosis and alternative treatment has resulted in high quality care in the field of sports medicine. His intention is to answer questions instrumental musicians and teachers may have about general health problems that affect performance. Dawson concentrates on medical problems involving the musculoskeletal system and upper extremities.

There are a total of 11 chapters that were originally written as a series of articles for the Journal of the International Double Reed Society and The Double Reed journal. The author made major additions to the articles produced in these journals and added new ones as well to complete the manual.

Chapter 1, “Playing with Pain,” examines pain as a warning sign that is produced by one’s body to alert us of abnormal body use. It goes on to explain that slight alterations in musical techniques can not only stop the pain but prevent further damage. Chapter 2, “Some Basics of Structure and Function,” presents basic anatomy and physiology to the instrumental musician using “lay” terminology. Bone, joints, the movements of muscles and tendons and nerves are explained with very basic and clear diagrams.

Chapter 3, “Teacher and Student,” reviews playingrelated problems, playing a life -time and teaching the young through adulthood. Dawson explains that although music teachers may be able to provide part of the rehabilitation for some injuries, musical exercises can be devised to facilitate and improve movement and coordination. Chapter 4, “Overuse,” explains what overuse is, what happens to the body tissues in overuse, the causes of overuse, including genetic factors, the signs and symptoms of overuse and the kinds of available treatments. Chapter 5, “Tendinitis and Tenosynovitis,” is about the two conditions that occur with overuse: inflammation and other causes that frequently arise as a result of a specific disease or another factor. Chapter 6, “Carpal Tunnel and Other Nerve Problems,” describes and explains nerve compression conditions that are most prevalent among musicians, and how a performer can recognize and care for them. Chapter 7, “Arthritis and Other Problems of the Mature Musician,” gives an overview of age- related conditions pertinent to the instrumentalist and presents basic methods of dealing with them. Osteoarthritis, loss of joint motion, stiffness in the joints, osteoporosis, degenerative tendonitis, micro-fractures, Dupuytren’s contracture, vision problems such as presbyopia, cataractand glaucoma, conductive hearing loss, sensorineural loss or nerve deafness, dental and embouchure changes that occur gradually as one ages due to a lifetime of pressure on the teeth from a mouthpiece or reed, chronic gum and tooth socket infections-gingivitis, periodontitis, temporomandibular joints (TMJ), teeth grinding (brusism) are all explained in this chapter with coping mechanisms discussed.

Chapter 8, “Hand Injury (Trauma),” gives the basics of injuries involving the hand; such as ligament sprains, bone fractures and joint dislocations. The causes, common symptoms, care and treatment are reviewed. Chapter 9, “Treatment Alternatives,” is about health care options-both tradition and nontraditional healings are considered. Physical therapy, massage therapy, chiropractic, topical therapy and body awareness methods such as Alexander technique, Feldenkrais technique, yoga, acupuncture, acupressure and shiatsu, reflexology, dietary therapy and homeopathy are all evaluated.

Chapter 10, “Getting Back to Music (Rehabilitation),” is about experiencing difficulty in returning to music making after being treated for a medical problem that affected musical performance. Problems, solutions and prevention are looked at. Chapter 1 1 is titled “Keeping your ‘Equipment’ in Shape,” and is about the dos and don’ts, dietary considerations and proper exercise and examines regular care of the finger joints, wrist, hand and finger tendons, elbows, shoulders, neck and lower back. Taking medications on a regular basis, the use of tobacco and chronic obstructive pulmonary disease, use of alcohol, respiratory diseases, noises and overall good body mechanics is discussed in relationship to good, general health principals. Suggestions for further reading are included at the end of each chapter. A section on Web Resources and a Glossary of helpful medical terms is included.

Audience: instrumental musicians and pedagogues

Iznaola, Ricardo. (2000) The Physiology of Guitar Playing. International Centre for Research in Music Education, The University of Reading, Bulmershe Court, Earley, Reading RG6 1HY, UK 74 pp.

Written by the internationally known guitarist, Ricardo Iznaola, this spiral manual is divided into 12 sections. It begins with an overview of the musculoskeletal anatomy and the limbs’ joint movements, in the context of guitar technique, followed by brief surveys of related physiological factors and the principles of leverage. Basic theories of artistic motor skills training are explored in the context of tension as an obstacle to achieving experiences of mastery; sitting position, nails and left- and right- hand positioning and basic techniques are assessed. There are also sections on somatic training and the pathology of playing that deal with methods of movement and postural re-education, medical and non- medical dysfunctions that affect guitarists and the final section focuses on training for virtuosity A list of references is included at the end with a Recommended Reading list as a separate section.

Audience: guitarists

Johnston, Philip. (2007) Practiceopedia. PracticeSpot Press, 52 Pethebridge St., Pearce ACT 2607 Australia; www.practiceopedia.com. 376pp. ISBN: 0-9581905-3-4

The purpose of this manual/encyclopedia is to give you tips on how to fit effective practicing in while having too much to do and not enough time to do it. It is intended to be for students and parents but can serve all musicians. There are a total of 61 chapters covering everything about developing effective practice habits. Readers can start anywhere in the book; preview any chapter via two line summaries of every chapter in the book; use cross- references since each chapter links to other related chapters, and skim-read chapters and paragraphs due to the subheadings and bolded texts to allow easy scanning.

Chapter titles are as follows: “Beginners,””Blinkers,””Boot Camp,” Breakthroughs,””Dairy,””Bridging,””Bug Spotting,””Campaigns,””Cementing,””Chaining,””Clearing Obstacles,””Clock- watchers,””Closure,””Color Coding,””Coral Reef Mistakes, “”Cosmetics, “”Countdown Charts,””Designer Scales,””Details Trawl,””Dress Rehearsals,””Engaging Autopilot,””Exaggerating,””Excuses and Ruses,””Experimenting,””Fire Drills,””Fitness Training,””Fresh Photocopies,””Horizontal vs. Vertical,””Isolating,””Lessons Agenda,””Lesson Preflight Check,””Lesson Review,””Level System,””Marathon Week,””Metronome Method,””Not wanting to Practice,””One way Doors,””Openings and Endings,””Painting the Scene,””Practice Buddies,””Practice Traps,””Pressure Testing,””Randomizing,””Prototypes,””Recording Yourself,””Recordings,””Reflecting,””Restoration,””Rogue Cells,””Scouting,””Session Agenda,””Shooting the Movie,””Speeding,””Stalling,””Thematic Practice,””Tightening,””Triage,””Triggers,””Turnaround Time,””Varying Your Diet,””Visualizing” and “Your Practice Suite.”

The layout is quite succinct and attractive with colored diagrams, charts and amusing pictures that would interest any student who needs help and advice about healthy practicing techniques. Bibliography not included. Also by Philip Johnston: Not Until You’ve Done Your Practice (1989); The Practice Revolution (2002) and The PracticeSpot Guide to Promoting Your Teaching Studio (2003).

Audience: all musicians

King, Vicki. (1999) PUying the Piano Naturally. Conners Publications, 503 Tahoe St., Natchitoches, LA 714575718; [email protected]; http://hostnet.pair.com/conners. 51pp. ISBN: 0- 9654324-1-6

This short manual compares playing the piano with other kinds of physical activities and gives suggestions for avoiding performance injuries. There are eight chapters, concise and to the point. In chapter 1, “Why Concern Yourself with Technique,” King explains that her ideas are simple ones, based on practical solutions and analysis of what the arms, wrist and fingers do. She goes on to state that the secret in all this is that one rarely has physiological problems while doing normal daily activities because we only expend the amount of energy and muscle use needed to do the task and we immediately relax. If we would apply these same principles to playing the piano then we would be able to play for many hours without fatigue. Chapter 2, “Tips on Improving Your ‘Grip’,” gives four steps in playing the piano naturally: fingers rest on keys in a relaxed manner; the finger and key ride down to the key bed as a unit; the finger depresses key down but there only needs to be enough muscle tension to keep it relaxed; the finger and key ride up together as a unit. King also reviews hand position, sitting at the piano and arm weight. She ends the chapter with a summary of the secret to playing for many years without injury. Chapter 3, “Natural Playing at All Levels,” gives a concise overview of what young and older beginners can easily grasp about natural playing, and examines adult beginners, intermediate and advanced students and the difficulties they face with regard to playing naturally. Double- jointed fingers are also examined in relationship to collapsed fingers and fallen arches. Chapter 4, “Natural Solutions to Specific Problems,” examines the practice of: scales, triads, trills, fast, running passages, repeated notes, arpeggios, broken chord passages that cover wide ranges, octaves, tremolos, double notes, stretches, large leaps involving chords and glissandos. Chapter 5, “Technical Problems of Style,” is about stylistic performance practice in relationship to overall finger and wrist technique. Chapter 6, “Miscellaneous Topics” gives an overview of general health of the hand, sight reading, playing staccato, tone color, dynamics, voicing chords and use of the Una Corda pedal. Chapter 7, “Vocal Accompanying” discusses musical balances between the instruments, touch, styles and tips for orchestral transcriptions. Chapter 8, “Conclusion,” summaries the physical side of playing the piano and that interpretation and technique cannot be separated. King mentions the famous pianists through the centuries and their technique as explained in Reginald R. Gerig’s Famous Pianists and Their Technique. Bibliography not include but footnotes are given where appropriate.

Audience: pianists

Llobet, Jaume i Rosset, edited by George Odam. (2007) The Musician’s Body: A Maintenance Manual for Peak Performance. Co- published by The Guildhall School of Music & Drama; Barbican, Silk Street, London and Ashgate Publishing Company, Ste. 420, 101 Cherry St., Burlington, VT 05401-4405; www.ashgate.com. 118 pp. ISBN:978-0- 7546-6210-5

This book is addressed to student musicians, practicing musicians and instrumental and vocal teachers. The authors’ goals are to help musicians understand and educate them on how and why their bodies function the way they do, so that they can prevent or reduce injuries and achieve the highest performance standards possible. The premise is made that many problems happen during student years or even before and the older a performing musician, the worse these long ignored problems become.

The manual begins with a foreword, a preface about being well and playing better and unique sections titled: “Safety Instructions,””Musician’s Body Warranty Terms” and “Four Warnings.” Here, the authors explain there is no guarantee for good body functioning, organic replacement or a refund for a body particularly if the body is not treated well. A healthy, balanced and sustainable mode of playing and overall musicianship depends upon a physical perspective that synergizes the body, mind and soul. There are a total of seven chapters, each containing diagrams, charts, a section called “Musicians Often Ask” and a quiz on the material discussed in each chapter at the end. Chapter 1, “Basic Functions,” explains how the body works. The motors of movement, the fuels used by muscles to work, why muscles get tired, ways to avoid muscle fatigue, why we need to train muscles and why not every type of exercise is equally beneficial practice does not always make perfect, memory and forgetting, mental practice, breathing and sound production.

Chapter 2, “Situations that Place the Musician at Risk,” examines nine problems a musician faces and gives a solution for each: taking more care of your musical instrument than of your own body not compensating for asymmetric work, the technique you use, unsuitable fit between the body and instrument, failing to consider your overall state of health, poor environmental conditions, carrying and holding an instruments other daily activities, psychological aspects and socioeconomic factors. The last section is titled “Are You at Risk?” with a list of 13 questions to answer.

Chapter 3, “Posture: Your Body in Harmony with your Instrument,” explains what good posture consists of and gives some basic points for good posture when playing and singing; examines the best chair position with information and websites on buying special stools, chairs or cushions gives suggestions on how to carry your instrument how to lift and carry weights; and gives some information about musicians and computers.

Chapter 4, “Musicians, Instruments and the Workplace: Adjusting the Task to Suit Your Body,” is about ergonomics and how to apply it to your instrument or working environment to benefit your performance and overall health. There is a section on accessories for each instrument with a chart for all instruments listed in three categories: problem detected, possible solution and possible drawbacks identified. Companies and website information is included where appropriate how to modify accessories such as the chair, music stand or score and how to change the environment is reviewed.

Chapter 5, “The Musician’s Body Explained,” examines some of the essential elements of a musician’s body in order to understand the mechanics of performance. Basic information on the skeleton is reviewed. Bones, joints, muscles, protective coverings, hypermobility, some important areas such as the shoulder joints, connections to the trunk, the forearm and hand bones; muscles of the posterior forearm, tendinous bridges, muscles of the anterior forearm, muscles of the hand, tendon sheaths, the spinal column, alignment, basic connections, weak points basic information about the respiratory system, sound production and the modulation system and the ear are all discussed and reviewed.

Chapter 6, “Mind and Music: Further Psychological Aspects,” reviews anxiety both from a positive and negative aspect how performance anxiety manifests itself, why it happens and what we can do about it; substances and general lifestyles are also discussed. How to deal with and reduce negative physiological and psychological responses to performance anxiety via making lists, deep breathing, positive self-talk, positive mental images/visualizations along with combined therapies is reviewed.

Chapter 7 is titled “Troubleshooting for Musicians: Basic Body Maintenance and Solving Problems.” Here, the authors discuss general tips for body maintenance such as a balanced diet, exercising and physical activities that complement a musicians’ balanced body, stretching and a chart on how to solve particular problems such as pain, fatigue, inflammation, tension, numbness, lack of agility, sore throats, hoarseness, impossible high notes, nasal congestions and so on. Tips for when to see a doctor, massage therapy, medications, and a table of diagnoses with a list of the symptoms and causes of things like trigger finger, overuse of muscles, carpal tunnel, tennis elbow and so forth are reviewed.

This manual is an excellent resource for all musicians, but is a particularly useful book for academic programs that include a wellness course for musicians. The layout of the book is in manual form, easy to read sections and appealing to students with colored sections throughout. Included at the end are sections on: where you can find more information and medical assistance, national members of the International Musicians’ Medicine Committee and a recommended bibliography.

Audience: all musicians and pedagogues

Marquart, Linda. (2005) The Right Way to Sing. Allworth Press, 10 East 23rd St., New York, NY 10010; www.allworth.com. 127pp. ISBN: 1- 58115-407-0

Lea Salonga writes in the forward that in spite of the compact size of this book, it is very thorough and extensive-a “nuts and bolts” manual that will benefit both the novice and the seasoned pro. Technical information on vocal classification as well as the physiology of the singing voice is examined.

The manual is divided into eight chapters. Chapter 1 serves as an introduction and gives an explanation of how to use the book.

Chapter 2, “Thoughts about Singing,” shows the significance of mental attitude in learning how to sing. Marquart draws on ideas of Neuro-Linguistic Programming; introducing the idea that singers can use these skills to learn vocal technique and performance preparation. The importance of mental conditioning in establishing muscle memory is explained. In the remaining chapters, the author uses the concept discussed in chapter two.

Chapter 3, “Vocal Equipment,” describes the mechanics of the singing voice from the physiological point of view and shows how the various parts of the vocal apparatus work, by themselves and in combination. Basic singing vocabulary is included, as well as a chart of “vocal categories” with definitions of each.

Chapter 4, “Vocal Technique,” is explained by the author to be the core of the book. It begins with the basics through advanced techniques and gives a step by step program of vocal instruction. Exercises for breathing, resonance and interpretation are provided in this chapter. The author firmly states that solid vocal technique is the basis for healthy singing.

Chapter 5, “Musical Skills,” gives some advice about reading musical scores and how to learn a piece of music. Chapter 6, “Training the Voice,” is about how to find a teacher, coach and accompanist. Chapter 7, “Singing Solo in Public,” examines performance preparation holistically, how to prepare a program, what to wear and what to do the weeks before getting ready to the day of counting down until you are there is reviewed.

Chapter 8, “Frequently Asked Questions,” answers 20 questions that are asked time and time again by singers of all levels, school music teachers, choral conductors and parents of young singers. Bibliography not included.

Audience: singers

Peckham, Anne. (2006) Vocal Workouts of the Contemporary Singer. Berklee Press, 1140 Boylston St., Boaston, MA 02215-3693; (617) 747- 2146; www.berkleepress.com. 117pp. ISBN: 0-87639-047-5

This book is addressed to singers who are interested in contemporary, non-classical singing styles. It examines breath support, tone production and voice strengthening. Vocal workouts are presented in the text with an accompanying sing-along CD (like an accompanist) for making vocal exercises and the practice of them accessible. The book includes 26 exercises for warming up and developing the voice, basic and advanced workout for both high and low voices; twoand three-part exercises for harmony practice and a routine to help you organize your practice time according to your level and schedule. The manual also includes detailed descriptions and helpful tips for how to warm up and develop your voice, breath control, practice strategies, and specific technical advice for improving your control over vibrato, range and belting. Advice on vocal study, voice maintenance and auditioning is also given.

Part 1, “Vocal Essentials,” contains six chapters. Chapter 1, “Getting Ready to Sing,” tells how to practice with the CD, how to get your voice into shape and how to listen to your body. Chapter 2, “Breathing,” gives four steps to effective breathing, explains posture, deep breathing, keeping the ribs open and quiet breathing exercises. Chapter 3, “The Four P’s: Essential Building Blocks for Vocal Training,” deals with the concepts of practice, patience, perseverance and play as the ingredients for developing a contemporary voice. Chapter 4, “Vibrato, Vocal Registers, and Belting,” looks at these vocal issues. Chapter 5, “Essential Vocal Care,” is about maintaining vocal health, detecting a vocal problem and the signs of possible problems, and what to do if you suspect one. Chapter 6, “Auditioning,” talks about criticism and auditions.

Part 2, “Complete Vocal Workouts,” contains warm-ups for all voices, basic and advanced workouts, and a section titled “What Next.”

Written by a professor in the voice department at Berklee College of Music, this is a companion book to The Contemporary Singer, a book/ CD set. Peckham also produced Vocal Technique: Developing Your Voice for Performance, a DVD released in 2004. Bibliography not included.

Audience: contemporary non-classical singers

Ricci, Ruggiero. (2007) Ricci on Glissando: The Shortcut to Violin Technique, edited by Gregory H. Zayia. Indiana University Press, 60 1 North Morton St., Bloomington, IN 47404-3797; (800) 842- 6796, fax: (812) 855-7931; http://iupress.indiana.edu. 114pp. ISBN: 978-0-253-21933-6 Includes DVD on bowing.

This is a manual on left-hand violin technique. Common problems in shifting are addressed; training the ear and short-cuts for difficult technical passages are provided. Ricci introduces and compares old and new systems of playing, outlines a series of glissando scales and includes a DVD where he demonstrates various bowing techniques. This manual has four chapters: Chapter 1, “The Old and New Systems of Violin,” briefly explains and compares both systems of violin playing, explaining the pre-chinrest era with the chinrest era and how to maintain the most economical way possible of playing with keeping the principles of the old system and incorporating the new system-one that moves a finger from one note to the next without simultaneously moving the thumb, thus developing less problems in advanced violin technique. Chapter 2, “Exercises, Etudes, and Cadenzas,” shows that the glissando is the shortcut to developing a left-hand technique and a trained ear. Ricci believes the art of playing a scale with one finger should be learned from the start. He gives glissando scales and guidelines for practicing them. Chapter 3, “Miscellaneous Aspects of Technique,” provides exercises designed to increase the player’s flexibility, ear training, coordination and crawling technique. Fingering guidelines, vibrato, tone production, bowing, articulation and evenness in slurred passages, grouping, tuning, ear training, practicing, instrument setup, hand development, holding the violin and hand position are examined. Ricci also includes representative etudes and short pieces that have specific problem intervals, Ricci’s cadenzas for Paganinis Concerti Nos. 4 and 6, Paganini’s original glissando fingerings for the Cantabile and Waltz and the cadenza for the Brahms concerto.

Strings Magazine, General Editor. (2007) Healthy String Playing: Physical Wellness Tips from the Pages of Strings Magazine. String Letter Publishing, Hal Leonard Corporation, 7777 W. Bluemound Rd., P.O. Box 13819, Milwaukee, WI 53213; www.halleonard.com. 159pp. ISBN: 13: 978-1-423-41808-5; 10: 1-423-41808-5

There are 22 contributors to this manual on Healthy String PL- ying with a total of 20 chapters. The purpose of the book is to discuss how to avoid stress and injury to your body while practicing and keep your body in “great string-playing shape.” General topics covered are repetitive stress injury prevention, performance anxiety, tension-free bowing tips and other helpful tips from performers, teachers, students and doctors.

Chapter 1, “The Healthy String Player,” by Joan Hamilton, discusses the medical maladies of musicians and how varied and complex they are when taking into account life styles and other factors. She explains the various musician clinics around the United States and how the health-care climate is changing. She also examines pain, what can go wrong and the need to seek help when pain first occurs. Chapter 2, “Staying Healthy,” by James Reel, talks about never being too young to get hurt. He overviews healthy habits, posture and taking medication if pain occurs. Chapter 3, “The Ten Dos and Don’ts,” by Janet Horvath, could be applied to any musician. Basically Horvath annotates 10 different dos and don’ts of a musicians’ practice. Chapter 4, “It’s a Stretch! An Occupational- Therapy Perspective on Player Health and Wellness,” by Carrie Booher, Joanne Horner and Derek Noll, reviews repetitive strain injuries with regard to lifestyle design, trying out things that can help maintain good health, including stretching exercises and hand massage, as well as being proactive about prevention. Chapter 5, “The Pleasures of Stretching,” (excerpted from Staying Supple: The Bountiful Pleasures of Stretching} by John Jerome, is all about in and out stretching exercises. Chapter 6, “You Are Your Instrument: Muscular Challenges in Practice and Performance,” by Julie Lyonn Lieberman, reviews muscle balance and rejuvenation and healing. She reviews specific mental and physical actions one needs to balance to maintain a relaxed and fluid technique. Chapter 7, “Keeping Fingertip Cracks at Bay,” by Yvonne Caruthers, is all about using alpha-hydroxy lotions and how to use them for cracks. She also examines the use of super glue and its problems. This chapter is excellent for any musician with dryness problems. Chapter 8, “Heimberg’s Handy Hints: Tips and Tricks of the Trade,” by Tom Heimberg, is about trying to achieve true comfort and good body awareness. Heimberg gives a list of things he carries in his case to protect his instrument and body-from vinyl tubing to rubber bands. Chapter 9, “A Helping Hand: Tension-Free Bowing Tips that Adult Amateurs can Grasp,” by James Reel, examines the right and the wrong bowing grips. Chapter 10, “Finger Tips,” by David Templeton, talks about the care, repair and injury prevention of the musical hand. He looks at small problems that produce pain such as carpal tunnel syndrome, tendonitis, DNA family history, arthritis and other similar aliments, when to take a break from practicing after sustaining an injury and culminates with “Three Things to Think About” to avoid injury and what should be done when injuries occur. Chapter 11, “Playing Hurt: Doctors, Musicians, and Teachers Talk about When to Stop, What to Do, How to Cope,” by Ruth F Brin, discusses the different kinds of overuse, what different pedagogues and medical doctors of performing musicians have recommended. Chapter 12, “Overuse Injuries: How String Players can Recognize, Prevent, and Treat Them,” by Richard Norris, M. D., chats about predisposing factors a musician who suffers from overuse injuries has to take into account: genetic predisposition, inadequate physical conditioning, sudden or abrupt increase in the amount of playing time, errors of technique, change in instrument, errors in practice habits, inadequate rehabilitation of previous injuries, improper body mechanics and posture, stressful non-musical activities and anatomical variation. He reviews the symptoms of overuse, nerve compression, treatment and the general activities of daily living that should also be considered. Chapter 13, “Surviving Overuse Injuries,” by Edith Eisler, is about the occupational hazards of performing musicians who develop severe symptoms. She describes Peter Oundjian’s problems as a member of the Tokyo Sting Quartet and how he has now turned to a conducting and teaching career. An interesting read for anyone familiar with Oundjian as a violinist or conductor. Chapter 14, “Preventing Overuse Injuries: The Power is in Your Hand,” by Darcy Lewis gives 1 1 good “warm ups” to do before playing. Chapter 15, “Double Trouble: Quick Action Can help Address Potentially Debilitating Double-Crush Injuries,” by Avram Lavinsky, is about musicians who show signs of injury to the same nerve at two different locations such as injury to the median nerve and the carpal tunnel of the wrist simultaneously. Early intervention, problematic posture and elbow flexion are reviewed. Chapter 16, “Stress and the String Player,” by Shannon Mar, is about options available for controlling performance anxiety. Chapter 17, “From Fear to Freedom: Developing a Nondrug Strategy for Combating Performance Anxiety,” by Gabriel Sakakeeny, talks about the mechanics of fear, bypassing the performance system via a chemical bypass of the sympathetic nervous system and parasitic memory activation and treatments available. Chapter 18, “A Different Kind of Practice: Musicians and the Alexander Technique, A Conversation between Jorja Fleexanis and Jon Berni,” interviews them about re – training musicians using the Alexander Technique. Chapter 19, “Injury Prevention and Healing Through Yoga,” by Lauryn Shapter, is about how doing yoga can help any musician in recovery from injury. She concludes the chapter with a number of annotated resources on yoga for getting started.

Chapter 20, “Pilates for the Cellist,” by Felicity Vincent, discusses the asymmetrical muscular development of the cellist, realignment of the muscles through yoga, Qi Gong, and Feldenkrais and the general imbalance of muscles cellists experience. The author advocates exposure to a Pilates Body Control Studio. She goes on to explain that pilates training enables you to isolate muscle groups and exercise “around” an injury. The body is realigned, and the muscles are either stabilized or mobilized along with thoracic breathing and pelvic stability. Kinesiology is examined in order for a cellist to reach her full playing potential.

Each chapter is clearly written, easily read and has appropriate diagrams when necessary. Bibliography or suggested reading is not included.

Audience: String players

BOOKS ON THE BRAIN AND MUSICAL PERCEPTION

Levitin, Daniel J. (2006) This Is Your Brain on Music: The Science of a Human Obsession. Penguin Group Inc. 375 Hudson St., New York, NY 10014; www.yourbrainonmusic.com. 314 pp. ISBN: 0-525-94969- 0

* How humans experience music and why

* What makes a musician-the extraordinary mastery

* Origins in genetic structure

* Identifiable at an early stage

* Likely to excel

* Only in a minority

* Extended bibliography (includes musician wellness resources)

Sacks, Oliver. (2007) Musicophilia: Tales of Music and the Brain. Alfred A. Knopf, Publisher, NY; www.aaknopf.com. 381 pp. ISBN: 978- 1-4000-4081-0

* Examines music through individual experience via the career of a physician

* How music animates people

* Extended bibliography (includes musician wellness resources)

WEBSITES

Music and Health: Piano Teaching, Anatomy/Biomechanics and Musicians’ Health

www.musicandhealth.co.uk

This website is the work of Richard Beauchamp, a pianist who, since 1977, has taught at the St. Mary’s School of Music, Edinburgh. Beauchamp’s work has been influenced by the writings of the renowned orthopedist and hand surgeon Raoul Tubiana, whose books have been reviewed in previous editions of this bibliography. Beauchamp has assembled an impressive collection of materials, including articles, slide shows and video clips primarily related to the ergonomics of keyboard playing with some attention to more general musician health issues, such as hearing loss and performance anxiety. This material is organized under three links: “Musicians’ Health,””Anatomy/ Biomechanics” and “Piano Teaching.” All materials are dated and proper attribution given. The first tab, “Musicians’ Health,” includes a listing of self-help articles and websites about many performance-related health issues, including hearing loss, focal dystonias and performance anxiety, along with links to sites explaining Feldenkrais and Alexander techniques. This section will be of interest to all musicians. The tab “Anatomy/Biomechanics” leads to extensive information related to keyboard playing, much of which is Beauchamp’s own work. For example, he provides video clips demonstrating the specific muscles and tendons used at the keyboard, a photo-essay on rotation movements demonstrating how to position the arms and fingers for efficiency and comfort in playing, and an article on passages from well-known pieces of music that can cause tendon problems. There are also notes from a lecture explaining the importance of accommodating individual anatomical variations in teaching or playing and other papers and slide shows dealing with the hand at the keyboard. The third section, “Piano Teaching,” cross references relevant material from the other two sections, as well as providing other articles and slide shows on such diverse topics as hand anatomy, tension and stress in piano playing, sight reading and various keyboard techniques. There are also links to instructional materials for everything from Schenkerian analysis to practice exercises that teach good fingering techniques. Anyone who plays or teaches will find this section fascinating, entertaining and informative.

This is a website that has much to offer for any student or teacher of piano. Creating and maintaining it is obviously a labor of love by a musician and teacher who is extraordinarily knowledgeable about the anatomy and physiology of the hand and who understands how to apply that knowledge to teaching techniques that minimize the potential for injury and stress.

Audience: pianists, keyboard players, music teachers

eMedicineHealth

www.emedicinehealth.com/script/main/hp.asp

This consumer health guide, created and maintained by a group of physicians, is a well-designed site that offers guides to symptoms, treatments, self-care and prevention of many disorders that are of interest to musicians and all other performing artists. From the homepage there are several ways to locate the desired information. One approach is to click on the tab “Topics A-Z,” which leads to a list of more than 800 health topics, grouped under broader headings such as “Anxiety,””Ear Nose and Throat” and “Headaches.” The user may click on the broad topic for an overview and listing of articles or immediately select one of the more specific subheadings. For each of the specific topics there is a lengthy article broken down into sections that provides an overview of the condition, plus a brief description of symptoms, causes, medical treatments, self care and prevention techniques. Articles are written in a clear, concise style that avoids jargon, while providing adult-level information. There are internal links to other related information on this and other websites and often a multimedia link leading to drawings and photographs. Each article is dated and the names of authors and editors are provided.

Information may also be found by clicking the tab labeled “Health + Medical.” This link leads to a list of health topics that can be clicked to reach detailed information. A box on the left offers a scroll-down menu of essentially the same topics in slightly different wording. Other features of the site include an online medical dictionary and a section on first aid and emergencies.

This site demonstrates many of the best features of website design. Its information is well-organized, interlinked and approachable from several different paths so that the user, regardless of skill level, is likely to find the topics of interest to him or her. Although frames are used extensively, each article includes a printer-friendly version. On the negative side, advertising throughout all pages of this site is intrusive and annoying in the extreme, with constant animation and scrolling. Worse still, is the fact that since the advertisements are all for health products, it is often difficult to tell at first glance which of the frames are advertising and which are subject content. This confusing display could be a problem for younger or inexperienced web users.

From a medical standpoint, however, the information on this site can be considered reliable. The authors and editors of the content are clearly identified by name and medical specialty, and the articles make a clear distinction between situations in which self care is adequate and those requiring professional medical attention. The articles are all dated and most are fairly recent. While the range of conditions described on this site is far from comprehensive, researchers will find good basic information for a variety of common disorders. Topics on this site that may be of particular interest to musicians include stress, anxiety, repetitive use injuries, muscle pain and stiffness, back and joint pain, tinnitus and hearing loss, and back and joint pain. There is also useful advice on nutrition, exercise and other aspects of overall wellness for both teens and adults.

Body Tuning

www.bodytuning.us

Body Tuning is arguably one of the very best internet sites for musicians seeking information about injuries and their treatment. This is the website of Shmuel Tatz, a celebrated New York physical therapist, whose long-term clients have included Yehudi Menuhin, the late Isaac Stern, Susan Jaffe and other performing artists, as well as a great many “ordinary folk.” In his Carnegie Hall studio, Tatz uses manual therapy augmented with exercise, thermal and electrotherapeutic treatments, and alternative medical approaches to treat a variety of musculoskeletal disorders. His methods emphasize the ageold approach of manual touch, rather than the use of machines to evaluate and treat all conditions.

Tatz’s website is far more than an account of his methods; it is a treasure trove of patient education material, all easily accessible from a sidebar on the main page. Tatz is firmly committed to the idea of patient education and believes that there is much individuals can do to help themselves. On this site, users will find links to information on a variety of conditions commonly associated with music and dance performance, along with detailed explanations of various therapies and self-help measures. Each link leads to an article describing symptoms, causes, differential diagnoses and therapeutic modalities. There are also detailed articles on the history, development and application of each of the treatment modalities mentioned in the articles. On the top bar, additional links provide information about several widely available therapies, their uses and effects.

For those interested in seeking treatment at this studio, there is a description of Tatz’s clinical approach and even a video clip of him treating a client. Articles from various newspapers and magazines provide an even clearer sense of his philosophy and techniques. But for all users, the wealth of self-education materials makes this site well worth an extended visit, and must reading for anyone considering a program of physical therapy for performance related injuries.

Audience: all musicians

Centre for Manual Physiotherapy

www.phyzio.biz/musicians.html

Musicians’ injuries is one of the specialties practiced at this Canadian clinic, the Centre for Manual Physiotherapy, and the Centre’s website offers health information specifically for musicians, as well as extensive information on various conditions that often affect musicians. The user will probably want to start by clicking on the link “Musicians Injuries,” which leads to an introductory article discussing the importance of not ignoring pain or discomfort in playing and gives an overview of the assessment provided at this particular clinic. The tips they offer on preparing for an initial evaluation could very well be used in any therapeutic program. For example, they ask clients to bring their instruments (pianists would presumably be exempt from this requirement!) so that therapists and music consultants can observe as the instrument is played, and to wear clothing that will allow the therapist to observe body movement as the instrument is played. The article concludes with tips for self care and injury avoidance, such as the importance of warm up activities and regular breaks during practice that will be valuable to any musician.

Also useful for musicians are the detailed help sheets for specific conditions, which are listed in a sidebar on the home page. Here users will find well-illustrated information about the symptoms, causes and prevention of common injuries, as well as advice on issues such as whether to apply ice or heat to a painful area. These fact sheets are PDF files that can easily be printed and kept for future reference.

Patient education is obviously an important component of any treatment for performing artists’ injuries, as the creators of these web pages affirm. Interestingly, this clinic works with music teachers, both as clients and as advisors, and they emphasize the important role that music teachers have in educating their students about healthy playing techniques. The writers assert: “Music teachers, in our opinion, are the main line of defense against playing injuries for the generations to come.”

The upbeat approach and positive philosophy emphasized by this clinic, along with the practical online information it provides, make this website worthy of a visit by anyone seeking to educate themselves about the kinds of injuries that can occur and the ways that these injuries can be treated and prevented. Audience: all musicians, teachers

Performance Wellness, Inc.

www.performancewellness.org/index.html

This is the homepage of Performance Wellness, Inc., a not-for- profit organization that focuses on the mind/body aspects of health and performance. The organization was founded in 2002 by Louise Montello, a licensed psychoanalyst and specialist in the treatment of stress related disorders in musicians, along with her research partner, Edgar E. Coons, a composer and neuropsychologist. The program they developed called Essential Musical Intelligence (EMI), seeks to use music as a way of reaching the inner creative processes that enable the individual to achieve new levels of healing and pleasure in performance as well as life in general. While this approach may sound somewhat vague or theoretical, it actually involves concrete techniques that encourage the person to use mental imagery and meditative states for relieving stress and freeing the creative instinct. These techniques are based in part on an understanding of the neurological processes that occur in hearing and performing music.

All users of this website will find much helpful information in the series of articles with tips for relaxation breathing, self care, overcoming perfectionism, and various other similar topics. There is also ordering information for the organization’s modestly priced publications, including Montello’s own book entitled Essential Musical Intelligence.

For those contemplating participation in one of Montello’s workshops, the site provides information about the many different seminars for both educators and musicians that are offered across the country. Much of the material on this site is mirrored on www.musicianswellness.org/aboutus.htm, possibly an older version of the organization’s website.

Audience: all musicians, music teachers

The Association of Adult Musicians with Hearing Loss

www.aamhl.org

While there are many organizations devoted to hearing loss that can be highly useful to musicians, there are few that have a particular interest in, or understanding of, hearing loss in musicians. Therefore, this website, which deals exclusively with musicians needs and concerns, fills a unique niche among the musician wellness resources available on the web.

The Association of Adult Musicians with Hearing Loss (AAMHL) describes its mission as supporting adult musicians with hearing loss through group discussion, performance opportunities and music education, as well as providing information about musicians needs to heath care professionals, music educators and manufacturers of assistive technologies. Website users will find many helpful resources by clicking on the link labeled “Knowledge Base.” There is a link to a well illustrated and detailed tutorial on how the ear works and an article explaining in non-technical terms how to understand an audiogram. Since many audiologists have no musical knowledge, they may have difficulty understanding how an individual’s hearing loss affects musical perception. To improve communications with audiologists, this site offers links to a chart that shows musical dynamics from pianissimo to fortississimo with their equivalent decibel values, and a table of the sound frequencies of notes on an 88-key piano. These tools are intended to help musicians explain their individual hearing problems to audiologists and, in turn, to understand the audiologists findings in terms of their own musical experience.

Other resources on this site include a selection of articles about musical perception with hearing aids and cochlear implants and a series of articles about music-induced hearing loss among musicians. There are also links to the websites of professional musicians who have suffered hearing loss. For music teachers, there are articles on music instruction and appreciation for hearing- impaired children.

At present this is a very simple website, with easy navigation but minimal eye appeal. However, because of the growing recognition of performanceinduced hearing loss among musicians, this website- and its parent organization-bear watching for further developments.

Audience: all musicians

www.gbmc.org/voice/index.cfm

This is the voice treatment page of the Milton J. Dance Head and Neck Center in Baltimore, Maryland. While this clinic deals with a wide variety of voice disorders, the webpages indicate much involvement with the diagnosis and treatment of people who use their voices professionally-singers, actors, teachers, public speakers and so forth. Their web pages offer a substantial amount of material designed to help people who are experiencing voice problems discover self help measures, as well as increase their understanding of medical diagnoses and treatments.

The website user will immediately notice a sidebar filled with links to information on voice disorders, beginning with a vividly illustrated “Anatomy and Physiology of the Voice.” Another link leads to a page on care of the voice, which emphasizes good health measures such as getting adequate sleep, keeping hydrated, avoiding tobacco use and not straining the voice. There is also a FAQ with answers provided by physicians and a page where readers may view professional answers to e-mail questions and submit questions of their own. Other sections offer practical advice for singers, voice exercise for warming up and cooling down, and a vocal self- screening exercise that allows users to assess their own risk factors for developing serious voice problems, and a photo-library of voice pathology. There is also information on some of the newest diagnostic techniques including videostroboscopy, which involves direct imaging of the larynx during voice production.

This site, with its reliable professional information, excellent illustrations, and easy navigation, is a must-see for anyone experiencing vocal problems or concerned about preventing them.

Audience: vocalists, choral singers, teachers

Linda Cockey, is professor and chair of the Department of Music at Salisbury University in Maryland. She has been teaching a wellness in performance class for more than W years now that includes injury prevention for all musicians and actors. She also teaches piano, music history and form and analysis. She holds a D.M.A. degree from the Catholic University of America.

Copyright Music Teachers National Association Jun/Jul 2008

(c) 2008 American Music Teacher, The. Provided by ProQuest LLC. All rights Reserved.

PATNA: Taking note of the health hazard caused due to impure drinking water in the flood-affected areas, the health department has come up with an innovative idea to ensure the purification of drinking water sources in theaffected areas.

The department is adding packets, in the food packets being dropped amongmarooned people, which contains Halogen tablets. These are used for purifying the sources of drinking water. The department has also put in a slip with the tablets giving guidelines for the use of the tablets.

“Water-borne diseases are very common in flood-affected areas. Judicious use of Halogen tablets would reduce its possibility,” health department principal secretary Deepak Kumar said on Monday.

The department has also supplied sufficient stock of anti- diarrhoea medicines and anti-venom injections to all the primary health centres (PHCs) in the blocks of flood-affected districts of Supaul, Madhepura, Araria and Saharsa. This apart, special teams of doctors and paramedical staff have been constituted for providing round-the-clock services to the people who are staying in relief camps after being evacuated from the affected areas. “These teams have been provided with sufficient stock of emergency drugs which aregenerally required,” Kumar said.

He said the department has also charted out an elaborate programme forspraying bleaching powder in flood-affected areas once the water receded from there. “Men and material are being kept in readiness so that the spraying work could be taken up as soon as the water recedes,” Kumar said.

Incidentally, more than one million of state population is facing flood fury which has taken into its grip the areas which hitherto were not considered to be flood-prone. Inundation of these areas took the state government by surprise which had to mobilise resources in a very short period of time for extending help to the marooned people.

Apart from shelter, food and safe drinking water, health services are key to ensure a quality relief operation as deluge is generally accompanied byhealth hazards.

(c) 2008 The Times of India. Provided by ProQuest LLC. All rights Reserved.

To: FAMILY EDITORS

Contact: Florida Hospital Media Relations, +1-407-303-8217

ORLANDO, Fla., Aug. 27 /PRNewswire-USNewswire/ — Officials from Florida Hospital today revealed new details about their visionary plans to shape the ‘Children’s Hospital of the Future,’ which will make a significant impact on children’s health throughout Central Florida and be a model for pediatric hospitals beyond the region.

(Photo: http://www.newscom.com/cgi-bin/prnh/20080827/DCW002)

The plans include sophisticated, interactive technology for patients; accomplished pediatric physicians who specialize in advanced, minimally invasive surgery; and a former United States Surgeon General who will provide leadership for the children’s health and policy platform. Administrators also unveiled the hospital’s new name, Disney Children’s Hospital at Florida Hospital. While The Walt Disney Company has long supported children’s hospitals both locally and around the world, Disney Children’s Hospital will be the first children’s hospital in history to bear the Disney name.

“This hospital will be on the forefront of technology and a model for patient experience that will be truly dedicated to the well- being of children,” said Marla Silliman, administrator of Disney Children’s Hospital at Florida Hospital.

One of the keystones of this visionary plan is the creation of a dedicated children’s emergency department that will be the first in the country to feature Ambient Experience Design solutions from Philips. First impressions set at the entrance, in addition to patient rooms and dedicated play areas, are designed to soothe young patients and their families. Areas throughout the department will feature lighting and design elements to bring the comforts of outside into the hospital setting. Patient treatment rooms will offer animation selections on the ceiling accompanied by soft lighting and music, allowing “escapes” to areas such as the beach or mountains.

“Philips is delivering a captivating and comforting, child- friendly space. We’re incorporating the latest in clinical design and technologies, as well as elements, to provide calming, positive assurances to patients and their families,” said Brent Shafer, executive vice president and CEO, North America, for Philips Healthcare. “In collaboration with Disney Children’s Hospital, we’re aiming to define the ‘Children’s Hospital of the Future.'”

Technology will extend to the in-room experience as well, where the first Interactive Patient Care technology of its kind in Central Florida will allow bedside access to the GetWellNetwork(R) Patient- Life System(R) so that pediatric patients can play video games, watch movies and surf the Internet. Parents may also view the latest information on childhood obesity, asthma, diabetes and other topics through patient education videos on the same system.

“GetWellNetwork is excited to contribute our Interactive Patient Care technology to the ‘Children’s Hospital of the Future’ at Disney Children’s Hospital,” said Michael O’Neil, Jr., founder and CEO, GetWellNetwork, Inc. “This technology enhances the patient experience and gives them access to interactive resources that educate and entertain to make their stay as comfortable as possible. With the touch of a keyboard or remote, patients or their parents can view vital health information and communicate with other areas of the hospital to help meet their health care needs.”

Joining the medical leadership of the hospital, Dr. Antonia Novello, former United States Surgeon General, will guide the children’s health and policy platform as the vice president of Women and Children Health and Policy Affairs. During her tenure as the first female and first Hispanic Surgeon General, Novello helped launch the Healthy Children Ready to Learn Initiative and actively promoted immunizations of children and childhood injury prevention efforts.

Also joining the hospital’s staff are Dr. Bryan C. Weidner and Dr. Christopher M. Anderson, who will provide advanced surgical services including minimally invasive procedures for pediatric patients. Minimally invasive surgeries require fewer incisions, reducing blood loss and hastening patient recovery. Weidner is board certified in general surgery, surgical critical care and pediatric surgery. Anderson is board certified in general surgery and board eligible in pediatric surgery.

“The addition of Dr. Novello to our staff is a real coup for Disney Children’s Hospital and the children of Central Florida and beyond,” Silliman said. “In addition, the skill and expertise of renowned pediatric surgeons and the Nicholson Center for Surgical Advancement will help keep us on the leading edge of surgical technology.”

The new dedicated lobby and entrance for Disney Children’s Hospital is expected to open in mid-2009. The three-level lobby designed by Walt Disney Imagineers will feature several of the most beloved Disney characters from “The Little Mermaid,””The Lion King,””Brother Bear” and “The Jungle Book.”

“Walt Disney World Resort is committed to the dreams of children in our community, and we’re pleased to lend some of our magic to Disney Children’s Hospital at Florida Hospital,” said Shannon McAleavey, senior vice president of Public Affairs for Walt Disney World Resort. “This will be a special place that will enable children to use their imaginations in a unique, immersive environment that will contribute to their overall health and healing.”

In the lobby, children of all ages will be able to draw individual markings on a cave wall, create jungle sounds on musical step pads, fish for virtual salmon, or play in a magical world of popping bubbles and dancing sea horses. And each night as the sun sets, the lobby will transform into a celestial display as unique as each child, featuring constellations on the ceiling and a musical score created by the young patients.

“The partnership between Florida Hospital and Disney demonstrates that Central Florida is quickly becoming known just as much for medicine and science as it is for its thriving tourism industry,” said Lars Houmann, president of Florida Hospital and chairman of bioOrlando. “We believe Disney Children’s Hospital will provide the blueprint for other children’s hospitals in the future.”

Disney Children’s Hospital at Florida Hospital is currently undergoing construction and renovation, which is expected to be completed by 2010. The project continues to rely on the generous philanthropic support of the community.

When complete, the seven-story, 200-bed hospital will have family- centered pediatric rooms; a first-of-its-kind, dedicated pediatric Emergency Department featuring ambient lighting; an Advanced Center for Pediatric Surgery led by renowned surgeons; destination pediatric programs including advanced surgery, oncology, neurosurgery, cardiology, transplant services and full-service pediatrics; and an innovative Health and Obesity platform.

SATELLITE INFORMATION: B-roll and sound available via satellite on Wednesday, August 27, from 3:30 p.m. to 3:45 p.m. EST. Galaxy 25 – Transponder 13 (C-band analog). Downlink frequency: 3960 (v) Audio 6.2/6.8. For satellite control during feed only, please call 407- 560-6844. For other needs, please contact Andrea Finger, Walt Disney World Media Relations, at 407-828-3814 or 407-925-3319.

NOTES: Satellite feed with b-roll and interviews available today, Wednesday, August 27, from 3:30pm -3:45pm Eastern Time. B-roll includes Mickey Mouse’s pal Goofy, having an ”X-ray” to reveal the name of the first children’s hospital to bear the Disney name, never- before-seen artist renderings of interactive lobby designed by Walt Disney Imagineers, and leading-edge patient experience lighting technology provided by Philips Healthcare. Interviews include Dr. Antonia Novello, former United States Surgeon General; Shannon McAleavey, vice president of Public Affairs at Walt Disney World Resort; Jack Blitch, Walt Disney Imagineer; Brent Shafter, executive vice president and CEO, North America, for Philips Healthcare; Lars Houmann, CEO for Florida Hospital; and Marla Silliman, administrator of Disney Children’s Hospital at Florida Hospital. Please see press release for exact satellite feed coordinates. In addition to the feed, tapes and/or photos are available on request by emailing [email protected].

For more information, please contact Florida Hospital Media Relations at 407-303-8217.

SOURCE Disney Children’s Hospital at Florida Hospital

(c) 2008 U.S. Newswire. Provided by ProQuest LLC. All rights Reserved.

Columbia Pacific, a Seattle-based investment and money manager, announces the close of a $135M second round of financing for its Asian hospital entity, Columbia Asia. This brings the total equity raised for Columbia Asia to $325M.

Columbia Asia, which opened its first hospital in Malaysia in 1994, currently operates 13 medical facilities, will have 14 more under construction by this fall and owns the property for another 12. Upon completion Columbia Asia will have 21 hospitals and an airport clinic in India, 11 hospitals in Malaysia, three hospitals in Vietnam and three hospitals in Indonesia, together representing an investment of over $600M.

The Asian operations are headed by Seattle natives Rick Evans and Matt Powell. Evans, who graduated from University of Washington and UW School of Business, is the company’s Chairman. Powell, also a UW graduate, is the company’s Managing Director.

While the firm has a strong presence throughout Asia, the majority of the company’s growth will be in India. In fact, Columbia Asia is the first American firm to enter the emerging Indian healthcare market in such a dramatic way.

To stand out in the booming healthcare market, the company offers a unique design: full-service hospitals built in residential areas.

“Our business model is based on providing affordable medical care to the underserved middle-income group in India,” Rick Evans said. “After nearly a decade of experience in Asia, we know that sophisticated hospitals built in neighborhoods, rather than the central city, are the best way to serve patients.”

At Columbia Asia facilities, patients are met with highly trained and culturally sensitive staff, advanced technology and the full range of hospital services. With efficient administration and fewer beds, the hospitals have an average patient stay of just two days, which keeps costs down.

In India, the site of most of the company’s current and future growth, the $34 billion private healthcare market is growing by 16 percent a year, and the number of hospital beds and physicians across the country is expected to double by 2015, according to Ernst & Young and McKinsey.

The middle-income group in India is projected to grow from 50 million people to a staggering 583 million people by 2025, as citizens pull themselves out of poverty, according to BusinessWeek. This will fuel a massive demand for healthcare, especially as the rate of “lifestyle” diseases common to the middle- and upper-income groups, such as obesity and diabetes, also rises.

“It only took a year for our first hospital in India, in the Hebbal District of Bangalore, to operate at full capacity,” Evans said.

Columbia Pacific manages two investment funds, the $300M Columbia Asia fund and the $200M Columbia Pacific Opportunity Fund. The Opportunity Fund, headed by Alex Washburn, focuses on a diversified portfolio. The investing group is made up primarily of Northwest individuals and families, with the Seattle-based Baty family as the principal investor in both funds.

For more information about Columbia Asia hospitals, go to www.columbiaasia.com.

By BAY AREA NEWS GROUP

at sea. The climbing wall is on the aft portion of Deck 14, and stretches an additional 30 feet up into the sky.

If you reach the top, you are 230 feet above the sea and have a breathtaking view — I’m told. A brief rain shower one afternoon and gusty wind the evening a “Senior’s Climb” was scheduled kept me off the wall. You might have to wait 20 to 25 minutes, but equipment, including helmet, shoes and harness, is free.

The sports deck includes a serpentine in-line skating course with 3-foot-high padded walls; a basketball court also used for volleyball; pingpong tables; miniature golf; a virtual driving range (where golfers can practice their swings on famous courses from around the world); and a golf hitting cage. A full-service spa that offers acupuncture and teeth whitening as well as mud baths and massages is at the opposite end of the ship.

Just below the spa is the fitness center, where you get a panoramic view of the ocean from all the treadmills that fan out around the starboard bow in front of floor-to-ceiling windows. All the exercise equipment in the fitness center was replaced in December with new Life Fitness machines.

Fun & Fitness

None of the big ships cater exclusively to passengers eager to exercise and eat healthfully as they cruise, but the Vitality program encourages them.

“We are more into helping people change their lifestyles than ever before: the way they eat and exercise and think. Cleansing and detoxification have become very popular, and acupuncture,” said Vivian Belbeck, the Voyager’s spa and salon manager. “You are more able to reap the benefits of a spa when you have time to relax. It can be life-changing. Some people hire a personal trainer for an hour a day for the entire week.”

Some passengers, such as my 88-year-old mother and a group of her friends, booked through Fun & Fitness Travel Club, which also sponsors cruises to Alaska, the Bahamas, Bermuda, Canada/New England, Europe, Hawaii, the Panama Canal and South America. The organization has no dues or fees, no meetings and about 3,500 members who travel with their water exercise classes and certified instructors from home, as well as friends and family.

Our seven-night Western Caribbean cruise was organized by Jodi Bruce, a Fun & Fitness hostess who teaches 14 water aerobics classes a week in Wichita Falls, Texas; and Parney Hundhausen, who leads 13 classes a week in Spokane, Wash. They had exclusive use of the saltwater Solarium Pool for their early-morning water exercise classes. Fun & Fitness cruisers were encouraged — not required — to participate in the two-a-day classes or the fitness walking class that Hundhausen led.

“Like with any cruise, we want them to have fun and do exactly what they want to do, and that doesn’t always include water aerobics or deck walking,” Hundhausen says. “Traveling together with people they know from water exercise gives them a comfort zone: A lot of our water people are widows.”

Break a sweat

I had not planned to work out with the “water people” every day, but the chilly saltwater was a great wake-up, and because you can do water exercise at your own pace, it’s easy to get your heartbeat up and even break a sweat running in place on warmer days.

Otherwise the Ship Shape Fitness Center opens at 6 a.m., and Belbeck says that by the time she gets on deck at 7:30 a.m., it’s full of people. The sunrise stretch class usually has 30 health- conscious passengers or more.

“It fills up first thing in the morning, until about noon, then fills back up between 3 and 6 p.m. It’s very busy, especially days we are at sea. We get all ages in here,” Belbeck says. “A lot of people are really into fitness or they haven’t been in a bathing suit in months, and they see themselves in the mirror and get to this gym quick.”

While I was on board, seminars were conducted on topics including “Secrets to a Flatter Stomach,””Detox for Health and Weight Loss,””Burn Fat Faster,””How to Increase Your Metabolism” and “Eat More to Weigh Less.” There were poolside swimsuit contests for things such as “Best Triceps” for women and “Best Belly Flops” for men.

The cruise line partners with New Balance to bolster the Vitality program with a virtual personal trainer to help guests create customized fitness regimens as well as post-vacation exercise plans.

As for food, you have every option, whether you want to taste everything or follow a special diet based on allergies, weight goals or cholesterol control.

In the elegant main dining room, as well as the casual Windjammer Cafe, low-fat and vegetarian entrees are always available along with sugar-free, fat-free and vegan desserts.

I felt a little foolish one night at dinner bragging about how rich and delicious my full-fat cheesecake was after tasting my daughter’s fat-free version and realizing they tasted exactly alike. Ditto the sugar-free coconut cake, compared with regular. (I took one of each, and ended up eating both.)

As part of the Vitality program’s “Eat More to Weigh Less” agenda, you can get a personal tour of the Windjammer Cafe, the cruise line’s huge buffet restaurant, with an instructor who provides tips on more healthful food choices and information on developing eating habits for lifelong health.

Look first

My best advice is to take a complete walk around the buffet the first day, before you even start filling your plate, so you see all the choices — such as egg-white omelets; turkey sausage; fat-free yogurt; an oatmeal bar with walnuts, raisins and dried apricots; three kinds of pizza (including veggie); sushi; all kinds of fresh fruit; huge salad bars that stayed fresh and tasty all day; low-fat and fat-free milk; and a make-your-own-sandwich bar, where there are plenty of fixings without the cheese and mayo.

Or, you can mix up your healthful and sinful choices, as did the woman in front of me in the omelet line one morning. She ordered “an egg-white omelet with everything, double the cheese,” smiling brightly at the chef as she said, “I’m watching my cholesterol.”

It was good to learn that as of last year, Royal Caribbean replaced all the trans fat on its ships, with trans fat-free oils, including olive and canola. The switch was made after testing the idea on passengers traveling on the Navigator of the Seas and finding that the majority either could taste no difference or liked the healthier-oil taste better, a ship spokeswoman said.

“This (healthy cruising) is really something that’s catching on,” said Randi Butcher, a 43-year-old health-conscious cruiser from Short Hills, N.J., whom we found in the fitness center the last evening of the cruise. She had worked out with weight machines six days and run 16 to 18 times around the deck two of the days we were at sea.

“And I took a stretching class,” she added. “I always work out at home, and I’ve been eating too much on the cruise so I can’t stop now.” IF YOU GO– DEPARTURES: Carnival and Royal Caribbean have ships departing every Sunday from Galveston for the popular seven- day cruises to Montego Bay, Jamaica; Georgetown, Grand Cayman; and Cozumel, Mexico. There are also three- and four-day excursions and 10-day and two-week cruises in the Caribbean. — COST: Cabins on this cruise range from $570 to $1,729, depending on size, location and how early you book. (See a travel agent, go online or contact Fun & Fitness to see all the options.)

Extras: Spa services are pretty pricey ($100 to $120 for various 50-minute massages and $150 to $175 for acupuncture sessions), the interactive golf simulator is $25 an hour, and some fitness classes (Wheels in Motion, Pilates in Motion, Pathway to Yoga and Tai Chi) are an extra $10, but most other activities come with the cruise.

Soft drinks and alcohol are extra. — SHORE EXCURSIONS: Dozens of “Explorations,” or tours, are available at every port, costing an extra $29 to $169, and they take time.

Tips: Watch out for the time it takes on a bus, van or other shuttle to get to where you can swim with dolphins or snorkel with stingrays. If it takes longer to get to the river where you want to go rafting than the raft ride itself, it might not be worth the effort. Ask questions before you sign up. Also, remember there are taxis and vans readily available at most ports to take you to beaches, shops, museums, churches and bars, and they are much less expensive than the packaged excursions.– MUST-HAVES: Cruise passengers are required to have passports for travel to and from all international destinations, including the Caribbean and Mexico.

Once officially checked in, you can use your cabin key to get on and off the ship as well as in and out of your room and to pay for anything extra you want from a ship store or bar. It also can be used to pay tips at the end of the week. The “key” looks like a plastic credit card and is issued after all your passport information is recorded and an imprint is made of your credit or debit card.

At some ports it also is recommended that you take along photo identification, such as a driver’s license, on shore excursions, but none was required anywhere we stopped. (Passports are best left locked in your cabin’s safe.) — MORE INFORMATION: Call your travel agent or go to www.fun-fitness.com or www.royalcaribbean.com.

Online extra

For more coverage on cruise trends, see www.ContraCosta

Times.com/Travel.

(c) 2008 Oakland Tribune. Provided by ProQuest LLC. All rights Reserved.

To: NATIONAL EDITORS

Contact: U.S. Department of Veterans Affairs Office of Public Affairs, +1-202-461-7600

Service Coming to 24 Counties in Six States

WASHINGTON, Aug. 27 /PRNewswire-USNewswire/ — The Department of Veterans Affairs (VA) is rolling out four new mobile health clinics outfitted to bring primary care and mental health services closer to veterans in 24 predominately rural counties, where patients must travel long distances to visit their nearest VA medical center or outpatient clinic.

VA is committed to providing primary care and mental health care for veterans in rural areas, said Secretary of Veterans Affairs Dr. James B. Peake. Health care should be based upon the needs of patients, not their ability to travel to a clinic or medical center.

The pilot project is called Rural Mobile Health Care Clinics. It features a recreational-type vehicle equipped to be a rolling primary care and mental health clinic.

VA is currently in the process of procuring and outfitting the vehicles, and officials expect the mobile clinics to be operational by early 2009. Rural areas in Colorado, Nebraska and Wyoming will share a single mobile van, while Maine, Washington state and West Virginia will each have a VA mobile van.

The clinics are planned to serve:

–Colorado:Larimer, Jackson, Logan, and Weld counties;

–Maine:Franklin, Somerset and Piscataquis counties;

–Nebraska:Cheyenne, Kimball, and Scottsbluff counties;

–Washingtonstate:Greys Harbor, Mason, and Lewis;

–West Virginia:Preston, Randolph, Upshur, Wetzel, Roane, and Taylor counties; and,

–Wyoming:Albany, Carbon, Goshen, and Platte counties.

Factors considered in the selection of the participating sites included a need for improved access in the area, the degree to which clinics will expand services and collaborations with communities the clinics serve.

For the latest news releases and other information, visit VA on the Internet at http://www.va.gov/opa.

To receive e-mail copies of news releases, subscribe to VAs list server at:

http://www.va.gov/opa/pressrel/opalist_listserv.cfm.

SOURCE U.S. Department of Veterans Affairs

(c) 2008 U.S. Newswire. Provided by ProQuest LLC. All rights Reserved.

SUN VALLEY, Calif., Aug. 27 /PRNewswire-FirstCall/ — XTend Medical Corporation (Pink Sheets: XMDC), a company that delivers cutting-edge telemedicine solutions to the healthcare industry, has announced they have begun a Remote Patient Monitoring Program through the University of Ulster, U.K., with Dr. Kevin Curran heading up the program.

In addition, the company feels the current share price of their stock is not a true reflection of the value of the company’s current business state.

The company released the following statement: “We’re pleased to announce the company has begun a program in the U.K. to monitor patients remotely managing their diabetes and blood pressure. This program will be managed by Dr. Kevin Curran who states that the main focus of the program is to show how technology can assist in monitoring patients from their home in modern life with the main emphasis being to reduce costs for the healthcare systems worldwide and improve the care delivered to patients. Our program is designed to assist doctors in helping patients to control diabetes through the up-to- the-minute online reports of their insulin levels.

The company further announced that the current share price is not indicative of the true value and potential of the company. This program, along with the others that are set to begin soon, have the potential to bring in excess of $100 million dollars for the length of these contracts. This makes no sense to us how the share price declines while the business is poised to be a force in the very near future. Management’s confidence remains high and feels the future of this company remains bright.”

To find out more about Ulster University, please visit their site at http://www.ulster.ac.uk/

For any healthcare agency or physician group that would like to find out more about how XTend can assist in your management of diabetic patients, please visit the company website at http://www.xtendmedical.com/ or email us at [email protected]

About XTend Medical: XTend Medical Corporation markets and sells healthcare and wellness products to hospitals, managed care companies, nursing homes, physician groups and individual patients. XTend has developed a complete Remote Diabetic Patient Monitoring System that is currently being used by physicians and other healthcare agencies throughout the U.S. Through their alliances, XTend offers pharmacy services, diabetic supplies, and telemedicine products that increase patient care yet reduce costs associated with servicing those patients. For more information, please visit their website at http://www.xtendmedical.com

Safe Harbor

This press release contains or may contain forward-looking statements such as statements regarding the Company’s growth and profitability, growth strategy, liquidity and access to public markets, operating expense reduction, and trends in the industry in which the Company operates. The forward-looking statements contained in this press release are also subject to other risks and uncertainties, including those more fully described in the Company’s filings with the Securities and Exchange Commission. The Company assumes no obligation to update these forward-looking statements to reflect actual results, changes in risks, uncertainties or assumptions underlying or affecting such statements, or for prospective events that may have a retroactive effect.

    Contact:    Company Contact:    FutureTechIR for XTend Medical Corporation    Investor Relations    (817) 812-2105  

XTend Medical Corporation

CONTACT: Investor Relations, FutureTechIR, +1-817-812-2105, for XTendMedical Corporation

Web site: http://www.xtendmedical.com/http://www.ulster.ac.uk/

Centene Corporation (NYSE: CNC) today announced that Patrick J. Rooney has been appointed President and CEO of Centene’s Indiana subsidiary, Managed Health Services (MHS). Mr. Rooney is based in the MHS corporate office in Indianapolis and reports to Christopher D. Bowers, Senior Vice President, Health Plan Business Unit.

Mark W. Eggert, Centene’s Executive Vice President, Health Plan Business Unit, stated, “Mr. Rooney brings a wealth of healthcare experience and company insight to Managed Health Services. As a seasoned executive in finance and management, he will help support and execute the health plan’s vision of providing better health outcomes to its members at lower costs to the state.”

Mr. Rooney has more than 14 years of experience in the healthcare financial industry. Most recently, he was Vice President of Health Plan Finance for Centene, in which he provided leadership for the centralized finance and accounting departments. In addition, he played a critical role in Medicaid contract renewals and developed and analyzed product and new market expansions. Previously, Mr. Rooney held financial positions with Mercy Health Plans and Group Health Plans in St. Louis. He received a bachelor’s degree in Accounting from the University of Missouri-St. Louis.

About Centene Corporation

Centene Corporation is a leading multi-line healthcare enterprise that provides programs and related services to individuals receiving benefits under Medicaid, including the State Children’s Health Insurance Program (SCHIP), Foster Care, Supplemental Security Income (SSI) and Medicare (Special Needs Plans). The Company operates health plans in Arizona, Georgia, Indiana, New Jersey, Ohio, South Carolina, Texas and Wisconsin. In addition, the Company contracts with other healthcare and commercial organizations to provide specialty services including behavioral health, life and health management, long-term care, managed vision, nurse triage, pharmacy benefits management and treatment compliance. Information regarding Centene is available via the Internet at www.centene.com.

By Mary Beth Schweigert

Health

Nicole Kidman stepped out to Starbucks, looking unbelievably toned and taut, just two weeks after having a baby.

Heidi Klum strutted her miraculously stretch mark-free stuff on the runway – wearing only underwear, no less – a mere two months after giving birth.

Glossy mags and gossip sites gush about celebrity moms who have “gotten back” their amazing bodies before the paint dries on the nursery walls.

It’s enough to give your average less-than-svelte, more-than- exhausted new mom a complex.

Instantly dropping pounds post-pregnancy is unrealistic and often unhealthy, Lancaster General Women & Babies Hospital physical therapist Erika Maust-Niederer says.

“Your body doesn’t just ‘go back’ like Heidi Klum’s,” she says.

“That’s not the norm.”

Here in the real world – minus the personal trainers and private chefs – new moms looking to lose weight face challenges from sleep deprivation to worn, even torn, muscles.

Lise Karpel, a registered dietitian at Ephrata Community Hospital, says pervasive media images of perfect pregnant and postpartum celebrities (airbrushed, of course) can bruise a new mom’s often-fragile self-image.

Sometimes, she says, it’s almost like a competition to see who can squeeze back into her skinny jeans first.

“These (new moms) are standing in front of a mirror, trashing themselves,” Karpel says. “It’s sad. You just did the most amazing thing in the world.”

Instead of crash diets or hard-core exercise, Karpel and Maust- Niederer say new moms should drop pounds slowly and set reasonable goals.

“It takes some people six weeks,” Maust-Niederer says.

“It takes some people five years.”

Laying The Foundation

Exactly how long it takes to get back in shape depends largely on how much weight Mom gained during pregnancy – and how much she weighed before.

Jenn Reed, who teaches a mommy and me exercise class at Universal Athletic Club, 2323 Oregon Pike, urges women to start pregnancy at a healthy weight.

Sweating it out at the gym can fight excessive weight gain during those nine long months.

“People get pregnant and quit their (gym) membership,” says Reed, also a registered dietitian and new mom. “If you’re healthy, you should be exercising during pregnancy.”

Besides, Reed points out, pregnant women have a lot more time to work out than brand-new moms.

Doctors generally recommend that women gain between 15 and 40 pounds during pregnancy, depending on their starting weight.

Moms who stay within those limits will leave the hospital with fewer pounds to drop.

But some women view pregnancy as a free-for-all, eating with abandon.

“Whatever goes on has to come off, or they’re stuck with it,” Reed says.

Getting Back

to the Gym

New moms ready to start exercising again should set realistic goals.

So if you didn’t have Heidi’s rockin’ bod before you got pregnant, don’t expect to slip into her skivvies now.

According to the American College of Obstetricians and Gynecologists, new moms can start gentle exercise, like walking, as soon as they feel up to it.

More vigorous workouts are usually OK by four to six weeks postpartum (longer for Caesarean or complicated births), but women should check with their doctor first.

Postpartum moms can generally stick to the same exercise guidelines they followed during pregnancy.

But women should stop exercising if they notice pain, or increased vaginal bleeding or discharge.

Maust-Niederer, who will co-teach an upcoming postpartum nutrition and exercise class, says pregnancy-related body changes present special challenges when it comes to exercise.

Abdominal muscles may separate, stretch or tear during pregnancy or birth. Ligaments and joints loosen, making injury more likely.

Good breast support during exercise is also critical, especially for nursing moms.

Lack of time – and sleep – can conspire against new moms looking to work out, Maust-Niederer says.

“Everybody doesn’t have time to go to the gym for three hours anymore,” she says.

“(And) I don’t know a new mother who’s sleeping eight hours a day.”

Eating Right

Good nutrition is especially important after the rigors of pregnancy, says Karpel, who urges new moms to focus on gradual weight loss, not fad diets.

“They want the weight to come off really, really fast,” she says. “Really rapid weight loss is never healthy for anybody.”

New moms should focus on whole grains, and fresh fruits and vegetables. They should also be realistic about new demands on their time.

“Maybe you can’t cook an elaborate meal, but you can eat … a piece of fruit for a snack,” Karpel says.

Dieting while nursing isn’t recommended. Women who go too low- cal can jeopardize their milk supply – and their baby’s health.

Nursing moms should consume roughly the same amount of calories as moms-to-be (at least 2,000) and drink plenty of fluids, Karpel says.

On the plus side, nursing’s high calorie demands allow many moms to shed pounds fairly quickly.

“(Nursing) is like a natural calorie-burner, if you will,” Reed says.

Regular exercise can help those women whose excess pounds stubbornly stick around until weaning.

Above all, new moms shouldn’t obsess over things they can’t change.

No exercise will tighten saggy, stretched-out skin. Sadly, like stretch marks, it’s largely genetic.

For Details

Lancaster General will hold Saturday morning postpartum exercise and nutrition classes, at Women & Babies Hospital, 690 Good Drive, beginning in September.

A registered dietitian and physical therapist will teach the classes.

The first session meets 8 a.m. to noon Sept. 20 and 8 to 10 a.m. Oct. 18. The second session meets 8 a.m. to noon Oct. 11 and 8 to 10 a.m. Nov. 8.

Cost is $25. Call the LG Wellness Center, 544-3811.

Universal Athletic Club, 2323 Oregon Pike, holds Exer-Strides mommy and me exercise classes, 12:30 to 1:30 p.m. Tuesdays and Thursdays.

The class is free for members, who may join anytime. Nonmembers may join the next eight-week session, which begins Tuesday, Oct. 14. Cost is $99. For details, call 569-5396.

Photos At Mommy And Me Exercise Classes, Like Universal Athletic Club’s Exer-Strides,New Moms Can Socialize While They Sweat.

Ian Fitzgerald (Above) And Kayla Atteberry (Left) Play While Their Moms Work Off Post-Pregnancy Pounds. “Whatever Goes On Has To Come Off, Or They’re Stuck With It,” The Instructor Says.

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

By PHYLLIS JOHNSON

By Phyllis Johnson

Correspondent

Western Branch

Got the urge for something spicy? Want some steaming southwestern chow at south-of-the-border prices? The place to go is La Tolteca Restaurante Mexicano on Taylor Road, one of three such restaurants owned locally.

The other two are at 6031 High St. W. in Churchland and at 1 High St. in Olde Towne. There are four more locations in Williamsburg and Lynchburg.

Owner Francisca Onate opened the Churchland restaurant in 1993, followed by the Olde Towne property . He opened the Taylor Road location last September. On entering, there is the feeling you are truly in the Southwest from the color scheme to the decor.

When you go to dine, Louis Lastra, 10, may greet you in his Mexican outfit. The grandson of the manager, it’s obvious Louis enjoys showing off his outfit.

Friendly staff will usher you in . Whether you like your sauce mild or smoking hot, their enchiladas and burritos are great. You’ll also enjoy the fajitas and quesadillas. My favorite combinations always include chicken enchiladas. There are lunchtime specials at $6.25 or less. Special dinners cost upwards of $12.50. Combination dinners are $8.25 and under.

There’s a vegetarian section of the menu starting at $8.25 featuring Anaheim peppers . They’re filled with cheese and potato, covered with egg batter and fried. It comes with rice and refried beans. If you’re in the mood for seafood, they have fish tacos and shrimp quesadillas.

The dessert menu includes fried ice cream, flan and a choco-taco which is a waffle cone with ice cream and chocolate.

Flan is to die for and is a Mexican-style custard with whipped cream and a cherry.

Phyllis Johnson, [email protected]

Phyllis Johnson, [email protected]

Find the restaurant at 3308 Taylor Road in Western Branch

Hours are Monday-Thursday, 11 a.m.-10 p.m.; Friday, 11 a.m. to 10:30 p.m.; Saturday, 11:30 a.m. to 10 p.m.; and Sunday 11:30 a.m. to 9 p.m.

Find La Tolteca at 3308 Taylor Road

Hours are Monday-Thursday, 11 a.m.-10 p.m.; Friday, 11 a.m. to 10:30 p.m.; Saturday, 11:30 a.m. to 10 p.m.; and Sunday 11:30 a.m. to 9 p.m.

Originally published by BY PHYLLIS JOHNSON.

(c) 2008 Virginian – Pilot. Provided by ProQuest LLC. All rights Reserved.

LOS ANGELES, Aug. 27 /PRNewswire-FirstCall/ — Sunnylife Global, Inc. (Pink Sheets: SNYL) announced today the appointment of Dr. Chen Li-An as the Honorary Chairman of the Board.

Dr. Chen is a well known and well respected individual whose integrity, honesty and service to both mankind and country are documented voluminously. Dr. Chen, the eldest son of former Vice-President, Premier and Chief of Staff of the Republic of China Chen Cheng, graduated from MIT with a degree in Electrical Engineering and received a Ph.D., in Mathematics from New York University. Subsequently, Dr. Chen was invited by President Chiang Ching Kuo of the Republic of China to join the Cabinet. He was appointed and served from 1972 to 1995 as the Minister of Economics; he devised and implemented plans to transform the economy from traditional manufacturing to high technology. As Minister of Defense he purchased modern equipment, elevated the military’s social status and published the first Defense White Paper. Then as Prime Minister of the Control Yuan, he was in charge of all civil servants and all public functionaries. He started the “Enlightened Mind” radio broadcasts and gave hundreds of speeches inspiring people to perform kind and benevolent acts. In September 1995 he resigned from the government to run as an independent candidate for President of Taiwan, the Republic of China. Later, Dr. Chen announced he would retire from politics to focus on philanthropy and social organizations. Dr. Chen also organized charities to financially assist the needy in Mainland China, Tibet and Nepal. He presently serves as Chairman of the Chen Cheng Foundation and as Honorary Chairman of the Hwa-Yu Foundation.

Mark Chen, commenting on the appointment indicated that with the Company now entering this growth cycle, Dr. Chen’s involvement will provide an access to certain levels of finance, government, and management talents that are necessary to complete the Company’s mission. Sunnylife is pleased and honored to have Dr. Chen support and advise their mission.

Sunnylife Mission

Sunnylife is committed to develop a membership-based hospital chain in China which will:

   I.    Provide quality medical services to the patients;   II.   Offer affordable healthcare for the public; and,   III.  Become an ideal partner for other hospitals.    

In the next 10 years, World Friendship Hospital Group aspires to upgrade, manage, and own up to 100 membership hospitals in China (2.4% of hospitals owned by state owned corporations). Sunnylife will also provide world-class training in medical care and hospital management for Chinese doctors, nurses, and hospital personnel. Currently, Sunnylife has partially renovated one hospital and is in the process of finalizing the upgrading plans for a second one.

Safe Harbor Statement

The statements contained herein, which are not historical, are forward-looking statements that are subject to risks and uncertainties that could cause actual results to differ materially from those expressed in the forward-looking statements. All forward-looking statements attributable to the Company, or persons acting for the Company, are expressly qualified in their entirety by these cautionary statements.

    Contact: Angela Kao    626-919-1898    http://www.sunnylifeglobal.com/  

Sunnylife Global, Inc.

CONTACT: Angela Kao, +1-626-919-1898, for Sunnylife Global, Inc.

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

CHICAGO and STATE COLLEGE, Pa., Aug. 27 /PRNewswire-FirstCall/ — Allscripts, the leading provider of clinical software, connectivity and information solutions that physicians use to improve healthcare, announced today that Centre Medical and Surgical Associates, P.C. (CMSA) has selected the company’s Electronic Health Record (EHR) and Practice Management (PM) solution for its 69 providers.

(Logo: http://www.newscom.com/cgi-bin/prnh/20061005/ALLSCRIPTSLOGO-b)

Centre Medical and Surgical Associates is one of the largest multi-specialty physician groups in Central Pennsylvania, with 53 physicians and 16 mid-level providers in offices located in State College, Boalsburg, Bellefonte, and Huntingdon, Pennsylvania. CMSA is replacing its financial automation system with Allscripts — and adding the Allscripts Electronic Health Record — to improve its ability to provide high quality care more cost-effectively.

“CMSA hopes to achieve a new level of efficiency through a paperless record system,” said John J. McQueary, CMSA’s Chief Operating Office and Administrative Director. “Allscripts will make records immediately available to physicians for medical decision-making, improving patient care and accessibility. Because of the quality of the Allscripts system, we expect a smooth implementation of the solution to recover our cost quickly.”

The Allscripts Electronic Health Record enables physicians to instantly access patient information when and where they need it — in the clinic, at the hospital or while on-call at home. The web-based solution speeds and automates everyday clinical tasks such as prescribing and refilling medications, ordering and viewing tests, and documenting care. More than simply automating manual tasks, the Electronic Health Record helps to transform healthcare with breakthroughs in connectivity including preloaded connections to a range of medical devices, and seamless support for public and private pay-for-performance and quality initiatives, as well as an advanced user experience that lets physicians in any specialty easily configure the system to their own specific needs.

The Allscripts Practice Management solution combines sophisticated scheduling and Revenue Cycle Management tools in a single package and incorporates advanced features such as rule-based appointment scheduling, multi-resource and recurring appointment features, referral and eligibility indicators, and appointment and claims management.

“Our physicians unanimously selected Allscripts after seeing how much more intuitive and functional the electronic health record was compared with others on the market,” said Paula A. Wray, Associate Administrator of CMSA. “We determined from the beginning that we wanted an integrated electronic health record and practice management system so we could easily exchange information between the clinical and financial areas. Allscripts not only had the best products geared toward practices our size, but the Allscripts clients we visited lost little productivity during the EHR go-live phase, and acceptance from their physicians was outstanding.”

Allscripts Chief Executive Officer Glen Tullman commented, “As a forward-looking practice, Centre Medical and Surgical Associates chose their electronic health record based on physician usability, ROI, the enhanced connectivity our systems offer and an understanding of our vision for the future. CMSA has been making the right decisions to improve care for their patients since 1974, and we’re pleased that they’ve selected Allscripts as their partner in taking them to the next level.”

As part of the Electronic Health Record implementation, Allscripts will interface the Electronic Health Record with the Meditech inpatient clinical information systems of Mount Nittany Medical Center, a 203-bed acute care hospital in State College. The connection will benefit both CMSA and the hospital, allowing physicians to access the latest clinical information on patients, no matter where they are being seen.

About Centre Medical and Surgical Associates, P.C.

Centre Medical and Surgical Associates is a private multi-specialty medical practice providing primary and specialty care to central Pennsylvania since 1974. Dr. Jonathan Dranov is the founding member who established an Internal Medicine and Nephrology practice bringing subspecialty medical care to the region for the first time. He also developed the region’s first kidney dialysis unit at Mount Nittany Medical Center. Since that time, CMSA has grown in response to community needs, and today includes 4 locations providing 19 medical specialties and a range of diagnostic services such as radiology and medical laboratory. The practice strives to stay at the leading edge in responding to community needs, whether with advanced technology, additional subspecialties, or increased levels of service.

About Allscripts

Allscripts is the leading provider of clinical software, connectivity and information solutions that physicians use to improve healthcare. The company’s unique solutions inform, connect and transform healthcare, delivering improved care at lower cost. More than 40,000 physicians and thousands of other healthcare professionals in clinics, hospitals and extended care facilities nationwide utilize Allscripts to automate everyday tasks such as writing prescriptions, documenting patient care, managing billing and scheduling, and safely discharging patients, as well as to connect with key information and stakeholders in the healthcare system. To learn more, visit Allscripts at http://www.allscripts.com/.

This announcement may contain forward-looking statements about Allscripts Healthcare Solutions that involve risks and uncertainties. These statements are developed by combining currently available information with Allscripts beliefs and assumptions. Forward-looking statements do not guarantee future performance. Because Allscripts cannot predict all of the risks and uncertainties that may affect it, or control the ones it does predict, Allscripts’ actual results may be materially different from the results expressed in its forward-looking statements. For a more complete discussion of the risks, uncertainties and assumptions that may affect Allscripts, see the Company’s 2007 Annual Report on Form 10-K, available through the Web site maintained by the Securities and Exchange Commission at http://www.sec.gov/.

Photo: http://www.newscom.com/cgi-bin/prnh/20061005/ALLSCRIPTSLOGO-bAP Archive: http://photoarchive.ap.org/PRN Photo Desk, [email protected]

Allscripts

CONTACT: Dan Michelson, Chief Marketing Officer, +1-312-506-1217,[email protected], or Todd Stein, Senior Manager|Public Relations,+1-312-506-1216, [email protected], both of Allscripts; or Paula A.Wray, Associates Administrator of CMSA, +1-814-689-3131,[email protected]

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

PITTSBURGH, Aug. 27 /PRNewswire/ — The first child in the United States to receive a heart-double lung-liver transplant is marking the 10th year anniversary of his history-making procedure at Children’s Hospital of Pittsburgh of UPMC.

Brendon Ednie was 2 years old when he underwent the quadruple-organ transplant at Children’s Hospital on Aug. 21, 1998. A team of transplant surgeons began his surgery at 10:30 a.m. and finished 20 hours later. Now 12, Brendon lives in South Daytona, Fla., with his mother and father, Rebecca and Bryon, and his 15-year-old sister, Rachell. He is entering the fifth grade.

“Brendon has overcome so many challenges in his life and there have been ups and downs over the last 10 years, but it is amazing to see how far he has come since his transplant,” Rebecca Ednie said. “We are forever grateful to the donor family and Children’s Hospital for giving Brendon a second chance at life.”

Brendon received all four organs from the same donor. He needed a transplant because he was born with Alagille syndrome, a rare, hereditary disorder characterized by a reduced number of bile ducts in the liver. The severity of the disease can vary greatly from patient to patient, with some experiencing very few, if any, symptoms.

Others, like Brendon, have severe symptoms. Brendon was born without bile ducts in his liver or a pulmonary artery — the blood vessel that connects the heart with the lungs. If Brendon had not received the transplant, doctors at Children’s Hospital determined he would have suffered liver and heart failure and would have died within a year.

“Children’s Hospital has been at the forefront of pioneering many types of transplant surgeries, which have offered a second chance to hundreds of children like Brendon,” said one of the doctors involved in his case, Steven A. Webber, MBChB, chief of Pediatric Cardiology and medical director of Pediatric Heart and Heart-Lung Transplantation at Children’s Hospital. “We’re proud to see Brendon and our other patients reach these milestones and know that we’ve played a part.”

George V. Mazariegos, director of Pediatric Transplantation in the Hillman Center for Pediatric Transplantation at Children’s Hospital, was one of Brendon’s transplant surgeons.

“Brendon’s transplant was groundbreaking in that a surgery with such a combination of organs had never been performed in a child before, but we were successful because of the tremendous collaboration among the various teams involved,” Dr. Mazariegos said. “It has truly a privilege to be involved in Brendon’s care and watch him grow into adolescence.”

Children’s Hospital is the world’s first comprehensive pediatric solid organ transplant program, established in 1981. It performed its first pediatric heart transplant in 1982. Since then, Children’s Hospital’s transplant teams have expanded the cardiopulmonary transplant program to include procedures such as heart-liver transplantation, heart-kidney transplantation, heart-lung transplantation and double- and single-lung transplantation.

In addition to Brendon’s transplant, Children’s Pediatric Heart and Lung Transplantation program:

   -- Performed the world's first pediatric heart-liver transplant in 1984   -- Performed the first successful pediatric heart-lung transplant in 1985  

— Has performed more pediatric heart-lung transplants than any other center in the country

For more information the Hillman Center for Pediatric Transplantation at Children’s Hospital, please visit http://www.chp.edu/transplant.

Children’s Hospital of Pittsburgh of UPMC

CONTACT: Mark Lukasiak, +1-412-692-7919, +1-412-692-5016,[email protected], or Melanie Finnigan, +1-412-692-5502, +1-412-692-5016,[email protected], both of Children’s Hospital of Pittsburgh of UPMC

Web site: http://www.chp.edu/http://www.chp.edu/transplant

ST. PAUL, Minn., Aug. 27 /PRNewswire/ — Prime Therapeutics, a thought leader in pharmacy benefit management, announced today that it has completed certification with SureScripts-RxHub. This certification will allow prescribers using SureScripts-RxHub certified technology to send their patients prescriptions electronically to PrimeMail(R), Prime Therapeutics’ mail order pharmacy.

In 2007 PrimeMail processed nearly 3.6 million prescriptions. By enabling electronic access to mail order operations, the value and benefits associated with paperless prescribing will be available to millions more patients. Electronic prescribing (e-prescribing) increases patient safety by eliminating illegible prescriptions and allowing for real-time safety checks. It also reduces the cost of health care delivery by providing prescribers with secure access to real-time patient eligibility, formulary and medication history information at the point of care and allows them to electronically transmit the prescription to the patient’s choice of mail order or retail pharmacy.

“Our partnership with SureScripts-RxHub is part of a broader set of programs to transform health care by providing timely information to physicians which ultimately benefits their patients,” said Keith McFalls, Vice President of Mail Operations at Prime. “E-prescribing is a gateway to increased physician use of health information technology. E-prescribing can improve patient safety and even save lives by helping to eliminate harmful drug events.”

With secure access to patient information more readily available, the process of prescribing medications is measurably improved by:

   -- providing prescribers with added knowledge of their patients;   -- enabling a more informed choice of therapy;   -- ensuring that the medicine intended by the prescriber is actually and      accurately communicated to the pharmacy;   -- allowing patients to weigh important economic considerations within a      range of appropriate clinical options before a prescription is written;      and   -- adds convenience to the overall process.    

“SureScripts-RxHub is very excited to welcome Prime Therapeutics’ mail order service to our network,” stated Tom Groom, Senior Vice President for SureScripts-RxHub. “The continued support for electronic prescribing from payer organizations will only help drive the adoption and utilization by the prescriber communities across the nation.”

About Prime Therapeutics

Prime Therapeutics is a pharmacy benefit management company dedicated to providing innovative, clinically-based, cost effective pharmacy solutions for clients and members. Providing pharmacy benefit services nationwide to approximately 14.6 million covered lives, its client base includes Blue Cross and Blue Shield Plans, employer and union groups, and thirdparty administrators. Headquartered in St. Paul, Minnesota, Prime Therapeutics is collectively owned by ten Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those plans. Learn more at http://www.primetherapeutics.com/.

Prime Therapeutics

CONTACT: Sheila Thelemann, Sr. Manager, Public Relations and CorporateCommunications of Prime Therapeutics, +1-651-414-1863,[email protected]; or Chris Van Horrick, Director, Marketingand Communications of SureScripts-RxHub, +1-651-855-3078,[email protected]

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

The third largest public healthcare system in the United States doesn’t let size stand in the way of personalized care. For Carolinas HealthCare System(2), the very best personal care begins with a virtual contact center from Nortel(1) (TSX: NT)(NYSE: NT) that directs each patient call to a person, not a recording.

Carolinas HealthCare System has deployed a Nortel VoIP solution over an existing, non-Nortel data network to support six hospitals and 50 doctors’ offices and other medical facilities throughout the Carolinas Physicians Network(2). This includes a virtual contact center with intelligent, skills-based routing to quickly connect callers to the person most qualified to immediately address their needs.

“We pride ourselves on delivering personalized patient care second to none,” said Daniel Wiens, senior vice president, Carolinas Physicians Network. “We believe the tone is set with the patient’s very first call, and in a medical situation, people will always be more comfortable dealing with a person. That’s why reaching a person right up front, rather than a recorded message, is so very important. Providing superior personalized service and fostering enduring patient relationships is one of our core strategies.”

“No environment is more critical than healthcare when it comes to making sure calls are handled promptly, efficiently and with personal care and attention,” said Dietmar Wendt, president, Global Services, Nortel. “We’ve designed a solution for Carolinas HealthCare with this absolute priority top of mind.”

With Nortel’s multimedia contact center solution for healthcare, Carolinas HealthCare System handles more than 640,000 callers a month. Calls are directed to one of more than 1,000 available home and office-based agents trained to provide the utmost care and attention to any medical question or situation.

This personal touch provides the highest possible levels of quality and safety. It has also improved patient retention and satisfaction. Carolinas Physicians Network has experienced a 31 percent improvement in patient satisfaction with telephone access since the Nortel VoIP system was implemented.

The virtual contact center has saved time and cost because it is more efficient and easier to manage than previous standalone key systems and small PBXs, which provided only basic automatic call distribution and no management reporting. Additional capital costs were avoided by using remote gateways – rather than more expensive IP PBXs – to deliver voice services to smaller locations, and by implementing the Nortel IP-based solution over an existing, non-Nortel data network.

Nortel’s healthcare solution for Carolinas HealthCare System includes Nortel Communication Server 1000 IP PBXs, Nortel Contact Center 6.0, Nortel Survivable Remote Gateways, Nortel Branch Office Media Gateways and Nortel IP phones and softphones.

Innovative healthcare solutions built on Unified Communications technology and Network Managed Services from Nortel are helping hospitals and other healthcare providers around the world to better serve their patients by saving critical time and enhancing productivity in an increasingly demanding environment.

Nortel Contact Center Services, part of Nortel’s Global Services portfolio, offer planning, design, implementation, integration, maintenance, optimization and certified program management throughout the lifecycle of a contact center to help businesses maximize competitive advantage while minimizing risk and cost.

About Carolinas HealthCare System

Carolinas HealthCare System (www.carolinashealthcare.org(2)) is the largest healthcare system in the Carolinas, and the third largest public system in the nation. CHS owns, leases or manages 23 hospitals in North and South Carolina, including Levine Children’s Hospital in Charlotte and CMC-NorthEast in Concord, a 457-bed medical center which is home to the Jeff Gordon Children’s Hospital.

CHS employs over 1,000 physicians who practice in more than 275 locations. CHS also operates rehabilitation hospitals, nursing homes, ambulatory surgery centers, home health agencies, radiation therapy centers and physical therapy facilities. Together, these operations comprise over 4,900 licensed beds and employ more than 35,000 full-time or part-time employees.

CHS’s flagship facility is Carolinas Medical Center (www.carolinasmedicalcenter.org(2)) in Charlotte, an 874-bed hospital which includes a Level I trauma center, a research institute and a large number of specialty treatment units (heart, cancer, organ transplant, behavioral health, etc.). CMC also serves as one of North Carolina’s five Academic Medical Center Teaching Hospitals, providing residency training for over 200 physicians in 15 specialties. CMC is listed as a “Best Hospital” by U.S. News & World Report for urology and orthopedics, and has been designated 10 times as Charlotte’s “Consumer’s Choice Preferred Hospital” by the National Research Corporation. HealthGrades, a leading healthcare ratings company, named CMC-NorthEast “The Best Hospital in North Carolina” for cardiac services.

About Nortel

Nortel is a recognized leader in delivering communications capabilities that make the promise of Business Made Simple a reality for our customers. Our next-generation technologies, for both service provider and enterprise networks, support multimedia and business-critical applications. Nortel’s technologies are designed to help eliminate today’s barriers to efficiency, speed and performance by simplifying networks and connecting people to the information they need, when they need it. Nortel does business in more than 150 countries around the world. For more information, visit Nortel on the Web at www.nortel.com. For the latest Nortel news, visit www.nortel.com/news.

Certain statements in this press release may contain words such as “could”, “expects”, “may”, “anticipates”, “believes”, “intends”, “estimates”, “targets”, “envisions”, “seeks” and other similar language and are considered forward-looking statements or information under applicable securities legislation. These statements are based on Nortel’s current expectations, estimates, forecasts and projections about the operating environment, economies and markets in which Nortel operates. These statements are subject to important assumptions, risks and uncertainties, which are difficult to predict and the actual outcome may be materially different from those contemplated in forward-looking statements. For additional information with respect to certain of these and other factors, see Nortel’s Annual Report on Form10-K, Quarterly Reports on Form 10-Q and other securities filings with the SEC. Unless otherwise required by applicable securities laws, Nortel disclaims any intention or obligation to update or revise any forward-looking statements, whether as a result of new information, future events or otherwise.

(1)Nortel, the Nortel logo and the Globemark are trademarks of Nortel Networks.

(2)This is a 3rd party link as described in our Web linking practices.

 Contacts: Nortel Mark Buford (972) 362-1512 Email: [email protected] Website: www.nortel.com

SOURCE: Nortel

By Monica Rodriguez

POMONA – More than a week after Pomona Valley Hospital Medical Center ended its contract with Anthem Blue Cross, the insurance company’s members are still calling the hospital’s help line with questions about receiving care.

And the insurance company members aren’t the only people with questions. Doctors also have questions, said hospital spokeswoman Kathy Roche.

Among those who attended a recent physicians’ meeting was Dr. Sri Gorty, a radiation oncologist with the hospital’s Robert and Beverly Lewis Family Cancer Care Center.

“Going in, I was a little bit scared,” he said this week.

Gorty, who has admitting privileges exclusively at the hospital, was concerned patients who are Anthem Blue Cross members wouldn’t be able to access services there. After the meeting Gorty felt better.

Based on the various rules the vast majority of his patients will be able to see him and receive care at the hospital, he said.

Overall, most Anthem Blue Cross members will still be able to get the services they need at the hospital until mid-December, even after the break between the hospital and the insurance company, said Roche.

More than a dozen exceptions exist that would allow patients to receive care at the hospital or through its doctors, Roche said Monday, under a plan developed by the insurance company that received approval, with some conditions, of the state Department of Managed Health care.

Anthem Blue Cross gave doctors who have admitting privileges only at Pomona Valley 120 days from Aug. 15 to secure privileges at other hospitals that do have contracts with the health insurance company. In the meantime, their patients will be covered at PVHMC.

Sixty-five percent of all the 2007 Blue Cross admissions to Pomona Valley involved doctors who had privileges exclusively at the hospital, Roche said.

monica.rodriguez

inlandnewspapers.com

(909) 483-9336

(c) 2008 San Gabriel Valley Tribune. Provided by ProQuest LLC. All rights Reserved.

Touchstone Health HMO has announced that Roger London has recently joined the organization as the new chief medical officer. In his new role, he will be responsible for the corporate oversight of the medical management strategy and medical policies of the company.

Mr London has broad managed care experience, having served as corporate vice president of quality and as vice president of medical management at Oxford Health Plans of NY-NJ-CT during Oxford’s successful corporate turnaround.

Most recently, Mr London was vice president and medical director of Flagship Global Health, a physician-founded, membership-based international company whose core business is the delivery of medical quality. Dr London also served at the Lenox Hill Hospital as acting chief medical officer and as vice president-medical director of the Lenox Hill Healthcare Network.

Michael Muchnicki, president and CEO of Touchstone Health, said: “We are privileged to have an accomplished healthcare leader, who brings to our organization a wealth of experience and specific expertise in the managed care industry. I am extremely pleased that Dr London has chosen to continue his career at Touchstone Health, where he can put his vast knowledge to work for our members.”

By Benaroch, Roy

Pacifiers Q How do I get my oneyear-old son to stop using his? Will using it cause him any harm?

A I’ll admit I’m kind of a softie on the pacifier issue. They help little kids relax, and are much less harmful than many of the things adults do when they’re feeling anxious. Think about it – at least your son isn’t smoking or drinking! At one year of age, a pacifier certainly isn’t doing any sort of permanent harm to your child’s teeth or mouth. If he seems to find using a pacifier a good way to relax, I’m not sure you need to worry about it or get him to stop using it.

A good rule of thumb would be to try to limit pacifier use to his crib or bedroom starting at age two. That’s a good time to teach him to throw it back in his bed when he gets up. You can also gently suggest he go to his room for time with his “lovey” when he does get anxious, upset, or frustrated at that age. By age four, it’s a good idea to stop pacifier use entirely – though by then, almost all kids will have stopped on their own.

If your son’s pacifier use is really bothering you, you can stop it at any time. Just throw them all away, all at once, and don’t look back. After only a few days it will be as if he never used one. It might be a rough couple of days, but if you decide that the pacifier has got to go, it’s best to do it all at once. You may have heard about a method of cutting the pacifier shorter every few days, but that may lead to choking on fragments. I no longer recommend this method.

Eat Your Vegetables

Q How can I make my 5-year-old son eat his veg- 9 etables?

A Some rules cannot be broken. The three unbreakable rules of raising children are: You can’t make them sleep, you can’t make them eat, and you can’t make them poop. Making a child eat veggies isn’t something that parents ought to do.

Though you can’t make a child eat vegetables, there are things you can do to encourage him to eat a larger variety of foods as he grows older. But keep in mind that some kids – and even some adults – are going to be picky eaters. There are many adults here in the United States who never, ever eat a vegetable of any kind, without suffering any ill effects. Many foods are fortified, so your child is likely getting all the vitamins he needs even without the veggies.

Encouraging a child to eat a variety of foods starts with breastfeeding. Nursing, rather than feeding formula, offer ss very young babies a chance to experience a variety of tastes, and breastfed babies are more likely to accept a variety of flavors later.

When babies are ready to start solid meals, it’s very important to eat as a family. Children at every age should eat with their parents, so parents can model good eating behaviors: accept- ing a variety of foods, using table manners, and enjoying good conversation during a meal. (The benefits of family dining extend well beyond the picky toddler years. In teenagers, studies have shown that family dining helps prevent obesity, academic problems, and substance abuse.)

Once toddlers are past baby foods, they should be offered the same foods as everyone else in the family. Don’t assemble separate plates of food for each member of the family. Instead, have everyone sit down in front of an empty plate and help him or herself to serving platters of food (“family style” dining). Parents should not get up to prepare something different if everything on the table is refused. Getting up to make different foods for the kids encourages them to develop a habit of always refusing the first foods offered. It’s perfectly fine if some of the items on the table are things that the kids usually eat, but those ought to be part of the meal from the beginning, not added on at the end at a child’s request. And they ought to be on serving plates from which everyone can help themselves to a portion, not on individual “kid’s plates.”

Don’t make some foods available only if other foods are eaten. For example, you might be tempted to make a rule, “you can only get a brownie if you eat your broccoli.” That’s a bad idea. It makes the brownie seem extra-super special, and makes the broccoli seem extra- super bad. It reinforces the idea that broccoli is terrible, and that no one would eat it unless they got a super-special food – brownies! – afterwards.

A better plan is to decide in advance what things are in the meal, and if brownies are part of dinner, just include them on the table at the beginning. Anyone can have his brownie whenever he wishes. Don’t make some foods more “special” than others. (An even better plan for those brownies is to avoid “dessert” altogether, saving sweet treats for special times outside of regular meals. A regular meal’s dessert should be fresh fruit, maybe with some whipped cream on top. Yum!)

One goal of mealtimes is to reinforce this message for each individual of the family: Eat when you’re hungry, and don’t eat when you’re not hungry. Mealtimes should also be a time for families to communicate and share experiences together, and to learn important manners and social skills. Avoid using coercion, tricks, or rewards to get your child to eat what you think he ought to eat, or to eat as much as you think he ought to eat. You’ll have happier, healthier mealtimes, and you’ll help your child develop healthy food attitudes for his entire lifetime.

Send your questions to [email protected] or Pediatrics for Parents, PO Box 219, Gloucester, MA 01931. Please keep them general in nature as we can’t give specific advice nor suggest treatment for your child. All such questions should be asked of your child’s doctor.

By Roy Benaroch, MD

Dr. Roy Benaroch is a general pediatrician in practice near Atlanta, Georgia, and an assistant clinical professor of pediatrics at Emory University. He’s a frequent contributor to Pediatrics for Parents and has written two books for parents.

Copyright Pediatrics for Parents, Inc. May 2008

(c) 2008 Pediatrics for Parents. Provided by ProQuest LLC. All rights Reserved.

By Barr, Mark L

In the late 1700’s, the capacity and incapacity of legal institutions to produce justice was at the center of social discourse. If the sensations of the Scottish and English sedition and treason trials of 1793 and 1794 are insufficient support for this proposition, David lieberman’s catalogue of historiographical pronouncements on the issue is more general evidence for a consensus. In the 18th century, “The Law was elevated … to a role more prominent than at any period” in English History, claims E.P.Thompson (1978, 144). Roy Porter adds that “the law and its execution were not just Government fiats or ruling class weapons but an intimate part of community life” (1982, 150). John Brewer suggests that “Most Englishmen experienced government and understood politics through their dealings with the law” (1980, 133, 135). Lewis Namier agrees as does J.C.D Clark, implying the importance of law and local legal tribunals in mediating the encounter between citizen and government (Namier 1929, i:54; Clark 1985). The confluence of law and politics was not merely an obvious but a compelling topic of literary concern. Coming to political awareness during the 1780’s and 1790’s, Samuel Taylor Coleridge became highly interested in the nature and social role of law early in his career. His 1794 sonnet to the prominent barrister Thomas Erskine, his “Lecture on the SlaveTrade” (1795), his trenchant condemnation of the 1795 “Gagging Acts” in “The Plot Discovered,” and even the millenarian frenzy of “Religious Musings” (1794) all evidence not merely a general concern with law, but a keen engagement with its textual, procedural and political dimensions. Focusing on the second half of Coleridge’s career, this paper will suggest that his concern did not fade with time but rather increased in sophistication of analysis and scope. Part I traces Coleridge’s continued interest in legal issues and how it began to find expression in his latest writings on politics. Part II suggests that Coleridge found in the legal concept of the trust a vehicle he hoped could house and preserve a cultural inheritance that could help stabilize textual interpretation; such stabilization could, he felt, produce justice through adherence to a system of precedent administered by a group of quasi-judical “Clerisy,” discussed in part III. However, while part IV argues that Coleridge saw this justice as arising from a cultural belief epitomized in a kind of literary interpretation based on Shakespearean principles, partV goes on to argue that then, as now, any claim that “objective” standards of textual interpretation produce justice are illusory, a mere covering for an historical trauma that can be traced back to the Romantic period or before.

I.

In May of 1811, Samuel Taylor Coleridge wrote a strident letter to the London Courier regarding sentences handed down to criminals in the recent County Sessions, among these the whipping of three women for various acts of petty theft:1

Shakespeare, who alone of all the dramatic poets possessed the power of combining the profoundest general morality with the wildest states of passion . . . whose moral aphorisms are … sparks of fire that fly off from the iron, . . .; our philosophic Shakespeare has not suffered this debasement of our common nature [the whipping of women] to … elude the inevitable tact of his moral sense: and we cannot doubt that hereafter our Legislature, which has already shewn itself so friendly to all dispassionate and unfactious attempts to amend the penal code, will allow us to repeat, fey authority, the Poet’s bidding –

“Thou rascal Beadle, hold thy bloody hand!

Why dost thou whip that woman?” (King Lear 3:ii:139-41)

In this instance, Coleridge turns England’s “philosophic Shakespeare” into a legal authority (his emphasis) to refute the legislative pronouncement embodied in current penal law. The artistic creations of this greatest English poet contain “moral aphorisms” that guide individuals to just action better than any statute or legal precedent. Moreover, these principles are “dispassionate and unfactious,” standing as a potential objective corrective to the supposedly party-driven interests that guide innovation in the legal and political realm. But what may go unnoticed in this application of Shakespearean precedent is Coleridge’s role as selector and interpreter of the quotation. As a dramatic utterance, the quotation’s meaning is at best ambiguous, nor does Coleridge explain why a quotation from perhaps MacBeth or Julius Caesar, encouraging murder and punishment, might not be more appropriate. What Coleridge presents here as authority is not so much the moral aphorism of England’s national poet as law derived through interpretive practice, wherein one presented as having a special relationship to authority is given the capacity to act as sibyl or prophet, selecting and interpreting that authority in some desired fashion. In voicing doubts about the injustice enacted through current legislation, Coleridge joins Jeremy Bentham, William Godwin and even Sir William Blackstone in a concern over the failure of contemporary political and legal institutions to manifest “justice.” Unlike his contemporaries, however, as he outlines more fully in On the Constitution of the Church and State (“Church and State”), Coleridge suggests that justice should arise from the interpretive aesthetic of a group of literary and cultural critics, the “clerisy.” In Church and State, Coleridge erects a constitutional scheme to enable a national reading community guided by this clerisy, so that the circulation of print through that community will result in readings of literary and legal texts regulated by a shared sense of custom and value. Using the Bill for the Relief of His Majesty’s Roman Catholic Subjects (“The Catholic Relief Bill”) as the focus of interpretation, Church and State becomes one extended guide to the reading of that bill and its constitutional implications, thus demonstrating the clerisy s role in the process of political decision-making (here, the evaluation of proposed legislation) and showing that role to be a new manifestation of the systematic organization Coleridge sees as necessary to curtail the radical potential of free will in the act of interpretation.2 Nor, I suggest, is this a mere historical curiosity: for here lie the seeds of a modern legal interpretive practice that had its beginnings in Coleridge’s day. In the increasing predilection of legal theorists such as Ronald Dworkin, Stephen Knapp and Roberto Unger to invoke Romantic paradigms of literary interpretation for use in judgment, we see the replication of a Coleridgean illusion that justice can be achieved through a reading strategy which simply masks the very Jacobinical innovation it seeks to eliminate.

In Church and State, Coleridge advocates a form of social organization in which the balance between opposing and mutually regulating structures is maintained by an external organization of trustee-like figures, the clerisy. Near the start of his treatise to propound a new constitutional form, he defines how a constitution should be constructed:

A Constitution is the attribute of a state, i.e. of a body politic, having the principle of its unity within itself, whether by concentration of its forces, as a constitutional pure Monarchy, which, however, has hitherto continued to be ens rationale, unknown in history . . .-or-with which we are alone concerned-by equipose and interdependency: the lex equilibria, the principle prescribing the means and conditions by and under which this balance is to be established and preserved, being the constitution of the state (Coleridge 1969, 10:23).

“Antagonistic powers” within the constitution itself maintain balance and preserve the English nation from the kinds of “disturbance” (i.e. revolutions and wars) that had recently occurred in Europe (Coleridge 1969, 10:23). These powers, or opposing interests in the state, Coleridge labels “PERMANENCE and … PROGRESSION” (10:24). These opposing interests Coleridge claims are embodied in the landed classes and the “Novi Homines,” or rising, mercantile and financially mobile middle classes, respectively (10:24-25). The goal of the latter, he suggests, is to acquire a sufficient mass of mobile property or personalty to be able to transform it into real property, to acquire titles and hereditary entitlements and to become “the staple ring of the chain, by which the present will become connected with the past; and the test and evidence of permanency afforded” (10:25). Thus, Coleridge associates each opposing class force with a further opposition embedded within economic and legal discourse. The landed classes derive their power mainly from real property, the others from the mobility and speculative potential inherent in personalty. Thus, their fundamentally opposed and mutually regulating social roles are further manifested in a type of property, a step Coleridge sees as necessary stemming from as far back as the lecture of 1795 when, under the influence of Burke, he theorized that only the backing of property (especially real property) could give the power necessary to any group to maintain power and authority over the frenzied and untutored mob that was the fear of every fledgling democrat.3 However, Coleridge goes on to suggest that even this fundamental opposition lying at the heart of the state needs regulation. That regulation is provided by the trusteeship of a new group, the clerisy. Coleridge describes the clerisy as a “permanent class or order” with the following organization and duties:

A certain smaller number were to remain at the fountain heads of the humanities, in cultivating and enlarging the knowledge already possessed, and in watching over the interests of physical and moral science; being, likewise, the instructors of such as constituted, or were to constitute, the remaining more numerous classes of the order. This latter and far more numerous body were to be distributed throughout the country, so as not to leave even the smallest integral part or division without resident guide, guardian, and instructor; the objects and final intention of the whole order being these-to preserve the stores, to guard the treasures, of past civilization, and thus bind the present with the past; to perfect and add to the same, and thus to connect the present with the future; but especially to diffuse through the whole community, and to every native entitled to its laws and rights, that quantity of knowledge which was indispensable both for the understanding of those rights, and the performance of the duties correspondent. (Coleridge 1969, 10:43-44)

In short, the clerisy are guardians of knowledge and culture who disseminate and maintain cultural values over time. They are a conglomerate body with a permanence established through legal institutionalization who control both real and cultural property or “nationally” and can stop it from being alienated, transformed and destroyed-this property is their source of power and authority, analogous to the realty and personalty held by the Landed and Mercantile classes respectively. An important distinction, however, between these groups and the clerisy is that the latter do not hold their nationally for their own good, but for the use of the nation- they “preserve” and “guard” these national treasures for the people’s enjoyment. This division between ownership and enjoyment is a pattern analogous to that found in the legal concept of trust.

II.

The technical idea of a trust does not appear early in Coleridge’s work. Perhaps the first notice he takes of it (in the context of fiduciary relationships) is in the Watchman article on the case of Docksey v. Panting. In a report partially or completely written by Rev. John Edwards, the Watchman describes Thomas Erskine’s speech on behalf of the plaintiff in a case of fiduciary breech, in which an apothecary (Panting, the defendant) persuaded Peter Garrick, the senile brother of David, to revise his will and bequeath all his estate to the defendant. In the report, as Garrick is described in terms of his brother’s famous portrayal of Lear, Panting’s violation of the brother becomes somewhat extravagantly described as a violation of the actor and, moreover, as a violation of the actor’s work done in the cause of bringing Shakespeare to the stage. Fiduciary breech becomes the violation of a cultural inheritance. Coleridge was at least impressed by Erskine’s speech and we may perhaps interpret Erskine’s moral outrage at the fiduciary breach as Coleridge’s own (1969, 2:142 n2).Yet, although Coleridge does not more fully explore his interest in fiduciary relationships until Church and State itself, the prevalence of trusts in the contemporary social and legal spheres may have suggested to him the utility of the trust as a metaphor governing relationships between clerisy and nationally.

The trust had its heyday through the eighteenth and early nineteenth centuries, finding its strongest expression in the desire of the landed gentry to restrict alienation of real and (to a lesser extent) personal property in their heirs. Although the doctrine of estates had always applied to land, allowing the establishment of tenures less than the fee simple, such as the fee tail and life estate, the common law decision allowing entails to be barred had shortcircuited the utility of these lesser tenures to restrict alienation in heirs.4 Unlike the fee simple (which allows full rights to the owner to, e.g., sell the property), the fee tail estate bound the current holder of that interest to alienate the property only to the heirs of his body. Thus, barring the entail (the “tail” being the restriction to the descendants) essentially converted the fee tail to a fee simple. After that decision, an individual with a fee tail could freely alienate property, not just mortgage it to the hilt. Real property could be traded like a commodity. However, the trust, embedded at the heart of the legal structure known as the “strict settlement” could solve this problem. Schematically, a strict settlement was the granting of a life estate to a son (usually a groom on the occasion of his wedding) with a remainder to his unborn heirs with the provision that, should the groom’s estate determine or end (e.g., he tried to sell it) prematurely (i.e., before his death) the land would go into trust for the remainder of the groom’s life and then devolve to the groom’s male heirs. The trust was necessary because the life estate to the groom (remainder to his heirs) was considered to create a fee tail in the groom, a fee tail with only a contingent remainder (to unborn children) which was barrable at common law-i.e., without the trust, the groom actually got a fully alienable fee simple with no guarantee that he would keep the land in the family. Thus, the trust was crucial to ensuring the family dynasty remained intact between generations. Only the imposition of a trust to maintain the contingent remainders (to the unborn heir or heirs) enforced absolutely the will of the grantor. Lawyers developed the strict settlement (with the vital trust element) as a reaction to the unfortunate effect of the barrable remainder in order to fulfill the desire of their clients to control property dynastically.Thus, the trust (in both the strict settlement and in the executorship) allowed the creation of a type of property that could be effectively controlled by the dead, one in which (when necessary) the legal title was separated from the beneficial ownership, entailing the preservation of the property for future generations (Spring 1988, 454-60).

The strict settlement was the (virtually) sole vehicle through which the landed classes were able to and did control the devolution of real property through a series of generations (from the 1700’s through the early 20th century). The reason that a trust was so effective in maintaining this control from beyond the grave was that its administration and the legal title to the trust property resided with one party (the trustee or trustees) while the equitable benefit or enjoyment of the property resided with the trust beneficiaries according to the dictates of the trust instrument as administered within the conscience of the trustees. The conscience of the trustee was that which bound him to follow and supplement the orders of the deceased and administer the trust property fairly according to the instruments dictates (in the case of a strict settlement, this was often a bare or simple trust without restrictions save on alienation). Thus, the trust enabled control beyond the point of alienation and allowed a grantor the same control over personal as real property. Furthermore, the trust maintained an immortal conscience which ensured the controlled and proper devolution of this inheritance.

In suggesting that the clerisy holds the nationally in trust, Coleridge invokes a form of legal control intermediate between those available to realty and personalty. Trust can encompass and combine both forms of property. Metaphorically, therefore, the clerisy can knit together realty and personalty, upper and middle class, noble and merchant, permanence and progression-past and future. For, above all, the trust was a vehicle for enabling the will of the past to be manifest in the present and into tomorrow. It was a means of control partly fixed and partly adaptable to particular circumstances based on the conscience of the trustee. Coleridge implies that by “constituting” a trust (which is still the technical term for trust formation), out of public and private property for administration by the clerisy, the clerisy itself will become the embodiment of historical and traditional ideology, ideology that will both guide and be modified in accord with the conscience of the trustees. Due to the construction of the constitution itself, insofar as the nation was required to listen to the clerisy’s containing dictates, the nation would come to express the clerisy’s conscience, an echo of the past that determined the alteration of the political form in years to come and guide the will of the people into appropriate political, literary or religious expression. The clerisy is thus “an essential element of a rightly constituted nation, without which it wants the best security alike for its permanence and its progression” (1969, 10:69). The practical function of the clerisy Coleridge himself demonstrates in Church and State: Coleridge as interpretive guide becomes a representative of the clerisy and acts to direct his reader’s act of judgment by uttering a body of traditional cultural and academic knowledge necessary both for the reading of this one Bill and for the exercise of discretion by any large body of people that decides the future state of the law, the constitution and the nation itself. In doing this, Coleridge creates an institution designed to safeguard the very framework of society itself, a constitutional function which Coleridge suggests the common law judges have failed to uphold.

III.

Historical sources for Coleridge’s notion of the clerisy are many, but they are often ones that tie the clerisy to the interpretation and application of the law. One example is in his Lectures on the History of Philosophy in 1818, in particular in his description of the Pythagoreans. In his second Lecture, recorded in the Ferer manuscript as having been given December 28 1818, Coleridge calls Pythagorus the “first philosopher,” describing him in terms remarkably similar to those he would apply to the clerisy a decade later in the Constitution of Church and State. Pythagorus was of a wealthy but middleclass background, having been raised in a trading town, a center of commerce that provided him with opportunity to converse with mariners, to travel and see much of the known world (1969, 8:i:65). On return, he immigrated to southern Italy because the political climate under the dictator Polycrates would, he believed, create “factions and revolutions inconsistent with his purpose,” which was to began a broad-ranging project of education (8:i:69). Through appearing disinterested and objective he convinced first the highest ranks of people, but eventually even the lowest, that their current miseries arose from ignorance. Although the people requested that he provide them with constitutions, or modes of government, he refused, claiming that they must find their own form of government which could not be instigated or continued without self-reformation. To encourage this self reformation, he created schools in which the carefully-selected pupils were trained in morality and self discipline, only then being offered some of the master’s secret truths so as to prepare their minds for the greater truths that they would discover on their own. Coleridge describes this as the method of “moral politics,” in which the student does not become mastered by received wisdom, but has an inner principle awakened that exerts a self-governing force to cover multiple future situations.5 These students would then leave the school and participate in the two great ends of the Pythagorean method-to prepare men to be governed and to govern. Consequently, many cities took all their magistrates from the ranks of the Pythagoreans. However, in pursuing rulership the Pythagoreans began to neglect education and therein lay the seeds of their own destruction- unprepared for self government, roused by demagogues, the people rebelled against this perceived privileged, prosperous and exclusive organization. It disintegrated (8:i:71). Coleridge saw the Girondins of the 1795 Moral and Political Lecture suffer this fate, and it is anxiety over this doom which leads to his admonitions to the clerisy for restraint in the 1829 Church and State. The role of the clerisy, insofar as it is similar to that of the Pythagoreans, is to govern through a dissemination of knowledge that awakens appropriate modes of thought and discretion. A further source Coleridge expresses for the clerisy is in the Levites, described in the second Lecture on Revealed Religion as “the Lawyers as well as the Priests of the Country” whose interest it was “to make up Quarrels and prevent lawsuits to the utmost of their Power” (1:137). Moreover, they were “teachers in order to keep the People free from Idolatry, and they were directly appointed by Moses” (1:137). As he states in Church and State, the role of the Levites in arbitrating disputes and maintaining cultural tradition was part of the “perfection of the machinery” of the Hebrew state. Their function in that ancient nation is analogous to the one Coleridge propounds in his treatise (10:34, 32-5.). Whether the clerisy is a caste of Greek philosopher kings who govern and judge according to a principle of morality awakened within them by the study of moral rules and self discipline, or a priestly order that both teaches and maintains a traditional mosaic law while applying it to resolve disputes between citizens, Coleridge often specifically stresses the legalistic nature of their guardianship: they help in the permanence and progression of “laws, institutions, tenures, rights, privileges, freedoms, obligations” (1969 10:53). In at least one draft he also states that their role is to train up the populace into “legality” and “the obligations of a well calculated Self interest” (10:213- 14). This role of embodying and expressing a traditional knowledge to guide a public (often legal) exercise of discretion is very similar to that described by Blackstone as the role of the common law judge.

For Blackstone, the royal judges are the arbiters of an unwritten common law “discovered” by applying reason to tradition: “They [the judges] are the depositary of the laws; the living oracles, who must decide in all cases of doubt, and who are bound by an oath to decide according to the law of the land. Their knowledge of the law is derived from experience and study . . . and from being long personally accustomed to the judicial decisions of their predecessors” (2001, 1:69). This “law of the land” of which the judges are depository is a law supposedly common to us all evidenced by established tradition:

… in our law the goodness of a custom depends on it’s [sic] having been used time out of mind; or, in the solemnity of our legal phrase, time whereof the memory of man runneth not to the contrary. This is it that gives it it’s weight and authority; and of this nature are the maxims and customs which compose the common law. (Blackstone 2001,1:67)

Thus, steeped in a knowledge of tradition maintained and supplemented by the written rules of past decisions, the judge speaks as the member of an institutionalized community that does not innovate so much as gradually perfect the expression of a supposedly complete and stable ground of justice:

For it is an established rule to abide by former precedents, where the same points come again in litigation; as well to keep the scales of justice even and steady, and not liable to waver with every new judge’s opinion; as also because the law in that case being solemnly declared and determined, what before was uncertain, and perhaps indifferent, is now become a permanent rule, which it is not in the breast of any subsequent judge to alter or vary from, according to his private sentiments. (Blackstone 2001, 1:69)

Blackstone, like Coleridge, sees this role as maintaining the coherence and balance of the constitution. As Stanley Katz argues in his introduction to a modern facsimile edition of the Commentaries, Blackstone conceived of the royal judges as guardians of the constitution, “constitution” at that time being defined as all the laws of the nation. Existing outside the tripartite structure of English government, the judges nevertheless played an important role in keeping the balance between King, Lords and Commons (1979, xi). Evidence for this position in Blackstone is implicit but extant. For example, he at one point stresses the independence of judges from the King, his ministers and agents and places this independence in the context of other 1688 reforms that placed the law above the King, reforms such as regulating the laws of high treason and restraining the King’s pardon for impeachments in Parliament (2001, 4:433). By safeguarding the law, the judges safeguard the constitutional balance.

This is a role Coleridge explicitly discusses in Church and State, suggesting that it must now ultimately be taken up by the people in consultation with the Clerisy. Citing the 1648 pamphlet “The Royalist’s Defence,” Coleridge acknowledges that the role of judges is to uphold the common law and ensure that parliament follows these laws:

Upon the whole the matter clear it is, the Parliament itself (that is, the King, the Lords, and Commons) although unanimously consenting, are not boundless: the Judges of the Realm by the fundamental Law of England have power to determine which Acts of Parliament are binding and which void. (Coleridge 1969, 10:97-98)

However, Coleridge goes on to assert that judges now refuse to fulfill this sacred duty, leaving it to fall to a new institution:

[This right] has been suffered to fall into abeyance. [Consequently] the potency of Parliament [is the] highest and uttermost, beyond which a court of Law looketh not: and within the sphere of the Courts quicquid Rex cum Parliamento voluit, Fatum sit! [Whatever the King with Parliament has decided, let it be Fate.]” (Coleridge 1969, 10:97)

In an allusion to the imprisonment of Leveller John Lilburne in 1645 (where his main argument in defence was that the people held ultimate legal authority) (Green 1987, 347-8; see also 307, 311, 336 and 382.), Coleridge maintains that the right to determine law still adheres in the people, quoting the following verse of the Puritan George Withers from that time:

Let not your King and Parliament in One,

Much less apart, mistake themselves for that

Which is most worthy to be thought upon:

Nor think they are, essentially, the STATE.

Let them not fancy, that th’Authority

And Priviledges upon them bestown,

Conferr’d are to set up a MAJESTY,

A POWER, or a GLORY of their own!

Bet let them know, ’twas for a deeper life,

Which they but represent

That there’s on earth a yet auguster Thing,

Veil’d tho’ it be, than Parliament and King. (Coleridge 1969, 10:10)

This “auguster Thing” is the very readership Coleridge addresses and guides through a reading of the Catholic Relief Bill in Church and State.

The relationship Coleridge suggests should exist between clerisy and populace mirrors closely that which Blackstone posits between judge and jury. Looking back to the decision in Bushel’s case (roughly contemporaneous with Lilburne’s trial), Blackstone emphasizes that the judge can no longer control the jury’s verdict- they cannot be imprisoned, starved or punished for rendering a “wrong” verdict (2001, 3:354-55). The judge’s role is to give directions and advice and to provide the legal context (i.e., the context of custom and history) within which the jury will fit its factual findings to a verdict:

When the evidence is all gone through on both sides, the judge in the presence of the parties, the counsel, and all others, sums up the whole to the jury; omitting all superfluous circumstances, observing wherein the main question and principle issue lies, stating what evidence has been given to support it, with such remarks as he thinks necessary for their direction, and giving them his opinion in the matters of law arising from that evidence. (Blackstone 2001, 3:375) This is the role Coleridge enacts as clerisy in Church and State. Suggesting that the status of judges as constitutional guardians is now defunct, he lays the power in the people, properly guided by the context of precedent and history provided by the Clerisy, to keep, safeguard and evolve the constitution in a fit and stable direction. This power, he suggests, is exercised primarily through acts of interpretation, the clerisy holding in trust the cultural keys to appropriate reading. The raison d’etre of Church and State is a description of the idea of a constitution so as to provide guidance to Coleridge’s readers (an educated elite) who are like the second level of clerisy who will go out and change and safeguard the world. As Coleridge is at pains to point out, the idea of the constitution is something ineffable but which can be manifested (imperfectly) in a political system (10:18- 20, 2). By describing what he believes to be the best manifestation of that idea, Coleridge (like a representative of the first level of clerisy) gives an objective basis on which others can evaluate alterations or additions to the current constitutional manifestation in political organization, including the current Catholic Bill under consideration in Parliament. The commentator in Church and State supplies criteria for judging legislative text, a context that guides the interpretation. Articulating fundamental constitutional principles, the author of Church and State provides,

the final criterion by which all particular frames of government must be tried: for only [in the constitution] can we find the great constructive principles of our representative system (I use the term in its widest sense, in which the crown itself is included as representing the unity of the people, the true and primary sense of the word majesty); those principles, I say, in the light of which it can alone be ascertained what are excrescences, symptoms of distemperature and marks of degeneration; and what are native growths, or changes naturally attendant on the progressive development of the original germ, symptoms of immaturity perhaps, but not of disease; or at worst, modifications of the growth by the defective or faulty, but remediless, or only gradually remediable, qualities of the soil and surrounding elements. (Coleridge 1969, 10:20)

Although the metaphor is predominantly medical, it starts with the legal-the clerisy, like a judge, provides the framework in which new ideas will be “tried.” In short, Coleridge envisions the clerisy as not merely guardians of literary or cultural taste, but as authorities who contain a mass of shared knowledge that will enable the “correct” interpretation of literary and legal texts, interpretations that will ensure the shape and framework of the nation remains stable and intact during any period of social or political change. Coleridge, like a Shakespearean critic, Pythagorean statesman, or Levite, is an oracle of a “common law” on which to base decisions in the political realm. In Coleridge’s mind there is no separation between legal and literary discourse: being a cultural guardian means to interpret legal and literary writing with equal authority. The clerisy must read Shakespeare and legal precedent with equal facility and authority, for they must embody the capacities of sage and common law judge if they are to guide the polity to express truly the law common to us all.

IV.

However, the ultimate principle to guide the interpretation of legal texts arises, Coleridge suggests, in the literary realm. Although his appeal to Shakespeare as moral and legal authority is clear in his letter on the whipping of women, Coleridge again invokes Shakespearean authority as the motto to Church and State itself.

THERE IS A MYSTERY IN THE SOUL OF STATE, WHICH HATH AN OPERATION MORE DIVINE THAN OUR MERE CHRONICLERS DARE MEDDLE WITH (Coleridge 1969, 10:10).

Added to the second edition, this adaptation from Troilus and Cressida suggests that “mere chroniclers,” mere historians, cannot fully apprehend the nature of the state. Looking merely at historical precedent is insufficient. The “mystery in the soul of the state” is, by implication, something open to exploration by Shakespeare, Coleridge’s epitome of authorship and, by extension, open to other authors and those who study their works. The literary sphere and most particularly Shakespeare becomes for Coleridge the quintessential embodiment of the nationally, cultural property and sense of common value that will guide legal and literary interpretation.

As far back as 1808, Coleridge had been speaking of Shakespeare not as some wild, radical genius who broke the historically- established laws of literary propriety, but as a legislator of the true poetic law, as one who expressed the laws of poetry written in the heart of every person which corrected the corrupt manifestation of these laws found in established literary and legal institutions (1969, 5:i:78-79). R.H. Fogle in his study of “organic unity” first fully articulated Coleridge’s quest for objective principles of judgment, noting his claim that if there is any basis on which to judge art there must be:

in the constitution of the human soul a sense, and a regulative principle, which indeed may be stifled and latent in some, and be perverted and denaturalized in others, yet is nevertheless universal in a given state of intellectual and moral culture; which is independent of local and temporary circumstances. (Fogel 1962, 37- 38)

Following in the Eighteenth-Century tradition of Addison, Johnson and Blair, Coleridge argues for innate taste that must necessarily be expressed by any sufficiently-developed mind living within the requisite “state of intellectual and moral culture.” Like his conceptual forebears, Coleridge attempts to articulate as a set of maxims the elements of taste, a task necessary before they can be used to constitute an objective measure for literary judgment. In his analysis of Shakespeare, the embodiment of the English literary heritage, Coleridge begins to shape (really find or insert) his guide to judgment under the head of “organic unity,” a concept he develops from Leibniz, Sulzer, Herder, Goethe, and particularly Schlegel.

As Fogle shows, Coleridge places organic unity at the center of human imagination embodying a “fundamental reconciliation of opposites” (1962, 52). The principle of organic unity, supposedly the pattern and form of life and thought, becomes the criterion of judgment in the aesthetic and legal realms. Coleridge’s reading of Hamlet for instance, treats the first scene as “a microcosm of structural harmony, containing gradation, transition, development, contrast and variety of intensity and pace” (16). The scene is a whole in itself which is repeated throughout the play, all the component parts creating a unified harmonious body which constantly repeats itself in miniature. Within any artistic work is the germ or seed from which it grows in a complex, fractal design, ever- repeating the pattern of thesis, antithesis and synthesis which is the reconciliation of opposites Coleridge sees as the essential form of this seed: While the nebulous concept of “organic unity” in truth supplies no more objectivity to the process of judgment than the politicallydriven criteria Coleridge himself decries, the concept does have a putative English history, in Shakespeare-a history giving it the supposed cultural context and containment Blackstone (and Coleridge) saw as so crucial to the purity and justice of the common law. The concept of balance and inner harmony Coleridge imports into his conception of the state-those who maintain that balance, the clerisy, thus become an expression of the Shakespearean common law.

V.

However, in spite of his efforts to anchor reading practices in supposedly objective and culturally common criteria and principles, Coleridge cannot avoid the very innovation and Jacobinical imagination he decries in lawmakers.6 As with his manipulation of the quotation from Lear, used to condemn the whipping of women, in his work he reveals the same predilection to modify as any judge or legislator. The verses Coleridge cites in Church and State and attributes to Withers have Coleridge’s own significant alterations and emendations. In his alteration of line 9 (substituting “deeper life” for “a deeper thing,”), deleting part of line 10, omitting lines 11-26 and altering the last two lines from the original (originally “And, know there is, on earth, a greater-thing,/ Than, an unrighteous Parliament or King”) he reveals that the office of clerisy is open to the same attack Bentham levied against the office of common law judge, that he is an inventor, that the common law he guards and discovers is suffused with “fiction,” a “syphilis which runs into every vein and carries into every part of the system the principle of rottenness” (1962, 5:92).

This is the very same accusation that was levied against Sir John Scott’s work as solicitor general during the Regency Crisis and which Coleridge revives in reaction to Scott’s (Lord Eldon’s) WatTyler decision in 1801. On November 20 of 1788, George III had what was likely the first of his periodic lapses into insanity, instigating a flurry of political activity and legal wrangling to determine who should run the state during his disability. Speaking on the issue of appointing a regent to administer the King’s affairs, namely to open parliament in order that legislation could be passed to appoint a regent, Scott was of the opinion that no regent was needed, that the political capacity of the King was intact (if not his personal capacity) and that the constitution established no precedent for appointing a regent in such a situation. There was especially no precedent, he urged, that the next in the line of succession should be regent; this was the Prince of Wales whose politics were greatly at odds with those of his father and the established government. In such a case, Scott argued, it fell to Parliament to appoint whatever regent it saw fit. In concluding his argument to the House, Scott stated: I will therefore vote for the Commission upon the simple ground of preserving the forms of the constitution; and be it remembered that upon the preservation of the forms depends the substance of the constitution. (Campbell 1878,8:405)

Since the King’s “politic capacity” remained intact, it was sufficient to affix the King’s Seal to the commission to open parliament so that legislation could be passed appointing the regent. Although the King’s fit of madness passed before it was found necessary to appoint the regent, the opposition’s reaction to Scott’s maneuvering is telling. As Campbell records, Scott’s maneuvering was seen in the 20th edition of The Rolliad as a kind of prestidigitation that placed his act of legal interpretation on par with MacBeth’s witches’ spell:

INCANTATION,

or Raising a Phantom; Imitated from “MacBeth,” and lately performed by

His Majesty’s Servants in Westminster.

Thunder.-A Caldron boiling.

Enter three Witches

First Witch. Thrice the Doctors have been heard,

Second Witch. Thrice the Houses have conferr’d.

Third Witch. Thrice hath Sydney cock’d his chin,

Jenky Cries-Begin, begin.

First Witch. Round about the caldron go,

In the fell ingredients throw.

Still born foetus, born and bred

In a lawyer’s puzzled head,

Hatch’d by ‘Metaphysic Scott,’

Boil thou in th ‘enchanted pot.

All. Double, double toil and trouble;

Fire burn, and caldron bubble.

second Witch. Skull, that holds the small remains

Of old Camden’s addle brains;

Liver of the lily’s hue,

Which the Richmond carcass grew;

Tears which, stealing down the cheek

Of the rugged Thurlow, speak;

All the poignant grief he feels

For his sovereign – or the Seals;

For a charm of powerful trouble,

Like a hell-broth, boil and bubble.

All. Double, double toil and trouble;

Fire burn, and caldron bubble.

Third Witch. Clippings of Corinthian brass

From the visage of Dundas;

Forg’d address, devis’d by Rose,

Half of Pepper Arden’s nose;

Smuggled vote of City thanks,

Promise of insidious Banks;

Add a grain of Rollos courage,

To inflame the hellish porridge.

First Witch. Cool it with Lord Kenyon’s blood.

Now the charm is firm and good.

All. Double, double toil and trouble;

Fire burn, and caldron bubble.

Enter Hecate, Queen of the Witches.

Hecate. Oh! well done! I commend your pains,

And ev’ry one shall share i’ th’ gains (qtd. in Campbell 1878, 8:409).

Campbell adds that Lord Belgrave likewise satirized Scott’s efforts in the following lines:

With metaphysic art his speech he plann’d,

And said-what nobody could understand. (Campbell 1878, 8:410)

Many began to see Scott as one who dissembled and used his legal authority to disguise decisions made on more arbitrary and less legally consistent and coherent grounds; moreover, they saw Scott’s act of legal interpretation as associated with a kind of literary imaginative flight of fancy-he created and manipulated precedent. Published in The Rolliad in 1789, the MacBeth satire implies Scott’s exercise of “legal judgment” is imaginative, fickle, arbitrary and unbounded by any considerations of precedent. Scott is here satirized as a kind of original author-he makes a “stillborn” something from nothing, or at most from a hodgepodge of trivial and unrelated ingredients stirred in an “enchanted pot.”

This accusation of invention Coleridge himself picked up and levied against Scott in 1801. Poking fun at Scott in a note to “An Ode to Addington” printed in The Morning Post of 27 May, Coleridge alludes to the one-time prosecutor’s ability to play fast and loose with interpretive rule:

Sir J. Scott, the present Chancellor, is the only enlightened expounder of prophecies. He foretold the fate of the East India Bill, from Revelations; and the condemnation of Home Tooke and Hardy, from the celebrated Act of Edward III. His brother, Sir William, if we may venture to judge from his profound and mysterious elucidatory comments on ordination and marriage, may be joined in this sacred office. (Coleridge 1969, 3:i:264)

Although Coleridge here satirizes Scott, Lord Eldon, as a prophet, the central message, that Eldon’s exercise of judicial discretion is arbitrary and despotic, is a serious one. Equity, claims Coleridge in an attack on Eldon’s inequitable stance during the Bullion Controversy, is supposed to be “equal justice for all mankind, whether authorized by law or not” (1969, 3:iii:12). Justice for Coleridge is that which arises from reading law within its historical and institutional context-it must be read within a system or it will merely express the desires of the interpreter. What Coleridge sees Eldon as doing is a kind of wrong-headed “prophecy:” he engages in a form of literary interpretation that is unbound by anything but his own predilection and, as a consequence, is satirized as always reading a text incorrectly. Although, in Church and State, Coleridge designs a constitutional balance guarded by cultural trustees, trained to find and express a “common law” that contextualizes and grounds public exercises of discretion, his manipulation of his own precedents reveals them to be just as groundless and “imaginary” as the common law expounded and preserved by the common law judges the clerisy is supposed to replace.

In short, the Coleridgean interpretive aesthetic is bankrupt if its goal is to seek any objective cultural criteria for judgment, a Shakespearean common law. Perhaps it could not help but be so. However, in an imitation of how the common law is formed through individual judgments either being cited or ignored in subsequent decisions over time, the rhetorical power of Church and State has caused it to be “picked up” by subsequent legal and political thinkers, has caused its authority to crystallize into reality as modern legal scholars have seemingly absorbed Coleridgean ideas. In Law’s Empire Ronald Dworkin suggests that the incorporation of new decisions into lines of precedent should be like the creation of a “chain novel” in which judgments should “follow from the principles of personal and political morality … explicit decisions presuppose by way of justification” (1986, 96). Both a reader and writer, Dworkin’s judge fits his new decision into aesthetic criteria deemed to create the best “fit” between past themes and those extending into the future. In short, supposedly within precedent are latent, universal principles that enable judges to read and write new texts in the present.

It is a notion similar to Coleridge’s organic unity-after all, both seem little more than a paraphrase of Blackstone’s concept of the common law enunciating a morality common to us all. In both cases, the ultimate judgment, after all the verbal and rhetorical gymnastics involved in writing the newest chapter, requires the judge to determine which interpretation fits “best, all things considered” (Dworkin 1986, 231). Although they follow a method designed to minimize the exercise of unfettered imagination in the act of judgment, Dworkin’s judges are no less Jacobinical than Coleridge’s sibyl-like clerisy. Both are trustees of an encoded past that only they are supposedly qualified to interpret and apply to present texts-but both at the core use personal conscience as the central criterion of judgment. It is their choice as to what precedents to follow, their choice how to interpret and apply those precedents. As Roberto Unger suggested as far back as 1975, even those judges who genuinely feel they bow to the dictates of precedent are at best deluding themselves: they are adhering to the illusory essentialist notion that words and precedents have “objective” meanings that may serve to guide present decisions (1975, 83-103).

I’m not suggesting that Dworkin has been reading Coleridge so much as that our entire society has been reading and absorbing Coleridge and a romantic ideology of literary interpretation for the last 200 years. As Jerome McGann has suggested in his seminal new historical study of the romantic influence on modern critical practice, modern romantics scholars have at least uncritically absorbed romantic norms (1983,1). I would suggest that this absorption can be applied to legal interpretive norms as well. Law is a reading practice, and legal scholars have rightfully been obsessed with the criteria used to interpret legal texts. As with Coleridge’s application of Shakespeare to the whipping of women, while many judges would like us to think that the law speaks for itself or can at least be read within a context of safeguards that limit or eliminate personal discretion, it remains in the interpretation and selection of precedent that law and justice arise. The ability to make such interpretations predictable would go a long way to assuaging criticism as common today as in Coleridge’s time-that law is legislation from “activist judges,” or the rule of the chancellor’s foot (as Lord Eldon said in 1805), or what the judge had for breakfast (in Dworkin’s words) (Holdsworth 1956-82, 13:620; Dworkin 1986, 36, describing legal realism). Other legal theorists such as Steven Knapp have quite consciously invoked romantic norms (in this case, Keats’ negative capability) in an attempt to stabilize legal meaning and eliminate discretion. One can read it as an institutional development parallel to the elimination of the medieval King’s Eyre, the creation of the common law writ process or the abolition of privy seal courts in Elizabethan times. It is an attempt to make justice a flexible, adaptive machine capable of grinding off one man’s sack of meal the same as another (as Coleridge put it; 1969, 7:ii:111-12). But the difficulty with modern attempts to adapt romantic literary concepts to create such a machine is the illusion of “objectivity” they create. Embedded within our romantic notions of literature and literary interpretation lie ideological investments that inevitably colour the interpretive result. Richard Posner once went so far as to suggest that romantic values evidence an infantile desire to be free of the “political, legal and religious restraints that have evolved to tame the beast in man and create peace and prosperity” (1988,146), implying that a literature encouraging the breach of ideological constraint naturally leads to a variety of damaging radical positions like fascism and communism, even to the extremism of Nazi racial policies (148). Although this is actually the very jacobinism Coleridge and Dworkin are at pains to prevent, there is inherent in the process of interpretation an act of romantic imagination which organic unity, law as integrity or legal economic theory anxiously seek to cover, a truth confronted in the work of Roberto Unger.

Abandoning his own essentially Romantic position of “internal argument” and “deviationist doctrine” outlined in The Critical Legal Studies Movement, Unger develops a more revolutionary approach in What Should Legal Analysis Become, suggesting that law and legal methodologies are an expression of conservative Capitalist vision and claiming that legal discourse is nothing more than a rhetoric of rights and order that stops the people from analyzing society’s basic institutional structure (1986, 53ff; 1996). Instead, he suggests a radical alternative mode of legal analysis in which Judges strip away the rhetorical cover of legal language and directly confront and negotiate between the competing social interests that legal discourse represses. Judges should unabashedly become legislators, or rather, recognize fully that they have been legislators all along. In this way, Unger suggests, legal analysis becomes “social prophecy”-here is a conception of legal reasoning as an expression of radical imagination to instigate a supposedly true political justice (1996,23,113).

Thus Unger delineates and seeks to confront the very Jacobinism that in reality lies at the heart of Coleridge’s, Dworkin’s or any other attempt to regularize textual interpretation. Tracing the historical source of this concern to the Romantic period, I would suggest that the reason we continue to couch legal reasoning in the mysticism of precedent is not so much the repression of capitalist realities as the trauma of revolution. Living in a world after Thomas Paine we have a need to believe that legal rights have substance, are real and tangible in some way. But as anyone knows who has been assaulted in a back alley, legal rights never rise to the rescue. They were themselves created through rhetoric (the power of which is evidenced in Paine’s enormous publication), through an imagination that became true because it was believed, it was “taken up” and written into legal texts. But the very possibility of a different imagination rising up in revolution and overthrowing those rights, this society, is that which necessitates the lie of precedent, of a “context” within which to read and render decisions: for if we allow the imagination, the interpretation of texts and of the past, to go unchecked, we can find ourselves under surveillance, victims of extraordinary rendition or detention without trial-we can find ourselves annihilated from legal and political existence. It is no coincidence that a robust notion of legal precedent arose only after the American and French Revolutions. Coleridge’s own concern with Jacobinism and its effect on literary and legal interpretation is evidence for the connection. Therefore, I would read precedent and legal interpretation according to method as a repression and sublimation of the trauma of the radical imagination and would conclude by suggesting that, although the revolutionary potential of Unger s legal realism may sound like the gateway to a Blakean paradise of social justice, it may equally lead to an Orwellian nightmare-it all depends on whose imagination, whose Neitzschean “will to truth” dominates in the legal, political, and social sphere.

This paper traces Samuel Taylor Coleridge’s engagement with issues of legal interpretation late in his career and most particularly in On the Constitution of the Church and State. Having long noted the political and social ramifications of the supposedly systematic interpretation of legal precedent lying at the heart of the common law, Coleridge suggests that a group of cultural trustees, the Clerisy, could perform a quasi-judicial role to guide reading in the public sphere. Only through such leadership, he suggests, could justice be revived from its then-defunct state. However, the paper concludes by suggesting neither Coleridge nor any modern legal scholar who invokes romantic reading strategies can achieve the vaunted interpretive objectivity legal authority seems to require. Precedent is, in fact, a rhetorical illusion, a repression of revolutionary trauma experienced in and before the Romantic Period.

Notes

1 All references to Coleridge’s works are to S.T.Coleridge Collected Works (1969), hereafter abbreviated as ” Works” followed by volume, sub-volume, and page number.

2 See, for instance, Coleridge’s own characterization of his project in Works (1969,10:11-12.

3 E.g., expressed in Coleridge (1969, 1:6).

4 See Capell’s case, 76 Eng. Rep. 134 (K.B. 158 1).

5 See Coleridge (1969, 8:i:70 n84) for the sources of this idea.

6 See for example, Coleridge’s fear of Jacobinical interpretation in “The Plot Discovered” and his open letters to Justice William Fletcher regarding his address to the grand jury of County Wexford, Ireland in the Summer of 1814: (1969, 1:291 and 292; 3:ii:376, 377, 393).

Works Cited

Benthamjeremy. 1962. The Works ofjeremy Bentham. 11 vols. Ed.John Bowring. New York: Russell & Russell.

Blackstone, William. 2001. Commentaries on the Laws of England in Four Volumes. 9th ed. London: Cavendish.

Brewer, John. 1980. “The Wilkites and the Law, (1763-74).” In An Ungovernable People. The English and their Law in the Seventeenth and Eighteenth Centuries, ed. John Brewer and John Styles. London: Hutchinson.

Campbell, John. 1878. Lives of the Lord Chancellors and keepers of the Great Seal of England. 10 vols. 7th ed. New York: Cockcroft.

Clark, J.C.D. 1985. English Society 1688-1832. Cambridge: Cambridge University Press.

Coleridge, Samuel Taylor. 1969-. S.T.Coleridge Collected Works. 16 vols. Ed. Kathleen Coburn. Princeton: Princeton University Press.

Dworkin, Ronald. 1986. Law’s Empire. Cambridge, Mass.: Harvard University Press.

Fogle, Richard Harter. 1962. The Idea of Coleridge’s Criticism. Berkeley, CA: University of California Press.

Greene, T. A. 1985. Verdict According to Conscience. Chicago: University of Chicago Press.

Holdsworth, William. 1956-82. A History of English Law. 17 vols. London: Methuen.

Katz, Stanley N. 1979. “Introduction.” In Blackstone’s Commentaries on the Laws of England, ed. Stanley N. Katz. Chicago: University of Chicago Press.

McGann, Jerome. 1983. The Romantic Ideology. Chicago: University of Chicago Press.

Namier, Lewis. 1929. The Structure of Politics at the Accession of George III. 2 vols. London: Macmillan.

Porter, Roy. 1982. English Society in the Eighteenth Century. London: Penguin.

Posner, Richard. 1988. Law and Literature: A Misunderstood Relation. Cambridge, Mass.: Harvard University Press.

Spring, Eileen. 1988. “The strict settlement: its role in family history.” Economic History Review, 2nd ser. 41.3: 454-60.

Thompson, E.P. 1978. “Eighteenth Century Society: Class Struggle Without Class?” Social History 3: 144.

Unger, Roberto. 1975. Knowledge and Politics. New York Free Press.

_____.1986. The Critical Legal Studies Movement. Cambridge, Mass: Harvard University Press.

_____. 1996. What Should Legal Analysis Become? London: Verso.

Mark Barr is an assistant professor at Saint Mary’s University in Halifax. Once a practicing lawyer, he wrote his dissertation on the Romantic rivalry between law and literature, portions of which have appeared in SiR, SEL and ERR.

Copyright West Chester University Summer 2008

(c) 2008 College Literature. Provided by ProQuest LLC. All rights Reserved.

By Davidovitch, Nadav Alberstein, Michal

INTRODUCTION The development of the therapeutic jurisprudence (TJ) movement in the last decade significantly challenges traditional legal thinking and is relevant to understanding new modes of institutionalizations in law.1 Although substantial research exists on the various interdisciplinary implications of TJ on the law,2 theoretical reflection on the methodologies and underlying principles of TJ as a reform movement is lacking.3 This Article elaborates on the theoretical foundations and methodologies of TJ by referring to another reform movement that challenges an established profession: the public health discipline. Although the concerns and practices of public health have existed since antiquity, it developed into its modern form since the nineteenth century, with the rise of the modern state.4 It joined other social reform movements and entered previously “private sphere” areas such as the family, communities, and education. Also, it offered new perspectives on, and professional challenges to, medical practice and education. There is fertile ground for a dialogue between the disciplines of TJ and public health, which share some general aspirations and concerns. Both challenge well-established professions, TJ that of law and public health that of medicine. Both professions have long histories and, over the past two centuries, they established themselves as highly competent in dealing with the social order.5

TJ scholarship can benefit and be enriched by public health theories, methodologies, and practices in the areas of disease prevention and health promotion. Public health practitioners and academics, in turn, can benefit from a TJ approach to law by correcting their rigid, authoritarian image of the law and by emphasizing the roles of emotions and individual psychology in the promotion of public health law enforcement.

The following section introduces the public health field and the basic principles and methodologies which characterize it. Part II briefly introduces TJ theory and how its goals parallel those of public health. Part III discusses the potential contributions public health can make to TJ, and vice versa. Finally, Part IV presents some theoretical reflections and open questions for future collaboration and research between TJ and public health.

I. PUBLIC HEALTH: BRIEF HISTORY AND GUIDING PRINCIPLES

This section presents briefly the historical roots of public health theory and practice. It will explain the basic tenets of public health including the relations between the state, community, and individuals and the traditional role assigned to the law as one of the prerequisites for public health activities.

A. Public Health

Although many definitions exist for public health, a recent report submitted to the United Kingdom’s Prime Minister defined public health as “the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals.”6

The principles of public health, as distinct from those of clinical medicine, are based on a population approach. Additional important components include the following: (1) an upstream focus (primary prevention, health promotion), (2) targeting a range of forces (economic, political, and environmental) that affect populations and cause diseases, and (3) strategically modifying social and environmental variables and promoting public health via active social and political involvement.7 This strategy sharply contrasts with that of “traditional” modern medicine, especially as practiced in hospitals.8

Public health preservation is a function of the complex relationship between the social actions of the state, various institutions, and groups of citizens. Dorothy Porter, a historian of medicine and public health, wrote, “[i]n the modern period, the study of the operation of power in relation to population health necessarily involves an examination of the rise of the modern state as an autonomous political sphere.”9 This involves understanding “different interpretations, made in different periods, of the rights and obligations of citizens within the ‘social contract’ of health between the state and civil society in modern democracies.”10 Therefore, the analysis of public health policies and practices “is concerned largely with social, economic, and political relations of health between classes, social structures and organizations, pressure groups, polities, and [the state].”11

Conceptualizing the interrelationships between the individual and the state, in the context of the state’s public health policies, requires an understanding of the socialphilosophical basis of the entire relationship between the individual and the state. Thus, for example, the liberal approach focuses on the right of an individual to defend her freedom in the face of coercive state actions performed in the interest of the greater good. On the other hand, a communitarian approach views public health care as part of community welfare.12 The authority of the state in the area of public health is broad, permitting extensive interventions in the private sphere. Hence, critics view the field of public health care as open to exploitation by the state, which can engage in coercive practices.13 The health domain is a potential area for hegemonic control that tramples individual rights to enforce what it perceives as proper, “normal” behavior.

The perception and interpretation of disease, both by the patient and by her environment, are defined by social and cultural contexts. State actions for maintaining public health and security are applied to, and sometimes even forced upon, individuals, either singularly or because they belong to certain social groups.14 As a result, ethical questions in the field of public health must relate to both the individual and public dimensions. Furthermore, the unique socio- historical relationship under which public health acts are performed by state authorities must be examined. Such multifaceted analysis is necessary when dealing with public health responses for specific diseases, as well as for injuries caused by state actions.15

B. Public Health Law

Law is interwoven into each segment of public health care described above.16 It defines the boundaries for the activities of the public health authorities, the limits to their power, and the restrictions placed upon them in their array of relationships with individuals or social groups. Law determines the balance between private interests and public welfare. With differing degrees of success, the state attempts to use law to construct and impart lifestyle norms and healthy, safe behavior.17 To a great extent, therefore, the various institutions of the law constitute a central arena for public discourse on public health measures.

Although a wealth of literature exists on health law, it is concerned mainly with medicine and personal health care services, and issues such as clinical decision making, delivery, organization, and finance. Public health law has a different focus. Albeit personal medical services are an important part of community health, medical care is only one contributor to health, and probably not the major one. Public health law shares conceptual terrain with the fields of law and medicine, but is a distinct discipline. American public health law theorist Lawrence O. Gostin defined public health law as

the study of the legal powers and duties of the state to assure the conditions for people to be healthy (e.g., to identify, prevent, and ameliorate risks to health in the population) and the limitations on the power of the state to constrain the autonomy, privacy, liberty, proprietary, or other legally protected interests of individuals for the protection or promotion of community health.18

Accordingly, Gostin claims that a model public health statute should reflect at least three principles: (1) Duty: “the law should impose duties on government to promote health and well-being within the population;” (2) Power: “the law should afford public health authorities ample power to regulate individuals and businesses to achieve the communal benefits of health and security;” and (3) Restraint: “the law should restrain government from overreaching in the name of public health.”19

Traditionally, public health law was directed largely at communicable diseases and other externalities with negative health impacts, such as pollution.20 Recently, the main impetus in the public health law reforms of various countries was that of enforcing public health measures: quarantine in the case of SARS21 and other infectious diseases, or enforcement of environmental standards in the case of polluting industry.22 Although this level of enforcement is crucial for protecting public health, there are alternatives to the law that are more in line with the archetypal public health principles of promoting good health and civic participation in advancing public health. As such, the integration of TJ principles into public health law can only contribute to a more cooperative mode of operation in this field, as will be discussed later. II. THERAPEUTIC JURISPRUDENCE: BRIEF HISTORY AND GUIDING PRINCIPLES

The TJ school of law introduced ideas of care and therapy into legal theory and practice. TJ emerged in the area of mental health law in response to various aspects of the then existing mental health law with its seemingly anti-therapeutic effects.23 Soon thereafter, however, TJ found applicability in other areas of the law-criminal, juvenile, family, personal injury-and has emerged as a therapeutic approach to the law in general.24

The TJ perspective regards the law as a social force that affects behaviors and consequences, the latter of which can be either therapeutic or anti-therapeutic. “Therapeutic Jurisprudence concentrates on the law’s impact on emotional life and psychological well-being. It is a perspective that regards the law (rules of law, legal procedures, and roles of legal actors) itself as a social force that often produces therapeutic or antitherapeutic consequences.”25 Promoting more therapeutic goals and perceiving law as a helping profession are important goals of the movement. TJ scholars declare that it aims to supplement rather than criticize the existing regimes of law.26 The principles of TJ have already been applied in a wide variety of legal environments, including preventive law, mental health law, problem-solving courts, and legal counseling. They inspire new pedagogies of legal education27 and therapeutic manuals for judges,28 and they are broadly applicable to legal rules, legal procedures, and legal actors.29 In the case of problem-solving courts, TJ is suggested as the supporting theory for the special practice of judges, which is very different from the adversarial mode of the regular court.30

The emphasis of TJ on interdisciplinary teamwork among court staff, social workers, and lawyers in problem-solving courts, and on taking a holistic, coordinated approach to criminal offenders, finds parallels in current interdisciplinary approaches to patient care and to public health in general. TJ and the new problem-solving courts actually represent a public health approach to the problems of juvenile delinquency, drug addiction, domestic violence, and mental illness.31

III. THE DIALOGUE BETWEEN THERAPEUTIC JURISPRUDENCE AND PUBLIC HEALTH

There are a few possible interactions between TJ and public health. This section analyzes the potential contribution of public health to TJ theory and practices and, from the other side, examines how TJ can supplement public health studies and public health law practice in particular. It concludes with a preliminary discussion of potential academic programs which may integrate TJ with public health.

A. Contribution of Public Health to Therapeutic Jurisprudence

A broad perception of public health law dovetails with a TJ approach to law, which supports promoting the well-being of the subjects of the law.32 Yet, according to common perceptions, public health law operates from above, focusing on the general population as the target. TJ, on the other hand, focuses on the individual activities of the legal actors and mainly examines rules and legal procedures as they affect concrete situations.33 In terms of prevention, TJ focuses on particularized counseling that considers psychological soft points and well-being in general.34 Both approaches, however, still share an interest in promoting well- being and in preventing disease.

The main emphasis of TJ scholarship, in its various manifestations, is on individual psychology and mainly on the interpersonal interactions among legal practitioners.35 TJ is actually defined as focusing “on the law’s impact on emotional life and psychological well-being.”36 The emphasis of public health scholarship, on the other hand, is on the community at large, trying to prevent diseases and to promote the welfare of society in general, with a strong emphasis on a population approach.37 Applying the focus, target, and strategy of public health to TJ scholarship enables a more “public” orientation of TJ that transcends the interpersonal level.

1. Upstream Focus: Primary Prevention, Health Promotion

How will primary prevention appear when law, and not medicine, is the guiding discipline? This raises the question whether the prevention of legal disputes is a legitimate goal for TJ to promote, especially when the disputes are considered crucial for the development of society, such as constitutional controversies and human rights debates. Initially, in contrast to medicine, which is primarily concerned with curing and preventing diseases, the law functions as both regulator and educator-not only as a means to resolve and prevent disputes.38 Following the complex functions of the law and their intersection, prevention may be relevant only when other functions of the law are not compromised. Perhaps prevention is compatible with the basic definition of TJ, which declares that its therapeutic goals are not meant to trump other, more conventional goals, and which aims to enrich legal discourse and to avoid injustice.39 On a deeper level, learning to manage social conflicts while minimizing the anti-therapeutic consequences of the process may contribute to more effective functioning of the law in all its manifestations, including its regulative and expressive embodiments. In other words, TJ should aspire to manage legal conflicts in ways that maximize the positive elements of the conflict while minimizing the psychological distress conflict creates.

What does primary prevention mean when we discuss preventing unnecessary disputes or minimizing their antitherapeutic effects? On a very basic level, it seems different from “preventive law” as traditionally understood in legal scholarship. When prevention is defined as “preventing legal risks from becoming legal problems”40 or as securing “more certainty as to legal rights and duties,”41 the intersection between TJ and preventive law is limited to the lawyer’s role in interviewing a client. “It emphasizes the lawyer’s role as a planner and proposes the careful private ordering of affairs as a method of avoiding the high costs of litigation and ensuring desired outcomes and opportunities.”42 When prevention includes a broader focus on group behaviors and public goals, as in a public health perspective, other legal players such as judges and educators should be involved in the therapeutic mission. Prevention in this public sense includes legislation and education. In criminal law, it might include involvement of problem solving courts in educational campaigns and in advising legislative reforms. In civil cases, it might include recommendations for a new procedural framework for processing tort litigation or other areas of law where TJ can be applied.

2. Targeting Economic, Political, and Environmental Forces that Affect Populations and Cause Disease

When we try to manipulate the environment to prevent unnecessary legal conflicts, the significance of cultural disputing behavior comes to mind. Legal disputes are social constructs reflecting unanswered claims.43 These claims are based on the perceived gaps between legal norms and injurious behavior.44 Intervention aimed at shaping forces that affect legal disputes thus requires more primary enforcement of legal norms, such as environmental regulation, safety rules in public facilities, and so forth. Better compliance with the law and increased normative behavior will help to reduce legal claims and unnecessary disputes. Preventing disputes is also achievable by changing disputing behaviors and educating people to tolerate deviation from the social norms.45 But such a goal will not be recommended from a broader perspective which aspires to address the functions of law in their multiplicity, especially the regulative and educative ones. We can educate a person to learn to minimize the anti-therapeutic effects of a coercive legal rule, but we would not like to do so since sustaining this rule will be worse and anti-therapeutic in the long term, or even just immoral.

3. Strategically Modifying Social and Environmental Variables and Social and Political Action

Modifying social and environmental variables where legal disputes are concerned is related to the broader interest of affecting cultural behavior. It is reasonable to assume that in a liberal, modern society, changing disputing behavior will not include challenging individual assumptions and will not entail transforming society to become more collectivist and harmonious. Therefore, more sophisticated techniques for instilling therapeutic concerns into individual behavior should be considered. Ethically oriented public health discussions on the relation between the individual and the community are relevant here. The study and teaching of modern mediation, with its emphasis on problem solving, depersonalization, the interests of the parties involved, and creative brainstorming, can be used as a therapeutic means to manage hard legal conflicts. Educating people to deal with disputes creatively while developing their dispute resolution skills can be suggested as a starting point for modifying disputing behavior.

On another level, public health literature can help TJ by providing methodologically improved tools to enhance compliance and to measure the effectiveness of TJ interventions. The emphasis of public health on research methodologies, as expressed in epidemiology and other social science approaches, can be adapted to TJ research. Multi-disciplinary teams working on the evaluation of public health interventions can serve as a model for TJ.

B. Contribution of Therapeutic Jurisprudence to Public Health

The design of public health administration and its policy formation have generally been rooted in a classic perception of law as an authoritative mechanism based on rules and coercion. Traditionally, compliance with public health measures was promoted through legislation and strict enforcement mechanisms and focused on detailed regulations to govern each branch of public health activities.46 This emphasis on enforcement through coercion and black letter law still prevails in some areas of public health development today. 47 In preventing diseases and monitoring risk behavior, public health scholarship is very much aware of the problem of compliance with medical norms and, as such, sophisticated methods of persuasion and education are employed to convey its messages.48 When approaching the legal field, public health providers adopt a very rigid perception of legal norms.49 According to this perception, legal methods are considered the ultimate measure to achieve compliance and less attention is allotted to the problems of compliance with legal norms, which are no less prevalent in public health than in other legal fields. Indeed, the institutionalization of a TJ approach in public health theory and practice favors the use of soft power methods to promote compliance, which need not rely only on external motivation as exemplified in legal norms.50 Instead, TJ promotes alternative forms of conflict resolution (i.e., mediation and arbitration) and encourages more care and attentiveness among public health practitioners, especially for those who are responsible for enforcing public health regulations.

Since TJ has always been preoccupied with encouraging a more therapeutic and functional version of law, the introduction of TJ philosophy into public health law practice, training, and scholarship is only natural. A TJ emphasis in public health will strengthen the interpersonal level that exists in any enforcement mechanism.

C. Preliminary Questions Concerning a Public Health Approach to Law and a TJ Approach to Public Health

Can TJ be described as a public health approach to law? Can we imagine a future TJ professional as a graduate of a TJbased academic education that is considered a branch of public health? Perhaps we can envision the professionalization of TJ to an MPH-like program in law schools. Approaching TJ as a serious discipline might mean enriching it with public health principles and methodologies. Maybe a TJ approach can function as an alternative to how law is currently taught and applied.

The exchange between the disciplines can be enhanced by adopting a broad perspective of public health (and of its goals, missions, and field of action) combined with a broad perspective of law as an interdisciplinary arena. According to our claim, the broadening of the concept of public health enables a deeper dialogue between TJ and public health, and collaborative projects can be imagined and planned. Concurrently, the dialogue between the disciplines can continue, focusing on the transformation in legal thought in the past century and the shift from a narrow to a broad perception of law. As the legal field becomes more diverse and interdisciplinary in its nature, the interest in TJ and public health is growing.

Just as the interdisciplinary nature and maturity of the field of law today can benefit public health studies, which have been addressing questions of individual-state tensions for hundreds of years,51 TJ scholarship can benefit from the in-depth public health discussion of paternalism.

As discussed above, public health scholarship discusses the existing, basic tension between the individual and the community.52 Introducing this discussion into TJ studies may enrich the existing debate on the application of therapeutic measures, which is currently limited to addressing the problem of paternalism only in particular cases.53

IV. INTERDISCIPLINARY EXCHANGES: LEVEL OF DIALOGUE AND INTERACTIONS

The legal field has been steadily moving in an interdisciplinary direction in recent decades, transforming much of the academic work into diverse spheres of “law and . . .” writing.54 Intersections between law and other academic disciplines usually foster several opportunities for dialogue and exchange. In this Article we use the existing modes of interdisciplinary collaboration in law55 to draw preliminary outlines for developing a public health approach to TJ and vice versa. An intersection between TJ and public health represents different levels of dialogue and opportunity for interdisciplinary exchanges.

Certain classic public health discussions can be included in TJ studies and enriched by TJ principles. Issues of malpractice, apologies in public health, prevention, and compliance can be studied within a public health curriculum or a TJ seminar, and each discipline can use materials from the other to enrich its case studies and reading materials. Such a mode of exchange between the two fields produces a very basic form of dialogue that preserves a shallow level of interaction between scholars in both disciplines. In fact, it is currently the only mode of interaction between public health and TJ and, as such, this Article aims to promote a deeper exchange between the two disciplines.

The study of TJ and public health as a unique interdisciplinary mixture involves more than a curricular exchange of case studies that invoke mutual interest. When a thorough study of the engagement of these disciplines is considered, a broader framework of collaboration between the disciplines can be imagined. Using the methodologies and principles of public health when applying TJ studies can be one way of collaboration. Establishing graduate programs defined as specialized TJ studies tracks, which are dedicated to public health, or building public health graduate studies tracks that educate TJ professionals, as suggested above, may be the beginning of a broader dialogue. Intensive dialogue focusing on the guiding principles of TJ and public health, that highlights their similarities and differences, can more fully engage the two fields of study. This would produce fertile projects of collaboration. The juxtaposition of TJ and public health can help reframe the basic assumptions of each field.

Greater interaction between TJ and public health, which may symbolize the end of the dialogue and the beginning of assimilation, entails understanding TJ as a branch of public health or vice versa. Since public health is a more established profession, however, in the assimilation scenario, TJ would most likely be incorporated as a branch of public health and not the opposite. Under this perception TJ may promote well-being in a manner similar to that of public health scholarship, but this possibility is still only a prospect for the distant future.

CONCLUSION

The fertile dialogue between TJ and public health, as outlined in this Article, has fostered some preliminary links between the two approaches.

First, both TJ and public health can be perceived as reform movements that challenge basic tenets in medical and legal education and practice. They are both interested in developing alternative views of these professions.

Second, the broad formulae of both TJ and public health are concerned with promoting the well-being of the community: public health addresses disease prevention and health promotion, while TJ addresses the prevention of psychological discomfort and of unnecessary legal disputes.

Third, both TJ and public health strive to prevent what their original disciplines consider their lifeblood: legal disputes and medical diseases. While in public health the focus is on prevention through referring to the public at large, in TJ the focus is on individual conflicts. Each approach, then, can be enriched by adopting the focus, either individual or public, of the other.

Fourth , TJ focuses on individual psychology and may be enriched by a broad public focus, with limitations of preserving the expressive elements of the law. Public health may benefit from an approach which promotes negotiation, therapeutic contracts, and less coercive legal measures.

Fifth , public health methodologies can help TJ encourage behaviors with therapeutic consequences and measure the effectiveness of TJ interventions. At the same time, TJ can help public health to encourage more compliance through emphasis on the interpersonal and psychological well-being of the subjects involved.

In summary , there are several possible levels of interaction between TJ and public health. This Article calls for a sincere approach that supports intense dialogue in which each discipline borrows methodologies and sensitivities from the other-an approach in which mutual influences and transformations are considered desired outcomes of the interaction.

1. LAW IN A THERAPEUTIC KEY: DEVELOPMENTS IN THERAPEUTIC JURISPRUDENCE (David B. Wexler & Bruce J. Winick eds., 1996) [hereinafter LAW IN A THERAPEUTIC KEY]; PRACTICING THERAPEUTIC JURISPRUDENCE: LAW AS A HELPING PROFESSION (Dennis P. Stolle, David B. Wexler & Bruce J. Winick eds., 2000); JUDGING IN A THERAPEUTIC KEY: THERAPEUTIC JURISPRUDENCE AND THE COURTS (Bruce J. Winick & David B. Wexler eds., 2003) [hereinafter JUDGING IN A THERAPEUTIC KEY]. On institutionalization of ADR, see Judith Resnik, Many Doors? Closing Doors? Alternative Dispute Resolution and Adjudication, 10 OHIO ST. J. ON DISP. RESOL . 211 (1995).

2 . See LAW IN A THERAPEUTIC KEY, supra note 1.

3. For a preliminary discussion of some theoretical dilemmas, see Christopher Slobogin, Therapeutic Jurisprudence: Five Dilemmas to Ponder, in LAW IN A THERAPEUTIC KEY, supra note 1, at 763-94. For a reasoned refusal to define “therapeutic” for purposes of TJ, see David B. Wexler, Reflections on the Scope of Therapeutic Jurisprudence, 1 PSYCHOLOGY, PUBLIC POLICY AND LAW 220 (1995). Wexler prefers to keep the definition of the term very flexible for purposes of promoting research. Id. at 223. He still provides a preliminary definition which speaks about “[a] focus on the mental health and psychological aspects of health,” and adopts Slobogin’s definition above: “the use of social science to study the extent to which a legal rule or practice promotes the psychological or physical well-being of the people it affects.” Id. at 223-24. 4. On the connection between public health care and the rise of the welfare state in such contexts, see DOROTHY PORTER, HEALTH, CIVILIZATION AND THE STATE: A HISTORY OF PUBLIC HEALTH FROM ANCIENT TO MODERN TIMES (1999).

5. There is ample literature on the history and sociology of the professions. One useful survey and analysis is by ANDREW ABBOTT, THE SYSTEM OF PROFESSIONS: AN ESSAY ON THE DIVISION OF EXPERT LABOUR (1988). See also THE FORMATION OF PROFESSIONS: KNOWLEDGE, STATE, AND STRATEGY (Rolf Torstendahl & Michael Burrage eds., 1990); KEITH M. MACDONALD, THE SOCIOLOGY OF THE PROFESSIONS (1995); ELIOT FREIDSON, PROFESSIONALISM: THE THIRD LOGIC (2001).

6. DEREK WANLESS, SECURING GOOD HEALTH FOR THE WHOLE POPULATION 23 (2004).

7. For a recent general overview of public health characteristics, see INSTITUTE OF MEDICINE, THE FUTURE OF THE PUBLIC’S HEALTH IN THE 21ST CENTURY (2003).

8. On the tensions between public health and clinical medicine, see Allan M. Brandt & Martha Gardner, Antagonism and Accommodation: Interpreting the Relationship Between Public Health and Medicine in the United States During the 20th Century, 90 AM. J. OF PUB. HEALTH 707 (2000).

9. PORTER, supra note 4, at 5.

10. Id.

11 . Id. at 4.

12 . See, e.g., MICHAEL WALZER, SPHERES OF JUSTICE: A DEFENSE OF PLURALISM AND EQUALITY 68-91 (1983).

13. PORTER, supra note 4, at 128-46, discussed the issue of coercion and resistance in Chapter 8: The Enforcement of Health and Resistance. Traditional issues of content included public health measures, such as vaccination, quarantine, water fluoridation, medical examination of immigrants, as well as forced sterilization and other eugenic measures. See JAMES COLGROVE, STATE OF IMMUNITY: THE POLITICS OF VACCINATION IN TWENTIETH-CENTURY AMERICA (2006); see also JOHANNA SCHOEN, CHOICE AND COERCION: BIRTH CONTROL, STERILIZATION AND ABORTION IN PUBLIC HEALTH AND WELFARE (2005); ALEXANDRA MINNA STERN, EUGENIC NATION: FAULTS AND FRONTIERS OF BETTER BREEDING IN MODERN AMERICA (2005); HOWARD MARKEL, QUARANTINE! EAST EUROPEAN JEWISH IMMIGRANTS AND THE NEW YORK CITY EPIDEMICS OF 1892 (1997); AMY L. FAIRCHILD, SCIENCE AT THE BORDERS: IMMIGRANT MEDICAL INSPECTION AND THE SHAPING OF THE MODERN INDUSTRIAL LABOR FORCE (2003).

14. These groups can be immigrants, ethnic minorities, or indigenous populations in colonial regimes. See, e.g., PORTER, supra note 4; STERN, supra note 13; MARKEL, supra note 13; FAIRCHILD, supra note 13.

15. For an analysis of state reaction to past traumatic public health events, see Nadav Davidovitch & Avital Margalit, Public Health, Law, and Traumatic Collective Experiences: The Case of Mass Ringworm Irradiations, in TRAUMA AND MEMORY: READING, HEALING, AND MAKING LAW (Austin Sarat, Nadav Davidovitch & Michal Alberstein eds., 2008).

16. On the intimate relationship between the law and public health care, see LAWRENCE O. GOSTIN, PUBLIC HEALTH LAW: POWER, DUTY, RESTRAINT (2000).

17 . Id. at 145-72.

18 . Id. at 4.

19 . See Lawrence O. Gostin, Public Health Law Reform, 91 AM. J. OF PUB. HEALTH 1365, 1365 (2001).

20 . See GOSTIN, supra note 16, at 85-109.

21 . See Lawrence O. Gostin, Ronald Bayer & Amy L. Fairchild, Ethical and Legal Challenges Posed by Severe Acute Respiratory Syndrome: Implications for the Control of Severe Infectious Disease Threats, 290 JAMA 3229 (2003).

22 . See GOSTIN, supra note 16.

23. Mae C. Quinn, An RSVP to Professor Wexler’s Warm Therapeutic Jurisprudence Invitation to the Criminal Defense Bar: Unable to Join You, Already (Somewhat Similarly) Engaged, 48 B.C. L. REV. 539, 543- 46 (2007); DAVID B. WEXLER, MENTAL HEALTH LAW: MAJOR ISSUES 11-57 (1981); Bruce J. Winick, Competency to Consent to Voluntary Hospitalization: A Therapeutic Jurisprudence Analysis of Zinermon v. Burch, in ESSAYS IN THERAPEUTIC JURISPRUDENCE 83 (David B. Wexler & Bruce J. Winick eds., 1991).

24. JUDGING IN A THERAPEUTIC KEY, supra note 1, at 7.

25 . See David B. Wexler, International Network on Therapeutic Jurisprudence, http://www.law.arizona.edu/depts/upr-intj (last visited Mar. 7, 2008) [hereinafter Therapeutic Jurisprudence website].

26. For a critical discussion of this claim, see Michal Alberstein, Therapeutic Keys of Law: Reflections on Paradigmatic Shifts and the Limits and Potential of Reform Movements, Bruce J. Winick and David B. Wexler eds., Judging in a Therapeutic Key: Therapeutic Jurisprudence and the Courts, 39 ISRAEL L. REV. 140 (2006) (book review).

27 . See Andrea Kupfer Schneider, Building a Pedagogy of Problem- Solving: Learning to Choose Among ADR Processes, 5 HARV. NEGOT. L. REV . 113 (2000).

28 . See SUSAN GOLDBERG, NATIONAL JUDICIAL INSTITUTE, JUDGING FOR THE 21ST CENTURY: A PROBLEM-SOLVING APPROACH (2005), available at http://www.nji.ca/nji/Public/documents/Judgingfor21scenturyDe.pdf.

29 . See Therapeutic Jurisprudence website, supra note 25.

30. See JUDGING IN A THERAPEUTIC KEY, supra note 1.

31 . See Charity Scott , Judging in a Therapeutic Key: Therapeutic Jurisprudence and the Courts, 25 J. LEGAL MED. 377 (2004) (book review).

32. See also the discussion of Slobogin, supra note 3, who reaches the conclusion that the reasonable interpretation of TJ’s notion of “therapeutic” is the promotion of well-being.

33. On micro emphasis of TJ on “the subtle impact of law on therapeutic outcomes,” see Wexler, supra note 3, at 229-36.

34 . See Dennis P. Stolle et al., Integrating Preventive Law and Therapeutic Jurisprudence: A Law and Psychology Based Approach to Lawyering, in PRACTICING THERAPEUTIC JURISPRUDENCE: LAW AS A HELPING PROFESSION 5 (Dennis P. Stolle, David B. Wexler, & Bruce J. Winick eds., 2000); Andrea Kupfer Schneider, The Intersection of Therapeutic Jurisprudence, Preventing Law, and Alternative Dispute Resolution, 5 PSYCHOL. PUB. POL’Y & L. 1084 (1999).

35. See, for example, the TJ approach to client counseling as described in Schneider, supra note 34.

36 . See Therapeutic Jurisprudence website, supra note 25.

37 . See supra Part I (describing public health principles).

38. For a basic description of the functions of law, see Steven D. Smith, Reductionism in Legal Thought, 91 COLUM. L. REV. 68 (1991).

39 . See Therapeutic Jurisprudence website, supra note 25.

40 . California Western School of Law, Nat’l Center for Preventive Law, http://www.preventivelawyer.org/main/default.asp (last visited Mar. 7, 2008).

41. Stolle et al., supra note 34, at 6.

42 . Id.

43. Richard E. Miller & Austin Sarat, Grievances, Claims and Disputes: Assessing the Adversary Culture, 15 L. & SOC. REV. 525 (1980-1981) (defining a dispute as a social construct which exists mainly in the eye of its beholder).

44. William L. Felstiner, Richard L. Abel & Austin Sarat, The Emergence and Transformation of Disputes: Naming, Blaming, Claiming, 15 L. & SOC. REV. 631, 631 (1980-1981). According to the authors, disputes develop through three stages: naming, when an injurious experience becomes perceived; blaming, when an attribution of responsibility is given to someone and a grievance is created; and claiming, when the claim is brought before the other side and becomes a dispute. Id.

45. An illustration of a TJ position which calls for a modification of behavior to tolerate a non progressive rule is the so-called “don’t ask, don’t tell” antigay policy in the U.S. military. See 10 U.S.C. [section] 654 (2000); see also Victor C. Romero, Crossing Borders: Loving v. Virginia as a Story of Migration, 51 HOW. L.J. 53, 69-70 (2007) (mentioning the statute by its commonly known name, “don’t ask, don’t tell”). The offer is to learn to live with this rule while minimizing its anti-therapeutic consequences through training for discrete responses.

46 . See PORTER, supra note 4.

47 . See GOSTIN, supra note 16.

48. On the social and political aspects of education and persuasion in public health, including their tension with coercion in the case of compulsory vaccination, see COLGROVE, supra note 13.

49. For such a typical example of how public health law should be implemented, see INSTITUTE OF MEDICINE, supra note 7. The report calls for public health law reform, which is directly tied to issues of preparedness and law enforcement (as in the case of pandemic influenza, SARS). This is how it is presented in their list of the essential public health services: “Enforce laws and regulations that protect health and ensure safety.” Id. at 32. No other lawrelated alternatives are mentioned. Id.

50. For a systematic overview and discussion of the bases of social power and the relative effectiveness of soft powers over coercive influence, see Bertram H. Raven, A Power/Interaction Model of Interpersonal Influence: French and Raven Thirty Years Later, 7 J. SOC. BEHAV. & PERSONALITY 217 (1992).

51. For discussions of paternalism law, see, for example, Cass R. Sunstein & Richard H. Thaler, Libertarian Paternalism is Not An Oxymoron, 70 U. OF CHI. L. REV. 1159 (2003); Anthony T. Kronman, Paternalism and the Law of Contracts, 92 YALE L. J. 763 (1983).

52 . See supra Part I (discussing public health definition).

53 . See John Petrila, Paternalism and the Unrealized Promise of Essays in Therapeutic Jurisprudence, in LAW IN A THERAPEUTIC KEY, supra note 1, at 685. Petrila claims that in the case of mental health law the editors ignore the growing challenge to the professional hegemony of mental disability law and treatment. Id. at 688. They ignore criticism of the existing therapeutic values in the field; they do not answer the question who decides what constitutes a therapeutic outcome; they assume too easily that researchers, practitioners, and lawyers working together are capable of defining and implementing therapeutic values. Id.

54. For a description of the interdisciplinary approach which characterizes legal academia, see DUNCAN KENNEDY, A CRITIQUE OF ADJUDICATION (1997).

55. For a discussion of the various ways in which law and literature intersect in legal writing, see LAW AND LITERATURE: TEXT AND THEORY (Lenora Ledwon ed., 1996). Nadav Davidovitch* and Michal Alberstein**

* Nadav Davidovitch, M.D., M.P.H, Ph.D. is a senior lecturer, Department of Health Systems Management, Faculty of Health Sciences, Ben Gurion University, Israel and adjunct lecturer, Center for the History and Ethics of Public Health, Mailman School of Public Health, Columbia University, New York.

** Michal Alberstein, LL.M., S.J.D. is a senior lecturer, Faculty of Law, Bar Ilan University. We would like to thank David Wexler for his comments as well as for his constant support, advice, and friendship. An earlier version of this paper was presented at the International Association of Law and Mental Health Annual Conference, Padua, Italy, June 2007.

Copyright The Law Review Association Spring 2008

(c) 2008 Thomas Jefferson Law Review. Provided by ProQuest LLC. All rights Reserved.

MUMBAI, India, Aug. 26 /PRNewswire/ — Sun Pharmaceutical Industries Ltd. (Reuters: SUN.BO, Bloomberg: SUNP IN, NSE: SUN PHARMA, BSE: 524715) today announced it was victorious in all elements of its defense of the litigation brought against it in the Tel-Aviv District Court by Taro Pharmaceutical Industries Ltd. (Taro) and certain of its directors.

The Tel-Aviv Court yesterday rejected Taro’s contention that Sun Pharma should have conducted a “special tender offer” under Israeli Law. As a result, Sun Pharma will be in a position to complete the previously announced Tender Offer by its subsidiary, Alkaloida Chemical Company Exclusive Group Ltd. (Alkaloida). Following the closing of the Tender Offer, all conditions to Sun Pharma’s Option Agreement to acquire all the shares held by the controlling shareholders of Taro will be satisfied and the controlling shareholders will have to deliver their shares.

In a well reasoned and comprehensive decision, Honorable Judge Dr. Michal Agmon-Gonen J. of the Tel-Aviv District Court ruled that it was “disingenuous” for Taro’s directors to claim now, over a year after they approved the transaction, that a special tender offer was required. The court stated that the directors should have “studied the agreements” prior to their being signed, and should have confirmed then that they were in the company’s best interest. The court stated that the directors cannot claim now that they suddenly decided a special tender offer is necessary.

Dilip Shanghvi, Chairman and Managing Director, Sun Pharma said, “It is clear based on yesterday’s ruling that the lawsuit by Taro’s independent directors was part of a calculated effort by Barry Levitt to avoid living up to his obligations under the Option Agreement. It is time for Dr. Levitt and his family to live up to the contract and do what is required of them under the Option Agreement.”

With respect to those directors who are also shareholders, the court stated that “these shareholders benefited from Sun’s investment, which basically saved Taro from collapse,” and characterized their conduct in challenging Sun Pharma’s exercise of its contractual option as “grave.”

The court also ordered Taro and the other plaintiffs to pay Sun Pharma’s costs related to the litigation.

The complete terms and conditions of the tender offer are set out in the Offer to Purchase, which is filed with the U.S. Securities and Exchange Commission. Taro shareholders may obtain copies of all of the offering documents, including the Offer to Purchase, free of charge at the SEC’s website (http://www.sec.gov/) or by directing a request to MacKenzie Partners, Inc., the Information Agent for the offer, at 105 Madison Avenue, New York, New York 10016, (212) 929-5500 (Call Collect) or Call Toll-Free (800) 322-2885, Email: [email protected].

Greenhill & Co., LLC is acting as the Dealer Manager for the Tender Offer and MacKenzie is acting as the Information Agent for the Tender Offer.

About Sun Pharmaceutical Industries Ltd.

Established in 1983, listed since 1994 and headquartered in India, Sun Pharmaceutical Industries Ltd. (Reuters: SUN.BO, Bloomberg: SUNP IN, NSE: SUNPHARMA, BSE: 524715) is an international, integrated, speciality pharmaceutical company. It manufactures and markets a large basket of pharmaceutical formulations as branded generics as well as generics in India, U.S. and several other markets across the world. In India, the company is a leader in niche therapy areas of psychiatry, neurology, cardiology, diabetology, gastroenterology, and orthopedics. The company has strong skills in product development, process chemistry, and manufacturing of complex API, as well as dosage forms. More information about the company can be found at http://www.sunpharma.com/.

   Contacts   Uday Baldota   Tel         +91 22 6645 5645, Xtn 605   Tel Direct  +91 22 66455605   Mobile      +91 98670 10529   E mail      [email protected]    Brunswick Group for Sun Pharma   Nina Devlin / Andrea Shores   +1 212 333 3810    Arad Communications for Sun Pharma   Gali Dahan   +972 3 7693320    Mira Desai   Tel         +91 22 6645 5645, Xtn 606   Tel Direct  +91 22 66455606   Mobile      +91 98219 23797   Email       [email protected]    MacKenzie Partners   Robert Marese   +1 212 929 5500    Greenhill   Ashish Contractor   +1 212 389 1537  

Sun Pharmaceuticals, Inc.

CONTACT: Uday Baldota, +91-22-6645-5645, Xtn 605, Direct,+91-22-66455605, Mobile, +91-98670-10529, [email protected], or MiraDesai, +91 22 6645 5645, Xtn 606, Direct, +91-22-66455606, Mobile,+91-98219-23797, [email protected], both of Sun Pharma; Nina Devlin orAndrea Shores of Brunswick Group, +1-212-333-3810, or Gali Dahan of AradCommunications, +972-3-7693320, all for Sun Pharma; Robert Marese of MacKenziePartners, +1-212-929-5500; Ashish Contractor of Greenhill, +1-212-389-1537

Web site: http://www.brunswickgroup.com/http://www.sunpharma.com/

Pacific Retirement Services, Inc. (PRS), a national, not-for-profit leader in the senior living industry, announced today that the bond closing for the construction of its affiliate, Mirabella at South Waterfront, occurred on August 26, 2008. Mirabella, an award-winning 30-story, not-for-profit Continuing Care Retirement Community by PRS, is under construction now in South Waterfront. Mirabella has entered into an affiliation agreement with Oregon Health and Science University (“OHSU”) in connection with this project. The $221.7 million in bonds were issued by The Hospital Facilities Authority of Multnomah County, Portland, Oregon, for the construction of Mirabella (“the Project”).

Issued were $212.2 million of Hospital Facilities Authority of Multnomah County, Oregon, Variable Rate Demand Revenue Bonds, Series 2008A; and $9.5 million of Hospital Facilities Authority of Multnomah County, Oregon, Variable Rate Demand Revenue Bonds, Taxable Series B (Mirabella at South Waterfront Project). The Letter of Credit is from Bank of Scotland plc, New York Branch. Herbert J. Sims & Co., Inc., served as the senior managing underwriter, and Cain Brothers served as the underwriter for the issue.

Mirabella’s award-winning, 325-foot-tall green design is by Ankrom Moisan Associated Architects of Portland, Oregon, and construction is by Hoffman Construction Company. From proper site selection and careful planning, to resource conservation and improved indoor environmental quality, Mirabella Portland will be built and operated in a sustainable manner. It is now being constructed to achieve the highest possible LEED (Leadership in Energy and Environmental Design) rating–a Platinum certification–though South Waterfront only required a Silver certification.

The groundbreaking ceremony occurred on May 3, 2008, and Mirabella is expected to open in 2010 on an approximate 1.16-acre site bordered by S.W. Curry, S.W. River Parkway, S.W. Pennoyer St., and S.W. Bond Ave. This is the second Mirabella CCRC for PRS. The first is Mirabella Seattle, which is expected to open December 15, 2008, in South Lake Union, and under development now is Mirabella San Francisco Bay, which is planned for the new cultural center of Foster City known as Park View Plaza.

Mirabella is being designed to provide seniors urban access, resort-style venues, and scenic views. Penthouse and apartment homes are spacious, with the finest finishes and extra-large windows and balconies that frame views of Mount Hood, the Willamette River, and the Portland skyline.

World-class amenities are throughout to support healthy living and offer social opportunities, lifelong learning, and entertainment. There are various dining venues, including the Penthouse View Dining Room on the 24th floor, a Cafe/Bistro, and private dining rooms. The Fitness Center has an indoor lap training pool, a spa, and exercise classes. Mirabella also has a Cocktail Lounge and various other lounge areas, the Lifelong Learning Center/Activity Rooms, a Library and Business Center, planned activities and excursions, and convenient services such as a salon/barbershop, a bank, a store, underground parking, valet parking, and transportation, among others.

Levels of care and senior living include Independent Living, Residential Living, and Memory Care and Skilled Nursing Care in all private suites. An on-site Wellness Clinic will also offer a variety of services and therapies.

In connection with the Project, PRS has entered into an affiliation agreement with OHSU, though OHSU will not own or have any financial obligation in regard to the Project or the Bonds. OHSU and PRS will collaborate in the development and implementation of new technologies that will meet the needs of residents, assist in the operation of the Project, and help to enhance the independence and well-being of residents.

To learn more about Mirabella Portland, call 503-245-4742 or 1-877-254-9371, or visit www.mirabellaretirement.org. Mirabella’s marketing office is located at 3030 S.W. Moody Avenue, Suite 107, Portland, OR 97201. To learn more about Pacific Retirement Services, Inc., call 888-724-6424 or visit www.retirement.org.

About Pacific Retirement Services, Inc. (PRS)

PRS is a national, not-for-profit senior living developer, operator, and manager that serves a growing family of 55 organizations, including retirement communities and service organizations. Headquartered in Medford, Oregon, with another office in Memphis, Tennessee, PRS has approximately 2,014 employees and provides housing and services to more than 4,850 seniors through its many affiliated organizations in California, Oregon, Washington, Texas, and Wisconsin, with Florida coming soon. PRS affiliates include nine Continuing Care Retirement Communities (CCRCs), two managed retirement communities, and twenty-five affordable housing communities, with more in development. Mirabella Portland, Mirabella Seattle, and Mirabella San Francisco Bay represent PRS’s newest brand of urban CCRCs. To learn more, call (888) 724-6424 or visit www.retirement.org.

Aptuit, Inc. announced today that Timothy (Tim) C. Tyson, a 30-year pharmaceutical industry veteran, has been appointed Executive Chairman and acting CEO. Michael A. Griffith, the company’s founder and Chief Executive Officer since 2005, has resigned in order to pursue other opportunities.

“The Board wishes to thank Mike for his outstanding success in creating a world-class organization that is a trusted partner to hundreds of innovative clients throughout the world,” said Tony Ecock, outgoing Chairman of Aptuit’s Board of Managers. “With 2,700 employees working with more than 800 clients throughout the world, Aptuit has established a solid foundation for continued growth and success.”

Aptuit’s interim CEO, Tim Tyson, is the former COO, President and CEO of Valeant Pharmaceuticals International, where he served from 2002-2008. Prior to Valeant, Tyson’s pharmaceutical industry experience includes a 14-year tenure at GlaxoSmithKline, where he was President of Global Manufacturing and Supply and ran Glaxo Dermatology and Cerenex Pharmaceuticals. There he managed all sales and marketing for GlaxoWellcome’s U.S. operations. Tyson has also held executive positions at Bristol-Myers in commercial and technical operations and R&D. Previously he was a manufacturing manager for Procter & Gamble.

“I am honored to have the opportunity to help lead the next phase of Aptuit’s growth, and to build on the many achievements the company has had to date,” Tyson said. “Aptuit is uniquely positioned to help innovative partners create the new medicines of tomorrow, and we will work tirelessly to ensure that we do all that we can to help improve the way drugs are developed.”

About Aptuit

Aptuit, Inc. is a global company focused on streamlining and supporting the drug development process for biotechnology and pharmaceutical innovators. The company was founded by a group of industry experts with extensive market experience who have a track record of building a similar, highly successful company through acquisitions and investment. Aptuit provides a comprehensive suite of product development services and competencies to more than 800 biotechnology and large, fully integrated pharmaceutical innovators worldwide. Aptuit’s mission is to engineer a better drug development process, and is partnered with Welsh, Carson, Anderson & Stowe, one of the world’s largest private equity investors. For more information about Aptuit, please visit www.aptuit.com.

LAS VEGAS, Aug. 26 /PRNewswire/ — Desert Radiologists, Nevada’s largest and most trusted medical imaging company today announced that five new physicians have joined the team of board certified radiologists serving Southern Nevada for over 42 years.

(Logo: http://www.newscom.com/cgi-bin/prnh/20050322/DRLOGO )

Dr. Howard Francois began his medical career in 1995 when he graduated from the University of Pennsylvania in Philadelphia, with a Bachelor of Arts in Biology. He then graduated from Howard University, College of Medicine in Washington, DC where he received his Doctorate of Medicine in 2001. In 2002 he finished his internship at the Brooklyn Hospital Center, Department of Internal Medicine in Brooklyn, NY. Dr. Francois completed his residency in Diagnostic Radiology at Wayne State University/Detroit Medical Center in 2007 and his fellowship in Musculoskeletal Imaging in 2008 from Henry Ford Hospital in Detroit, MI.

Dr. John S. Anderson graduated Summa Cum Laude from Case Western Reserve University in Cleveland, OH in 1995 with a Bachelor of Arts in Biology. He also received his Doctorate of Medicine from Case Western Reserve University in 1999 graduating with Alpha Omega Alpha honors. In 2000 he finished his internship in Categorical General Surgery from Brooke Army Medical Center. Dr. Anderson completed his residency in Diagnostic Radiology from the Mallinckrodt Institute of Radiology/Barnes-Jewish Hospital, Washington University School of Medicine in 2007. He completed a fellowship in Clinical MRI in 2008 from the University of California, San Diego. Dr. Anderson also served as General Medicine Officer/Emergency Physician form 2000 to 2003 for the United States Army in Heidelberg, Germany.

Dr. Lavanya Vuddagiri received her Medical Degree from Guntur Medical College and Government General Hospital in Guntur, India in 2001. In 2003 she finished her internship at the University of Arkansas for Medical Sciences in Little Rock, AR as well as her residency in 2007. Dr. Vuddagiri completed her fellowship in MRI in 2008 from the University of California, San Diego.

Dr. Terence Scipione graduated from Christian Brothers University in Memphis, TN in 1995 with a Bachelor of Science in Chemistry. He then graduated from Albert Einstein College of Medicine in Bronx, NY where he received his Doctorate of Medicine in 2000. In 2003 he finished his internship at St. Luke’s/Roosevelt Hospital in New York, NY. Dr. Scipione completed his residency in Diagnostic Radiology at Mt. Sinai/Atlantic Health System in Morristown and Summit, NJ in 2007 and his fellowship in Musculoskeletal Imaging and MRI in 2008 from Columbia/Presbyterian Hospital in New York, NY.

Dr. Frank K. Hsu graduated from the University of Michigan in 1989 with a Bachelor of Science in Biomedical Sciences. He continued his education at the University of Michigan where he received his Doctorate of Medicine in 1992 in the Integrated 7-year Pre-medical/Medical Program. In 1993 he finished his internship at William Beaumont Hospital in Royal Oak, Michigan. Dr. Hsu completed his residency in Diagnostic Radiology at the University of California, San Francisco in 1997 as well as his fellowship in Abdominal Imaging in 1998. Dr. Hsu then completed an additional fellowship in Angiography and Interventional Radiology in 1999 from the University of Michigan Medical Center. Prior to joining Desert Radiologists, Dr. Hsu worked for Columbia Imaging Group in Vancouver Washington; Kaiser Permanente Hospital in Sacramento, California; University of Michigan Medical Center in Ann Arbor, Michigan; William Beaumont Hospital in Troy, Michigan and St. Vincent Radiological Medical Group in Los Angeles, California.

“Desert Radiologists is so pleased to add such specialized and diversified radiologists to our group,” said William Moore, CEO of Desert Radiologists. “The completion of each of their fellowship training programs adds to our depth of specialty-trained physicians.”

About Desert Radiologists

Desert Radiologists has been serving Southern Nevada since 1966. Our expert team of radiologists is the largest group of physicians providing quality diagnostic imaging in Nevada. We have 5 outpatient locations throughout Las Vegas and Henderson and provide radiology services for 6 Southern Nevada hospitals. Desert Radiologists offers the most comprehensive procedures available including Angiography, Computed Tomography (CT), CT Colonography, Dexa Bone Densitometry, Dental Implant CT Scanning, Diagnostic Radiology (X-ray), Interventional & Cardiovascular Radiology, Magnetic Resonance Imaging (MRI), Mammography, Nuclear Medicine, Positron Emission Tomography (PET/CT), Stereotactic Breast Biopsy, Uterine Fibroid Embolization (UFE) and Ultrasound. In addition, Desert Vascular Institute provides a complete array of vascular services. For more information visit http://www.desertrad.com/.

   Contact: Michele Crawford   Phone: 702-759-8700   Fax: 702-598-3400   Email:  [email protected]  

Photo: NewsCom: http://www.newscom.com/cgi-bin/prnh/20050322/DRLOGOAP Archive: http://photoarchive.ap.org/PRN Photo Desk, [email protected]

Desert Radiologists

CONTACT: Michele Crawford of Desert Radiologists, +1-702-759-8700,+1-702-598-3400 fax, [email protected]

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

SALEM, Ore., Aug. 26 /PRNewswire/ — The Oregon Tourism Commission launched its new free online Quality Care Customer Service Training Program (Q Care) this week on http://www.oregonqcare.com/.

Oregon Q Care is a training program created to support the tourism and hospitality industry through enhanced employee education. By emphasizing the importance of quality customer service, the training will equip employees with tools and resources to better serve Oregon’s visitors.

“We’ve all heard the adage that it costs more to attract a first-time guest than a repeat customer,” said Todd Davidson, Travel Oregon’s CEO. “The heart and soul of this principle resides in that first-time customer’s experience and how likely they will be to return as a result. The Oregon Q Care program raises the bar on the level of customer service provided by staff in every position of the organization — helping them understand the central role they play in customer satisfaction.”

Preferred partners in the Q Care program, the Oregon Restaurant Association (ORA) and Oregon Lodging Association (OLA), have provided access to the online training on their websites also.

“Excellence in customer service is often the difference between success and failure in the hospitality industry,” said Steve McCoid, ORA President & CEO. “Because of this, the Oregon Restaurant Association is proud to add this terrific training program to our menu of quality online training products.”

Initially launched in 2003 as a classroom-based training, approximately 9,000 people have been certified through the Q Care program. The new online program is designed to reach thousands more across the state.

“Oregon Q Care allows hoteliers to train their entire staff with a consistent message, and it’s free,” said Gregg Mindt, OLA President & CEO. “If we can convince visitors to come back again, and tell their friends about the Oregon experience, we ensure the long-term success of the Oregon lodging and tourism industries.”

To learn more about how your business or organization can become an Oregon Q Care Preferred Partner or to become certified, visit http://www.oregonqcare.com/.

The Oregon Tourism Commission, dba Travel Oregon, works to enhance Oregonians’ quality of life by strengthening economic impacts of the state’s $8.3 billion tourism industry. Visit http://www.traveloregon.com/ for details.

Travel Oregon

CONTACT: Linea Carlson, +1-503-378-2084, [email protected], orMichelle Godfrey, +1-503-378-8861, [email protected], both of TravelOregon

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

LEWISTON – The Androscoggin County Chamber of Commerce and Healthy Androscoggin is sponsoring a six-week Southern Maine Wellness Council certificate course in The Fundamentals for Worksite Wellness. This is a professional training series designed to teach best practice models, strategies and guidelines for successful wellness programs at workplaces.

The course will begin Wednesday, Sept. 24, and end Oct. 29 at the chamber’s Community Conference Room, 415 Lisbon St., from 9 to 11 a.m.

The facilitator is Dean Paterson, a nurse with a degree in community health education. She is an experienced worksite wellness professional and owns Healthcare Solutions, a consulting firm. She is also the senior consultant for the Lifeline Institute for Workplace Health Promotion.

The registration deadline is Sept. 19. Discounts are available for chamber members and SMWC members. For more information on the cost of the course, how to register and other information, contact Tom Downing, executive director of the USM Lifeline Center for Wellness and Health Promotion, at 780-4879 or at [email protected], or call the chamber at 783-2249.

(c) 2008 Sun-Journal Lewiston, Me.. Provided by ProQuest LLC. All rights Reserved.